Perceptions of an ‘international hospital’ in Thailand by medical travel patients: Cross-cultural tensions in a transnational space
Introduction
The growth of medical travel involving patients travelling for medical services to other countries, commonly termed medical tourism, is producing new forms of health care and transforming hospitals in terms of their architecture, design and organization (Bochaton and Lefebvre, 2009, 97). A growing literature on medical travel describes the economic and health resource implications, demand and supply of the trade, the involvement of the state, and the advantages and disadvantages of its promotion (Bookman and Bookman, 2007, Chanda, 2002, Chee, 2010, Connell, 2011, Smith et al., 2009, Smith et al., 2011). This paper considers the perceptions of in-patients to one such hospital in Thailand. We are interested in how such hospitals are organized for foreign patients and experienced by them. In this paper we use the term ‘medical travel’ rather than ‘medical tourism’, in recognition that for many patients medical travel involves pain and suffering not the pleasures of mainstream tourism.
Thailand is one of the leading ‘medical tourism hubs’ in the Asian region with a sophisticated tourism and health care infrastructure. In 2004 the government launched three programmes in a five-year plan to position Thailand as the ‘Health tourism hub of Asia’, by fast-tracking the development of the health care industry in campaigns spearheaded by the Ministry of Public Health and the Ministry of Commerce (Whittaker, 2008). The Director-General of Health Services Support within the Ministry of Health states that 2005 revenue from these services was 23 billion baht (approx. USD 0.5 billion) (Aungkasuvapala, 2006). Data on the total numbers of people travelling to seek health services in Thailand is uncertain given different classification systems and definitions and a lack of systematic research. A recent study of patient records from five largest private hospitals in Thailand found that a total of 104, 830 ‘medical tourists’ visited in 2010, accounting for 324, 926 separate visits and generating 180 million USD (Noree et al., 2014). The top three countries of origin of patients to Thailand in 2010 were UAE (accounting for twenty percent of total foreign patients), Bangladesh and USA, followed by Myanmar, Oman and Qatar, then the United Kingdom (Noree et al., 2014). There has been a major increase in patients particularly from the Gulf Cooperation Council Countries many through tie-in contracts to supply care. It is estimated that by 2015, 7 million outpatients and 0.4 million in-patients are expected to come to Thailand for medical care, requiring 200–300 extra physicians to service demand, especially for specialists (Wibulpolprasert and Pachanee, 2008, Kanchanachitra et al., 2011).
In her analysis of the biopolitics of Bumrungrad Hospital, one of Thailand's leading international hospitals, Ara Wilson (2010) emphasizes the history enabling the realization of ‘international’ standards in Thailand, including features such as state investments and forms of affective labour. Wilson notes the deployment of pre-existing capacities already available in Thailand, such as a skilled medical workforce, extensive tourism infrastructure, and service industry. She suggests these hospitals need to be viewed as part of a ‘domestically situated transnational assemblage that redeploy capacities already available in the country’ (2010:119), and describes the medical tourism industry as an example of ‘a national biopolitical strategy for addressing domestic uncertainty, geopolitical conditions and global capital flows’ (2010:119). Similarly, other recent work on the medical travel industry in Asia, and Thailand more specifically (Connell, 2011, Toyota et al., 2013, Whittaker, 2008, Wilson, 2010), demonstrates the development of these industries as national projects associated with pre-existing domestic capacities and the deliberate intervention of Asian states.
Although they are based on local capacities, within Thailand and elsewhere, hospitals involved in the medical travel trade are promoted and branded through marketing as ‘international’, by implication differentiating them from ‘local/national’ hospitals for local patients and implying standards of care, technology and services appropriate to foreign patients. For example, in Bangkok these include a number of private hospitals such as Bangkok International Hospital (BIH), Bumrungrad International, Samitivej Hospital and Vejthani Hospital. Despite the fact that all of the aforementioned hospitals also cater to large numbers of local Thai (elite) patients, they are marketed to locals and foreigners as ‘international’. Throughout the paper we use this term ‘international hospital’ as a means to denote these hospitals in Thailand, terminology derived from local usage and reflecting the hospitals' marketing orientation/aspirations. The marketing of these hospitals as notionally ‘international’ reflects the ways in which within the trade in health services hospitals have become commodified and ‘packaged’ through the conscious manipulation of images and symbols (Kearns and Barnett, 2000, 84). Bochaton and Lefebvre (2009, 101) argue that the organization and production of hospitals designed for foreign patients in Asia may be described as ‘heterotopias’. Drawing upon Foucault's characterization of heterotopias as real places that are ‘effectively enacted utopias’, they note how such hospitals ‘insist on presenting themselves as very different compared to normal hospitals’ offering an imaginary perfected medical experience, special space demarcated by unconventional time, restricted entry and meticulous organization. Likewise, in her study of the medical travel industry of Malaysia, Ormond (2013) describes the conscious promotion of the medical travel industry as a Utopian flattened playing field. Yet despite deliberate global standardizing or ‘flattening type’ strategies – accreditation with international accreditation organizations, branding of the country, and targeted marketing emphasizing the international standards and competitive pricing, she notes the fictive nature of such discursive and material attempts.
In his theorization of the socio-spatial impact of the globalizing economy, Low (2009, 32) describes ‘how people move across borders creating new transnational spaces and territorial relationships’ and calls for studies which examine the articulation of ‘transnational and translocal’ space which ‘can be metaphoric and discursive, embedded in language and movement.... in this sense the global is ‘located’ in embodied space, and negotiated and given meaning through social relationships and specific cultural and political contexts' (2009:34). Likewise, other authors emphasize the significance of specific connectivities, relationships, and interactions within transnational spaces and focus on the need for grounded studies of the specificities of interactions within these spaces (Bochaton, 2013, Toyota et al., 2013, Wilson, 2010, Wilson, 2011). In this paper we begin such a grounded ethnography of the production of an ‘international hospital’ from within, looking at the production of an ‘international hospital’ through its spaces, organization and practices, and its consumption from the perspective of in-patients.
In this paper, we suggest that what is referred to as an ‘international’ hospital is an assemblage of patients, staff, technologies and expertise that is a local production of global biomedical forms (glocal), diverse in its manifestations and contingent upon the social actors involved. The case study reveals an incomplete attempt to reproduce a shared imaginary of ‘the international’ by staff hosts and in-patients—incomplete because it is riven with cross-cultural tensions. We offer a case study using empirical data from one such Thai hospital to explore the conscious attempt to produce an ‘international’ space, while problematizing its meanings for patients within it.
The first part of the paper describes the hotel-hospital hybrid characteristic of hospitals marketed to foreign patients in Thailand. Then we explore how the space of the ‘international’ hospital is produced, negotiated and given meaning through the practices and experiences of patients within it. We argue that the production of space is phenomenological, involving all the senses, but also dependent upon the perspective of the person interacting with it. We show how ethnicity, religion and cultural differences continue to affect the experience of these hospitals.
Our analysis draws upon work in geography and anthropology which explores the constructions and consumption of space, place and locality and problematize the ‘local’ creation of ‘universality’(Choy, 2005). Writing on environmental issues in Hong Kong, Choy (2005:6) suggests that concepts of universality and particularity are in ‘a constant process of self-conscious deployment, production and articulation’. Similarly, we suggest that notions of the ‘international’ and ‘local’ are in a constant state of flux and interplay within hospitals targeting foreign patients. Uniquely, in this paper we are interested particularly on how foreign patients themselves experience and consume these places.
Section snippets
Methods
The paper reports on work undertaken within a Thai hospital which includes observations and interviews with thirty in-patients and nine informal interviews with hospital administrative and international medical coordination staff and translators. It forms part of and is informed by a larger project on the experiences of patients undertaking international medical travel in Thailand and Malaysia. The hospital described in this paper strategically targets the international patient market; over
Conclusions
Health geographers recognize that the experience of medicine cannot be detached from the place in which it is received, whether this be in a hospital setting, community clinic or homecare (Kearns and Gesler, 1998). The body of work on therapeutic landscapes emphasizes the social connections to places and spaces (Gesler, 1992). But they also consider place and space as multi-dimensional, contestable and holding different meanings for differing social and medical groups and affecting the
Acknowledgments
This work draws upon research supported by an Australian Research Council Discovery Project ‘Medical travel in Asia: Therapeutic quests for hearts and hips’ (DP 1094895) funded by the Australian government. Ethical clearance for this study was obtained through the University of Queensland Behavioural Social Science Ethical Review committee and the Monash University Human Research Ethics Committee and permissions granted by various authorities at participating hospitals. We thank the hospital,
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