Expensive dental and cosmetic surgery here is creating a burgeoning industry overseas. Isssc Davison finds while a nip and tuck is cheaper offshore, experts say it might also be riskier.
Consumer champion Kevin Milne thinks New Zealanders should plead poverty if they cannot afford their exorbitant dental bills.
The tongue-in-cheek advice from the former Fair Go host was offered as a last-ditch option for a mother struggling to pay a $5000 bill.
But it highlighted a problem that is sending New Zealanders halfway across the world for dental care instead of down to the local clinic.
Medical tourism is booming, and though there are no definite figures on New Zealand departures for medical reasons, local agencies offering combined surgery and holiday packages say their business is doubling year-on-year.
Fifty countries now identify medical tourism as a national industry, and a Deloitte report has estimated the sector will be worth $150 billion a year by 2012.
Because Americans are the biggest medical travellers - 550,000 a year - their neighbours have some of the largest medical tourism industries.
Mexico, Costa Rica, and Argentina carry out operations from heart bypasses to stem cell transplants for less than a third of the price of the procedure in the United States.
Asia is expected to be the major player in the next 20 years, with India and Thailand already boasting billion-dollar turnovers and Malaysia investing heavily in attracting foreign patients.
Southeast Asia offers the best value for New Zealanders seeking dental, cosmetic and orthopaedic treatment, as well as the bonus of a beachside recovery.
Auckland-based company Stunning Makeovers sends around 10 people a week to Bangkok and Phuket, and is considering expansion into Malaysia.
Owner Paul McGowan said 90 per cent of his customers went overseas for cosmetic surgery.
"These are middle-income people. If higher-income people have plastic surgery, they'll do it on Remuera Rd. The main reason they are travelling overseas for surgery is to access it at affordable pricing.
"We get the whole gamut, from younger girls in their 20s who want to have breast augmentation to ladies looking to recover their looks after having children."
One of his clients approached Stunning Makeovers after being quoted $30,000 for a full facelift in Auckland.
She travelled to Thailand instead and paid $5500 for the surgery, return flights, 12 nights' accommodation, and a driver.
Entrepreneur Jo Hueston, founder of Beautiful Escapes, said dental surgery and corrective laser eye surgery were the growth sectors in medical tourism.
This week one of her clients was quoted $4800 for major dental restoration, including crowns and fillings. Hueston offered the same operation for $1100 in Phuket. She said crowns which cost $1200 in New Zealand were sold for $380 in Thailand, or $640 for full porcelain.
Both agencies said the growth in offshore elective surgery was "win-win".
Hueston believed her business did not take customers away from local clinics.
Firstly, the people who travelled for dental care would never consider a local operation because of the cost. Secondly, she said her company worked alongside local dentists, who were needed for follow-up care.
McGowan said improvements in technology meant hospitals in developing countries were on par with the First World.
"It's much safer than it has ever been."
New Zealand's tourism model was built on attracting foreigners for health reasons.
In the late 19th century, the Government recognised the potential of Rotorua's warm geothermal waters as a therapeutic cure for ailments such as arthritis and rheumatism.
More than a hundred years on, New Zealand has been relatively hesitant to expand its medical tourism industry.
Only one major clinic, Auckland-based Medtral, focuses on luring foreign patients here.
An expert on medical tourism, Professor Michael Hall from the University of Canterbury, said the industry is only an entrepreneur or policy-change away from major expansion.
"The justification for private or government providers offering these services is that it subsidises services for locals.
"That argument is used elsewhere, it's probably only a matter of time before it's used here as well."
But healthcare commentators warn that with new growth comes new risks.
A report by Professor Hall, who is writing a book on medical tourism, says the industry is growing rapidly without careful consideration for its potential economic and public health impacts.
His paper noted that tourists who travel for operations are deliberately engaging in medical practices that expose them to new pathogens.
Medical tourism was last year blamed in part for the spread of the superbug NDM-1, which was resistant to nearly every antibiotic.
It was found in bacteria in India, Pakistan and Britain, and was believed to be carried by patients who had travelled abroad for elective surgery.
Professor Hall told the Weekend Herald that without risk management, the incredible profits of medical tourism could be quickly reversed by a major health scare.
"The cost of the severe acute respiratory syndrome (Sars) outbreak in Asia in 2003 was around US$15 billion. This did not include the unmeasurable cost of the knock to business and tourism confidence in the region.
Professor Hall's report - published in Tourism Review - says that though the profits from medical tourism go offshore, local public health operators foot the bill if anything goes wrong.
If a tourist suffers a severe infection from a breast enhancement in Thailand, the weight of their ongoing treatment often falls on the New Zealand public health system.
Professor Hall says: "Here you have two very different perspectives on healthcare provision. You have the classic American profit-driven perspective versus the public health perspective.
"Personally, I [prefer] the public health perspective. In the long run it's economically better, in the sense that it also reduces risks.
"Ironically the global market is enormous because you have some really crap national health systems. The focus should be on good public health."
Travel and healthcare agencies the Weekend Herald spoke to say they are taking the business away from online "cowboys", and providing well-researched, certified doctors at a good price. Professor Hall said this business model could not be safe unless it was highly regulated.
International research is also beginning to unpick the ethical issues which surround travel for healthcare.
Proponents of medical tourism in Thailand claim that boosting the industry prevents a medical brain drain, and funds local health infrastructure.
But prominent Thai economist Ammar Siamwala warned in April that doctors were being drawn away from public hospitals for the bigger pay packets in private clinics. The clinics aimed at foreign patients often resembled five-star hotels, and paid doctors around eight times more than a state hospital.
The most pessimistic economic analysis says medical tourism could simply reinforce gaps between the "haves" and "have-nots".
Medical practitioners have told the Weekend Herald there is an inherent problem in businesspeople facilitating complex healthcare in a different country.
An Auckland cosmetic surgeon, who does not want to be named, says: "People are seduced by the pictures of a warm, kind doctor and a beach holiday.
"But they are thinking about the glamour of an exotic trip away, and not the risks involved."
Getting hip in India
Karen Dickson got a new hip in India.
It was her second new joint. She had a total hip replacement in New Zealand on her left hip in 1998 and knew eventually that the other would need repairs so she could find relief from years of arthritic pain.
The second time around, the West Coast woman spent a long time investigating her options and found advances in hip science meant that she could chose hip resurfacing instead of a full replacement.
Less bone is removed with hip resurfacing. The surgery suits younger patients because if the job needs to be done again - what surgeons call revision - there is still plenty of the femur left for the specialist to work with.
Encouraged by a friend, Dickson looked abroad because she faced a $22,000 bill to get the operation in New Zealand. She had to pay for surgery because her years of hip problems meant she was not covered by insurance.
Says Dickson: "I could have had the operation in Auckland but the surgeon had done only about 300 hips. With resurfacing, the more operations the better."
Her search for a hospital ended in Chennai - the southeast Indian city which used to be called Madras - and a clinic run by the Apollo Hospital Group, which specialises in joint surgery.
With her partner Neil Mouat, Dickson made the long trip to Chennai three years ago where her right hip was resurfaced.
"I was a bit apprehensive," she recalled. "But Vijay Bose - the specialist we went to - had done 1200 operations."
The clinic was like a "five star mini-hotel" with a choice of Indian or Western food. Most of the patients were Americans.
Dickson stayed a few days, before the couple flew to Sri Lanka for a month. The operation cost $10,000 but the total bill, including their island holiday, was about $20,000.
"I was totally happy with the care. They give you a laptop and make you comfortable."
Dickson said that since her surgery she has never had any complications, though she is aware she has a lot of metal through her middle.
She feels she made the right choice. "I'm pretty happy to be walking around."
- Andrew Stone