The Fourth "S"

Americans once visited the Third World for "sand, sea and sex." A local author says it's time to add "surgery."

by Ted Hesson

TRAVELIN' MAN: Rafael Richards went to Belgium for a "hip resurfacing" procedure and has no complaints about the results. The X-ray appears below. (CLICK IMAGE FOR LARGER VERSION)

Health Care

As Chris Baldwin boarded the bus for the Taj Mahal, dozens of men called to him from the parking lot, "Sahib, come here," trying to lure him on amateur tours. The air-conditioned bus ride was comfortable and from his window, he saw vendors pestering rickshaw passengers with phony marble miniatures of the Taj. On the roadside, people sold "chaat," spicy snacks flavored with onions and chili pepper.

But Baldwin wasn't lured to India by the Taj or the bustling marketplaces. He came because he was frustrated with his American health-insurance plan. Just days before boarding the tour bus, he went under the scalpel for major surgery some 7,300 miles away from home at a hospital in New Delhi.

"I was leery of going overseas. For all I knew you could get 'disappeared' in other countries,"says Baldwin, a 29-year-old Philadelphia Biblical University student. Despite his trepidation, Baldwin thought he had few cost-effective options. "I felt like a third class citizen."

More and more, Americans are going abroad for medical care because the system here doesn't provide for them. Some have insurance, some don't, but they are all looking for the same thing: quality medical services at affordable prices (with some sightseeing thrown in for good measure).

"Mostly people from the West go to Third World countries for the three S's," says Milica Bookman, an economics professor at Saint Joseph's University who is releasing a book on medical tourism next month. "Sand, sea and sex — and now you can add to that: surgery."

Medical tourism isn't exactly a new phenomenon. Foreign-born Americans have been returning to their home countries for medical treatment since U.S. health care became big business, and within the last few years, more Internet-savvy Americans are discovering doctors and hospitals in India, Singapore and Mexico. (Although there are no hard numbers, estimates have the number of Americans traveling for medicine reaching into the hundreds of thousands.)

Bookman's upcoming Medical Tourism in Developing Countries, which she co-wrote with her daughter Karla, isn't a how-to guide for the medical tourist. Instead, she examines how this emerging industry will affect the developing world. Through her research, she learned that most Americans go abroad for one reason: It's cheaper.

Patients without insurance or with policies that have high deductibles can hop on the Internet and find a top-notch surgeon in another country for half the cost.

But there are risks. Patients traveling overseas may not be able to sue for malpractice, depending on the host country's legal system. And U.S. insurance companies can refuse to treat someone for ailments related to medical work done abroad.

There have been even greater consequences. Joshua Goldberg, a 23-year-old from New York, died mysteriously in Thailand after seeking treatment for a swollen leg in 2006. Joshua's father, Jim, who is documenting an investigation into his son's death on www.bumrungraddeath.com, says he believes his son was murdered by hospital staff who perhaps intended to harvest his organs.

However, Bookman has heard from other doctors who say that the death could have happened in U.S. hospitals, as well. (In American hospitals, insurance companies would be liable for such an accident.)

For people like Chris Baldwin, though, the benefits outweighed the doubts. Baldwin landed flat on his back in September 2006, after an opposing lacrosse player checked him on a muddy field in Levittown. He iced his knee, went home and didn't think much of it. It felt like a sprained ankle, so he didn't use crutches. He hobbled around campus for a few weeks until the pain started to bother him as the weather turned cold.

At the campus medical facility, doctors told him that he could either try therapy or surgery. He opted for therapy for a few months, but his knee wasn't recovering enough for him engage in physical activity. As he talked to campus doctors about surgery, he realized his insurance, provided through the university, made it difficult for him to go forward with the procedure.

"I'd have to actually come up with the money and then after a lot of paperwork you'd get the money back," he recalls. "But I wasn't doing that."

Neither Baldwin nor his parents could front the $15,000 to $30,000 required for the surgery, and the idea of putting that amount on credit cards seemed preposterous. Around Thanksgiving, he was surfing the Internet and found Planet Hospital, a California-based company that links people to doctors and hospitals in places like Costa Rica, Mexico and Thailand.

"I tell people that America has the best medical care in the world if you can afford it," says Rudy Rupak, co-founder and president of Planet Hospital. The company offered to take care of all of the details for a surgery in New Delhi — doctor, airfare, passport and visa — for only $6,000. Compared to the mountains of forms and fine print required by his insurance company, this already felt like an improvement.

Baldwin had traveled to Mexico before, and some of the hospitals he saw there left him unsure of what to expect at other facilities abroad. "I've heard stories," he said. "I mean, I didn't want to get gangrene or something."

A representative from the company met Baldwin at the airport and drove him to MAX Hospital. The building was spotless and everyone spoke English. He was impressed when, after he arrived at 2 a.m., a doctor came to see him within a half-hour. During his stay, nurses constantly stopped by to check on him.

"I literally felt like a rock star," he said. "They went out of their way to be extra courteous and be really welcoming."

He went in for ACL repair after a day of tests, and then spent four days doing physical therapy and touring. The trip took eight days in all. Returning home, Baldwin continued therapy to strengthen his knee. He now runs and hikes without any problems.

"I am a bit leery of contact sports, though, because I do not want to risk an injury," he said. "But I could play lacrosse again if I wanted to."

While Baldwin went to India to save money, Rafael Richards of Exton traveled to Europe seeking a procedure that wasn't approved in the U.S. In 1999, Richards was running around the track at Penn Charter when he suddenly felt a crippling pain on the right side of his hip.The then-35-year-old Temple med student came to a full stop. He couldn't finish the run. As the hip pain worsened, Richards gave up his frequent runs as well as his regular squash matches and nights out dancing.

(CLICK IMAGE FOR LARGER VERSION)

He eventually went for an X-ray at Temple University Hospital, which showed that he had severe osteoarthritis as a result of the ball and socket in his hip rubbing together because the cartilage had worn away. The joint was not going to get better, and the pain grew more debilitating. In the fall of 2002, he visited four different surgeons from the best hospitals in Boston and two surgeons from elsewhere in the country;they all told him that he needed a hip replacement.

As a doctor himself, Richards knew that artificial hips don't last forever, and a young person with an artificial hip might need to have the hip repaired, perhaps more than once. Left with no choice, he scheduled a hip replacement for that October. But he wasn't satisfied with the decision.

"I did not want to be this patient who was in chronic pain," he said."Then I heard about this hip resurfacing thing."

A traditional hip replacement would require sawing off the top of the thigh bone. But the resurfacing procedure called for covering the top of the thigh with a metal cap, then implanting a metal cup in the hip socket. As a result, healthy bone would be preserved, while still alleviating the bone-on-bone rubbing that initially caused the hip pain.

Richards canceled his surgical appointment, but there was one big problem: Richards wanted a certain type of resurfacing that still wasn't FDA-approved, although it had been introduced in the U.K. in 1997. It existed only in the experimental stage in the U.S., meaning that the few doctors performing the surgery in the states had little experience. Inthe U.K. and Belgium, however, it had been approved for years.So in January 2003, Richards flew to England to meet the inventor of the procedure and then hopped on another plane to visit a surgeon in Belgium who specialized in hip resurfacings.As he learned more about the operation, his med school training gave him an investigative edge normally not available to patients.

"I asked if I could scrub in and watch the procedure," he said. When the surgery ended about an hour later, he had made up his mind. "I knew I wanted this hardware; I knew this was the right thing for me."

In March 2003, he returned to Belgium for the surgery.The building was simple but clean and sunny, and hospital personnel were extra friendly when they found out that Richards was a resident anesthesiologist. The food — a slice of wheat bread, some shredded carrots and few cold cuts — didn't appeal to Richards as much as the hamburger or mashed potatoes he might have gotten in the states, but he figured that it was probably healthier anyway.

Once the anesthesia kicked in, he passed out, and when the haze cleared he noticed that all of his pain had disappeared. His hip was sore from the surgery, but the joint felt great.The hospital moved him to a Hilton hotel across the street for the recovery, and his physical therapist and nurses visited him there. He began rebuilding his life after returning to Boston. He started jogging again and playing squash and soccer in his free time.

Recently, though, his other hip socket has felt sore.Although it isn't as bad as the original socket yet, he thinks another surgery is inevitable.Hip resurfacing has since been approved in the U.S., but when the time comes, he plans to travel back to his original doctor in Belgium.

"I am 100 percent satisfied that I made the right decision; it was the right thing for me to do," says Richards. "The standard of care I received was as good, if not better, than what I'd have gotten here."

(editinterns@citypaper.net)