Singer Nancy Agram and her like have popularized cosmetic surgery in the Arab world. In recent years, a burst of patients from the Middle East and Europe have flocked to countries including Egypt for cheap, safe plastic surgery. News Focus Freeing Taxpayers The ruling NDP cut personal income and corporate taxes in half, but the emergency law is here to stay High Times Bankers expect higher interest rates to heat up the investment climate and cool inflation Mastering Law A new law program at the American University in Cairo seeks to get students serious about law Until the Cows Come Home Consumers are still waiting for Sudanese beef to hit the market AloAchoo! The next generation of viruses has hit mobile phones Star Power The 2004 Olympics created some unlikely national icons and a powerful lineup of marketing potential Below Par The World Bank says Egypt is handicapped by the high costs to start a business and the difficulty of firing people, to name a few Corporate Bonding Orascom Telecom and Telecom Egypt have made a splash in the bond market, but rising interest rates may damper enthusiasm Unmaking Monopolies Opposition MPs say changes to a proposed anti-trust law defy the purpose of the law by protecting monopolies On Topic The Euromoney conference put an exclamation point on the liberalization efforts of the government Investment Matchmakers Egypt Invest 2004 seeks to convince foreign investors that the country has finally turned a corner ’Dish’ing it Out Satellite TV stations are set to give the state-run channels a run for their advertising revenues during Ramadan Cargo Crunch As exporters complain about skyrocketing airfreight prices, the government seems to be turning an unsympathetic ear Star Power The 2004 Olympics created some unlikely national icons and a powerful lineup of marketing potential By Alex Dziadosz Dr. Osama El-Shahawy at the entrance of the Esthetica hospital. His clinic is one of the foremost sponsors of health travel in Egypt. By Alex Dziadosz Many Gulf patients seek dental treatment in Egypt. By Courtesy Pyramisa Cairo ‘Wellness’ treatments, such as thalasso, are so far the most likely candidate to net Egypt a share of the billions of dollars generated by health tourists. By Matt Moyer The new post-op rehabilitation?

By Alex Dziadosz

Along Nakheel Street in Mohandiseen, window displays of Italian boots mingle with chic coiffeurs and silverware merchants. Sweepers clear debris from the stoops of limousine rentals, and signs are nearly as likely to be printed in French as in Arabic.

But even in this tidy district, the Esthetica Maxillofacial and Dental Hospital stands out. With its meandering, tiled pathways, ornate landscaping and sedate pastel color scheme, the designer clinic is more evocative of a resort than a hospital. And this is exactly their aim. Over the past decade, an influx of wealthy foreigners, propelled by eroding travel costs and stratospheric prices in their home countries, have made ‘health tourism’ a lucrative trade. And with as many as one in 10 European Union patients seeking treatment outside of their borders, there has naturally been a rush to cash in.

“This is part of our dream,” says Dr. Osama El-Shahawy, one of Esthetica’s founders. “It’s well-known that the prices of treatment here are much less than in Europe, the States and even the Gulf area. At the same time, we’re giving [patients] a quality service.”

Healthcare outsourcing, as the trend is sometimes called, broke into public consciousness about five years ago. Since then, a throng of reporters, doctors, government bureaucrats and tourist agents have dissected and scrutinized it. Publications as well known as The Economist and The New York Times have written about it. Dozens of websites have sprouted up, including medicaltourism.com, which offers price comparisons for major surgeries by country. There is even chatter that some US companies will soon offer health tourism as employee benefits.

The consensus is that sponsoring health travel is a good way for developing-world economies to make an extra buck. India, a giant of outsourced industry, scampered to capitalize, launching a program that aims to garner an annual $2.2 billion from medical tourists by 2012. Thailand, Costa Rica and Jordan have launched similar schemes.

“You can see [the advantages] from two viewpoints: the small viewpoint, which is the facility itself or the hospital itself; and the bigger viewpoint, which is the country,” says El-Shahawy. “People coming will move in different avenues. They will buy things. It’s perfect for all parties.”

India estimates nearly 150,000 medical tourists brought in $333 million (LE 1.84 billion) in 2006. About 250,000 visitors — almost half from the Middle East — seek treatment in Singapore every year, usually for plastic surgery.

Health tourism is not as new as it might seem. Over two millennia ago, pilgrims flocked to Epidaurus, a Greek town in the northeastern Peloponnese, where the god Asclepius reputedly diagnosed their illnesses and prescribed treatments. Medical pilgrims have frequented spa towns, such as England’s aptly named Bath, to “take the waters” for centuries.

But the field’s expansion into more complex treatments, such as hip replacements and kidney transplants, is distinctly modern. Its success is rooted in the wide effects of globalization — reduced travel costs, vastly superior communication technology, and the reduced importance of physical boundaries —all hallmarks of the post-Cold War international economy.

In 2006, Princeton economist Alan Blinder controversially claimed that offshoring would impact more jobs than economists first thought. “Nature’s whimsy is far less important than it was in the past,” he wrote. “The concentration of computer companies around Silicon Valley, for example, has nothing to do with bountiful natural deposits of silicon; it has to do with Xerox’s fabled Palo Alto Research Center, the proximity of Stanford University, and the arrival of two young men named Hewlett and Packard.”

The result is that free trade is not just shifting carburetor makers from Cleveland to Shenzhen, Blinder claimed; it is uprooting entire economies. If a job can be sent overseas, it will be. Doctors, at one point assumed to be among the educated class of jobs untouched by outsourcing, are now proving to be anything but immune.

But trade liberalization does not deserve all the credit. While the Internet and affordable airfare have made medical tourism possible, first-world healthcare problems have made it profitable. Excessive costs and waiting lines are hotly debated topics in the West, noticeably in the US, where 45 million are uninsured and the prices of vital procedures routinely surpass the limits of middle-class affordability. Across the border in Canada, where the state covers most costs, patients often wait 18 weeks for treatment.

Thus medical tourists — cynically referred to as “medical refugees” by Professor Mark Smith in the New England Journal of Medicine — are left with little choice but to go abroad. Often, politics get involved. In 2006, the West Virginia state legislature considered subsidizing overseas care for state employees, hoping it might pressure American healthcare providers to cut their costs.

So with demand blossoming and a flurry of countries institutionalizing medical tourism, where does Egypt fit in?

In theory, Egypt is fertile territory. The nation’s menu of vacation options is notable: It is easy to imagine sleeping off post-anesthetic grogginess at an idyllic Red Sea resort, for instance, and historic marvels like the Giza pyramids, the last of the Seven Wonders of the Ancient World, abound.

But despite the speculative din surrounding health tourism, the trade has stayed mostly on the sidelines in Egypt. Esthetica, which has branches in Maadi and El Gouna, keeps company with a surprisingly modest cohort of pioneers. “Egypt does have good credentials, that is known,” says El-Shahawy. “Our problem is that we are not organized.”

Indeed, Ministry of Tourism spokesperson Hala El-Khatib admits health travel in Egypt is still far from mature. So far, she says, the Ministry has not advertised medical tourism specifically. “Cultural, leisure, medical,” she says. “It’s all one.”

Yet there are signs of change. In August 2005 the government unveiled a plan to promote Egypt’s “recuperative sites,” which include about 1,350 natural springs — notably Safaga and Siwa Oasis — that are used to treat most varieties of rheumatism. In October of last year, Minister of Tourism Zoheir Garranah attended a conference in the Czech Republic, a hub of spa tourism. There, El-Khatib says, he signed a memorandum of understanding with the Czechs that could lead to future partnerships.

Then, last month, the Ministry of Tourism, alongside the Egyptian Tourism Authority and a cadre of European Union experts, hosted Medical and Therapeutic Tourism Potential in Egypt, an ambitious conference intended to jumpstart health travel to Egypt. The conference drew guests from nearly every specialty showing even a flake of interest in medical tourism — primarily hotel managers, spa owners, doctors, tourist agents and journalists. The discussion centered largely on therapeutic treatments at resorts and ‘wellness centers,’ popular in Eastern Europe and the Maghreb. Speeches included ‘Spa & Wellness Architecture: Chances and Traps’ and ‘New Tools of Management in Tunisian Thalasso Therapy Centers.’

But to this point there has been very little coordination between the public and private sectors. “I think we need to do that,” El-Khatib says.

About 9 million tourists visited Egypt in 2006, according to the Ministry. El-Khatib says they aim to boost this number to 14 million by 2011, while maintaining or raising the average length of stay — currently 10 nights. To do this, they will need to introduce new attractions like golf courses and cheap real estate, El-Khatib says. Medical tourism is likely to fall under this umbrella.

The bustling reception hall of Cleopatra Hospital is a clear enough indication that would-be health vacationers may have to hurdle a barrier more pressing than a lack of brochures or web sites.

“[Medical tourism] is a nice idea. But what about beds?” Sharif El-Essawy, Director of Medical Services, says over the commotion. “All the tourism background is available. But is it suitable to start while our medical service is not enough to cover the area here? You can see I’m fully booked.”

The website of Arab Medical Tourism Magazine, devoted to boosting and organizing Middle Eastern health vacations, advertises Cleopatra to tourists. But El-Essawy estimates it will be at least two years before the hospital can accommodate any. Cleopatra is adding about 200 beds, doubling the current capacity, but the ground has yet to be broken on the new wing. And even when complete, El-Essawy says, he will likely only commit 10 or 20 beds to tourists.

“A small example,” he says. “I am your best friend, but you have one chair in your dining room. You want me to visit you. But how? Where should I sit?”

El-Essawy’s concern reveals the inherent ethical question in offering top-notch care to foreigners in a country where, according to the most recent estimates, there are no more than 0.54 doctors per thousand people and the life expectancy, though much higher than its gruesome 39-year average in 1952, still falls well short of developed countries. India, arguably the forerunner of the medical tourism movement, has similar problems. The country has about 0.6 physicians and 0.9 hospital beds per thousand people. Thailand, popular for plastic surgery, fares even worse with a meager 0.37 physicians per 1,000 people.

University of Texas at Austin professor Prabhudev Konana, one of the most vocal critics of developing-world health tourism, recently penned an editorial in The Hindu berating the Indian government for overlooking domestic health needs in favor of foreigners. “Let’s assume a massively spreading disease creates global shortage of foodgrains,” he wrote. “Should India allow export of essential foodgrains for enormous profits? If you agree with the export ban, then you need to accept a ban on medical tourism.”

Konana also points to India’s dearth of available hospital beds. Many of these beds, he says, are filling with patients from countries with markedly better conditions, like the US (2.3 doctors and 3.3 beds per 1,000 people), France (3.37 doctors and 7.7 beds) and Kuwait (1.53 doctors and 2.2 beds). Price is another concern. Konana argues that encouraging foreigners to come to India may result in a “bidding war” for quality services, enlarging the already alarming gap between supply and demand and pushing healthcare even farther out of the grasp of India’s lower, and even middle, classes.

“It’s a point,” El-Shahawy says, reflecting on Esthetica’s role in the market. “I’m making the best of everything here: The best sterilization, the best materials, the best state-of-the-art equipment, and, on top of this, the best experienced doctors. Definitely we won’t be able to be exposed to the majority of people.”

While El-Shahawy says Esthetica cannot release specific figures, he says they generally charge in the “intermediate range.” That is, the high to average prices for dental and cosmetic work in Egypt.

Even at a sliver of rates in the US, where a bicuspid root canal rings in at about $600 (LE 3,300), these prices hover in an uncomfortable limbo: far below Western fees, yet well out of reach of the nearly 16 million Egyptians living on less than $2 per day.

Still, El-Shahawy says, they do what they can. Esthetica reserves 10% of their beds, as the law requires, for patients referred by the Ministry of Health. “We, the same people who are working here, are treating people free of charge at Cairo University,” he says. “But here in our hospital, we can’t do this.”

Such examples of disparity in as crucial a service as healthcare are often cited as inherent flaws of capitalist economies. Evidence, critics say, that such systems should be reformed or discarded. Fans of such policies, on the other hand, often invoke a ‘trickle-down’ theory, or the idea that foreign money, no matter where it goes, will enrich the entire country on some level; that is, a rising tide can lift even the smallest of ships.

That global neo-liberalism will be in style for some time is, for the most part, tacitly accepted. Health tourism will undoubtedly accompany it. Whatever the ethical and practical implications, scores of developing-world doctors, tourist brokers and governments will continue to scramble for profit. The only questions left, it seems, are how to do it and where to start.

In Egypt, most signs point to therapeutic, ‘holistic’ treatments. This is sensible: Egypt has a natural advantage here. Hydrotherapy and balneotherapy (the treatment of disease by bathing) work with sand and seawater — two resources Egypt has in abundance. The country already hosts plenty of seaside resorts, along both the Mediterranean and Red Seas, which are already incorporating health spas into their services.

This leaves open the question of how more complex treatments — such as angioplasties, which India is delivering with such success — can fit in. “We need high-standard hospitals everywhere,” El-Essawy of Cleopatra says. “Not just in Cairo, Alexandria and Sharm El-Sheikh.”

Clearly this is no simple task. It will require patience, investment and coordination between public and private sectors. But El-Essawy estimates medical tourism will be a significant boon to the Egyptian economy within three years. “Many hospitals are coming up,” he says. “And many, like us, are expanding.”

To some degree an unfettered market will ensure that designer clinics, wellness centers and private practices which target foreigners will continue to sprout up, as supply naturally stretches to meet demand. But wider success will not come as easily. The global nature of this trend means Egypt competes not only with regional neighbors — though both Israel and Jordan have developed formidable sectors — but with the entire world.

“We have to have a way to tell these people that we are there and that we are ready to help you,” El-Essawy says. This means travel agencies, governments and private practices will have to work together.

Quality standards were another recurring theme at the December conference. Christopher Gruber, an agent of Austria’s health tourism ‘national quality mark,’ described the need for public and private groups to work together as they monitor clinics and hotels. Unregulated, he said, too many hotels, spas and hospitals will act on their own, making it hard to sustain good, reliable service. “We don’t want satisfied guests; we want inspired guests,” he said.

Egypt will also need to stand out. Product differentiation is a key concept in any marketing textbook and, however unusual, medical tourism is no exception.

In one rare departure from his PowerPoint slides, conference speaker Alexander Aichner, an Austrian training specialist, urged Egypt to remember its culture. Build training centers here, he said, “You have real culture, you have real history. That’s the possibility for Egypt.” Each country has a specialty, he said. Austria uses skiing. “But if you were to invest in skiing, it would be the worst thing you can do.”

There are plenty of places to start. El-Khatib says Egypt is “easily” within the best five countries for plastic surgery —Esthetica itself offers an array of cosmetic work in addition to dentistry. She lists cardiology, geriatrics and dentistry as growing specialties. Aromatherapy, as one speaker at the December conference noted, is a Pharaonic invention.

As with the development of any new sector, there are of course obstacles to overcome. “We are importing staff. We are suffering from not having the proper equipment,” lamented one spa owner at the tourism conference. But Egypt has an extensive set of resources to work with, and encouraging foundations have already been laid. The conference saw many eager, if perhaps belated, pledges to bolster the industry. During a midday coffee break, a flurry of business cards and handshakes passed among the hotel managers, tourist agents, journalists and doctors present — a promising sign in a field where harmony across specialties is vital.

Countries such as India and Thailand have obvious head starts in the race for health travel dollars, raising a major question about Egypt’s future in the trade: Can it keep up? “We hope,” Dr. El-Shahawy says, laughing. “We hope. Getting started is pretty tough.”  bt