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Why Patients Are Turning to Medical Tourism

Statistics, Benefits, and Risks

Planning Ahead

Frequently asked questions.

Medical tourism is a term that refers to traveling to another country to get a medical or dental procedure. In some instances, medical tourists travel abroad seeking alternative treatments that are not approved in the United States.

Medical tourism is successful for millions of people each year, and it is on the rise for a variety of reasons, including increasing healthcare costs in the United States, lack of health insurance, specialist-driven procedures, high-quality facilities, and the opportunity to travel before or after a medical procedure.

According to a New York Times article from January 2021, pent-up demand for nonessential surgeries, as well as the fact that many Americans lost their health insurance during the coronavirus pandemic led to a surge in medical tourism once other countries re-opened.

However, there are specific risks that come with traveling overseas for surgery. If you're thinking of pursuing a medical procedure in another country, here's what to know about the benefits and the risks.

Medical Tourism Benefits

The most common procedures Americans go abroad for include dental care, cosmetic procedures , fertility treatments, organ transplants , and cancer treatment.

This is not to be confused with having an unplanned procedure in a foreign country due to an unexpected illness or injury.

Among the reasons a person might choose to go abroad for a medical procedure are:

Lower Costs

Medical tourists can save anywhere from 25% to 90% in medical bills, depending on the procedure they get and the country they travel to. There are several factors that play into this:

• The cost of diagnostic testing and medications is particularly expensive in the United States.
• The cost of pre- and post-procedure labor is often dramatically lower overseas. This includes labor costs for nurses , aides, surgeons , pharmacists, physical therapists , and more.
• High cost of malpractice insurance—the insurance that protects medical professionals against lawsuits—in the United States.
• Hospital stays cost far less in many overseas countries compared to the United States. In other words, quality care, hospital meals, and rehabilitation are far more affordable abroad for many people.

For someone who doesn't have insurance , or someone having a procedure that is not covered by insurance , the difference can be enormous.

Popular Countries for Medical Tourism

Dominican Republic

South Korea

Culture and Language

Many immigrants prefer to have treatments and procedures done in their country of origin—a sensible decision, considering just how much language barriers alone can affect the quality of their care.

Furthermore, at least 25% of immigrants and noncitizen residents in the United States are uninsured, compared to 9% of American citizens. Children with at least one noncitizen parent are also more likely to be uninsured.

Practicalities aside, many people choose to have their procedure done in their country of origin simply because it allows them to be close to family, friends, and caretakers who can assist them through their recovery .

Insurance Incentives

Some insurance companies have started promoting medical tourism. The reason behind this is simple: savings for the insured means savings for the insurance provider and vice versa.

Several insurance providers, including Aetna have programs specifically geared at promoting safe medical tourism. Some insurance providers even offer financial incentives for medical tourism, like discounts on medical bills .

That said, many insurance companies will not pay for surgery performed outside of the country unless it is an emergency.

Luxury and Privacy

Medical tourism is a lucrative business for many countries, and much of the money brought in by medical tourists is reinvested into the local economy and health infrastructure.

The effect of this is apparent in the spa-like luxury that some foreign hospitals offer, providing medical tourists the opportunity to be pampered during their stay for a fraction of the cost they would pay at home.

Some facilities offer hospital rooms that are more like a hotel suite than a traditional hospital room. Other hospitals offer one-on-one private nursing care, which is far more generous and attentive than the staffing ratios that most hospitals allow.

Medical tourists who seek that added layer of privacy can find it abroad. Many can return home from their "vacation" without anyone knowing they had a procedure at all.

Vacation in a Foreign Country

Medical tourists often take advantage of their stay in a foreign country to travel for pleasure by scheduling a vacation before or after their procedure.

This is an especially inexpensive way to travel to a foreign country, especially if their insurance provider is paying for the flight and the cost of staying is low. 

While it seems logical to recover on a beach or in a chalet by the mountains, keep in mind that it's important not to jeopardize your recovery.

Swimming isn't recommended until your incisions are completely closed. You may not feel up to doing much more than napping in the days following your procedure, either.

Don't let your vacation disrupt your recovery. Any time you have a procedure done, especially a surgery, it's important to listen to your body, take your medications as directed, and follow your doctor's recommendations closely.

Bypassing Rules and Regulations

Some travelers seek surgery abroad to bypass rules that are set in place by their own government, insurance company , or hospital. These rules are typically in place to protect the patient from harm, so getting around them isn't always the best idea.

For example, a patient may be told that their weight is too low to qualify for weight loss surgery . A surgeon in a foreign country may have a different standard for who qualifies for weight loss surgery, so the patient may qualify overseas for the procedure they want.

Talented Surgeons

Surgeons in certain countries are known for their talent in a specific area of surgery. For example, Brazilian surgeons are often touted for their strong plastic surgery skills .

Whereas in the United States, insurance companies might only cover cosmetic procedures if it is medically necessary, cosmetic surgery is often free or low-cost in Brazil's public hospitals—giving cosmetic surgeons there ample practice.

Thailand is reported to be the primary medical tourism destination for individuals seeking gender reassignment . It is often easier to qualify for surgery and the cost is significantly reduced. Surgeons are performing the procedures frequently, and as a result, many have become quite specialized in them.

It is often surprising to many medical tourists that their physician was trained in the United States. Not all physicians are, of course, but a surprisingly high percentage of them working in surgery abroad are trained in English-speaking medical schools and residency programs and then return to their home country. These physicians often speak multiple languages and may be board certified in their home country and a foreign country, such as the United States.

Medical tourism isn’t limited to countries outside of the United States, either. Many people travel to the United States for medical care due to the country's cutting-edge technology, prescription medication supply, and the general safety of healthcare.

Medical Tourism Risks

The financial and practical benefits of medical tourism are well known, and you may even know someone who had a great experience. Nonetheless, the downsides of medical tourism can be just as great if not greater. Sometimes, they can even be deadly.

If you are considering a trip abroad for your procedure, you should know that medical tourism isn't entirely without obstacle and risks. These include:

Poorly Trained Surgeons

In any country—the United States included—there will be good surgeons and bad. And just as there are great surgeons abroad, there are also some surgeons who are less talented, less trained, and less experienced.

Regardless of what procedure you are getting or where, you should always do some preliminary research into the surgeon or physician who will be treating you as well as the hospital you will be treated at.

In the United States, it is fairly easy to obtain information about malpractice lawsuits , sanctions by medical boards, and other disciplinary actions against a physician.

Performing this research from afar can be challenging, especially if you don't speak the local language. Yet countless people take the risk anyway, without knowing whether the physicians who will treat them are reputable.

A physician should be trained in the specific area of medicine that is appropriate for your procedure. For example, you should not be having plastic surgery from a surgeon who was trained to be a heart doctor. It isn’t good enough to be a physician, the physician must be trained in the specialty .

Prior to agreeing to surgery, you should also know your surgeon’s credentials : where they studied, where they trained, and in what specialty(s) they are board-certified. Do not rely on testimonials from previous patients; these are easily made up for a website and even if they are correct, one good surgery doesn’t mean they will all be successful.

Quality of Staff

Nurses are a very important part of healthcare, and the care they provide can mean the difference between a great outcome and a terrible one.

A well-trained nurse can identify a potential problem and fix it before it truly becomes an issue. A poorly trained nurse may not identify a problem until it is too late. The quality of the nursing staff will have a direct impact on your care.

Once again, it's important to research the hospital staff where you will be having your procedure done. Read the reviews but don't trust them blindly. If you can, seek out a recommendation from someone who can vouch for the medical staff where you will be going.

Quality of the Facility

While researching healthcare facilities for your procedure, you want to learn not just about the quality of the facilities themselves, but about the country's healthcare system as a whole.

In some countries, there is a marked distinction between public hospitals and private hospitals. In Turkey, for example, private hospitals are considered on-par with hospitals in the states, while many locals will advise you to steer clear of public hospitals if you can.

You will also want to seek out facilities that are internationally accredited. In the United States, the Joint Commission evaluates hospitals and certifies those that provide safe, quality care. The international division does the same for hospitals outside the United States.

Once you have a few options for potential facilities, you can start to investigate specifics. For one, you should find as many pictures and reviews of the facility as you can. Ask yourself whether the facility is state of the art or whether it seems dirty and outdated.

You will also need to find out if the facility has ICU level care available, in case something goes wrong. If not, there should be a major hospital nearby so that you can be transferred quickly.

To learn more about a healthcare facility, consider joining expat groups on social media for the city or country you will be traveling to. Ask the group for recommendations, or inquire about any positive or negative experiences they may have had at a particular facility.

Flying Home After Surgery

Any surgery comes with risks, including infection and blood clots . Flying home increases the risk of blood clots, especially on long-haul flights that are longer than four hours.

Try to avoid flying home in the days immediately after surgery; waiting a week will decrease the chances of developing a blood clot or another serious complication during the flight.

For longer flights, plan on getting up and walking up and down the aisles each hour to improve blood flow in your legs. You might also benefit from wearing compression socks with your doctor's approval.

If you are taking blood thinners or are at-risk of blood clots , be sure to talk to your doctor about how you can reduce your risk of blood clots after your procedure and while traveling.

Furthermore, you should know the symptoms of blood clots and stay alert.

Unplanned Illness

Any time you travel abroad, you run the risk of catching an illness that you have never been exposed to or that your body is not prepared to fight off. This is especially a concern when spending time in a foreign hospital.

If you have a sensitive stomach, you may also want to think long and hard about having surgery abroad. The food is often very different in foreign hospitals, and in some areas, there is a risk that even the water will be upsetting to your body.

Having diarrhea or postoperative nausea and vomiting makes for a miserable recovery experience, especially if you do not have a friend or family member nearby who can help you through it.

Before you travel abroad, check with your doctor to see if you need any vaccines to travel to your destination or if there are any foreign illnesses you should be aware of. Picking up an illness abroad, particularly after your surgery, can potentially be life-threatening.

Language Barriers

If you are having surgery in a country where English is not the primary language, you will need to make preparations in order to be able to communicate with the staff.

You may be pleasantly surprised to learn that the staff speaks your primary language well. If not, then you will need to consider how you will make your wishes and needs known to the surgeon, the staff, and others you will meet.

Whether you are at home or abroad, remember to speak up and advocate for yourself to make sure your needs are met. If you don't speak the local language, download a language translation app on your smartphone and don't hesitate to use it to communicate your needs. Hiring a translator is another option.

A Word About Transplant Tourism

Transplant tourism is one area of medical tourism that is strongly discouraged by organ and tissue transplant professionals in multiple countries. Most international transplants are considered “black market” surgeries that are not only poor in quality, but ethically and morally wrong.

China, for example, the country that is believed to perform more international kidney transplants than any other country, is widely believed to take organs from political prisoners after their execution.

In India, living donors are often promised large sums of money for their kidney donation, only to find out they have been scammed and never receive payment. Selling an organ in India is illegal, as it is in most areas of the world, so there is little recourse for the donor.

Then there is the final outcome: how well the organ works after the surgery is complete. With black market transplants, less care is often taken with matching the donor and recipient, which leads to high levels of rejection and a greater risk of death. Furthermore, the new organ may not have been screened for diseases such as cytomegalovirus , tuberculosis , hepatitis B , and hepatitis C . It is often the new disease that leads to death, rather than the organ rejection itself.

Finally, transplant surgeons are often reluctant to care for a patient who intentionally circumvented the donor process in the United States and received their transplant from an unknown physician.

It is important to arrange your follow-up care prior to leaving your home country.

Many physicians and surgeons are hesitant to take care of a patient who received care outside the country, as they are often unfamiliar with medical tourism and have concerns about the quality of care overseas.

Arranging for follow-up care before you leave will make it easier to transition to care at home without the stress of trying to find a physician after surgery .

Just be sure to inform your follow-up care physician where you are having your procedure done. After you return, they will also want to know what prescription medications you were given, if any.

What are popular countries for medical tourism? 

Mexico, India, Costa Rica, Turkey, Singapore, Canada, and Thailand are among the many countries that are popular for medical tourism.

How safe is medical tourism?

Medical tourism is generally considered safe, but it's critical to research the quality of care, physician training, and surgical specialties of each country. There are several medical tourism organizations that specialize in evaluating popular destinations for this purpose.

What countries have free healthcare? 

Countries with free healthcare include England, Canada, Thailand, Mexico, India, Sweden, South Korea, Israel, and many others.

A Word From Verywell

If you are considering medical tourism, discuss the risks and benefits with your doctor, and consider working with your insurance provider to arrange a trip that balances financial savings with safety. (Also, before you embark on a trip overseas for your procedure, make sure you are financially prepared for unexpected events and emergencies. Don't go abroad if you don't have enough money to get yourself home in a crisis.)

A medical tourism organization such as Patients Without Borders can help you evaluate the quality and trustworthiness of healthcare in various countries. Making sure a high level of care is readily available will lead to a safer, more relaxing experience.

Centers For Disease Control and Prevention. Medical Tourism: Getting medical care in another country . Updated October 23, 2017.

University of the Incarnate Word. Center for Medical Tourism Research .

Patients Beyond Borders. Facts and figures .

Kaiser Family Foundation. Health coverage of immigrants . Published July 2021.

Paul DP 3rd, Barker T, Watts AL, Messinger A, Coustasse A. Insurance companies adapting to trends by adopting medical tourism . Health Care Manag (Frederick). 2017 Oct/Dec;36(4):326-333. doi: 10.1097/HCM.0000000000000179

Batista BN. State of plastic surgery in Brazil .  Plast Reconstr Surg Glob Open . 2017 Dec;5(12):1627. doi:10.1097/GOX.0000000000001627

Johns Hopkins Bloomberg School of Public Health - Global Health Now. Brazilians' risky right to beauty . Published May 2018.

Chokrungvaranont P, Selvaggi G, Jindarak S, et al. The development of sex reassignment surgery in Thailand: a social perspective .  Sci World J . 2014 Mar;2014(1):1-5. doi:10.1155/2014/182981

The Joint Commission. For consumers .

Centers for Disease Control and Prevention. Blood clots and travel: what you need to know . Reviewed February 2021.

Hurley R. China harvested organs from political prisoners on substantial scale, says tribunal . BMJ . 2018 Dec;363(1):5250. doi:10.1136/bmj.k5250

Ambagtsheer F, Van Balen L. I'm not Sherlock Holmes: suspicions, secrecy, and silence of transplant professionals in the human organ trade . Euro J Criminol . 2019 Jan;17(6):764-783. doi:10.1177/1477370818825331

Centers for Disease Control and Prevention. Transplant Surgery. Key facts . Reviewed January 2019.

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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• Section 6 - Perspectives : Avoiding Poorly Regulated Medicines & Medical Products During Travel
• Section 7 - Pregnant Travelers

Medical Tourism

Cdc yellow book 2024.

Author(s): Matthew Crist, Grace Appiah, Laura Leidel, Rhett Stoney

• Categories Of Medical Tourism

The Pretravel Consultation

Risks & complications, risk mitigation, additional guidance for us health care providers.

Medical tourism is the term commonly used to describe international travel for the purpose of receiving medical care. Medical tourists pursue medical care abroad for a variety of reasons, including decreased cost, recommendations from friends or family, the opportunity to combine medical care with a vacation destination, a preference to receive care from a culturally similar provider, or a desire to receive a procedure or therapy not available in their country of residence.

Medical tourism is a worldwide, multibillion-dollar market that continues to grow with the rising globalization of health care. Surveillance data indicate that millions of US residents travel internationally for medical care each year. Medical tourism destinations for US residents include Argentina, Brazil, Canada, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, Germany, India, Malaysia, Mexico, Nicaragua, Peru, Singapore, and Thailand. Categories of procedures that US medical tourists pursue include cancer treatment, dental care, fertility treatments, organ and tissue transplantation, and various forms of surgery, including bariatric, cosmetic, and non-cosmetic (e.g., orthopedic).

Most medical tourists pay for their care at time of service and often rely on private companies or medical concierge services to identify foreign health care facilities. Some US health insurance companies and large employers have alliances with health care facilities outside the United States to control costs.

Categories of Medical Tourism

Cosmetic tourism.

Cosmetic tourism, or travel abroad for aesthetic surgery, has become increasingly popular. The American Society of Plastic Surgeons (ASPS) reports that most cosmetic surgery patients are women 40–54 years old. The most common procedures sought by cosmetic tourists include abdominoplasty, breast augmentation, eyelid surgery, liposuction, and rhinoplasty. Popular destinations often are marketed to prospective medical tourists as low cost, all-inclusive cosmetic surgery vacations for elective procedures not typically covered by insurance. Complications, including infections and surgical revisions for unsatisfactory results, can compound initial costs.

Non-Cosmetic Medical Tourism

Cancer treatment.

Oncology, or cancer treatment, tourism often is pursued by people looking for alternative treatment options, better access to care, second opinions, or a combination of these. Oncology tourists are a vulnerable patient population because the fear caused by a cancer diagnosis can lead them to try potentially risky treatments or procedures. Often, the treatments or procedures used abroad have no established benefit, placing the oncology tourist at risk for harm due to complications (e.g., bleeding, infection) or by forgoing or delaying approved therapies in the United States.

Dental Care

Dental care is the most common form of medical tourism among US residents, in part due to the rising cost of dental care in the United States; a substantial proportion of people in the United States do not have dental insurance or are underinsured. Dentists in destination countries might not be subject to the same licensure oversight as their US counterparts, however. In addition, practitioners abroad might not adhere to standard infection-control practices used in the United States, placing dental tourists at a potential risk for infection due to bloodborne or waterborne pathogens.

Fertility Treatments

Fertility tourists are people who seek reproductive treatments in another country. Some do so to avoid associated barriers in their home country, including high costs, long waiting lists, and restrictive policies. Others believe they will receive higher quality care abroad. People traveling to other countries for fertility treatments often are in search of assisted reproductive technologies (e.g., artificial insemination by a donor, in vitro fertilization). Fertility tourists should be aware, however, that practices can vary in their level of clinical expertise, hygiene, and technique.

Physician-Assisted Suicide

The practice of a physician facilitating a patient’s desire to end their own life by providing either the information or the means (e.g., medications) for suicide is illegal in most countries. Some people consider physician-assisted suicide (PAS) tourism, also known as suicide travel or suicide tourism, as a possible option. Most PAS tourists have been diagnosed with a terminal illness or suffer from painful or debilitating medical conditions. PAS is legal in Belgium, Canada, Luxembourg, the Netherlands, Switzerland, and New Zealand, making these the destinations selected by PAS travelers.

Rehab Tourism for Substance Use Disorders

Rehab tourism involves travel to another country for substance use disorder treatment and rehabilitation care. Travelers exploring this option might be seeking a greater range of treatment options at less expense than what is available domestically (see Sec. 3, Ch. 5, Substance Use & Substance Use Disorders , and Box 3-10 for pros and cons of rehab tourism).

Transplant Procedures

Transplant tourism refers to travel for receiving an organ, tissue, or stem cell transplant from an unrelated human donor. The practice can be motivated by reduced cost abroad or an effort to reduce the waiting time for organs. Xenotransplantation refers to receiving other biomaterial (e.g., cells, tissues) from nonhuman species, and xenotransplantation regulations vary from country to country. Many procedures involving injection of human or nonhuman cells have no scientific evidence to support a therapeutic benefit, and adverse events have been reported.

Depending on the location, organ or tissue donors might not be screened as thoroughly as they are in the United States; furthermore, organs and other tissues might be obtained using unethical means. In 2009, the World Health Organization released the revised Guiding Principles on Human Cell, Tissue, and Organ Transplantation, emphasizing that cells, tissues, and organs should be donated freely, in the absence of any form of financial incentive.

Studies have shown that transplant tourists can be at risk of receiving care that varies from practice standards in the United States. For instance, patients might receive fewer immunosuppressive drugs, increasing their risk for rejection, or they might not receive antimicrobial prophylaxis, increasing their risk for infection. Traveling after a procedure poses an additional risk for infection in someone who is immunocompromised.

Ideally, medical tourists will consult a travel medicine specialist for travel advice tailored to their specific health needs 4–6 weeks before travel. During the pretravel consultation, make certain travelers are up to date on all routine vaccinations, that they receive additional vaccines based on destination, and especially encourage hepatitis B virus immunization for unvaccinated travelers (see Sec. 2, Ch. 3, Vaccination & Immunoprophylaxis & General Principles , and Sec. 5, Part 2, Ch. 8, Hepatitis B ). Counsel medical tourists that participating in typical vacation activities (e.g., consuming alcohol, participating in strenuous activity or exercise, sunbathing, swimming, taking long tours) during the postoperative period can delay or impede healing.

Advise medical tourists to also meet with their primary care provider to discuss their plan to seek medical care outside the United States, to address any concerns they or their provider might have, to ensure current medical conditions are well controlled, and to ensure they have a sufficient supply of all regular medications to last the duration of their trip. In addition, medical tourists should be aware of instances in which US medical professionals have elected not to treat medical tourists presenting with complications resulting from recent surgery, treatment, or procedures received abroad. Thus, encourage medical tourists to work with their primary care provider to identify physicians in their home communities who are willing and available to provide follow-up or emergency care upon their return.

Remind medical tourists to request copies of their overseas medical records in English and to provide this information to any health care providers they see subsequently for follow-up. Encourage medical tourists to disclose their entire travel history, medical history, and information about all surgeries or medical treatments received during their trip.

All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. Advise medical tourists not to delay seeking medical care if they suspect any complication during travel or after returning home. Obtaining immediate care can lead to earlier diagnosis and treatment and a better outcome.

Among medical tourists, the most common complications are infection related. Inadequate infection-control practices place people at increased risk for bloodborne infections, including hepatitis B, hepatitis C, and HIV; bloodstream infections; donor-derived infections; and wound infections. Moreover, the risk of acquiring antibiotic-resistant infections might be greater in certain countries or regions; some highly resistant bacterial (e.g., carbapenem-resistant Enterobacterales [CRE]) and fungal (e.g., Candida auris ) pathogens appear to be more common in some countries where US residents travel for medical tourism (see Sec. 11, Ch. 5, Antimicrobial Resistance ).

Several infectious disease outbreaks have been documented among medical tourists, including CRE infections in patients undergoing invasive medical procedures in Mexico, surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic, and Q fever in patients who received fetal sheep cell injections in Germany.

Noninfectious Complications

Medical tourists have the same risks for noninfectious complications as patients receiving medical care in the United States. Noninfectious complications include blood clots, contour abnormalities after cosmetic surgery, and surgical wound dehiscence.

Travel-Associated Risks

Traveling during the post-operative or post-procedure recovery period or when being treated for a medical condition could pose additional risks for patients. Air travel and surgery independently increase the risk for blood clots, including deep vein thrombosis and pulmonary emboli (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism ). Travel after surgery further increases the risk of developing blood clots because travel can require medical tourists to remain seated for long periods while in a hypercoagulable state.

Commercial aircraft cabin pressures are roughly equivalent to the outside air pressure at 6,000–8,000 feet above sea level. Medical tourists should not fly for 10 days after chest or abdominal surgery to avoid risks associated with changes in atmospheric pressure. ASPS recommends that patients undergoing laser treatments or cosmetic procedures to the face, eyelids, or nose, wait 7–10 days after the procedure before flying. The Aerospace Medical Association published medical guidelines for air travel that provide useful information on the risks for travel with certain medical conditions.

Professional organizations have developed guidance, including template questions, that medical tourists can use when discussing what to expect with the facility providing the care, with the group facilitating the trip, and with their own domestic health care provider. For instance, the American Medical Association developed guiding principles on medical tourism for employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States ( Box 6-07 ). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism, with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to providers in the United States, which can facilitate continuity of care and proper follow-up, if needed.

Box 6-07 American Medical Association’s guiding principles on medical tourism 1

• Employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States should adhere to the following principles:
• Receiving medical care outside the United States must be voluntary.
• Financial incentives to travel outside the United States for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients or restrict treatment or referral options.
• Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
• Prior to travel, local follow-up care should be coordinated, and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
• Coverage for travel outside the United States for medical care should include the costs of necessary follow-up care upon return to the United States.
• Patients should be informed of their rights and legal recourse before agreeing to travel outside the United States for medical care.
• Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
• The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
• Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.

1 American Medical Association (AMA). New AMA Guidelines on Medical Tourism . Chicago: AMA; 2008.

Reviewing the Risks

Multiple resources are available for providers and medical tourists assessing medical tourism–related risks (see Table 6-02 ). When reviewing the risks associated with seeking health care abroad, encourage medical tourists to consider several factors besides the procedure; these include the destination, the facility or facilities where the procedure and recovery will take place, and the treating provider.

Make patients aware that medical tourism websites marketing directly to travelers might not include (or make available) comprehensive details on the accreditations, certifications, or qualifications of advertised facilities or providers. Local standards for facility accreditation and provider certification vary, and might not be the same as those in the United States; some facilities and providers abroad might lack accreditation or certification. In some locations, tracking patient outcome data or maintaining formal medical record privacy or security policies are not standard practices.

Medical tourists also should be aware that the drugs and medical products and devices used in other countries might not be subject to the same regulatory scrutiny and oversight as in the United States. In addition, some drugs could be counterfeit or otherwise ineffective because the medication expired, is contaminated, or was improperly stored (for more details, see the previous chapter in this section, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel ).

Table 6-02 Online medical tourism resources

Checking credentials.

ACS recommends that medical tourists use internationally accredited facilities and seek care from providers certified in their specialties through a process equivalent to that established by the member boards of the American Board of Medical Specialties. Advise medical tourists to do as much advance research as possible on the facility and health care provider they are considering using. Also, inform medical tourists that accreditation does not guarantee a good outcome.

Accrediting organizations (e.g., The Joint Commission International, Accreditation Association for Ambulatory Health Care) maintain listings of accredited facilities outside of the United States. Encourage prospective medical tourists to review these sources before committing to having a procedure or receiving medical care abroad.

ACS, ASPS, the American Society for Aesthetic Plastic Surgery, and the International Society of Aesthetic Plastic Surgery all accredit physicians abroad. Medical tourists should check the credentials of health care providers with search tools provided by relevant professional organizations.

Travel Health Insurance

Before travel, medical tourists should check their domestic health insurance plan carefully to understand what services, if any, are covered outside the United States. Additionally, travelers might need to purchase supplemental medical insurance coverage, including medical evacuation insurance; this is particularly important for travelers going to remote destinations or places lacking medical facilities that meet the standards found in high-income countries (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ). Medical tourists also should be aware that if complications develop, they might not have the same legal recourse as they would if they received their care in the United States.

Planning for Follow-Up Care

Medical tourists and their domestic physicians should plan for follow-up care. Patients and clinicians should establish what care will be provided abroad, and what the patient will need upon return. Medical tourists should make sure they understand what services are included as part of the cost for their procedures; some overseas facilities and providers charge substantial fees for follow-up care in addition to the base cost. Travelers also should know whether follow-up care is scheduled to occur at the same facility as the procedure.

Health care facilities in the United States should have systems in place to assess patients at admission to determine whether they have received medical care in other countries. Clinicians should obtain an explicit travel history from patients, including any medical care received abroad. Patients who have had an overnight stay in a health care facility outside the United States within 6 months of presentation should be screened for CRE. Admission screening is available free of charge through the Antibiotic Resistance Laboratory Network .

Notify state and local public health as soon as medical tourism–associated infections are identified. Returning patients often present to hospitals close to their home, and communication with public health authorities can help facilitate outbreak recognition. Health care facilities should follow all disease reporting requirements for their jurisdiction. Health care facilities also should report suspected or confirmed cases of unusual antibiotic resistance (e.g., carbapenem-resistant organisms, C. auris ) to public health authorities to facilitate testing and infection-control measures to prevent further transmission. In addition to notifying the state or local health department, contact the Centers for Disease Control and Prevention at [email protected] to report complications related to medical tourism.

The following authors contributed to the previous version of this chapter: Isaac Benowitz, Joanna Gaines

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Pavli A, Maltezou HC. Infectious complications related to medical tourism. J Travel Med. 2021;28(1):taaa210.

Pereira RT, Malone CM, Flaherty GT. Aesthetic journeys: a review of cosmetic surgery tourism. J Travel Med. 2018;25(1):tay042.

Robyn MP, Newman AP, Amato M, Walawander M, Kothe C, Nerone JD, et al. Q fever outbreak among travelers to Germany who received live cell therapy & United States and Canada, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(38):1071–3.

Salama M, Isachenko V, Isachenko E, Rahimi G, Mallmann P, Westphal LM, et al. Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review). J Assist Reprod Genet. 2018;35(7):1277–88.

Schnabel D, Esposito DH, Gaines J, Ridpath A, Barry MA, Feldman KA, et al. Multistate US outbreak of rapidly growing mycobacterial infections associated with medical tourism to the Dominican Republic, 2013–2014. Emerg Infect Dis. 2016;22(8):1340–7.

Stoney RJ, Kozarsky PE, Walker AT, Gaines JL. Population-based surveillance of medical tourism among US residents from 11 states and territories: findings from the Behavioral Risk Factor Surveillance System. Infect Control Hosp Epidemiol. 2022;43(7):870–5.

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Medical Tourism

The allure of american healthcare: an overview of inbound medical tourism to the united states.

Inbound medical tourism to the United States has been growing rapidly in recent years, as more and more foreign patients seek high-quality medical care in the world's leading economy. According to a report by Patients Beyond Borders, the US is the top destination for inbound medical tourism, attracting more than 1.4 million patients annually and generating over $14 billion in revenue. In this article, we'll explore the benefits and challenges of inbound medical tourism to the US, the most popular procedures and destinations, and the impact of COVID-19 on the industry.

Benefits of Inbound Medical Tourism to the United States

Inbound medical tourism to the US has several benefits for both healthcare providers and foreign patients. For healthcare providers, it can generate significant revenue and boost their reputation in the global medical community. For foreign patients, it provides access to high-quality medical care that may not be available or affordable in their home countries.

One of the biggest advantages of inbound medical tourism to the US is the high level of quality and safety in American healthcare. The US is home to some of the most prestigious hospitals, medical centers, and healthcare professionals in the world, with cutting-edge technology and a focus on patient-centered care. Foreign patients are attracted to the US for medical treatment because of the reputation of American healthcare, and many choose to return for follow-up care or other medical procedures.

Challenges of Inbound Medical Tourism to the United States

While inbound medical tourism to the US has many benefits, it also presents several challenges. Healthcare providers and destinations need to be aware of these challenges in order to attract and accommodate foreign patients successfully.

One of the biggest challenges is the cost of medical care in the US, which can be significantly higher than in other countries. Foreign patients may be willing to pay more for high-quality medical care, but they still need to be able to afford the procedures they require. Healthcare providers need to be able to offer competitive pricing while still maintaining their quality standards.

Another challenge is the complexity of the US healthcare system, which can be difficult for foreign patients to navigate. Healthcare providers and destinations need to be able to provide clear and concise information about their services, pricing, and procedures to foreign patients in their native languages. They also need to be able to offer support and assistance throughout the entire process, from booking appointments to follow-up care.

Popular Procedures and Destinations for Inbound Medical Tourism to the United States

Inbound medical tourism to the US covers a wide range of medical procedures and destinations. According to Patients Beyond Borders, the most popular procedures for foreign patients in the US are:

• Cancer treatment
• Cosmetic surgery
• Orthopedics

The most popular destinations for inbound medical tourism to the US include:

The Impact of COVID-19 on Inbound Medical Tourism to the United States

The COVID-19 pandemic has had a significant impact on inbound medical tourism to the US, with many foreign patients unable or unwilling to travel due to travel restrictions and health concerns. According to a report by Global Healthcare Resources, inbound medical tourism to the US dropped by more than 60% in 2020 due to the pandemic.

However, as vaccination rates increase and travel restrictions are lifted, there is hope that inbound medical tourism to the US will rebound in the coming months and years. Healthcare providers and destinations need to be prepared to adapt to the new normal of the post-COVID world, with enhanced safety protocols, telemedicine services, and other measures in place to ensure the safety and well-being of both foreign patients and healthcare professionals.

Working with Global Healthcare Resources to Attract More Foreign Patients to the US

If you're a healthcare provider or destination looking to attract more foreign patients to the US for medical treatment, working with a healthcare consulting firm like Global Healthcare Resources can help you navigate the complex world of inbound medical tourism.

Global Healthcare Resources offers a wide range of consulting services for healthcare providers and destinations, including market research, business planning, marketing and management, and more. With our expertise and experience in the inbound medical tourism industry, we can help you attract more foreign patients, enhance your reputation, and generate more revenue for your healthcare services.

Inbound medical tourism to the United States is a growing industry with many benefits for both healthcare providers and foreign patients. While it presents several challenges, healthcare providers and destinations can overcome these challenges by offering competitive pricing, clear and concise information, and high-quality medical care and services. With the help of a healthcare consulting firm like Global Healthcare Resources, healthcare providers and destinations can tap into the lucrative inbound medical tourism market and succeed in the global healthcare industry.

If you're interested in learning more about how Global Healthcare Resources can help you attract more foreign patients to your healthcare destination or services, visit our website at https://www.globalhealthcareresources.com/medical-tourism-consulting . Contact us today to learn more about our consulting services and how we can help you tap into the growing inbound medical tourism market in the US.

Exploring the Surge of Cosmetic Tourism: Trends and Considerations in Aesthetic Procedures Abroad

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The Medical Tourism Magazine (MTM), known as the “voice” of the medical tourism industry, provides members and key industry experts with the opportunity to share important developments, initiatives, themes, topics and trends that make the medical tourism industry the booming market it is today.

The Rise of Medical Tourism

• Medical tourism is a new term but not a new idea. Patients have long traveled in search of better care. Today, constraints and long waiting lists at home, as well as the ease of global travel, make medical tourism more appealing.
• Superior medical schools, a low cost of living, family preferences, and the barriers to foreign accreditation mean that Indian doctors may prefer to work in India rather than elsewhere.
• The medical services industry is evolving quickly. Khanna expects to see dynamics in China similar to those in India and in other parts of Southeast Asia.

What used to be rare is now commonplace: traveling abroad to receive medical treatment, and to a developing country at that.

So-called medical tourism is on the rise for everything from cardiac care to plastic surgery to hip and knee replacements. As a recent Harvard Business School case study describes, the globalization of health care also provides a fascinating angle on globalization generally and is of great interest to corporate strategists.

"Apollo Hospitals—First-World Health Care at Emerging-Market Prices" explores how Dr. Prathap C. Reddy, a cardiologist, opened India's first for-profit hospital in the southern city of Chennai in 1983. Today the Apollo Hospitals Group manages more than 30 hospitals and treats patients from many different countries, according to the case. Tarun Khanna, a Harvard Business School professor specializing in global strategy, coauthored the case with professor Felix Oberholzer-Gee and Carin-Isabel Knoop, executive director of the HBS Global Research Group.

The medical services industry hasn't been global historically but is becoming so now, says Khanna. There are several reasons that globalization can manifest itself in this industry:

• Patients with resources can easily go where care is provided. "Historically doctors moved from Africa and India to London and New York to provide care. Now we are basically flipping it around and saying, 'Why don't the patients move? It's not as difficult as it used to be.' "
• High quality care, state-of-the-art facilities, and skilled doctors are available in many parts of the world, including in developing countries.
• Auxiliary health-care providers such as nurses go where care is needed. Filipino nurses provide an example, perhaps.

"From a strategic point of view you can move the output or the input," explains Khanna. "Applying this idea to human health care sounds a bit crude, but the output is the patient, the input is the doctor. We used to move the input around, and make doctors go to new locations outside their country of origin. But in many instances it might be more efficient to move the patients to where the doctors are as long as we are not compromising the health care of the patients."

Khanna recently sat down with HBS Working Knowledge to discuss the globalization of health care in the context of India and Apollo Hospitals.

Q: What led you to research and write this case?

A: I came across the company during some of my travels in South India. It was so unusual to find "first-world health care at emerging-market prices" as the case says. Often better care—by which I mean technologically first-rate care with far greater "customer service" and accessibility—is available in parts of India than in my neighborhood in Boston.

Felix Oberholzer-Gee, Carin-Isabel Knoop, and I decided to write the case just because health care is such a primal thing—it arouses a lot of emotions and insecurities. After all, it's one's life and health that one is dealing with. And the prospect of entrusting health care to a developing country had a pedagogical "shock value," too.

“A lot of entrusting medical care to different locations is about a psychological fear of the unknown.”

For a long time I've been interested in studying world-class companies in developing countries. For me and my colleague Krishna Palepu, India has served as an intellectual laboratory. So I've always been anecdotally aware of the possibility that people could benefit from India's soft assets, so to speak. In this case that means skilled health-care professionals—doctors, nurses, technicians, etc. The fact that the cost of living is so much lower in India means that the same service is possible at a fraction of the price elsewhere. For most routine issues, as well as invasive procedures that are routine, I see no reason why more people would not go to India.

Q: The term "medical tourism" is fairly new, but how new is the phenomenon of going overseas for medical treatment?

A: When I was a college student in the United States I discovered that dental care was very expensive. Even back then, many of my international classmates essentially engaged in medical tourism—they would simply bundle up the care they needed, make a trip to their country of origin, and take care of it. India was certainly one of those countries I was aware of due to my own personal background.

We didn't have a term for medical tourism, but in a sense it was all around us. It took a set of entrepreneurs to begin to make it happen. By the late 1990s, when I was teaching courses in global strategy, some of my Thai, Malaysian, and Singaporean students were perfectly aware of the term, because these countries of Southeast Asia already had very good tertiary-care hospitals.

Medical tourism usually refers to the idea of middle-class or wealthy individuals going abroad in search of effective, low-cost treatment. But there is another dimension of medical tourism that is not called medical tourism. Narayana Hrudayalaya, a heart hospital in India [see article ], treats indigent people from neighboring countries—Pakistan, Bangladesh, Burma—who suffer from heart disease and can't afford surgery. Treatment for them is free. The hospital is able to provide it because surgical methods are efficient enough that pro bono care doesn't hurt the bottom line.

Q: Why is India gaining prominence for medical tourism?

A: India is encouragingly less "scary" now. I think a lot of entrusting medical care to different locations is about a psychological fear of the unknown. An important strategic challenge for developing-country hospitals is to reduce the psychological fear.

In addition, India is rising because there's just a ton of very well-trained doctors just like there is a ton of well-trained engineers. Over the decades, many engineers have relocated to Silicon Valley, but for doctors it remains the case that barriers to entering the U.S. medical profession are still large.

In India, the same depth of pool of engineering and mathematical talent for software, offshoring, and outsourcing is there for medicine, too. In the 1950s and '60s, the Indian government invested a lot in tertiary education. By now there is at least a small handful of medical institutes that are really first-rate, and the doctors they produce are extremely well trained.

When my colleagues and I began to research this case, some other countries had already stolen a march on India—Singapore, and Malaysia in particular, and areas of the Middle East—yet there was still a lot of room for growth. India has had a unique competitive advantage as a result of this deeper pool of technical knowledge and the fact that it is simply a large country and has more people.

I would expect to see dynamics in China similar to what is happening in other parts of Southeast Asia. China frequently makes the news for stem cell therapies that are not allowed in the West. So while I think India has some unique features it is not strictly unique.

Q: What are the recruiting challenges for staffing these hospitals with doctors?

A: In the case, Dr. Prathap C. Reddy, the founder and chairman of Apollo Hospitals, says he spent a lot of time studying specialists almost like an executive search firm would, to identify their pleasure points and pain points in terms of building a successful practice in the West and potentially in India. He wanted to understand not just medical training and specialties but also family circumstances, since it is always a family decision to relocate.

In the past, Indian doctors left India so they could multiply their incomes. But now we're seeing the reversal of that. India is booming so why leave, and by the way, patients can go there.

As the case describes, accreditation is a pretty huge barrier for doctors going abroad. Just as Dr. Reddy had to spend time convincing the Indian government that the idea of medical tourism was a good use of national resources, when we wrote the case he was in the process of convincing various countries that similar development made sense. So it's a tricky public policy issue.

Q: How does growth in private hospitals affect public health care in India?

A: There is an assumption in the view often expressed in the media in India and Europe, for instance, that when private hospitals in India provide care to heart patients from England, the hospitals are somehow taking care away from poor people in India. The assumption seems to be that if medical tourism was banned, the doctors in question who were catering to wealthy patients would suddenly, as a practical matter, move to a village. It takes a different set of individuals, a different set of infrastructure circumstances to create that scenario. We need good scholarship to verify the idea that there is a potential substitution between caring for sick people from England and providing medication for malaria in an Indian village. I'm not aware of such analysis yet.

My guess is that the bulk of India's problem is primary health, and has nothing to do with tertiary care. And the primary health problem is not going to be addressed by a private hospital for the most part anyway. These are almost different industries. If someone analyzes the landscape and discovers that there is substitution between care, then there is a real public policy issue that needs to be debated.

Q: How are marketing strategies evolving?

A: My observations are that medical tourism is promoted much more heavily in the United Kingdom than in the United States. Public interest in Britain is in the context of the National Health Service and its constraints. Initially the rules required that patients be treated only in the United Kingdom. I believe there has been a gradual relaxation in these rules, so that some care can be provided within some EU countries. I know that various Indian hospitals are continually attempting to get accredited to perform certain procedures.

What is striking is that in London medical tourism makes the front page of newspapers. People ranging from generals in the British Army to politicians to blue-collar workers are quoted, all saying, in effect, "I had a great time, and now I'm well." The most common treatments seem to be for cardiovascular issues, bone-related issues such as hip replacements, and general age-related issues. Most of these articles depict people going to India, but they almost never profile an Indian going to India. They profile a wide spectrum of citizens, not just British citizens of Indian or Asian origin.

Q: For-profit hospitals around the world have been associating with well-regarded U.S. medical schools and clinics. How can Apollo Hospitals differentiate itself from growing competition?

A: What is happening now is the normal evolution of an industry, and these hospital companies are all trying to figure out what their angle will be.

I certainly don't think affiliating with a medical school or clinic in the West is a panacea. We will see solutions emerge that have nothing to do with the West and that specialize in particular kinds of care where the West may not even have much competence: tropical diseases in Southeast Asia and Africa, for instance. On the other hand, you might see very interesting links between particular companies, research institutes, and hospitals in different parts of the world—in the Middle East, Europe, the United States. My guess is that 3 or 4 prominent hospital companies will survive because the demand is so huge.

At the end of the day we all ought to celebrate the development of these hospitals, because a lot of people who would have to wait in pain for 8 months for a hip replacement can get it tomorrow, at much lower expense. People with excruciating dental pain can get it fixed, cost effectively, much quicker. And patients who need a kidney transplant and have to be on dialysis can get attention sooner. As always there are challenges, but from humanity's standpoint we ought to celebrate.

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COVID-19: how can travel medicine benefit from tourism’s focus on people during a pandemic?

Irmgard l. bauer.

College of Healthcare Sciences, Academy - Tropical Health and Medicine, James Cook University, Townsville, QLD 4811 Australia

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In 2020, COVID-19 affected every aspect of life around the globe. The spread of SARS-CoV-2 through travel led to lockdowns, travel bans and border closures, crippling the tourism industry. Without tourists, there would be no tourism industry—and no travel medicine. Therefore, scholars started to research the human aspect of tourism immediately to develop strategies for economic recovery. The resulting insights are useful for travel medicine not only to see how tourism dealt with a medical crisis but also to understand travellers better who may be seeking health advice during and after a pandemic.

This article presents tourism research of 2020 covering risk perception and travel intentions including mass-gatherings, the use of technology to protect from infection, impacts on tourism workers, residents’ reactions to potentially infected travellers, discrimination, and racism. A potential fork in the road to tourism’s future may have implications for travel health practitioners. Research recommendations conclude the paper. Understanding the industry response during the early days of panic and uncertainty may help prepare not only appropriate guidelines for travellers but also clearer instructions for tourism, transportation, and hospitality in anticipation of the next pandemic.

Introduction

In November 2019, cases of a pneumonia of unknown cause appeared in Wuhan/China, reported to the World Health Organisation (WHO) on 31 December. Early January 2020, the virus SARS-CoV-2 was isolated. On 12 February, the WHO named the resulting disease COVID-19, declaring it a global pandemic on 11 March. From early 2020, publication floodgates opened from many medical specialties (PubMed on 6 July 2021 for ‘COVID-19’ yielded 150,445, six months later 213,484 results). Early health advice for the public, ‘personal non-pharmaceutical protection interventions (PNPIs)’, included cough and sneeze etiquette, self-isolation, avoiding contact/touch, social distancing, hand hygiene, mask wearing, all reasonable textbook instructions many of which were only feasible in affluent countries. From major outbreaks in China and Italy, the virus spread around the world. Travel, a key facilitator of the spread, was first restricted and then prohibited nationally and internationally in many countries via suspension of visa-on-arrival policies, travel restrictions/bans and closed borders. Not always was the relationship between health and politics harmonious or directives aligned.

Media coverage and social media posts during a crisis influence risk perceptions and travel intentions [ 1 , 2 ]. From the start, WHO alerted to a massive ‘infodemic’, an over-abundance of correct and false messages making it difficult for people to extract useful information, and attempted to debunk myths with accurate information on social media and collaborate with platforms to mitigate the damage [ 3 ]. This attempt was unsustainable and unrealistic considering the volume of data and skills necessary to spot the difference [ 4 ]. It was difficult to agree on what was reality and what were ‘alternative facts’ or strategic misinformation. COVID-19-misinformation has been deplored in medicine, where it provides the ideal ground for anti-science groups to the point of influencing government policy or being spruiked by political leaders [ 5 ]. Anti-vaxxer Facebook posts created doubt about COVID-19-vaccines long before vaccines existed, based on mistrust in the pharmaceutical industry, misinformation and conspiracy theories [ 6 ]. In tourism, misinformation became a serious issue for travellers, such as changes in risk perception or questioning public health measures, and residents, including the rise of racial discrimination [ 7 , 8 ].

The traveller, who is potentially spreading the virus or being exposed to it, is part of the tourism industry. How did tourism respond to the emerging medical crisis? For a for-profit industry (as for stand-alone travel clinics), a downturn in travel is devastating. All global regions experienced a decrease in international arrivals, e.g., Europe and Africa by 85%, Asia and Pacific by 96% [ 9 ]. In the US alone, the pandemic led to $645 billion in cumulative losses for the travel economy through March 2021 [ 10 ], costing the US economy 41.1 trillion in economic output [ 11 ]. Forecasts and potential recovery strategies responded quickly [ 12 – 14 ]. However, to plan for a post-pandemic future, the tourism and hospitality sector had to look not only at balance sheets but focus more than ever on the heart of the industry, the travelling public, employees and residents, to understand their response, concerns and perceptions regarding current and future travel decisions. Many questions arise, for example, how tourism cooperates with health authorities and receives, responds and implements health directives, how the accommodation and food industry executes instructions, how the industry trains staff to be COVID-19-safe, how it looks after expats and local employees, and how these measures are communicated to instil trust in all involved. Furthermore, and directly important for travel medicine, what are travellers’ perceptions of the pandemic? How has travellers’ interest and confidence in travel been affected by constantly and rapidly changing, often perplexing, directives that were different for the same situation in different countries?

Medicine published on COVID-19 right away – and so did tourism academia. While travel medicine uses the combined evidence of several medical specialties to care for the health and wellbeing of travellers, tourism is much better in understanding them. Therefore, it is useful to take advantage of this knowledge to inform travel medicine and travel health clinicians’ work now and in the post-pandemic future. This article presents and discusses tourism research conducted over the first year of COVID-19 as it relates to people involved in the industry: travellers, employees and residents at destinations, the very population that is travel medicine’s focus of care.

At the time of the literature search (July 2021), the Scimago Journal & Country Rank site listed 123 academic tourism and hospitality journals. Starting with the top-ranked journals (from IP 10.982) and descending the list, ‘COVID’ was entered into English-language journals’ search engine. The search covered all papers published in 2020 with a focus on people. Later advance publications were added if data were collected in 2020. Excluded were papers on industry economics, e.g., forecasts, business, and management. This article starts with a general assessment of the targeted literature before addressing individual themes.

Tourism literature’s focus on people in COVID-19 times

It is fascinating to witness the start of an entirely new thread of literature triggered by a novel topic of concern (see AIDS-literature in the 1980s). As soon as SARS-CoV-2 used travel to spread, the tourism industry responded to a threat that could devastate an entire industry. Rapidly designed research started as early as February 2020. Most papers present original research utilising social science or econometric methods and are highly complex, testing often more than ten hypotheses with the subsequent complex statistical analyses and presentation. Using mainly online surveys due to restrictions, the samples are large and comprehensive, resulting typically in an intricate network of causal relationships between variables. This much detail may be of no direct use to clinicians, but the overall trends give meaningful insights and inform travel health advice. Apart from references to the WHO, there are few cited medical sources; no paper was co-authored by health and tourism practitioners or scholars. Many studies originate in the Far East or in countries with high COVID-19 burden. Due to the delay between acceptance and publication, some statements are now outdated. Authors at the time could not foresee the duration of the pandemic, and one needs to think back to the early months of bewilderment and uncertainty when vaccination and the many attempts ‘to return to normality’ were unknown. As all authors had the same starting line, publications started independently without cross-referencing until later in the year. From 1 May 2020, the author guidelines of the high-profile Journal of Travel Research stipulated that submissions ‘must not ignore the effect of COVID-19’ [ 15 ]. An early warning to expect a COVID-19 research paper ‘tsunami’ prompted the call for a system-based research approach [ 16 ]. Lacking such a structure, papers presented here are organised into thematic clusters starting with risk perception and travel intentions including mass-gatherings, the use of technology to minimise infection, the impact of the pandemic on hospitality employees, residents’ reaction to travellers, hostility and discrimination, and a look into the future of tourism. Research recommendations for travel medicine, as they emerge from the tourism literature, conclude this discussion.

The traveller – To travel or not to travel

Without tourists, there is no tourism. The rapidly evolving existential threat to the industry within the context of global bewilderment triggered studies focusing strongly on (potential) travellers. Researchers’ differing academic backgrounds guided the choice of research questions, resulting in a wide range of topics. These can be categorised into aspects out of people’s control and those where travellers play an active role.

Being subject to outsider-control and disallowed the freedom of movement one is accustomed to, impacts mental wellbeing [ 17 ], in line with the exceptionally diverse psychology of pandemics [ 18 ]. Denied mobility, the ‘lockdown captivity phenomenon’[ 19 ] and ‘travel craving’[ 20 ] have been studied in Italy and Hungary in May/June, while an analysis of National Geographic promoted Instagram posts in April demonstrated a marked change in expression of personal experience and skills, social facets and in lifestyle [ 21 ]. In the pre-travel stage, in April, sentiment analysis on over 600 Italian online posts showed customer concern with airline cancellation and compensation, but also the much-unexpected result that a rise in COVID-19-deaths, not cases, increased empathy with struggling airlines [ 22 ]. In February, three US-studies demonstrated that the threat of infection decreased the willingness to accept price inequalities [ 23 ].

Other aspects can be controlled by travellers: the avoidance of crowding [ 24 ], or a willingness to pay for enhanced safety measures [ 25 – 28 ]. Most importantly, adherence to PNPIs lies very much with the individual. End of April, of over 400 Kosovar, 90% planned to travel to Albania that summer. At the time, 15% did not follow strict health ministry directives, 25% sometimes to never socially distanced, while 28% sometimes to never wore masks appropriately around others [ 29 ]. In the US, men were more likely to refuse masks for international travel [ 30 ]. In China, more women adhered to pro-social behaviour [ 31 ]. A far greater area of research covers people’s risk perception and subsequent intentions to travel during and after the pandemic.

Risk perception and travel intentions

The notion of the ‘crisis-resistant tourist’ who ‘travels despite’ or ‘not cancels because of’ crises, but does not risk-shift, i.e., take out travel insurance more than others [ 32 ] may help appreciate the following results. Because of the economic impact of reduced/cancelled travel, border closures and lockdowns, the industry is keen to understand potential travellers to be able to develop strategies to get people travelling again. First, it is especially important to appreciate people’s perception of risk during a pandemic.

Risk perception

Travel medicine is interested in risk perception (274 hits in Journal of Travel Medicine and 134 hits in Travel Medicine and Infectious Disease , 22 Dec 2021) because it influences decisions to visit a travel clinic, destination and behaviour choices, and subsequent adherence (or not) to health advice. For tourism, risk perception influences business decisions to secure profits. In contrast to real risk, perceived health risks are based on cognitive, affective, individual and contextual components and, therefore, subjective [ 33 ], influenced, for example, by the media [ 1 , 2 , 34 ]. In the first four months of the pandemic, media coverage influenced risk perception in Korea more than case numbers [ 35 ]. In two secondary data analyses from Hong Kong combined with four original US-surveys ( n  = 744), the perceived threat of infection increased the tendency to avoid extreme travel options [ 36 ]. A South African survey (May/June) of 323 potential tourists from Africa, Europe and Asia assessed psychographic factors: dogmatic, sceptical and apprehensive, depending on risk perception and level of caution [ 37 ]. Important for travel medicine, dogmatic tourists may not follow risk mitigation measures. Over 1000 Indian travellers perceived risk differently depending on their fear of infection. Women, married and older travellers saw COVID-19 as more severe and adopted PNPIs more readily. While education made no difference in risk perception, higher education levels increased PNPIs usage. People on lower incomes and travellers for work and education were less willing to implement such measures [ 38 ]. Surveys in Germany, Austria and Switzerland ( n  = 1370) before and immediately after the WHO-proclamation demonstrated relative low concern about COVID-19 before but strong increase in risk perception after, viewing as irresponsible business trips and travel to destinations with cases. Contact with tourists in one’s hometown were to be avoided [ 39 ]. Mothers avoided business trips to protect their family from potential infection [ 40 ].

Consumer distrust in hotel hygiene standards existed before, based on the assumption that service providers act negligently and incompetently [ 41 ]. Almost 99,000 Chinese hotel reviews of all 185 five-star hotels in Shanghai demonstrated a shift in consumer preferences beyond hygiene expectations. Breakfast, location and surroundings lost importance while in-hotel, in-room experience, service, cleanliness and front desk gained importance due to the ‘cocooning’, i.e. staying in hotel rooms for one’s own safety [ 42 ]. Staying in ‘love hotels’ in Ho Chi Minh City rather than tourist hotels appeared less risky, possibly because of less crowding and low tourist contact [ 43 ].

End of 2020, US restaurant and hotel customers ( n  = 809) were reluctant to eat in sit-down restaurants, wanted visible evidence of sanitising efforts and accepted technology and robots [ 25 ]. A comprehensive exploration of tourists’ risk perception of COVID-19 proposed a conceptual model to interpret and explain travellers’ behaviour patterns. The section on risk included the obvious health and psychological risks as well as social risks (disapproval of one’s travel plans), performance risk (not receiving expected service), image risk (stigma of a location), and time risk (time-related costs, quarantine) [ 44 ].

For tourism and travel medicine, it may be important to consider shifting the public’s concentration on risk avoidance to risk management [ 45 ]. Normally, travel insurance provides some reassurance in case of misfortune. However, most insurer policies exclude pandemics and known events, and travellers were unable to purchase cover when they most needed it, leading to a ‘reverse moral hazard effect’, i.e., a reluctance for future travel. Yet, insurers need to exclude catastrophic events to remain solvent [ 46 ]. Willingness to pay (WTP) for perceived or actual better service/goods is a well-known tourism concept, which also emerged during the pandemic. WTP related to the expectation of particularly stringent health measures on transport, in restaurants and accommodation, for example, in Italy where, however, WTP was lower in regions with COVID-19 [ 28 ]. Because high adherence to hygiene measures was expected, no WTP was evidenced in Spain, especially when there was a strong intention to travel [ 47 ]. To manage risk, apart from WTP for superior crisis management, some type of travel allows crowd avoidance, for example, camping [ 27 ] or a ‘safe’ destination, e.g., geological sites in Oman [ 48 ]. To enable the public assessing a location’s safety from epidemics as part of travel preparations, a ‘country-level index of epidemiological susceptibility risk’ was proposed built on health infrastructure, demographics, environmental safety infrastructure, economic activity, communications infrastructure and governance institutions [ 49 ]. The onus would be on tourists to assess if the chosen destination can deal with potential risks adequately – a formidable task. It is unclear who was to compile this index, especially in poor countries. Regardless how this risk is perceived, what counts for travel medicine and tourism is the public’s actual plan to travel.

Travel intentions

Intentions differ from desire as they are perceived as more realistically ‘do-able’ within a firm timeframe [ 50 ]. At the time of data collections, as everybody else, neither researchers nor study participants knew how long this pandemic would last or if there was a clear end. Nobody knew of the varying individual and global policies and travel bans or about potential vaccines. Therefore, people’s travel intentions could not always be classified clearly as during, post-pandemic or loosely ‘sometime later’, nuances usually lost in quantitative data. Interviews with potential travellers and tourism professionals in Western Australia formed the basis for a motivator-demotivator approach to travel during COVID-19. Motivators were needs for mental wellbeing and social connectedness including personal growth and relaxation. Demotivators consisted of health and safety risks including the level of perceived competence of authorities to handle the crisis [ 51 ].

In Greece, travel was unlikely not because of COVID-19 but lack of funds [ 52 ]. In Italy – as in Egypt [ 53 ] – trust in responsible provision of safety protocols influenced travel plans [ 28 ]. In May, among 1144 18–90-year-old Italians, age influenced vacation preferences [ 54 ]. In the same month, students and workers in Macau reduced their travel intentions but felt safe due to strict policies; however, tourists were urged to stay away [ 55 ]. In contrast, in India, intended travel did not necessarily mean adoption of PNPIs [ 38 ]. Unexpectedly, in June, Spanish data suggested that living in an area with worse case numbers and having personal experience with the disease, increased plans to travel this very summer, especially in men and those very concerned about the pandemic. Adhering to health rules, such travel may be mentally beneficial [ 56 ]. Some intended travel leads to the accumulation of large numbers of people, for example, travelling on cruise liners or gathering for religious or cultural festivals.

Mass-gatherings

The close distance between people and their mingling at large gatherings provides the perfect scenario for ‘super-spreader’ events.

One such example are ocean liners where large numbers of passengers are inescapably confined by the perimeter of the vessel. The unfortunate outcome revealed itself in the dramatic events on cruise ships early in the pandemic. On 1 February, a passenger leaving the Diamond Princess earlier in Hong Kong tested positive. The ship arrived in Japanese waters on 3 February, and 3711 passengers and crew were quarantined [ 57 ]. On 19 March, 2650 passengers disembarked the Ruby Princess in Sydney before COVID-19 test results were known, to avoid missing connecting domestic and international flights. This mishandling became the single largest source of Australia-wide infections [ 58 ] resulting in over 900 cases around the country and 28 deaths [ 59 ]. Especially frightening for the public were the rapid deaths, the first on 24 March. On 15 March, four days after the WHO declared a pandemic, and while companies cancelled cruises and ships at sea were denied access to ports, the Australian luxury expedition ship Greg Mortimer left Argentina for Antarctica with 217 people on company advice that no virus was on board. Day 8 recorded the first fever. The original itinerary abandoned, and Argentinian ports closed, Uruguay allowed docking offshore. Eight passengers and crew were evacuated, including one ship physician. Of all 217 on board, 128 (59%) tested positive [ 60 ]. One Filipino crewmember died [ 61 ]. What polished written reports cannot convey is captured brilliantly in the 2-part documentary Deadly Trip of a Lifetime [ 62 , 63 ]. Staff are often forgotten when the focus is on travellers. After passengers disembarked, the crew of many ships were stuck at sea, often confined to their small windowless bunks instead of being moved to the then vacated passenger cabins, away from their families, with often limited communication and, in some cases, exposed to irresponsible company pressures [ 64 – 66 ]. Staff’s mental distress led to a number of alleged suicides on-board [ 64 ].

By the end of March, many ships were still wandering the high seas unable to find a port to dock. The cruise industry came to an abrupt halt with massive economic losses. Trust in a company’s crisis management was essential for lower-income US-travellers who were willing to cruise again with a steep discount [ 67 ]. In contrast to new customers, influenced by other consumers’ negative experiences, repeat customers were guided by their own previous experiences [ 67 ]. This interesting concept could be explored in travel medicine research on risk perception of new vs repeat travellers in general.

Trust in government/public health agencies and cruise companies played an important role in risk-reducing behaviour and future cruise intentions of 504 Australians. To regain trust, the perception of competence, consistency, consideration (in the best interest of public) and conviviality (good will toward the information provider based on trust) will need to be restored [ 68 ]. Almost 55,000 tweets (1 Feb – 18 June) reflected the global public sentiment toward cruising, mirroring the evolving events during the early pandemic. A growing interest in river cruising showed attempts to gain distance from the masses [ 69 ]. Legal questions regarding humanitarian obligations to assist cruise passengers in need vs a country’s obligation to safeguard its population [ 70 ] also involve health and medicine.

Religious tourism

Religious travel spans from crusades, historic pilgrimages, and missionary travel to today’s faith-based conventions or retreats. Modern day international examples are Hajj and Umrah, the Shia pilgrimage to Iran and Iraq, Kumbh Mela in India, Easter at the Vatican, or Christmas in Bethlehem, and smaller local festivities. A pandemic requires sudden decision-making of health authorities at the faith-based destination, e.g., the Ministry of Hajj and Umrah [ 71 ] and in countries of pilgrims’ origins [ 72 ]. Cancelled in 2020, in 2021 only 60,000 vaccinated pilgrims were admitted to the Hajj. Not only is overcrowding of concern, but the touching/kissing of objects such as walls of shrines [ 73 ] or statues of saints. There is a clear concern for the economic effect on religious destinations [ 73 , 74 ], and the impact of COVID-19-measures on the faithfuls’ ability to follow religious obligations.

Appreciating the role faith plays in a crisis, WHO published in April 2020 practical recommendations for religious leaders and faith-based communities, asking to share clear, evidence-based steps to reduce fear, provide reassurance and promote health-saving practices [ 75 ]. The detailed guidelines focus on gatherings, safe burial practices and leaders’ role in COVID-19 education. The recruitment of religious leaders was crucial with the introduction of vaccines. While Pope Francis saw vaccinations as a moral obligation [ 76 ], others warned of vaccines causing homosexual tendencies, inserting microchips, or being produced from cow’s blood (to harm Hindus) or slaughtered foetuses [ 77 ]. In the Serbian Orthodox Church, Holy Communion during Easter is of highest importance as medicine for soul and body. The church’s appeal to observe health directives was met with strong resistance and many requests to lift the travel ban during Easter. The ban represented not only ‘physical’ social distancing, but social (and religious) distancing in its true sense [ 78 ].

An Indonesian study compared pre-Eid travel intentions in February 2020 and actual travel (despite a travel ban) after festivities in May. Lack of travellers’ personal agency, e.g., perceived obligation to religion and family, promoted risky behaviour and ‘wished away’ potential health risks [ 79 ]. In India, before the Delta variant, people were willing to continue travel post-COVID-19 to religious sites provided reliable health and safety measures were in place during travel and stay [ 80 ]. An often-overlooked travel situation is being stuck overseas due to unforeseen events. A study with Pakistani pilgrims to Iran, unable to return home, explores the topic of travel burnout [ 81 ]. Where normally spirituality is a source of well-being, pilgrims were confronted with unexpected out-of-their-control situations of border closures, delays, need for food and shelter on top of the fear of becoming infected. Pilgrims showed low self-efficacy (existential fear, xenophobic response on return, restricted mobility), travel exhaustion (stress, new protocols, friction among the group, homesickness) and emotional maladaptation. Coping strategies included faith, better future travel planning, and reliance on friends and family. Coping with being trapped unexpectedly during travel is much under-researched and fits easily the travel medicine research portfolio.

Technology meets health directives

The understanding that close human contact, an important part of travel, increases the spread of infection, prompted tourism to find ways to provide safe travel experiences, using robots and virtual travel. Artificial intelligence devices have been employed in tourism previously and consumers’ attitudes towards them studied eagerly [ 82 ]. Now they are an important attempt to minimise person-to-person contact with the bonus of frequent sanitising.

During COVID-19, anthropomorphic robots, robotic vehicles and other autonomous devices were used in hospitals, communities, airports, recreation areas, and hotels and restaurants [ 83 ]. There are challenges, as in the unfortunate Henn na Hotel in Nagasaki [ 84 ], but also job losses, privacy and data security, misuse by governments [ 83 ], and a robotic barman unable to listen to personal problems. However, in pandemic times, the acceptance of robots may be greater [ 85 ]. Just before COVID-19, over 500 TripAdvisor reviews (2013–2019) of three robotic hotels in the US and Japan were positive, though the sample may be biased towards technology-fans who enjoy robots as added preference. In a pandemic, robots could assist those who want to travel [ 86 ]. As physical distancing reduces the risk of infection, 1062 US and Chinese customers’ risk perception when interacting with hospitality staff influenced their acceptance of service robots [ 87 ]. Tourists from 18 countries preferred anthropomorphic robots to all other types, but robots should not replace the innate anthropocentric nature of travel. The increased use of robots during and after COVID-19 may change acceptance as a means to avoid infection [ 88 ].

Travel bans, lockdowns and social distancing favoured the increase of webcam-travel and virtual tours – free or purchased. Though of differing quality, technology brings attractions to the ‘traveller’s’ home. University students and staff ( n  = 401) in Oman and Germany found virtual travel beneficial for the disabled and those less affluent, and during lockdown or crises. Not replacing real travel, it could entice people to visit the actual site after the pandemic [ 89 ]. Locals, of course, gain little from virtual tourism. US citizens suggested that perceived high COVID-19 threat severity, response efficacy and self-efficacy raised social distancing behaviour which increased the likelihood of using virtual tours, while those with perceived low threat severity continued to travel in person [ 90 ]. Feelings of freedom, nostalgia and connection triggered by webcam-travel were associated with happy memories made before lockdown, and so uplifted people’s mood [ 91 ].

The impact of COVID-19 on hospitality employees

While a pandemic can cripple an industry economically, an industry only exists on the shoulders of employees who are not only personally at risk of infection but experience a dramatic change in demands on them. Tourism workers suddenly had to clean, serve, communicate, distance, and implement bespoke instructions without a health background, much like the general public who was supposed to follow rules without understanding the link between the required activities and viral behaviour. The first studies into the impact of COVID-19 on tourism workers focussed on hotel and hospitality employees. The comments of 36,793 employees on the US-site Reddit, posted 3 January to 19 April, displayed real-time perceptions. Up to April, anxiety led all other negative emotions, when anger joined other factors, such as employment and racism [ 92 ]. In Turkey, 151 staff from two 5-star hotels responded in June to the risk of infection with increased mental health problems, absenteeism and low life satisfaction, the latter somewhat balanced by being married with children. Companies should, therefore, demonstrate a level of care by offering stress management programs (resilience, alcohol, finances), affordable groceries and medical care [ 93 ]. Unemployment, pandemic-induced panic and lack of social support caused distress in US tourism employees ( n  = 1231), especially in women and young employees [ 94 ]. US immigrant hospitality workers, disproportionally represented in hotel and food services, on low wages and poor working conditions, were even more affected considering their ineligibility for COVID-19-aid despite paying taxes [ 95 ]. A company’s response to COVID-19 influences employees’ perceptions on risk. In Vietnam, a surprising result was obtained from almost 400 employees in that satisfaction with the organisation not only helped raise job performance but strengthened the positive effect of a perceived health risk on job performance; full trust in organisations allowed concentration on the job [ 96 ]. This might indicate the importance of an employer when lacking national relief polices; it could also mean that desirable responses were collected.

Socially responsible workforce management influences employee anxiety. Over 400 Chinese tourism workers (almost half from Wuhan) indicated in February the importance of trust in the organisation to overcome fears, especially of unemployment, and poor mental health [ 97 ]. Similar results arose from 1594 employees from 23 Chinese hotels. Close person-to-person contact makes hotel-employment a high-risk occupation. Using the constructs: safety coaching, control, motivation, care, compliance, participation, adaptation, perceived susceptibility, perceived severity and belief restoration, employee perception of a hotel’s socially responsible initiatives promoted compliance with specific directives and citizenship behaviour. Hotels should assist employees in managing perceived risk by providing objective up-to-date information, assisting in dealing with negative emotions, providing stability, developing emergency response plans and support belief restoration [ 98 , 99 ]. While COVID-19 highlighted the immediate effect on tourism workers, the question arose if this is, indeed, a different situation ‘from the precarious lives they normally lead or just a (loud) amplification of the “normal”’ [100,p. 2813]. The authors propose that hospitality work in a pandemic is a magnification of misery, not something new, and highlight the problem at three levels. At the top level (macro), governmental, international agency and global policies ensure a framework of low wages, poor working conditions, and insufficient social security, e.g., ‘flags of convenience’ with uncontrolled exploitation of cruise ship workers. At the meso level, organisations control through outsourcing, ‘business hibernation’ and furloughing. In a pandemic, this leaves the employee at the micro level even more vulnerable to crises, especially young, women, immigrants, and international student workers [ 100 ].

Residents’ reaction to travellers during COVID-19

An important part of the tourism experience is the interaction with local people who, in general, and even if only for economic reasons, welcome visitors. Does this welcome change with visitors potentially bringing disease? In February, comparing the perception of social cost (shortage of necessities, travel restrictions, pressure on hospital beds) of a combined 3364 residents in Hong Kong, Wuhan and Guangzhou by using two hypothetical scenarios, confidence in authorities was easily lost when policies were compiled hastily. Positive framing of messages and ‘mental accounting’ of pros and cons, based on evidence, are important to ensure trust in directives [ 101 ]. In the same cities, in February/March, 1627 residents were most concerned about the risk of cross-infection due to tourism activities and, especially younger people, showed a WTP for risk reduction and appropriate action [ 26 ]. From March, and for a year, a qualitative study monitored the impact of COVID-19 on tourism in Bali. Already a mass tourism destination producing 55% of GDP, Bali’s original plan was to increase international arrivals to 20 million in 2020. While the Balinese people followed health directives, initially without any official advice for the tourism industry and with rising case numbers and deaths, those dependent on tourism had grave fears for their economic survival. On the other hand, those without links to the industry saw the break in arrivals as a welcome pause in ‘over-tourism’ and pointed to the need for more respectful, sustainable approaches. For them, COVID-19 was a wakeup call from God to the Balinese regarding the unsavoury sides of tourism. The official line, however, appears to support a return to mass tourism to make up for the losses [ 102 ]. In May/June, 634 residents on the Korean Jeju Island, which experienced an increase in domestic tourism, indicated that the perceived risk of being infected by visitors influenced their level of welcoming emotions. Residents cannot identify infected tourists. In contrast to tourists who can avoid hotspots, residents cannot leave [ 103 ]. The dilemma between supporting the economy and risking infection emerged from a Japanese survey. The ‘Go to Travel’ campaign, providing discounts and vouchers to increase domestic travel, was unwelcome by many. Even if residents followed all health directives, they could not escape tourists [ 104 ].

The vulnerability of indigenous destination communities has been of concern. They suffer equally a loss of business, but being often in remote or isolated settings and further away from suitable health care, infections would be disastrous. In Australia, most indigenous communities were off-limits to individual and organised tourists. Canada [ 105 ], New Zealand [ 106 ] and Brazil [ 107 ] voiced similar concerns with a shift to more emphasis on social and environmental wellbeing and respect rather than the insistence on the ‘right to travel’[ 105 ].

COVID-19 and travel: hostility, discrimination, racism

Fear of infection also shows in discriminatory reactions of residents to visitors. Press reports emerged very early on from India of international tourists being directed to leave accommodation and country, refused food or met with severe hostility [ 108 , 109 ]. Even more pronounced were aggressive reactions around the world towards not only travellers of Asian appearance but also residents in non-Asian countries [ 110 – 112 ]. Chinese international students in the US found that their mask wearing indicated illness and put them at even greater risk of racial abuse [ 113 ]. In February/March, 26 tourists to India reported a sense of mistrust towards tourists, subsequent negative emotions towards India and a lack of willingness to interact with locals due to the perceived rejection, but also an observed lack of implementation of health directives [ 114 ]. A similar link between unwelcoming resident behaviour and destination perception emerged in Hong Kong [ 115 ]. In February, 203 US citizens indicated that residents who experienced everyday discrimination themselves based on some social attributes, were more likely to support hostile responses against tourists, especially Mainland Chinese [ 116 ]. A study on host–guest relations in Singapore mid-2019 offered a chance to compare such views with those in April 2020 (combined n  = 468). Before COVID-19, Mainland Chinese were tolerated for their spending power despite being stereotyped unfavourably. Perceived risk of infection and expected restrained spending may lead to increased intolerance towards these visitors [ 117 ]. Much blame for this discrimination lies with the media [ 7 , 8 ].

Tourism has studied xenophobia before. The xenophobic tourist anticipates and/or experiences unpleasant emotions related to the encounter with locals at foreign destinations. For example, the more xenophobic a traveller, the higher the uptake of travel vaccination, insurance, group travel and booking through an agency, and the lower the interest in local food. Men were more xenophobic; education or age made no significant difference [ 118 ]. This deep-seated unease extends to purchasing behaviour in general, e.g., buying local products, but also choosing familiar airlines and hotels when travelling to a destination similar to home [ 119 ]. COVID-19 added the unpleasant perception of crowding [ 120 ].

Tourists’ fear of the ‘other’ (host) originates from the same ancestral disease-avoidance mechanism as the fear of residents of the ‘other’ (visitor). In ancestral social groups (in-group), people learned about the potential ill effect from contact with people from other social groups (out-group) and developed adaptive behaviours. Based on cues of ‘strangeness’, i.e., an otherness to one’s own ‘normality’, out-group people were avoided not only for cues, such as their physiognomy, food and hygiene practices, but the perception of vulnerability to potential disease. Negative attitudes including disgust then led to the culturally evolved behaviour of keeping a distance [ 121 ]. Furthermore, staying within one’s own group poses less of a risk of disease transmission as well as ensures the likelihood of being cared for and supported in need [ 122 ]. This ‘behavioural immune system’, the avoidance of contact and sticking to the in-group, is easier to implement [ 123 ]. After all, pathogens are invisible; therefore, other cues need to be employed. This leads to in-group conformity and out-group exclusion [ 124 ]. However, this exclusion also applies to in-group members who had the misfortune of being caught out at an out-group location, such as Balinese cruise ship workers returning home [ 102 ] or Pakistani pilgrims returning from Iran [ 81 ]. Having limited or no control over COVID-19-events, people’s own locus of control may also attribute blame, for example, on destinations [ 125 ] or on marginalised people, such as refugees and asylum seekers [ 126 ], and perhaps, in the future, the unvaccinated. Evolutionary motives are the ultimate explanation of discrimination during COVID-19, but this does not condone the widespread hostility experienced by travellers and residents alike. Media misinformation and conspiracy promoters have much to answer for, although health and medicine have not excelled in improving general health literacy on which to base appropriate health information in the event of a pandemic.

Future directions in tourism

For decades, scholars have warned of negative outcomes through relentless growth in tourism. As late as 2019, these warnings demanded a ‘de-growing’ and reprioritising, while proposing wide-ranging strategies for change [ 127 ], strategies widely ignored by corporate giants. Ironically, just one year later, COVID-19 showed precisely not only the trouble tourism had created for itself, but also how it contributed to the spread of the virus. To salvage some profits, like everybody else, business owners and executive boards had to make decisions based on knowledge of the virus, constantly changing government and public health directives and their different interpretations in different countries, personal opinions of health professionals, poorly constructed messages to the public, often questionable media involvement and crass conspiracy theories. The questions arise how the pandemic has shaped our desire to travel, and what tourism will look like after the crisis. Two aspects may support a change in direction, long asked for by tourism scholars and residents at destinations.

First, lengthy lockdowns and restrictions have modified many people’s worldviews, lifestyles and previous behaviours. Mindfulness, ‘slowing-down’, a measured approach to consumption and a focus on ‘what is really important’ gained prominence, at least for those who can afford such luxury. This view may now extend to many more travellers beyond those who travelled mindfully before. Second, media reports of wildlife moving into seemingly abandoned suburbs, cleaner water in rivers and oceans, better air quality, less waste (apart from an unprecedented increase in medical waste [ 55 ]), and peace and quiet showed an almost forgotten picture of a different world. Considering tourism’s involvement in and suffering from COVID-19, how the industry will progress from here is important for travel medicine as it may influence travellers’ different care requirements depending on changes in destinations or holiday activities. There are two opposing schools of thought: either return to growth and mass tourism or take advantage of the opportunity to reset.

The first view is that tourism must recuperate the enormous losses and get ‘back to normal’ as soon as possible, trusting that people have short memories (shortly after the Ruby Princess debacle, long waiting lists for the next possible cruise filled quickly). Opening borders, spare funds, boredom, and fear of missing out may lead to ‘revenge travel’ or ‘catch-up travel’ [ 128 ] without considering impacts or consequences. The economic benefits of tourism, driven by the World Tourism Organisation and supported by government interventions, may again be the driving force behind the ‘business-as-usual’ return to pre-COVID-19 business behaviour, a possibility that sparked a fiery debate between the two tourism camps [ 129 ]. This dilemma is evident in Bali, where residents who depend on tourism desperately want it back while others relish having the island to themselves. Government intentions seem to favour a return to growth-tourism [ 102 ]. Similar concerns apply to Nepal, which had declared 2020 the ‘Visit Nepal Year’, with a potential return to excessive over-tourism that prevailed before the pandemic [ 130 ].

The second view, recognising that mass-tourism is not resilient and inert in responding to sudden changes, suggests treating the pandemic as a chance to transform global tourism away from unsustainable and destructive growth towards mindful and equitable forms that prioritise quality over quantity [ 131 , 132 ]. Suggestions are a preference for slow nature-focused tourism [ 133 ] and its mental health benefits [ 134 ], avoidance of mass-cruises [ 135 ] and a greater consideration for host communities [ 136 ]. In April 2020, Tourism Geographies devoted a highly recommended special issue to the discussion of how COVID-19-events can contribute to a ‘substantial, meaningful and positive transformation of the planet in general and tourism specifically’ [ 137 ,p. 455] where growth is in well-being, not profit. This goes far beyond the call for responsible tourism, i.e., the call for having less damaging impacts, and requires a radical transformation away from systematic inequalities [ 138 ] towards a balanced, resilient and just post-pandemic tourism [ 139 , 140 ]. Pleasingly, small operators may turn out more resilient due to their potential flexibility within a specific local community than unwieldy multinationals [ 141 ].

Compared to previous pandemics and large-scale disease outbreaks over the last 100 years, COVID-19 will be the costliest, at least in economic terms. While some locations may opt for a mindful change, it is highly likely that the focus remains on growth, which may prove even more unsustainable than before [ 142 ].

Recommendations for research

Looking at other disciplines’ research topics and methods can unearth useful ideas adaptable by travel medicine for better travel health care and understanding of travellers’ motives, attitudes and behaviour [ 143 ]. The criticised lack of a structural research agenda at the beginning of the pandemic [ 144 ] and the subsequent flurry of diverse topics and approaches nevertheless provides travel health practitioners with a vast range of frameworks, topics and methods useful in novel travel medicine research. Theories, such as the Protection Motivation Theory, Theory of Planned Behaviour, Risk Aversion Theory, Attribution Theory (Locus of Control), Cognitive Appraisal Theory, Theory of Reasoned Action, Motivations Reasoning Perspective, and many more are useful to study travel health behaviour, risk perception, coping strategies and so on, thereby elevating the usual KAP (Knowledge, Attitudes and Practices) studies to a more robust level. Equally, several tested tools could be explored and modified to suit travel medicine concerns, such as the Tourist Worry Scale [ 145 ], Tourism Fatigue Scale [ 146 ], Travel Safety Attitude Scale [ 147 ], Pandemic Anxiety Attitude Scale [ 148 ], Tourist Xenophobia Scale [ 118 ], or Sentiment Analysis [ 69 ] for text-mining of social media data.

This article has covered a wide range of topics, all of which could be examined from a travel medicine perspective and in multidisciplinary teams, the latter a particularly valuable way to develop fresh research questions [ 149 ]. The impact of infectious disease on travellers’ psychological state [ 23 ], distrust in service providers [ 41 ] including travel health providers, perceptions of inconsistent/conflicting medical advice, vaccine acceptance influenced by religious leaders or ‘anti-vaxxers’, or the acceptance of travel health advice during a pandemic are only some examples. Assaf et al. suggested 17 topics for future research for consumer/traveller behaviour alone [ 150 ]. Many harbour health aspects. The effects of sensational media coverage regarding travel medicine concerns are little understood. Discrimination and racism may influence certain health behaviours abroad, e.g., choosing familiar food from questionable hotel kitchens over freshly prepared ‘foreign’ local food. For more detailed insight, the times of data collection for the presented studies could be linked to the respective country’s case numbers, health directives, government policies, travel restrictions and lockdowns at that time, for example, matching the medical response in Vietnam [ 151 ] to a study on employees in Vietnamese hotels [ 96 ]. Travel medicine research usually focuses on travellers’ wellbeing. So far, travel health professionals themselves, especially during a pandemic, have been of limited interest to researchers.

Limitations

This article only utilised English-language academic tourism journals, potentially missing important findings. Journals of other specialties, such as aviation, transport, food and catering, were not consulted. No doubt, there were many manuscripts still in the peer-review or revision phase. With evolving knowledge of the virus’ behaviour and subsequent policy responses, there may be a shift to an entirely different focus of concern in later studies.

Even before the pandemic was announced, tourism scholars recognised the existential threat to the industry, reacted quickly and commenced research depending on their respective area of expertise. Although these early studies were, naturally, uncoordinated, many focused on the lifeblood of tourism: travellers, workers and residents, the very core of travel medicine. Parallel interests emerged. Risk perception and travel intentions are examined here from the industry’s perspective. Health directives advise strongly against mass-gatherings, yet people insist on getting on cruise ships as soon as possible or wish to follow religious or cultural obligations. On the other hand, technology in the shape of virtual travel or robotic devices keeps people at safe distance and so minimises person-to-person contact. The impact of COVID-19 on tourism workers and residents at destinations including the arising hostility and discrimination, are firmly based in a health context. If and how tourism learns from the current business model’s vulnerability will affect travel health practitioners’ work.

While the results are tourism results, they allow a better insight into people than travel medicine research typically can, with implications for travel health practitioners. If travellers are reluctant to travel for a long while, travel health clinics lose revenue and practitioners may lose recency of practice. People who will travel regardless may present to clinicians different sets of issues, require a modified approach to travel health advice, ask different questions, e.g., ‘do robots really protect me?’, or state their distrust in (health) authorities and so challenge practitioners to provide evidence so that travellers can make sensible informed decisions.

Travel medicine and the tourism industry are tightly connected via the traveller, yet there is still little cooperation, collaboration and acknowledgment of the other. This connection should be exploited more for the benefit of travel health and medicine and, ultimately, for the traveller. The first 6–12 months of the pandemic seem now a long time ago due to vaccination, anti-viral treatment and adoption of a ‘new normal’, with the realisation that COVID-19 will not disappear in a hurry. It is prudent to remember those first months and the ‘hits and misses’ in medicine and tourism. Presumably, the next pandemic is aided by travel again – and may be just around the corner.

Acknowledgements

Authors ’ contributions.

The author read and approved the final manuscript.

Availability of data and material

Declarations.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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• Medical Tourism

Getting Started as a Medical Tourist: A Step-by-Step Guide

When seeking treatment abroad, it’s important to remember that medical tourism differs from a typical vacation. While it may offer new experiences, knowing the risks of choosing a medical institution is crucial. However, it can also be viable if you seek treatments unavailable in your home country. We’re here to provide you with the necessary information to make an informed decision before you apply for treatment abroad.

Research Your Destination Options 

If you’re considering getting medical treatment abroad, the first step is to choose the right destination. It requires considering various factors, such as your financial plan, proficient physicians, accessibility, and weather conditions. It’s also beneficial to stay informed about the latest developments and popular medical tourism destinations. By keeping up-to-date, you can discover new and advanced treatments that may increase your chances of recovery. 

Each year, the Association of Medical Tourism rates the best locations for medical tourism. Experts evaluate numerous criteria such as reputation, the professionalism of doctors and clinics, service quality, cost of treatment, and rehabilitation period. The most popular destinations that traditionally top the rankings include:

• Germany. People prioritizing quality, accuracy, and good service choose it regardless of cost. Modern technology makes early detection of serious illnesses achievable, allowing for complete recovery. Moreover, many doctors in Germany , such as  Thomas J. Vogl and Frank Gansauge , engage in research activities while actively practicing medicine.
• Israel. The Promised Land is renowned for its advanced treatment methods and state-of-the-art clinics, which draw in patients seeking diagnosis and treatment for severe diseases like cancer . 
• Spain. It attracts over 200,000 guests annually from the Netherlands, Great Britain, Germany, and the US. The country is renowned for its outstanding transplantology services and advanced gynecology , cardiology , and neurology treatment. 
• Czechia. It is an ideal destination for both medical and rehabilitation tourism . Many patients visit it to seek treatment for various medical conditions such as infertility, eye diseases , and cardiovascular diseases .
• Turkey. Turkey’s hospitals are 30% more affordable than well-known European and American clinics, making them an accessible option. Plastic surgery , neurosurgery, and weight loss are among the top priorities.

Consider The Cost of Your Healthcare 

When traveling abroad, it’s essential to plan for medical expenses. Since you’ll likely be dealing with foreign currency, it’s crucial to research payment options and exchange rates. It is essential to check for any money restrictions or limits for visitors before traveling to your destination country. Lastly, it is wise to have extra cash in case of emergencies or insufficient funds for medical treatment and other necessities.

When seeking medical treatment abroad, it’s important not to base your decision solely on cost. Please keep in mind that the overall expenses of medical treatments can differ based on the hospital and location. You should compare prices from the best hospitals offering the necessary medical services.  It will help you discover a clinic that provides the required medical procedures at a reasonable price. However, it’s vital not to sacrifice quality while searching for lower-priced options. 

Before signing any documents, it’s essential to keep an eye on the transparency of treatment costs at your chosen hospital and ensure no hidden charges are in your final bill.

Compare Accreditations and Quality of Care 

Choosing a medical facility that is widely recognized locally and internationally is essential. Look for a clinic with accreditations and certificates that demonstrate their adherence to high medical standards, use of modern treatment methods and technologies, professionalism of doctors, and patient-centered approach. Joint Commission International ( JCI ) is one of the most well-known accreditations among top hospitals. Experts advise paying attention to international symbols and certificates:

• ISO. A proven hospital that meets the quality standards of clinic management and organization of medical staff.
• MTQUA. An advanced clinic that meets the best international standards and constantly improves its service.
• EFQM. The badge of distinction from the European Management Foundation testifies to the organization’s compliance with high requirements in the field of management of medical institutions.
• OECI. A clinic where modern standards of cancer treatment are implemented.
• ESMO . Professional training of oncologists in the world’s leading clinics .

Make Travel Arrangements 

Once you have chosen a few clinics, make sure to get in touch with their representatives and clarify the following details:

• Will the clinic be able to perform the necessary procedures?
• How soon can they accommodate your request?
• What documents and certificates should you bring, such as a medical history extract or previous examination results?
• When will you be able to see the desired doctor ?
• What are the prices for the necessary procedures?
• How long is the rehabilitation period?
• What is the required length of stay in the country for budget planning?
• Does the clinic have an interpreter on staff, or will you need to find one yourself?
• Is a deposit required to make an appointment at some clinics?

Based on the information received, make the final decision.

Ask for an official invitation from the medical center – with it, you can get a visa, if necessary, to enter the country. Ensure you collect and translate all the required certificates and documents in the chosen country’s language, although many medical centers accept English. Once the arrival date is confirmed, arrange travel and plan logistics accordingly. Also, book accommodation in advance if you plan on receiving outpatient treatment.

How Do I Make Sure I Receive Quality Care Abroad? 

If you’re considering medical tourism, it’s essential to exercise caution due to the high level of competition in the industry. Not all clinics and doctors overseas are of the same quality, so you should conduct a market analysis to avoid any potential regrets later. Before traveling abroad for medical treatment, selecting a trustworthy clinic that focuses on treating your condition is crucial. 

The hospital should also have access to advanced equipment for diagnosis, treatment, and surgical procedures. Obtain all relevant information about your upcoming trip, including the treatment process, potential side effects, complications, and expected outcomes. 

Reviewing other patients who have received therapy from the same doctor can also help make an informed decision. Their experiences can provide valuable insight to ensure you make the best choice possible.

AiroMedical – the best medical travel platform that helps you 

Getting quality medical care while traveling abroad can be difficult. It’s easy to overlook important details when considering different options. That’s why it’s a good idea to seek the help of a medical tourism operator. They can quickly organize the entire process, from choosing the right clinic and doctor to assisting with travel preparations. 

AiroMedical is a trustworthy online platform that assists patients globally in finding the most effective medical solutions, irrespective of their geographical location. 

Who is addressing us?

• Those who have doubts about a diagnosis made at home.
• People who seek truthful and precise responses to complex inquiries.
• Those who prioritize their well-being and desire to be treated by top-notch experts.
• Those who value professionalism and treatment quality.

At AiroMedical, we combine medicine and modern technology to meet your healthcare needs. Our team includes highly skilled medical professionals and healthcare facilities from 16+ countries, ready to help you find the best solution.

• Medical tourism market size, 2023-2027. GlobalData. Published June 20, 2023. https://www.globaldata.com/store/report/medical-tourism-market-analysis/
• Volvak N. Treatment in Germany (advantages and benefits). AiroMedical. Updated December 05, 2022. https://airomedical.com/blogs/articles/treatment-in-germany-advantages-and-benefits
• Volvak N. Treatment in Turkey (advantages and benefits). AjroMedical. Updated December 05, 2022. https://airomedical.com/blogs/articles/treatment-in-turkey-advantages-and-benefits

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