Please cite as: Ormond, Meghann. (2011) Medical tourism, medical exile: Responding to the cross-
border pursuit of healthcare in Malaysia. In Minca, C. and Oakes, T. (eds), Real Tourism: Practice,
Care and Politics in Contemporary Travel, London: Routledge.
Medical tourism, medical exile: Responding to the cross-border pursuit of healthcare in Malaysia
Medical tourism may be a business, but that doesn’t mean that it’s solely for business
purposes. It’s still very much based on the very foundation that healthcare is for all, that
healthcare should be affordable, equitable and of quality. We [Malaysia] are based on
those kinds of premises.
(Malaysian Health Ministry representative, in Ormond 2011)
Both travel (as bodily displacement) and health (as bodily ailment), as moments of corporeal
vulnerability, have been intimately linked over time to the concept of hospitality – of ‘being moved
to respond’ (Barnett 2005: 15) to the precarious situation of another. Premised upon the traveller’s
displacement from his/her home, hospitality entails a ‘guest’ being temporarily welcomed across the
threshold into the domain of a ‘host’, with the host offering a mixture of tangible and intangible
elements that ensure the guest’s security and fulfil his/her psychological and physiological needs
(King 1995: 220). While conceptual engagement with ‘hospitality’ in the realm of tourism studies has
largely taken place through the lens of business and management, with its focus on ‘commercial
hospitality’ (where ‘guest’ and ‘host’ become ‘buyer’ and ‘seller’), the uneasy tension between ‘host’
and ‘guest’ at the heart of hospitality has long been at the core of social science engagement with
tourism and its impacts (see Smith 1989; Lashley and Morrison 2000). With this dichotomy growing
blurrier by the day as the question becomes not only where one is a ‘host’ and a ‘guest’ but also
when (Crang 2005), social scientists are increasingly mobilising Kantian, Levinasian and Derridian
conceptualisations of ‘hospitality’ in order to critically explore the mediation and regulation of
‘relations among members and strangers’ (Benhabib 2004: 27) in a mobile world in which
conventional mobility categories (e.g., ‘tourist’, ‘migrant’, etc.) are rendered increasingly obsolete
and new types of moorings grow ever more patent (see Barnett 2005; Bell 2007; Germann Moltz and
Gibson 2007). Accordingly, much scholarly and mediatic attention has been given over to the
question of ‘political hospitality’ – that conditional invitation extended to a foreign Other across a
sovereign threshold – at a moment in history when the contours of the modern nation-state are
increasingly challenged, shifting and adapting. In ‘developed’ western societies grappling with the
dilemma of extending political membership within a ‘cosmopolitan’ migratory context (Benhabib
2004; Dikeç 2002; Dikeç et al. 2009; Darling 2010), for example, we see the foreign Other having
crossed that sovereign threshold often discursively constructed as a costly burden – the fruit of so-
called ‘unproductive, disruptive hospitality’ (Derrida 2002: 100). As such, while the hotel has become
symbolic of the commodification of hospitality, the fortress has come to represent the ‘political
ethics’ of hospitality (Gibson 2006).
With this chapter, I seek to offer a reading of the nexus between ‘commercial’ and ‘political’
hospitalities to explore attempts at developing ‘productive hospitality’ through the metaphorical
space of the ‘hotel-fortress’. Using the lens of international medical travel (IMT), I examine the
responsiveness of one of the world’s prime IMT destinations – Malaysia – to the plights and needs of
its foreign patient-consumer ‘guests’, laying out some of the complex ethical, economic and political
logics shaping the recognition of the corporeal vulnerabilities of different foreign patient-consumers
and the correlate extension of hospitality to them. In casting ‘Malaysia’ as a moral safe-haven free
from many of the barriers that produce unsettlingly stark differences in access to healthcare
throughout the world, the comments by a Malaysian Health Ministry representative at the start of
this chapter point to an entrepreneurial medical solidarity being extended by the Malaysian state to
international consumers which envisions an ‘all’ that departs markedly from earlier interpretations
of the state’s biopolitical scope. I advance that receiving a foreign patient-consumer as a ‘Somebody,
[and] not as a serialised nobody’ (Barnett 2005: 15) is part of a conditional ‘pact’ between ‘hosts’
and ‘guests’ that insists on mutual recognition in order to ‘give place’ to the claims of both parties
(Derrida 2000: 23-25). Yet this reciprocity – speaking to the continuing significance of national
borders in the accessing and provision of different regimes of care, medical expertise and technology
– is complicated, as it involves not only commercial but also political recognition of the legitimacy of
certain groups’ claims for ‘care’ and, in return, the recognition of the expertise of the care provider
to respond to them, serving to constitute ‘guesting’ and ‘hosting’ subjects, places and moments.
The chapter is organised into four parts. The first section situates IMT destinations within a
broader temporal and spatial context of hospitality and well-being practices, tracing shifts and
transformations in the ways in which places have come to be recognised as therapeutic and
hospitable. The second analyses the politically-charged language commonly deployed in
distinguishing categories of medically-motivated cross-border mobility in relation to their value to
their ‘sending’ and ‘receiving’ contexts and how specific mobile subjects come to be recognised as
deserving of care. Section three identifies a disjuncture between IMT destinations’ growing desire
for patient-consumers from ‘developed’ countries and their corresponding investments in
spectacular ‘medical tourism’ infrastructure, on the one hand, and the foundational role that
‘everyday’ intra-regional medical travellers from nearby ‘developing’ countries play in constituting
these destinations, on the other. Seeking to draw attention to the relevance of these more
‘everyday’ medical mobilities, the fourth section contemplates complementarities and solidarities
imagined and performed in the extension of a commercial-political hospitality to regional patient-
consumers by IMT destinations in Malaysia which, in sometimes defying conventional economic
logic, hint at the negotiation of more nuanced allegiances. In the conclusion, I underscore the
importance of considering how non-citizen mobile subjects’ corporeal vulnerabilities are differently
recognised by destinations seeking to harness IMT flows so that we may begin to consider what
might be the consequences of such recognition.
International medical travel: From exceptional to everyday
‘Hospitable’ spaces respond to the anxieties of those that seek them out, with ‘new’ arenas
continuously being identified and proffered as havens for rejuvenation (O’Dell 2007: 115). People
have travelled long distances in hopes of restoring their spiritual and physical well-being for
millennia, seeking out natural sites around the world perceived to be sacred due to their healing
properties around which places of worship and travel infrastructure were built to access them
(Gesler and Kearns 2002; Smith 2008; Connell 2011). With the expansion of ‘modern’ medicine and
in correlation with shifting conceptualisations and spatialisations of disease and illness (Foucault
1994), health-motivated travel gradually extended beyond places endowed with natural
morphologies held as therapeutic to include medical facilities in which the ‘specific geographical
location [was thought to be] of less significance in its therapeutic role than the physical, social and
symbolic organisation of the space itself’ (Smyth 2005: 488). Today, ‘medical travel’ constitutes yet
another point on the broad spectrum of travel motivated by the pursuit of well-being, a
‘contemporary elaboration’ on earlier pursuits of beneficial health outcomes – with the outcomes of
modern medical intervention expected to be more substantial and long-term (Connell 2006: 2; Smith
and Puczkó 2009: 254).
Given medicine’s privileged relationship to modern discourses of science and progress, it
comes as little surprise that the ‘centres of the health care universe’ (Toral, in MacReady 2007)
commonly have been perceived to be located in the ‘developed’ world. For decades, wealthy
patient-consumers from far and wide have made ‘pilgrimages’ (Wachter 2006: 661) to these modern
medical ‘meccas’, sites of ‘miraculous’ achievements that ‘boast[ed] unrivalled medical facilities and
funds to fuel research and innovation in many aspects of medical treatment’ (Jenner 2008: 237). The
last two decades, however, have seen an unprecedented proliferation of internationally-renowned
centres of medical excellence outside of the ‘developed’ countries in which such expertise had been
held to be concentrated. By the end of the 1990s, several prominent medical facilities in ‘developing’
and former socialist countries (e.g., Thailand’s Bumrungrad Hospital1), often backed by their national
and provincial governments, began to launch programmes to both attract specific types of foreign
medical travellers and retain their own domestic elite, complicating the presumed directionality of
That which is identified by many as the novelty of the crossing of national borders for medical
care, or international medical travel (IMT), today is rooted to its apparent gradual massification
among middle-class Westerners and the emergence of non-Western spatialisations of care
corresponding to their growing demand (Carrera and Bridges 2006; Cortez 2008; York 2008). In
recent years, media, policy-makers and the private sector have come to acknowledge a growing
number of patient-consumers from ‘developed’ countries who, faced with decreasing healthcare
entitlement and access in their countries of origin, have begun to seek timely and more economical
care in this new global constellation of private medical facilities (Carrera and Bridges 2006; Turner
2007a). With these middle classes – affected by welfare state retrenchment and ‘frustrated by their
own diminishing entitlements’ (Sparke 2009: 11) as citizens – now involved, IMT could no longer be
explained away as an escape valve for the few ‘exceptions’ (Wachter 2006: 661) dissatisfied with
their countries’ (more or less) functional healthcare systems. Rather, it came to be discursively
reincarnated as a harbinger of social crisis wherein traditional care boundaries could not hold. With
this movement of people redrawing the boundaries to the pursuit of care in order to sidestep
obstacles perceived to inhibit their access ‘at home’,2 IMT therefore has come to symbolise a shift
away from what were previously imagined as nationally-bound, locally-based care settings to what
are now increasingly conceived as ‘chaotic global networks… in an era of ever deteriorating national,
technological, mental and physical boundaries in the delivery of healthcare services’ (Jenner 2008:
Articulated through this complex and emerging global healthcare assemblage, argues
Whittaker (2008: 273), is ‘a range of new relations between capital and labour, bodies and the state,
belonging and extraterritoriality, transformations in political governance, and realignments of
medical citizenship and the meanings of public health’. For the few able ‘to both circumvent and
benefit from different nation-state regimes’ (Ong 1999: 112, original emphasis), the crossing of
national borders has the potential to produce significant shifts in political and socio-economic status
that directly condition access to healthcare, such that care not accessible in one country may be
within reach in another. As a result, IMT often gets cast as a ‘democratising’ force for both
healthcare consumers and providers (Turner 2007b; Jenner 2008) – a ‘“disruptive innovation” that
can transform traditional processes and relationships’ (Deloitte 2008; see Brooker and Go 2006;
Wachter 2006; Bookman and Bookman 2007). With this ‘de-territorialisation’ of care calling into
question and renegotiating the relationship between the pursuit of health and the assumedly
1 Medical travellers from over 150 countries have sought medical care at Mayo Clinic in the United States
(Mayo Clinic 2009), while Bumrungrad Hospital, alone responsible for 31% of all international medical travel to
Thailand, has hosted patient-consumers from 190 countries (Bumrungrad 2010).
2 Four categories of obstacles are most often cited in the literature. Firstly, prohibitively high medical care
costs and inadequate insurance coverage may keep essential and elective treatment financially out of reach
(e.g., invasive surgeries, dental and cosmetic work) (Connell 2006; Rajeev and Latif 2009). Secondly, scarcity of
supply of human resources and/or materials may significantly delay treatment (e.g., waiting lists for joint
replacements or transplantations (Scheper-Hughes 2000, 2005; Katz et al. 2002; Turner 2007a, 2009; Hadi
2009)). Thirdly, states’ regulatory controls may deny access to treatment on moral grounds (e.g., gender
reassignment, IVF procedures for single women, pre-implantation sex selection of embryos, commercial
surrogacy and abortion (Pennings 2002, 2004; Whittaker 2009)) or due to their experimental status (e.g., stem
cell therapies and fertility treatments (Blyth and Farrand 2005; Horowitz et al. 2007; Kiatpongsan and Sipp
2008; Whittaker 2008, 2009; Clarke 2009)). Finally, care providers may be perceived to lack sufficient
sensitivity to linguistic, cultural and religious needs (Bergmark et al. 2008; Lee et al. 2010). Each of these
categories provides evidence of the multiple ethical issues being worked out across the regulatory and
economic patchwork of a globalising healthcare ‘marketplace’.
‘traditional’ bounded settings of its provision, the globalising healthcare ‘marketplace’ thus becomes
envisioned as a hopeful space of distributive justice for mobile ‘patient-consumers’.
This neoliberal celebration of ‘deterritorialised’ care provision constructs medical travellers as
pioneering patient-consumer agents of their own emancipation, leaving behind healthcare systems
that have somehow failed them for destinations envisioned as almost indiscriminate nodes of
‘world-class’ care provision. Yet Benhabib (2004: 23) suggests that the resulting ‘disaggregated
citizenship’, wherein people ‘come under the purview of different rights regimes and multiple,
nested sovereignties’ through their participation in global markets is not the same as ‘cosmopolitan
citizenship’. Cresswell (2001) cautions against the romantic gloss of ‘resistance’ linking mobility and
consumption: while some mobilities may appear transgressive, they also perpetuate existing power
structures. International medical travellers’ very presence and ‘needs’ are recognised, received,
attended to, ignored, disapproved of or rebuked in accordance with their value to those sending,
losing, abandoning, attracting, discouraging, filtering or unified with them. There is, therefore, a
need to critically examine the production of medical mobilities and the biopolitical distinctions
drawn around medical travellers by their ‘sending’ and ‘receiving’ contexts.
What place for ‘medical tourism’ in a world of ‘medical exile’?
Terms such as ‘tourism’, ‘outsourcing’, ‘migration’ and ‘exile’ are frequently employed in media,
political and academic coverage of a spectrum of health-motivated mobilities produced in the
crossing into and out of national healthcare jurisdictions. They implicitly point to a host of social,
cultural, political and economic imaginings and interpellations of the subjects and spaces engaged in
these cross-border movements (Germann Molz and Gibson 2007). To employ such terms is to
effectively identify in IMT a profound challenge to sovereignty by ‘wandering peoples who… are
themselves the marks of a shifting boundary that alienates the frontiers of the modern nation’
(Bhabha 2004: 256) through their transgression of a political ‘care’ relationship that, until recently,
has been widely held as a decidedly national domain of action (Nye 2003). In line with Clifford’s
(1997) call for new representational strategies of and around mobile subjects, such a rich lexicon
offers substantial material to explore complex dynamics shaping responsiveness to mobile health-
seeking bodies that at once challenge and reassert the relevance of national borders in accessing
‘care’ in ways that refuse ‘to place the emotion, the mess, and the softness of care in some
prepolitical zone’ (Staeheli and Brown 2003: 774; see Raghuram et al. 2009).
Critically, only a handful of authors have begun to unpack the politics of IMT’s semiotics.
While authors like Smith-Cavros (2010) and Kangas (2010) have adopted more ‘neutral’ descriptors
such as ‘medical travel’ and ‘transnational therapeutic itineraries’ to step around the minefield of
connotations linked to ‘tourism’, ‘outsourcing’ and ‘exile’, Inhorn and Pasquale (2009), to the
contrary, insist that we be careful to recognise the power relations that drive people across borders
and to avoid their linguistic de-politicisation in our work. Calling for greater acknowledgement of the
breadth of influences that drive people across borders for health, Thompson (2008) distinguishes
what she calls medical tourism, ‘with its emphasis on the movement of empowered, biosocial
citizens… seeking medical care by travelling down scientific, regulatory and/or economic gradients’,
from medical migrations, those ‘movements across regional and national boundaries in ways
relating to health status and care and to immigration… status and the freedom from various kinds of
persecution’ (Thompson 2008: 435). Her distinction between these categories of medical mobility
draws attention to the less-than-elite nature of the vast majority of IMT, highlighting the nuanced
influences that contribute to variably fostering and disallowing a range of mobile subjectivities.
Crucially, however, the link that she draws between ‘tourism’ and ‘migrations’ superficially supposes
a dichotomy separating the savvy self-regulating patient-consumer capable of transcending and
rendering irrelevant the bonds of the nation-state, on the one hand, from the dejectedly displaced
for whom those bonds constitute significant obstacles, on the other.
Alert to the plethora of value-laden judgements at various scales involved in deciding who
may and may not receive treatment ‘at home’, authors writing on ‘reproductive tourism’ (e.g.,
Pennings 2002, 2005; Inhorn and Pasquale 2009; Smith-Cavros 2010) have produced some of the
strongest critiques of the violence generated by the term ‘tourism’. They argue that ‘connotations of
the term are negative when considered in a medical context (recreation), thus devaluing the
motivation for the journey, implying that the… tourist goes abroad to look for something exotic and
strange’ (Pennings 2002: 337). In theorising the relationship between ‘reproductive tourism’ and
reproductive rights, Inhorn and Pasquale (2009: 904) specifically question ‘the language of tourism
as an appropriate gloss’. Contrasted with the real emotional, social and financial costs shouldered by
infertile people, the use of ‘tourism’ seems to mock their suffering. The authors endorse, instead,
the term ‘reproductive exile’ for its recognition of the legal, social and economic barriers to their
ability to access quality services ‘at home’ and the pursuit of such services abroad. Exile becomes
both forced migration and a sense of estrangement from one’s ‘natural’ community (Cresswell 2001;
Kaplan 2005). In a similar vein, Milstein and Smith (2006) polemically describe American medical
travellers as ‘refugees’ escaping from an ailing healthcare system. ‘Refugee’ here differentiates
‘real’, urgent medical needs from discretionary ones: ‘This is not what is sometimes snootily referred
to as “medical tourism”, in which people go abroad for elective plastic surgery… People are
desperate’ (Smith, in Ansorge 18/10/2006). With ‘tourism’ widely held as an experience of leisure,
hedonism and escape in which everyday obligations are inverted (Urry 2002), therefore, IMT
industry players are increasingly reshaping the terms of their practice by recognising mobile patient-
consumers’ desperation, pushing for an industry-wide shift from ‘medical tourism’ to ‘medical travel’
to lend their services greater integrity (see Yap 2006; Woodman 2008).3 Being driven – and limited –
by ‘real’ medical needs is held to distinguish ‘medical refugees’ from ‘medical tourists’.
Drawing from a predominantly Western base of concern with how health-motivated mobility
categories get produced through ‘sending’ contexts, these conceptual critiques and
accommodations, however, fail to adequately address the constitutive role of ‘receiving’ contexts.
While acknowledging the role of ‘sending’ contexts in countless medical travellers’ suffering and
desperation, I also want to call attention to what often gets obscured: ‘medical tourism’ and
‘medical exile’ are also produced by how these travellers get constituted as care-pursuing subjects
by IMT destinations themselves. It is through processes of re-territorialisation that different sets of
values come to inform the contours of access to healthcare and form the relationship between
medical travellers and care providers, ‘foreground[ing] the social construction of identity-in-place’
(Dahlman 2008: 496). Rooted to their discursive deployment in dismissing or affirming what drives
medical travellers abroad, the terms ‘medical tourism’ and ‘medical exile’ also indicate destinations’
practices and expectations in sorting and relating to the categories of mobile patient-consumers to
which they may or may not extend this commercial-political hospitality.
Destinations – frequently located within ‘developing’ Asian countries – have embraced IMT as
both a ‘passport to development’ (Wood 1993: 48), via the ‘“trickle-down” of modern skills, new
technology and improved public services… imagined to follow in the wake of foreign tourists’ (Enloe
1989: 40), and a platform for demonstrating that they can ensure ‘world-class’ quality for foreign
patient-consumers in ‘medical exile’ from faltering healthcare systems in ‘developed’ countries. This
holds potent declarative value for destinations to improve their international visibility and prestige,
since ‘becoming a tourist destination’, suggests Urry (2002: 143), ‘is part of a reflexive process by
which societies and places come to enter the global order’. Indeed, throughout Asia, government
authorities and IMT industry players focus extraordinary energy and investment in learning how to
best appeal and cater to these prospective markets and their ‘disorders of affluence’ (Jagyasi 2008).
The term ‘medical tourism’, therefore, often gets used to evoke the growing ‘world-class’
commercial hospitality infrastructure and services catering to their demands and pocketbooks. In
3 Furthermore, while a ‘conventional’ tourism component (e.g., ‘post-op’ safaris, Taj Mahal tours and
recuperation at tropical beach resorts) may be used in place-imaging techniques to attract patient-consumers
and their families to long-haul destinations, the ‘recreational value of travel’ is held to decrease in importance
the more serious the condition being treated (Horowitz et al. 2007), whittling it down to little more than ‘long-
distance migration for surgery’ (Connell 2006: 6).
her work on IMT to Thailand, Wilson (2010: 138) retains ‘tourism’ as a signifier to distinguish ‘a
sector of the medical industry in relation to privileged foreign citizenship and currencies’. That ‘the
emblematic medical tourist’ has been popularised as ‘a wealthy white Western or East Asian tourist’
(Whittaker 2009: 323) reveals a commercial-political hospitality that is contingent upon ‘the
differential capacities and dispositions’ of destinations to be ‘affected by and moved to respond to
certain claims and not to others’ (Barnett 2005: 20), hinging on a distinction between invitation and
visitation shaped by differences in national belonging, race and class. ‘Tourism’ here espouses a
conditional hospitality, a politics of ‘care’ that implies a return ‘home’ by ‘guests’ who cannot
demand the same as local citizens from destinations’ governments – a no-nonsense consumer
relationship with the ‘hosts’.
At the same time, IMT destinations offer a temporary haven for paying bodies recognised to
be in ‘medical exile’. Destinations do not thrive because they are ‘the best in the world’ but because
healthcare systems in patient-consumers’ countries of origin are perceived to be somehow at fault –
meaning that the success of an IMT destination is not merely a measure of its individual excellence
but, rather, is also contingent on an imagined geography of ‘care’ that identifies perceived gaps and
failures elsewhere. Take, for example, the conscious framing of Malaysia – a principal Asian IMT hub
– as a ‘value for money’ destination for a transnational bourgeoisie, where emphasis has been
placed on the various plights that its prospective clienteles encounter in seeking healthcare in their
habitual places: un(der)insured middle-class Americans are simply ‘priced out’ of adequate medical
care, while Middle Easterners have been turned away from their traditional IMT destinations in the
West as a result of post-9/11 ethnic and religious discrimination. Malaysia is, in turn, marketed as
capable of responding to these unmet needs through an auspicious combination of territorialised
factors, including the material trappings of ‘world class’ care, so-called ‘Asian hospitality’ and the
‘peace of mind’ assured through political and economic stability.
Such a strategy hinges upon a ‘magic’ transformation of these patient-consumers who, ‘likely
not part of the upper class within their own societies’ (Smith-Cavros 2010: 472), can be temporarily
cared for in relative luxury thanks to favourable exchange rates, low wages and the ‘medical tourism’
infrastructure built with them in mind. Medical travel agencies, top hotels and serviced apartments
are teaming up with private hospitals to attract foreign patient-consumers from ‘developed’
countries to offer ‘seamless’ door-to-door care services, and hospitals themselves have begun to
redesign their patient quarters to offer exclusive international patient wards, guest lounges and
deluxe suites that allow families to stay with inpatients. Serving this ‘emblematic medical tourist’
(Whittaker 2008) furthermore involves ensuring quality standards of treatment that meet or surpass
those of Western benchmark facilities by investing in acquiring staff with internationally-recognised
credentials and big-name accreditation (e.g., Joint Commission International – JCI), perceived as key
for attracting these ‘gold mine’ patient-consumers.
What place for ‘medical exile’ in destinations increasingly designed for ‘medical tourism’?
As a test-site for some of the world’s most cutting-edge medical technologies and home to highly-
skilled foreign-trained medical professionals, the Malaysian context offers insight into shifting
centres of ‘world-class’ medical expertise and the varied manners in which newly recognised IMT
destinations relate to the mobile embodied subjects they attract. Illustrative of the growing desire to
tap into the potential of IMT, one of the country’s most important IMT hubs, Penang, which made a
name for itself as a destination for lower middle-income patient-consumers from the nearby
Indonesian island of Sumatra, is increasingly under pressure to ‘diversify’ by opening facilities
capable of attracting patient-consumers from ‘developed’ countries. Committed to establishing
Penang, one of Malaysia’s richest states, as a ‘centre of medical excellence’ and ‘world-class
getaway’ (Emmanuel 14/06/2008; NCER 2009), the state government is encouraging greater
investment in ‘medical tourism’ to help transform Penang’s ailing tourism industry and foster growth
independent of electronics manufacturing – its previous mainstays (SERI 2004). Key to this plan has
been retaining, and improving on, Penang’s share of non-Indonesian foreign patient-consumers.4 Yet
responding to the urgent medical needs of lower middle-income Indonesians looks very different
from catering to ‘medical tourists’. Accordingly, regional development plans prescribe the cultivation
of spaces to attract higher-yielding (i.e., ‘big spender’) patient-consumers. In addition to seven
private hospitals in Penang endorsed by the Malaysian Ministry of Health for ‘medical tourism’,
there are proposals for turning a former island penal colony into a ‘medical tourism’ resort and for
the construction of an integrated specialist hospital and wellness resort bringing together ‘Western’
and ‘Eastern’ medicines and homeopathy under one roof, complete with a nursing college,
convention centre, hotel, serviced apartments and a herbal farm (Emmanuel 29/09/2008). With such
plans for upscale medical facilities, Penang officials are looking to boost overall prestige. ‘It adds to
their resumé’, observes one anonymous Malaysian medical travel agent (interview, 12/02/2008)
about this general trend, ‘They can say, “I get patients from the UK and Australia”, rather than “I’ve
merely got patients from Indonesia”’.
Whereas Penang may appear as yet another indiscriminate node on the map of ‘world-class’
care for those from more ‘developed’ countries, it assumes a different sort of relevance to Sumatran
patient-consumers who consistently generate the volumes that bulk up Malaysia’s overall IMT
figures and play a significant role in constituting the country as a destination (Ormond 2011).5
Indeed, while Malaysia received only around 11% of its foreign patient-consumers from ‘developed’
countries (6% of which hailed from ‘developed’ Asian countries) in 2007, more than 83% came from
‘developing’ Asian countries – and the vast majority of these from neighbouring Indonesia (APHM
2008). In spite of Malaysia’s heavy reliance on these intra-regional flows, however, this reality has
attracted little media, policy and academic attention for simple economic reasons. The per capita
expenditure of intra-regional flows from ‘developing’ countries packs a significantly smaller punch
than that of ‘medical tourists’,6 leading Malaysian and other Asian IMT government and industry
actors to increasingly invest in courting and cultivating Western, Middle Eastern, East Asian and elite
Southeast Asian ‘global health consumers’. Still, as an inpatient in an upscale Malaysian hospital
endorsed for ‘medical tourism’ in late 2007 myself, it seemed odd that my private room in the
international wing inaugurated only months prior by the Tourism Minister was the only one
occupied. The clamour for patient-consumers from ‘developed’ countries has produced an
infrastructure still largely devoid of ‘medical tourists’ to use it, revealing a significant disjuncture
with the real presence of foreign patient-consumers who are, by and large, not part of the IMT
markets in which the private healthcare sector and government have heavily invested. These ‘real’
IMT flows, due to the political and economic circumstances of the lower middle-income Indonesians
that by and large comprise them, have far more limited physical and economic mobility to access the
exclusive ‘medical tourism’ infrastructure being built.
The significant flows of patient-consumers out of Indonesia can be attributed to its substantial
socio-economic polarities, political instability and overall poor access to healthcare, a reality which
has long led middle- and upper-income nationals to seek healthcare in Singapore and Australia. Until
the end of the 1990s, however, Malaysia was not recognised as a suitable IMT destination. This
changed with the advent of the Asian Economic Crisis in 1997 when – contrary to neighbouring
Malaysia, Singapore and Thailand, whose nationals shifted from the private to the public healthcare
4 Some 73% of Americans, 56% of Europeans and 53% of Australians receiving care in Malaysia in 2007 did so
in Penang. However, these comprised only 1.22%, 2.7% and 1.12%, respectively, of the overall foreign patient-
consumer population (APHM 2008).
5 This is in fact the case throughout the region. According to an influential 2008 McKinsey & Company industry
report, some 93% of Asian medical travellers are estimated to seek out IMT destinations also within Asia, an
overwhelming figure compared to the relatively meagre 27% of North Americans, 10% of Europeans and 2% of
Middle Easterners that stay within their respective regions for care (Ehrbeck et al. 2008: 5).
6 While Singapore brings in USD2111 per capita by using cutting-edge medicine to lure wealthier patient-
consumers, Malaysia, with its reliance on higher volumes of lower middle-income Indonesians, attracts little
more than one-tenth of that amount per capita (APHM 2008; IMTJ 25/11/2010).
sector due to reduced out-of-pocket health expenditure – Indonesia experienced a steep overall
decline in the use of public sector provision and, correspondingly, of ‘Western’ medicine more
generally as real wages dropped by 40% at the peak of the Asian Economic Crisis (Waters et al. 2003:
174-179; Pradhan et al. 2007).7 While health expenditure declined within Indonesia, however, it was
precisely at this point in the economic crisis – correlating to currency devaluation that made
Malaysian exchange rates attractive for those who could no longer afford to go further afield for
treatment – that Malaysian private hospitals began to notice rapid growth in the number of non-
resident Indonesians turning to them for diagnostics and tertiary care. That this shift away from the
wealthier IMT destinations and towards Malaysia was partly responsible for having kept Malaysia’s
private healthcare sector – which had been expanding at a rapid pace prior to the crisis – afloat
during and in the wake of the economic crisis was not lost on the Malaysian government (Chee
2007). Its National Committee for the Promotion of Health Tourism identified ASEAN countries home
to emerging middle classes, like Indonesia, Cambodia and Vietnam, as its core market early on (MOH
2002: 106). Even now, government rhetoric on the resiliency of Malaysia’s IMT industry in the
present economic crisis emphasises the country’s medical prowess within, and solidarity with,
ASEAN, seeking out its patient-consumers ‘to cushion the impact of fewer arrivals from other
markets’ (IMTJ 27/11/2008).
With the Malaysian government’s embrace of the IMT industry as a ‘National Key Economic
Area’ (EPU 2010), the territories and scales through which ‘national development’ is pursued have
effectively been re-scripted to better link up with the foreign patient-consumer flows unevenly
distributed across the 35 private hospitals endorsed for ‘medical tourism’ by the Malaysian Ministry
of Health.8 Recognition that this significant internal variation is largely attributable to IMT flows from
neighbouring Indonesia has made the national and state governments more active in their
endorsement and fostering of greater cross-border regionalisation. This can be seen with the
Indonesia-Malaysia-Thailand Growth Triangle9 (IMT-GT), whose role has been to identify and
capitalise upon ‘complementarities’ both to benefit from and ultimately reduce disparities between
the three countries’ member-areas by taking advantage of geographical proximity and improving
cross-border mobility. Political leaders involved in the Triangle have suggested that cross-border
patient-consumer mobility would be ‘the key for IMT-GT members to get through the current global
economic crisis’ (The Bangkok Post 28/02/2009) for both ‘sending’ and ‘receiving’ areas. Indeed,
‘health without frontiers’ has become one of the pillars of cooperation between ASEAN member-
states, in line with the notion that ‘[c]ooperation across borders may enable better use of resources,
sharing of potential capacity and improving access of patients to quality care’ (Pennings 2007: 506).
The increasing focus on pooling resources and patient-consumers views this type of collaborative
‘outsourcing to other developing countries, especially for specialist, high-technology, diagnostic and
rehabilitation services’ as ‘a more cost-effective approach than attempting to develop national self-
sufficiency’ (Wolvaart 1998: 64; see McDonald et al. 2000; Morgan 2003; El Taguri 2007; Lautier
2008; Hopkins et al. 2009; Smith et al. 2009; Walraven et al. 2009).
The number of Indonesians travelling abroad for care during the Asian Economic Crisis did not
decline after the crisis. In fact, the Indonesian Medical Association (IDI) estimates that one million
Indonesians currently go abroad for medical care annually (IRIN 06/08/2009). With quality health
7 This was due to a significant increase in the cost of treatment and scarcity of basic medicinal products and
supplies caused by a crippled tax base and the system’s heavy dependency on imported pharmaceuticals.
8 In spite of efforts to portray the Klang Valley as the national anchor for the IMT industry, with no less than 17
MOH-endorsed hospitals for ‘medical tourism’, the capital city’s metropolitan region was responsible for
treating only 11% of all foreign patient-consumers in 2007. The bulk pursued care elsewhere: 61% to Penang,
with seven endorsed hospitals; 19% to Malacca, with three; and the remainder to the states of Kedah, Johor,
Sabah and Sarawak (APHM 2008).
9 Having expanded significantly since it began in 1993 as part of a broader ASEAN development policy, it
currently encompasses 100 million people across the Indonesian island of Sumatra, nine Malaysian states and
14 Thai provinces.
professionals, equipment and facilities sparse throughout Indonesia, national commentators have
suggested that ‘[l]ittle can be done to limit the practice [of IMT] as the government struggles to
provide access to health care for average Indonesians who are financially weaker and generally in
greater need’ (Hulupi 16/04/2006). In light of these constraints, the IDI has admitted, ‘We cannot
blame people for seeking treatment overseas’ (Gunawan 01/11/2007). Industry commentators,
however, caution against Malaysia’s over-reliance on Indonesia, given the presumed volatility of
intra-regional IMT and attempts at improving the quality of care in ‘sending’ countries (Suwinski, in
IMTJ 25/11/2010). Efforts to curb the outflow of Indonesian patient-consumers include the 2010 re-
opening of Zainoel Abidin State Hospital (RSUZA) in Aceh. At its launch, the Aceh Governor
RSUZA is the most advanced hospital in Indonesia, and its facilities can match prominent hospitals in
Penang and Singapore. I hope the new hospital will put an end to the practice of thousands of Acehnese
going to Penang, Malaysia, or Singapore each month for medical treatment. Including myself, who had
to opt for Singapore as a place to have medical treatment because the facilities there were far more
advanced than what we have had in Banda Aceh. But with this new hospital, I am certain that the
equipment we have now can rival hospitals abroad. (Irwandi, in IMTJ 03/02/2010)
Despite the Governor’s optimism and pundits’ foreboding, however, the Indonesian healthcare
system has a long way to go. The problem facing many hospitals in Indonesia is not necessarily the
lack of technology but rather the persistent lack of trained specialists with the technical expertise
required to operate the equipment.
Responsiveness to Indonesian patient-consumers’ ‘exile’ from their country’s healthcare
system has presented a series of challenges for Malaysian private hospitals, generating an
‘interdependency [that] is not cosy but… contested, complicated and productively unsettling’
(Raghuram et al. 2009: 10-11). With the ability to respond to and attract these intra-regional flows
contributing towards asserting Malaysia’s broader regional relevance, medical professionals and
political authorities throughout ASEAN have at times interpreted Malaysian private hospitals’
extension of hospitality to mobile Indonesian consumers not as a collaborative act but rather as the
patronising flexing of political and economic muscle by a more ‘developed’ country to poach their
‘rightful’ patients instead of demonstrating ‘solidarity’ with their citizens through more conventional
humanitarian aid avenues that recognise nation-states as the most appropriate venues for ensuring
the welfare of their populace. Taking the provision of care to Indonesians away from the space of
‘home’ has led Malaysian private hospitals to delicately re-frame themselves as a ‘complementary’
resource to regional medical professionals and not as competition. An anonymous Malacca hospital
marketing representative (interview, 21/03/2008), whose institution’s corporate social responsibility
policy allocates funds for educating Indonesian health workers, explains:
Many think that we are just being opportunists, going in and taking whatever we can from Indonesians.
But we need to be a responsible corporate body, to show some responsibility and initiatives to help
them. We say that we are always here to offer alternatives to your people. You should go to your
doctor first. However, if you want a second opinion or a procedure that is not available in your country,
then come here.
With Indonesian political authorities doing little to improve healthcare conditions on the ground to
stem their nationals’ cross-border healthcare pursuits (Praptini 31/10/2007), this facility’s active
reinvestment in improving Indonesian healthcare delivery is indicative of a starkly different kind of
engagement that is more intimate and sustained compared to that with ‘medical tourists’, presumed
to come from contexts where such aid is deemed less necessary or inappropriate.
‘Complementarities’ and ‘solidarities’
This section speaks to how globalising concepts and ideals – such as the practice of ‘world-class’
medicine – travel, as Minca and Oakes in this volume suggest, ‘through the production of new
experimental tourist spaces but, once grounded, become something radically different in terms of
practice and experience’ by exploring components of a commercial-political hospitality taking place
within the Indonesia-Malaysia-Thailand Growth Triangle (IMT-GT), a space of supposed
‘complementarities’ and ‘solidarities’ in which Indonesian Sumatrans enter parts of Malaysia more
easily than other Indonesians to access ‘world-class’ care. I draw upon in-depth interviews10 with
social actors engaged with IMT in the country’s three main IMT destinations – Penang, Malacca and
the Klang Valley – in the scope of research undertaken on the material and discursive positioning of
Malaysia as an IMT destination to relate how private Malaysian hospitals in Penang and Malacca,
specifically, respond to mobile Indonesian patient-consumers in ways not frequently extended to the
subjects of ‘medical tourism’. Indeed, as we shall see, the sole overlaps with the spaces and
subjects of ‘medical tourism’ may be the ‘world-class’ hospital staff and materials used for
Considered more within reach physically and economically than the national alternative which
entails a flight to Jakarta with care costs equal to or greater than in Malaysia, Penang and Malacca
provide healthcare services critical for the Indonesian island of Sumatra. Nearly 88% of all
Indonesians receiving private medical care in Malaysia in 2007 did so at the ten IMT-endorsed
hospitals in Penang and Malacca. Physical connectivity, therefore, has been key to overcoming
‘national’ barriers, leading to the improvement of transport linkages across the Straits of Malacca.
Among the most significant measures taken to facilitate Indonesian mobility was exemption from
the IDR1,000,000 (EUR84) exit tax (fiscal) for departures from Indonesian parts of the IMT-GT to
other areas of the Triangle, rendering more frequent travel across the Straits to nearby Malaysia
economically feasible for larger numbers of Sumatrans and, in turn, fostering greater intra-regional
trade, healthcare, tourism and educational ‘complementarities’ (ADB 2007a, 2007b; Emmanuel
05/07/2008; Mathaba 26/10/2008; Suhaimi 07/04/2009).11 Consequently, multiple regional airlines
set up routes between Sumatran cities selected for their IMT ‘sending’ potential (e.g., Djambi,
Medan, Padang, Palembang and Pekan Baru) and Penang and Malacca, bolster their status as
‘regional’ IMT hubs (NST 06/03/2008; D-8 Secretariat 19/08/2008). Symbolic of the growing
functional alliance between low-cost regional airlines and hospitals, Riau Airlines – whose 50-seater
plane makes its daily 30-minute flight from Pekan Baru in Sumatra to Malacca with an estimated
average of 30 patient-consumers on board – has a ticket counter in Malacca’s Mahkota Medical
Centre, allowing travel arrangements to be made within the hospital itself (Lim interview,
While some ‘health-conscious’ travellers use Penang and Malacca for preventive diagnostic
screenings and first opinions before ultimately turning to Singapore for second opinions and
treatment, many tend to put off seeking care in Malaysia until their illnesses have grown irreversibly
chronic or acute. Regional airlines are adapting their fleets in order to transport Indonesian patient-
consumers on stretchers, and authorised ambulances can now meet aircraft on the tarmac to
10 From late 2007 to early 2008, forty-nine interviews were held with respondents in top-level executive and
administrative positions (e.g., CEOs, directors, senior managers, board members and advisors) for
governmental, private and not-for-profit bodies; research, business development, marketing, policy, public
relations and customer service executives and officers; medical travel facilitators and medical professionals to
better grasp how they conceptualise IMT flows and responses and act to influence the course of the industry’s
development within Malaysia.
11 The fiscal was enforced upon exit from Indonesia everywhere else outside of the Indonesian part of the IMT-
GT until 1 January 2009 when the Indonesian government’s reformed regulation came into force. By showing
their tax identity cards at border crossings, Indonesians can now travel abroad from anywhere in Indonesia
without paying the tax. However, if they are without the card and not exempt from taxation, they are required
to pay IDR 2,500,000 to leave the country (The Jakarta Post 24/12/2008). Paradoxically, this policy change now
adversely affects Indonesian IMT into Malaysia. With many Indonesians unwilling or unable to acquire tax
identity cards due to the pervasiveness of the informal economy, some Malaysia-based IMT facilitators have
begun to pressure private Malaysian hospitals popular among Indonesians to discount the cost of the penalty
exit tax from high-ticket procedures in order to ensure that the Indonesian patient-consumer flow continues.
12 Similarly, with some 100 people departing daily from Medan to seek healthcare overseas, for instance, an
estimated 80% of passengers on a daily 40-minute flight to Penang are thought to be seeking treatment
(Gunawan 01/11/2007; anonymous Penang private hospital public relations officer, interview, 04/03/2008).
transport emergency cases without the need for passing through conventional immigration controls
(Emmanuel 09/09/2008). Such emergency transport measures hint at the gravity of conditions and
immediacy of treatment required by Sumatran patient-consumers crossing into Malaysia. ‘This
means that it’s very hard to treat some people because of the advanced states of their illnesses’,
observes an anonymous Malacca hospital marketing representative (interview, 21/03/2008). An
anonymous Penang hospital public relations officer (interview, 04/03/2008) concurs:
It depends on their [Indonesian patients’] financial ability – if they are financially secure. For those with
less funds, it's quite restrictive, though they may come here for serious illnesses... We have to screen
them [remotely] before they arrive because otherwise there will be a big shock when you see the
patient. Really! Sometimes they report that they have this [degree of medical problem] but when they
come in, it’s usually worse than they described – people are a degree worse than they actually tell us.
And sometime the results aren’t so great. We just have to deal with that when the patients come in.
Though patient-consumers with particularly urgent needs may be denied admittance by airlines and
hospitals if their conditions are too acute to be transported safely, this ‘open-arms’ approach to
Sumatrans in need contrasts with private hospitals catering principally to a ‘medical tourism’ market
that, concerned with cultivating their reputations for through untarnished success rates, turn away
patient-consumers that risk yielding negative medical outcomes.
Travelling to Malaysia involves significant financial planning and investment for many
Sumatrans. Unlike the luxury inpatient suites and hotels geared towards ‘medical tourism’, budget
accommodation is sought by Indonesian patient-consumers with limited funds. Inpatients tend to
stay in shared hospital rooms for MYR70 (EUR17) per night, leaving the single-bedded rooms
(MYR200 [EUR48]) and VIP suites (MYR500 [EUR121]) for wealthier inpatients, while private
hospitals receiving many Indonesians will work directly with local hostels and long-stay
accommodation to secure affordable rates for outpatients and inpatients’ family members:
Most of them [family accompanying Indonesian patients] don't stay at a hotel, unless they are super-
rich... Most of them will stay at apartments where, it's like – can you imagine hospitals? – they sleep on
cots. And I think that it's not easy to get that in Kuala Lumpur, where it's, of course, very expensive... It
very much depends on patient. There are apartments with or without attached bathrooms, with or
without air-conditioning... They just need to tell us the budget. (Anonymous Penang private hospital
public relations officer, interview, 04/03/2008)
Indicative of the growing institutionalisation of Malaysia as an IMT destination, some hospitals have
begun to pair up with select Indonesian banks and credit card companies to provide credit facilities
to account holders. Yet, given the extent of Indonesia’s informal economy, some patient-consumers
– uninsured and without credit – carry suitcases of Indonesian rupiah (IDR) to pay for treatment in
cash. Notes Francis Lim (interview, 22/03/2008), the CEO of Mahkota Medical Centre in Malacca:
Generally, they [Indonesian patient-consumers] are middle-class people. They normally would be able
to afford to pay for their treatment... But sometimes we do have cases where, after the operation
starts, the procedure becomes complicated. When that happens, the patient’s family is liable for the full
amount. In such cases, the doctors usually understand. We’ll talk about how to help the patient, and we
normally charge less. We want to do this business from the heart. We’re not just here to make money
from providing a service. Of course, we must be profitable because we have shareholders and we must
pay competitive salaries. But we do this because we understand that it’s more complicated than what
With medical travel insurance covering complications largely out-of-reach to non-Western markets,
private Malaysian hospitals acknowledge that uninsured foreign patient-consumers – particularly
from ‘developing’ countries – may not always be capable of fully covering their medical costs.
While the steady stream of Indonesian patient-consumers crossing the Straits of Malacca for
care in Malaysian private hospitals more than compensates for any shortfalls, the pervasive
‘business from the heart’ rhetoric in facilities in Penang and Malacca identified here hints at a certain
flexibility and willingness to provide care to patient-consumers whose healthcare ‘needs’ are placed
against the backdrop of Indonesia’s poor socio-economic circumstances. The ways in which these
private facilities cater to the perceived requirements of quality and comfort of their predominantly
Sumatran patient-consumers is powerfully indicative of providers’ simultaneously political and
commercial negotiation of responsible engagement with patient-consumers who appear to require
very different regimes of support than those which are extended through ‘medical tourism’.
Narrow focus on the seemingly ‘novel’ spectacle of the ‘developed’ relying on ‘developing’ has
filtered how we have come to understand the extension of hospitality by contemporary IMT
destinations, leading to an impoverished awareness of IMT destinations’ multifaceted ‘care’
relationships with an array of foreign patient-consumers and their implications. By drawing attention
to responses to lower middle-income regional patient-consumers who – in spite of comprising the
bulk of IMT flows today – too often pass below the mediatic, political and academic radar locked
onto the spectacle of ‘medical tourism’ from ‘developed’ countries and its associated trappings, I
have sought to contribute to contemporary mappings of the wide ‘range of new relations between
capital and labour, bodies and the state, belonging and extraterritoriality, transformations in political
governance, and realignments of medical citizenship and the meanings of public health’ (Whittaker
2008: 273) being produced through the international pursuit and provision of healthcare.
IMT destinations are held to have the potential to derive considerable benefit from profiling
themselves as capable of responding to the ‘needs’ of patient-consumers in ‘medical exile’. ‘Care’, as
‘the response to a need’ (Tronto 1993: 170), undertakes fundamental political work. Through
entrepreneurial attempts at harnessing IMT flows, foreign patient-consumers’ ‘needs’ get assessed,
measured and subsequently framed as motivated by discontent with healthcare ‘back home’,
conveniently repositioning foreign patient-consumers as ‘“cases” for the state and the development
apparatus’ (Escobar 1995: 225). Via claims to IMT destination status, we have seen Malaysian
authorities try to accomplish this by promoting a commercial-political hospitality that seems to
transcend national belonging by playing into biosocial claims to universal access for consumers, from
wherever they might come. The provision of ‘care’ through this extension of hospitality constitutes
both international patient-consumers and IMT destinations in new ways in relation to the political,
social, cultural and economic barriers to ‘care’ in patient-consumers’ countries of residence.
My reading of the Malaysian IMT context has sought to present some of the dilemmas faced
in the metaphorical space of the ‘hotel-fortress’ evoked by an ever-larger number of IMT
destinations throughout the world as they promote themselves (Ormond 2011). Government- and
industry-sponsored IMT campaigns with taglines such as ‘Korea: Hospitality in healthcare’, ‘Malaysia
Healthcare: Quality of care for your peace of mind’, ‘Philippines: The heart of Asia’, ‘Singapore
Medicine: Peace of mind when health really matters’ and ‘Taiwan cares for your health’ increasingly
welcome patient-consumers across the globe. Contrary to Lawson’s (2007: 5) assertion that
neoliberalism has ‘effectively privatised responsibility rather than politicised it’, we see here that
markets are not necessarily ‘exempt from an ethic of care’ (Smith 2005: 15). Yet, if recognising
courted patient-consumers as being in ‘medical exile’ implies recognising their dignity and the
gravity of their unmet needs ‘at home’, then IMT destinations are entering into an ethical playing
field in which they are challenged by the political consequences of market-based recognition of the
‘needs’ of their foreign markets. As Benhabib (2004: 19) suggests, there may be an ‘irresolvable
contradiction... between expansive and inclusionary principles of moral and political universalism, as
anchored in human rights, and the particularistic and exclusionary conceptions of democratic
closure’. While ‘tourism’ frequently gets deployed to designate an IMT destination’s recognition and
reception of patient-consumers from ‘developed’ countries as well as its deflection of extended
responsibility towards them, what becomes of the largely ignored intra-regional IMT flows from
‘developing’ countries – so fundamental to forging and sustaining many Asian IMT destinations –
that rely more significantly on these destinations? Important work remains to be done that explores
the ethics of market-mediated responsiveness to ‘medical exile’ in the context of IMT.
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