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INTRODUCTION
Healing holidays? Itinerant patients, therapeutic locales and the quest for health
Harish Naraindasa and Cristiana Bastosb
aJawaharlal Nehru University, India; bSocial Sciences Institute, University of Lisbon, Portugal
This special issue on medical ‘tourism’ draws upon the panel ‘Healing Holidays’ held at the Society for Medical Anthropology’s 50th anniversary conference in 2009. The issue brings together anthropologists and historians whose work addresses the historical evolution and contemporary transformation of the traditional spa built around the iconic image of ‘taking the waters’, and the more recent phenomenon of medical ‘tourism’, with its super-speciality hospitals and clinics that repair and replace organs and body parts, or assist infertile people in their quest for conception. The final article addresses medical travel websites that serve as mediators between patients and their destinations in their itinerant quest for health.
The articles as a whole problematise whether holidays can be healing and whether healing can be a holiday, exemplified by the often-raised question of whether the spa is medicine or vacation. Using different perspectives and ethnographic contexts, the first five articles address the spa – which in the contemporary imagination is associated with a pleasurable vacation with some health thrown in, best described by the currently popular word ‘wellness’. Partly fashioned by literary and cinematic conventions, this picture of the spa is often used as a form of social commentary on the contemporary middle class. In earlier eras, it was used in much the same way to comment on the aristocracy and the rising bourgeoisie. Or, as is the case in the opening article, spas could be used in the mid-nineteenth century America to craft a distinctly southern ideology of race identity. This function has its counterparts in the spas of the colonial tropics (Jennings 2006) and continental Europe. While this vein of using the spa as a form of social commentary runs through all the articles in this issue, these papers also, and in fundamental ways, point to the fact that until recently in the Euro-American world, the spa lay within the provenance of conventional medicine. This is still the case on the European continent, where the traditional training in medical hydrology, balneology, and climatology available in formal curricula evolved into the specialty of spa medicine. Although not everyone in the medical profession in Europe endorse its ‘scientificity’, spa medicine (or ‘thermalism’) is a legitimate practice in the continent.
The opening piece by LaFauci fuses these two strands – of reading the spa as social commentary and investigating it as a site of medical practice – by showing that the constructed distinctiveness of the southern waters of Virginia is clearly located within the medical lexicon of the time, allowing white Southerners to see them and use them as a cure to a southern climate and its southern diseases, reinforcing, with this difference, a distinct southern ideology of nationalism.
Hence, not only was the spa once legitimate medicine in the Euro-American world, but it continues to be so on the European continent, where it is supervised and supported by the state and is a reimbursable medical expense to varying degrees in the different countries, although this is now dwindling. This situation is a far cry from its practice in either contemporary America or Brazil, where the spa as medicine slowly fizzled out from the early part of the twentieth century, reappearing instead as an alternative healing practice.
Climatology and medical hydrology developed a body of knowledge about the healing properties of locales, with their special composition of airs and waters. Within these disciplines, mineral waters were at times considered medicinal substances capable of curing patients of long-standing chronic conditions, or at least relieving their worst symptoms. The uses of waters for healing and for leisure had been around for thousands of years, often supported by religious beliefs and rituals, which medicine came either to prolong or to replace. The developments of medical hydrology helped classify the different therapeutic locales according to the diseases and conditions that they were best thought to cure. And to cure was what many patients were looking for at the different spas; and unlike today’s image of the spa as a site only for the posh and well-heeled, there were many poor and indigent patients taking the waters, as shown by Brockliss (1990), Mackaman (1998), and Weisz (2001) for France, and Bastos (this issue) for Portugal.
This double argument of the spa as medicine and the spa as a place that also catered to the hoi polloi re-appears across the articles. In Virginia, one can see, through the mise-en-scene that LaFauci creates, that despite the erasing of enslaved black people from the narrative of the spa – in which at best they appear as servants with separate quarters and different fees – there was also a ‘black sulphur spring’ set apart at one of the most prominent resorts, and in others, where enslaved people could be treated for various illnesses in exchange for their labour. In Europe, through the Termas in Portugal, or the Czech Marienska Lanske, or the Ayurvedic spa in Germany, one can see that the spa is the site of salvation for patients with rheumatic pains, unresolved and painful chronic diseases, and kidney stones. Additionally, in a place like Marienbad, until the collapse of communism, the spa was both a reward for hard work and was part of an economic rationale of extending the productive life of the worker.
Such a double rationale, supported by state socialism in the former Czechoslovakia and by a kind of socialised insurance scheme in the former West Germany, seems to symbolise the democratisation of a set of therapeutic and social practices that were once seen to be the sole preserve of the aristocracy and the bourgeoisie. While it is evident from the early history of Monchique, Portugal, that this state of things is partly an illusion, the argument is not untrue, as even those places that were indeed the sole provenance of the elites are now opened to other social classes, enabled by state support and by various models of health insurance.
The continental European spa, caught in a web of science, medicine, and socialised insurance, emerges slowly in the early twentieth century and fully consolidates itself by the mid 1970s. But with the collapse of state socialism in the East, and the shrinking of the welfare state in the West, the spa was re-invented as a wellness destination, leading to tensions and conflicts (as in Marienbad), or at times to creative pluralism (as in Monchique), or setting out in wholly new directions (as in Germany). While Bastos and Speier show this transformation with respect to Portugal and Czechoslovakia/Czech Republic, Quintela’s comparative study of Brazil and Portugal shows how this change is, in part, a replay of a phenomenon that occurred in Brazil in the 1920s. Here, the older medical spa, as it steps out of the realms of both conventional medicine and state support, reinvents itself as alternative therapy and a wellness destination, where a focus on energising the body – rather than pain and its alleviation – becomes the new idiom through which bodies are made whole and healthy. In Monchique, by contrast, this replay creatively combines the old and new. Rather than jettisoning the medical aspects of the spa, it offers patients a variety and choice of treatment not envisaged in the old spa, thus lifting the sagging spa economy – already hit by shrinking social insurance and a reduced, ageing clientele – and making it into a trendy consumer product. In Marienbad, on the other hand, the collapse of socialism sees the exit of the trade unions and workers, and with them, Czech patients more generally. These spas now begin to compete for wealthy German spa goers, and for a new group of English-speaking tourists from the UK and North America, who, unlike the Germans, are not familiar with the conventional spa etiquette and its rituals. This confluence of tourists leads to tensions and contradictions between the old notion of the spa and the new vacationer in search of pleasurable relaxation.
These transformations and the ensuing contradictions are played out on a grand scale in Germany, the largest spa-going nation in Europe, where the spa is captured in the three German terms of Bad (bath), Therme, (a hot mineral water source or pool), and the Kur (cure, or the regimen). It is evident from the German case that the Kur-Bad or the Therme slowly re-invents itself by expanding its therapeutic repertoire. This re-invention, in response to a shrinking insurance fund and an ageing and unproductive population (which is true for the whole of Europe), leads the large Kur industry to look at new therapeutic formats like Ayurveda, which is now appropriated and organised as a Kur experience with its own Kur regimen, although it is removed from the Therme or the Bad. This is enabled in part by the German ability to accommodate therapeutic pluralism and attention to order, best exemplified in the institution of the Heilpraktiker or ‘lay healer’, who is allowed to practice, with some kind of nominal training, a host of therapies. This kind of rule-bound, licensed, poly-therapeutics, enshrined in a non-university trained non-physician, and the surprising mimicking of this kind of poly-therapeutics by university-trained physicians, provides the larger climate within which the Kur readily transforms itself into new therapeutic formats, while the new formats are minted in the idiom of the Kur.
While German therapeutic practice exemplifies the blurring of boundaries between what is seen as a contrast between the spa and medicine in the non-European world, this blurring of boundaries is equally evident in all the articles dealing with the spa in the western world, past and present. Thus, a ‘healing holiday’ is not a contradiction in terms, as one would read from contemporary conventions that establish that people should be cured (and not healed) by hospitalisation or by the ubiquitous pill. Healing and pleasure can indeed coexist well, albeit in tension; travelling to posh locales for medical reasons may raise judgments and comments about the nature of that healing, counter-argued by an emphasis on the harshness of the spa regimen. The current transformations of the European spa, where ‘patients’ seem to turn into ‘consumers’, and ‘cures’ turn into ‘commodities’, best exemplified by the experiences at Monchique and Marienbad, may enhance the distance between the pleasurable and the painful sides of the experience. Hence, it is not surprising that in Germany the word Kur was officially erased from the lexicon in 2000, although it survives in popular vernacular: its survival is due in part to inertia and in part to a perceived need for it, which is explored in richly textured ways by both Quintela in Brazil and Naraindas in Germany.
It is in the light of this orthodox norm of organic pathology requiring expensive hospitalisation, which is increasingly beyond the reach of uninsured and underinsured patients in the first world, that the second proposition of healing-as-holiday has run into most difficulty. This new kind of travel, often for surgical procedures, is even harder to reconcile with a holiday than the spa regimen that often included pleasurable pursuits. This has, understandably enough, led authors to either discard the term (Inhorn, this issue), or call it ‘medical travel’ (Sobo 2009, and this issue), or even suggest that such patients are in a kind of exile (Inhorn and Patrizio 2009).
‘Medical exile’ is best exemplified in this issue by Inhorn’s moving depiction of a rural and well-to-do Sunni Islamic couple’s quest for conception. In contrast to the stereotypical picture of Islamic societies as blithely polygamous, where the stigma of infertility is believed to result in the man taking another wife, a not-so-young couple, after close to two decades of marriage, repeatedly set out to conceive. Disallowed by Sunni law to have donor eggs, the couple goes in search of Shia gametes. Since any kind of surrogacy is frowned upon, their travel is conducted under the guise of a holiday. Here, the holiday functions as a trope for a painful and traumatic quest, relieved in this case by a deep and abiding love that unites the couple, who are simultaneously surrounded by a horde of children produced by the man’s several siblings. What Inhorn calls a ‘reproscape,’ this kind of ‘holiday-exile’ is propelled by legal and religious injunctions, associated with technology and money, and concerned at every moment with movements and boundary crossings between Sunni and Shia bodies and American gametes in Arab wombs.
If affect is easily but implicitly at the centre of this holiday-exile narrative, in the case of Harris Solomon’s depiction of Euro-American travel to India, affect is explicitly at the centre of his narrative. Solomon argues that emotion, rather than being ancillary to any analysis of medical travel, should be explicitly addressed as conditioning medical travel. Drawing on a body of theoretical literature that has attempted to address this through the notions of ‘emotional economy’ or ‘affective economy’, he uses affect as both a thematic and theoretical resource to show how emotion is central to the selling of medical tourism by five-star Indian hospitals to prospective Euro-American clients. He sees affect as ‘the linchpin between everyday sentiments and objects, clinical care, and medical travel’s institutional structuring’. It can appear in many forms, including, for example, as fully accredited, high-quality, and worry-free care for anxious and prospective patients. In Solomon’s narrative, this is best embodied by a personal and exclusive attendant, who soothes the passage of a nervous American couple into an Indian landscape of sights and smells that assault their senses. While the couple is driven into exile by high cost and no insurance, an Englishman is cast into exile by an insensitive and uncaring National Health Service (NHS), which refuses to give him an MRI for his lower back pain as it has decided that his pain is in ‘his head’ (imaginary) and not in his spine. This lack of affect at home, which should be seen as a fusion of the emotional, the economic and the medical, is offset by the abundance of affect at the Icon Indian hospital, with its fawning nurses and personal attendants, and with the continuous crooning of care beamed over its in-house television. The acme of this care bubble is the immediate MRI on arrival, which results in a quick diagnosis of his problem, which the NHS had missed over 20 years, and subsequent surgery that resolves the pain.
The same affect, through the central and recurring trope of a ‘worry-free experience’, is sold by Medical Travel Agencies’ websites to prospective American patients. Through a novel and carefully conceived method, Elisa Sobo presents an ethnographic account of American MTA websites to show how a particular picture of the patient as a savvy consumer is constructed. This consumer, who knows what is best by consulting an array of information before exercising her choice, is also a patient who will be fully attended to by various kinds of concierge services in a world-class facility and operated upon by world-class (read: American-trained) doctors. Sobo shows how these savvy consumers exercising choice are at odds with the cognate construction of patients who want to be fully looked after. But the MTA websites resolve this contradiction by presenting these two facets in different parts of their sites; in the process, they iron out – if not altogether negate – possible contradictions into experiences that at once promise to be self-fashioned and a worry-free travel bubble.
It is evident that what makes patients itinerant in both the old and new kind of medical travel is either a perceived shortage or constraint at ‘home’, or the sense of having reached a particular kind of therapeutic impasse, with the two often so intertwined that ...
