KESEHATAN PARIWISATA

(HEALTH TOURISM)
Tuti Parwati Merati
Divisi Ilmu Penyakit Tropis dan Infeksi
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran,
Universitas Udayana
What is Health Tourism ?
• The World Health Organization (WHO) definition of health, that
health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.
• Health tourism is the broadest of all possible categories of health-
related activity that involves travel.
• In other words, medical tourism is a subset of health tourism.
• Other subsets of health tourism may include culinary tourism,
accessible tourism and sports tourism.
What is medical tourism?
• The term medical tourism has come to embrace all facets of
consumers seeking treatment, improvement or change through
medical or wellness practices – provided, they cross an international
border to do so.
• Medical tourism is the go-to keyword phrase for internet searches
and advertising campaigns. For search engines like Google and Bing,
medical tourism by far exceeds any other phrase when searching for
cross-border health care options.
• Medical tourism, the phrase, is here to stay. It’s a popular, consumer-
driven search term. When looking for information about medical
treatment abroad, media and consumers alike search out medical
tourism.
Medical tourism
• Medical tourism: pada prinsipnya adalah perjalanan seseorang ke luar
negeri (atau mungkin juga dalam negeri), untuk tujuan mendapatkan
perawatan kesehatan, baik general check up, treatment maupun
rehabilitasi.
• Merupakan konsep baru dibidang medis yang diprediksi akan menjadi
menjadi lifestyle dan mempunyai potensi besar.
Types of
Medical
Tourism
Model pendorong terjadinya Medical Tourism

Globalization Technology
Medical Tourism

Consumerism
Is it medical? Is it health? Is it wellness?
• Medical tourism, health tourism, medical travel, and health travel –
these phrases are not interchangeable, yet they are being used
interchangeably, but with very different meanings, by different
interest groups, leading to some of the current confusion
• Researchers, economists and government statisticians have a need to
define medical tourism in economic and sociological terms. Medical
professionals, health care providers, medical travel service providers
and wellness companies have a different need, relevant to the
medical and health related services they offer
Is it travel or is it tourism?
• The word travel – as in medical travel or business travel – suggests a
purposeful, not recreational trip. Highly-skilled, professional services
accompany purpose-driven travel – educational conferences,
continuing education workshops, various business, trade, or
professional meetings.
• The word tourism – as in medical tourism, adventure tourism, cultural
tourism, or culinary tourism – reflects a more leisurely or pleasurable
trip. Associated with all varieties of tourism are non-professional
service industries such as transportation services (airlines, cruise
ships, tour buses), hospitality services (hotels, resorts) and
entertainment venues (amusement parks, casinos, shopping malls,
music and sports venues, theaters).
Medical tourism is not medical travel
• Medical travel is a phrase very much preferred over medical tourism by
health care leaders, hospital executives, doctors and other medical
professionals.
• Most have reluctantly accepted the term medical tourism but many
continue to dislike it because they feel it trivializes the process of getting
and giving treatment and care.
• Medical travel is the process by which a consumer (a patient) gets
treatment for a medical condition. Treatment is nearly always invasive. It
includes dental implants, fertility treatments, alternative or experimental
procedures, addiction treatment, Lasik eye surgery, cancer therapies, as
well as major surgery procedures.
• Many medical travel patients, or medical travelers, require admission to
hospital, whether for ambulatory care and a stay of less than 24 hours, or
for inpatient care and overnight stay. Most require light or general
anesthesia, administered by a licensed medical professional
Characteristics of the medical traveler
• They are not resident in destination country
• They travel from home to a different country for care
• The cultural or social environment and/or language of the medical destination may be different or
strange
• They are traveling international patients.

A medical travel journey is distinguished by the following:

• advance planning
• exchange of medical records and medical history
• pre-surgery instructions that may need to be followed prior to reaching the medical destination
• consideration about the kind of accommodations that will be needed post-surgery
• recovery care management
• care planning and follow-up upon returning home
• possible additional, unexpected medical attention

This last item is very important. The medical traveler may acquire an infection, get a complication,
or have a bad outcome, likely needing further medical attention.
Are international patients medical tourists?
• International patients are not medical travelers or medical tourists. By reason of
employment or retire-ment, they may reside in a foreign country, and they
usually will seek medical care there. They are expatriates. Their homes and
families are nearby.
• Other international patients are people on vacation who are struck by illness,
experience health-related symptoms that need attention, or have an accident
while on vacation.
• Most of these international patients make their way to nearby clinics or hospitals
for emergency care.
• These international patients may be offered translation services, travel
arrangements, assistance with cross-border insurance or financial transactions
and other “concierge” style activities by the hospital.
• Migrant workers, retirees and new immigrants may sometimes be considered
international patients rather than medical travelers. Issues surrounding access to
health care for these groups are political issues, not issues of individual health
choice.
• All international patients would be well-served if hospitals used similar care
management protocols as they reserve for medical travelers.
Travel medicine (TM) or emporiatrics
• is the branch of medicine that deals with the
prevention and management of health problems of
international travelers.

• Concerned with both prevention and management of

illness related to travel

• Focus : travel related to Host, Agent, Environtment

Kedokteran wisata atau
travel medicine (TM)
• adalah bidang ilmu kedokteran yang mempelajari persiapan
kesehatan dan penatalaksanaan masalah kesehatan orang yang
bepergian (travellers)
• Bidang ilmu ini baru saja berkembang dalam tiga dekade terakhir
sebagai respons terhadap peningkatan arus perjalanan internasional
di seluruh dunia.
Travel Clinic
• Adalah klinik yang memberikan pelayanankedokteran wisata
• Umumnya berada di negara-negara maju untuk memenuhi kebutuhan
warga mereka yang akan bepergian ke negara-negara berkembang
• Sekarang di Indonesia sudah mulai berkembang, terutama utk orang2
yg bepergian dalam jumlah besar (naik haji,dll)
TM
• Kedokteran wisata masih belum dianggap sebagai
suatu spesialisasi tersendiri di kalangan medik dan
belum ada standar pelayanan untuk itu. Namun jelas
bahwa praktek kedokteran wisata berbeda dari
praktek kedokteran konvensional.
• Jika praktek dokter biasanya ditujukan untuk kuratif,
maka praktek kedokteran wisata lebih banyak pada
aspek promotif dan preventif
TM
• Dalam pelayanan kedokteran wisata, orang yang datang umumnya
adalah orang sehat yang membutuhkan informasi dan tidak
menganggap dirinya seorang pasien, meskipun mungkin saja
statusnya berubah menjadi pasien setelah pulang dari perjalanan. Di
sini ada perbedaan bentuk komunikasi yang fundamental yang harus
dipahami oleh tenaga kesehatan
TM
• Dalam hubungan antara dokter dan klien, mempunyai
hubungan sejajar yang bersifat informatif (dokter
berperan sebagai ahli teknis), interpretive (dokter
berperan sebagai konselor untuk membantu klien
memutuskan yang penting bagi dirinya), dan
deliberatif (dokter berperan sebagai guru yang
memberi tahu klien apa yang harus dikerjakan dan
mengapa hal itu harus dikerjakan)
• Ref : Pakasi L.V., 2006 . Pelayanan Kedokteran Wisata: Suatu Peluang.. Cermin Dunia
Kedokteran No. 152,2006 (ISSN : 0125-913X)
HISTORY OF TM (1)
• The disciplines of TM evolved initially from infectious disease,
tropical and preventive medicine and historically from
quarantine and international health regulations, the subject
encompasses the whole range of clinical and preventive
medicine; this includes care of the travelers with special needs
such as, children, the elderly, pregnant women, and person
with underlying medical problems: cardiovascular, respiratory,
kidney, GIT, metabolic , neurological, malignant, HIV and
behavioral dis.
• Important component of TM includes not only vaccination
and prophylaxis for malaria, but also advise on accident
prevention, sexual health and guidance on contraception,
safety food and water, hygiene and other precautions
 HISTORY OF TM (2)
• It is well known that medical students,
nurses, doctors and other HCW in
developed countries receive little training
on tropical medicine and diseases and
hazards outside their own environment. Yet
many infectious disease largely ignore
temperature gradient.
• This has now been recognize by a number of
universities in North America, Europe,
Australia , and the Far East which have
established academic departments in travel
and geographical medicine
HISTORY OF TM (3)
• Proposed by Jane Zuckerman :
the establishment of an academic centre on travel medicine at
the Royal Free Hospital School of Medicine, University of
London. The concept and the need of such a centre was
approved by the R&D Committee, education and council of
the school, and
• The Royal Free Hampstead NHS Hospital Trust, supported the
school ‘s initiative, and later the proposal for dedicated travel
clinic to serve the staff, students and patients and the traveling
public.
• in 1995 The Centre for Tropical Medicine and Vaccines
was opened.
 Why Travel Medicine?
Increased trend of travelers
TOURISM 2020 VISION

International
arrivals are
expected to
reach +1.6
billion:
• 1.2 billion will
be
intraregional
and
• 378 million
will be long-
haul travellers.
Why Travel Medicine important?
• Scope : has largely evolved in response to
changing of travel trend 
• many more people are travel abroad,
• the reason for travel and types of travel has become much more diverse.
• Organized package tour remain popular, but many traveler are becoming
more adventurous and choose to backpack out with ‘tourist‘ areas, go on
expedition into remote areas sometime in several countries and work as
volunteers for prolonged period.
• Travel for business take a common place.
• In addition, potentially vulnerable groups of people such as the very young,
the elderly, pregnant women and those with underlying medical problems
or disabilities and immunecompromized are traveling more than ever
before.

• As a result of these changes: more people need

information, more advise and more prophylactic
prior and during travel
Why Travel Medicine is important
Travel Medicine (TM)
1. Concerned with both prevention and management of illness
related to travel
2. Illness may result from exposure to infection, accidents,
psychological upset, environmental hazards and political
unrest
3. The specialty of TM therefore is truly interdisciplinary and
international specialty involving numerous disciplines
including , tropical medicine, infectious diseases,
microbiology, public health and nursing, to name but a few
4. Continued surveillance of illness and disease both in the
host countries and returning travelers is necessary to allow
sound risk assessment to be made for intending travelers.
This is a crucial area for development within the specialty
5. Dissemination of information regarding real or potential risks
can both prevent illness and increase detection of illness in
travelers who have returned to their country of origin. This
may have important public health implications when
considering secondary cases or outbreaks as a results of
travelers returning with infections
Travel Medicine is a unique specialty

• It is part of preventive
medicine
• It includes
epidemiology of
diseases
• It accommodates
curative care and self-
treatment
 The Primary Goal in
Travel Medicine …..

is to keep travelers alive and healthy.

Steffen, 1994
 Traveller’s Health Risks
Traveller’s Health risks Traveller’s Health
Steffen R et al. J Infect Dis 1987; 156:84-91 Scope Of Problem - Yearly(CDC, 2008)

Of 100,000 travelers to a developing • 24M travel to developed areas

country for 1 month: • 6M ill (25%)
• 50,000 will develop some health • 6M travel to developing
problem countries
• 8,000 will see a physician • 3M ill (50%)
• 5,000 will be confined to bed • 2M exposed to malaria
• 1,100 will be incapacitated in their • Mortality: 3000 (.0015%)
work • 2000 MVA
• 300 will be admitted to hospital • 600 Falls
• 50 will be air evacuated • 200 ID
• 100 Miscellanous
• 1 will die
Mortality and morbidity
Mortalitystudies indicate that the cardiovascular disease accounts for
most deaths during travel (50-70%), while injury and accident follow
(~25%). Infectious disease accounts for about 2.8-4% of deaths
during/from travel.
Morbidity studies suggest that about half of the people from a
developed country that stay one month in a developing country will
get sick.[1] Traveler's diarrhea is the most common problem
encountered.
Pendekatan dalam Travel Medicine

Traditional Disciplines New Discipline

Tropical Medicine
Infectious Diseases
Internal Medicine
Epidemiology

Specific: travel related

Pediatrics
Geriatrics
Obstetrics TRAVEL
Dermatology MEDICINE
Venerology Prevention
Psychiatry
Ophthalmology
Otolaryngology
Traumatology Self-Therapy
Clinical Microbiology
Physiology (altitude, diving) Therapy
Pharmacology

Robert Steffen, 1994

Types of Travellers
• Business Travellers brief, high standards, may be frequent
• Organised Tours usually 2-6 weeks, “safe”, groups
• Backpackers unpredictable, 8-52+ weeks, wide-ranging, low budget
• Ex-pats local knowledge, use local systems

 All have different risk profiles

Anthony Geraldine (2009)

Travelers risk profiles
• Business: URTI, GIT, Alcohol, STDs

• Organised Tours: GIT, URTI, environmental hazards

• Backpackers: GIT, tropical diseases, accidents

• Ex-pats: MVAs, accidents, infectious diseases

Anthony Geraldine (2009)

Special Risk Groups
• Pregnancy
• Children
• Elderly
• Expats and long-term travelers
• VFR (visiting friends and relatives)
• Cardiac or Lung disease
• Diabetes
• Immuno compromised
Scope of TM
• Travel medicine includes pre-travel consultation and evaluation,
contingency planning during travel, and post-travel follow-up and care.
• Information is provided by the WHO that addresses health issues for
travelers for each country as well as the specific health risks of air
travel itself.[2]
• Also, the CDC publishes valuable and up-to-date information.
Pre-Travel Consultation

• To give updated and

accurate advices to
travelers prior to their
trip regarding the health
risk and its prevention.
• To assess the traveler’s
fitness for travel.

INFORMATION IS IMPORTANT
 Potential issues in travel advice/education
Risks in Travel
Non Communicable Risks
• Aircraft travel, reduced O2, pressure and humidity
• Motion sickness
• Jet Lag
• DVT’s and immobility
• Altitude
• Heat/cold/humidity
• Sunburn
• Water safety
• Accidents and Injuries
• Alcohol drinking habit and safety (methanol intoxication)
• Animals and Insects
Potential issues in travel advice/education
Communicable Risks
There are many potential diseases spread via :
• Food and water
• Insect vectors
• Soil and water
• Sexual contact, Body-fluid exposures
• Animals
Potential issues in travel advice/education
Communicable Diseases
No vaccines
• Dengue
• HIV
• Amoebiasis
• Filariasis
• Novel /New H1N1
• Avian Influenza
• Others: ciguatera, legionella, leptospirosis,
meliodosis, Typhus, strongyloides, hookworm, hep-E,
schistosomiasis
 Potential issues in travel advice/education
Communicable Diseases
Vaccine Preventable
Routine background
• Diphtheria/tetanus/pertussis
• Polio
• MMR Varicella
• Influenza

Travel Related
• Hep A and B
• Typhoid
• Cholera
• Japanese Encephalitis
• Rabies
• Tuberculosis
Documents needed
Principles of TM Practice
• Identify general and specific risks for traveler
• Provide specific advice about hazards which may lead
to appropriate behavioural change
• Recommend specific risk reduction interventions with
perspective of priority (vaccine,
medications ,repellants)
• Provide preventive interventions safely and efficiently
• Provide the mechanisms for safer management of
illness while traveling and on return
Medical kits and health products
• Traveller’s medical kits are part of good preparation.
They contain prescription and nonprescription
medications and first aid items to treat common
travellers' ailments early and avoid complications or
need for accessing treatment while travelling.
Typically they deal wit h gast roi nte st i nal and
respiratory infections.
Medical kit contents
All travellers
• Items to treat cuts, scratches, burns, strains,
• splinters
• Paracetamol
• Repellent
• Consider condoms
Additional for western countries
• Anti nauseant
• Broad spectrum antibiotic for respiratory infections
• Antacids
• Pseudoephedrine/antihistamine
• Minor sedative
• Laxative
Medical kit contents
Additional for less developed countries (gastro kit)
• Rehydration solution
• Loperamide
• Tinidazole
• Norfloxacin (or azithromycin for children)
Additional for comprehensive kit
• Sterile needles and syringes
• Alcohol swabs
• Antihistamines
• Antifungal and antibiotic cream
During Travel : Important Notes to Remind
Common issues to be discussed for all travellers are:
To know and care about general information on local
situation
• eating and drinking safely
• insect avoidance
• traveller’s diarrhoea management
• dog bite management, and
Specific topics : Safe sex practices, alcohol drinking habit :
drink safely (where and what) to avoid the harm of alcohol
intoxication
Post-travel illness

• Managing post-travel illness is an important part of travel medicine. Illness

following travel is quite common, and much presents in general practice.
Recognition of life threatening syndromes is paramount, and any fever post travel
must be investigated including blood films for malaria.
• Common presentations include fever, diarrhoea, respiratory illness and rash.
• Referral to an infectious disease physician or travel medicine centre may be
appropriate.
What are the International Health Regulations?
• The International Health Regulations (IHR) are an international legal
instrument that is binding on 194 countries across the globe,
including all the Member States of WHO.
• Their aim is to help the international community prevent and respond
to acute public health risks that have the potential to cross borders
and threaten people worldwide.
ABOUT IHR
• Since 15 June 2007, the world has been implementing the
International Health Regulations (2005).
• This legally-binding agreement significantly contributes to global
public health security by providing a new framework for the
coordination of the management of events that may constitute a
public health emergency of international concern, and will improve
the capacity of all countries to detect, assess, notify and respond to
public health threats.
IHR con’t
• The IHR can also apply to other public health emergencies such as
chemical spills, leaks and dumping, or nuclear melt-downs.
• The IHR aim to limit interference with international traffic and trade
while ensuring public health through the prevention of disease
spread.