Whether traveling to a spa for some serious rest and relaxation or flying somewhere to seek non-traditional medical therapies, cosmetic surgery or diagnostic testing, a multitude of people can be classified as health tourists. This is good news for the hospitality industry since an affluent population that is determined to stay well and stress free is an expanding and profitable market for those who meet their needs.

Health tourism is concept as ancient as prehistory and as up-to-date as tomorrow. While we don't know whether troglodyte innkeepers made any money on such travel, health tourism may be just what the doctor ordered for today's hospitality marketers.

Definition

There is no single definition for health tourism, but a simple and succinct description comes from Mary Tabacchi, a registered dietician and Ph.D. who teaches courses in spa management, wellness and business, and healthy cuisine at Cornell University's School of Hotel Administration. According to Tabacchi, health tourism is "any kind of travel to make yourself or a member of your family healthier."

Most health tourism today focuses on two areas: pampering and wellness. Pampering involves offering people an experience that makes them feel good—services such as massages, herbal wraps and exfoliating scrubs. Wellness involves helping healthy people prevent problems so they stay well, both physically and mentally. Sometimes this means offering diagnostic testing to identify potential problems. More often, guests who have self-identified concerns are taught how to relieve stress, change eating habits, reduce the likelihood of sports injuries or improve their sex lives.

There are also enterprises, however, that go beyond Dr. Tabacchi's definition to include services designed for travelers who have special health needs. For example, 160,000 people in the United States need dialysis. Dialysis at Sea is a company that puts the machines on select cruise ships so people with kidney problems can enjoy cruising without compromising their health. Hotel de Health, a beachfront resort in Anguilla, offers island delights such as snorkeling, windsurfing, and fishing as well as eight dialysis stations "with a magnificent view of the Caribbean."

Impetus for Growth

Several demographic, economic and lifestyle developments are fueling growth in health tourism. First and foremost is the aging of the Baby Boomers, 78 million of them in the United States alone. Seeing the grim reaper in their rear view mirrors has increased Boomers' interest in and need for travel opportunities that also meet their health needs. Already boomers represent 60 percent of the spa market.

Another factor is America's fascination with fitness and alternative therapies for health maintenance and healing. These statistics tell the story. In 1997, 42 percent of Americans spent $21 billion on non-traditional medical therapies and products. In the past three years nearly 25 million U.S. travelers fought the battle of bulge by using a fitness center or gym while on the road.

The third element spurring on health tourism is the fact that today's consumers are already well traveled. As a result they seek something new and different in a holiday experience. They often want something educational or experiential and various aspects of health tourism fulfill those requirements.

The fourth reason can be found in the health care system itself. In Canada and Britain, long waiting lists at home are causing some to go abroad to seek medical care. Cost can also be a factor. According to England's Daily Express newspaper, a cataract operation in Britain costs around $4,500, but only $2,250 in France. In India, the same cataract removal is only $345. A hip replacement in London costs as much as $12,000, but in Siberia a mere $1,500. If managed care continues to deny U.S. consumers access to certain medical services, Americans too may begin to look abroad for lower-cost options for out-of-pocket procedures.

Background

The earliest form of health tourism—visiting mineral or hot springs—dates back to the Neolithic and Bronze ages in Europe. Legend says Bath, England was founded by Bladud, father of King Lear, in 863 BC.

By the Middle Ages belief in the curative powers of thermal springs was firmly established. In the 16th Century, Ponce de Leon brought the concept to the New World when he traveled to Florida in search of the fountain of youth. In the 1700s and 1800s, "taking the waters" at spa towns such as Baden-Baden was popular with the upper crust on both sides of the Atlantic. In the late 19th Century, the emerging urban middle class sought the healthful benefits of fresh sea or mountain air as an antidote to the overcrowding and pollution wrought by industrialization. The early 20th century saw the emergence of "health farms" or "fat farms" where the emphasis was on fitness and good diet. A new era of health tourism began in 1939 when Deborah and Edmond Szekely opened a $17.50-a-week bring-your-tent spa and healthy-living retreat, which became the renowned Rancho La Puerta fitness resort. In 1958 Deborah moved north to the San Diego area where she created the Golden Door, a luxurious destination spa known for its lavish individual service and successful mind-body programs. In the same vein, Mel and Enid Zuckerman opened Tucson's Canyon Ranch in 1979. Today it provides pampering, fitness and medically supervised wellness programs to their well-heeled clientele.

The notion of spas for the mass tourism market, however, didn't take off until the late 1980s. The International Spa Association was not formed until 1991. Since that time, the number of spas has grown geometrically. Most such spas give only a cursory nod to wellness, instead focusing primarily on feel-good services.

Recently, however, some organizations have gone a step further by making hospitals more like spas and spas more like hospitals. Such facilities integrate alternative medical therapies with conventional Western medicine. They perform operations and otherwise treat and rehabilitate people who are sick or injured, but they do so in a more congenial, resort-like atmosphere.

For example, the Bougainvillea Clinic in Tortola, British Virgin Islands, offers plastic, reconstructive and general surgery in a setting replete with gentle Caribbean breezes; tropical gardens; fountains, waterfalls, a swimming pool; and an antique Chinese bar. It also provides recuperating patients with a full range of pampering services such as aromatherapy, seaweed wraps, facials and massages.

Destination spas such as Canyon Ranch and La Quinta Resort and Club have added staffs of doctors, nurses and technicians who can perform and evaluate a variety of medical tests and provide behavioral counseling and physical therapy.

Cornell's Tabacchi noted, "From the consulting I've been doing and the phone calls I'm getting, hospital-spas are a natural match, a natural marriage. People know what spas are and they expect to be healed at spas. If hospitals can integrate this some way, I think it would be the hottest business you could have."

U.S. Spas

Spas for healthy people currently represent the lion's share of the health tourism market.

In November 2000, the International Spa Association released the results of a survey by PricewaterhouseCoopers. The study found 5,689 spas in the U.S. The number of spas grew by 52 percent between 1997 and 1999 and spa visits rose 70 percent during

that period.

Nearly three-quarters of the spas in the survey were day spas, sometimes nothing more than glorified beauty salons, that serve a local clientele rather than travelers. In terms of health tourism in the U.S., the important types of spas are:

• Resort/hotel spas, which are located within a resort or hotel and provide spa services, fitness and wellness components, and some spa cuisine menu choices.
• Destination spas where the sole purpose is to provide guests with lifestyle improvement and health enhancement through spa services, physical fitness, a spa cuisine menu, educational programming, and on-site accommodations.

According to Travel & Tourism Analyst, the number of destination spas in the United States actually decreased between 1987 and 1997, while the number of hotel/resort spas increased dramatically.

Victor Lopez, division vice president of Hyatt Resorts, described his company's rationale for adding spas to its properties. "We've certainly found over the years that in the resort business, sun, sand and sea were not enough any more. People were looking not only for adventure and learning activities, but they really wanted to be able to exercise and be pampered.... Where before the beach or the pool or the golf course were fine, now people definitely want a spa. They want a full-service spa as a part of the amenities a place offers and many of them are making their vacation plans based on whether a property offers a full-service spa or not."

Results of a 1997 consumer survey conducted by Health Fitness Dynamics, Inc., a Florida spa consulting firm, confirms Hyatt's experience. It revealed 81 percent of consumers who went to resort-based spas said they expected a property to offer spa services. These consumers said they actively seek out resorts that offer those services. Hyatt's response to consumer demand mirrors that of the hospitality industry. Lopez said, "Most of our properties had health clubs. Most of them had a room with some bicycles, some Stairmasters, treadmills, etc. We started expanding on that. We built some big beautiful spas—anywhere from 15-25,000 square feet-and offer treatments of all kinds." He added, "And it's not just for the ladies any more. The men are getting not only massages, but facials and manicures and pedicures. It used to be that the ladies were at the spa and the men were on the golf course, but it's really changed. Now we're finding almost as many men using spas as the women."

Another HFD survey found that meeting consumer demand for spa services translates into direct and indirect benefits for hoteliers. According to general managers or directors of operations at 30 resort-based spas, spa facilities generate net operating profit of 15-25 percent. Among the GMs and DOOs surveyed, 97 percent said spas enhance or increase their marketing advantages, 83 percent said they boost revenue per occupied room and 73 percent said having a spa on site increased occupancy.

To maintain the competitive advantage spas give them, hotels and resorts are adding Asian, Native American or "alternative" therapies and approaches to the services they offer. Bernard Burt, publisher of and co-author of the book "100 Best Spas in the World", reported options often include:

• Spiritual encounters such as the Javanese Lulur, a body cleansing based on Balinese wedding rituals;
• Native American traditional healing adapted for exfoliations and wraps;
• Massages with heated stones;
• Grapeseed oil in French and American facials; and
• Whipped cocoa baths (at, where else, but Hotel Hershey).

Some hotel/resort spas also offer physical and mental wellness activities such as yoga, meditation, reflexology and reiki and the water-based therapies popular in Europe and Asia.

The concept of the hospi-spa, the next logical step in the development of the spa business, "hasn't arrived yet" in the United States, "but many companies are considering it," said Cornell's Tabacchi. Who will finally break the barrier and open up the market? Tabacchi said, "My experience with established hospitality organizations and established hospitals are they are not flexible enough. They're too big, too unwieldy. It takes too much grinding to change their direction.... It would be my guess that it will take an entrepreneurial effort. It won't come from Ritz-Carlton. It won't come from Brigham & Women's."

Destinations

Certain destinations have catered to health tourists for centuries. Bath and Baden-Baden were spa destinations since Roman times. The supposedly healing waters put Saratoga Springs, New York, and Hot Springs, Arkansas, on the map. In the late 19th and early 20th centuries, the warm dry climate of the Southwest attracted those with respiratory problems.

Today, once again, promoting the healthful and health-care benefits of a destination is gaining popularity because tourism marketers need ways to differentiate their products. A search of the Internet finds dozens of countries touting their health tourism products, including some most Americans would not associate with healthy conditions or excellent medical care, i.e. Ethiopia, Pakistan, Yemen, Bulgaria, Siberia and El Salvador. According to "Travel & Tourism Analyst," Germany, with its 330 spa towns, is the number one spa destination in Europe. Britain has 11 spa towns, including Bath where the primary "watering hole" was recently refurbished with $12 million from the national lottery, one of the country's Millennium projects.

While some of Canada's citizens are crossing the 49th parallel to seek medical care in the United States, the Canadian Tourism Commission is trying to lure American health tourists to its side of the border. The CTC gave Spa Canada, a national trade association, a grant to create a 40-page "Canadian Spa Escapes" brochure as a direct mail piece targeted at the U.S. market. Spa Canada is also working with the CTC on advertising and media relations efforts to increase the visibility of Canada as a destination for spa travel. Spas are not the only things that draw health tourists to a destination. Promotion of a country's low cost and/or high quality health care and medical innovations have proven very effective in attracting visitors. One percent of all international visitors to the United States come here for medical treatment, that's nearly 247,000 people. According to Costa Rica's Health Tourism Corporation, this tiny Central American nation attracts 150,000 health tourists annually. "U.S. News On Line" reported Cuba earned $25 million from health tourism in 1997.

Not all health tourism, however, is considered desirable. In Britain, the same government system causing Britons to go abroad for health care is attracting foreigners who want free medical services. Treatment is free in Britain to citizens of 60 countries, with which the U.K. has a reciprocal arrangement, who have been in the U.K. for 12 months or more, are emergency patients, and for people in several other limited categories. One member of Parliament decried this development saying Britain is becoming the "health supermarket for the rest of the world," and the situation is costing "taxpayers millions of pounds a year."

Tour Operators and Cruise Ships

The appeal of health tourism has not been lost on tour operators or cruise lines. listed a variety of "Aroma Tours," including a "Provence Aromatherapy Retreat," which includes meetings with aroma therapy experts and visits to essential oils distilleries. It also has yoga-for-golfers tours to the Yucatan and Hawaii.

offers "High Feminine Healing—A Sacred Women's Tour to Bali," which includes "yoga, meditation and connection," mask making, "a purification ritual at a spring in one of Bali's most sacred temples," and two spa treatments. lists tour operators such as Thermalia Travel, which arranges "health and beauty vacations in spas around the world," and Palmland Tours, offering "Ayurvedic health holidays" at a lake resort in southwestern India. Travelers who want a little nip and tuck can book a cosmetic surgery package to Colombia through Surgeries Overseas.

Lacey Gude, owner of Amazon Adventurers and Gerosa Tours in Arlington, Virginia, develops special itineraries to the Brazilian Amazon for individuals and groups interested in the indigenous medicinal herbs and traditional healing practices. Cruise lines also have responded to consumer interest in health and fitness. Today virtually every large cruise ship has a spa, fitness center, and healthy-eating choices on their menus.

And since turnabout is fair play, destination spa Canyon Ranch recently announced plans to build two cruise ships of its own. Mel Zuckerman, Canyon Ranch's founder said, "We're very excited to offer an exotic travel experience consistent with our goal of providing a healthy, life enhancing vacation. Our ships will be like no other cruise ships afloat."

According to the press announcement, each ship will be equipped with amenities such as a 50,000-square-foot, state-of the-art gym; studios; a rock-climbing wall; a jogging track; 35 spa treatment rooms; and a beauty salon. In addition, they would have a health and healing center staffed by physicians, health educators, nutritionists, exercise physiologists, physical therapists and others.

Those plans, however, may be in permanent dry dock. In late January, Roxanne Housley, vice president of sales, said, "There is a delay in building right now." She also noted, "Obviously there will be components from behavioral and medical when and if we build ships, but at this point that decision has not been made."

Conclusion

With the economy beginning to weaken, perhaps now is a good time for hospitality marketers to give their marketing plan a thorough checkup. Something as simple as targeting health tourists may be just the prescription for maintaining a healthy bottomline.

Jason Smith
703-610-9024
HSMAI