It would be a win-win situation, but no government, health or finance ministry has done anything significant to promote medical tourism to Israel. With a little investment in medical infrastructure, this "niche industry" could easily bring in $100 million a year (15% of all current tourism income), reduce the temptation among the most experienced and promising doctors to leave the country, boost the quality of "hotel services" in hospitals and spread Israel's good name, even in countries that have no diplomatic relations with us. Even Likud chairman MK Binyamin Netanyahu, who has been prime minister and finance minister, was unfamiliar with the subject when asked about it during a recent appearance at The Jerusalem Post. Without urgent state initiatives, Israel is pretty much leaving the field to other countries with much-less-impressive medical systems - countries such as India, China, Singapore, Poland, Costa Rica, Mexico, Brazil, Argentina, South Africa, Malaysia and Thailand, which understood the potential quite early. In the meantime, a handful of Israeli hospitals are trying to develop their own medical tourism facilities. Prof. Shlomo Mor-Yosef, director-general of the Hadassah Medical Organization (HMO), raised the subject for the first time at a July 2007 Hadassah conference in Jerusalem. He said medical tourism should be a national priority, with the revenue used to improve domestic healthcare and disease prevention for the poor. FOREIGNERS SEEK treatment outside their own countries because of an inadequate level of medicine at home; a local lack of experience in providing special treatments; specializations found only in a handful of medical centers; and the lack of advanced medical equipment in developing countries. In addition, says Mor-Yosef, foreigners may seek care abroad because of high prices for medical treatments in developed countries, especially those with no or insufficient insurance; there are long waiting periods for surgery; regulations that bar certain procedures (such as abortions and organ transplants); treatments have not been authorized in the country of origin but are permitted in others; insurance companies seek to cut costs by sending patients abroad; and chronically ill patients needing ongoing care (such as kidney dialysis) also want to travel, do business or visit family members in other countries. Although Israel offers world-class medicine, he continued, medical tourism constitutes only a small fraction of the country's tourism income. Of the 16,000 foreign patients who came for treatment in 2006, public hospitals like Jerusalem's Hadassah University Medical Centers (founded by voluntary organizations) cared for 7,000, and private hospitals for 3,500, with only a few going to government and health fund-owned facilities. Estimated annual revenue for these services total $40 million. Mor-Yosef and Amitai Rotem - HMO's marketing director, whom Mor-Yosef appointed to promote medical tourism to Hadassah - say that major treatments such as surgery, organ transplants, dental care and plastic surgery are sought by medical tourists - unlike "healing-therapy tourism" that offers complementary and quality-of-life treatment. Mor-Yosef notes that healing-therapy tourism has been known since the Roman Empire. Mineral water spas that served ancient Roman caesars and other prosperous people developed elaborate infrastructures. In the 19th century, various sites were developed that attracted tourists to bathe in their mineral water. It was only in the middle of the 20th century that the necessary technologies for medical tourism first appeared. Pan American Airlines carried out the first transatlantic flight in 1939; the Holiday Inn chain opened in 1952; and the McDonalds fast-food chain broke into the market in 1955, Rotem notes. Despite its relatively young age, the tourism industry is today the world's third-largest after automobiles and gasoline; it employs over 200 million people, has a turnover of $400 billion and encompasses 760 million arrivals a year. Medical tourism has received a big boost from the Internet. Seriously ill patients and their families can look up the best medical centers and specialists in the world. Thousands of Web sites and portals specialize in the field, and medical institutions often have their own Web sites. Many entrepreneurs run portals that coordinate a bevy of medical information. HMO has an average of 60,000 virtual visitors per month. Unlike ecological tourism, in which the traveler chooses a destination and only then selects the elements of the vacation, Rotem notes, medical tourism begins with a defined medical need. To this is matched an appropriate destination in terms of medical specialization, cost, service (such as a suitable language and culture) and in certain cases cultural availability (such as a Saudi Arabian tourist who wants to visit Jerusalem's Dome of the Rock). From a desire to minimize cost and waiting time, the modern patient turns into a tourist, and tourism experts and health industry people supply the "merchandise." The market potential is huge, says the HMO marketing chief. "During the past year, residents of Asia and Africa spent over $20 billion on medical services outside their countries. Nigerians alone bought over $1 billion, and India - which actively works to increase the number of medical tourists - expects a turnover of $2.2 billion in 2012. Even Costa Rica reports the annual arrival of 150,000 medical tourists. Some 43 million Americans lack health insurance, and many others have only partial insurance. The "baby boomer" generation will reach retirement age in 2015, increasingly needing healthcare." Mor-Yosef says that while foreign tourists receive the same level of treatment as Israeli patients, profitability from the foreigners is much greater. The Health Ministry's rates for tourists are much higher than those for Israelis, and discounts for tourists are lower. Payment is made in advance, unlike the local market that pays with credit. Prices in Israel are higher than those in the East, but the medical reputation here is much better, and one can suppose that many will be willing to pay the additional amount in exchange for quality. The dollar price in the US for angioplasty is $57,000 to $82,000, compared to $17,000 for foreign tourists in Israel, and ranges between $11,000 to $13,000 in India, Thailand and Singapore. The proportions are similar for heart or gastric bypass surgery, heart-valve replacement, hip replacement, spinal fusion or knee replacements. It is clear that prices in the East are lowest, but the rates in Israel are much cheaper than those in the US and Europe. Medical tourists, continues Rotem, face complications, including the danger of diseases that don't exist in their own countries, such as certain types of hepatitis, HIV, gastrointestinal disorders or avian flu. They may also see doctors who rush to operate or suggest an expensive or sometimes unnecessary treatment because they earn money. In this field, Israel has a big advantage. Existing infections here are similar to those in the advanced Western countries, and an advanced justice system offers good protection to foreign tourists. The HMO director-general stresses that without doubt, the need to upgrade facilities to meet the expectations of medical tourists by improving "hotel services" will make it possible for Israelis to enjoy them as well. "Tourists' more demanding attitude to healthcare will affect the attitude and services offered to Israelis. In addition, senior physicians will not seek foreign positions, and at the end of the day, all will benefit from advances in the field." MOST MEDICAL tourists arrive at the treatment facility with at least one companion. The growth in demand that results from these visitors and patients will lead to additional commercial flights and the development of "flying ambulance" services to meet local and other needs, says Rotem. The number of tourist stays in hotels will also grow, thanks to the accompanying persons and the patients who will use hotels for recovery. Like any other tourists, these too will see the sites, buy food and souvenirs and leave behind foreign currency. They will also use domestic transportation, banks and information services, and need many complementary services during their stay, which can sometimes last months. Some foreigners, Rotem says, need not even come to Israel to get help. Telemedicine opens a new window to the medical tourist. Without leaving his home, he can get a diagnosis from some of the best doctors in the world, and in the not-too-distant future he will be able to lie in a surgical theater in his city for an operation performed by the world's leading expert sitting in another continent. Hospitals in India already supply this service and radiology, diagnosis and even monitoring of intensive-care patients as backup to US hospitals. The time gap between Israel and the US, he continues, can be an additional basis for the development of medical advice in leading medical centers: At night, when medical teams are comprised mostly of residents learning a specialty, an Israeli expert can advise them online to interpret images and even monitor intensive-care patients. Income from medical tourism, and the high level of treatment needed for it, will help finance infrastructures - hospitals, imaging institutes, labs and research. Encountering other diseases, explains Mor-Yosef, will contribute to the advance of medicine, disease prevention and the accumulation of varied experience. Medicine has always been a bridge to peace between peoples, he continues. "Countries that lack formal diplomatic ties have provided medical treatment in other countries to their citizens who need it. The late King Hussein of Jordan was treated at our hospital in Ein Kerem, and other Arab leaders have been here. There is no doubt that this humanitarian service can be turned into a means of bringing hearts together." The new government, Mor-Yosef and Rotem urge, must take an active role in promoting the field. Existing infrastructures in most hospitals here can't compare with those now in the East. For Israeli hospitals to compete, the level of hotel services must be improved and the number of beds increased. Current marketing and administrative systems, not built for the speedy responses needed for competition, must be upgraded. Prices are not flexible enough, and the quality of service offered today in most cases is suited to local needs rather than meeting international tourist standards. "We must overcome administrative conservatism," they stress. "Government ministries need to work to advance this, each in its own field. The Health Ministry must set a supportive policy, both in setting prices and allocating additional beds to hospitals that cater to medical tourists. The Interior Ministry needs to establish speedy and friendly processes for providing tourist visas to patients." The Tourism and Foreign ministries must market the State of Israel as a destination for medical tourism. The Finance Ministry has to allocate funds, both for marketing and for improving the infrastructure that will be needed as medical tourism increases. "Proper handling of the subject will bring in much income and foreign currency, improve our status in the world, and especially in the region, contribute to the creation of new jobs, increase the satisfaction of doctors and contribute to their remaining in Israel. All this will raise the level of medicine in Israel," Mor-Yosef concludes.