Ethnocultural Aspects of Improving the Tourist Support of Medical Tourism

Bakhtin Viktor Aleksandrovich Lecturer, Department of Service, Tourism and Hospitality Industry, Don State Technical University 344022, Russia, Rostov-On-Don, Gagarin Pl., 1 bakhtinvictor@icloud.com Other publications by this author

The processes taking place in the field of medical tourism depend on a complex complex, where socio-cultural, ethnic and medical grounds are equally mixed. The trajectories of medical tourism are determined mainly by the resources of medical provision of the territory, which, in turn, is adjusted by ethnicity within the specified socio-cultural parameters. However, the ethnocultural features of the receiving locus in the proposed tourist and medical product, as a rule, are used spontaneously or are not presented at all. The role of ethno-cultural factors in the development of medical tourism was explicated in ^[3]. Special attention is paid to ethnomedical tourism. The authors of the study ^[11] set the task of institutionalizing medical tourism. It is indisputable that the following are the main institutional factors of medical tourism:  

1. Offers of medical services, their level and quality;

2. Existing medical schools;

3. Awareness of consumers about medical services offered on the market;

4. Differentiation of the medical services market by region and separately by localities of a particular region;

5. State preferences to subjects and actors of medical tourism.

The patient's health is at the forefront of such a phenomenon as medical tourism. The nature of the disease affects the patient's choice of the medical institution he needs outside of his place of residence. Therefore, the complex of the main institutional factors includes, first of all, the level and quality of medical services ^[15]. 

It should be noted that medical tourism is a therapeutic practice involving the interaction of two social groups:  "patient" - "medical staff". But the specificity of it as a type of tourism consists in the division of the second social group into two subgroups – medical personnel and specialists of the tourism industry.    The roles and functional significance of these subgroups differ: the first directly provides medical care, the second provides tourist support for the patient. The explication of the above factors as the main ones is determined by the universality of relevant structures, since they are shared by all social groups/subgroups involved in this process.

In the work ^[11], the differentiation of medical tourism by types is carried out, taking into account the differences in the factors that ensure their functioning. Thus, health tourism is systematized taking into account the environment and recreation; therapeutic – the environment, rehabilitation and recreation; medical – the level of medical services with the prevalence of its uniqueness / exclusivity.  It is clear that in the case of medical or medical tourism, the above factors are of paramount importance. The service component in this case plays the role of a background factor, is of secondary importance. Meanwhile, the level of services in drafting contracts, visas, insurance, transportation, accommodation of clients and accompanying persons, which in principle should be performed by representatives of tourist organizations, cannot be underestimated. The ethno-cultural components of medical tourism also act as background factors, among which we have identified the following:

1. Ethno-cultural representation of the host territory. 

2. Ethno-confessional preferences of the patient (peculiarities of nutrition, traditions, specific forms of national festivals and religious rites, etc.).

3. Ethno-cultural preparation of a medical tourist to stay in a different environment in terms of social interaction in the context of multiculturalism.

4. Access to the services of ethnomedicine.

5. Awareness of consumers about ethno-cultural factors. 

  The first factor is sufficiently implemented in health tourism within the framework of entertainment events involving the services of tour bureaus and other organizations of the tourism sector. However, this is not of a systemic nature, which was established during four focus group discussions on the topic "Ethno-cultural factors in the practice of medical tourism", information about which is presented in the author's work ^[3].  Here is the prevailing attitude, supported by almost all participants of the first focus group, which included doctors: "My task is for the patient to be satisfied with the quality of work. Our specifics are such that he has personal time, can organize his own acquaintance with ethno-cultural attractions, or let him contact some travel agencies." Here we are talking about medical tourism.As for medical tourism, depending on the disease and the complexity of medical intervention, this factor may be completely absent. The second focus group was presented by specialists of the tourism industry, who also noted that by themselves, appeals to travel agencies of medical tourists are one-time, assistance is provided mainly in the purchase of vouchers to sanatoriums.  "There is no structured interaction with medical institutions. In the case of outbound tourism, we provide assistance mainly in obtaining a visa and insurance."  The imbalance in the interaction of medical workers and tour operators/agents was confirmed by the participants of the third focus group, which included medical tourists themselves, who noted that they did not notice "a single system in the distribution of roles between tour operators and medical workers. There are some fragments on the provision of travel services, but outside the unified system." This conclusion was confirmed by the results of a mass survey of residents of the Rostov region (453 respondents). Moreover, 30% of respondents believe that recreation carries a wellness potential, forms a good psycho-emotional state. 31.6%, almost a third of respondents, indicated their interest in the framework of medical tourism in combining treatment / recovery with familiarity with the culture and life of another people, which indicates the legitimacy of the inclusion of ethno-cultural factors in the system of medical tourism. We have already written about the interest in ethnomedicine in ^[3]. As for consumer awareness about the ethnocultural features of the receiving locus, both focus group discussions and survey results showed that there is no decent information, for example, through tourist information centers ^[14], which again indicates the absence of a single complex of tourist and medical support for the phenomenon.

I would like to pay special attention to the third factor we have identified, especially since it includes aspects of the second factor. The problem of ethno–cultural preparation of a medical tourist to stay in a foreign cultural territory is important both for all types of tourism – health, medical and medical, and for all its forms - outbound, inbound, and taking into account the polyethnicity of Russia and domestic tourism.  Let's turn to the statements of the experts of the first focus group.  "By the nature of my work, I have encountered such undesirable effects accompanying the disease as mental attacks, depressive states of patients who have already been admitted. Surely our compatriots who have gone abroad for medical care have such manifestations. Their preliminary training is needed for a more adequate perception of another ethno-cultural environment. But this whole process, although it is called medical tourism, does not have any effective support from tourist organizations. Their participation is not visible. At least, I don't know."  This is confirmed by all participants. Another expert noted: "There is such a question, do we know the peculiarities of the ethnic culture of the country, if we advise the patient to continue treatment in this country. We know something, of course. But mostly we advise on the level of medical care.  This is where communication with tourist enterprises is needed, not some one-time, but contextual, single-directional.  We need a system."  The participants of the fourth focus group discussion, which brought together medical practitioners, sociologists and philosophers, recognized that it was irrational to create a system of medical tourism "in parts". It is necessary to develop all factors, including relying on the ethno-cultural characteristics of each particular region to attract medical tourists. There is a need for a state program and its implementation on the basis of a public-private partnership.

It is obvious that this ethno-cultural factor requires the consolidation of the actions of socio-professional subgroups of tourist specialists and medical workers with the leading role of representatives of the tourism industry in performing intermediary activities aimed at influencing the psychosomatic state of the patient during his stay in a different ethno-cultural environment.

We emphasize that this training should be conducted not in the context of inculturality, but in the context of multiculturalism.

The policy of multiculturalism was aimed at achieving links between different cultures of communities and ethnic minorities living in the same territory. In the conditions of intensification of migration processes, this problem does not lose its significance. This policy has been adopted for implementation in a number of states, for example, in the USA, Canada, England and others. However, the idea of recognizing and consolidating the independent existence of cultures in nearby topos in these countries has not found a satisfactory solution, which has aroused interest in an alternative model of inculturality with an emphasis on the interpenetration of cultures. The confrontation between multiculturalism ^{[8, pp. 108-109]} and inculturality is a problem that requires the deepest understanding.

 Any type of tourism is always marked by certain restrictions in time intervals and spatial location. This restriction is especially significant for medical tourism. It should be taken into account that the tourist's journey is associated with a certain type of disease, in the field of which he is for a long time and which forms his psycho-emotional state.  This is well said by the authors, who emphasized that "disease" is "inserted" into existential and social coordinates, is also understood as a phenomenon of human life with its fears, hopes, limitations caused by certain pathological changes in the body, as a sphere of individual and/or collective (family, close people) experiences, in general, how is life with pathology" ^{[5, p. 3832]}. When it comes to a sick person, moreover, with his immersion in a different ethno-cultural environment for a limited time, it is hardly feasible to build a line of interaction on the principles of inculturality. That is why we have emphasized the need to take into account the positive and negative factors of the specifics of multiculturalism. According to Parsons, the interaction of interdependent actors defines a double contingent ^{[9, p. 204]}. R.E. Barash defines multiculturalism as the absence of a double contingent ^{[2, p. 40]}.   And here a concomitant phenomenon may be even a partial self-exclusion of a tourist from communication with medical personnel. This problem is especially acute in the modern world of high technologies and information realities.

Therefore, the next important point in the preparation of a medical tourist is to inform him about the models of interaction between a doctor and a patient. It should be noted that T. Parsons considers the doctor-patient relationship system as a type of social interaction ^{[9, p. 226]}. Speaking about the models of interaction between them, we prefer the concept of Robert Veatch ^{[4, pp. 67-72]}, who identified four models: pastoral, engineering, collegiate, contract. It is clear that none of the models exists in its pure form. Medical tourism for the most part involves paid provision, accompanied by the drafting of contracts and contracts. But the contract hardly explicitly states which model of interaction with medical staff the tourist chooses. In any case, he needs an explanation of what is written in this document. Veatch preferred the contract model. The pastoral model is based on close contact, participation and empathy of the doctor to the patient's condition, but practically excludes the patient's participation in decision-making. The engineering model, as the authors rightly note ^[6], leads to depersonalization of the doctor-patient relationship: "The availability of high-tech medical equipment capable of performing high-precision diagnostics and treatment has defined a new role of the doctor as an intermediary between the technique and the patient, reduced the status of the doctor to the level of an engineer, operator, technical worker, who sometimes does not even enter into direct contact with the patient."  The collegial type model defines the patient as a doctor's colleague. For these reasons, depersonalization of the patient as an object in the engineering model, taking into account the use of all high-tech treatment techniques and modern equipment, which is, of course, extremely important, can lead to undesirable consequences. The other extreme, associated with the paternalistic approach, is also in a certain sense unproductive, since the patient's passivity becomes a concomitant factor. Experiencing fear, anxiety and other negative emotions, the patient will try to understand the reasons for his complex psychological state, which he can also associate with ethno-cultural differences. Following L. Gumilev ^{[7, pp. 86-95]}, we can talk about the coherence of fluctuations of ethnic fields, the coincidence of which determines the achievement of complementarity, where the determining factor in our case is the location and trust of the patient to the doctor. Therefore, the question of finding a common logic of communication without focusing on reconciling differences is put forward to the fore ^[13], since the risks of rejection of ethnic culture give rise to the desire to protect it in socially aggressive ways. The contradiction between these two trends becomes especially painful when the highest values – life and health - are the subject of dispute. Therefore, ethnoculture in the analyzed situation cannot be underestimated, it should be regarded as a derivative of communication. It is clear that intercultural determinants include many factors, the main of which is the factor of education, enlightenment and the factor of traditional norms of ethnic culture. Of course, the factor of the patient's education contributes to overcoming interethnic boundaries. Meanwhile, one should not underestimate the importance of the difference between verbal and nonverbal features of the behavior of various ethnic groups, the identity of a number of cultural markers and especially the situational factor, which manifests itself especially sharply in the modern international situation. A.P. Sadokhin rightly notes that ethnic contacts at the individual level have their own characteristics and develop specifically ^{[10, p. 251]}. A person who has taken a trip to another country to receive medical care, often involving surgical intervention, finding himself in a foreign cultural environment, psychologically, unexpectedly for himself, may experience a special condition accompanied by fear of physical contact with representatives of another culture; a feeling of helplessness and a desire to gain patronage from a representative of his own culture. This undoubtedly affects the patient's compliance ^{[1, pp. 77-81]}. Therefore, the collegial model seems to be the most preferable, taking into account the ethno-cultural context. And the question arises about the need for an intermediary link in the social interaction between the patient and the medical staff, who prepare the client of medical services to perceive the peculiarities of culture in another ethnic environment.

Medical personnel are guided by the principle common to all world practice, which in our country is set out in Article 71 of the Federal Law of the Russian Federation No. 323 of November 21, 2011 "On the basics of protecting the health of citizens in the Russian Federation" (Doctor's Oath).  The doctor undertakes to act in the interests of the patient "regardless of gender, race, nationality, language, origin, property and official status, place of residence, attitude to religion" ^[12]. Therefore, the manifestation of any ethnic differences in such a situation is leveled. But for the patient, there are possible options of trust / distrust towards a representative of another culture providing medical care. Distrust reduces the effect of treatment, trust increases it. Thus, trust acquires the status of the main factor in the formation of an effective system of interaction between all actors that are built in social connections for patterns:  a) medical tourist – specialists of the tourism industry, b) specialists of the tourism industry – medical personnel, c) patient – medical personnel. The correlation of all these social connections serves to achieve the main task – the recovery of the patient.

The main role in the inclusion of ethno-cultural factors belongs to tour operators, here the influence of the tourist component accompanying the entire complex of medical tourism is noticeably increasing. Tourist operators and travel agents should take on the role of the intermediary link mentioned above, focus their attention not only on choosing a medical institution, preparing contracts, legal and insurance support for a tourist, but also acquaint him with the peculiarities of another ethnic culture. This indicates the need for additional training of tourist specialists for medical tourism.  

The development of medical tourism could be facilitated by the creation of an expert formation at the regional level in order to achieve consolidation of the actions of doctors and specialists of the tourism industry for a more active entry of the tourist component into this activity and for a collegial assessment of the possibilities of including the ethnocultural potential of the territory in a medical product.