Where The World Comes To Get Well

Inside Baltimore’s booming health-care tourism industry.

Evan Serpick - November 2010

Where The World Comes To Get Well

Inside Baltimore’s booming health-care tourism industry.

Evan Serpick - November 2010


In 2004, Kuwaiti businessman Adel Alzankawi received word that his wife had a malignant tumor. Concerned that local doctors would not be able to remove the growth and save her life, he went to the Internet.

"I typed in 'best hospital in the world,'" he recalls. "It came back 'Johns Hopkins.'"

Months later, Alzankawi and his wife traveled to Baltimore to have her tumor removed. Six years later, she returns every year to monitor her condition.

"Everything is fine now," says Alzankawi. "She had another operation last year—at Hopkins, of course."

Mrs. Alzankawi is one of 3,000 people who will come from abroad to be treated at The Johns Hopkins Hospital this year, with 36,000 scheduled appointments and 1,100 inpatient admissions, making Baltimore probably the most popular global destination for health care. Patients come from South America, Asia, and Europe, but the largest number come from the Middle East, and often include members of royal families, high-ranking government officials, and heads of state.

The Herculean task of catering to this demanding and specialized clientele falls to Johns Hopkins Medicine International (JHI), a 150-person department including interpreters who speak more than 20 languages. JHI specializes in the delicate task of communicating with people from a wide range of backgrounds, cultural traditions, and religions, who are often in the most precarious of life-and-death situations.

"The people who come here from abroad are mostly very, very sick," says Raffaella Molteni, the chief administrative officer at JHI. "They come here because this is one of the last options, if not the last or only option for their care. People who come here are desperate for their medical condition to improve and we need to handle the complexity of their family situation, their cultural situation."

International patients coming to Hopkins most often come for medical or surgical treatment of advanced cancer, neurosurgery, or orthapedics. The group frequently includes children suffering from genetic defects, cancer, or birth abnormalities. These kinds of patients, who often arrive with families, have been coming to Hopkins for decades, as part of the "International Services" department, but, in 1999, the hospital created JHI, increasing staff and aiming to create a concierge level of service for them.

"We designated staff members to be ambassadors for the patients coming here, to go and help them, when arriving here at the airport, really making a point of being here for them at any point of their journey, even when they were not at the hospital," says Molteni, who has been part of JHI since its inception. "We had a 24/7 phone number people could call when they had questions, we had people visiting the patients at their hotels and homes just to make sure they felt comfortable."

These ambassadors, now called international care coordinators, usually speak the same language as the clients they serve and are generally from the same part of the world. They quickly become not just interpreters, but advocates, helping patients navigate the complicated world of medical diagnosis and treatment through the lens of their unique cultural and religious background.

"For example, there are times where you cannot use the word 'cancer' right away," says Molteni, citing the cultural importance of discretion, particularly in patients from the Middle East. "At one point, the patient has to know, to make appropriate decisions regarding the care, but when is the time to let the patient know? You need to be a cultural broker betweens the physicians and medical staff and the family."

These cultural brokers are crucial, says Dr. Charles Cummings, executive medical director of JHI, who regularly sees patients from abroad. "Patient coordinators are very much a part of the treatment process here, along with doctors and nurses," he says. "Very frequently, those coordinators are present with a patient when the physician is in the process of treatment or evaluation."

Since the creation of JHI, the number of international patients coming to Hopkins has tripled, based largely on word of mouth—the hospital does little marketing overseas.

"There is this unique relationship that gets established," says Molteni. "Everybody is the same when they get sick. We all go through the same experiences, the same anxiety, the same fears."

Passersby are frequently perplexed by the comings and goings on the corner of Aliceanna and S. Essex Streets in swanky Harbor East. There, large red vans, some handicap-accessible, often drop off or pick up large numbers of passengers in Middle Eastern garb. The women often have head-to-toe hijabs, the men wear long, flowing white robes and head coverings. Frequently, at least one member of the party will be wheelchair-bound, walking with crutches, or attached to an I.V.

These men and women are guests of Chase Street Properties, located in The Promenade building at 1001 Aliceanna Street. Argentinian expatriate Gonzalo Jouan founded the company in 1997 after working in the International Services department at Hopkins for 10 years. He is now JHI's biggest contractor for housing international patients. His company owns or leases 82 apartments in the Baltimore area, including 38 in The Promenade, and Jouan says he is generally at about 97 percent capacity.

Often, Jouan and his staff are on the front lines, shuttling Hopkins' international clientele to and from the hospital and the airport, taking them on shopping trips, tracking down markets with halal meat, and generally making their stay in Baltimore as pleasant as possible. He knows what it's like to be a foreigner in this town.

"When I first came, I was kind of a novelty in Baltimore," says Jouan, an ex-rugby player who first moved to town in 1987. While he was working at Hopkins, Jouan noticed that hotels and long-term housing companies didn't know how to handle patients coming to the hospital from abroad.

"Corporate housing companies didn't know anything about these people," says Jouan, sitting in Chase Street Properties' cramped office, which includes an unclaimed stack of luggage from Abu Dhabi, and a poster with camels riding into a desert sunrise that reads, "Colors of Libya." "When they come to Baltimore, it's because they're really sick. They need help."

He started his business by buying four apartments at the Belvedere Hotel in Mt. Vernon for $27,000, but quickly realized that the location wasn't right.

"People from the Middle East, in particular, are very concerned about safety," he says. "They need secure buildings, buildings with 24-hour front desk, everything within walking distance."

Next, Jouan bought several units in Federal Hill's Harbor View building, but soon found a hub in the rapidly developing Harbor East area. In addition to snapping up apartments in The Promenade, he bought dozens at Spinnaker Bay around the corner. He says his clients love all the dining and shopping options in the area, in addition to the proximity to the Inner Harbor.

Jouan gradually expanded his services as he realized his clients' needs. He bought vans to shuttle them from the apartments to the hospital at no additional fee, and when he realized that they were paying $70 to get a wheelchair-accessible ride, he bought wheelchair-accessible vans. His drivers take clients to and from BWI at no cost and help them find whatever they need in town, whether it's a Hindu temple or a rare ingredient to make stew. During the historic local snowstorms earlier this year, Jouan was in his Hummer around the clock, shuttling patients—including several who were not his clients—to hospitals, pharmacies, and markets.

"My mom was a cancer patient at Hopkins," says Jouan, known to most of his clients as Gonzo. "I know what these people are going through."

Some of Jouan's clients have become friends over the years. Amer Al-Fulasi, for example, has been one of Chase Street's most frequent clients. He first brought his son from Qatar to Hopkins in 2006 after the boy was diagnosed with Hodgkin's disease. They return once a year for treatment, usually staying in the same two-bedroom apartment at The Promenade.

"Gonzo is always great," says Al-Fulasi, who has become something of a leader among the Middle Eastern families traveling to Hopkins. "It has been a great comfort, staying here."

His apartment is simple, with wall-to-wall carpeting and plain white walls. One unique feature is the massive satellite dish on the balcony, capable of picking up stations throughout the Middle East—also a great comfort, says Al-Fulasi. On a visit during the month-long holiday Ramadan, when Muslims fast during daylight hours, packages of food are lined up for Al-Fulasi and his son to eat after sundown.

For the past two years, Jouan has set aside an apartment at The Promenade during Ramadan, where his clients from the Middle East can gather, pray, and break their daily fast. "You meet people from Kuwait, UAE, Saudi Arabia," says Al-Fulasi, who helps to pull together patients and families from different Middle Eastern countries for the gatherings, which are a welcome respite from what are often grim circumstances for visiting families.

In the lobby of The Promenade, Hend Ebrahim waits with her two sons for a shuttle to take them to appointments at Hopkins. One son, wearing a mask, suffers with cancer and recently had a tumor removed from his face. The other has epilepsy. Raffaella Molteni says Hopkins gets a disproportionate number of children with genetic-related diseases from the Middle East, because of the incidence of marriages within families.

Ebrahim first brought her sons to Hopkins from Kuwait on the recommendation of their Kuwaiti doctor in 2004. They've been back every year for the past three years. Through a smile and broken English, Ebrahim says she values the knowledgeable Arabic translators at Hopkins, as well as the mosque at the hospital, where she frequently prays. Also, she was surprised and delighted to meet so many Kuwaitis at the Ramadan gatherings at The Promenade. Like Al-Fulasi, she says her favorite restaurant in town is The Helmand in Mt. Vernon, which specializes in Afghan cuisine.

Her children, in giggling but more refined English, say they have particularly loved the Aquarium and a day trip to Six Flags, outside of D.C. The children help Ebrahim express how much she likes Harbor East, noting that two new buildings have gone up in the area since they first came three years ago.

Molteni says the development of Harbor East, a safe area with condos, high-end restaurants, and shopping downtown, has been very popular with international patients.

"They have seen a great improvement with Harbor East," says Molteni. "They still would like to see a high-level department store, like Saks or Nordstrom, downtown."

Although certainly many come from great wealth and even royalty, the staff at JHI is quick to point out that not all of the patients they work with are well-off. Some governments in the Persian Gulf, in particular, have a policy of paying for medical care overseas if treatments are not available at home. But it's fair to say that most clients can easily pay for their health care out of pocket.

And catering to wealthy patients is good for Hopkins. Besides paying the cost of the services rendered, international patients make over 100 contributions to its research funds every year, some very substantial. It's also good for Baltimore, which benefits from the influx of healtcare tourists with disposable income.

Elizabeth Titterton, who has come to Hopkins from Bermuda for a hip replacement, says her country is devoted to Hopkins. "Bermudians like the best-quality health care," she says. "And Hopkins is definitely considered the best."

In fact, surprisingly, Bermuda is one of the most common countries of origin for international patients at Hopkins. It fits the bill for the kind of country that sends a lot of patients to the hospital: Bermuda, like countries in the Middle East, and certain parts of Asia and Central and South America, has a population with significant wealth and a health care system without high-end services. Although Hopkins does frequently see patients from Europe, they are far fewer and generally for more specialized services.

In particular, patients from the royal families of the Middle East have kept the Hopkins staff on its toes. These patients are often treated at the Marburg Pavilion, an area of the hospital often set aside for wealthy patients, with rooms that look more like hotel suites and dining provided by the Marriott.

This year, one female member of a royal family came to Hopkins for treatment with an entourage of 70 people, including a chef, teachers for the children, their own private physician, and several assistants and servers. In addition to the primary patient, several members of her entourage asked to be treated, ultimately filling 11 of the Marburg Pavilion's 15 private rooms.

JHI has a unique staff set up to accommodate the needs of VIP clients, including security, amenities, transportation—really anything they need—but, sometimes, there are problems.

"The last time we had member of the royal family, in the middle of the night, one of the sheiks wanted to have scrambled eggs made by one of her staff," Molteni recalls. "The issue is that you cannot say, 'No.'"

To sidestep rules about non-Hopkins staff using Hopkins facilities—particularly when they're closed—Molteni called the director of food services and had a staff member open the kitchen and supervise the sheik's personal chef preparation of the eggs.

"There is a story almost every week," Molteni says with a weary laugh. She recalls the time a patient insisted on having kiwis, which the kitchen did not offer. She sent an employee to buy two cases of the fruits. Another time, a patient didn't like her mattress and refused to sleep on it. Employees were dispatched to buy a new one.

But there are limits to the hospital's flexibility, particularly with Hopkins personnel. Molteni says her staff tries to accommodate patient requests with regard to gender and race, assigning a patient coordinator of the same sex and background as the patient, if asked. Sometimes, patients will request not to work with certain staff members because of a perceived slight. "It could just be that the staff member sat down at a time when the patient thought they should stand up," she says. "So they say, 'I don't want to see that person anymore.'"

But with medical staff, there is limited accommodation. "It becomes a matter of managing expectations," she says. "They come for the best possible medical care, and that's what they get."

The fifth floor of the 550 building at Hopkins, where many of JHI's international care coordinators work, looks a bit like the U.N. Desks are grouped by region. In one area, where coordinators who work with Asians sit, Asian-themed artwork—mostly gifts from appreciative patients—covers the walls. In another, staff who work with clients from Central and South America huddle below walls papered with flags from that part of the world.

One of the least-known facts about Johns Hopkins Medicine International—and yet one of its most beneficial to the community—is that, because of the staff's language skills, it also caters to non-English-speaking Baltimore residents, mostly recent immigrants. For Spanish-speaking staff, local residents, many from nearby Upper Fells point, make up most of the clientele.

"The majority are Spanish-speaking, but we have Russian-speaking, a few Korean, Chinese, Farsi," says Molteni.

And coordinators often connect their international patients with people in local immigrant communities during their stay.

"Especially for the patients here for a long time, it's great to integrate with existing communities," says Molteni, noting that patients from Greece have loved finding countrymen in Baltimore's Greektown, and those from Korea are shocked to discover a vibrant Korean community in Howard County.

But even when there is a limited local community, having a patient coordinator from a patient's own background can make a big impact. "The interaction with our staff people makes a huge difference in the patient experience," says Molteni. "You interact with someone who understands your culture, maybe he is from the same town you came from, and that makes the patient feel at ease."

And Molteni, who oversees the hiring of JHI staff, says that beyond language skills and intelligence, she looks for people with a deep sense of compassion.

"Our people are amazing," she says. "When there is a patient in the hospital, I know that they come during the weekend, they bring homemade food, they bring additional friends to visit the patient—it's the little human touch that is our main marketing tool."

For Elizabeth Titterton, whose fractured hip was misdiagnosed by a Bermudian doctor before she came to Hopkins, having patient coordinator Ashley Jones to guide her through a new city—especially considering that Titterton was in pain and on crutches—made everything a little easier to manage.

"I would have been completely lost and miserable," says Titterton, who has remained in Baltimore for specialized physical therapy since her hip replacement. "Ashley has been there, holding my hand every step of the way."

transforming.

"They never stopped trying new things, they never gave up," she says. "My parents put a lot of trust in them, and it was definitely not easy for my parents; it was all an incredible shock for them. It changed my perspective. It changed me."

She's held several research jobs while in school, but when making her career choice, she knew she wanted closer interaction with hospital patients.

"I know I'll make a great nurse practitioner," she says. "I know how it feels to be in that position. I know that feeling and the difference people make."





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