The phrase “medical tourism in Lebanon” conjures for many the idea of visitors from the Gulf sitting in cafés and waiting for nose jobs. In reality, plastic surgery makes up only a small percentage of the country’s international patients’ needs.

Eighty-five percent of foreigners who seek treatment in Lebanon do so for other medical reasons, according to Mounes Kalaawi, partner and chief executive of Clemenceau Medical Center (CMC). 

Despite the declining number of tourists visiting Lebanon, the country remains a regional healthcare destination because when it comes to one’s life, travel warnings and political turmoil become surmountable obstacles. 

Driven by necessity

International patients account for roughly 20 percent of the total number of patients in the hospitals interviewed. Those patients are mainly from the region — 80 percent of Clemenceau Medical Center’s international patients are Arab — and feel that their countries cannot provide a competitive level of healthcare. “I was a consultant for some hospitals in the Gulf, and I can tell you that their level of treatment is not as advanced as ours,” says Dia Hassan, president and CEO of Bellevue Medical Center (BMC).

Mohamad Sayegh, dean of the Faculty of Medicine and vice president of Medical Affairs at the American University of Beirut Medical Center (AUBMC), says that international patients are drawn to the highly specialized healthcare services at AUBMC. He says that the majority of cases that the center sees are serious and complicated and have been referred to them. 

Lebanon’s hospitals are especially reputable in the fields of oncology and digestive, cardiac and brain surgeries.

“The Iraqis don’t have a lot of good resources for radiation therapy…, so they tend to come here for those purposes,” says Sayegh. The number of Iraqis who come to AUBMC for treatment, mainly for cancer cases, has risen from 39 percent of the 2,297 international patients in 2010 to 58 percent of the 2,497 international patients in 2012. Both AUBMC and CMC plan to establish cancer centers in the coming years to keep up with the growing demand for such treatment.

CMC also introduced robotic surgery to the region, which is in high demand by international patients due to its noninvasive nature. 

Affordable & accessible

Medical procedures in Lebanon cost less than they do in Europe or the United States, says Kalaawi of CMC. 

BMC’s Hassan explains that most Gulf governments subsidize treatment abroad for their nationals. They choose Lebanon because the country is close to them — not only in distance but also in language and culture.

The unstable political climate of summer 2012 did impact medical tourism: demand for elective surgery from international patients decreased, and hospitals that depended on that saw their business decrease. “The Gulf countries simply stopped sending their nationals to Lebanon for healthcare and we… felt their absence,” says Hassan. The most performed operations in BMC are plastic surgeries. 

But those who could not afford to go elsewhere for pathological services still came to Lebanon. AUBMC reported a 5 percent growth in the number of its international patients in 2012. 

“We have a steady flow of international patients but this flow goes up and down according to the regional stability. The events of 2012 saw a reduction of international patients by 50 percent from certain nationalities but they were replaced by patients from other countries who were not affected by [travel] bans,” says Kalaawi, adding that if it were not for these regional disturbances, medical tourism would be a very important factor in the Lebanese economy. 

The number of patients from Syria is increasing as well. “The war in Syria obviously had an impact on the medical centers there and people who have complicated illnesses are forced to seek healthcare elsewhere and some come to Lebanon,” says AUBMC’s Sayegh, who adds that the massive influx of Syrian refugees augments this number. 

Travel outside one’s country for healthcare is not a new or unique situation, and while Lebanon remains a key destination for medical tourism in the region for the moment, instabilities in the country may drive some potential business away and allow other countries to catch up with us in this field. 

Between an executive order from United States President Barack Obama in 2009 and a papal endorsement in 2011, stem cell science has reached the forefront of medical research and is revolutionizing healthcare. Not surprisingly, the stem cell wave has reverberated in Lebanon, and the Bsalim-based Middle East Institute of Health (MEIH) is looking to take an early lead in using stem cells for regenerative medicine.

MEIH’s new project, the Regenerative Medical Center, or Reviva, takes the unique approach of coupling both stem cell storage and therapy units under one roof. Dr. Henri Azar, chairman of MEIH, first toyed with the idea when the institute was installing its genetics lab five years ago. According to him, a French specialist that came specifically for the genetics lab told him at the time, “you are the only one who is talking about this.” 

Two and a half years later, Azar and several other doctors performed a feasibility study on implementing Reviva, which began the process of laying the foundations for the project. The wing of MEIH that the $4 million project will be incorporated into is 600 square meters, and it is expected to be completed and operational this summer.

Simplifying regenerative medicine

Stem cell banking is the preservation of stem cells — which can be found concentrated in embryos, fat, peripheral blood bone marrow and especially umbilical cord blood and tissue — to be used for future operations. Patients who have stored their stem cells in the past have eliminated the often difficult task of finding a donor match, making regenerative medicine a simpler option.

Stem cell banking first came to Lebanon via international stem cell banks that offer logistical services overseeing the transportation of the cord blood to the storage facilities abroad. However, there are disadvantages to sending your sample abroad, particularly the issue of expediency. The cord blood has to be sent by plane and must be processed and frozen within 36 hours, otherwise the cells will die off. Even if there are no delays in transportation, up to 40 percent of the stem cells could become nonviable. Moreover, retrieval of the sample for use presents the same logistical problems.

Reviva’s operations are divided into three key areas: the storage of the stem cells, reconstructive cosmetic surgery and acute therapy, such as treating blood cancer. 

Although Reviva is not the first stem cell bank in Lebanon, it will be the first bank to be all-inclusive, storing any type of sample that carries stem cells, including fat, bone marrow, and peripheral blood. But the main target is umbilical cord blood, the richest and most versatile sample of stem cells. Under the MEIH umbrella are some one hundred specialty private clinics, and Reviva aims to tap this expertise to provide future uses for stem cell transplantation, not to mention those treatments that are already available.

The market for stem cells

Reviva expects to be profitable in four years, according to Azar, but admitted the target market is not in Lebanon. “For the cell therapy, there is a huge demand, but not in Lebanon,” he says, adding that Reviva will market to doctors abroad, particularly in the region. Given Reviva’s “technical knowhow” and Lebanon’s reputation for cosmetic surgery, Azar expects Reviva to be received well. Indeed, he told Executive that the private clinic already has 100 files of potential patients, 80 of whom are from the Middle East and North Africa region. 

As for the Lebanese market, Azar estimates that there are a potential 5,000 clients — 7 percent of the 65,000 births that occur annually in Lebanon — looking to have the cord blood of their children stored. Each client can expect to pay $2,700 to $3,500, depending on whether they want to store the cord blood only or also cord blood tissue.

Another stem cell facility that preserves cord blood, called Transmedical for Life (TFL), began operating in 2010 and houses both public and private banking. The idea behind public banking, according to Dr. Marwan Masri, TFL chief executive and the president-elect of the Middle East Society of Organ Transplant, is rooted in the French model,  which states that umbilical cord blood should be universally available and makes it illegal to store it privately.

Anyone in Lebanon can donate to TFL their baby’s cord blood free of charge for others to use, and the Ministry of Public Health will reimburse the recipient of the stem cells for the transplant operation. However, only 6 percent of TFL’s 280 clients have opted for public banking, while the rest went for private banking,  meaning the stems cells are reserved for personal and family use. Each paid a fee of $1,900.   

The Sin El Fil office processes the blood samples and then delivers them to TFL’s storage facility in Salima. However, the storage facility only operates for the Lebanese.

Both TFL and Reviva aim to run their programs on international standards. When asked if other companies could compete, Azar exclaims, “They will not be able to compete with us because you need the technical specification, you need human resources, and you need a lot of money.”

Masri disagrees, however, citing the fact that there are stem cell facilities, albeit on a smaller and non-multidiscplinary scale, in some of the bigger hospitals such as AUBMC, Makassad and Hotel Dieu. According to him, it would not be difficult for these established players to dive deeper into the field of regenerative medicine. In addition to the Lebanese market, Masri also cited the fact that there are stem cell facilities in Dubai, Jordan, Turkey and Egypt. 

The need for regulation

With the expansion of Lebanon’s capacity to store stem cells and practice therapy comes the need for a governing body or watchdog to oversee the appropriate use of stem cells. A representative of one of the seven logistics companies that constitute the international stem cell bank presence in Lebanon told Executive that without laws and regulation, the idea of storage in Lebanon is “scary”. “Where are the boundaries that give you the rights and freedom of ‘you can do that, you can’t do that’… What happens if something goes wrong? Did you know… that those stem cells and umbilical cord blood can be used for [human] cloning?” he asks. 

While the stem cells from cord blood can theoretically be used to clone, the idea that a few years down the road we will be able to manufacture replicas of ourselves is highly unlikely. Nonetheless, there is an onus on government and the medical community to settle on laws and regulations regarding stem cell use. 

Until a regulatory authority can be established, however, the responsibilities of applying standards and educating the public on stem cells rest with the doctors in the field of regenerative medicine. Both Masri and Azar advocate the adoption of regulatory laws and public education on the uses of stem cell. These measures would undoubtedly increase patient confidence and subsequently the market size for stem cell banking.