LA APLICACIÓN DE LA INTERPRETACIÓN CONSTITUCIONAL EN LAS “SENTENCIAS INTERPRETATIVAS” DEL TC.

Both travel (as bodily displacement) and health (as bodily ailment), as moments of corporeal vulnerability, have been intimately linked over time to the concept of hospitality, of ‘being moved to respond’ (Barnett 2005: 15) to the precarious situation of another (Butler 2004). Until some centuries ago, travel had been held as an experience of suffering, penitence and hardship that exposed the traveller to myriad dangers (e.g., exposure to weather and other natural dangers, crime and violence). Hospitality is therefore premised upon the traveller’s displacement from his/her home, and involves the interaction between a provider (host) and receiver (guest) in which the host

offers a mixture of tangible and intangible factors that fulfil the guest’s security, psychological and physiological needs and expectations (King 1995: 220). This relationship emerged in many cultures around the world as a code of conduct, wherein the host was obliged to protect the traveller from harm and, in turn, the traveller-cum-guest would not harm the host. Temporarily welcomed across the threshold into the host’s domestic space, the guest would be afforded both security and a degree of comfort, in return for the obligation to reciprocity of hosting in the future. This relationship facilitated commerce, security and stability. It also functioned as a space within which power relations were played out, with the practice of hosting doubling as a demonstration of religiosity9 and/or social status (Ibid. 1995: 223).

Figure 1.2 Imagery used in campaigns promoting countries as IMT destinations

(images removed)

Promotional imagery accompanying IMT destination narratives is awash with Asian doctors and nurses demonstrating their dedication to their smiling patients of multiple origins surrounded by cutting-edge technology within modern facilities, nestled among each country’s ‘traditional’ landmarks and ultra-modern cityscapes. Some logos even include country maps, suggesting a homogeneous national space dedicated to the care of foreigners. Source (top-bottom): Honors Integrated Marketing Communications (2008); SingaporeMedicine (2007); MOH (2009)

The concept of hospitality permits an examination of the spatial and temporal relations articulating the identities of ‘host’ and ‘guest’ within IMT. Contrasting with an unconditional Levinasian hospitality to the unexpected visitor in which responsiveness may ‘not [be] straightforwardly an attribute of a subject at all’ (Barnett 2005: 13) and a Kantian ‘cosmopolitan right to universal hospitality’ (Derrida 2000a; Dikeç 2002), I wish to advance that national IMT destinations, as hosts, extend a conditional hospitality that is partial to ‘a guest whose identity is already attributed’ (Barnett 2005: 13; Derrida 2000b), an ideal subject that requests recognition and responsiveness with his/her ability to pay. Not passive receivers, hosts actively identify to whom their services are geared, under what conditions they are to be provided and how to attend to the particularities of the guest. Receiving the guest as a ‘Somebody, [and] not as a serialised nobody’ (Barnett 2005: 15) is essential to the extension of hospitality as part of a conditional ‘pact’ between the host and guest that insists on mutual recognition and the reciprocity of exchange between the ‘named’ to ‘give place’ to the claims of both parties (Derrida 2000b: 23-25). Invitation is offered through the assertion of ‘a secure sense of self-possession… [and] premised on a logic of unrelinquished mastery over one’s own space’ (Barnett 2005: 13; Derrida 2000a). The nationalised hospitality achieved through the harnessing of IMT flows reinforces the host’s sovereignty through an ‘active reciprocity’ (Silk 2004: 234) of naming, premised upon foreign patient-consumers crossing

9 This includes the recognition of being equal before the gods, accepting the stranger as a messenger, facilitating access to holy sites, etc.

the border, a ‘threshold across which relating is made possible’ (Barnett 2005: 16). As the courted Other, foreign patient-consumers can thus be considered an ‘intervention of the “beyond” that establishes a boundary’ useful for the elaboration of ‘strategies of selfhood – singular or communal – that initiate new signs of identity, and innovative sites of collaboration, and contestation’ within the world of travel (Bhabha 2004: 2, 12-13).

Much focus has been given to the question of hospitality, that welcoming extended to a foreign Other across a sovereign threshold, in ‘developed’ Western societies grappling with hosting asylum-seekers and extending the benefits and responsibilities of citizens to refugees and immigrants (e.g., Darling 2010; Dikeç 2002). By contrast, and perhaps because of the sovereign foundations that the relationship of hospitality assumes and upon which it builds, little work has used it as a means with which to interrogate the extension of care from within ‘developing’ countries to outside others and the recognition this act affords both host and guest. In this thesis, therefore, I wish to contribute to the existing body of work by offering a reading of the commercialised hospitality embodied by the international tourism ‘industry’ within which IMT destinations – largely concentrated within ‘developing’ countries – participate and the ways in which this participation complements and colludes with a vast range of potent social, cultural, economic and political logics.

Governments of ‘developing’ countries are increasingly reliant upon international tourism, a common means with which to increase economic diversification and secure an inflow of capital investment and foreign currency in contexts tempered by the inequalities of international trade and the ‘international politics of debt’ (Enloe 1989: 40). As a tertiary industry, tourism lessens dependence on agriculture and manufacturing and permits national economies greater integration into the lucrative global service and knowledge economies. Labour-intensive, it employs the ‘traditionally underemployed’ (Richter 1980: 240), and the building of tourism infrastructure helps keep the construction and real estate industries afloat. Though there may exist concerns as to the uneven distribution of the wealth it generates, international tourism is oft celebrated as a ‘passport to development’ (Wood 1993: 48) and engine of modernisation, via the ‘“trickle-down” of modern skills, new technology and improved public services… imagined to follow in the wake of foreign tourists’ (Enloe 1989: 40). Thought by some to play an intermediary socialising role that brings the ‘traditional’ into direct contact with the ‘modern’ world, there is also significant resistance to what are seen as neo-colonial projects of cultural objectification and homogenisation, recalling tourism’s links to imperial travel and exploration (Wearing et al. 2010). While this dualism is critiqued for perpetuating a rigid tourist/local dialectic that ignores their hybrid and mobile subjectivities (since, as Crang (2005: 39) notes, increasingly ‘those who are tourists one day are the toured the next’),

such a vision frequently persists in policy and practice. With Malaysia, for example, international tourism has made the country the ninth most travelled destination in the world (UNWTO 2010), and it is today the most economically productive service sector, second only to manufacturing in its contribution to GDP. Accordingly, it has earned a prominent place in Malaysia’s long-term national development plans, with an express view to helping the country acquire ‘developed’ status by 2020 (Henderson 2008, 2009).

At the same time, international tourism holds potent declarative and interpellative value for destinations involved. Serving as a powerful communicant of ‘being’ (Hollinshead 2004: 32), it gets mobilised as a prime method with which to improve countries’ international visibility and prestige. ‘[B]ecoming a tourist destination’, suggests Urry (2002: 143), ‘is part of a reflexive process by which societies and places come to enter the global order’. Chang and Yeoh (1999: 103) demonstrate this with their work tracing the discursive shift from tourism campaigns in the 1970s that framed Singapore as a self-contained (if internally diverse) destination to the 1990s ‘New Asia – Singapore’ campaign that communicated Singapore’s vital reliance on the outside world and its positioning as the heartland of Asian values and a privileged gateway to a thriving Asia. They demonstrate that tourism policy, as a ‘symbolic means of framing space’ (Zukin 1991, in Chang and Yeoh 1999: 102), goes frequently hand-in-glove with national authorities’ broader political objectives and aspirations. There are countless other examples of this. In the Philippines under Marcos during the period of martial law in the 1970s, for instance, the government rapidly developed a national-scale tourism apparatus to sell the country as a ‘safe and delightful’ destination (Richter 1980: 242), so as to neutralise both internal and external opposition to Marcos’ leadership and to demonstrate to foreign investors that martial law would not interfere with the flow and stability of foreign investment and aid. This underscores governments’ ‘willingness to meet the expectations of those foreigners who want political stability, safety and congeniality when they travel’ (Enloe 1989: 31). International tourism, with its success pivoting on responsiveness to the invited Other, therefore, works as a powerful mode of surveillance and control over the behaviours of subjects.10

In their study of private and corporatised hospitals in New Zealand, Kearns et al. (2003: 2305) argue that neoliberalism has ideologically transformed healthcare landscapes, resulting in the production in the built environment of ‘overt symbols of exclusionary consumption’ which reflect ‘new sets of power relations’. IMT destinations can be symbolised by the ‘hospitel’, a chimerical

10 The commercialised host-guest relationship, in which the guest is prioritised, is far from a balanced exchange between equal participants, further polarised by social, cultural and economic differences between providers and recipients. In correlation with a state’s reliance on international tourism, its nationals often are enjoined to be smiling, helpful, friendly, respectful and courteous ‘ambassadors’ to international tourists as well as tolerant and considerate of their customs, behaviours and wishes (see Tee 21/02/2009). See Chapter IV.

space of commercialised hospitality uniting the luxury, exclusivity, comfort and attentiveness to customer service of high-quality hotels with the medical skill and practices found within ‘traditional’ hospitals (see Bochaton and Lefebvre 2009; Kearns et al. 2003; Rodrigues and Meera 16- 30/06/2006). The hospital, historically an institution of protection and refuge as much as of partition and surveillance, under the eye of religious orders, communities and charities, and later on the state (Pelling and Harrison 1995; Turner 1995)11, merges with commercialised hospitality. Exclusive international patient wards, hotel-style suites, special extended-stay visas for IMT, personal assistants, dedicated language interpreters, private transportation, in-house foreign exchange kiosks and menus catering to diverse dietary requirements and tastes are just some of the ways in which foreign patient-consumers are made to feel welcome. Kearns and Barnett (1997: 179) suggest that places such as these ‘project caring social relationships which are often absent in their home environments’. As we saw with Woodman’s (2009) evocation of the personalised touches and ‘creature comforts often offered abroad’ that guarantee ‘welcome relief from the sterile, impersonal hospital environments so frequently encountered at home’ (Woodman 2009: 5), the desire for more caring exchanges within a medical context makes private healthcare and IMT appealing, with a greater amount of time expended on individual patients’ needs and comfort. Driving patient- consumers to certain providers are not only ‘rational’ factors of cost and distance but also this ‘irrational’ desire for comfort, care and dignity, as we saw with the taglines employed by national councils seeking to promote their countries as IMT destinations.

Many patient-consumers are thought to travel with emotional baggage ‘packed’ by the healthcare systems they were motivated to leave behind. As the then Director of SingaporeMedicine, Dr Jason Yap (interview 15/02/2008), suggests, IMT destinations do not thrive because they are ‘the best in the world’ but because they are considered the best available alternative to what is accessible closer to home. In other words, the healthcare systems in patient- consumers’ countries of origin are generally perceived to be somehow at fault – meaning that the success of a particular IMT destination is not a measure of its individual excellence but, rather, is contingent on perceived gaps and failures elsewhere. IMT destinations’ market-mediated responsiveness to paying foreign subjects’ (presumed) suffering/distress results in targeted extensions of care to specific clienteles. This reveals a temporal politics of hospitality ‘conditionally extended as a right to certain categories of person, implying an apparatus of laws, states and borders’ (Barnett 2005: 14). Such a politics is contingent upon ‘the differential capacities and dispositions of individual or collective actors to be affected by and moved to respond to certain

11 Early hospitals also involved confinement of those representing ‘social’ ills (e.g., poor, unemployed, criminals, insane), not necessarily to ‘cure’ them but primarily to segregate them and maintain order outside (Gesler 1991: 173).

claims and not to others’ (Ibid. 2005: 20). As such, hospitality hinges on a ‘distinction between

invitation and visitation [that] indicates that the category of the Other… is not primarily understood with references to a position in space’ (Ibid. 2005: 18) but rather to the social, economic, cultural or political value of the Other at the time – leading, as we saw earlier with the debate about asylum- seekers receiving care in the UK’s NHS, the host to engage in the ‘hostile dynamic of incorporation and exclusion’ (Ibid. 2005: 8) in deciding the ‘near’ and the ‘far’.

In the case of Malaysia, marketing efforts over the last decade have focused on healthcare consumers from the West, Middle East and neighbouring Southeast Asian countries, emphasising the various plights these prospective clienteles encounter in seeking care in their habitual places. Un(der)insured middle-class Americans are simply ‘priced out’ of adequate medical care (Cannon and Tanner 2005; Turner 2007a). Impoverished nearby ‘developing’ countries, like Indonesia, are unable to offer necessary resources and skills for quality care (Hulupi 16/04/2006; Gunawan 01/11/2007; Praptini 31/10/2007). Middle Easterners are turned away from their traditional IMT destinations in the West as a result of post-9/11 racial and religious discrimination (Chua 25/09/2004; Connell 2006; Ehrbeck et al. 2008). In highlighting the problems these target markets have encountered in their pursuit of care elsewhere, IMT promotional strategies focus on demonstrating why ‘Malaysia’, at the national level, is capable of responding specifically to their unmet needs. ‘Medical tourism’, observes Tan Lee Cheng, Principal Assistant Secretary for Health Tourism of the MOH’s Corporate Policy and Health Industry Division (interview, 17/01/2008),

may be a business, but that doesn’t mean that it’s solely for business purposes. It’s still very much based on the very foundation that healthcare is for all, that healthcare should be affordable, equitable and of quality. We [Malaysia] are based on those kinds of premises.

As a reterritorialisation of care, IMT undertakes very explicit political work, mediated through a globalised market, that helps places promoted as therapeutic to ‘do very well by doing good’ (Henrikson 2007: 68) for, in Barnett’s (2005) words, certain ‘Somebodies’.