New Zealanders travelling abroad for surgical procedures say they cannot access the same surgeries in our national healthcare system because of criteria eligibility, or the unaffordability of having them carried out privately.
One woman who escorts New Zealanders on medical tourism trips, says she has now taken more than 150 kiwis to Mexico for bariatric weight-loss surgery.
As with any surgery, there are risks attached. Some argue the risks of having medical procedures in countries like Thailand, Turkey, and Mexico are greatly exacerbated.
It's not hard to find examples of surgeries that have gone wrong in these countries with a quick search online. So, is it a wise move for Kiwi patients?
I was in line at LAX Airport in Los Angeles waiting to board a flight back to New Zealand in March when I first met Kirsten Leonard.
Our conversation was relatively mundane from memory, about the airport, the flight home - insignificant small talk. That was until Kirsten told me what she did for a career.
"I take medical tourism groups overseas for surgeries," she revealed. She explained her most common destination was Tijuana, Mexico.
Admittedly, my internal reaction was both one of surprise and shock.
"How many people are actually doing this?" to "That sounds incredibly risky", were thoughts that instantly came into my mind. I later found out she claims to have taken more than 150 patients during her 25+ trips there.
For the next two months, I spoke to Kirsten regularly in the hope she would allow us to follow one of her tours and asked her to put the word out to her patients about what I wanted to do - a television piece for Paddy Gower Has Issues.
It was always going to be a difficult ask for someone to share such a private healthcare journey with a journalist - and in reality, the entire nation on TV.
Risking both judgment and ridicule from keyboard warriors, we met one of those patients in May a few days before heading to Tijuana.
Colleen Walters, a Rotorua woman, was heading on the next trip to Tijuana and she was both nervous and excited.
Colleen is a typical case study for why a New Zealander looks overseas for weight-loss surgery. She has the added complication of suffering a stroke which has left her with left-side paralysis.
The Problem
Like others, Colleen says she was told she wasn't eligible in the New Zealand public system. This isn't uncommon due to the low number of publicly funded bariatric surgeries being performed each year.
Each healthcare region can only perform a set number of surgeries depending on the resources available.
To determine who is eligible, Te Whatu Ora - Health New Zealand has a series of requirements patients must meet to make sure those who will benefit most from the surgery are the ones who actually receive it.
Dr Richard Barbour from Middlemore Hospital describes how surgeons like him aren't able to meet the demand. Dr Barbour suggests it also comes down to a lack of funding.
"We're working hard to keep going again (post-pandemic) and get up to about 150 cases a year.
"But we get 600 referrals a year, roughly, probably more even than that, and we just don't have the resources to do it", he says.
He adds bariatric surgery is "a chronically underfunded and underappreciated part of medicine, it's got the stigma around it".
To have bariatric surgery completed privately in New Zealand can be costly. Auckland Weight Loss Surgery lists its prices publicly on its website.
A gastric sleeve procedure can start at $23,629 while a gastric bypass procedure starts at $25,837. For many, these prices are well outside what they can afford.
The situation arises where overweight New Zealanders are being rejected by the public system and cannot afford to access private healthcare.
The Tour Guide
Kirsten Leonard is managing what appears to be a growing business taking patients to Tijuana, and is actively looking to take more people for surgeries to Thailand as well. She saw a business opportunity after her own surgery in 2017.
"To be honest when I had the surgery, (I was) just walking up and down the corridor thinking, more people would come over here if they came in a group," she says. Since then she has taken scores of people to Mexico for bariatric surgery.
Kirsten says she is paid from a package price, like a tour guide on a foreign trip. She says she doesn't have a set 'fee' from each tour but her payment can vary on a number of factors.
For example, if flights are cheap she may earn more from the package price. If they are expensive, she might earn very little at the end of it.
Follow Paddy Gower Has Issues on social media:
On this journey, she had two helpers named Teresa and Kiri who were both former patients. They volunteer their time, but flights and accommodation are paid for, and they receive a little money for shopping or activities when they escort the patients to markets or shopping malls.
Kirsten admits she has seen her clients suffer from complications while traveling, on the rare occasion.
Despite that, she says most of these occur once patients have arrived home - which, I felt, wasn't completely reassuring.
"There have been complications but they don't tend to show up until they get back to New Zealand, so we're quite lucky in that respect," Kirsten told me over lunch.
Despite no medical qualifications I was made aware of, Kirsten spends a large amount of time at the hospital with her clients "making sure they are comfortable".
I noticed this while we were in contact during the trip and we both were staying at the same hotel.
She says she won't leave the hospital until she is satisfied her clients are comfortable. It's obviously in the hospital's interests to keep her and her clients happy considering the flow of business she is bringing them.
The Patient
Colleen Walters arrived in Mexico in June with a positive mindset, and by her own admission was potentially naive to the risks of heading there.
She had to access her KiwiSaver to fund this trip, so obtaining medical insurance with its added costs was out of the question for her.
"I was in that same mindset of everything's positive. I know that's naive because coming over on the plane I was thinking, 'I can't afford for anything to happen to me if I get stuck over there, I've got no money to bring me home'," she told me shortly after her arrival.
Colleen hadn't travelled much before, besides to Australia, so a long journey to Mexico would be a new experience.
Admittedly, I was slightly worried for her. Colleen came across as a kind grandmother who genuinely needed help.
Whenever she fell over at home, she would have to call St John ambulance to assist her in getting up again.
Some may argue people like Colleen should focus on physical exercise, but that simply isn't possible given the paralysis she has been left with after her stroke.
I was consistently impressed by Colleen's positivity given the pressures she faces in life both financially and physically. Throughout the many times we met, I asked her where that optimism came from.
"There's so many things that I need to get out and do, and too many people who love me. You've got to be positive about life".
The Surgeon and Hospital
Dr Ismael Cabrera is easy to get along with. A short man with facial hair wearing surgical scrubs, he greeted our crew in the lobby with a wide smile and plenty of enthusiasm.
I had many questions for him. He is the man supposedly operating on New Zealand patients, and is responsible for their future health outcomes.
At my request, Dr Cabrera started our interview by listing his medical qualifications. It sounded extensive, and he crucially informed me part of his training had been conducted in the United States for a period of months. A complicated, expensive, but otherwise high-quality Western healthcare system.
He told me he has now operated on 8000 patients, mostly from the US but also from Australia, New Zealand and Canada. Dr Cabrera claims this is why some Tijuana bariatric surgeons are the best in the world. He might operate on three to four patients a day, while clinicians in other countries might only operate on one a day or less, he said.
Like Kirsten, he never denied complications exist. These could range from leaks to internal bleeding in the hours, days, or weeks after a procedure has been carried out.
Dr Cabrera insisted (many times) the difference between a good surgeon and the ones people hear about online connected to medical mishaps, is whether or not they know how to remediate these complications when they appear.
I asked him if a patient had ever died under his watch. He told me it hadn't happened at the hospital, but a person once died after returning home. He suspected they had not taken the blood thinning medication he had prescribed for them and they developed a blood clot.
Unusually, patients only see the surgeon on the day of the operation. Personally, this would make me feel very uncomfortable. I would want to know and trust the person responsible for my health while I'm under anesthesia. But in these cases, it's seemingly common practice to only meet the medical professional on the day of the surgery.
Dr Cabrera told me he has the patient's entire medical history and details on hand to review before operating and has only once rejected a patient on the day of surgery because he found out that they had lied about heart problems which put them at an increased risk.
In March, I visited New Zealand and was in Auckland's Mercy Ascot private hospital for a short time. I was struck by how modern the Tijuana hospital was and how similar it was to Mercy Ascot.
Colleen's room was arguably more comfortable than mine earlier in the year, and adding to her comfort she had managed to log into her Netflix account on the flatscreen TV. Perhaps my preconceptions were unfair, but this wasn't what I expected from a less developed country when compared to my own.
The Risks
Like all operations, there are risks associated with bariatric surgery. In New Zealand, Te Whatu Ora is open and transparent about this.
Here's what they told me when I asked for information about weight loss surgery in New Zealand.
"People have died from having surgery for morbid obesity. This happens rarely. The risk is higher if the patient is older and or if the patient has other problems related to obesity. Mortality rates for obesity surgery are not zero. Rates are in the order of less than or equal to 1 percent."
"The death rate from banding operations is around 1 in 2000, and 1 in 1000 for sleeve gastrectomy and gastric bypass operations. Heart attacks can occur after the operation, blood clots can form in the leg veins and pass to the lungs, or leakage of stomach joins can cause death. Bleeding can occur after any surgery, but is greatest after stapling operations (1 percent of people will need a blood transfusion)."
It would be impossible to accurately compare the risks between New Zealand and Tijuana when it comes to bariatric surgery.
We can point to anecdotal evidence provided by Dr Richard Barbour from Middlemore Hospital who says Kiwi surgeons are having to fix issues that arise with medical tourists when they return home.
"I know there are really good hospitals in places like Mexico that do a lot of this work. Even they have complications," he says.
"I have colleagues who have had to deal with people arriving back from Mexico or India or Thailand with severe life-threatening complications from bariatric surgery that has been done overseas. Some of them have been lucky to make it back."
You don't have to look far to find examples of where procedures have gone wrong. Just last month a TVNZ report detailed the experience of a woman who returned home from Mexico with a leak in her stomach that formed a 6 cm abscess, which had then turned septic.
Earlier this year, four Americans were kidnapped in Matamoros, Mexico, and two are reported to have been killed. One of them was in Mexico to receive cosmetic surgery.
Dr Cabrera is not shy in talking about medical incidents which make the news, pointing the blame at unqualified doctors, who he says are creating negative perceptions of all clinicians in the region.
"You have to do your research because not all the doctors are qualified, and not all doctors have the experience." Dr Caberea says Tijuana has a problem in which some general practitioners are undertaking extremely short (two to three month) training courses to then advertise that they are qualified surgeons when in fact they aren't. He says these surgeons won't know what to do when complications appear during surgery.
The Result
It's early days, but Colleen's surgery went well. It has only been a week and a half, but during my most recent conversation with her she told me she was feeling fine, although had a sore and sensitive stomach which I assume would be par for the course after a gastric sleeve operation.
After meeting Colleen, I really hope this procedure gives her the life she wants. She has given up her superannuation to fund her surgery in the hope she can become more mobile and interactive with her mokopuna.
I have to admit, my perceptions of medical tourism have been slightly altered too. I didn't realise how common this was in Tijuana until arriving there. It really is a city thriving on the business of foreign medical patients.
Our hotel was swarming with people arriving for surgery, my taxi in and out of Tijuana was filled with medical patients, and the city was covered in billboards advertising what procedures are available. Despite that, Dr Barbour's comments have to be taken extremely seriously.
"It's only a worry for 1 in 100, but that's about what it is. If you will get 1 and 100 you're in trouble," he says. The overriding message I was conveyed from both those in Mexico, and the medical professionals back in New Zealand was that deep research is essential, and not all professionals are the same in countries where medical tourism is booming.
Stream Paddy Gower Has Issues in full on ThreeNow.
