The boom in medical tourism has increased the need for hospitality staff training and education. The food service facet is no exception. While restaurants and hotel food and beverage operations are already seeing the demand for healthy menu options and safer food handling practices, the medical tourist segment could quite literally make these compliances a matter of “life and death.”
KNOWLEDGE OF RESTRICTED DIETS
A key consideration when serving the medical tourist will include knowledge of restricted diets and ingredient effects. A pinch of salt or a dollop of butter may appeal to restaurant patrons, but it will certainly conflict with the recommendations of some recovery plans. Food preparation in the traditional food outlet is done in one of two ways: innovatively following one’s instincts and skills for creating what tastes good, or alternatively, following explicit instructions. The menu and recipe decision maker in a property serving the medical tourist will require in-depth knowledge of restrictive diets and dietary health considerations, as well as an understanding of how ingredients affect the body (i.e. Bouillon cubes equal sodium equals a no-no for those suffering from congestive heart failure or kidney disease). Operations will also want to take into account ingredients that can cause minor, but equally uncomfortable complications, such as those with high amounts of chemical additives, sugar, salt, and fat. It will be important to have access to a dietitian regularly for consultation.
Staff responsible for simply following food preparation directions will also benefit from knowledge of such dietary restrictions. To these chefs it must be explained that necessity of avoiding “creative freedom” or being careless in food preparation when serving this new segment of the traveling public. Chefs frequently enjoy exercising some creativity, so it will be important that they understand the reasons behind such insistence of sticking to a recipe.
Knowledge and expression of the severity of consequences may increase awareness and responsibility in all levels of the foodservice establishment. For example, any employee who understands that the germs on their hands can actually kill one of their guests who may have a weakened immune system is more likely to wash and sanitize as frequently as needed.
Foreseeable areas for additional training will include preparation and service knowledge, attitudes and practices. A traditional foodservice outlet may not recognize the dramatic effects that otherwise acceptable practices can have on at-risk (or patient) populations. For example, foods prepared in advance may contribute to the increased risk of food poisoning, but it is not uncommon for a restaurant to participate in these practices on a daily basis. Kitchen staff will routinely cook and hold partially prepared menu items and ingredients. Everyday tasks such as utensil storage will require a greater attention to detail in an aftercare setting, so as to maintain the utmost of sanitary conditions.
Dietary considerations need not only by focused on foods that are not recommended for a recovering patient, but also on items that may be recommended to aid in healing. Menu items that are low in salt, sugar, fat, and chemical additives will prevent uncomfortable complications, such as bloating or constipation. Ingredients with high fiber, nutrient and vitamin contents may play a role in expedited recovery, and whole foods should take precedent over processed foods (i.e. baked potatoes versus French fries, whole grain breads versus refined white breads, and fresh fruit and vegetables versus canned, sugary or sodium laden versions). Other menu considerations should include lean protein offerings, which could come from lean poultry cuts, nuts, beans, or protein powder supplements – a stark contradiction to the ever-present cheeseburger. All operations should consider offering a “smoothie” like item on their menus, as it is an ideal approach for supplements, and is often a desired option for those suffering from a decrease in appetite or painful intake or digestion side effects.
This is not just a kitchen concern. The preparers of the menus and the servers must also be educated on the needs this new clientele poses. In restaurants and hotel facilities serving many medical travelers, special menus or specially identified portions of the regular menu may help guide the guest to those items most appropriate. If a destination is serving a specific sort of medical traveler, such as India’s emphasis on cardiovascular patients, the wait staff may be trained in the special needs of such recovering guests. Verification that menus have been checked and confirmed by dietician experts will provide peace of mind for the medical traveler in assuring their diet is appropriate, and also assist servers in guiding not only the traveler to appropriate menu offerings.
FOOD SAFETY
In addition to dietary considerations, operations serving the medical tourist population will require an increased focus on food safety. Foodborne illness and insufficient food safety practices continue to remain a significant problem in the foodservice industry. In the United States alone it is estimated that 1 in 6 (48 million) individuals become ill from foodborne illness, causing 128,000 hospitalizations and 3,000 deaths annually. At risk populations, such as recovering patients, are at a significantly increased risk for severe outcomes in the event of a foodborne disease. While death may be an extreme outcome of unsafe foodborne disease and unsafe food handling, symptoms such as abdominal cramping, fever, diarrhea and dehydration are very common, and can cause not only patient discomfort, but damage to stitches and a critical weakening of the immune system.
As described by the Department of Health and Human Services Centers for Disease Control and Prevention, foodborne disease is caused by consuming food or beverage that has been contaminated by disease-causing pathogens, poisonous chemicals, or other harmful substances. There are more than 250 food borne diseases, thus there is no “one syndrome” associated with foodborne illness. However, the initial (and most frequent) symptoms include abdominal cramping, nausea, vomiting and diarrhea. The most common disease-causing pathogens are Campylobacter, Salmonella, E. coli and Calicivirus (or Norwalk-like virus).
Campylobacter is responsible for the most food-related cases of diarrhea in the world, and is primarily contracted by eating undercooked chicken or foods that have come into contact with raw chicken; this often occurs from cross-contamination due to inadequate or infrequent hand washing or insufficient cleaning and sanitization. Salmonella and E. coli have gained a great deal of recognition due to the media’s coverage of foodborne illness outbreaks, and both can cause severe complications and life-threatening infections. Norwalk-like virus, or Calicivirus, is an extremely common occurrence, yet is rarely diagnosed, as the laboratory test is not widely available, and it usually resolves itself within two days. This illness is characterized by acute gastrointestinal illness, and is typically spread by infected food preparers’ interaction with ingredients and utensils.
The ways that food is procured, stored and prepared play a critical role in preventing foodborne illness. Facilities will need to take great care to ensure that ingredients have been purchased from reputable and “safe” suppliers. Proper cleaning, refrigeration, freezing, thawing, cooking, storage, and handling of food, as well as frequent cleaning and sanitizing work stations, equipment, utensils, and hands remain critical to safe food preparation and consumption. Granted, restaurant and hotel foodservice employees are typically required to have some training in proper food handling, but many practices and precautions may not be taken as seriously in the typical kitchen as compared to a hospital foodservice facility. Properties serving the medical tourist will need to ensure that its staff are trained and held to the utmost standards of food safety practices.
The types of food most often associated with foodborne illness are raw meat, poultry, eggs, and shellfish. Foods that combine the products of more than one animal are also a risk, such as ground meat, milk, and eggs: a carton of eggs can contain eggs from a dozen different chickens, making it statistically more likely for the unit to contain ingredients from a contaminated bird. Using the same analogy, one hamburger or one glass of milk may contain products from hundreds of different cows. Nonetheless, bulk products play an essential role in commercial foodservice, and will not be replaced – but foodservice outlets can direct more attention to these ingredients with the knowledge of the increased risk they pose.
Additionally, improper washing of raw fruits and vegetables can cause illness, a step that sometimes receives less recognition, as raw meat products are seen as far more of a threat than other food items. Such washing may, in itself, be a problem in areas with limited potable water, so some menu items offered medical travelers may need to be restricted not because of their inherent problematic nature, but because there is not a way of preparing them that does not expose the traveler to potentially contaminated water. In some countries, the average traveler has been warned for years to avoid fruits that cannot be peeled, or lettuce that may have been washed in questionable water. For the medical traveler, an extension of this precaution seems prudent.
Restaurants offering to collaborate with hospitals seeking medical tourists may usually count on a positive response from such facilities; the international patient offices will appreciate dining facilities which demonstrate such proactive care for their medical guests. Equally important is having menus in the language of the traveler, so they may have a degree of certainty that what they are ordering is in keeping with their recommended diet. In some countries, where the usual diet may be quite different from that of the traveler’s native land, explanation of menu content will also help reassure the traveler that the items are not only on their diet, but something they are comfortable in consuming – no small step toward peace of mind for the medical tourist already under the emotional stress of traveling for medical procedures. Something as simple of a photocopied sheet, available upon request, detailing content and describing local ingredients, can be a significant reassurance to someone in recovery.
Are these additional costs worthwhile for the restaurant? Each will need to judge for itself, but if a medical traveler finds a restaurant at which he or she feels comfortable at which to dine, given that recovery time in the country after an operation may be up to two to four weeks, the loyalty of that customer and their family during the recovery process may lead to repeated patronage.
About the Authors
Dan Cormany is a Visiting Assistant Professor at the School of Hospitality and Tourism Management at Florida International University and is finishing up his doctoral dissertation on medical tourism. He has a Master of Science in Hotel Administration from the University of Nevada, Las Vegas, and a Master of Arts in Higher Education Administration from Bowling Green State University. He has also studied at the University of Hawaii and University of South Florida, and has a Bachelors degree in communication from the University of Akron. He may be contacted at dancormany@yahoo.com
Miranda Kitterlin is an Assistant Professor in the School of Hospitality, Sport and Recreation Management at James Madison University. She received her doctoral degree in Hospitality Administration from the University of Nevada, Las Vegas, with an emphasis in Food and Beverage Management. Prior to beginning a career in academia, she worked for 11 years in the restaurant industry. Miranda holds a Master of Human Resources Management and a Bachelor of Science in Hospitality Management from the University of Louisiana, Lafayette with a concentration in dietetics.
