The Emergence of Global Healthcare Destinations … a Historic Perspective

How The Emergence of Medical Knowledge Led to Medical Tourism:

Throughout history medicine has been a byproduct of society’s investment in science, education and technology.  To this end, affluent nations became magnets for science-based education and innovation upon which rests the development and production of pharmaceuticals, medical technology and advanced medical treatment protocols (a/k/a: Centers of Excellence). 

Centers of Medical Excellence have attracted patients from neighboring countries, regardless of time and place in history. 

The following evolutionary summary helps understand the cyclical nature of “knowledge-migration” from one country and region to another.  It demonstrates the dynamic nature of medical knowledge and therefore should help mitigate inherent cultural biases about treatment destination.          

No Geographic Boundaries on Medical Research and Expertise

The old world of Mesopotamia was anchored by the Egyptian Empire to the East and South and the Babylonian Empire at the North-North West part of the region.  Archeological evidence suggests that the knowledge of medicine was an integral part of their societies, a reflection of their wealth and power, and embedded in their system of higher education. 

While earliest known physicians, specialists, hospitals and medical records were in Egypt; the earliest known Physician’s Handbook was found in Babylon (1050 BCE).  Given the centrality of these empires in the old world, it is reasonable to assume that both were regional magnets for business and the political elite from the entire region who sought a cure for their maladies. 

The earliest medical record dates to 1800 BCE Egypt.  It is a fascinating record of 34 gynecological cases, including infertility problems. Medical institutions, referred to as Houses of Life are known to have been established in ancient Egypt as early as the 1st Dynasty (3000 BCE) By the time of the 19th Dynasty (1298 BCE) some civil servants enjoyed such benefits as medical insurance, pensions and sick leave.

The earliest known physician is also credited to ancient Egypt:  Hesy-Ra, “Chief of Dentists and Physicians” for King Djoser in the 27th century BC.(2680 BCE).  Also, the earliest known woman physician, Peseshet, practiced in Ancient Egypt at the time of the 4th dynasty (2613 BCE).  Her title was “Lady Overseer of the Lady Physicians.” In addition to her supervisory role, Peseshet trained midwives at an ancient Egyptian medical school in Sais. 

While evidence about Chinese traditional medicine dates back to the same period, the Neijing (hand book of traditional Chinese Medicine) can only be traced to about 5 century BCE.  In 56 BC, Zhang Liang invented an instrument named "Meng", the precursor of the modern stethoscope.

Global Contributors to the History of Medicine

The first known Greek medical school opened in Cnidus in 700 BC.  The Greek physician Alcmaeon authored the first comprehensive anatomical work.  A towering figure in the history of medicine was the physician Hippocrates of Kos (ca. 460 BC – ca. 370 BC), considered the "father of modern medicine." The Hippocratic Corpus is a collection of around seventy early medical works from ancient Greece strongly associated with Hippocrates and his students.

Most famously, Hippocrates conceived the physicians’ oath, also known as “The Hippocratic Oath” (“Do No harm”) for physicians, which is taken by all graduates of medical education.

Hippocrates began to categorize illnesses as acute, chronic, endemic and epidemic, and use terms such as, "exacerbation, relapse, resolution, crisis, paroxysm, peak, and convalescence."

Another of Hippocrates's major contributions may be found in his descriptions of the symptomatology, physical findings, surgical treatment and prognosis of thoracic empyema, i.e. suppuration of the lining of the chest cavity. His teachings remain relevant to present-day students of pulmonary medicine and surgery. Hippocrates was the first documented chest surgeon and his findings are still valid.

The Romans invented numerous surgical instruments, including the first instruments unique to women, as well as the surgical uses of forceps, scalpels, cautery, cross-bladed scissors, the surgical needle, the sound, and speculas. Romans also performed cataract surgery.

Medieval medicine was an evolving mixture of the scientific and the spiritual like Unani.  In the early Middle Ages, following the fall of the Roman Empire, standard medical knowledge was based chiefly upon surviving Greek and Roman texts, preserved in monasteries and elsewhere.

Ideas about the origin and cure of disease were not, however, purely secular, but were also based on a spiritual world view, in which factors such as destiny, sin, and astral influences played as great a part as any physical cause.

Oribasius was the greatest Byzantine compiler of medical knowledge.  Several of his works, along with many other Byzantine physicians, were translated into Latin and eventually, during the Enlightenment and Age of Reason, into English and French. The last great Byzantine Physician was John Actuarius, who lived in the early 14th century in Constantinople.

The Islamic civilization rose to primacy in medical science as Muslim physicians contributed significantly to the field of medicine, including anatomy, ophthalmology, pharmacology, pharmacy, physiology, surgery, and the pharmaceutical sciences. The Arabs were influenced by, and further developed, Greek, Roman and Indian medical practices. Galen, Hippocrates, Sushruta and Charaka were pre-eminent authorities.

The translation of 129 works of the ancient Greek physician Galen into Arabic by Hunayn ibn Ishaq and his assistants, and in particular Galen's insistence on a rational systematic approach to medicine, set the template for Islamic medicine which rapidly spread throughout the Arab Empire.

Muslim physicians set up some of the earliest dedicated hospitals which later spread to Europe during the Crusades, inspired by the hospitals in the Middle East.

Muhammad ibn Zakariya al-Razi became the first physician to systematically use alcohol in his practice as a physician. The Comprehensive Book of Medicine (Large Comprehensive, Hawi, "al-Hawi" or "The Continence") was written by the Iranian chemist Muhammad ibn Zakariya al-Razi, the "Large Comprehensive" was the most sought after of all his compositions. In it, Muhammad ibn Zakariya al-Razi recorded clinical cases of his own experience and provided very useful recordings of various diseases.

The "Kitab fi al-jadari wa-al-hasbah" by Muhammad ibn Zakariya al-Razi, with its introduction on measles and smallpox was also very influential in Europe.  Al-Kindi wrote De Gradibus, in which he demonstrated the application of mathematics to medicine, particularly in the field of pharmacology. This includes the development of a mathematical scale to quantify the strength of drugs, and a system that would allow a doctor to determine in advance the most critical days of a patient's illness.

Razi (Rhazes) (865-925) recorded clinical cases of his own experience and provided very useful recordings of various diseases. His Comprehensive Book of Medicine, which introduced measles and smallpox, was very influential in Europe.

Abu al-Qasim (Abulcasis), regarded as the father of modern surgery, wrote the Kitab al-Tasrif (1000), a 30-volume medical encyclopedia which was taught at Muslim and European medical schools until the 17th century. He used numerous surgical instruments, including some that are unique to women.

Why Some Nations Evolved as Centers of Excellence

The dark ages of Europe were marked by the decline of science and affluence.  While some medical science continued to evolve in secluded theological enclaves, the vacuum in creativity become the backdrop to the Golden Age of Knowledge of the emerging, affluent, Islamic Empire that embraced the sciences, higher education and medicine.

Consequently, the best doctors and health care facilities were found in the Eastern and Western corners of the Empire, the location of great universities and medical schools (The Iberian Peninsula to the West, and Byzantium and Persia to the West). 

Arab and Persian scientists were the guardians of medical science and for the next 500 years provided an immense pool of medical innovation. Again, we can safely assume that the affluent class traveled from nearby nations and city-states for medical treatment.

 Avicenna, considered among the most influential medical scholars in history, wrote The Canon of Medicine (1025) and The Book of Healing (1027), which remained standard textbooks in both Muslim and European universities until the 17th century.

Avicenna's contributions include the discovery of the contagious nature of infectious diseases, the introduction of quarantine to limit the spread of contagious diseases, the introduction of experimental medicine and clinical trials, the first descriptions on bacteria and viral organisms, the distinction of mediastinitis from pleurisy, the contagious nature of phthisis and tuberculosis, the distribution of diseases by water and soil, and the first careful descriptions of skin troubles, sexually transmitted diseases, and nervous ailments, as well the use of ice to treat fevers, and the separation of medicine from pharmacology, which was important to the development of the pharmaceutical sciences.

In 1242, Ibn al-Nafis was the first to describe pulmonary circulation and coronary circulation which form the basis of the circulatory system. 

He is considered the father of the theory of circulation.  He also described the earliest concept of metabolism, and developed new systems of physiology to replace the Avicennian and Galenic systems, while discrediting many of their erroneous theories on the four humours, pulsation, bones, muscles, intestines, sensory organs, bilious canals, esophagus, stomach, etc.

The Tashrih al-badan (Anatomy of the body) of Mansur ibn Ilyas (c. 1390) contained comprehensive diagrams of the body's structural, nervous and circulatory systems.

During the Black Death, or bubonic plague in 14th century al-Andalus, Ibn Khatima and Ibn al-Khatib discovered that infectious diseases are caused by microorganisms which enter the human body.  

Other medical innovations first introduced by Muslim physicians include the discovery of the immune system, the introduction of microbiology, the use of animal testing, and the combination of medicine with other sciences (including agriculture, botany, chemistry, and pharmacology).

Ammar ibn Ali al-Mawsili in 9th century Iraq, is credited for the invention of the injection syringe.  Muslim physicians are credited with the emergence of the first drugstores in Baghdad (754), the distinction between medicine and pharmacy by the 12th century, and the discovery of at least 2,000 medicinal and chemical substances

The 17th century ushered in the Renaissance period in Central and Western Europe.  With it there has been an increase in experimental investigation, principally in the field of dissection and body examination, thus advancing our knowledge of human anatomy.

The development of modern neurology began in the 17th century with Vesalius, who described the anatomy of the brain and other organs.  He had little knowledge of the brain's function, thinking that it resided mainly in the ventricles. Understanding of medical sciences and diagnosis improved, but with little direct benefit to health care.

Few effective drugs existed, beyond opium and quinine. Folklore cures and potentially poisonous metal-based compounds were popular treatments.  While Arab physicians first theorized about the role of bacterial and germs as early as the 11th Century, it was the Dutch scientist Antony Philips Van Leeuwenhoek who perfected the microscope to where it became a diagnostic device (1617) and with it ushered the era of microbiology.

As the Islamic Empire began to disintegrate into local tribal societies, it also experienced a decline in affluence and radicalization of religious views.  Academic discovery and science could not be sustained by economically weak tribal-based societies. 

The decline in affluence resulted in stunting of scientific discovery and gradual shifting of scientific leadership to emerging colonial forces with rapidly expanding economies and academic institutions. 

The wealth of the industrial nations was fed by systematic raping of natural wealth and human resources from newfound colonies in America, Africa and Asia.  The Arab and Chinese Empires that were left out of the Colonial power grab found it increasingly difficult to sustain their investment in higher education, and as they disintegrated Western Europe experienced a quantum leap in discovery and medical treatment capabilities.   

Medical Achievements in the 19^th Century

Medicine was revolutionized in the 19th century by advances in chemistry and laboratory techniques and diagnostic equipment.  Old ideas of infectious disease epidemiology were replaced with crud bacteriology, virology and diagnostic testing.  

Microbiology led to the modern infection control concept of hand washing before and after treating a patient.  First introduced by Hungarian physician Dr. Ignaz Semmelweis in 1847, this technique dramatically reduced the death rate of new mothers from childbed fever.  His discovery pre-dated the germ theory of disease.

This discovery was not appreciated by his contemporaries and came into general use in main stream practice with discoveries of British surgeon Joseph Lister, who in 1865 proved the principles of antisepsis in the treatment of wounds. 

After Charles Darwin's 1859 publication of The Origin of Species, Gregor Mendel (1822–1884) published in 1865 his books on pea plants, which would be later known as Mendel's laws. Re-discovered at the turn of the 20th century, they would form the basis of classical genetics.

The 1953 discovery of the structure of DNA by Watson and Crick would open the door to molecular biology and modern genetics. During the late 19th century and the first part of the 20th century, several physicians, such as Nobel prize winner Alexis Carrel, supported eugenics, a theory first formulated in 1865 by Francis Galton.

Eugenics was discredited as a science after the Nazis' experiments in World War II became known; however, compulsory sterilization programs continued to be used in modern countries (including the US, Sweden and Peru) until much later.

Semmelweis's work was supported by the discoveries made by Louis Pasteur. Linking microorganisms with disease, Pasteur brought about a revolution in medicine. He also invented with Claude Bernard (1813–1878) the process of pasteurization still in use today.

His experiments confirmed the germ theory. Claude Bernard aimed at establishing scientific method in medicine; he published An Introduction to the Study of Experimental Medicine in 1865. Beside this, Pasteur, along with Robert Koch (who was awarded the Nobel Prize in 1905), founded bacteriology. Koch was also famous for the discovery of the tubercle bacillus (1882) and the cholera bacillus (1883) and for his development of Koch's postulates.

The Role of Women in Medicine

The participation of women in medical care (beyond serving as midwives, sitters and cleaning women) was brought about by the likes of Florence Nightingale.

These women showed a previously male dominated profession the elemental role of nursing in order to lessen the aggravation of patient mortality which resulted from lack of hygiene and nutrition. Nightingale set up the St Thomas hospital, post-Crimea, in 1852. Elizabeth Blackwell (1821–1910) became the first woman to formally study, and subsequently practice, medicine in the United States.

It was in this era that actual cures were developed for certain endemic infectious diseases. However the decline in many of the most lethal diseases was more due to improvements in public health and nutrition than to medicine.

Medical Achievements in the 20^th Century

It was not until the 20th century that the application of the scientific method to medical research began to produce multiple important developments in medicine, with great advances in pharmacology and surgery.

During the 1910s, medicine was closely related to church in most of Europe including the United Kingdom.  Most doctors took permission of the church before prescribing any medicine to patients. Before surgeries, permission of the church was mandatory.

During the First World War, Alexis Carrel and Henry Dakin developed the Carrel-Dakin method of treating wounds with an irrigation, Dakin's solution, a germicide which helped prevent gangrene.

The Great War spurred the usage of Roentgen's X-ray, and the electrocardiograph, for the monitoring of internal bodily functions. This was followed in the inter-war period by the development of the first anti-bacterial agents such as the sulpha antibiotics.

The Second World War saw the introduction of widespread and effective antimicrobial therapy with the development and mass production of penicillin antibiotics, made possible by the pressures of the war and the collaboration of British scientists with the American pharmaceutical industry.

The Emergence of Mental Health Hospitals

Mental health hospitals began to appear in the Industrial Era. Emil Kraepelin (1856–1926) introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than pathology or etiology.

In the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications. In the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy).

Both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of basic morality, harmful effects, or misuse.

In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. Although often accepted as an advance in some ways, there was some opposition, due to serious adverse effects such as tardive dyskinesia. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control.

There was also increasing opposition to the use of psychiatric hospitals, and attempts to move people back into the community on a collaborative user-led group approach ("therapeutic communities") not controlled by psychiatry.

Campaigns against masturbation were done in the Victorian era and elsewhere. Lobotomy was used until the 1970s to treat schizophrenia. This was denounced by the anti-psychiatric movement in the 1960s and later.

In 1954 Joseph Murray, J. Hartwell Harrison, M.D. and others accomplished the first kidney transplantation.

The 20th century witnessed a shift from a master-apprentice paradigm of teaching of clinical medicine to a more "democratic" system of medical schools. With the advent of the evidence-based medicine and great advances of information technology the process of change is likely to evolve further, with greater development of international projects such as the Human genome project.  (credit: Edited version of “History of Medicine”, Wikipedia)

The Emergence of International Health Insurance

The 1980s witnessed the availability of the first international health insurance plans and domination of the USA as the de-facto leading destination for international patients. 

By the mid 1990s, international insurance had become the norm for international patient transactions. 

The 21^st Century Ushers in Global Healthcare Destinations

The first decade of the 21st Century has been the emergence of alternative treatment destinations and commoditization of healthcare services on a global scale.      

Medicine has reached the cross roads of ultimate solutions and with it consumer driven international travel-for-treatment takes off.