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Q. Koraz, M.A., M.D., M.P.H.

Program Director, Oakland University William Beaumont School of Medicine

La frontera entre lo sano y lo enfermo, entre lo normal y lo patolуgico se diluye. Estar saludable no es estar fuera de conflictos sino tener la capacidad de afrontarlos y/o resolverlos. La enfermedad no es sуlo un desequilibrio de la psique sino un esfuerzo natural del individuo para lograr un nuevo equilibrio. La salud es un bien, la enfermedad es la negaciуn de ese bien que implica desvalorizaciуn o sufrimiento. Para el psicoanбlisis, no hay persona que se considere "sana" ya que todos tenemos mecanismos de defensa para poder relacionarnos con otros y vivir. Algo muy importante es la represiуn que empuja al inconsciente los deseos que no pueden ser cumplidos. De acuerdo a las personalidades, la neurуtica (sana) usa la represiуn para poder convivir y la psicуtica (enferma) no ha logrado con йxito la represiуn y vive dominada por las pulsiones del inconsciente. Nuestro cuerpo reacciona ante las emociones como enamoramiento, rencor, odio, tristeza, enojo, etc. Aquн encontramos trastornos como gastritis, respiratorios, circulatorios, inmunolуgicos, hormonales, cutбneos, cefaleas entre muchos otros. Como se trabajan las enfermedades segъn el Psicoanбlisis Restaurar el afecto es la vнa para que descarguemos las tensiones psнquicas y nuestra expresiуn es siempre somбtica como ante el miedo por la precepciуn de amenza real o fantasнa todo nuestro organismo reacciona. Cuando restauramos el flujo de los afectos y podemos manejarlos nuestro organismo vuelve a funcionar normalmente. Reconocer y expresar nuestros sentimientos es el efecto terapйutico de primer orden. Hay trastornos que permanecen cercanos a la conciencia como la vinculaciуn de la diarrea con el miedo, un infarto cardiaco con una ofensa profunda, el cбncer y la hipertensiуn tienen represiones mбs profundas. Las enfermedades que se sospecha tienen un factor psicosomбtico son: hipertensiуn arterial, ъlcera pйptica, sнndrome de colon irritable, sнndrome de fatiga crуnica, fibromialgia, neurodermatitis, colitis ulcerosa, tirotoxicosis, artritis reumatoide, asma bronquial, enfermedad de Crohn. Asн, el sistema nerviosos estб нntimamente ligado con nuestro sistema inmunolуgico, nuestras emociones se relacionan con el sistema inmunolуgico a travйs de las hormonas que liberamos con el estrйs. El estrйs anula nuestra resistencia inmunolуgica, y la anulaciуn persiste existe una gran vulnerabilidad para enfermarnos. La intensa tensiуn emocional, la aflicciуn emocional, la inseguridad favorecen la enfermedad y la muerte. La hostilidad crуnica y los episodios repetidos de ira afectan a los hombres en enfermedades cardiacas; las emociones mortales para las mujeres son la ansiedad y el temor. La ansiedad por estrйs es desproporcionada y fuera de lugar, es el estrйs emocional de la vida moderna. La depresiуn empeora las enfermedades ya que interfiere con la resistencia del sistema inmunolуgico a los tumores e infecciones. Las emociones positivas previenen enfermedades, una vez que ya se manifiesta la enfermedad, las emociones positivas contibuyen a la curaciуn; las emociones negativas favorecen a contraer enfermedades. Los sentimiento positivos y el poder curativo del apoyo emocional por los que rodean al enfermos son de gran beneficio para la curaciуn. Cуmo se trabajan las enfermedades desde la Inteligencia Emocional Ayudar a las personas a manejar mejor sus sentimientos perturbados -ira, ansiedad, depresiуn, pesismismo y soledad- nos permite prevenir enfermedades o superarlas16 1) Las tйcnicas de relajaciуn alivian los sнntomas de una amplia variedad de enfermedades crуnicas como cardiovasculares, diabetes, artrнtis, asma, alteraciones gastrointestinales y dolor crуnico. Ejemplos de como se relaciona la enfermedad desde el manejo deficiente de las emociones: a) La presencia de un tumor maligno estб ligada a la deseperanza y desamparo, la falta de sentido de vida, no poder expresar la ira o el resentimiento y la pйrdida de una relaciуn emocional importante. Un torrente de palabras siempre alivia las penas del corazуn; es como abrir las compuertas cuando el molino estб rebosante" (Robin Hood) Anбlisis desde la medicina china Concepciуn de salud desde la medicina china17 La medicina China Tradicional comprende un conjunto de prбcticas mйdicas tradicionales desarrolladas en China que integra virtudes tanto medicinales como filosуficas y que forma parte de su cultura milenaria. Los principales fundamentos teуricos mйdicos se basan en la Teorнa de los Cinco Elementos, el sistema de circulaciуn energйtica por meridanos del cuerpo y el yin-yang. La medicina China distingue 6 уrganos Yin: hнgado, corazуn, pericardio, bazopбncreas, pulmones y riсones, y 6 уrganos Yang: vesнcula biliar, intestino delgado, calentador triple, estomago, intestino grueso y vejiga. Los primeros son mбs sуlidos y compactos y producen, transforman y almacenan diferentes tipos de Energнa Vital. Los уrganos Yang son huecos y sus funciones principales son la digestiуn de los alimentos y todo tipo de eliminaciуn. Ademбs, existen otros уrganos llamados extraordinarios que son el cerebro, el ъtero, la mйdula, los huesos, los vasos sanguнneos, y la vesнcula biliar. Nuestro cuerpo se divide en meridianos de energнa que se relacionan con determinados уrganos para promover la sanaciуn y el equilibrio del organismo. Cada estado emocional corresponde a un elemento y cada elemento se corresponde con уrganos del nuestro cuerpo o funciones que йstos ejercen en nuestra salud.

For more detailed guidance, reference is made to the specific guidelines from the participating societies, which are in full congruence with this publication. The partner societies co-operate in the Joint Societies Implementation Committee, which aims to stimulate dissemination of the guidelines, acceptance at national levels, and the formation of national alliances to translate the recommendations into clinical practice. The bases of prevention are rooted in cardiovascular epidemiology and evidence-based medicine. The document differs from 2007 guidelines in several ways: there is a greater focus on new scientific knowledge. A literature search of clinical guidelines aimed at cardiovascular risk assessment in clinical practice identified. Finding time to read and implement the many guidelines can be an overwhelming task in a busy primary care centre or a regional hospital clinic. Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. Should be considered May be considered Is not recommended Table 2 Levels of evidence Data derived from multiple randomized clinical trials or meta-analyses. Data derived from a single randomized clinical trial or large non-randomized studies. Consensus of opinion of the experts and/ or small studies, retrospective studies, registries. In short, experts from the nine organizations performed a comprehensive review and a critical evaluation of diagnostic and therapeutic procedures, including assessment of the risk­benefit ratio. Changes in conflicts of interest that arose during the writing period were notified. Variability due to differences in patients studied, intervention, outcomes assessed. Typically trials showing no effect of intervention are not published or are published in local non-indexed journals. Population and high-risk preventive strategies should be complementary; an approach limited to high-risk persons will be less effective; population education programmes are still needed. Despite gaps in our understanding, there is ample evidence to justify intensive public health and individual preventive efforts. There is still substantial room for improvement in risk factor control, even in individuals at very high risk. Judgements are then made on these indicators to rate evidence quality from high. This judgement is made on quality of evidence for the critical outcomes and not those that are not critical for decision-making. Similarly, observational data from cohort or case­control studies may be upgraded from moderate or low (as is typical in the old levels-of-evidence approach) to high if bias is unlikely, and findings are consistent and precise. Recommendations are based on the quality of the evidence, the degree of uncertainty about the balance of benefits and harms of the intervention, uncertainty about the values and preferences of patients, and uncertainty about whether the intervention is a wise use of resources. The implications of a strong recommendation are: most informed patients would choose the recommended intervention (and request discussion if not offered); clinicians would ensure that most patients should receive the intervention; and the recommendation would be adopted as policy in organized healthcare systems. In contrast, for weak recommendations, some patients would want the intervention but many would not; clinicians would help patients make choices dependent on their values and preferences; policy makers would require debate among various stakeholders to decide on the role of the intervention. This results in ups and downs of cardiovascular morbidity and mortality over relatively short periods with wide variability across the globe, including developing countries where the major proportion of all events occurs nowadays. In different parts of the world, the dynamics of the epidemic vary greatly in pattern, magnitude, and timing. A valid and actual description of the epidemic by place, time, and personal characteristics is continuously needed to guide and support health policies. The majority of these patients develop the disease at an advanced age, leading to a compression of morbidity in the very old of the community and to a prolonged life expectancy in good health. This strategy is primarily achieved by establishing ad-hoc policies and community interventions. The advantage is that it may bring large benefits to the population although it may offer little to the individual.

Another factor which contributed to a sense of helplessness was a realization of the magnitude of the disaster, that it was just not a looalized incident. Another important factor oontributing to a sense of helplessness was tha nature of the disaster itself. A somewhat typical oonnnent was 'We just had this awful helpless feeling until the men came back. Some other women, on the other hand, reported in the words of one of them that, "The worst thing about the whole experienoe was the feeling of utter helplessness. The subjective teeling that the immediate crisis, at least, was over depended on what the people saw going on around them. One at the most reassuring events was when the employees of the gas company came to each house and checked that the gas was turned otf. This action was interpreted as denoting the tact that there would be no more explosions. But when the men Јrom the gas company actually went down into your basement to check to see that everything was all right you really began to feel that they knew what they were talking about and that you could begin tc relax a little bit. The other general event marking the end of the immediate crisis period occurred when family members began. As one woman put it, "When my husband got baok trom the otfice I was so glad to see him that I lost that helpless and lost teeling that had covered me. He had been worried terribly because he had seen all the smoke coming from the house next to ours and was coming to see it I was sate. It Getting in contact with all immediate family members was also one at the first actions on the part of peop le who left the area. For mothers with children in the school, another primary concern was getting in touch with the school to let the child know where they were and to ascertain what was being done With iihe children. People experienced considerable ditficul~ in getting calls through as everyone tried to phone at the same time. Outside the immediate disaster area there were two large groups who were very deeply involved psychologically. One consisted of the 2,300 children who were in school at the time of the exp:l,osions. Only after some time did they hear explosions and see blaok smoke rising in an increasing number of places near their own homes. This evidently led to some anxieties, but the teachers were able to maintain almost complete order. As one second grade teacher reported: athl~tio They were all perfect little angels. They did ask me about their homes and I assured them that if anything would happen they would. In most cases, the ohildren were kept at the sohool· until Gomeone, usually a par. The men who were allay working in Rochester appeared to have found out about the disaster in many difterent ways. Others did not even attempt to phone but immediately upon hearing the tirst disaster report, started tor their homes. In a~least one case, a man who returned was responsible tor turning otf all the gas valves in his particular block. If When they got to Brighton there was a road blOck to keep people out ot the area. And then they were saying it was just the homes with gas heat in it and others were saying that it was the possibili~ it was oil burners and then· too. Several women noted that betore the disaster prestlllably everything had been arranged with regard to the gas so nothing could go wrong. But "it did, and in matters like this, how can one really know everything is all right now? Still other reactions reported were vomiting, hysterical crying, loss ot appetite, headaches, inability to concentrate, feelings of weakness, or exhaustion, pains in the abdomen, and chills.

The other category is those women who have 55 years of age and over and are sitting at home due to retirement or as housewives. They are characterised by having more time and disposable income than the first category. They prefer beauty treatment than massage or stress management programmes that suit to the younger counterparts. They may hesitate to try health tourism in the beginning, but after experience they become loyal customers and repeat visitors. According to Pollock and Williams (in Gartner and Lime: 2000: 169), when the corporation has healthy employees, the turn over will be less and productivity increases, and in turn, this leads to customer loyalty, which in fact, resulted in more profits to the organisation. It is widely accepted and encouraged, in nowadays businesses, to have seminars and ceremonies or any other corporate activity at spas, where employees can use the spa services and be involved in health tourism. Women are more involved in health tourism services, and then their partners will follow. When couples go in a holiday, women practice spa services and their males play golf for example and or practice sport therapies. As mentioned earlier in this chapter, the age over 50 years have become more dominant in the market of health tourism. They tend to enjoy their retirement age in good health and heal their body ailments that come by age. They enjoy educational and social programmes held at health resorts and spas to learn how to keep up their health and other activities such as diet programmes. According to Whitiam (in Pollock and Williams in Gartner and Lime: 2000: 170), the family segment of health tourism market has increased dramatically in the resent years. This segment is concerned with children facilities that are available in the curative sites such as swimming pools and other playing facilities, while their parents are doing spa health services. Therefore, the health tourism destinations should take into consideration the greater growth in the family segment and then create and introduce health services tailored to the whole family in a funny and playful setting. The health tourism market is affected by the generating countries that have a profound history and experience (Pollock and Williams in Gartner and Lime: 2000: 170). This can be achieved through the following: · · · Good positioning of health-care products by using different channels of distribution. Providing a wide range of programmes and activities that satisfy the needs of different market segments. Developing natural-based methods of treatment (less emphasis on equipments and technology) and natural materials such as herbs mud, curative water, sun, etc. Developing a less-capital investment health spas and resorts that can be used by different segments, for example low income patients. Collaboration with experts and professionals in the field of health tourism to develop the health tourism product and finding ways to satisfy the needs and wants of health tourists. There is a big need to communicate the health tourism products (curative therapy, mud, cosmetics, herbs, etc. This effort should be done through health tourism destinations with cooperation with the whole health tourism bodies in the country. The marketing campaign should be targeted to the customers directly or through intermediaries such as tour operators or in certain cases to the national insurance funds or insurance companies, by using different ways of promotional techniques. This can include upgrading the infrastructure networks, directing the public to the benefits of natural therapy through the mass media and in certain countries giving financial support to the national tourist organisations for better marketing and promotion of the health tourism products. So the first step is to develop the destination in terms of infrastructure and public policies to enhance the sector. The core concept should emphasise on health rather than diseases that need treatment. Some professionals18 in the sector do not like the term "tourist" when referring to health tourism; they mean that they receive patients who need treatment not tourists who seek fun or other purposes. This is in harmony with the marketing concept versus the selling concept, where the former concern about creating the needs of customers and trying to fill them with profit, where as the later is concerned with selling the products or service the business offers regardless whether the customers are satisfied or not. For curative tourism to work efficiently and effectively, the following requirements should be met: 1. Interview with Nader Amr, Marketing and sales manager at Dead Sea Spa and Medical Centre, Jordan, 16-6-2002, Amman, Jordan. According to Lund (2000:2)21, the term "spa" is a Latin abbreviation for: S = salud (health), P = per (through) and A = agua (water).