Health tourism has been defined as ‘the attempt on the part of a tourist facility or destination to attract tourists by deliberately promoting its healthcare services and facilities, in addition to its regular tourist amenities’ [1], or ‘any kind of travel to make yourself or a member of your family healthier’ (Mary Tabacchi, a well-known authority on spa management, quoted in Ross, 2001: 1).

Health care tourism includes all kinds of travel which related to health. There are two pull motivations for traveler in this sector in this sector. The first is “medical tourism” which concentrates on medicine treatment and/or surgery for curing of illness. The second is “wellness tourism” where the focus is on maintaining health or prevention of illness.

Carrera [2] defined medical tourism as “organized travel outside of someone’s healthcare jurisdiction to enhance or restore health”. Regarding the motivation, Rory et al. [3] Mentioned that while Canadian medical tourists are often thought to be motivated by wait times for surgery, cost and availability of procedures were common primary and secondary motivations for participants, demonstrating that motivations are layered and dynamic.

Camille and Laszlo [3] stated that “Wellness Tourism Worldwide is an international trade alliance comprised of wellness and tourism related businesses, organizations and institutions. Founded in recognition of the wide gap between health, wellbeing, leisure, tourism and sustainability, WTW is based on the domains of well-being and Quality of Life”.

However, Zhang Li (2014) emphasized that the pursuit of health is one of the early human’s travel motivations, and is also one of the important trends in current international tourism. The earliest tourist activities taking medical treatment as the main purpose happened in Europe in 1989. In that year, 25 000- 30 000 traveled to for medical treatment. In the new century medical tourism industry grows very fast, during 2012, the number of worldwide medical tourists increased to 40 million from 20 million of 2006. As a leader in the Asian medical tourism, Thailand received annually about 400 000 tourists to participate in tourism activities of the health care. Singapore received 374000 international medical tourists in 2005 and that figure increased to more than one million in 2012. Medical tourism has become the fastest growing industry worldwide with great economic benefits. The amount of medical tourism services in Asia reached US dollars 100 billion in 2012.

Starting from the 1990’s, Traditional and complementary medicine has been reinforced by the World Health Organization with respect to exercise, examination principally in scientific academies. Natural remedy procedures have been favored by folks in advanced countries because of the side effects of chemical used in present medication and they have chosen natural remedy means in emerging nations owing to economic factors. In addition, the consumption of traditional and supplementary therapies in treatment has been reinforced in relation to public health (Bozer C. 2014).

Micheal et.al (2014) added that an estimated 80% of the population in much of the developing world relies on traditional systems of medicine, and 70-80% of the population in developed countries has used some form of alternative or complementary medicine. In 2008, herbal treatments are the most commonly utilized form of traditional medicine, and are lucrative in the international marketplace yielding US dollars 5 billion in revenues in Western Europe, US dollars 14 billion in China and US dollars 160 million in Brazil.

The cupping therapy (Al-Hijama) is considered as one of the main components of traditional or Arabic medicine. Al Hijamah is an Arabic word which means application of cups and the literary meaning of Hijamah is sucking.

The purpose of this study is to explore the current situation of Al- Hijama in Egypt compared to other international experiences. Thus the study seeks to address the following questions:

- Is this kind of treatment available now in Egypt and who is authorized to practice?

- Is there a regulatory framework for practicing Al-Hijama?

- May Al-Hijama be used in developing the health care tourism in Egypt?

- Which approach should be implemented to flourish this method of treatment?

World Health Organization (2013), mentioned that Traditional and Complementary Medicine (T&C M) is growing and expanding, particularly with respect to products bought in person or over the Internet. The T&CM sector now plays a significant role in the economic development of a number of countries. At the same time, with prevailing current global financial constraints, use of T&CM for health promotion, self-health care and disease prevention may actually reduce health-care costs. In many developing countries, T&C M plays an important role in meeting the primary health care needs of the population, and specific types of T& CM have been used for a long time. Potential cost savings are an important reason for individuals to opt for T&CM services. For example, a randomized controlled trial included an economic evaluation of physiotherapy, manual therapy, and general practitioner care for neck pain: results showed that the manual therapy group improved faster than the physiotherapy and general practitioner care group.

Yulia et.al (2015), added that in developed countries the main health burden involves cardiovascular disease, diabetes mellitus, hypertension, mental illness, smoking, and substance abuse. Since lifestyle, obesity, lack of physical exercise, and stress are important factors for these diseases, the Complementary and Alternative Medicine (CAM) approach can be of great benefit in the development of healthcare strategies.

Increasing public and physicians’ attention to the complementary and alternative medicine (CAM) is one of the most prominent symbols of structural changes in the health service system. Several factors affect this tendency in different cultures. Focus of these holistic methods to lifestyle, emotional and spiritual aspects of patients is one of the most important supportive factors of these methods (Ameneh et.al 2015).

Yasuhiro et.al (2015) argued that in modern society, information about CAM has become easily accessible. Thus, even healthy young people could rapidly become CAM users.

Complementary and alternative medicine is gaining popularity all over the world and people are shifting towards alternative medicine because of less adverse effects and low cost. Many research studies were conducted regarding cupping therapy in different countries but no such study has been conducted in Pakistan. There is high public interest to know more about cupping therapy so there must be some awareness campaigns organized to increase the level of awareness and to provide more alternatives for treatment of ailments. There is positive attitude towards cupping therapy, yet most participants are reluctant to discuss it with their physicians Tasneem et.al (2013: 22)

Health care, traditional medicine and Arabic medicine

Hyun-Woo Cho1 (2014) argued that Traditional medicine is an indigenous medicine used to maintain health and to prevent, diagnose, and treat physical and mental illnesses and is distinct from allopathic medicine based on theories, beliefs, and experiences.

Michealet.al (2014) mentioned that Arabic medicine or prophetical medicine is a system of healing practiced since antiquity in the Arab world within the context of religious influences of Islam and comprised of medicinal herbs, dietary practices, mind-body therapy, spiritual healing and applied therapy whereby many of these elements reflect an enduring interconnectivity between Islamic medical and prophetic influences as well as regional healing practices emerging from specific geographical and cultural origins.

Since health care medicine consists of medical, curative and therapeutic medicine, so either traditional medicine or Arabic medicine both could be considered as health care medicine. Traditional medicine or Arabic medicine may be defined as “the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses.

In Arab regions, Prophetical medicine is a term given to the medical knowledge gained from teachings, sayings (hadeeths), advices and hadeeds of prophet Mohammed related to health and disease treatment. Prophetical medicine (in Arabic: Tib Nabawi) is defined as medicine related to Prophet Mohammed peace be upon him.

Loukas et al. (2010) reported that medical knowledge gained from Qur’an (spoken word of God) and hadeeths (spoken word of Prophet Muhammad peace is upon him) can be an important source of human medicine in light of their astonishing agreement with modern medical knowledge.

The Common Components of Traditional and Arabic Medicine

The common components of traditional and Arabic medicine may include:

Medical herbs: There are approximately 250 plant species currently used in traditional and Arabic medicine for the treatment of various diseases. Medicinal plants are used in the form of herbal teas, syrups, infusions and ointments. One commonly used herb, Nigella sativa, also known as black seed, is traditionally used both as an herb and oil, and is used for the prevention and cure of many ailments in the Middle East and South East Asia.

Dietary practices: Dietary Practices include the utilization of certain foods, such as honey, for its traditional and prophetic indications (There are many others dietary practices like sana& sanut, Zamzam water, dates of Madinah, olive oil, camel’s milk and urine, talpinah soup and others). Other dietary practices include observing a fast, considered the oldest form of natural healing. Observed fasts are in tune with the cycles of the moon, planets and other natural phenomena. Fasting is a core tenant of the Islamic faith, and the primary fast is called Ramadan.

Islamic ritual prayer is both an external and internal meditative practice with a set of physical postures, similar to yoga, each with a different meaning and effect both physically and psychologically. Another meditative practice- in Arabic- is Dhikr, or divine remembrance.

Mind-body therapy: Mind-body Therapy denotes techniques designed to enhance the mind’s positive impact on the body, and include such Similar to meditation, Dhikr is the process of “listening within, the activation of a presence capable of witnessing inner and outer events without becoming absorbed in them.

Applied therapy: Michael & Sara (2012) emphasized that applied therapy contains home remedies such as massage, hydrotherapy and cupping. A type of cupping, Hijama or wet cupping, used by several nations around the world, is taken from visionary mythology with detailed approach.

The cupping therapy as an important part in the traditional medicine

The cupping therapy has a deep-rooted history that is shared by different human civilizations.

According to Izharul Hasan et.al (2014), cupping therapy was used in Egypt dating back some 3,500 years, where its use is represented in hieroglyphic writing.

The earliest recorded use of cupping is from the famous Taoist alchemist and herbalist, Ge Hong (281–341 A.D.). In ancient Greece, Hippocrates recommended the use of cups for a variety of ailments, while in the early 1900’s eminent British physician, Sir Arthur Keith, wrote how he witnessed cupping performed with excellent success..

In China, extensive research has been carried out on cupping, and the practice is a mainstay of government-sponsored hospitals of Traditional Chinese medicine (TCM). The fundamental therapeutic value of cupping has been documented through several thousand years of clinical and subjective experience and has advanced its application to many areas.

The cupping therapy technique

Izharul Hasan et.al (2014) stated that cupping therapy is the oldest & most globally medical treatment in human history. Although cupping therapy is a safe and easy technique, it is very effective in treatment of many health issues. The cupping therapy uses negative pressure for treatment. The negative pressure relaxes the tight tissues and helps to loosen adhesions and body. It also allows a flow of fresh blood and nutrients to the muscles. Moreover, cupping therapy helps tissues to get rid of toxins, clear colon blockages and stretch marks and activates the system, veins, arteries, capillaries and the skin. Moreover, cupping technique can be easily learned and practiced.

Elsayed et.al (2014) stated that cupping therapy is distinguished with excretion of the excess unwanted molecules in blood and interstitial fluids that may cause problems such as high serum iron and low density lipoproteins, which no physiological mechanism can do. There are several types of cupping therapy such as dry cupping therapy and wet cupping therapy which are used in China and many other countries.

Cupping therapy is an old technique that is still universally practiced worldwide. For example, cupping therapy has been used in China for at least 3,000 years (Abdul Kabir Dar et al. 2015).

The modern medicine and Al-Hijama

Elsayed et al (2014) stated that most diseases are characterized by an abnormality in blood chemistry where a normal constituent may be high e.g. serum iron or an abnormal constituent may be high e.g. serum auto antibodies in autoimmune diseases. Al-Hijamah-induced nonspecific clearance of the interstitial fluids and serum may normalize blood chemistry and restore physiological homeostasis through exerting multiple therapeutic functions. The major therapeutic value in Al-Hijamah - over the Chinese wet cupping therapy- is the better blood clearance and excretion of the collected fluid mixture.

In modern medicine, there is no treatment modality that can purify both blood and interstitial fluids from noxious substances that are responsible for (or resulting from) disease pathogenesis. Cupping therapy is distinguished with excretion of the excess unwanted molecules in blood and interstitial fluids that may cause problems such as high serum iron and low density lipoproteins, which no physiological mechanism can do. There are several types of cupping therapy such as dry cupping therapy and wet cupping therapy which are used in China and many other countries.

The successful initiatives and best practices in traditional medicine tm

According to World Health Organization (2002: 19) TM has many positive features including: diversity and flexibility; accessibility and affordability in many parts of the world; broad acceptance among many populations in developing countries; increasing popularity in developed countries; comparatively low cost; low level of technological input; and growing economic importance. These can all be seen as opportunities to be maximized. In Africa, many countries are seeking means of making best use of local TM resources and how to make TM an integrated component of minimal health care packages. For European WHO Member States, safety and quality, licensing of providers and standards of training, methodologies, and priorities for research, have rapidly become issues of great importance.

There are fruitful efforts and best practices that include the cupping therapy as follows: Bozer C. (2014) declared that in Turkey, the Ministry of Health established the department of “Traditional, Complementary and Alternative Therapies in Medicine” to determine the type of the traditional methods, conduct the relevant training courses, set standards for the practitioners, identify the ethical standards and legal liabilities. The Ministry of Health regulates a lot of therapy methods including acupuncture, homeopathy, chiropractic, cupping, maggot therapy, ozone therapy, and reflexology. Some public and private universities established education and research centers for the traditional complementary and alternative therapies in medicine. The therapy methods are included in the anatomy education. The courses of the traditional therapy provide new and different techniques for the anatomists

World health organization (2001: 65- 149), stated many successful practices in the field of traditional and complementary medicine: Complementary/alternative medicine has a substantial presence in the United States of America health care system. Both public and professional interest in these therapies is increasing. The College of Physicians and Surgeons at Columbia University and the Falk Institute of Pittsburgh University have research projects devoted to assigning an integrative role in the health care system to complementary/alternative therapies. In 1991, Congress established the Office of Alternative Medicine within the National Institutes of Health to encourage scientific research in the field.

Traditional medicine is deeply rooted in the history and culture of Jordan. Traditional practitioners and remedies ensure equitable access to primary health care, particularly where a large portion of the population relies on it. Over the last decade, there has been a growing interest in traditional and complementary/alternative medicine, including Chinese traditional medicine, acupuncture, homeopathy, and chiropractic. Traditional medicine is practiced by herbalists, practitioners of traditional medicine, and allopathic doctors and other health professionals.

In response to the increased use of complementary/alternative medicine by the public and the Government’s concern over its effectiveness, the British Research Council on Complementary Medicines was formed in 1982. Among other things, it noticed the Europe major role of complementary/alternative medicine in reducing the costs of the health care system.

In the Democratic People’s Republic of Korea, traditional medicine is integrated into the official health care system. This policy of integration is reflected in a number of policy declarations since 1947. It was a prominent feature of the Government’s 1967 political program and was reiterated in a 1980 public health law (188).

Traditional Chinese medicine has been practiced in Australia since the influx of Chinese migrants to the Australian gold fields in the 19th century. Its popularity is growing, as reflected by the proliferation of traditional Chinese medicine practitioners, training courses, and professional associations during the last decade.

In China, the integration of traditional medicine into the national health care system and the integrated training of health practitioners are both officially promoted.

The Government of China has reinforced its commitment to the integration of traditional and allopathic medicine on a number of occasions. Adopted in 1982, Article 21 of the Constitution of the People’s Republic of China promotes both allopathic and traditional Chinese medicine.

Zhan Li (2014) added that traditional medicine is widely used in India, especially in rural areas where 70% of the Indian population lives. There are 2860 hospitals, with a total of 45 720 beds, providing traditional Indian systems of medicine and homeopathy in India. There are 587 536 registered traditional medicine practitioners and homeopaths, which are both institutionally and non-institutionally are qualified. The medical services usually were provided as medical tourism packages in India. Such medical tourism packages include both front-line consultations, after consultation, treatment recovery period also included all the travel arrangements, such as hotel transportation leisure activities. Some medical institutions and tourism product operators also launched “Family Plan”, providing their own medical services for each family member. In addition, some companies introduced a medical conservation packages, such as Vedic company developed medical tourism packages for the Nordic retirees.

Brandon and Colleen (2013) added that the hospitals serving foreign patients enjoy corporate tax concessions, reduced tariffs on imported medical equipment, and financial assistance with marketing expenses.

World Health Organization set a traditional medicine strategy 2014-2023. The goals for the strategy are to support member States in (World Health Organization, 2013, p.57):

1. Harnessing the potential contribution of T&CM to health, wellness and people health care;

2. Promoting safe and effective use of T&CM through the regulation, evaluation and integration of T&CM products, practices and practitioners into health systems, as appropriate.

The strategy has been developed to aid Member States in determining and prioritizing their needs, providing for effective delivery of services, and developing appropriate regulations and policy to ensure the safe use of T&CM products and practices. It is important to remember that this strategy is merely a guide to assist countries in developing T&CM strategic goals in accordance with their own national capacities, priorities, relevant legislation and circumstances.

To this end, WHO is committed to monitoring the implementation of the strategy and will disseminate it as broadly as possible.

The objective of this exploratory qualitative study was to gather empirical insight into Al-Hijama in Egypt. The author used two different tools to measure the current status.

• Firstly: An interview (face to face) for 90 minutes was conducted with undersecretary for the licenses at the Egyptian ministry of health and population, to measure the situation of Al-Hijama and the regulatory framework for practicing it.

• Secondly: A questionnaire, 150 questionnaires were sent to physician therapists and dietary doctors to measure the opportunities and challenge that facing the cupping therapy in Egypt. To avoid unwillingness of responding to the author’s e-mail, questionnaire were sent by mail to a consultant of physical therapy in Egypt and resent through him. Data collection was during October and December 2014.

The questionnaire used a descriptive demographic and personal data as the respondent’s age, gender and experience in the cupping therapy. The questionnaire also included a descriptive approach to explore their opinions, participations and recommendation towards this matter.

Frequency analysis was conducted for the questions. The survey results analyses were performed using SPSS. Statistical analysis was done using SPSS program version 16.0.

Also; the outcome measurements used in this study seem to be suitable for evaluating the strength and weakness of the cupping therapy, moreover the opportunities and challenges that facing it.

According to these results, the author would be able to highlight the main recommendation for reviving the cupping therapy as an Egyptian tourism product.

• Thirdly: validity and reliability

Joppe (2000: 1) defines reliability as: The extent to which results are consistent over time and an accurate representation of the total population under study is referred to as reliability and if the results of a study can be reproduced under a similar method ology, then the research instrument is considered to be reliable. Whereas she added that: validity determines whether the research truly measures that which it was intended to measure or how truthful the research results are. In other words, does the research instrument allow you to hit “the bull’s eye” of your research object? Researchers generally determine validity by asking a series of questions, and will often look for the answers in the research of others.

Statistical validity

The researcher calculates the value of statistical validity from a sample of 39 respondents (coefficient of reliability) for all questions, and has reached statistical validity coefficient (Cronbach’s Alpha =0.956), which allows us to say that the questionnaire items contain a high statistical indicator of validity (Table 1).

Table 1: High statistical indicator of validity (Reliability Statistics).

To get higher statistical validity we will use another method is to the Spearman equation - Brown Spearman - Brown indivisible midterm Split - half, where they were divided each variable phrases into two halves, it includes a first section values obtained from the response of individual words, and the second section comprises the mouthpiece of marital values statements, and came the test results in Table 2:

Table 2: Mouthpiece of marital values statements (Reliability Statistics).

It is clear from the above table that the reliability coefficients for variables (Spearman-Brown Coefficient=0.983) enjoys a high degree of stability, so that it can rely on their results, and thus became a questionnaire in its final form.

Interview

Interview with undersecretary for the licenses at the Egyptian ministry of health and population reveals that:

• There is a sharp antagonism towards the participating of cupping therapy –and even acupuncture which is widely used worldwide.

• Al-Hijama is practiced in Egypt through illegal frame work by doctors at private clinic or even illiterate person at home and there is no chiropractic law.

• The justification of this rejection –from his perspective- is that there is no scientific evidence about the efficiency of Al-Hijama.

• The physician therapists are the most providers of traditional medicine and according to the recent statistics (August 2014), there are 15098 physician therapists in Egypt.

• Based on this evidence neither increased private investment in the traditional sector nor governmental strategies to raise the supply of this treatment method.

Questionnaire

For the questionnaire in total, 101 questionnaires were returned and analyzed.

Among the respondents, 83.5% were males. Totally, 88.4% of the participants had no previous education on traditional medicine, and 77.8% showed interest to learn in this area. Also, 57.6% of participants had the experience of personal use for traditional therapy.

Questionnaire statistical analysis

The age range of the sample age was 34 to 78 years with a mean of 56 years and 84% of it was males. About 39% of the sample has previous experience in practicing the cupping therapy.

The previous table shows that the majority has no education or training in this field (Table 3).

Table 3: Source of the previous experience in practicing the cupping therapy (Q1).

Their answers may merge to four main categories as mention above (Table 4). The first group shows that the majority has experience in back pain and lumbar pain, for the second group the hypertension is the most common, whereas in the third and fourth groups most of respondents are specialists in clean blood, excess iron and massage the tissues.

Table 4: List of the particular illness they are specialized/ had the most experience in (Q2).

The results (Tables 5 and 6) show that cupping therapy may be promoted as an effective, simple and relatively safe product for medical or wellness purpose.

Table 5: Strength of the cupping therapy as a product compared to chemical medicine (Q3).

Table 6: The potential side effects for cupping therapy as a treatment method (Q4).

Like most of chemical medicine, cupping therapy is restricted for certain case (Table 7).

Table 7: The categories that should avoid using the cupping therapy (Q5).

The bureaucracy and lake of expertise in the governmental authorities seem to be the main obstacles (Table 8).

Table 8: The main challenges that facing the cupping therapy in Egypt (Q6).

The Table 9 refers that cupping therapy could be used as a tourism promotional tool.

Table 9: Reviving the cupping therapy may flourish the health care tourism in Egypt (Q7).

A burning question to the Egyptian government is: will the trend of Al-Hijama remain limited to the minority or become wide spread? The Egyptian government has to adopt a series of policies and measures in order to facilitate practicing this method and attract international medical tourists.

The Global Spa Summit (2011) stresses that, in order to offer a truly differentiated product, offerings need to be location specific, focusing on local natural assets and the environment, as well as being authentic and drawing on local traditions, skills and ingredients.

Promoting Al-Hijama as a medical product abroad should focus on the delivering of an authentic experience that personally engage the tourist and that its origins date back to more than 3500 years BC in ancient Egypt.

Most of the respondents don’t have experience on traditional medicine; therefore create new training opportunities for medical practitioners seem necessary. Moreover, international collaboration with the associations of the cupping therapy (like the British cupping therapy society, the American therapy association, the Australian traditional medicine society) is recommended.

It is highly recommended to encourage the practice of Al--Hijamah inside the hospitals in a pure medical atmosphere and by well trained professionals.

There is a bad need for using Al-Hijamah in treating human diseases that are not responding well to current treatment modalities. The need for Al-Hijamah as a therapeutic modality increases more in the modern societies where the incidence of some diseases like hypertension and diabetes increase.

Al-Hijamah itself can be considered as a medical science (Hijamatology) to which scientific research should be directed to set up the standard way for gaining maximal therapeutic benefits from Al- Hjamah.

It is also important that future research addresses the role of stakeholders in promoting this kind of treatment in Egypt and providing broader context and grounding for the international trend.

This work was supported by Prof. Saber Ghoneim, undersecretary for the licenses at the Egyptian ministry of health and population. My sincere thanks are offered to the Egyptian professor Hani Elghazawy, the consultant of traditional medicine. Thanks are extended to Mr. Sayed Moussa, Ex chairman of Egyptian General Authority for the promotion of Tourism. Also the author is grateful to the editor and the reviewers for their valuable comments for improving quality of the paper.