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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Health is an often-overlooked issue in the touristic development of territories. However, the recent pandemic linked to Covid-19, by bringing the tourism sector to a halt, has revealed the importance of health issues for this economic sector.
This book deals with the interaction between tourism and health in all its facets and offers a complete overview of the subject, the beginnings of which date back to Antiquity. The arguments presented here are based on a back-and-forth approach between tourism studies and health sciences. Various themes are thus addressed, such as health risks, health issues for travellers linked to tourism practices, medical tourism, health mobility and the global processes that accompany it, as well as the impact of tourism development on public health in destinations.
A Back and Forth Between Tourism and Health highlights the need to include the health dimension in tourism planning and invites a paradigm shift in thinking about the tourism sector.
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Veröffentlichungsjahr: 2022
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Table of Contents
Cover
Title Page
Copyright Page
Foreword
1 Tourism and Health, a Long-standing and Renewed Relationship
1.1. From Hippocrates to thermalism
1.2. From sea bathing to coastal tourism and thalassotherapy
1.3. Fresh air, nature, health and tourism
1.4. From heliotropism to a reflection on social inequalities in tourism
2 Travel Health, Risks and Diseases
2.1. Diseases and risk areas
2.2. Circulation of tourists, circulation of diseases
2.3. Bodies, tourism activities and health
2.4. Accidents, insurance and repatriation and access to travel healthcare
3 Medical Tourism, Health Mobilities and Global Processes
3.1. Medical tourism, definition(s) and trends
3.2. The patient tourist experience
3.3. Tourism and disability
3.4. Retirement tourism: from tourism to winterization
3.5. The backpacker phenomenon and health
3.6. Circulations, vernacular knowledge and health versus tourism and globalization
4 Impact of Tourism Development on the Health of Destinations
4.1. Impacts on health systems
4.2. Health and environmental impacts
4.3. Social health impacts
5 Health, Ignored in Tourism Development? A Neglected Asset?
5.1. Health and wellness as a tourist segment
5.2. Synthesis of potentials
5.3. What role for each category of actor?
5.4. Transforming tourism: Goal 3 of the Berlin Declaration
Conclusion Health to Change the Development Paradigm?
References
Index
Other titles from iSTE in Science, Society and New Technologies
End User License Agreement
List of Illustrations
Introduction
Figure I.1.
Determinants of health, simplified diagram from Dahlgren and Whi
...
Chapter 1
Figure 1.1.
Advertisement for the Paris–Lyon–Marseille railroads (19th cen
...
Figure 1.2.
The main thermal centers of the Roman period
Figure 1.3.
Ceremony at the Tamba Waras Temple baths
Figure 1.4.
The Royal Crescent Hotel in Bath
Figure 1.5.
The Gradierwerke at Bad Rothenfelde
Figure 1.6.
Evaporation basin on top of the structure
Figure 1.7.
Runoff along the walls
Figure 1.8.
Advertisement for Evian water, 1930
Figure 1.9.
Thermal treatment establishments in France and their capacitie
...
Figure 1.10.
Thalassotherapy centers
Figure 1.11.
Reproduction of the figure of the climate stations in Indochi
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Chapter 2
Figure 2.1.
Primary causes of premature mortality by country
Figure 2.2.
Worldwide deaths from infectious and parasitic diseases
Figure 2.3.
World malaria zones
Figure 2.4.
Worldwide deaths due to vector-borne diseases
Figure 2.5.
Spread of lockdown measures during the Covid-19 pandemic
Figure 2.6.
International air traffic shutdown during the Covid-19 pandemi
...
Figure 2.7.
Activist campaigns in reaction to the Covid-19 crisis in the B
...
Figure 2.8.
Worldwide incidence of traveler’s diarrhea
Figure 2.9.
Deaths due to poor access to water, hygiene and sanitation
Figure 2.10.
Countries affected by sex tourism
Figure 2.11.
Sexually Transmitted Infections prevention document, the text
...
Figure 2.12.
The global health risk
Figure 2.13.
a) Ragweed and b) poison ivy
Figure 2.14.
Rates for wellness services in a spa in Bali
Figure 2.15.
Argan trees between Marrakech and Essaouira in Morocco
Figure 2.16.
Khaosan Road, Bangkok, Thailand
Figure 2.17.
Temporary black henna tattoo in a Bangkok street
Figure 2.18.
Population without access to adequate sanitation
Figure 2.19.
Health performance around the world
Figure 2.20.
Medical cases and emergency room activities according to the
...
Figure 2.21.
Variations in medical and surgical costs by country
Chapter 3
Figure 3.1.
Galenia Hospital and the Sheraton Four Points in Cancún
...
Figure 3.2.
The main destinations for medical tourism
Figure 3.3.
Types of disabilities and those affected
Figure 3.4.
Extract from an advertisement for the adapted wheelchair at Te
...
Figure 3.5.
Iconography for Routard’s Guide™
Figure 3.6.
Global drug supply chains
Figure 3.7.
Medicinal hut in Yodzonot
Figure 3.8.
The Yodzonot cenote in Mexico
Figure 3.9.
Advertising for a Mayan shamanism initiation trip
Chapter 4
Figure 4.1.
Low-cost pharmacy in Mexico
Figure 4.2.
Variations in access to medicines and vaccines around the worl
...
Figure 4.3.
Translated screenshot from the Tripadvisor website
Figure 4.4.
Masbate, Philippines
Figure 4.5.
Excerpt from Booking.com, 02/03/2021
Figure 4.6.
Psychiatrists around the world
Figure 4.7.
Variations in body mass index around the world
Figure 4.8.
Variations in the prevalence of obesity worldwide
Figure 4.9.
Queenstown: the city seen from the top of the cable car above
...
Chapter 5
Figure 5.1.
Integrative well-being tourism experience according to Smith a
...
Figure 5.2.
Street handwash with disinfectant installed in Bali during the
...
Guide
Cover Page
Title Page
Copyright Page
Introduction
Table of Contents
Begin Reading
Conclusion Health to Change the Development Paradigm?
References
Index
Other titles from iSTE in Interdisciplinarity, Science and Humanities
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Tourism and Mobility Systems Set
coordinated byPhilippe Violier
Volume 5
A Back and Forth Between Tourism and Health
From Medical Tourism to Global Health
Sébastien Fleuret
First published 2022 in Great Britain and the United States by ISTE Ltd and John Wiley & Sons, Inc.
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms and licenses issued by the CLA. Enquiries concerning reproduction outside these terms should be sent to the publishers at the undermentioned address:
ISTE Ltd27-37 St George’s RoadLondon SW19 4EUUK
John Wiley & Sons, Inc.111 River StreetHoboken, NJ 07030USA
www.iste.co.uk
www.wiley.com
© ISTE Ltd 2022The rights of Sébastien Fleuret to be identified as the author of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s), contributor(s) or editor(s) and do not necessarily reflect the views of ISTE Group.
Library of Congress Control Number: 2022936845
British Library Cataloguing-in-Publication Data
A CIP record for this book is available from the British Library
ISBN 978-1-78630-538-1
Foreword
In January 2020, the writing of this book was already well advanced when the first echoes reached us from China of a new virus that seemed to be spreading rapidly and generating serious cases, certainly few in proportion to the number of people affected, but enough to saturate hospital capacities. This was not the first time that such an alert had been issued to the world: SARS in 2002–2003, the H5N1 “bird flu” in 2004 and the A/H1N1 “swine flu” in 2009–2010 were all such alerts where the anticipated catastrophes had failed to materialize. It was therefore with some initial incredulity, but almost a small sense of vindication, that I was considering adding a “Covid-19” section to this book on the interactions between tourism and health. After all, diseases travel in our luggage and this one seemed to be another to add to the list, except that this infection escalated out of all proportion. The world quickly froze, borders were closed, populations were locked down and tourism stopped. The United Nations World Tourism Organization (UNWTO) estimated that in one year of crisis, industry losses amounted to more than 1,000 billion dollars. This was a statistic that was impossible for me to ignore. What should I do? Rewrite the book completely? Adapt it? My decision was to continue the writing and wait until the end before integrating the SARS-CoV-2 disease into the manuscript, depending on the evolution of the pandemic. This took me more than a year, as I had to suspend the writing process in order to prioritize other research and publications related to Covid-19, and, more than a year and a half after the first lockdown in France, the situation remains uncertain. Certainly, vaccines exist, but vaccination campaigns have been slow in countries that do not agree to pay the full price for the doses. Then, after an improvement in the summer of 2021, the arrival of the autumn chill in Europe marked the onset of a fifth epidemic wave. The need for a booster dose of vaccine became apparent. France, which had often procrastinated in its decisions and had not wanted to lock itself down for a third time in January 2021, renewed this decision and is counting on a good rate of vaccination coverage to cope. As for tourism, it started again during the summer of 2020 for a while by adapting, focusing on short journeys and domestic tourism and reconsidering long trips. Then came the crisis and the time of uncertainty before a new recovery the following summer. When will we see the light at the end of the tunnel? History has taught us that global pandemics usually last two to three years at most, less if treatments are available, which is the case with Covid-19. However, this epidemic has provided so many surprises that caution is warranted; nevertheless, this pandemic will end. Therefore, while Covid-19 is a major and impactful event, it should not obscure the complexity of the relationship between tourism and health that pre-existed it and will survive the pandemic, or the fact that health remains largely forgotten in tourism development outside of health crisis episodes. Consequently, the editorial line of this book remains resolutely that which prevailed before the pandemic: the aim is, on the one hand, to present, as broadly as possible, the range of interactions between tourism and health from various perspectives and, on the other hand, to reveal the protean and multiscalar impacts of tourism on health. Covid-19 is specifically covered in Chapter 2 (section 2.1.1).
According to the French Ministry of the Environment, the tourism industry accounts for 9% of global GDP and 6.5% of French GDP (2012), and is directly responsible for the creation of some 900,000 jobs in France. For Stock et al. (2003), the geographical approach to tourism focuses on describing the development of tourist areas, their functioning, their dynamics, the spatial differentiation between tourism factors and the practices of tourism actors and their relationships to space. In other words, tourism reveals both individual and spatialized group practices, influences places, differentiates them from one another and shapes stakeholder interactions. It is therefore a major element of economic development that is highly territorialized, with areas of concentrated activity where direct and indirect effects, environmental impacts and social changes can be observed, all of which fuel the interest in sustainable tourism development. However, there is one component of the sustainability of economic development through tourism that is never addressed: health. It is nowhere to be found, with the notable exception of “medical tourism”, or is only mentioned in passing when discussing certain environmental concerns or those related to the well-being of populations. According to a Harris Interaction study (Duhamel 2018), although 90% of French people say they are attentive to the environment and the lives of local populations when they travel, and 70% wish to travel responsibly, sustainable tourism accounts for only 1% of the French market.
However, health can be an interesting lever in a tourism development logic. The number of medical tourists is estimated at around 16 million individuals per year worldwide, representing a turnover exceeding 60 billion dollars and covering geographical areas that capture a significant portion of this market (Latin America, Eastern Europe, India, Southeast Asia) with potentially strong impacts. With regard to the medical profession, first, what happens when trained doctors (and other health professionals) are more interested in the lucrative practice of working for tourists than in working in their local health systems? Then, more broadly, what happens to the health of populations in tourist locations when the healthcare available is more structured towards tourism than towards the local population?
Additionally, it is instructive to examine the way in which promoters of tourism development rely on determinants of health and well-being of populations in order to make health an element in attracting tourism (whether through the environment – air, water, food – or through various so-called “healthy” activities). Territorial marketing is increasingly mobilizing health to increase the attractiveness of certain territories, as part of a broad and global vision of health (Figure I.1).
Figure I.1.Determinants of health, simplified diagram from Dahlgren and Whitehead (1991)
“Individual determinants” of health refers to personal factors which, when aggregated, produce what is known in epidemiology as compositional effects. Thus, a tourist population composed mainly of senior citizens does not pose the same challenges as a population of young spring breakers, for example. “Individual lifestyles” refers to the behavior of tourists, on the one hand (do they comply with prevention messages? Do they take precautions or expose themselves by taking risks?), and to the changes in lifestyles that result from confrontations between receptive local societies and visitors with different habits, on the other (all the more so where the initial differences between lifestyles and living standards is great).
At the neighborhood (local) level, social and community networks strongly determine health. Travel is a temporary separation from these supports, which can pose health problems. Within host societies, tourism can lead to a transformation of social relationships and, sometimes, to the ex nihilo (re)construction of a place. It then takes time to build support networks, which are essential for health, in new territories that are shaped by tourism (see, for example, Cabezas 2008).
Finally, “general socio-economic conditions” refers to systems organization: the globalized system of the travel and tourism industry, national health systems and more localized systems of territorial planning form a general framework in which the interactions between tourism and health are many but unstated.
Structured into five chapters, this book proposes to pass back and forth between tourism and health in order to catalog the interactions that exist between these two sectors and to discuss the issues at stake. In this way, the importance of taking health into account in tourism development will be highlighted.
1Tourism and Health, a Long-standing and Renewed Relationship
First quoted in the 19th century, the word tourism referred to “a journey relating to a Grand Tour and the mobility of ‘health’ towards spa towns” (Duhamel 2018). This was well before the advent of the so-called leisure society and the development of mass tourism. The Grand Tour then was a male practice of educational travel across Europe, reserved for the aristocracy, which led the young notables who engaged in it to put the finishing touches on their education, and to tour certain high places, the premises of the great tourist destinations.
The main destinations of the Grand Tour were France (from Calais to Paris – a must – then to the Alps and/or Provence), Germany (Munich, Frankfurt, Berlin and even the shores of the Baltic Sea), Switzerland (Geneva) and especially Italy (Venice, Milan, Pisa, Florence, Rome, Naples, and so on). Some ventured to the Iberian Peninsula or to Greece and the Middle East, but this required up to five years of travel and a substantial family fortune.
Some famous writers such as Johann Wolfgang von Goethe and Alexandre Dumas took the Grand Tour, with its benefits described as being, above all, cultural and personal. The first of these benefits was to make friends and build up an international social network that could potentially be useful for a military or diplomatic career, for example. Works of art (such as statues and paintings) were also purchased, thus contributing to the circulation of culture and artistic trends. The Grand Tour promoted the diffusion of neoclassicism in Europe. On a more personal level, it was an opportunity to strengthen skills, to build self-confidence, to learn what constituted “good manners” in different countries, as well as to develop sexual education, albeit at the risk of certain diseases.
Around the same time, winter tourism developed, which consisted of seeking a milder and more temperate climate, as well as, if possible, good sea air in order to escape the harsh winters of northern Europe. This is how, for example, a wintering community of British people in Nice raised funds to build a resort path that has now become the famous Promenade des Anglais (a promenade associated with sea bathing or spa treatment was considered to be beneficial for health).
To understand these phenomena, we must place ourselves in the context of the time. The medical and hygienic discourse that developed in the 19th century was accompanied by a rejection of the town and its miasmas. Doctors lauded the benefits of nature, pure air, sea or alpine air, water, etc. A plethora of guides and works codified therapy through resorts or treatment.
Figure 1.1.Advertisement for the Paris–Lyon–Marseille railroads (19th century)
(source: INA)
It was only following a long process (Chessex 1997; Bertrand 2010), stimulated by the development of the railroad (Figure 1.1), that the practice of tourism was democratized on initial foundations largely linked to preoccupations with health. Then, little by little, bathers discovered the joys of the beach, and travelers in search of relaxation sought worldly distractions in the palaces and casinos that flourished to meet this new demand.
Thus, the medical discourse strongly contributed to the development of travel and vacationing practices and, by extension, to the birth of tourist resorts. However, while it effectively developed during the 19th century, the origins of this phenomenon date back to ancient history.
1.1. From Hippocrates to thermalism
As a primitive form of tourist travel, mobility towards the spa towns certainly, historically, wove the first links between tourism and health. In ancient times, medicine and religion were intertwined. It was Hippocrates who laid the first foundations of modern medicine, notably through his treatise On Airs, Waters and Places, in which he advocated the systematic observation of climatic and hydrological conditions and lifestyle habits, particularly dietary habits, in the places where the disciples of the School of Kos were to practice their medicine. Through these propositions, he introduced the notion of the systematic observation of the conditions of appearance of a pathology and, in so doing, distinguished between the environmental or behavioral origins of diseases and a divine origin linked to beliefs. Following Hippocrates’ recommendations, it was no longer a question of moving from one place to another according to the seasons to escape from bad conditions (a form of nomadism), or of going on a pilgrimage to a spa, but, for example, to get away from the city in search of fresh mountain air and sunshine. The locations of the Greek sanctuaries and places of convalescence testify to a consideration of the environment and the climate. The presence of the sea was already a notable factor in Kos, the Mecca of the Hippocratic school.
1.1.1. The Roman period
The Romans also developed second homes, which were often coastal. Rome was known to be unhealthy in summer and was deserted by the wealthy classes who retired to the nearby Apennines which, despite their low elevation, offered milder temperatures. The quality of the air and water in these secondary villas was reputed to be better, as evidenced by the habits of Cicero, for instance, who would retire to his villa in Tusculum (20 km from Rome and 670 m above sea level) when he suffered from an upset stomach.
Figure 1.2.The main thermal centers of the Roman period
(source: according to Guérin-Beauvois (2000))
At that time, the pharmacopoeia available to doctors was limited and thermal waters and muds had already been identified for their therapeutic virtues, but in connection with divinities who were often identified as protectors of thermal springs. Priests were the first hydrologists! The remains of ex-voto offerings and fragments found near the thermal baths have provided archaeologists with indications of the pathologies treated (some of these remains are sculptures representing treated organs). We find testimonies on the interest of taking thermal baths in the writings of Aristotle, Plutarch and Galen.
The Roman Empire placed great emphasis on thermal baths, and Pliny the Elder and Herodotus described the first principles of crenotherapy through a reflection on the duration of treatments, the best season to carry them out, the different types of baths, and so on.
In addition to the daily practice of bathing in the city or in the richest villas, there were treatments that combined the therapeutic principle of water use with recreational practices and festive or sports activities. “It was therefore a question of the acts that constituted treatment: hygiene and body care, but also appeasement of the spirit, relaxation and sociability, all activities within the framework in which thermal man evolved, as much in antiquity as nowadays” (Guérin-Beauvois 2000).
In Gaul, therapeutic uses of the springs were already widespread but were to develop during the Gallo-Roman period. These springs were protected by the thermal deity Borvo, whose name is composed of two evocative Celtic words: berw (which means hot, boiling) and von (which means fountain). We can detect these terms in the etymology of certain thermal spas, such as La Bourboule. Other places would develop later under Roman influence and inherit Latin toponyms linked to water, Aix-les-Bains, for example (Aquae Gratianae).
1.1.2. Elsewhere in the world
While the Greeks and Romans were pioneers in Western history, the search for beneficial waters was not the prerogative of the Europeans. Historical forms of thermal tourism have been found in Asia, for example.
In the center of China, one example is the Huaqing Hot Springs at the foot of Mount Li, near the modern-day city of Xi’an, whose first thermal pools date back to the Qin dynasty (221–206 BCE). This was a resort for the emperors and their court during the subsequent Han dynasty (206 BCE to 220 CE) and later the Tang dynasty (618 to 907 CE), who built a palace around an artificial pool. The site was then taken over by Taoist monks who built several temples. In 1936, Chiang Kai-shek was captured there by the communists and released on the condition that he promised to collaborate against their common enemy, the Japanese invader. Finally, the communist regime developed a spa there (still in operation) in order to offer treatments to the workers of the nation. Thanks to this thermal and historical past, this site has now become a tourist and heritage site.
Figure 1.3.Ceremony at the Tamba Waras Temple baths
(photos: S. Fleuret 2016)
In Bali, Indonesia, the tradition of purification through bathing gave rise to the construction of numerous sacred temples around springs and pools, which, in addition to their attractiveness for the spiritual tourism of the locals, constitute a heritage attraction for international tourists. In some places, bathing is authorized for international tourists, whereas in others (Figure 1.3), internal Indonesian tourism has developed in connection with ceremonies.
In Latin America, also, thermalism is the basis for the attractiveness of certain sites, in connection with volcanism. This is the case, for example, in Cajamarca, a which includes Los Banõs del Inca (the Baths of the Inca) District. This modern-day coastal resort in the north of the Andes is probably the most famous in Peru: its waters are rich in chloride and sulfur and gush out at a temperature of 70°C. Since the Inca period, the therapeutic properties attributed to these waters have been used in the treatment of bone and nervous system disorders. The stone bathtub in which, according to legend, the Inca Atahualpa bathed before confronting Pizzaro, is preserved as a testament to a past that some archaeologists have traced back a millennium.
1.1.3. To the Middle Ages, then in the Renaissance
The medieval period in the West saw the Hippocratic concepts stifled by religious dogma, and pilgrimages for health reasons faded for a number of centuries. However, at the same time, in the Arab world, physicians such as Avicenna and Averroes advocated mobility towards certain regions for people suffering from pulmonary and tubercular diseases: Avicenna proposed Crete, while Averroes recommended the hot and dry air of Egypt or Ethiopia.
In the 16th century, a schism between the Church of Rome and England caused the decline of pilgrimages whose purpose was spiritual fulfillment and which were condemned by Protestantism. Pilgrimage became introspective, without the need for mobility, but the quest for fulfilment remained and gradually shifted to the search for bodily fulfilment through healthy lifestyles and particularly through travel to spa destinations, with the goal being physical healing (Duhamel 2018). The coastal resorts became “healthy places”, and doctors prescribed bathing in the sea as a remedy for all sorts of ailments.
The Hippocratic trend re-emerged with the Renaissance, accompanied, in the cities, by the development of hygienism and the invention of epidemiology. In Europe, there was a renewed interest in water, which, with the advent of sanitized urbanism, was no longer simply a vector of diseases.
The example of Bath, a spa town since Roman times, is a model of its type. Before becoming a popular tourist center in the 17th and 18th centuries, Bath still largely resembled a medieval city, surrounded by ramparts and narrow streets.
John Woods was the architect responsible for the city’s transformation, and although much of his design was never realized, his work laid the foundation for Bath’s transformation into the Georgian city that became the recreational capital of England and a model for other spas. Yet, the city did not originally have much going for it beyond its baths, only an abbey and a declining trade. It is its status as a spa town that has shaped its development and its recognition as a major destination. The integration of historical remains, notably its Roman baths into its Georgian architecture, has contributed to this success, which is now reflected in the site’s Unesco World Heritage listing.
Figure 1.4.The Royal Crescent Hotel in Bath
(source: geograph.org.uk)
Among Bath’s architectural symbols is The Circus, inspired by the Colosseum in Rome in an attempt to recreate a small palatine in the center of Bath with the adjacent Queen Square and a forum that was never built. The three orders (Doric, Roman and Corinthian) are superimposed on the curved façade of this building. The Royal Crescent Hotel (Figure 1.4), designed by Woods’ son, follows the same inspiration. Other emblematic buildings related to health mark the architectural landscape of Bath, such as the Royal National Hospital for Rheumatic Diseases. Thus, welcoming the aristocracy for treatment shaped the architecture of these buildings, and it was the same in other cities around Europe.
The Belgian resort of Spa, launched by the English at the end of the 18th century and based on the Bath model, was also successful in that its name has become the generic term describing thermal resorts and bathing facilities. Following these successes, the principal monarchies around the continent followed England’s lead and founded their own spas: Baden-Baden near Stuttgart, Karlovy Vary (Karlsbad) and Mariánské Lázně (Marienbad) in Bohemia, Montecatini in Tuscany, Aix-les-Bains in Savoy, and Bagnères-de-Luchon and Vichy in France (Lecler 2008).
1.1.4. Modern history of spa towns
Bad Rothenfelde in Germany is another example, somewhat different from Bath, but equally interesting. In 1724, an underground salt water spring was discovered there. In order to exploit the salt, a wall (Gradierwerk) about 500 m long and 20 m high, a wooden frame with thin blackthorn branches and twigs, was built (Figure 1.5). There are approximately 50 Gradierwerke in Germany and a few in Austria and Poland. This very open structure made it possible to heat the water in a basin at the top (Figure 1.6) and then, by making the water flow towards its base (Figure 1.7), provoke partial evaporation (the structure being well ventilated) and increase the concentration of salt from 6 to 20%, facilitating its subsequent collection. However, it turned out that this wall had a secondary effect, that of purifying the surrounding air. An activity was therefore developed related to the inhalation of this air purified by the salt water. After the closure of the salt works in 1969, the site became known as an Inhalatorium and attracted visitors from Lower Saxony and Rhineland-Westphalia, as much for this as for the city’s treatment activity, which had been developed since 1908 with the creation of salt baths and a spa.
In Bad Rothenfelde, good water and good air are the basis of hygiene and are generally associated with urban planning, but – unjustly – not so much with tourism.
To complete this commentary on the uses of water in an approach combining health and tourism, let us expand upon our last case: the town of Évian-les-Bains, on the edge of Lake Geneva, a thermal and tourist resort where an industry has been developed around the commercialization of mineral water.
Figure 1.5.The Gradierwerke at Bad Rothenfelde
(source: zoover.com)
Figure 1.6.Evaporation basin on top of the structure
(source: Osnabrueckerland.de)
Figure 1.7.Runoff along the walls
(source: Osnabrueckerland.de)
Évian was, first of all, one of the favorite places of the nobility of Chablais (province of Thonon-les-Bains), who were attracted by the waters of the ferruginous spring of a neighboring city, Amphion. The sovereigns of Sardinia and their court made frequent visits there before the attachment of Savoy to France, which gave the region an international reputation. At the same time, at the end of the 18th century, the curative virtues of the water from the Cachat spring in Évian itself were discovered. Medical recognition was just around the corner, as Jules Cottet, a doctor at the resort, established the principles of a cure for diuresis and proved the relationship between a large intake of pure water and improvement in kidney function. A shift took place, and the bathers became patients. Since Amphion had no accommodation capacity, Évian replaced it and developed as a tourist and spa resort. In 1826, a bathing facility was built there, and some modest equipment including about 30 residences. The annexation of Savoy by France in 1860 brought about a period of development that resulted in the construction of rich residences on the shores of Lake Geneva and the acquisition of a status as a center of global importance, highly prized by the Parisian upper middle class. Tourism had an impact on urban planning: the lakefront was developed with a promenade – bathing and walking formed the basis of the treatment – and in 1865, a casino was built to entertain this clientele. The same year, an imperial decree consecrated the vocation of the resort by granting it the name of Évian-les-Bains and, in 1881, a railway station was built following an agreement between the Paris–Lyon–Marseille (PLM) railway company and the Société Anonyme des Eaux Minérales d’Évian (SAEME). From then on, the railroad served the resort, encouraging an influx of visitors.
While the thermal spa experienced difficulties during the 20th century (it had been locked in a sector where it was specifically considered as a luxury and limited to the treatment of renal diseases, which were now able to be very well cared for without treatment, thanks to advances in medicine), SAEME, initially conceived on the back of tourism development, was destined to literally “define the French bottled mineral water market” (Watin-Augouard 2002) and to write its own success story1.
The story is as follows. Escaping the French Revolution, the Marquis of Lessert, suffering from kidney stones, decided to go to Amphion to take the waters and treat his kidneys. By pure chance, he stopped in Évian and quenched his thirst at a spring belonging to a certain Mr. Cachat and found the water he drank there pleasant, light and easy to drink. He came back regularly and found himself cured, which was proven following a medical report. Mr. Cachat saw this as a great opportunity, fenced in his spring and began to market his water under the name Evian-Cachat. At the beginning of the 20th century, the development of the glass bottle and the aluminum cap allowed the water to be sold across France (Figure 1.8). Until 1960, it was sold in pharmacies as alkaline mineral water, recommended for diets. The growth of supermarkets provided an outlet for the brand which, in the 1970s, came under the control of the BSN brand (now the Danone group). The strength of the Evian mineral water brand lies in its ability to use both contextual factors and strong, ideally targeted communication messages. The context was the development of tourism, a quest for natural spaces and waters in the 18th century, and then the extension of these aspirations in the face of growing urbanization (cities need to be supplied with water) and its attendant pollution and other frenetic lifestyles. Communication was initially focused on health benefits, the message at the end of the 19th century being that Evian-Source-Cachat was “the most effective diet water and the best table water” (slogan of the time). In the 1930s, the argument of bacterial purity took over: mineral water is sterile, which makes it an excellent bottled water that does not need to be boiled. Then, a change of direction took place when the spa industry entered into crisis, and the number of curists stagnated and even declined. Evian refocused on its origins, and the brand reused the arguments and visual references that had made the place attractive to tourists; except that instead of bringing the tourist to the destination, it was the destination that came to the tourist, in a bottle and with promises in the form of slogans: “L’eau d’Evian, issue des Alpes, a le goût délicieux des sources de montagne” (Evian water, from the Alps, has the delicious taste of mountain springs), “Boire Evian, c’est respirer à 3 000 mètres” (Drinking Evian is like breathing at 3,000 m), “L’eau d’Evian vous donne ce que les Alpes lui ont donné” (Evian water gives you what the Alps have given it), “L’eau que vous buvez est aussi importante que l’air que vous respirez” (The water you drink is as important as the air you breathe), etc.
Figure 1.8.Advertisement for Evian water, 1930
(source: gallica.bnf.fr)
With this image of a natural product with healthy properties conferred on it by mountains, Evian water accompanied the evolution of a consumer society that increasingly questioned the quality and healthy or harmful nature of what it was ingesting. In the mid-1980s, it promoted the product’s physiological properties with the slogan “La force de l’équilibre” (The power of equilibrium) and the promise of visible effects on the body: “Je bois Evian et ça se voit” (I drink Evian and it shows). From there, under the direction of advertisers, Evian began to systematically use babies, animated by computer graphics, to convey the idea, through television commercials, that “Drinking pure water balanced in minerals every day maintains your body’s youth”, and like a return to the origins of thermalism, we return to the idea of a fountain of youth.
Beyond the success of an industrial brand, what is interesting in the story of Evian is the interweaving of geography (its use of places and their imagery), tourism (the frequentation of places that makes it attractive) and the development of an industry that markets a product based on these assets, and in the example of Evian, we find all the uses of water that have made health a factor in the development of tourist destinations: “Water that heals, water that washes and protects health” (Bruston 2000).
1.2. From sea bathing to coastal tourism and thalassotherapy
There is thus a long heritage that has shaped the reputation of spa towns to which curative virtues are attributed without the need for medicalization, such as the fountains of youth and “miraculous” springs which constitute milestones or stages of pilgrimages. However, a new factor emerged at the end of the 18th century: the practice of sea bathing. As early as 1769, Hugues Maret published Mémoire sur la manière d’agir des bains de mer et leurs usages vivifiants (Memoir on the way sea bathing works and its invigorating uses), discussing the improvement of rheumatism in particular (quoted by Vincent (2007)). At the beginning of the 19th century, Dieppe and Boulogne-sur-Mer inaugurated the first French sea bathing establishments for therapeutic purposes. Over the years, numerous resorts were established along the French coast, including Boulogne-sur-Mer, La Rochelle, Cherbourg, Deauville, Arcachon, Biarritz and Cannes. There were “hydrotherapy baths” or “wave baths” that were always carried out within a medical framework: immersions in seawater were timed and only lasted a few minutes. “Bathers and doctors agree on the three major qualities required of the sea: coldness or at least freshness, salinity and turbulence. Pleasure is born from water that lashes us. The bather delights when he experiences the weight of the ocean’s immense forces” (Corbin 2018).
A large number of scientific works by doctors were published to codify the practice of bathing and to highlight the care and therapeutic benefits that it could bring, depending on the diseases. “These guides constitute true geographical classifications of seawater and consequently highlight coastal resorts, with each doctor extolling the benefits of their own seawater compared with others” (Bertaud 2012; see Box 1.1).
Box 1.1.The therapeutics of sea baths (translated extract from Bertaud (2012))
Dr. Pouget, physician-inspector of the Royan sea baths, naturally advocated the Royan coast in his book Recherches et observations sur l’emploi hygiénique et médical de l’eau de mer et sur les influences de l’atmosphère maritime (Research and observations on the hygiene and medical use of sea water and on the influences of sea air), published in 1851. Dr. L. Gigot-Suard wrote that he would not have produced his guide, published in 1860, if he “only had to repeat to the reader what has been said in all the bathing manuals. However, through the happy and exceptional disposition of its beaches, Royan offers resources to therapeutics and hygiene that cannot be found elsewhere.” Gigot-Suard favored the gentle undulations of Grande-Conche rather than the agitation of the sea at Pontaillac: “While at Grand-Conche the movements of the water are extremely moderate, so that bathers receive only a very weak wave, at Pontaillac on the contrary, it is a real wave with its jolts, percussions and shocks. Between these two extremes, we still find intermediate degrees on the conches of Foncillon and Chaiz.” At the same time, in 1862, Dr. Salmon, a colleague but competitor of Gigot-Suard, wrote his booklet, Coup d’œil médico-philosophique sur l’emploi de l’eau de mer (Brief medico-philosophical look at the use of sea water). This doctor, who was attached to the hydrotherapy establishment of the Royan casino, wrote that “sea water is administered in an infinite variety of ways, each of which requires sustained care and particular attention, the omission or negligence of which can compromise the success of this energetic and often heroic medication. Thus, outside: (1) the cold bath, taken at sea, under the exciting and tonic action of waves; (2) the bathtub bath, pure or mixed, at temperatures which should vary depending on the cases, that is, according to lesions which are to be combatted; (3) the cold affusion, exerted on the totality of the body; (4) top-down showers; (5) foot baths; (6) lotions; (7) various local applications; (8) sweating, with its various modes and degrees; (9) pulverization, with its multiple conditions. […] Among the resorts we visited, there are many that lack hydrotherapy equipment and very few of them offer more complete and better established equipment than in Royan. In Dieppe, as in Trouville, Le Havre and Fécamp, there is only a single beach, while in Royan there are three, maybe four, in which the agitation of sea waves presents different degrees, hence different modes of action, a circumstance of great interest for the treatment of illnesses, according to the measure of tonicity that one wishes to produce or provoke.”
Bathing was not permitted without supervision, especially for women: the bather’s guide set the bathing times and administered immersion, plunging the head of the bather at the top of the waves and keeping it under water in order to generate a suffocation, which was considered therapeutic. Men were able to benefit from more autonomy, and their bathing guide’s main function was to advise and guarantee their safety.
The first sea baths were thus battles against the elements, “a fight against engulfment” (Corbin 2018). The dimension of pleasure, of basking or of communion with the elements through swimming intervened later in history, and moreover, in a trend concomitant with the development of sports practices, was aimed at maintaining a healthy body and mind. Thus, coastal tourism progressively evolved from its initial form of asceticism through cold baths to become a recreational pleasure time, as described by P. Morand in his book Bains de mers (Sea bathing) in 1960. The three S model – sea, sand and sun – was born and led to bodily hedonism (Duhamel 2018), on which we will return later in this book.
The advent of pleasure bathing and relaxing seaside tourism relegated therapeutic activities to the confines of thalassotherapy establishments. Thus, we come full circle: the quest for water, whether sea water (thalassotherapy) or spring water (balneotherapy) in the context of therapeutic practices, is nowadays included within the term crenotherapy. At this stage of our analysis, it is advisable to take the time to differentiate between medical thermalism and thalassotherapy, which, although having common origins, today constitute two distinct families.
1.2.1. Thermal medicine
The practices of thermal medicine are recognized as complementary medicines in France, where 12 therapeutic orientations for thermal cures have been defined by the social security2 and may possibly lead to treatment if prescribed by a doctor. At the European level, the recognition of these treatments is also progressing (Canista 2015). The treatments provided are of two types: external (such as showers, water baths, mud baths, massages, etc.) and internal hydrotherapy (drink cures, inhalations, and so on). The website of the French National Council of Thermal Establishments (Conseil National des Etablissements Thermaux, CNETh) highlights a number of supporting scientific studies.
These cures can be prescribed as well as, or as a complement to, certain treatments, in particular chemotherapy or heavy anti-inflammatory treatments in the care of rheumatism, for example. Today in France, there are 600,000 people taking spa treatments and 10 million days of treatment per year (2018) across the 110 French spa establishments (spread over 90 spas; see Figure 1.9). A spa treatment consists of thermal mud applications and freshwater treatments: thermal water jets, high-pressure showers, submerging, steam rooms, massages and hydromassages, walking sessions in a swimming pool, and so on. It may be accompanied by tourist activities in the surrounding areas, as treatments generally last only two to three hours per day.
Figure 1.9.Thermal treatment establishments in France and their capacities
(source: www.location-cure.net 2017; Conseil National des Etablissements Thermaux 2021; design and production: Fleuret S., Lepetit A., UMR 6590 ESO)
Two-thirds of clients are over 60 years old, and the efforts of spa towns to rejuvenate their clientele and their image through offers oriented more towards fitness and sport than towards treatment have not been met with the expected success. According to CNETh (2015), following a 20% drop in attendance during the 1990s and 2000s, the spa industry has been experiencing the following:
for the last ten years or so a period of measured dynamism, with a growth of around 2% per year in the number of patients under contract; in other words, those taking treatments covered by the health insurance. However, while the recovery is real, it is not particularly dynamic and is more reflective of demographics and an increase in the 60–74 age group, rather than an increase in the rate of treatments.
The clientele is no longer the aristocracy, but a modest population which will often prioritize cheap accommodation (such as hotels with less than three stars, or private, furnished accommodation), which doesn’t encourage them to extend an offer in spite of the possible outcomes. For example, the current poor level of internationalization of thermalism (less than 1% of tourists in French establishments are international) suggests a new potential market.
Thermalism is an essentially European phenomenon, and some major cities, such as Budapest, have made it a major element of their brand image. We have observed significant variations in the importance attached to thermalism (and more widely to alternative and complementary medicines) in the care (curative) and social protection (insurance) systems of different countries.
In the United Kingdom, the spa industry has undergone a major crisis, although the city of Bath has continued to be cited as a founding example of water tourism. During the International Festival of Geography at Saint-Dié-des-Vosges in 2000, Marc Lohez (2000b) made the following observation: “The most prestigious of the spa towns saw […] its eponymous activity disappearing in the 1970s [author’s note: this was in 1978], a victim of the mistrust of British doctors. The National Health Service withdrew its approval and the UK spa industry, deprived of social security benefits, went out of business.” With its architectural heritage and history dating back to Roman times, the city maintained its tourist appeal, but it was not until 2006 that the royal baths were reopened, testifying to a renewed interest in gentler approaches to medicine and care.
Conversely, in Eastern Europe, thermalism is particularly valued and was the object of significant research investment in the former USSR. Today, Russia still has a Scientific Center for Restorative Medicine and Balneotherapy (Persianova-Dubrova et al. 2012) and a scientific journal, the Journal of Physiotherapy, Balneology and Rehabilitation.
Elsewhere in the world, thermalism is less prevalent; there are only approximately 20 spa centers in the United States, for example.
1.2.2. Thalassotherapy
Thalassotherapy centers are, by their very nature, located by the sea and use natural sea water for its various virtues: rich in minerals and trace elements (such as magnesium, potassium, sodium, calcium, silicon and fluorine), it also contains microorganisms with, for instance, antibacterial, antiviral and hormonal properties.
Various types of treatments are offered by thalassotherapy centers: hydrotherapy using heated sea water (such as hydromassage baths), algotherapy using seaweed poultices enriched with essential oils and dry treatments in the form of various massage treatments. Thalassotherapy centers are a mix between a tourist accommodation, with its hotel functions, and a healthcare establishment. In the field there are doctors, physiotherapists, hydrotherapists, dieticians and beauticians. In the thermal spas previously mentioned, in addition to curative treatments, are purely tourist activities relating to water (spa relaxation), wellness (sports activities), the mind (workshops and conferences) or simply the discovery of the region and its beauty, like any other tourist destination.
In contrast to spa resorts, which have experienced an economic slump and an aging clientele, thalassotherapy centers appear to be in good health according to the In Extenso TCH – France Thalasso Thalassotherapy Observatory (2017), with an increase in revenues and relatively stable attendance. The clientele is primarily domestic, and there seems to be a clear distinction between tourists looking for simple relaxation, who will visit hotels with non-medical spas, and tourists looking for a specific treatment who will not hesitate to pay more for treatment in a specialized establishment. The list of ailments treated at the 50 or so centers in France (Figure 1.10) is long. Personalized treatment programs found on the Internet include those for: back and joint pain, getting back into shape after childbirth, menopause support, programs for resuming sports activity, relaxation and even help with quitting smoking!
The distinction between a thalassotherapy center and a thermal spa is that, while the former is limited to one establishment, the latter is an entire city. Thalassotherapy centers are, however, systematically positioned within tourist destinations that offer other seaside attractions (such as beaches and marine leisure activities).
Over time, since the emergence of the phenomenon in France during the second half of the 20th century, we have seen an evolution in thalassotherapy centers, from an initially highly medicalized approach (functional rehabilitation centers) to less medicalized centers, with a sports focus (thalassotherapy institutes) and finally, more recently, more luxurious and even less medicalized “thalasso-spas”. This shift seems to be going hand in hand with the evolution of the touristification of the destinations that host thalassotherapy centers. When the health argument, on which the phenomenon is based, is no longer sufficient to ensure its sustainability, it is the broader argument of well-being that is put forward.
Figure 1.10.Thalassotherapy centers
(source: France Thalasso; Thalasso-line; Thalazur 2021; design and production: Fleuret S., Lepetit A., UMR 6590)
1.3. Fresh air, nature, health and tourism
Climate and health had long-established links with travel, long before the invention of the word tourism, and there is evidence dating back to the 3rd millennium BCE of mobilities for curative reasons (Kevan 1993), probably in the form of pilgrimages.
Evidence of consideration of the impact of atmospheric factors3 on health can be found in the practices of Mesopotamian, Egyptian, Chinese and Indian physicians in antiquity. In an article entitled “Quests for cures: A history of tourism for climate and health”, Kevan (1993) attributes the first known statement by a physician of the need to undertake seasonal migrations for health reasons to the Indian sage Sustra (600 to 500 BCE):
He [Sustra] pointed out that Varsah (the rainy period from mid-July to mid-September) was an unhealthy time of year and suggested that rulers should move their courts away from the cities of the Ganges to drier upland climates. The ancient Indian elite appear to have accepted this advice with the same enthusiasm as did the English colonial counterparts of the nineteenth and early twentieth centuries.
