Workshop on Regional Health Information Networks

* The text is an abridged version of the original text included in the Financial Times Report 'Telemedicine and Telecare for the New Information Age', published by Financial Times Pharmaceuticals, in November 1999 - Authors Boddy K., Karp P and Sotiriou D.

Please note that the words NEW and MODERN are used interchangeably in the relevant documents, for the time being.

The Asclepieions, Ancient and New

1. The Ancient Beliefs and The Asclepieions

1.1 Introduction

To be Healthy has always been regarded as being of the greatest importance and advantage when considering the quality of life. The ancient societies understood this and they placed great emphasis on achieving and maintaining ‘physical fitness’ as well as on promoting the ‘general well being’ of the whole person. They provided philosophies that viewed man in his ‘wholeness’ and their concepts and notions were often given weight by being surrounded in the myths and the legends of the time. Stories of ‘great physical feats’ and ‘worthy champions’ were provided to give ‘examples’ and ‘role models’ for the population to respect and to emulate. Healthcare itself however remained relatively primitive until the recent era of scientific discovery.

Before the philosophical enlightenment’s that occurred with Christianity and with the current evolutionary science, mankind also sought answers to life’s enigmas through the creation of ‘the pleuristic gods’ or through the Old Testament writings of the ‘One God’. They ascribed to these deities the ‘power’ and the ‘will’ to provide for human needs and to cause or to alleviate their sufferings. In this context the ‘faithful’ were encouraged to be ‘worshippers’ whilst their ‘god’ became their champion and their mentor who required ‘allegiance’ by providing a set of rules or actions for the faithful to follow.

The modern world’s ethos is not too dissimilar to these two ancient approaches although the philosophies concerning the origins of disease and the means whereby to satisfy man’s needs have changed. Scientific medicine has explained many ‘causes’ and provided many ‘cures’ whilst human institutions have taken up the roles of ‘authority’ and ‘persuaders’. International bodies, National, Regional and Local Governments, (with their Members of Parliaments, City Councillors and Mayors), as well as the Health and Education Authorities are now the one’s who provide for the well being of those who elected or appointed them. Their policies determine the shape and the quality of all our lives. Laws are passed to safeguard our health and the environment. Healthcare and social systems are established to deliver services. The individual is ‘encouraged’ to take up health maintenance, life-long learning and socio-cultural pursuits whilst sports and other personalities still provide ‘examples’ and ‘role models’.

1.2 The Ancient Asclepieion’s Health and Culture Movement

In the 5^th century BC the ancients of the Greek world created a ‘myth’ that declared allegiance to the god Asclepios and through him they began a new ‘health and culture movement’, which provided an holistic view of man in the context of his total environment. These ancients made Asclepios their ‘champion’ and described him as the offspring of the god Apollo and the mortal Koronis. This was a combination that provided the necessary ‘divine power’ for healing and the ‘human empathy’ that was appropriate to their time and to their view of man and his ‘health’ including his ‘frailties’, ‘illnesses’ and ‘death’. They also elevated Asclepios to the status of a full deity (in spite of his part human parentage) and the myth depicts him as rising from the inferno to be a true ‘healing god’ for all mankind.

The Asclepieion movement reached its height in the 4^th century BC and never lost its human appeal until the end of the ancient world and the rise of Christianity in the 1^st. and the 2^nd. centuries AD. Practically no Greek city was without its own Asclepios temple and ‘the faithful’ built their ‘worshipping’ and ‘healing’ centres as well as their ‘sanctuaries’ throughout the ancient world. The most renowned of these were at Trikki, Epidaure, Titani, Athens, Kos island, Lissos, Levin and Kyrene. The temples of Asclepios were located in ‘parklands’ or ‘groves’ so that a clean and tranquil environment could be ensured for those pursuing their health needs. These Asclepieion centres, provided the ‘healthcare sites’ of their day, where ‘cures’ were achieved in two ways:

a) by psychologically strengthening the patient and his faith in the healing capabilities of Asclepios (reassurance, relaxation, suggestion, miracle), and

b) by application of the then known pharmaceutical treatments and the pursuit of a healthy way of living (herbal remedies, exercise, diet and other holistic treatments).

Usually both of these methods were practised in a combined form to be mutually complementary. The miraculous epiphany (appearance) of Asclepios was another way of achieving healing and this took place during the patients' sleep, inside the "sacra-sanctum" space of the temple. This latter form of healing much resembles the New use of ‘hypnosis’ and ‘faith healing’.

The faithful ‘worshipped’ in the temples of Asclepios and in other surrounding ‘sacred premises’. These included certain buildings used for medical assistance and for specific treatments, similar to the ‘infirmaries’ of today. Specially constructed ‘hospitality’ or ‘guest houses’ were also provided for the use and the sanctuary of itinerant pilgrims. There are still similar ‘monastic houses’ used for respite in Greece and other countries today.

Apart from the healing ministries, other elements of ‘worship’ (appreciation) and ‘cultural pursuits’ were included in the overall system that was developed to care for man’s health. These included the ‘holy’ water for ritual cleanings as well as for bodily bathing. There were also athletic contests as well as musical and theatrical performances, which were held in honour of Asclepios and were staged in stadiums and in theatres respectively. In this way the benefits of athleticism and the performing arts were brought to bear on the well being of the participants.

Trust or ‘faith’ in this overall system of ‘healthcare’ and ‘wellness’ was generated by repeated narration about the ‘miracles’ that had been performed by Asclepios. Evidences and reminders of these ‘benefits’, (and the expressions of the gratitude of those who were ‘healed’), have been found as ‘inscribed art’ on the walls of the sacred buildings. They have also been found in the form of ‘man-made offerings’, which often depicted the part of the body that had been healed. These ‘offerings’ were mostly sculptured or were made in some other material art form and were then used to decorate the Asclepieion parks or groves. Art in its many forms was part of the ethos that was used to promote health.

The ‘worship’ of Asclepios was the last of the ‘old-world systems’ to regress following the prevalence of Christianity which brought about the replacement of ‘the many gods’ in favour of the ‘One God’. The ‘promise’ of the new Christian philosophy provided something better for mankind in terms of ‘a new socio-political order’ and ‘a new and better future’ in which there would be a permanent release from his sufferings,

“Then I saw a new heaven and a new earth; for the first heaven and the first earth had passed away and the sea was no more….

…he will wipe away every tear from their eyes, and death shall be no more, neither shall there be mourning nor crying nor pain any more, for the former things have passed away” [2]

Thus, the era of the Asclepieions was overtaken by a new philosophy that offered more help than they could, namely a new world and an end to sorrow, pain and death. Palaeo-christian basilicas gradually replaced the sacred buildings that were built in the name of Asclepios and these new ‘temples’ provided a different environment in which the faithful could worship whilst the ‘one God’ could provide for their ‘healing’.

2. A Model For Today

The creators of the myth of Asclepios were far in advance of their time. They had demonstrated an approach to health and well being, which included a means of healthcare delivery that had overcome the human factors concerned with acceptance. Their overall system provided for an holistic view of man in his natural environment and in his socio-cultural world and their philosophy had many similarities with the Christian approach to man’s needs but could not offer the same promise of complete relief from the ‘curse’ of suffering and death. Their organisational and structural systems for healthcare delivery were however remarkable and they can provide today’s world with many lessons as ‘a model’ to follow.

The ancient Asclepieions made use of the entire ‘up-to-date’ medical knowledge and the ‘tried and tested’ healing methods that were available at the time, just as we would. They also combined this ‘science’ with all the elements of an holistic approach and in this way they utilised ‘de-facto’ the elements of ‘trust building’, ‘social interaction’ and ‘outdoor activities’ as well as ‘health maintenance’, ‘education’ and ‘appreciation’ (worship), to achieve their goals.

2.1 Today’s Societal Structures and the Awakening of New Asclepieions

In the scientific world of today, the focus of healthcare delivery has shifted from the ancients’ emphasis on ‘health’ to the New preoccupation with ‘sickness’. Our cities and institutions reflect this change in their design and in their organisation of services.

There are now separate establishments to support ‘medical services’, ‘education’ and ‘socio-cultural’ pursuits. There is even a separation in the sites and in the organisational systems that are directly involved in the delivery of ‘healthcare’ itself, e.g. the primary and secondary care installations such as hospitals and local community healthcare centres and this extends to social care and to counselling agencies. These arrangements and their established systems have created both ‘structural’ and ‘conceptual’ boundaries that serve to separate the components of our healthcare systems as well as to cut them off from their traditional links with the natural environment including the related socio-cultural and educational worlds. They provide an isolationist and competitive ethos rather than a synergistic environment in which to deliver services.

Today, there are no suitable societal structures (let alone establishments), which could cover the overall needs that are related to an holistic view of man and his well-being. There is therefore a less emphasis on the quality of life and a greater concern with the quantity (or rationing) of the services that should be delivered. There is also a dependency on centralised hierarchies and economic models as the driving forces. The general well being, trust and empowerment of those seeking information and knowledge concerning their health and their health maintenance has been overlooked and there is currently a divisive force between the information rich and the information poor.

These modern societal structures and concepts are not in line with the principles promoted by the World Health Organisation (WHO) where ‘health’ is described as “the state of complete physical, mental and social well-being”. The WHO philosophical approach is much more closely aligned to that of those who created the myth of Asclepios and to that of the believers in the ‘pre-scientific’ Christian era. It is now however becoming evident again, that there is a necessity for the balanced development and the essential well being of every individual in society and it is increasingly being recognised that modern lifestyles need the re-awakening of New Asclepieions.

Most cities today have some open green spaces, where the concepts of an asclepieion park could also be established. Citizens of all ages could then enjoy an agreeable and inviting environment where the natural world, health and socio-cultural activities could be brought together. This approach would have a considerable positive impact on the health and well being of all our cities and on all city residents. The new developments taking place in the growth of the information society are now making it possible to achieve such ‘cross sector’ activities and the cities of the future will need to provide both the environment and the services, which are directed toward an holistic view of needs.

The New Asclepieion Movement has the ambition to provide such facilities and to contribute decisively to the search for immediate and effective integrated solutions to the complex and perplexing lifestyle stresses and the organisational problems that are faced by modern societies. Economic forces are part of this endeavour and the business and industrial sectors will need to come together with the other ‘stakeholders’ to create the new ‘health movement’ of the future.

2.2 The Total Environment and the New Asclepieions

In ancient time’s healthcare was always associated with both the physical and the emotional well being of man as well as his social and educational environments. Today, the advent of medical science and the new medical technologies has led to an emphasis on ‘centralised services’ and on ‘physical and biochemical illness’, which promote a dependency on ‘pharmaceutical and operative cures’ that are based on ‘proven’ knowledge and on ‘specialised’ expertise. There has been a rejection of ‘nature’s healing power’, and of ‘human empathy’ both of which can not readily be quantified or scientifically evaluated. There has also been a turning away from dealing with ‘the whole man’ in the totality of his environmental, spiritual and socio-cultural contexts.

The nature of man has not however changed and the ancients recognised that an agreeable and healthy environment influences health and wellbeing through its affects on the physical as well as the mental and emotional state of individuals. Man needs a contact with the natural world even if its just his own garden, his household plants or a companion pet and many of the ancient ways to maintain a healthy lifestyle are now becoming more and more regarded as being beneficial to his well being. Man is also a ‘worshipping’ creature whether he places his trust in his ‘carers’ or in ‘the fates’ or ‘the gods’, or in the one God, or in evolutionary science, or market forces or job-career prospects. Modern lifestyles place 'stresses' on every aspect of bodily and mental functions and the ‘health promoting guidelines’ laid down by the ancient Asclepieions have much to say to our present and future generations.

Despite the good progress that has been made in the modern world, in having food, shelter and sanitation as well as employment and entertainment, there are still large populations and segments of populations that live in very difficult circumstances. It is also not unusual to find environmental and social factors that adversely affect everyone, even those who live in developed societies, which are technologically advanced and affluent. “Time and chance happen to all men”[3] and ‘disadvantage’ occurs in every society so that the totalities, which influence the quality of life, concern us all.

The ancient Greeks had the saying 'Νους υγιής εν σώματι υγιή', meaning “A Sane Mind in a Sane Body” (in Latin, ‘Animus Sani in Corpus Sani’). Despite the WHO definition of Health, this wisdom of maintaining bodily and mental ‘fitness’ (wellness), has been lost in the way that societies have now become organised and in the way that our cities have been structured. There is a current neglect of the environmental promoters of well being and the integrated services that can provide high quality health and wellness programmes as well as the enjoyment of the arts, entertainment and creative pursuits. The barriers of separation that have grown up between the different societal organisations and systems involved are now a major cause for concern.

Health maintenance (wellness) is a focus that can only be pursued in such a multiple and yet integrated service context. It requires to be addressed as part of the total elements that impinge on man’s welfare and therefore as part of the overall facilities provided for all. It is significant that the ancients regarded our well being to be related to the activities of the sports, leisure and entertainment industries. The activities concerned are now well known to be good promoters of health and to be beneficial to maintaining both our bodily as well as our mental fitness. In this context it is not only the activities, which are important. The buildings that are used for these purposes and the access to them are part of the city’s environment and the concept of ‘beauty’ in both art and architecture and in the design of facilities are all important to our wellbeing. Such factors include the provision of pedestrian areas and walkways and of transport systems that reduce traffic density and air pollution.

The wisdom of the ancients has suggested ‘a model’ whereby an agreeable and healthy environment, which best promotes bodily health and mental fitness, can be provided by combining the benefits of the natural world with the riches of well planned socio-cultural and health related facilities. In today’s world, this model of the ‘Asclepieion Parks’ could be used to provide the enjoyment of the natural environment and the architectural design of our cities. They could also combine these health promoters with the facilities to provide the high quality and effective services that keep us healthy and that treat our disorders as well as engendering our ‘trust’ by being tailored to the wholeness of man and by being brought within the reach of everyone. Apart from health benefits these environmental features and holistic services play a vital role in developing our life’s quality. They also span the elements of city planning, education (information and knowledge) and appreciation (worship), all of which have an important part to play in the balanced development of the healthy society.

New Asclepieions would re-structure the green-areas of our cities so that they act as ‘meeting places’, which are accessible to everyone and that combine all the facilities to provide for our health and welfare. In this way all individuals could be exposed to an holistic approach to the quality of their life and at the same time they could have access to integrated services that are without the structural and conceptual boundaries imposed by current societal systems. The new information and communications technologies (ICT’s), make this possible and can support the provision of such services in the home for those with mobility problems but ‘outside the home’ interaction should be encouraged to obtain the maximum ‘wellness’ benefit. Facilities for children, families, the elderly and the disabled are therefore needed.

3. New Asclepieions Parks and The New Scientific and Technological Innovations

The concept of New Asclepieion Parks is to design, as part of city planning, large enough green-areas where the natural world can be related to health and culture. These areas need to provide attractive facilities for all city residents and visitors so that they may have the opportunity to engage in ‘activities’, which will promote health maintenance, life-long learning, social interaction and cultural pursuits. In today’s world, such services can be most effectively supported by the new scientific and technological innovations of the developing information society. Suitable infrastructures will need to be built for the effective and efficient exploitation of the opportunities offered by these new technologies.

The developments in the telematic technologies i.e. the combination of information and communication technologies (ICT’s), are expected to provide new powerful products, processes and services for the solution of existing complex and chronic societal problems. As a result they will also facilitate the introduction of innovations in all the activities related to Environment, Health and Culture.

A number of cities in technologically advanced countries, have already developed ICT applications and services in several key areas. Many of them are focusing on information provision and education. Health and Arts appear as two sectors that will attract considerable interest in the next few years. The majority of the cities of the world have not however been decisively engaged in providing a digital environment for the new information era. The new millennium will see a generation of young people who will expect to use the new information and communications technologies as part of their normal everyday lives. Every effort therefore should be made to ensure the maximum benefit from integrated services that can improve the quality of life for all.

The expected results of such activities will have a very positive impact towards the materialisation of the vision of the developing Information Society, including the equity of access to high quality services, the participation of all residents to desired activities and the satisfactory provision of information and knowledge.

The planned use of the new information and communications technologies (ICT’s) can make all this possible and their implementation could translate the myth of Asclepios into a modern reality for all, irrespective of location and disadvantage.

The New Asclepieion Park of the City of Athens

4. Notions and Goals

The notion of starting a ‘New Asclepieion Movement’ was conceived in 1994 by Associate Professor Dimitrios Sotiriou of the School of Medicine of the University of Athens and by Thodoros Papadimitriou, sculptor and Professor of the Technical University of Athens.

The realisation of a first New Asclepieion Park was put forward as an endeavour for the city of Athens and an association under the name ‘Friends of the Asclepieion Park of Athens’ was created on June 21, 1994. The approach of the new millennium has stimulated a continued and growing interest in their work.

One of the goals of the Association is to promote and support R&D activities on Health and Culture and to seek collaboration with public and private organisations. The Association's current activities are aimed at:

· defining a long-term programme concerning ‘New Asclepieions’ and a medium-term programme concerning the ‘Asclepieion Park of Athens’

· co-operating with public and private authorities and institutions towards implementation

5. A Strategy for Realisation

5.1. Themes and Initial Steps

The strategy for the development of ‘The Athens New Asclepieion Park’ revolves around two main themes:

1. The first theme concerns medical services and aims at a gradual transition from the currently offered services at the existing and administratively independent medical installations towards a technologically advanced and co-operating service with additional ecological and cultural orientations

2. The second theme concerns the creation of new installations. These will be governed by the specifications emerging from research and development initiatives and the piloting of application conducted at the current site chosen for the Asclepieion Park of Athens (or from the results of these activities conducted at another site in the major Athens area). The overall specifications of the Athens Asclepieion Park will also be created from the results of current and future R&D activities

To what extend a New Asclepieion Park could affect urban planning procedures is left to the initiatives of the local communities that wish to participate to this novel and far reaching programme. The objective of central planning however will be embedded in the procedures for informing authorities and non-government organisations as well as the methodologies for planning, implementation and operation.

The Association, ‘Friends of the Asclepieion Park of Athens’, has created a database of relevant data and information, which is intended to facilitate the entire programme. The association is the ‘trustee’ of the initiatives of these endeavours and their outcomes. The members offer technical and R&D assistance to all interested parties.

The following R&D work sets out the initial steps that were taken to evaluate the possibilities and to make progress with the overall strategy.

5.2. Setting the Scene with Initial R&D Studies:

New Asclepieion Parks are areas in which the relevant activities, applications and services are based on the ideals and the values of the Ancient Asclepieions. They represent modern realisations of the ancient model with the prospect on the one hand to cover the current needs of city residents in relation to health, environment and culture and on the other hand to create new prototypes and installations suitable to serve the present and the future generations. Several issues relating to New Asclepieion Parks are innovative in city planning, environmental improvement and healthcare delivery, others are concerned with new services and business opportunities, others represent new approaches that will hopefully lead to new solutions for integrated cross-sector activities that can benefit all. There exists therefore a vast array of issues and topics suitable for state of the art research and development initiatives.

The strategy to be followed required an initial research and development phase. One of the main pillars of this was to establish an interdisciplinary approach for problem solution. A second one was the need to establish a spectrum of possible 'core activities’. These efforts were indispensable in order to preserve the original concepts, the harmonisation of the proposed approaches and the designs of the basic ethical, deontological and aesthetic principles as well as the conformance of the implementation mechanisms and the services to the same basic principles. Specific areas that were considered and in which it was felt that activities needed to be developed, were those of health maintenance, medicine, athleticism, culture, sociology, environment and education. The search for solutions, with the assistance of modern scientific and technological achievements and with the participation of the business and industrial communities, will constitute the fundamental characteristic of the research and the development strategy to be shaped.

The Asclepieion Park of Athens as a Digital Site

The Greek General Secretariat of Research and Technology, (based on a proposal by the ‘Friends of the Asclepieion Park of Athens’), commissioned a 5 member research group of scientists to undertake a study entitled ‘Design of A Digital Site for Healthcare: The Asclepieion Park of Athens’. The mandate was to describe the content of a project with emphasis on the economic and research aspects. It also included the description of a Technical Annex of the project and the supporting documentation for submission to the Management Committee of the 2^nd Community Support Framework (the joint European Union-Greek Programme of R&T Development for the years 1997-1999) for inclusion in the relevant activities.

The Group proposed activities, which were related to the exploitation of modern telematic technologies for applications and services in the domains of telemedicine; tele-education; tele-working; environmental management; management of energy needs; management of traffic around and inside the Asclepieion Park; provision of welfare services; support of cultural activities and athleticism. The study was completed in May 1998 and was approved by the Management Committee. The GSRT has agreed to procure, as soon as possible, the infrastructures mentioned as necessary for the services identified by the project. The results concluded that inside the Asclepieion Park of Athens it will be possible to offer a complete range of quality services in healthcare and welfare. These services will include:

The achievement of these goals necessitates modern infrastructures that exist only to a limited extend in Greece today. They will also necessitate a possible reorganisation of the existing healthcare units, the consensus on and implementation of new procedures and the introduction of new management techniques.

The ‘Asclepieion Park of Athens’ on the Internet WWW

The program for development of the Asclepieion Park of Athens as well as the promotion of the concept of New Asclepieions in general, already exploits the possibilities offered by the Internet, World Wide Web.

The design of the current Asclepieion Web Pages (http://asclepieion.mpl.uoa.gr), places emphasis on the opportunities for active participation at national as well as international level. A positive response to the concepts of the New Asclepieions, including deposition of proposals and ideas and alternative approaches will be a proof of the effectiveness of the Web Site.

The Web pages aim to become a repository of all the activities related to the promotion of the research work undertaken or to be undertaken in the context of New Asclepieions. In addition the ease of accumulation of new proposals and ideas originating from scientists linked to the WWW, is expected to strengthen the Site, so as to become a “reference repository” and “a starting point” for all future activities.

The original design and the continuation of the first stages started in the last trimester of 1997, at the School of Medicine of the University of Athens.

A collection of photographs, slides and maps concerning the Asclepieion Park of Athens has been maintained at the Internet site of the School of Medicine of the University of Athens since late 1997. The collection presents the current situation inside and around the Asclepieion Park and brings to the surface problems requiring immediate engagement and solutions in line with its character.

References

[1] D. Sotiriou et al. ‘The Asclepieion Park of Athens’, A study commissioned by the Organisation for Planning and Environmental Protection of Athens (ORSA), of the Hellenic Ministry for the Environment, Physical Planning & Public Works, Athens, 1988

The Project was carried out by a Research Team composed of scientist from the University of Athens, the National Technical University and the National School of Public Health, under the responsibility of the School of Medicine of the University of Athens. The complete text of the study (in Greek) can be found in the Web Pages of the Medical Physics Laboratory, at http://asclepieion.mpl.uoa.gr/Parko/.

Scientific Co-ordinator of the Project was Assoc. Prof. Dimitrios Sotiriou. The Project was completed in May 1998

[2] D. Sotiriou et al., ‘Design of A Digital Site for Healthcare: The Asclepieion Park of Athens’, A study commissioned by the Greek General Secretariat of Research and Technology, Athens, 1998. The report was produced by a team of scientists form the University of Athens and the GSRT. The complete text of the study (in Greek) can be found in the Web Pages of the Medical Physics Laboratory, at http://asclepieion.mpl.uoa.gr/Parko/. Editor and chief scientist was Assoc. Prof. Dimitrios Sotiriou

[3] Project ASPASIA. On going study to propose a Telematic network and services of health and culture which can be offered in a New Asclepieion.

[1]The text is an abridged version of the original text included in the Financial Times Report 'Telemedicine and Telecare for the New Information Age', published by Financial Times Pharmaceuticals, in November 1999 -

Authors Boddy K., Karp P and Sotiriou D. More information can be found in the electronic pages at http://asclepieion.mpl.uoa.gr

[2] Quoted from the Revised Standard Version of the Bible; The Revelation to John chapter 21 verses one to four.

[3] Ecclesiastes Chapter 9, verse 11