{"id":3597,"date":"2017-01-19T17:01:32","date_gmt":"2017-01-19T17:01:32","guid":{"rendered":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj26.pdf"},"modified":"2017-01-19T17:01:32","modified_gmt":"2017-01-19T17:01:32","slug":"wmj26-2","status":"inherit","type":"attachment","link":"https:\/\/www.wma.net\/es\/publicaciones\/world-medical-journal\/wmj26-2\/","title":{"rendered":"wmj26"},"author":2,"comment_status":"open","ping_status":"closed","template":"","meta":[],"acf":[],"description":{"rendered":"

wmj26<\/a><\/p>\n

vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, Inc
\nG20438
\nNr. 2, April 2010
\nPlacebo Controls in Clinical Trials\u2022
\nThe Climate Crisis and Global Health\u2022
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nAkseli Gallen-Kallela (26 April 1865 \u2013 7 March
\n1931) is one of the most famous Finnish artists.
\nHis illustrations of the Kalevala, the Finnish
\nnational epic, are considered very important for
\nthe national identity of the Finns.
\nIn the 1880\u00b4s Gallen-Kallela studied in Paris at
\nthe Acad\u00e9mie Julian, the Atelier Cormon and
\nother schools.There he painted Mother with
\nher sick child (1888). Now this painting is one
\nthe treasuries of the art collection of the Finnish
\nMedical Association.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 K\u00f6ln\/Germany
\nPhone (0 22 34) 70 11-0
\nFax (0 22 34) 70 11-2 55
\nProducer
\nAlexander Krauth
\nBusiness Managers
\nJ. F\u00fchrer, D. Weber
\n50859 K\u00f6ln, Dieselstr. 2, Germany
\nIBAN: DE83370100500019250506
\nBIC: PBNKDEFF
\nBank: Deutsche Apotheker- und \u00c4rztebank,
\nIBAN: DE28300606010101107410
\nBIC: DAAEDEDD
\n50670 K\u00f6ln, No. 01 011 07410
\nAt present rate-card No. 6 a is valid
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7% MwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nK\u00f6ln, Germany
\nISSN: 0049-8122
\nDr. Dana HANSON
\nWMA President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nProf. Ketan D. Desai
\nWMA President-Elect
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nI.M.A. House
\nIndia
\nProf. Dr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Yoram BLACHAR
\nWMA Immediate Past-President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nProf. Dr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n43
\nThe Vancouver Winter Olympic games are now history. We enthu-
\nsiastically admired sports such as bobsled, skeleton and acrobatic
\nsnowboard \u2013 sports in which very few people actually participate. If
\nwe regard athletic activity as important for the health of a popula-
\ntion, these sports have little meaning given their expense and their
\nunsuitability for children and senior people. Actually, these sports
\nmay not be very healthy pastimes.
\nIf we analyze the contribution of sports to the field of health pro-
\nmotion, popular sports such as hockey, football, and baseball fall
\nshort. Millions of dollars are spent to support these activities, but
\nthe greatest \u201cbenefit\u201dfor these sports is to the viewer sitting in front
\nof a television set with a beer in his hand. From the national point
\nof view in the 21st century we should value a sport first by its con-
\ntribution to health.
\nAs physicians we should encourage physical activity and sports par-
\nticipation. It is estimated that about 250-350 kilo-calories per day,
\nor 1000-1500 kilo-calories per week, are expended during exercise
\nthat is intensive enough to cause perspiration. People should par-
\nticipate in physical activities or sports five times a week.To motivate
\npeople who do not exercise, one can recommend activities such as
\nclimbing stairs, walking fast, working in the garden and dancing.
\nWalking 8000 to 10,000 steps a day, even going back and forth to
\noffice, is beneficial.
\nModerate athletic activity helps prevent illness, so it has an impor-
\ntant role in primary, secondary and tertiary health care fields. Basi-
\ncally, we recognize sport as a primary care resource in the popula-
\ntion because an active lifestyle lengthens life expectancy, diminishes
\nmorbidity, decreases risk of chronic disease, rises work productivity
\nand noticeably promotes general economic and social development
\nof the country.
\nAs a secondary prevention tool we know that adequate and pur-
\nposeful physical load reduces episodes of illness and lengthens re-
\nmission periods.
\nIn tertiary prophylaxis, sport is an important component in the re-
\nhabilitation process of successfully treated patients. Sport and phys-
\nical exercises are widely used to avoid coronary and blood vessel in-
\ncompetence after operations, as well as to prevent the development
\nof secondary pneumonia or decubitus ulcers. Athletic-type activities
\nhelp to improve lymphatic flow, venous circulation, healing of the
\nbones and soft tissues.
\nIn the 19th century, as well as during most of the 20th century,
\nlack of movement was not recognized as a disease risk factor. Ac-
\ntive movements were even considered to delay or interfere with the
\nhealing process. During the first three quarters of the 20th century
\nconfinement to bed was standard treatment for many medical dis-
\norders. Only research conducted toward the end of 20th century
\nhas proven that there is an inverse correlation between movement
\nactivities and certain diseases.
\nRegular physical activity helps prevent cardio-vascular disease, as
\nwell as improves treatment results for patients who already have
\nillnesses. Physical activity directly and protectively limits the de-
\nvelopment of atherosclerosis, including coronary artery disease.
\nModerate exercise also has an indirect influence on the profile of
\nthe risk factors of cardio-vascular diseases. Physical activity reduces
\nplasma LDL (low-density lipoprotein ) cholesterol and triglycer-
\nides, improves plasma HDL( high-density lipoprotein) cholesterol
\ndiminishes adiposity and lowers blood pressure.Several studies have
\nshown that physical activity lowers the risk of non-fatal coronary
\ndisease and death.
\nRegular physical activity has been shown to diminish the incidence
\nof cancerous diseases. It is thought that immunological factors may
\nbe important in the prevention of oncologic processes. Several stud-
\nies have shown that effective physical load suppress the malignant
\nprocesses in the body.Physical activity seems to diminish the growth
\nof malignant cells and may even create tumor-lysis. Sometimes the
\nseverity of the oncology disease is determined by side-effects, such
\nas anemia, diarrhea, immunosupression, and fatigue, which actu-
\nally are the most common symptoms of oncologic diseases. Proper
\nphysical therapy during chemotherapy and beam therapy, especially
\nat the end of the therapy course significantly decreases these side
\neffects. Daily stamina training for cancer patients increase their joy
\nSports at all ages \u2013 for a healthy
\npopulation
\nEditorial
\n44
\nWMA news
\nof living and increases their level of activity, thereby lessening the
\npsycho-motor stress level and decreasing side-effects.
\nPhysical activity decreases insulin resistance and the disturbances of
\ndextrose tolerance, as well as post-prandial hyper-glycemia. Like-
\nwise, physical activity together with weigh loss diminishes the inci-
\ndence of new II type diabetes in a population that is at high risk for
\ndeveloping diabetes.
\nSport has a very important role in the management of depression
\nand other mental illnesses. Exercise has an anti-depressive influ-
\nence. Any physical activity seems to be effective in the fight against
\ndepression.
\nThere is no age limit concerning sport activities.Several studies have
\nproved that purposeful training of old people in cycling sports in-
\ncreases muscle mass, diminishes adiposity, normalizes blood pres-
\nsure, lessens the \u201cnumber of falls\u201d, and improves bio-chemical blood
\nindicators.
\nThose who are taking exercises regularly, even in the age groups of
\n80-90, usually do not need social services and tend to live longer,
\nmore valuable lives, both physically and mentally.
\nIn all countries where senior sport has been given priority by the
\npublic health specialists, there has been enormous resistance from
\nthe politicians, clerks, journalists, and sport experts. These people
\nhave the common opinion that the main priority in preventive
\nhealth belongs to children and youth – to ensure good health of the
\nyoung. They propose that when these young people will grow up
\nthey will continue their sporting activities and, therefore, will later
\nturn into healthy seniors.
\nSports medicine as a branch of medicine is acknowledged today in
\nseveral countries. These doctors are important in promoting public
\nhealth through exercise. Our goal is: a healthier mankind. To reach
\nthis goal I would encourage each of you each start with yourself
\n-just five times a week engage in some type of active exercise. Even
\nin the World Medical Journal we need to speak about the necessity of
\nacknowledging sport as a component of preventive medicine.
\nP\u0113teris Apinis, MD
\nClarisse Delorme
\nImpunity is still the biggest impediment to
\nthe prevention of torture. Insufficient in-
\nvestigations and persistent challenges in the
\ncollection of evidence are significant factors
\nin the absence of action taken against per-
\npetrators of torture.
\nThe issue of how to promote and institu-
\ntionalise the forensic documentation of al-
\nleged cases of torture was the subject for a
\npanel of renowned experts gathered in Ge-
\nneva on the 9th of March, chaired by the
\nUN Special Rapporteur on torture, Profes-
\nsor Manfred Nowak. The event, hosted by
\nthe World Medical Association (WMA)
\nand the International Rehabilitation Coun-
\ncil for Torture Victims (IRCT), took place
\nin conjunction with the 13th regular session
\nof the UN Human Rights Council in Ge-
\nneva. The panel included Marija Definis-
\nGojanovic, member of the UN Subcom-
\nmittee for the Prevention of Torture, as well
\nas representatives from the Turkish and
\nDanish Medical Associations, the academic
\ncommunity and of the Association for the
\nPrevention of Torture.
\nWith nearly 60 participants from govern-
\nments, NGOs, the academic community,
\nUN agencies and health professional or-
\nganisations, this successful event demon-
\nstrated high interest in the subject. During
\nthe discussion, several recommendations re-
\nlated to medical training advocacy and the
\nneed for sustainable procedures were being
\nmade. In particular, the cooperation among
\nthe various stakeholders within the judicial
\nsystem and with the health professional as-
\nsociations was deemed necessary (see the
\nproposals in the separate box).
\nMany of those recommendations echo Pro-
\nfessor Nowak\u2019s latest report to the Human
\nRights Council, in which he wrote that
\n\u201cAll too often, the safeguards required by
\ninternational human rights law are neither
\nforeseen nor effective in preventing torture.\u201d
\nHe added that \u201cForensic medical science is
\na crucial tool since it can establish the de-
\ngree of correlation of the medical findings
\nExploring Sustainable Systems to Document
\nTorture \u2013 the Role of Health Professionals
\n45
\nWMA news
\nProposals made during the discussion at the IRCT-WMA side-
\nevent \u201cExploring sustainable systems to document torture \u2013 the
\nrole of health professionals\u201d
\nDeveloping training for health professionals
\nIncreasing the number of forensic medical specialists worldwide\u2022
\nto adequately cover the need of documenting incidences of tor-
\nture.
\nDeveloping training of non-forensic physicians in examining de-\u2022
\ntainees and alleged victims of torture.
\nAddressing the challenges for doctors working in the prison\u2022
\nsystem that are isolated and do not always have the appropriate
\ntraining.
\nDeveloping proposals for streamlining torture prevention into\u2022
\nmedical education. National medical associations can play a
\nleading role in training physicians, as the example of the large
\nscale training of 4000 physicians in Turkey shows.
\nAdvocatingfortheimplementationofinternationalinstruments
\nfor the prevention of torture
\nDeveloping multidisciplinary actions for the implementation the\u2022
\nUN Convention Against Torture and its Optional Protocol, the
\ninternational standards of the Istanbul protocol on documenting
\nand investigating torture, as well as the WMA medical ethics
\nguidelines on the role of health professionals in preventing tor-
\nture.
\nIncreasing the involvement of health professionals in National\u2022
\nPreventive Mechanisms put in place under the OPCAT.
\nDeveloping sustainable and systematic procedures for torture
\nprevention
\nSome basic steps can be taken by all countries in order to support
\nthe prevention of torture particularly in detention.Such procedures
\nshould include:
\nCompulsory medical examination in confidentiality by forensic\u2022
\nexperts that should report directly to relevant authorities
\nGuaranteed confidentiality of those medical examinations\u2022
\nIntroduction of systematic examination of detainees before and\u2022
\nafter transfer, as a preventive measure
\nDevelopment of independent mechanisms for systematic report-\u2022
\ning of report torture
\nEnsuring that domestic actors in the governmental and non\/
\ngovernmental sector are working together
\nInvolvement of a multitude of stakeholders – governmental and\u2022
\nnon-governmental as well as legal, medical and other relevant
\nexperts – need to work more closely together in strengthening
\nindependent investigation and monitoring systems.
\nA positive and collaborative attitude by all stakeholders, includ-\u2022
\ning health professional associations, involved in the administra-
\ntion of justice
\nwith the allegations brought forward and
\ntherefore provide evidence on which pros-
\necutions can be based.\u201d (A\/HRC\/13\/39, 9
\nFebruary 2010, parag. 55).
\n\u201cThis event is a follow-up to the 2009 Hu-
\nman Rights Council resolution on the role
\nand responsibility of medical and other
\nhealth personnel in the prevention of tor-
\nture.\u201d said Dr. Dana Hanson, President of
\nthe WMA. He continued, \u201cThe WMA has
\na clear and long-standing commitment in
\ncondemning all forms of doctors\u2019 involve-
\nment in acts of torture. But it is also an ab-
\nsolute ethical duty for the medical profes-
\nsion to document torture and to denounce
\nit. In that sense, physicians can and do
\nprevent torture, but more must be done in
\ncollaboration with other relevant actors to
\neradicate these flagrant human rights viola-
\ntions.\u201d
\nMs. Clarisse Delorme,
\nWMA Advocacy Advisor
\n46
\nWMA news
\nA call to eliminate female genital mutila-
\ntion as a gross form of violence against
\nwomen has come from the World Medical
\nAssociation (WMA) and the International
\nFederation of Gynaecology and Obstetrics
\n(FIGO).
\nTo mark the international day of ZeroToler-
\nance to FGM (February 6), the two organi-
\nsations, representing millions of physicians
\nand 124 obstetrical and gynaecological as-
\nsociations worldwide,strongly condemn the
\nmedicalisation of female genital mutilation.
\nProfessor Gamal I. Serour, President of
\nFIGO, said: \u2018Death, severe pain, haemor-
\nrhage, tetanus, sepsis, recurrent urinary tract
\ninfections, pelvic inflammatory disease, in-
\nfertility, increased complications of subse-
\nquent pregnancy and childbirth as well as
\nadverse psychological and sexual effects are
\njust a few examples of its extreme conse-
\nquences. The practice of FGM violates hu-
\nman rights principles.\u2019
\nHe said that according to a recent World
\nHealth Organisation report on women and
\nhealth there had been a small decrease in
\nthe extent of FGM in recent years, a de-
\ncline in the average age at which FGM was
\nperformed, and a marked increase in the
\nproportion of girls who underwent FGM
\nbefore the age of five years. The report also
\nsaid there was a growing tendency for FGM
\nto be carried out by health professionals.
\nDr. Dana Hanson, President of the WMA,
\nsaid: \u2018The medicalisation of FGM is a mat-
\nter of deep concern for us. It blatantly in-
\nfringes the code of medical ethics. Physi-
\ncians should need no reminding about the
\nacute dangers of FGM for women and girls
\nto discourage them from performing or
\npromoting such practices. They are a viola-
\ntion of women\u2019s human rights that physi-
\ncians and other health professionals should
\nnever practice under any circumstances.
\nWe would like to see physicians and medi-
\ncal associations taking a more robust stand
\nagainst these harmful and degrading treat-
\nments.\u2019
\nProfessor Serour added: \u2018Health profes-
\nsionals can play a unique role in working
\ntowards the elimination of FGM to ensure
\nthat girls and women enjoy the full extent of
\nhuman rights and freedoms, and are treated
\nwith dignity and understanding.\u2019
\nFor further information please contact:
\nClarisse Delorme, World Medical Associa-
\ntion, Advocacy Advisor
\n+33 4 50 407575 (office)
\nNigel Duncan, WMA Public Relations
\nConsultant
\n+44 (0) 20 8997 3653 (work)
\n+44 (0) 7984 944 403 (mobile)
\nnduncan@ndcommunications.co.uk
\nPhysicians Call for Elimination of Female
\nGenital Mutilation
\nNigel Duncan
\nThe way in which the health professions are
\nregulated has become a hot topic in recent
\nyears, with the concept of self regulation
\nunder the political spotlight as never before.
\nIn May 2008 global representatives of the
\nhealth professions came together under the
\numbrella of the World Health Professions
\nAlliance to hold a highly successful confer-
\nence on regulation in Geneva looking at the
\nrole and future of health professions regula-
\ntion.
\nFollowing the success of that conference,
\nthe Alliance (the International Council of
\nNurses, the World Dental Federation, the
\nInternational Pharmaceutical Federation
\nand the World Medical Association) in co-
\noperation with the World Confederation
\nfor Physical Therapy, organised a second
\nconference in Geneva in February, focus-
\ning on a theme of \u201cShaping the Future\u201d of
\nregulation.
\nMore than 300 representatives from the five
\norganisations gathered for two days to fo-
\ncus on three main objectives \u2013 to explore a
\ndesired future for health professional regu-
\nlation, to examine the regulatory and pro-
\nfessional issues related to the international
\nmigration of health professionals and to
\nevaluate the relationship between health
\nprofessional education, regulation and stan-
\ndards of practice.
\nSpeakers from around the world were invit-
\ned to address these objectives, backed up by
\nworkshops and an intriguing survey of par-
\nticipants about the state of regulation today.
\nHealth Professions Consider
\nthe Future of Regulation
\n47
\nWMA news
\nAlthough the conference did not achieve a
\nconsensus, which was not its aim, it proved
\nto be a stimulating two days, highlighting
\nthe common problems facing the different
\nhealth professions and the barriers to the
\nway forward. The main success of the con-
\nference was the very fact that it was once
\nagain bringing together the representatives
\nof 25 million health professionals to share
\ntheir ideas and prescriptions on one of the
\nmajor topics of the day.
\nThe proceedings opened with a stark warn-
\ning from Ann Morrison,of the Internation-
\nal Council of Nurses, that the pressures on
\nthe regulatory environment were increasing
\nwith self regulation now under mounting
\nthreat. She said that with moves away from
\nthe \u201cprofessional elite\u201dto more lay member-
\nship, self regulation was too often seen as
\na self serving or self interested system. The
\naim of regulating the professions was to find
\na balance.
\nWith the keynote speaker, Franz Knieps
\nfrom Germany, unable to attend at the
\nlast moment, Dr. Otmar Kloiber, Secre-
\ntary General of the World Medical As-
\nsociation (WMA), stepped in to speak
\nabout the history and complexities of
\nregulation. He said there were many dif-
\nferent models of self regulation, such as
\ncouncils, chambers and private associa-
\ntions, with a wide spectrum of both public
\nand professional functions. In some parts
\nof the world, such as the Nordic countries,
\nco-operative structures had evolved with
\nwhich all sides were happy. He also re-
\nminded the conference that many of the
\nAlliance organisations\u2019 constituents were
\nregulatory bodies.
\nDr. Kloiber said that the rights and privi-
\nleges to self govern, usually given by Par-
\nliaments to a profession or a group, had to
\nbe balanced by duties and obligations. In a
\ndemocracy, self governance was a matter of
\npower sharing with appropriate checks and
\nbalances, although often it was more of a
\nburden than a privilege. The three watch-
\nwords were responsibility, transparency and
\naccountability.
\nDuring the first day\u2019s proceedings, the
\npreliminary results of a survey on regula-
\ntion were revealed. The survey, the first ever
\nglobal survey on the subject, was designed
\nto find out about the current regulation
\nof health professionals around the world.
\nIt was completed by those attending the
\nconference and gave a snapshot of what is
\nhappening now. The full results will be an-
\nnounced in due course.
\nThe preliminary findings, presented by Dr.
\nPaul Rockey, from the American Medical
\nAssociation, and Luc Besancon, from the
\nInternational Pharmaceutical Federation,
\nwere based on more than 250 responses and
\nrevealed the huge variety of different systems
\nof regulation that existed. In the Americas
\nand south east Asia, for instance, self regu-
\nlation was much more common than in the
\nrest of the world. The survey showed that
\nregistration and discipline were the two
\nmost common activities of the regulators,
\nfollowed by investigation and recertifica-
\ntion. The survey also examined the differ-
\nences in regulation between federal and non
\nfederal countries and also whether income
\nlevels in a particular country materially af-
\nfected what system of regulation existed.
\nDr. Rockey said that what he took away
\nfrom the early findings was that the com-
\nplexity of regulation was much greater than
\nhe had thought. He was surprised by the
\ndiversity of systems and said the results
\nshowed little signs of any rapid move to-
\nwards harmonisation.
\nLooking ahead to possible reforms, Dr.
\nAmbrose McLoughlin, Registrar and Chief
\nExecutive Officer of the Pharmaceutical
\nSociety of Ireland, said that the European
\nUnion had established effective regulatory
\nregimes for civil aviation, for food safety
\nand for maritime safety. But patient safety
\nhad yet to be properly addressed. Now was
\nan opportune time for health systems to
\nlook at their obligations to patients. A ma-
\njor weakness in the current system was that
\nthere was no formalised structure at EU
\nlevel providing for collaboration between
\nregulators of health personnel and services.
\nWhat was required were global regulatory
\ncollaboration and the creation of a patient
\nsafety authority.
\nJan Robinson, Registrar and Chief Execu-
\ntive Office of the College of Physiothera-
\npists of Ontario, Canada, said there had
\nbeen an increasing disintegration of public
\ntrust in health professionals and the con-
\nventional understanding of the social con-
\ntract between regulators,professions and the
\npublic was no longer of primary relevance in
\nthe 21st
\ncentury.
\nDr.Christine Cassel,President and CEO of
\nthe American Board of Internal Medicine,
\nsaid that for physicians in the United States
\nthere was a mass of bodies holding them to
\naccount.It was completely chaotic and there
\nwas no coming together.
\nDr. Mukesh Haikerwal, from the Austra-
\nlian Medical Association, spoke about e-
\nhealth in Australia and the role it was play-
\ning in addressing inequities in access to care,
\nwhile Ivana Silva, from the Pharmaceutical
\nGroup of the European Union, provided an
\noverview of the main issues around the mi-
\ngration of pharmacists in the EU. Dr Flo-
\nrent Aka Kroo, from the Ordre National de
\nMedecins in Cote d\u2019Ivoire, spoke about the
\nharmonisation of GPs\u2019 training curricula in
\nhis country and the standardisation of qual-
\nifications.
\nThe second day\u2019s debate opened with a dis-
\ncussion about evaluating the relationship
\nbetween health professional education, reg-
\nulation and standards of practice. Dr. Mi-
\nchael Maves, CEO of the American Medi-
\ncal Association, spoke about the attempt
\nby some health professions in the USA to
\nexpand their scope of practice. There had
\nbeen an increase in nurse prescribing,and of
\npodiatrists and optometrists doing surgery.
\n48
\nWMA news
\nThe result was that there was a great deal of
\nconfusion in his country about who was a
\nphysician.The AMA\u2019s response had been to
\nconvene the Scope of Practice Partnership,a
\nforum where organised medicine discussed
\nlegislative, regulatory and judicial strategies
\nemphasising health care practitioners\u2019 edu-
\ncation and training.
\nLesley Bainbridge, Director of Interprofes-
\nsional Education in the Faculty of Medicine
\nat the University of British Columbia in
\nVancouver, Canada, said one of the primary
\ndrivers of interprofessional collaboration
\nwas patient safety. Yet the barriers to effec-
\ntive teamwork continued to impede a global
\nshift to collaborative practice models. She
\nsaid it was important not to ask practitio-
\nners to work outside their scope of practice.
\nThis was echoed by Dr. Jon Snaedal, past
\nPresident of the WMA, from Iceland, who
\nspoke about the various types of teamwork
\nand the difficulties involved in achieving
\nsuccessful teamwork as a result of turf war
\nand professional rivalry.
\nThe final part of the conference involved par-
\nticipants dividing up into profession-based
\ngroup discussions. Although the feedback
\nfrom each group indicated that there was
\nlittle consensus or conclusions from these
\nworkshops, the debates were often spirited.
\nThe speakers who reported back from the
\nworkshops effectively summed up the out-
\ncome of the whole conference when they
\nsaid that discussions tended to raise more
\nquestions than answers.
\nIt will now be for the WHPA and the or-
\nganisers of the conference to assess the suc-
\ncess of the event and to decide what further
\naction is now required.
\nMr. Nigel Duncan, WMA Public
\nRelations Consultant
\nEuropean colleagues from surgery and
\nlaboratory achieve a remarkable break-
\nthrough
\nA child aged 10, suffering from Long Seg-
\nment Tracheal Stenosis, has had a donated
\ntrachea implanted,stripped of its cells trans-
\nplanted and then applied with two types
\nof stem cells from the child\u2019s marrow and
\ngrowth factors onto the implanted stripped
\ntracheal framework to rebuild the airway in
\nthe body…
\nThe trachea and the stem cells were pre-
\npared by Dr. Mark Lowell, Director of Cel-
\nlular Therapy at the Royal Free Hospital,
\nthe Surgical team implanting the new tra-
\nchea and repairing the damaged aorta was
\nled by Professor Martin Elliot University of
\nLondon (UCL) and Great Ormond Street
\nHospital(GOSH),Professor Paolo Macchi-
\narini Careggi University Hospital and Hon
\nConsultant GOSH and Hon Professor
\nUCL applied the cells and growth factor to
\nthe trachea in the operating theatre, Profes-
\nsor Martin Birchall,UCL lead for regenera-
\ntive medicine led on ethics and regulatory
\napprovals.
\nProfessors Birchell and Macchiarini
\nachieved the world\u2019s first stem cell-based or-
\ngan transplant on an adult patient, in 2008.
\nProfessor Birchell\u2019s research programme
\nwith Professor Elliott includes the absorb-
\nable stent used in this 10 year old patient.
\nThe application of this technology should
\nreduce greatly the risk of rejection of the
\nnew trachea as the child\u2019s stem cells will not
\nproduce any rejection.
\nhttp:\/www.ucl.ac.uk\/news\/news-
\narticles\/1003\/10031903
\n(accessed 22.03.2010)
\nRevolutionary Transplant in University
\nCollege London \u2013 a world first
\n49
\nWMA news
\nThe WMA endorsed programme to support
\ncritical health care education to the most at
\nrisk communities, saw the launch of the lat-
\nest in the series of Speaking Books for low
\nliteracy communities, in Beijing, focusing
\non the inherent risks of smoking.
\nSmoking has been identified as the single
\nmost serious public health threat to China,
\nand if the country does not do more to re-
\nduce tobacco use, smoking deaths will dou-
\nble to two million per year by 2020, health
\nexperts predict
\nA speaking book is an interactive book
\nwhich consists of 16 pages of colorful illus-
\ntrations supported by straightforward and
\neasy to understand text. For each page there
\nis a corresponding push button that triggers
\na sound track of the text, so no matter the
\nlevel of reading comprehension, the infor-
\nmation will be seen, read, heard and under-
\nstood with powerful results.
\nThe Chinese Speaking Book,\u201cStay Healthy
\nBy Not Smoking\u201d is aimed at school chil-
\ndren and tells the story of one young boy\u2019s
\nstruggle to stay healthy in a household
\nwhere the father is a heavy smoker. It en-
\ncourages the family to declare their house a
\nsmoke free zone and for the father and his
\nfriends to attend a smoking cessation clinic.
\nThe book has been developed in a partner-
\nship between WMA, Pfizer, CDC Beijing,
\nCMDA and Chinese Association on To-
\nbacco Control.
\nThe launch was attended by senior repre-
\nsentatives of Chinese Ministry of Health,
\nChinese Health Education, Center for
\nDisease Control, Chinese Association on
\nTobacco Control, Chinese Medical Doc-
\ntors Association, the Chinese media, school
\nchildren and their teachers, as well as Pfizer
\nexecutives from both the USA and China.
\nFollowing the launch the books are now
\nbeing donated to schools and medical clin-
\nics in the Beijing area, as well as for distri-
\nbution by all the supporting agencies that
\nassisted in the creation of the book and at-
\ntended the launch.
\nBased on previous experience (and research
\nwhere an average of 27 users per book were
\nobserved) this initial pilot of 5000 books
\nbeing distributed is likely to reach and im-
\npact on 50,000 to 100,000 or more people,
\nat risk from smoking.
\nDr. Soeren Rasmussen, Senior Director Ex-
\nternal Medical Affairs and representing
\nPfizer at the launch, says that this pilot is
\njust the first step in what should become
\na much larger intervention to educate the
\nyoung on the dangers of smoking. Dr. Ras-
\nmussen firmly believes that a distribution of
\nmany more books could make a significant
\nand measurable change in the smoking hab-
\nits of that community. \u201cReducing tobacco
\nusage in China is a huge challenge, and we
\nbelieve by educating young children with
\nthese innovative Speaking Books, we can
\nmake a real difference\u201d, he says.
\nBrian Julius, President, Books of Hope
\nPfizer Launches Speaking Book in China on
\nDangers of Smoking
\n50
\nMedical Ethics, Human Rights and Socio-medical affairs
\nChristine K. Cassel
\nThe World Health Professions Conference
\non Regulation met for the second time in
\nGeneva on February 17 and 18, 2010. The
\ngrowing interest of health professions in
\nthe importance of setting standards in the
\npublic interest is evidence of consistent
\npressure from countries worldwide for
\nmore transparency and public engagement
\nin improving the quality of health care. In
\nmany countries, government has a major
\nresponsibility for financing of health care
\nand, in some cases, aspects of the delivery
\nsystem. Other countries are much more
\nheavily based on the private sector model.
\nAll are beginning to ask questions about
\nhow, in an era of increasing medical tech-
\nnical capabilities and with increasing costs,
\ngovernments can obtain the highest quality
\ncare for the money spent.Private consumers
\nwho pay for healthcare face the same chal-
\nlenge, perhaps even more intensely, because
\nof the impact of the cost of care on their
\nown finances. Some countries have been
\nenergized to examine the issue of standards
\neven more aggressively because of very pub-
\nlic scandals involving specific incompetent
\npractitioners, a general diminishment of
\nconfidence in the profession, or lack of ac-
\ncess to needed care. Regardless of the issue
\ndriving these pressures, there is no doubt
\nthat they will continue and are likely to in-
\ncrease and accelerate.
\nI would like to draw your attention to a mod-
\nel that is working well in the United States
\nthat is not government-run or even govern-
\nment-mandated. This model is an example
\nof the profession as a standard setter based
\non its own deep knowledge and expertise
\nfrom training in specific areas \u2013 reflecting
\nthat expertise in standards, but functioning
\nvery clearly in the public interest rather than
\nthe self-interest of physicians. I endorse the
\nsense of urgency that has emerged from oth-
\ner presentations in this program and believe
\nthat it is reflected in the growing interest
\nin the specialty-based standards model that
\nboard certification embodies from countries
\naround the world.
\nSpecialty boards are independent not-for-
\nprofit entities constituted by each function-
\ning specialty acting \u201cof the profession and
\nfor the public.\u201d Interestingly, they are inde-
\npendent in several dimensions.
\nFirst, they are independent of government \u2013
\nthey have a special status as tax-free organi-
\nzations in the United States, and to main-
\ntain that status they must show that they are
\noperating in the public interest and not for
\nfinancial gain. Secondly, they are indepen-
\ndent of membership pressures. The boards\u2019
\n(many of which have public members as
\nwell as members of the profession) financial
\nmodel is based on fees that the diplomates
\nwho are certified pay for the assessment pro-
\ncess and for the maintenance of the certifi-
\ncation records within the organization.Spe-
\ncialty boards do not have members in the
\nway that a membership organization does;
\nthey do not serve the functions of member-
\nship organizations, such as advocacy on be-
\nhalf of the specialty or educational services
\nprovided to the professional. Lastly, boards
\nare independent of industry influences and
\nare very careful to maintain a financial mod-
\nel that does not in any way involve potential
\nconflicts of interest.
\nAccountability and Transparency:
\nTwo Pillars of the Health Professions in the
\n21st
\nCentury
\nFigure 1. Model of Physician Responsibility in Relation to Influences on Health.
\n51
\nMedical Ethics, Human Rights and Socio-medical affairs
\nIt is important to understand that spe-
\ncialty board certification is also a voluntary
\nmodel \u2013 it is an indication of professional-
\nism driving a physician\u2019s interest in doing
\nthe work necessary to achieve and maintain
\nthis credential. While it is voluntary, a very
\nlarge majority of physician specialists in the
\nUnited States are board certified, indicating
\nthat the credential is valuable to them and
\nvalued by them. The voluntary model also
\nallows for a higher standard to be set and
\nsustained.
\nFigure 1 identifies an ethical model of phy-
\nsician responsibility in relation to influences
\non health that grew out of work done by
\nRichard Gruen, an Australian Harkness
\nfellow, during his time of study at Harvard
\nwith colleagues there[1]. He identified the
\ndirect areas of physician responsibility to be
\nindividual patient care, access to care and
\ndirect socio-economic influences that af-
\nfect health, such as diet, nutrition, smoking,
\netc. Poverty may fall into this area as well
\nas into the broader influences on health,
\nboth socio-economic and global health is-
\nsues. Gruen and colleagues have identified
\nall of these arenas as legitimate concerns
\nfor the medical profession but have singled
\nout the first three as the specific domain
\nwhere professionals are obligated to focus
\ntheir concern by virtue of the ethical tra-
\nditions of the profession. This is a much
\nbroader concept of medical ethics than that
\nderived from the ancient historical texts of
\nHippocrates, Maimonides and other still
\nimportant core codes to which our profes-
\nsion adheres. Gruen\u2019s work was based on a
\nPhysician Charter developed in collabora-
\ntion among the American College of Phy-
\nsicians Foundation, the American Board
\nof Internal Medicine Foundation and the
\nEuropean Federation of Internal Medicine
\nand published in 2002 simultaneously in
\nLancet [2] and the Annals of Internal Medi-
\ncine [3]. Since then it has been published in
\nnumerous other journals, endorsed by more
\nthan 130 medical organizations throughout
\nthe world and translated into at least 10
\ndifferent languages. This charter took as its
\ncore principle the primacy of patient wel-
\nfare, which is consistent with the ancient
\nand venerable texts of medical history, and
\nit added two additional principles: patient
\nautonomy and social justice, both of which
\nare reflective of the context of the profession
\nand its expanding role in the 21st
\ncentury.
\nDerived from the fundamental principals
\nare 10 commitments, listed in Figure 2.
\nA Commitment to:
\nprofessional competence\u2022
\nhonesty with patients\u2022
\npatient confidentiality\u2022
\nmaintaining appropriate relations with\u2022
\npatients
\nimproving quality of care\u2022
\nimproving access to care\u2022
\na just distribution of finite resources\u2022
\nscientific knowledge\u2022
\nmaintaining trust by managing conflicts\u2022
\nof interest
\nprofessional responsibility\u2022
\nFigure 2. The Physician Charter.
\nIn the United States the charter is widely
\nused in teaching and in the matriculation
\nand graduation ceremonies of medical stu-
\ndents and is often reviewed in discussions
\nof medical ethics. Indeed, it was the subject
\nof research by Campbell and colleagues[4]
\nwhere physicians throughout the United
\nStates, in multiple specialties, were asked
\nwhether they agreed with these 10 commit-
\nments.The researchers found that there was
\nwidespread agreement with the principles
\nespoused, but when physicians were asked
\nwhether they behaved in accordance with
\nthose principles their own self-reports indi-
\ncated a huge gap between the ideal ethical
\nbehavior and the actual behavior.One exam-
\nple concerns the responsibility of physicians
\nto report instances of significantly impaired
\nor incompetent colleagues in which 96% of
\nphysicians responded that they had an ob-
\nligation to report impaired or incompetent
\ncolleagues to relevant authorities, and yet
\nfully 67% (two-thirds) said that within the
\nlast three years they had had direct knowl-
\nedge of an incompetent physician colleague
\nand had not reported that individual to ap-
\npropriate authorities.
\nSimilarly, 77% of physicians said that they
\nshould undergo recertification examina-
\ntions periodically throughout their careers,
\nbut only 33% had done so within the last
\n3 years. This type of evidence has led to in-
\ncreasing public awareness of the need for
\ngreater transparency and greater scrutiny of
\nthe profession. Indeed, even we physicians
\nhave joined the call for greater accountabil-
\nity.
\nIn the United States there are three key
\ntypes of physician organizations. One is
\nmedical societies \u2013 colleges, academies and
\nassociations, many of which are based on
\nspecific specialties and which physicians
\njoin as members and pay dues. These orga-
\nnizations promote education and provide
\ncontinuing professional development, de-
\nvelop evidence-based clinical guidelines in
\ntheir specialty, and often publish medical
\njournals. In many cases they also are advo-
\ncates for specific approaches to payment for
\nthat specialty and other legislative or politi-
\ncal issues that affect their practice and eco-
\nnomic situations.
\nA second group are licensing boards. These
\nboards are run separately by the many states
\nin the U.S., similar to other federated mod-
\nels in Canada and countries that have a
\nprovincial or state-based government in
\naddition to a national government. These
\nlicensing boards are also not-for-profit or-
\nganizations, but are appointed \u2013 usually by
\npolitical forces, primarily a state governor
\nor legislature. Each state\u2019s licensing board
\nissues and regulates the license, so criteria
\nvary from state to state. The license is le-
\ngally required for a physician to practice
\nand is often based on credentials or exams
\nat a very basic level \u2013 and not at a specialty
\nlevel. In order to maintain the license the
\nphysician must be free of any disciplinary
\nactions, must pay a fee every 2-3 years and
\n52
\nMedical Ethics, Human Rights and Socio-medical affairs
\nusually must maintain some kind of records
\ndocumenting that he or she is engaged in
\ncontinuing medical education activities.
\nThe third group are certifying boards \u2013 inde-
\npendent, voluntary, national not-for-profit
\nstandard-setting organizations that develop
\nassessment tools. These tools, including ex-
\naminations, are specific to specialties so a
\nphysician is able to say that he or she is a
\n\u201cboard certified cardiologist\u201d or \u201cboard cer-
\ntified ophthalmologist.\u201d Requirements for
\ncertification are standard for all participants,
\nso \u201cboard certified\u201dmeans the same thing in
\nKansas as it does in California.
\nA recent article in the Journal of the Ameri-
\ncan Medical Association compared the recer-
\ntification processes in the United States,
\nCanada and the United Kingdom and
\nidentified the varying roles of government
\noversight and independent physician over-
\nsight in these three countries[5]. All of the
\ncountries are in active discussions about the
\nneed for certification to be an ongoing and
\nperiodically renewed credential indicating
\nthat the physician is keeping up to date with
\nthe field and, in many cases, also including
\nassessment of communication skills, profes-
\nsionalism and performance in practice.
\nYou may wonder how these standards can
\nwork if not required. My view is that physi-
\ncians are inherently driven by interest in the
\npublic good, and the more the profession
\nitself sets high standards the more reward-
\ning that public interest becomes. Physicians
\nalso tend to be high achievers and inherently
\ncompetitive. When board certification was
\nfirst introduced in the United States a much
\nsmaller percentage of specialists sought it
\nout; as it became increasingly recognized,
\nphysicians who saw their colleagues becom-
\ning certified also wanted to achieve that
\nlevel of recognition by their peers. Because
\nit is independent and evidence-based, the
\nassessment also has credible research be-
\nhind the tools that it uses[6]. Information
\nabout whether a physician is board certified
\nis freely available to the public on the web,
\nwhich responds to a very important need
\nfor greater transparency and availability of
\ninformation to the public. It also creates a
\nmarketplace where external entities, if they
\nso chose,can set a value on physicians meet-
\ning these standards. This could apply to in-
\nsurance companies or to employer require-
\nments. Increasingly, as mentioned, there
\nis a call for greater public input into these
\nstandards and many boards have developed
\nways of doing so ranging from public mem-
\nbers directly on the certifying board or vari-
\nous approaches to public advisory groups.
\nIt remains a question whether this model,
\nwhich has grown up over almost the last
\n80 years in the United States, could work
\nin other countries. We believe the potential
\nis there for at least some aspects of this ap-
\nproach to have relevance elsewhere. Over
\nthe past five years, we have received a grow-
\ning number of requests from a wide range
\nof countries throughout the world to learn
\nmore about our process and to consider
\nadopting parts of the process for their own
\nhealthcare systems. It is also the case that
\nbiomedical science is a universal language,
\nand most physicians base their work and
\npractice on the same body of knowledge.
\nThus, consistent standards are a reason-
\nable thing for people to expect, especially
\nin a world with increasing medical tour-
\nism \u2013 destination medical centers through-
\nout world \u2013 and more widespread travel by
\nmedical professionals themselves.
\nIn conclusion, I believe that professional re-
\nsponsibility combines both identifying and
\nremedying ethical lapses in our profession
\nand also includes raising the bar of compe-
\ntence. Together with public voices this can
\nlead to greater public confidence and to a
\nresponse that gives specialists the measures
\nand tools for quality improvement which
\nwill benefit all of us.
\nReferences
\nGruen RL, et al. Physician citizens \u2013 public1.
\nroles and professional obligations. JAMA.
\n2004; 291: 94-8.
\nHorton R. The doctor\u2019s role in advocacy. Lan-2.
\ncet. 2002; 359: 520-2.
\nSox HC. Medical professionalism in the new3.
\nmillennium: a physician charter. Ann Intern
\nMed. 2002;136(3): 243-6.
\nCampbell EG, et al. Professionalism in medi-4.
\ncine: results of a national survey of physicians.
\nAnn Intern Med. 2007; 147 (11) : 795-802.
\nShaw K, Cassel CK, Black C, Levinson W.5.
\nShared medical regulation in a time of increas-
\ning calls for accountability and transparency:
\ncomparison of recertification in the United
\nStates, Canada and the United Kingdom.
\nJAMA. 2009; 302(18): 2008\u20132014.
\nChoudhry NK, Fletcher RH, Soumerai SB.6.
\nSystematic review: the relationship between
\nclinical experience and quality of health care.
\nAnn Intern Med. 2005; 142: 260-73.
\nChristine K. Cassel, M.D, MACP,
\nPresident of the American Board
\nof Internal Medicine
\n53
\nMedical Ethics, Human Rights and Socio-medical affairs
\nUrban Wiesing
\nThe use of placebo controls is one of the key
\nissues in contemporary ethics of biomedical
\nresearch. Ever since critics in 1994 claimed
\nthat certain clinical trials would violate
\nparagraph 29 of what was at that time the
\ncurrent version of the Declaration of Hel-
\nsinki, this paragraph has remained the focus
\nof the debate on this subject [1]. In 2002,the
\nWMA added a highly controversial Note of
\nClarification to this paragraph (which ap-
\npeared as a footnote in the document). In
\n2008, the Note was modified and incorpo-
\nrated in the main body of the text in \u00a732 of
\nthe version adopted that year. This remains
\nthe current version of the Declaration of
\nHelsinki. It requires that a new interven-
\ntion must be tested against the best current
\nproven intervention, but provides for ex-
\nceptions when two conditions are fulfilled:
\nwhen there are \u201ccompelling and scientifical-
\nly sound methodological reasons\u201d and pro-
\nvided that \u201cpatients who receive placebo or
\nno treatment will not be subject to any risk
\nof serious or irreversible harm\u201d. However,
\ndifferences and contradictions between this
\nand other ethical or legal regulations1
\n(such
\n1
\nOur aim in this article is to analyse the proposed
\nnorms for placebo controls of different ethical and
\nas those by CIOMS, the Council of Eu-
\nrope, ICH etc.) remain, and there persists
\ndisagreement by some critics who ask for a
\ntotal ban of placebo control if a proven in-
\ntervention exists. This is a complicated and
\nunfortunate situation creating uncertainty
\namong researchers, research sponsors and
\nmembers of ethics committees. In an effort
\nto move closer to a resolution of this situ-
\nation, we will analyse three aspects of the
\nproblem: the scientific and methodological
\naspects, the problem of weighing individual
\nrisks and burden to social benefits, and fi-
\nnally the question of research in resource
\npoor settings.
\nArguments from science and the
\nmethodology of clinical trials
\nThe opposite extreme positions in this
\ncontext would be that 1. placebo is always
\nrequired for methodological reasons to
\nlegal guidance documents for biomedical research
\nand to relate them to the relevant arguments in the
\nbioethical debate. We do not distinguish such guid-
\nance documents according to their legally binding
\ncharacter for researchers, whether they mainly pro-
\nvide an ethical orientation or are indeed represent-
\ning legal requirements.
\nprovide comparative evidence for the effec-
\ntiveness of a new intervention 2
\nor 2. there
\nis never a methodological necessity to use
\nplacebo instead of an active comparator [3].
\nThe Declaration of Helsinki already covers
\na middle ground between these positions,
\nas do some other commentators or guide-
\nlines, contending that there are in certain
\ncircumstances \u201ccompelling and scientifically
\nsound methodological reasons\u201d for placebo
\ncontrolled trials (PCTs) when there already
\nexist proven treatments. What could be
\nsuch reasons? The related arguments reach
\nfrom very detailed assumptions about the
\nplacebo effect to general statements on sci-
\nentific progress and what is of real interest
\nfor medicine.
\nThe main controversial issues between the
\nopposed positions are:
\n1. Whether only placebo controls can
\nprovide a reliable reference point in a
\nclinical trial, or whether they cannot,
\nbecause the placebo effect itself is sub-
\nject to a high variability3
\n.
\n2. Whether active controlled trials (ACTs)
\noften lack the ability to distinguish an
\neffective from a non-effective treatment
\n(\u201cassay sensitivity\u201d)4
\nin many conditions
\n(e.g. depression), or whether ACTs can
\navoid this and other methodological
\nproblems including statistical signifi-
\ncance.5
\n3. Whether the important relevant knowl-
\nedge to be sought from a trial is whether
\nan experimental intervention is superior
\nto placebo6
\n, or, alternately, whether it is
\nsuperior or at least non-inferior to an
\nexisting treatment option.7
\nThe main problem in this context is to pro-
\nvide convincing empirical evidence for the
\ndifferent claims on the placebo effect and
\n2
\nThis position sometimes has been attributed to \u2013
\nand contested by – the FDA, e.g. by [2], 255.
\n3
\n[4], 197.
\n4
\n[5], 456.
\n5
\n[6], 199.
\n6
\n[7], 467.
\n7
\n[6], 246.
\nPlacebo Controls in Clinical Trials
\nHans-J\u00f6erg Ehni
\n54
\nMedical Ethics, Human Rights and Socio-medical affairs
\nits variability, as new research results on the
\nunderlying neurobiological mechanisms are
\navailable. These show how the placebo ef-
\nfect could be successfully analysed in par-
\ntial aspects (such as expectations of patients
\nor physician, and the behavioural context
\nof treatment8
\n). This will also contribute
\nto knowledge on the variability and the
\nmethodological necessity of placebo con-
\ntrols in different clinical areas (especially
\npsychiatry). Such evidence must be further
\ncollected, analyzed, and criticized in a com-
\nprehensive overview. Researchers should
\nprovide convincing empirical evidence for
\ntheir claims of a methodological necessity
\nof placebo controls. This also applies to evi-
\ndence concerning the need for an additional
\ntreatment option that is equally superior to
\nplacebo.
\nIf there are indeed\u201ccompelling and scientifi-
\ncally sound methodological reasons\u201dagainst
\nan ACT, an important precondition is met,
\nbut a PCT still might not be justifiable con-
\nsidering the risk for the participants in the
\ncontrol group. This leads to the question of
\nan acceptable risk of harm or burden.
\nWeighing individual risks and
\nburden against social benefits
\nSupporters of placebo controls in the case
\nwhere proven treatment exists are defend-
\ning the acceptability of possible risks and
\nburden to trial participants in light of the
\npotential social benefits, and more specifi-
\ncally with arguments that these risks and
\nburden are coherent with others which are
\ngenerally considered to be acceptable, pro-
\nvided that the trial participants give their
\nvalid informed consent.9
\nMinimal risks and
\nburden in research would have to be consid-
\nered in the same way as minimal risk and
\nburden generated by patients who decide
\nregularly to forego treatment for conditions
\nsuch as common cold or headache.10
\nEven
\n8
\nSee e.g. [8].
\n9
\n[5], 456.
\n10
\n[5], 467.
\nhigher risks and burden might be justifiable
\nas they could be compared with risks and
\nburden that society considers to be accept-
\nable in high risk jobs, such as fire fighting.
\nIn other words, they would be acceptable
\nif the social benefit is high enough.11
\nSuch
\nrisks and burden could often be reduced by
\nmodifications in the trial design, such as
\nearly escape options, add-on trials etc.12
\nThe opponents of placebo controls in the
\ncase where proven treatment exists are re-
\nferring to two general ethical principles:
\nthe priority of the individual over the inter-
\nests of science and society, and the duty of
\ncare of the physician\u2014even in the role as a
\nresearcher\u2014to provide the best proven cur-
\nrent intervention.13
\nBoth principles would
\nexclude withholding or withdrawing prov-
\nen treatment in a clinical trial in favour of a
\nplacebo if there is no doubt that the proven
\nintervention is actually better than placebo.
\nFurther,justifying the use of placebo in such
\na situation by invoking the argument of in-
\nformed consent would not be sufficient, as
\ninformed consent very often turns out to be
\nflawed by poor understanding by the subject
\nof scientific concepts (including the concept
\nof placebo), and also by a subject\u2019s poten-
\ntial lack of understanding of the objec-
\ntives of research (the so-called therapeutic
\nmisconception).14
\nIn addition, even allow-
\ning minor risks and burden would not be
\npermissible, as this would lead to arbitrary
\ndecisions by Research Ethics Committees
\nabout which kind of risk and burden are ac-
\nceptable in different cases. 15
\nClearly both lines of arguments are based
\non different methods of ethics. While the
\nproponents of placebo controls mainly for-
\nmulate consequentialist arguments, which
\nallow the weighing of different total out-
\ncomes in terms of social utility, their op-
\nponents\u2019 claims rest on the absolute and
\n11
\n[9], 484.
\n12
\n[7], 465.
\n13
\n[2], 253.
\n14
\n[4], 195.
\n15
\n[1], 398.
\ninviolable value of individuals and the strict
\nduties of physician researchers. However, it
\nis widely accepted from both perspectives
\nthat some risks in research are ethically
\njustifiable. A total ban of placebo controls
\nif a proven effective intervention exists is
\nnot convincing because the underlying ar-
\ngument that contends that physicians are
\nnot allowed to expose research participants
\nto avoidable risks is not, in itself, convinc-
\ning. Comparable risks are widely accepted
\nin medical practise (such as foregoing treat-
\nment as a free and informed decision of the
\npatient) and other research contexts. In a
\nphase I and II trial a researcher exposes a
\nhealthy volunteer or a patient unavoidably
\nto certain risks because nothing or little is
\nknown about the new treatment. This is
\nethically accepted; otherwise any phase I or
\nphase II trials (and consequently clinical re-
\nsearch as a whole) would have to be banned.
\nThe same is true for research with a verum
\nto test e.g. QT-prolongation. Therefore
\nthe modified central question becomes: To
\nwhat extent are physicians allowed to expose
\nresearch participants to risks by a placebo
\ncontrol or by a control less effective than the
\nbest proven intervention?
\nA well-justified, coherent position on gen-
\nerally accepted risks in medical practise
\nand biomedical research is required to an-
\nswer this question. A list with such risks to
\ncompare the risks in certain trials could also
\nhelp Research Ethics Committees to avoid
\narbitrariness. Another open question, how-
\never, is whether such risks also depend on
\nthe context of a trial.
\nResearch in resource poor settings
\nParticularly important examples for such
\ncontexts are found in research carried out
\nin resource poor settings. This is a separate
\nproblem closely but not exclusively related
\nto the problem of placebo control: Is the ab-
\nsence of a best proven current intervention
\nin resource poor settings a convincing argu-
\nment to allow researchers to expose research
\nparticipants to higher risks than they would
\n55
\nMedical Ethics, Human Rights and Socio-medical affairs
\nundergo in wealthy regions where the con-
\ntrol group would receive the proven inter-
\nvention? Does this lead to an ethical double
\nstandard in research? And if such a study
\nwould be acceptable, what other conditions
\ndo apply? Particularly, who should benefit
\nand what should that benefit be?
\nAgain, consequentialist and deontological
\npositions are conflicting. The most out-
\nspoken consequentialists endorse placebo
\ncontrols in the case of existing proven treat-
\nment in resource poor settings, even if the
\naim of the research is not the reasonable
\navailability of an alternative treatment op-
\ntion adapted to the local context. They are
\nclaiming that the participants have at least
\na 50:50 chance to benefit from a treatment
\nthat they otherwise would not receive, and
\nthat this clearly leaves them better off than
\na situation in which the trial would not take
\nplace at all or where it would be conducted
\noutside of that host country.16
\nHowever, this seems to be a minority po-
\nsition, at least considering the relevant
\ninternational guidelines, which generally
\nstipulate that such research has to meet the
\nhealth priorities of the host country and it
\nis only legitimate if the objective is to make
\nreasonably available a treatment option
\nadapted to that local context.17
\nParagraph 17
\nof the Helsinki Declaration should be noted
\nin this context: \u201cMedical research involving
\na disadvantaged or vulnerable population or
\ncommunity is only justified if the research
\nis responsive to the health needs and pri-
\norities of this population or community and
\nif there is a reasonable likelihood that this
\npopulation or community stands to benefit
\nfrom the results of the research.\u201d
\nThe general problem therefore is to define
\nthe conditions for placebo use in multina-
\ntional research in a systematic and com-
\nprehensive way, while preventing unethi-
\n16
\n[10], 207.
\n17
\nSee e.g. [11] http:\/\/www.cioms.ch\/frame_guide-
\nlines_nov_2002.htm [accessed 01.03.2010]
\ncal research, in particular exploitation, and
\ncreating incentives for necessary research.
\nSuch conditions have been suggested by the
\nCIOMS-guidelines and in a \u201cbenchmarks
\nfor research in developing countries\u201d-ap-
\nproach by Emanuel et al [12]. While the
\ndispute is still not settled, these attempts
\nprovide good examples how such an agree-
\nment could be reached, because they search
\nfor widely accepted principles and for co-
\nherence with widely shared moral intui-
\ntions, and they a consensus based on fair
\nprocedures.
\nOutline of a possible consensus
\nClearly, the fundamentally different ethi-
\ncal positions and approaches described
\nabove will complicate the formulation of
\na consensus on the ethical acceptability of
\nplacebo controls in clinical trials. However,
\nboth positions must accept that resolution
\nof the fundamental conflict between conse-
\nquentialist and deontological philosophies
\nis unlikely to occur; neither side can rea-
\nsonably be expected to abandon its ethical
\ntheory. Thus, the solution to the question at
\nhand must be found another way. Instead
\nof insisting on their general approach, both
\nsides should try to find rules on a middle
\nlevel, below their mutually exclusive first
\nprinciples This includes the recognition
\nof principles provided they are widely ac-
\ncepted, such as the priority of the individ-
\nual over the interests of science and society.
\nSuch principles must then be applied in co-
\nherence with equally widely accepted, more
\nspecific ethical convictions that are already
\nexpressed in ethical and legal regulations,
\nsuch as that it is generally accepted to ex-
\npose some participants of clinical research
\nto some risks and burden for the benefit of
\nothers in some cases \u2013 provided informed
\nconsent is given. Empirical assumptions
\nmade by either position should be based on
\nsubstantial evidence,and the need for future
\nresearch to provide such evidence should be
\nclearly identified. Finally, where disputes on
\nvalues cannot be settled easily, particularly
\nin international research cooperations, they
\nshould be discussed and decided in a fair
\nprocess involving all parties concerned, such
\nas foreseen in the benchmarks by Emanuel
\net al. [12]
\nIn sum, a total ban on placebo controls
\nwhere proven treatment exists is not a
\nconvincing option, in particular because it
\nwould be inconsistent with widely shared
\nmoral convictions about generally accept-
\nable risks in research. Precisely what these
\nrisks are should be further elaborated and
\ndiscussed in detail. Unrestricted use of pla-
\ncebo controls would also not be acceptable,
\nbecause research participants would be ex-
\nposed to risks that would be unacceptable
\nanywhere else in clinical research. Consid-
\nering the arguments both positions in the
\nplacebo debate put forward, formulating a
\ncompromise remains a difficult endeavour.
\nNevertheless, we believe that it is achievable
\nif approached within the general framework
\ndescribed in this article.
\nReferences
\n1. Rothman KJ, Michels KB. The continuing un-
\nethical use of placebo controls. N Engl J Med.
\n1994; 331:394-8.
\n2. Freedman B, Glass KC, Weijer C. Placebo or-
\nthodoxy in clinical research. II: Ethical, legal,
\nand regulatory myths. J Law Med Ethics. 1996;
\n24:252-9.
\n3. Howick J. Questioning the methodologic supe-
\nriority of \u2018placebo\u2019 over \u2018active\u2019 controlled trials.
\nAm J Bioeth. 2009:34-48.
\n4. Michels KB, Rothman KJ. Update on unethical
\nuse of placebos in randomised trials. Bioethics.
\n2003; 17:188-204.
\n5. Temple R, Ellenberg SS. Placebo-controlled tri-
\nals and active-control trials in the evaluation of
\nnew treatments. Part 1: ethical and scientific is-
\nsues. Ann Intern Med. 2000; 133:455-63.
\n6. Freedman B, Weijer C, Glass KC. Placebo or-
\nthodoxy in clinical research. I: Empirical and
\nmethodological myths. J Law Med Ethics. 1996;
\n24:243-51.
\n7. Ellenberg SS,Temple R. Placebo-controlled tri-
\nals and active-control trials in the evaluation of
\nnew treatments. Part 2: practical issues and spe-
\ncific cases. Ann Intern Med. 2000; 133:464-70.
\n8. Finniss DG, Kaptchuk TJ, Miller F, Benedetti
\nF. Biological, clinical, and ethical advances of
\nplacebo effects. Lancet. 2010; 375:686-695.
\n56
\nClimate change
\nColin David Butler
\nIntroduction
\nIn her speech to the United Nations Con-
\nference on the Human Environment, in
\nStockholm in 1972, the British economist
\nBarbara Ward mentioned \u201cthe newly recog-
\nnised fact that our total natural system \u2026
\ncould be irretrievably upset by man\u2019s activi-
\nties\u201d[1].Ward goes on to discuss the impor-
\ntance of reducing global inequality, the need
\nto rethink the meaning of economic growth,
\nand the vulnerability of the oceans. She did
\nnot mention climate change, but I don\u2019t
\nthink she would be surprised to learn, 37
\nyears later, that human emissions of green-
\nhouse gases are resulting in rapid ocean
\nacidification and are likely to soon damage
\nthe marine food web [2, 3].
\nThis paper arises from a talk I gave about
\nclimate change, education, health, limits
\nand ethics, to a working group of the World
\nMedical Association in 2009, in Copen-
\nhagen, quite near Stockholm, and not far
\nconceptually from the themes mentioned
\nthere by Ward. There is however an enor-
\nmous difference between now and then.
\nIn 1972 few doctors seemed aware or con-
\ncerned about the global environmental di-
\nmension to these matters[4], though the
\nmedical profession by then did have a long
\nhistory of working to promote health in low
\nincome settings [5], exemplified by Albert
\nSchweitzer, who divided his time between
\nFrance and the hospital he had established
\nin Lambarene, French Equatorial Africa,
\nnow known as Gabon[6].
\nToday, the issue of climate change has
\nmoved to almost head the global health
\nagenda [7-10] . The literature on climate
\nchange and health is now enormous, and
\ncontinues to grow rapidly. Health and cli-
\nmate change was the cover story of Nature
\nin 2005 [11]. At least two special journal
\nissues have recently been dedicated to this
\nproblem [12, 13], while perhaps the long-
\nest single paper ever published in the Lancet
\nconcerned climate change and health [9].
\nThe World Medical Association has also
\nrecently recognised and contributed to this
\nrapidly growing awareness, by releasing the
\nDelhi Declaration on Health and Climate
\nChange [14].
\nHealth effects of climate change: primary,
\nsecondary and tertiary
\nThe list of health conditions associated
\nwith climate change can seem bewilder-
\ning; from the fairly obvious to the obscure,
\nsuch as gastroenteritis caused by Vibrio Pa-
\nrahaemolyticus [15]. One way to categorise
\nthese diverse manifestations is by group-
\ning the most obvious effects as \u201cprimary\u201d
\nand less obvious effects as \u201csecondary\u201d[16].
\nPrimary effects include heat waves, heat
\nstress, and the physical impacts from ex-
\ntreme weather effects such as storms and
\nfires. The latter group includes ecologically
\nmediated vector borne diseases, such as
\nmalaria, and other communicable diseases
\nwhose epidemiology will be altered by cli-
\nmatic and associated ecological variation,
\nfrom plague [17] to hantaviruses [18].
\nMany more details of these effects are
\navailable elsewhere [16].
\nThere is one more level of effect that must
\nbe considered,\u201ctertiary\u201d[16,19].Ultimate-
\nly, these effects are the most threatening to
\nhealth. Yet, among the vast literature con-
\ncerning climate change very little discusses
\nthe likely impact upon global health from
\nthe bleak social and physical conditions
\nto which much of the world appears to
\nnow be heading. These consequences can
\nbe conceptualized as \u201ctertiary\u201d. It perhaps
\ntakes courage rather than imagination to
\ncontemplate a nuclear-armed world in
\nwhich sea level has risen by a metre, and
\nwhere the grain yield in South Asia has
\ndeclined by 18 to 22% [20], even though
\nseveral hundred million additional South
\nAsians are then predicted to be alive. Yet
\nThe Climate Crisis, Global Health,
\nand the Medical Response
\n9. Wendler D, Miller FG. Assessing research risks
\nsystematically: the net risks test. J Med Ethics.
\n2007; 33:481-6.
\n10. Wertheimer A. Exploitation in Clinical Re-
\nsearch. In: Ezekiel Emanuel et al., ed. The Ox-
\nford Textbook of Clinical Research Ethics. Ox-
\nford University Press; 2008:201-210.
\n11. Council for International Organizations of
\nMedical Sciences (CIOMS). International Eth-
\nical Guidelines for Biomedical Research Involv-
\ning uman Subjects. 2002.
\n12. Emanuel EJ, Wendler D, Killen J, Grady C.
\nWhat makes clinical research in developing
\ncountries ethical? The benchmarks of ethical re-
\nsearch. J Infect Dis. 2004; 189:930-7.
\nProf. Dr. med. Dr. phil. Urban Wiesing,
\nDirector of the Department for the
\nEthics and History of Medicine, Medical
\nSchool, University of Tuebingen
\ne-mail: urban.wiesing@uni-tuebingen.de
\nDr. phil. Hans-Joerg Ehni, Institut f\u00fcr
\nEthik und Geschichte der Medizin
\ne-mail: hans-joerg.ehni@uni-tuebingen.de
\n57
\nClimate change
\nsuch conditions, interwoven with many
\nother difficulties, may occur within 70
\nyears.Though the Intergovernmental Panel
\non Climate Change forecast a maximum of
\n60 cm sea level rise by 2100, this is now
\nviewed as very optimistic. More recent es-
\ntimates set the upper limit of sea level rise
\nby 2100 at two metres [21]. At least one
\nmeter of sea level rise by 2100 seems all too
\nplausible, not least because of the recently
\ndocumented, satellite-observed loss of ice
\nfrom Eastern Antarctica, which until re-
\ncently had been thought to be accumulat-
\ning ice [22-24].
\nThe Future
\nBeyond the health literature, frank discus-
\nsion of the likely conditions in which hu-
\nmanity will live in 2100 is also rare, and
\nwhere it exists, it is generally biased towards
\nthe optimistic [25]. Official socio-economic
\nforecasts and scenarios are excessively hope-
\nful,perhaps because humans cannot bear too
\nmuch pain, or perhaps because authorities
\nare concerned that bleak forecasts will be-
\ncome self fulfilling. However, in addition, a
\ngood deal of woolly thinking, \u201cgroup think\u201d
\nand frank denial is occurring, evidenced,
\nfor example, by the way the global financial
\ncrisis caught governments and their elite
\neconomic advisers by surprise. This discon-
\nnect between prediction and reality likely
\nextends to the size of oil supplies [26], and
\nto other critical limits to growth [27, 28].
\nIrrespective of the reasons for this optimism
\n[25] the health consequences of future glo-
\nbal climate change are likely to be severely
\nunderestimated, without consideration of
\ntertiary effects. Such effects are likely to ex-
\nceed the other impacts, even if combined,
\nperhaps by one or even two orders of mag-
\nnitude. Apprehension of these tertiary ef-
\nfects, though poorly articulated, appears to
\nbe a rational explanation not only for many
\nconcerns expressed by youth about the fu-
\nture [29], but also for the level of concern
\nabout climate change in both the health and
\nwider literature [28, 30, 31].
\nLinking the global climate and global
\nhealth inequality crises
\nThat humanity appears to be nearing an abyss
\nmight surprise some readers. However, an-
\nother immense problem has co-existed with
\nour increasing prosperity,since at least World
\nWar II [32] .This is the problem of appar-
\nently intractable Third World poverty, and of
\nthe resultant health gap between privileged
\nand poor populations. This gap takes many
\nforms.Most simply,it can be measured as life
\nexpectancy [33] ,or as differences in the bur-
\nden of disease [34]. It is also obvious in dif-
\nferent rates of childhood stunting,with other
\nmarkers of undernutrition and consequent
\ncognitive impairment [35, 36]. It can also be
\nexpressed less precisely, such as by contem-
\nplating the global organ trade [37], daily life
\nat one of Uganda\u2019s teaching hospitals [38] or
\nthe medical brain drain [39].
\nIn fact,the parallel problems of global health
\ninequality and of our trajectory towards
\ndangerous climate change can each be con-
\nsidered as manifestations of an intelligent
\nspecies, a clothes-wearing primate, who is
\nnot quite as smart as s\/he thinks. History is
\nreplete with civilisations that have collapsed
\n[40, 41]. Even before humans had devel-
\noped cities violent conflict among humans
\nhas been documented, from the end of the
\nPleistocene [42, 43].
\nOur species is territorial,inequitable,remark-
\nable but (in parts) also remarkably resistant
\nto science [44, 45]. Humans are ingenious
\nand co-operative [46]. Although the future
\nlooks very troubling, hope is not yet lost. If
\nhumanity is to traverse this future it will do
\nso in part because of the contribution of doc-
\ntors, together with many other actors and
\nnew ways of social organisation [47].
\nThe role of doctors in fostering a \u201cmuddle
\nthrough\u201d world
\nIt is easy for futurists to imagine solutions
\nto our problems. A new energy technology,
\nalready invented, might be about to revolu-
\ntionise global transport. Genetic engineer-
\ning might soon allow plants to thrive in
\ndroughts, or to survive weeks inundated in
\nsaline water [48].Unfortunately,even a suite
\nof technological breakthroughs will not be
\nenough.Replacing and upgrading global in-
\nfrastructure, such as buildings, power plants
\nand sea walls cannot be done overnight, or
\neven in a single decade. Many behavioural
\nchanges will also be needed, such as a lesser
\ndependency on private cars [49], and a re-
\nduction in the 150 trillion calories of food
\ncurrently wasted annually in the US [50].
\nIt is perhaps easier for doctors to contem-
\nplate the likelihood of famines and wide-
\nspread population dislocation that appear
\ninevitable, without concerted climate miti-
\ngation. However, provided widespread war
\ncan be avoided [51], and provided civiliza-
\ntion collectively undertakes the social and
\ntechnological re-organisation which is re-
\nquired to slow climate change then a \u201cmud-
\ndle through\u201d world may yet emerge.
\nAll doctors have,at times,been involved with,
\nor have had to personally convey bad news
\nto their patients. Neither the most expensive
\nmedication, nor the most sophisticated diag-
\nnostic test can always defer death. However,
\nthe impermanence of life is not a reason to
\nturn against it. Similarly, doctors can play a
\nrole in reassuring society that a good life is
\nstill possible, even if we and our fellow crea-
\ntures need to live better within limits.
\nConclusion
\nThere is much to be done. There are many
\nreasons to be anxious about the capacity of
\ncivilization to withstand the coming chal-
\nlenges, aggravated by climate change. Many
\nreaders will understand that the ninety years
\nwhich remain in this century are not long.
\nAnd, of course, selecting 2100 as a criti-
\ncal year is completely arbitrary. It is likely
\nthat tertiary health consequences of climate
\nchange will unfold well before 2100. Indeed,
\nthe future may show that phenomena such
\nas Cyclone Nargis [52], the overflow of the
\n58
\nClimate change
\nKhosi River in Bihar [9], and the conflict in
\nDarfur [53] were not isolated extreme events,
\nbut early evidence of such tertiary events.
\nDoctors also understand the value of preven-
\ntion. Few of us have ever seen a case of small-
\npox. Preventive medicine, the least glamorous
\nsphere of medicine, is the most powerful in
\ntermsofdeathsavertedandyearsoflifegained.
\nTackling the climate crisis is preventive medi-
\ncine.At the same time,doctors should also act
\nto reduce the crisis in global health inequali-
\nties. In particular, doctors should add their
\nmoral voice to resist any strategy of triage,
\nthe abandoning of large populations to their
\napparent fate. While it seems inevitable that
\nlarge scale humanitarian crises, dwarfing that
\nof the 2004 tsunami,will occur because of cli-
\nmate change, it is not inevitable that billions
\nmust die as a result. But in order to make this
\ntask possible doctors must join with the grow-
\ning coalition of youth,activists,visionaries and
\neco-billionaires who think similarly.
\nReferences
\n1. Ward B. Speech for Stockholm. In: Strong M, editor.
\nWho Speaks for Earth? New York: WW Norton and
\nCompany; 1973. p. 19-31.
\n2. McNeil BI, Matear RJ. Southern Ocean acidification:
\nA tipping point at 450-ppm atmospheric CO2. Pro-
\nceedings of the National Academy of Science (USA].
\n200;105:18860-4.
\n3. Orr JC, Fabry VJ, Aumont O, Bopp L, Doney SC, Fee-
\nly RA, et al. Anthropogenic ocean acidification over the
\ntwenty-first century and its impact on calcifying organ-
\nisms. Nature. 2005;437:681-6.
\n4. Boyden S. The environment and human health. The
\nMedical Journal of Australia. 1972;116:1229-34.
\n5. King M,editor.Medical Care in Developing Countries.A
\nPrimer on the Medicine of Poverty and a Symposium from
\nMakerere.Nairobi: Oxford University Press; 1966.
\n6. Schweitzer A. The scientists must speak up. Science.
\n1954;120:11A.
\n7. McMichael AJ, Neira M, Heymann DL.World Health
\nAssembly 2008: climate change and health.The Lancet.
\n2008;371:1895-6.
\n8. Lim V, Stubbs JW, Nahar N, Amarasena N, Chaudry
\nZU, Weng SCK, et al. Politicians must heed health ef-
\nfects of climate change.The Lancet. 2009;374:973.
\n9. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy
\nR, et al. Managing the health effects of climate change.
\nThe Lancet. 2009;373:1693\u2013733.
\n10. Haines A, McMichael AJ, Smith KR, Roberts I,
\nWoodcock J, Markandya A, et al. Public health effects
\nof strategies to reduce greenhouse-gas emissions: over-
\nview and implications for policy makers. The Lancet.
\n2009 (in press];374.
\n11. Patz JA, Campbell-Lendrum D, Holloway T, Foley JA.
\nImpact of regional climate change on human health.
\nNature. 2005;438:310-7.
\n12. Frumkin H, McMichael A, Hess JJ. Climate Change
\nand the health of the public. American Journal of Pre-
\nventive Medicine. 2008;35(5]:401-2.
\n13. Neira M. Foreword. Global Health Action. 2009 (in
\npress];special volume.
\n14. World Medical Association. Declaration of Del-
\nhi on health and climate change. 2009 [updated
\n2009; cited]; Available from: https:\/\/www.wma.net\/
\nen\/30publications\/10policies\/c5\/index.html.
\n15. McLaughlin JB, DePaola A, Bopp CA, Martinek KA,
\nNapolilli NP, Allison CG, et al. Outbreak of Vibrio
\nparahaemolyticus Gastroenteritis Associated with
\nAlaskan Oysters. New England Journal of Medicine.
\n2005;353:1463-9.
\n16. Butler CD, Harley DO. The climate crisis, sustainabil-
\nity, and the medical response. Post Graduate Medical
\nJournal. (in press].
\n17. Stenseth NC, Stenseth NC, Samia NI, Viljugrein H,
\nKausrud KL, Begon M, et al. Plague dynamics are
\ndriven by climate variation.Proceedings of the National
\nAcademy of Science (USA]. 2006;103:13110-5.
\n18. Klempa B. Hantaviruses and climate change. Clinical
\nMicrobiology and Infection. 2009;15(6]:518-23.
\n19. Butler CD, Corval\u00e1n CF, Koren HS. Human health,
\nwell-being and global ecological scenarios. Ecosystems.
\n2005;8(2]:153-62.
\n20. Tubiello FN, Fischer G. Reducing climate change
\nimpacts on agriculture: Global and regional effects of
\nmitigation, 2000\u20132080. Technological Forecasting &
\nSocial Change. 2007;74:1030\u201356.
\n21. Pfeffer WT, Harper JT, O\u2019Neel S. Kinematic Con-
\nstraints on Glacier Contributions to 21st-Century Sea-
\nLevel Rise. Science. 2008;321:1340-3.
\n22. Chen JL, Wilson CR, Blankenship D, Tapley BD. Ac-
\ncelerated Antarctic ice loss from satellite gravity mea-
\nsurements. Nature Geoscience. 2009.
\n23. Steig EJ, Schneider DP, Rutherford SD, Mann ME,
\nComiso JC, Shindell DT. Warming of the Antarctic
\nice-sheet surface since the 1957 International Geo-
\nphysical Year. Nature. 2009;457:459-62.
\n24. Allison I, Bindoff NL, Bindschadler RA, Cox PM, No-
\nblet Nd, England MH, et al.The Copenhagen Diagno-
\nsis. Updating the World on the Latest Climate Science.
\nSydney, Australia,: The University of New South Wales
\nClimate Change Research Centre (CCRC]; 2009 Con-
\ntract No.: Document Number|.
\n25. Butler CD. Peering into the fog: ecologic change, hu-
\nman affairs and the future (commentary]. EcoHealth.
\n2005;2:17-21.
\n26. Kerr R. Splitting the Difference Between Oil Pessi-
\nmists and Optimists. Science. 2009;326:1048.
\n27. Hall CAS,JohnW.Day J.Revisiting the limits to growth
\nafter peak oil. American Scientist. 2009;97:230-7.
\n28. Butler CD. Limits to growth, the climate crisis and the
\nmedical response. Finnish Medical Journal. 2010 (in
\npress].
\n29. Eckersley R. What\u2019s wrong with the official future? In:
\nHassan G, editor. After Blair: Politics After the New
\nLabour Decade. London: Wishart; 2006. p. 172-84.
\n30. Smith JB, Schneider SH, Oppenheimer M, Yohe GW,
\nHare W, Mastrandrea MD, et al. Assessing dangerous
\nclimate change through an update of the Intergovern-
\nmental Panel on Climate Change (IPCC] \u201creasons for
\nconcern\u201d. Proceedings of the National Academy of Sci-
\nence (USA]. 2009;106:4133-7.
\n31. Lenton TM, Held H, Kriegler E, Hall JW, Lucht W,
\nRahmstorf S, et al.Tipping elements in the Earth\u2019s cli-
\nmate system. Proceedings of the National Academy of
\nScience USA. 2008;105(6]:1783-5.
\n32. Butler CD. Inequality, global change and the sustain-
\nability of civilisation. Global Change and Human
\nHealth. 2000;1(2]:156-72.
\n33. McMichael AJ, McKee M, Shkolnikov V, Valkonen T.
\nGlobaltrendsinlifeexpectancy:convergence,divergence
\n– or local setbacks? The Lancet. 2004;363:1155-9.
\n34. Ezzati M, Lopez AD, Rodgers A, Hoorn SV, Mur-
\nray CJL, Group CRAC. Selected major risk factors
\nand global and regional burden of disease. The Lancet.
\n2002;360:1347-60.
\n35. Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onis
\nMd, Ezzati M, et al. Maternal and child undernutri-
\ntion: global and regional exposures and health conse-
\nquences.The Lancet. 2008;371:243\u201360.
\n36. Dillingham R,Guerrant RL.Childhood stunting: mea-
\nsuring and stemming the staggering costs of inadequate
\nwater and sanitation.The Lancet. 2004;363:94-5.
\n37. Scheper-Hughes N. Keeping an eye on the global traf-
\nfic in human organs. Lancet. 2003;361:1645-8.
\n38. Kavalier F. Uganda: death is always just around the cor-
\nner. Lancet. 1998;352:141\u20132.
\n39. Pond B, McPake B.The health migration crisis: the role
\nof four Organisation for Economic Cooperation and
\nDevelopment countries. The Lancet. 2006;367:1448\u2013
\n55.
\n40. Diamond J. Collapse: How Societies Choose to Fail or
\nSucceed. London: Allen Lane; 2005.
\n41. Tainter JA. The Collapse of Complex Societies. Cam-
\nbridge: Cambridge University Press; 1988.
\n42. Bowles S. Did Warfare Among Ancestral Hunter-
\nGatherers Affect the Evolution of Human Social Be-
\nhaviors? Science. 2009;324:1293-8.
\n43. Close AE. Plus \u00c7a Change.The Pleistocene-Holocene
\nTransition in Northeast Africa.In: Strauss LG,Eriksen
\nBV, Erlandson JM, Yesner DR, editors. Humans at the
\nEnd of the Ice Age. New York and London: Plenum
\nPress.
\n44. Mulder MB, Bowles S, Hertz T, Bell A, Beise J, Clark
\nG,et al.Intergenerational Wealth Transmission and the
\nDynamics of Inequality in Small-Scale Societies. Sci-
\nence. 2009;326:682-8.
\n45. Bloom P, Weisberg DS. Childhood Origins of Adult
\nResistance to Science. Science. 2007;316:985-6.
\n46. Ohtsuki H, Iwasa Y, Nowak MA. Indirect reciprocity
\nprovides only a narrow margin of efficiency for costly
\npunishment. Nature. 2009;457:79-82.
\n47. Walker B, Barrett S, Polasky S, Galaz V, Folke C, Eng-
\nstr\u00f6m G, et al. Looming global-scale failures and miss-
\ning institutions. Science. 2009;325:1345-6.
\n48. Inman M. Hot, Flat, Crowded\u2014And Preparing for the
\nWorst. Science. 2009;326:662-3.
\n49. Woodcock J, Edwards P, Tonne C, Armstrong BG,
\nAshiru O, Banister D, et al. Public health benefits of
\nstrategies to reduce greenhouse-gas emissions: urban
\nland transport.The Lancet. 2009 374.
\n50. Hall KD, Guo J, Dore M, Chow CC. The progressive
\nincrease of food waste in America and its environmen-
\ntal impact. PLoS ONE. 2009;4(11]:e7940.
\n51. Barnett J,Adger N.Climate change and conflict.Politi-
\ncal Geography. 2007;26 639-55.
\n52. Stone R. One year after a devastating cyclone, a bitter
\nharvest. Science. 2009;324:715.
\n53. Sachs J. Poverty and environmental stress fuel Darfur
\ncrisis. Nature. 2007;449:14-5.
\nColin David Butler, National Centre for
\nEpidemiology and Population Health,
\nAustralian National University,
\nCanberra Australia
\n59
\nMedical Ethics, Human Rights and Socio-medical affairs
\nWhen was the last time a patient ap-
\nproached you,asking what to do if they have
\nside effects from their medicine or if they
\nare even taking it correctly? These questions
\nmay not pop up in your practice every day
\nwhen seeing your patients, but they should
\nand we need to encourage it.
\nKnowing all the medications a patient takes
\ncan help prevent errors, so it\u2019s absolutely
\ncritical that patients feel empowered to talk
\nfreely with Climate change us about their
\nmedication questions. Furthermore, open
\ncommunication is necessary, particularly
\nto help the more than 89 million Ameri-
\ncan adults who have limited health literacy
\nskills.
\nA new online resource can help. It\u2019s a one-
\npage tip sheet to help facilitate patients\u2019
\nconversations with you about the medica-
\ntions they are taking, including vitamins
\nand drugs bought without a prescription,
\nand the questions they have or should be
\nasking. Print it off and keep it in your of-
\nfice or waiting room, and share it with the
\npatients in your practice.
\nIt\u2019s all a matter of keeping patients safe.
\nWhile we\u2019re inundated with this thought
\nevery second of every day, this particular
\ntopic received plenty of clout on the na-
\ntional stage. The entire health care com-
\nmunity, including the AMA and hospitals
\nand health care systems across the country,
\ntook the time to help mark the importance
\nof patient safety during year 2010. National
\nPatient Safety Awareness Week and the
\ntheme \u201cLet\u2019s talk: Healthy conversations for
\nsafer health care.\u201d
\nKicked off March 7 by the National Pa-
\ntient Safety Foundation and being observed
\nthrough March 13, the week centered
\naround health care organizations promot-
\ning patient safety and highlighting the work
\nthey have done and are doing to improve
\npatient safety, health care quality and pa-
\ntient education. The AMA established the
\nfoundation in 1996 and has since donated
\nmore than $7 million to help fulfill its mis-
\nsion. As part of the week, the AMA also fo-
\ncused on medication safety with its annual
\n\u201cKnow what\u2019s in your medicine cabinet\u201d
\nreminder and the new patient tip sheet I
\nmentioned earlier.
\nRemind your patients that medical safety
\nstarts at home, and that they are the ones
\nwho play a key role in keeping their families
\nsafe by making sure prescription drugs are
\nup to date and out of children\u2019s reach. Tell
\nthem to utilize the AMA Web site for guid-
\nance on proper disposal of expired or unused
\nprescription medications when cleaning out
\nthe medicine cabinet. And check out other
\npatient safety resources and programs from
\nthe AMA that help strengthen the patient-
\nphysician relationship and improve care by
\npreventing infections, as well as communi-
\ncation tools on medication reconciliation
\nand the AMA Physician Consortium for
\nPerformance Improvement.
\nLet\u2019s make a point to emphasize patient
\nsafety and communication with our patients
\nevery day throughout the year. It\u2019s an on-
\ngoing effort together to promote excellence
\nin patient care. That\u2019s our job as physicians,
\nand that\u2019s what our patients deserve.
\nJ. James Rohack, MD, President of the AMA
\nPeople are literally dying for the toilet.Join the
\nWorld\u2019s Longest Toilet Queue (WLTQ) and
\ntake a stand against this shocking injustice.
\n22 March was World Water Day, a global
\nobservance of our planet\u2019s most precious
\nresource. It is also a crucial moment in the
\nfight against the global sanitation and wa-
\nter crisis that\u2019s killing 4000 children every
\nsingle day. Just one month later, politicians
\nfrom across the globe will gather in Wash-
\nington DC. to discuss what they need to do
\nto fulfil some of the most basic rights of the
\nworld\u2019s citizens \u2013 access to a safe toilet and
\nclean water.
\nTheWorld\u2019sLongestToiletQueue(WLTQ)
\nmay sound like a joke but it is a mass mo-
\nbilisation event and Guinness World Re-
\ncord attempt bringing together thousands
\nof campaigners from across the world to
\ndemand real change at the meeting.
\nIn 2009, the Standing Committee of Euro-
\npean Doctors (CPME) accepted the British
\nMedical Association\u2019s invitation to endorse
\nEnd Water Poverty, the international cam-
\npaign to end the global crisis in water and
\nsanitation. In 2010, the BMA is asking all
\nCPME member organisations to urge their
\nmembers to join the WLTQ. Many Euro-
\npean countries have already confirmed that
\nthey will be holding queues – among them,
\nBelgium, France, Italy, the Netherlands,
\nDenmark, Finland, Norway, Spain, Sweden,
\nand Turkey.
\nOur task is to make sure that as many people
\nas possible join the queues and show world
\nleaders that action is needed now.
\nhttp:\/\/www.worldtoiletqueue.org\/eng\/
\nMartin Carroll, Deputy Head
\nInternational Department
\nBritish Medical Association
\nLondon, UK
\nTel: +44 (0)207 383 6231
\nEnd Water Poverty
\nKeeping the Lines of Communication Open \u2013
\nand Patient Safety First
\n60
\nMultidrug-resistant Tuberculosis
\nIntroduction
\nThis year, we commemorate the 100th an-
\nniversary of Robert Koch\u2019s death. Although
\ngreat diagnostic and therapeutic progress
\nhas been made since his discovery of the tu-
\nbercle bacillus in 1882, tuberculosis (TB) is
\nstill one of the most widespread infectious
\ndiseases and one of the leading causes of
\ndeath worldwide.The situation was declared
\nan emergency by the WHO in 1993 [1],but
\nhas become even worse since in several parts
\nof the world.
\nThe aim of this article is to give an overview
\nof the present epidemiological situation,of the
\nmain causes of this threatening development \u2013
\nin particular of drug resistance \u2013 and of strate-
\ngies urgently needed to solve the problems.
\nPresent epidemiological situation
\nAccording to the updated 2009 report of
\nthe World Health Organisation (WHO)
\non \u2018Global Tuberculosis Control\u2019,there were
\nin 2008 an estimated 9.4 (8.9 – 9.9) million
\nnew cases of TB worldwide [2]. This figure
\nrepresents an increase from the 9.27 million
\nin 2007. However, since the world popula-
\ntion has also grown,the number of cases per
\ncapita shows that there is a small decrease in
\nincidence of TB from 142\/100,000 in 2004
\nto 139\/100,000 in 2008. Figure 1 shows
\nthe regional incidence of TB, while Table 1
\ncontains statistics on the 22 \u2018high-burden\u2019
\ncountries which comprise 85 % of all new
\nTB cases. In absolute numbers, China and
\nIndia are the leading countries due to their
\nlarge populations. South Africa and other
\nsub-Saharan African countries are foremost
\nin incidences.
\nIn almost all industrialized countries the in-
\ncidences are constantly declining, but still far
\nfrom elimination of TB,defined as fewer than
\none case per 1 million population per year [2].
\nAn estimated 1.3 (1.1 – 1.7) million HIV-
\nnegative people died of TB in 2008, an ad-
\nditional 0.52 (0.45 – 0.62) million died of
\nMultidrug-resistant Tuberculosis:
\nProblems and Responses
\nR. Loddenkemper S. Castell B. Hauer
\nFigure 1. Estimated new TB cases (all forms) per 100000 population 2008 [2]
\n61
\nMultidrug-resistant Tuberculosis
\nTB among HIV-positive people (classified
\nas HIV death in the International Statisti-
\ncal Classification of Diseases) [2].
\nMortality rates are highest in countries with
\na high prevalence of TB\/HIV co-infections,
\nup to 265\/100,000. However, they reach al-
\nmost 20\/100,000 in some countries without
\nor with few cases with TB\/HIV co-infec-
\ntion, e.g. 18\/100,000 in the Russian Federa-
\ntion (Table 1).
\nCauses for the worldwide
\nincrease in TB
\nIn the 1970s, TB was thought to have been
\nnearly conquered. The two main reasons
\nwhy the opposite has occurred are the ap-
\npearance of HIV in the middle of the 1980s
\nand the large increase of drug-resistant TB
\ncases which became apparent in the 1990s.
\nBoth together were responsible for the dra-
\nmatic situation in New York and other US
\ncities in the 1990s [3].
\nAdditional factors are the demographic
\ndevelopment with population growth and
\nolder age structures, migration, civil con-
\nflicts, increasing poverty in some parts of
\nthe world and the lack or decreasing qual-
\nity of medical facilities [4]. TB is mainly a
\nsocial disease!
\nIncreasing drug resistance
\nIn early 2008, the WHO reported an un-
\nexpectedly large increase in drug-resistant
\ntuberculosis [5].An estimated half a million
\n(~ 5 %) of all new TB cases were infected
\nwith multidrug-resistant strains (multi-
\ndrug-resistant tuberculosis, MDR-TB), i.e.,
\na strain resistant to (at least) isoniazid (H)
\nand rifampicin (R), the two most powerful
\nanti-tuberculosis drugs currently available.
\nFigure 2 shows the estimated percentage of
\nMDR among new and re-treatment TB cases
\nin 2007 with rates of more than 20 % in the
\ncountries of the former Soviet Union, more
\nthan 8 % in China, and 3 – 5 % in India [5].
\nFor 2008, WHO estimated similar numbers
\nwith almost 50 % of MDR-TB cases world-
\nwide occuring in China and India,and causing
\nabout 150,000 deaths.The highest proportions
\nTable 1. 27 MDR high-burden countries 2008 [2, 6 and http:\/\/www.who.int\/tb\/country\/data\/
\ndownload\/en\/index.html (25.03.2010) ]
\nCountry
\nIncidence
\nof TB (all
\ntypes) per
\n100 000
\npopulation
\nMortality
\nper 100 000
\npopulation
\n(excluding
\nHIV)
\nHIV positive
\nTB patients
\nwith known
\nHIV status
\nin %
\nMDR
\namong new
\nTB cases
\nin %
\nSouth Africa 960 39 60 1.8
\nMyanmar 400 57 100 4.2
\nDemocratic Republic of the
\nCongo
\n380 77 18 1.8
\nEthiopia 370 64 24 1.6
\nNigeria 300 63 27 1.8
\nPhillippines 280 52 0 4.0
\nPakistan 230 39 0 2.9
\nBangladesh 220 50 no data 2.2
\nTajikistan 200 44 1 16.5
\nViet Nam 200 34 20 2.7
\nIndonesia 190 27 29 2.0
\nKazakhstan 180 24 1 14.2
\nIndia 170 23 14 2.3
\nRepublic of Moldova 170 4,6 5 19.4
\nKyrgyzstan 160 25 no data 12.5
\nUzbekistan 130 27 1 14.2
\nAzerbaijan 110 21 no data 22.3
\nGeorgia 110 13 1 6.8
\nRussian Federation 110 15 3 15.8
\nUkraine 100 15 8 16.0
\nChina 97 12 3 5.7
\nArmenia 73 12 3 9.4
\nLithuania 71 9,3 no data 9.0
\nLatvia 50 5,5 8 12.1
\nBelarus 43 5,2 3 12.5
\nBulgaria 43 5,8 0 12.5
\nEstonia 34 1,9 11 15.4
\n62
\nMultidrug-resistant Tuberculosis
\nof MDR-TB ever documented in new cases
\nwere reported for some regions in the Russian
\nFederation (22.8 – 28.3 %).
\nThe WHO report also contains data on ex-
\ntensively drug-resistant tuberculosis (XDR-
\nTB), which was first described in 2006 [7].
\nBy definition,XDR-TB is MDR-TB that is
\nadditionally resistant to at least one of the
\nfluorochinolones and to one of the three in-
\njectable second-line anti-tuberculosis drugs,
\namikacin, kanamycin, and capreomycin.
\nPrecise data on XDR-TB are not available,
\nbecause findings regarding resistance to sec-
\nond-line drugs are not routinely reported.
\nXDR is thought to account for about 5 %
\nof MDR cases, but up to 20 % have been
\nobserved in some regions [8], more than 58
\ncountries up to now have found XDR-TB
\ncases in their population (Figure 3). How-
\never, it can be assumed that XDR-TB is
\nalready present in many other poor coun-
\ntries where the capacities for testing the
\nsensitivity\/resistance to anti-tuberculosis
\ndrugs are not available [9]. A few cases of
\nextreme drug resistance (XXDR), defined
\nas resistance to almost all drugs [10], and
\neven total drug resistance (TDR), defined
\nas resistance to all currently available drugs,
\nhave been reported, too [11].
\nReasons for the development
\nof resistance
\nWhen streptomycin was introduced in 1944
\nas the first antibiotic for the treatment of
\nTB, the majority of those treated improved
\ndramatically.There were, however, many re-
\ncurrences of tuberculosis thereafter, because
\nof the selection of streptomycin-resistant
\nbacterial strains by monotherapy [12]. The
\nmore widespread tuberculosis is in the pa-
\ntient\u2019s body and the greater the number of
\nbacteria present, the more likely it is that
\nsome of the pathogenic organisms will con-
\ntain spontaneous mutations inducing drug
\nresistance [13].
\nThe need for combination therapy against
\ntuberculosis was recognised after the in-
\ntroduction of para-aminosalicylic acid
\nin 1944, and of isoniazid, as the rate of
\nmutations inducing resistance to multiple
\ndrugs is very low [14]. Furthermore, com-
\nbination therapy can better reach bacteria
\nwith different levels of metabolic activity
\nat multiple sites in the body. The treat-
\nment must be continued long enough to
\nkill \u2018dormant persisters\u2019 as well. The next
\ndrugs to be introduced were pyrazinamide
\nand cycloserine in 1952, capreomycin in
\n1960, ethambutol in 1961, and rifampi-
\ncin in 1966. The introduction of rifampi-
\ncin and pyrazinamide enabled a marked
\nFigure 2. Proportion of MDR among new and re-treated TB cases 2007 [WHO 2009 modified
\nfrom Paul Nunn, Dubrovnik]
\nFigure 3. Distribution of countries and territories reporting at least one case of XDR-TB as of
\nJanuary 2010 [6]
\n63
\nMultidrug-resistant Tuberculosis
\nshortening of the duration of therapy,
\nfrom 18 \u2013 24 to 6 months (\u2018short-course
\nchemotherapy\u2019), provided that the pa-
\ntient\u2019s tuberculosis is fully drug-sensitive.
\nThe recurrence rate after such treatment
\nis less than 5 % in patients who take all
\ntheir medications correctly every day, as
\nprescribed [14].
\nFaulty prescriptions, treatment compli-
\nance problems, inadequate intestinal re-
\nsorption of drugs, and poor drug quality
\nare factors that can promote the devel-
\nopment of resistance [5, 15]. Multidrug
\nresistance was first recognised as a ma-
\njor problem in 1992, when 12 % of the
\ntuberculosis patients in New York City
\nwere found to have MDR tuberculosis
\n[3]. MDR tuberculosis spread around the
\nworld because of the lack or inadequacy
\nof tuberculosis control programmes, in-
\nsufficient resources, and inadequate pro-
\ntective measures against infection, as well
\nas delayed diagnosis of tuberculosis, all
\nmostly man-made and thus to a large ex-
\ntent avoidable [16, 17].
\nThe following are special risk factors for
\nMDR\/XDR tuberculosis [18]:
\nPrior treatment with anti-tuberculosis\u2022
\ndrugs
\nImmigration from an area where MDR\u2022
\ntuberculosis is highly prevalent (or con-
\ntact with MDR tuberculosis patients)
\nImprisonment [19]\u2022
\nPossibly, HIV infection [20]\u2022
\nPrisons require special attention, particular-
\nly in the Newly Independent States of the
\nformer Soviet Union. Here, the high rates
\nof MDR-TB \u2013 sometimes accounting for
\nmore than 30 % of overall incidence \u2013 and
\nthe rising prevalence of HIV are causes for
\nconcern. Prisoners have been found to have
\nhigher rates of MDR-TB in Western, in-
\ndustrialised countries as well [19].
\nIn some regions of the world, the so-called
\nBeijing genotype of Mycobacterium (M.) tu-
\nberculosis is associated with a high resistance
\nrate and, in particular, with a high MDR
\nrate (the \u2018W\u2019 strain) [21]. These strains may
\nbe more virulent, and\/or more likely to mu-
\ntate, and\/or able to spread more easily be-
\ncause of poorer tuberculosis control in the
\nareas to which they are endemic.
\nResistant tuberculosis and
\nco-infection with HIV
\nIt is estimated that, in 2008, 15 % of the
\n9.4 million new TB cases were co-infect-
\ned with HIV, with a high mortality rate
\n[2]. In some countries of sub-Saharan
\nAfrica, the TB\/HIV co-infection rate
\nhas risen dramatically, up to 50 – 80 % [2,
\n22]. HIV-positive persons carrying a la-
\ntent M. tuberculosis infection are at mark-
\nedly higher risk of developing tuberculo-
\nsis [22]. Tuberculosis is one of the main
\ncauses of death in HIV-infected persons
\n[22]. It is unclear whether HIV infection
\nis a risk for drug-resistant or multidrug-
\nresistant tuberculosis itself [5, 20]. Higher
\nTable 2. New WHO Classification of anti-tuberculosis drugs [30]
\nGroup Description Substance\/medication International
\nabbreviation
\n1 Oral first-line antitubercu-
\nlosis drugs
\nIsoniazid
\nRifampicin
\nEthambutol
\nPyrazinamide
\nRifabutin
\nH
\nR
\nE
\nZ
\nRfb
\n2 Injectable anti-tuberculosis
\ndrugs
\nKanamycin
\nAmikacin
\nCapreomycin
\nStreptomycin
\nKm
\nAmk
\nCm
\nS
\n3 Fluoroquinolones Levofloxacin
\nMoxifloxacin
\nOfloxacin
\nLfx
\nMfx
\nOfx
\n4 Oral second-line anti-
\ntuberculosis drugs
\nEthionamide
\nProtionamide
\nCycloserine
\nTerizidone
\nP-aminosalicylic acid
\nEto
\nPto
\nCs
\nTrd
\nPAS
\n5 Anti-tuberculosis drugs
\nwith unclear effectiveness
\nand\/or an unclear role in the
\ntreatment of MDR-TB (not
\nrecomended by the WHO
\nfor routine use)
\nClofazimine
\nLinezolid
\nAmoxicillin\/clavulanic acid
\nThiocetazone
\nClarithromycin
\nImipenem
\nCfz
\nLzd
\nAmx\/Clv
\nThz
\nClr
\nIpm
\n64
\nMultidrug-resistant Tuberculosis
\nresistance rates might be explicable as a
\nresult of higher susceptibility to resistant
\nbacterial strains, which are often less viru-
\nlent than non-resistant strains, as well as
\nof the higher precentage of new infections
\n[20]. Other factors that can promote the
\ndevelopment of resistance in HIV\/TB
\nco-infection include malabsorption, drug
\nintolerance, drug interactions, and non-
\ncompliance among IV drug abusers [20].
\nHospitalization also increases the risk of
\nexposure [18].
\nIn 2006, a catastrophic development was
\nseen in South Africa, when XDR tuber-
\nculosis was transmitted from TB\/HIV pa-
\ntients to members of a village community
\nwith a high prevalence of HIV [23]. The
\naffected patients were hospitalised, where-
\nupon a large number of patient and hospi-
\ntal employees died within a few weeks. The
\nmain causes for the persistent transmission
\nof XDR-TB in South Africa are, aside from
\nthe high prevalence of HIV, delays in di-
\nagnosis and treatment and the inadequate
\navailability of modern diagnostic proce-
\ndures, second-line drugs, and infection con-
\ntrol.
\nAnother current cause for concern is the
\nrising rate of HIV infection in Eastern
\nEurope, particularly in the Russian Fed-
\neration and the Ukraine [24]. Prisons in
\nthese countries are high-risk areas for dual
\ninfections because of an increasing rate of
\nIV drug abuse,combined with a high preva-
\nlence of MDR-TB [25].
\nThe diagnosis of drug-
\nresistant tuberculosis
\nDrug resistance should be suspected if
\none or more of the risk factors mentioned
\nabove are present. Definite confirmation is
\nonly possible with the aid of standardised,
\nquality-controlled bacteriological sensitivity
\ntesting. Because directed therapy is possible
\nonly on the basis of drug susceptibility test-
\ning (DST), bacteriological proof of tuber-
\nculosis should always be attempted, even
\nin types of pulmonary or extrapulmonary
\ntuberculosis, where relatively few bacteria
\nare present.
\nThe gold standard for DST are culture
\ntechniques; such testing previously took
\neight to twelve weeks, but its duration has
\nbeen shortened to two to three weeks with
\nthe aid of liquid cultures and radiomet-
\nric methods [26]. More rapid molecular
\nbiological methods for the detection of
\ngenetic mutations that induce resistance to
\nvarious drugs (rifampicin, isoniazid) are an
\noutstanding recent advance [26, 27]. Mi-
\ncroscopic observation of drug susceptibil-
\nity (MODS) is one of several promising
\nnew techniques.
\nResistance testing for second-line drugs is
\nhighly demanding and requires the exper-
\ntise of specialised laboratories [15]. More-
\nover, in-vitro results often do not accu-
\nrately reflect drug efficacy. A rapid test for
\ntuberculosis that could be performed easily
\ndirectly on the sputum sample, with which
\nthe pathogens could be simultaneously de-
\ntected and comprehensively tested for resis-
\ntance, would certainly be a milestone in the
\nfight against tuberculosis [28, 29].
\nThere is an urgent need for more lab facili-
\nties, which are the basis for the successful
\ntreatment of MDR- and XDR-TB. Drug
\nsusceptibility testing is performed with the
\npurpose of providing crucial information
\nfor the treatment of the individual patient.
\nSecond-line drugs should be given only on
\nthe basis of appropriate drug susceptibility
\ntests [16, 30].
\nThe treatment of drug-
\nresistant tuberculosis
\nTuberculosis must be treated with a com-
\nbination of antibiotics [30]. The currently
\nrecommended standard chemotherapy
\nof non-resistant tuberculosis consists of
\nthe initial administration of four first-line
\ndrugs (isoniazid, rifampicin, pyrazinamide,
\nand ethambutol) in combination for two
\nmonths,followed by a four-month stabilisa-
\ntion phase with a combination of isoniazid
\nand rifampicin [30].
\nSensitivity testing should be performed as
\nrapidly as possible, particularly when drug
\nresistance is suspected, so that the develop-
\nment of further resistance will not be pro-
\nmoted by non-directed therapy [30, 31]. A
\nsingle drug should never be added to an ex-
\nisting regimen, as this creates the danger of
\nmonotherapy [15, 30].
\nNo randomised trials or evidence-based
\ndata are available on the treatment of resis-
\ntant tuberculosis [28, 32]. The WHO rec-
\nommends that patients who were previously
\ntreated for TB should be treated with at
\nleast three drugs that they have not received
\nbefore. When MDR is suspected, at least
\nfour drugs that are still potentially effective
\nshould be given [2, 30]. As a rule, complex
\ncases of resistant TB should be treated by
\nphysicians with special experience in this
\narea.
\nThe new WHO classification of first- and
\nsecond-line anti-tuberculosis drugs is
\nshown in Table 2. The fluorochinolones are
\namong the most important types of second-
\nline drugs [30].
\nThe treatment takes up to two years and is
\noften poorly tolerated.It therefore requires a
\nhigh degree of patient cooperation, and the
\ndefault rate is higher than in non-resistant
\ntuberculosis (up to 30 %) [28, 32].Thus, ex-
\ntensive patient education is needed and the
\npatient should take the medications under
\nprofessional supervision, if possible. The
\npossibility of transmission necessitates ad-
\nequate infection control measures. Patients
\nwho are unwilling or unable to comply with
\nsuch measures may need to be involuntarily
\nquarantined; such decisions are to be taken
\non a case-by-case basis, according to the le-
\ngal regulations [33].
\nThe success rate of treatment is lower for
\nMDR-TB than for less resistant or non-
\n65
\nMultidrug-resistant Tuberculosis
\nresistant tuberculosis, and it is lower still
\nfor XDR-TB [34, 35], although, under
\noptimal conditions, better treatment out-
\ncomes have been observed [36]. In HIV
\nco-infected patients it is much worse,
\nwhere a one-year mortality of 71 % for
\nMDR- and 83 % for XDR-TB patients
\nhas been reported [37].
\nThe relevant percentage of patients whose
\ntherapeutic outcome is unknown, or whose
\ntreatment has not yet been completed, can
\nsubstantially diminish the success rate, de-
\npending on how this rate is defined [34,35].
\nFurthermore, the therapeutic outcome may
\nbe difficult to categorise: for example, when
\nthe treatment has been changed or inter-
\nrupted for a long time [38]. Nonetheless,
\neffective surveillance of DST findings and
\ntherapeutic outcomes is very important if
\nthe quality of tuberculosis control is to be
\naccurately judged.
\nImproved nutrition and improvement of
\nthe patient\u2019s social environment are among
\nthe most important interventions that can
\nsupplement drug treatment for TB [15, 32].
\nSurgical treatment, adjunctive to drug ther-
\napy, may be indicated in cases of MDR- or
\nXDR-TB, especially if not enough medica-
\ntions are available, and also in cases of non-
\nconversion of sputum cultures, persistent
\ncavities, and\/or mainly localised disease, as
\nlong as there are no functional contraindi-
\ncations to surgery [32, 39, 40, 41]. Good
\nresults have been described, but often with
\nquite high complication rates [32, 34, 40,
\n42]. There have been no controlled trials on
\nthis subject; it seems likely that the operabil-
\nity criteria that were applied led to selection
\nof prognostically more favourable cases.
\nThe cost of treatment in cases with com-
\nplex drug resistance is several times higher
\nthan that of drug-sensitive tuberculosis [43,
\n44]. Moreover, the indirect costs, includ-
\ning those of prolonged inability to work,
\nare often substantial. When these costs are
\ntaken into account, the cost of some cases
\nof MDR-TB in the USA is found to be in
\nexcess of one million dollars [45]. The cost
\nof treating XDR-TB is even higher.
\nStrategies against drug resistance
\nIn 2006, WHO announced an ambitious
\nglobal plan to lower the rate of new cases
\nof TB and the death rate from tuberculo-
\nsis to half of their 1990 levels by the year
\n2015 [46]. A further goal is the elimina-
\ntion of the disease by the year 2050, i.e.,
\nlowering the incidence to less than one
\nnew case of tuberculosis per one million
\npopulation per year. The overall financing
\nplan envisions 56 billion dollars of financial
\nsupport for the period 2006 \u2013 2015 [47].
\nMore than one billion dollars are budgeted
\nfor the successful treatment of MDR- and
\nXDR-TB cases in the year 2006 alone, in
\naddition to the necessary overall expendi-
\ntures for global tuberculosis control, which
\namounts to 5.3 billion dollars. A basic pre-
\nrequisite for the prevention of drug-resis-
\ntant tuberculosis is adherence to the stated
\nprinciples of treatment, in the setting of an
\neffective national tuberculosis control pro-
\ngramme, whenever possible [10, 16]. The
\nDOTS strategy (\u2018Directly Observed Treat-
\nment Short Course\u2019) is recommended for
\nimplementation [46]; in recognition of the
\nproblem of resistance, the DOTS strategy
\nhas been extended to the so-called \u2018DOTS-
\nplus strategy\u2019,and to other action plans that
\nbuild upon it [43, 48, 49].The implementa-
\ntion of these plans is difficult, however, not
\njust because of inadequate financial means,
\nbut often also because the necessary infra-
\nstructure is lacking, e.g. adequately trained
\npersonnel.
\nThe Green Light Committee established
\nby the WHO provides technical support
\nto poorer countries and negotiates reduced
\nprices for quality-controlled second-line
\ndrugs. A functioning national tuberculosis
\ncontrol programme is a prerequisite [50, 51].
\nIn regions of the world where MDR tuber-
\nculosis is highly prevalent, it is recommend-
\ned to replace standard treatment regimens
\nfor non-responders to therapy by individu-
\nalised regimens based on (rapid) resistance
\ntesting [28, 30].
\nResearch also needs to be substantially in-
\ntensified in this area [10, 52]. Alongside
\nbetter diagnostic techniques for tuberculo-
\nsis, including techniques for the determina-
\ntion of drug resistance, there is an urgent
\nneed for the development (or further de-
\nvelopment) and testing of highly effective
\nanti-tuberculosis drugs. Over the long term,
\nthere are high hopes that effective vaccines
\ncan be developed through the improvement,
\nsupplementation, or replacement of BCG
\n(Bacille Calmette-Gu\u00e9rin), a vaccine based
\non an attenuated strain of M. bovis [53].
\nThe \u2018Global Stop TB Partnership\u2019, founded
\nin 2000 and now with more than 700 pri-
\nvate and governmental partners, serves to
\nmerge common interests and capabilities.
\nIt receives major financial support from the
\nGlobal Fund to Fight AIDS, Tuberculosis
\nand Malaria, as well as other organisations.
\nTogether with the WHO tuberculosis sec-
\ntion, it has recently published a revised ver-
\nsion of the \u2018International Standards of Tu-
\nberculosis Care\u2019 [54].
\nAll of these approaches need to be continuous-
\nly maintained and vigorously supported. Even
\nin low-prevalence countries,in which there are
\nadequate high-quality laboratory services and
\nall second-line drugs available, success rates
\nin the treatment of MDR- and XDR-TB re-
\nmain unsatisfactory. It follows that the wors-
\nening resistance situation together with the
\nHIV epidemic all over the world can only be
\ncombated and alleviated through a common
\neffort. The political will of the industrialised
\ncountries and their assumption of responsibil-
\nity for health policy, which were expressed in
\nthe \u2018Berlin Declaration\u2019by a WHO European
\nMinisterial Forum organised by the German
\ngovernment and held in Berlin in 2007 [55],
\nmust now be practically implemented through
\nsupport for research on the national and inter-
\nnational levels,and through adequate financial
\ncontributions.
\n66
\nMultidrug-resistant Tuberculosis
\nConclusions
\nAlthough the incidence of TB in industria-
\nlised countries is now declining, the world
\nas a whole faces a threat of catastrophic di-
\nmensions that will also affect industrialised
\nnations. The main reason, aside from TB\/
\nHIV co-infection,is the increase of resistant
\nTB strains. The situation is already serious
\nbecause of the spread of multidrug-resistant
\nTB, i.e.,TB that is resistant to the two most
\nimportant anti-tuberculosis drugs, and is
\nbeing further aggravated by resistance to
\nsecond-line drugs as well.
\nAt present, there are an estimated half a
\nmillion cases of MDR-TB worldwide, and
\nso-called extensively resistant TB (XDR-
\nTB), with additional resistance to defined
\nsecond-line drugs, is now prevalent in more
\nthan 58 countries.
\nAn accurate assessment of the situation is
\nhampered by a widespread lack of labora-
\ntory capacity and\/or proper surveillance.
\nThe problem is mainly due to inappropri-
\nate treatment, which may have many causes,
\nbut is theoretically avoidable. Aside from
\nprogrammatic weaknesses, a lack of diag-
\nnostic and therapeutic tools causes difficul-
\nties in many countries.
\nOnly rapid and internationally concerted ac-
\ntion, combined with intensified research ef-
\nforts and the support of the affected nations,
\nwill be able to prevent the development of a
\nsituation that will no longer be manageable
\neven with 21st
\ncentury technology.
\nWe thank the German Ministry of Health
\nfor support.
\nReferences
\nWHO declares tuberculosis a global emergency.1.
\nSoz Praventivmed. 1993;38:251-2.
\nWorld Health Organization: Global tuberculosis2.
\ncontrol: a short update to the 2009 report. WHO,
\nGeneva, Switzerland, WHO\/HTM\/TB\/2009.426.
\nFrieden TR, Sterling T, Pablos-Mendez A, Kilburn3.
\nJO, Cauthen GM, Dooley SW. The emergence of
\ndrug-resistant tuberculosis in New York City. N
\nEngl J Med. 1993;3:521-6.
\nLoddenkemper R, Hauer B. Drug-resistant tuber-4.
\nculosis: a worldwide epidemic poses a new chal-
\nlenge. Dtsch Arztebl Int. 2010;107:10-9.
\nWorld Health Organization:Anti-tuberculosis drug5.
\nresistance in the world: Report No. 4, 2008. WHO,
\nGeneva, Switzerland, WHO\/HTM\/TB\/2008.394.
\nWorld Health Organization: Multidrug and ex-6.
\ntensively drug-resistant TB (M\/XDR-TB). 2010
\nGlobal report on surveillance and response. WHO\/
\nHTM\/TB\/2010.3.
\nCenters for Disease Control and Prevention (CDC).7.
\nEmergence of Mycobacterium tuberculosis with ex-
\ntensive resistance to second-line drugs \u2013 worldwide,
\n2000-2004. MMWR Morbidity Mortal Wkly Rep.
\n2006;55:301-5.
\nPunga VV, Jakubowiak WM, Danilova ID, et al.8.
\nPrevalence of extensively drug-resistant tuberculosis
\nin Vladimir and Orel regions, Russia. Int J Tuberc
\nLung Dis. 2009;13:1309-12.
\nCohen T, Colijn C, Wright A, Zignol M, Pym A,9.
\nMurray M. Challenges in estimating the total bur-
\nden of drug-resistant tuberculosis. Am J Respir Crit
\nCare Med. 2008;177:1302-6.
\nMigliori GB, Loddenkemper R, Blasi F, Raviglione10.
\nMC: 125 years after Robert Koch\u2019s discovery of the
\ntubercle bacillus. Is \u2018science\u2019 enough to tackle the
\nepidemic? Eur Respir J. 2007;29:423-7.
\nVelayati AA, Masjedi MR, Farnia P, et al. Emer-11.
\ngence of new forms of totally drug-resistant tuber-
\nculosis bacilli. Chest 2009;136:420-5.
\nMitchison DA. Chemotherapy of tuberculosis: a12.
\nbacteriologist\u2019s viewpoint. BMJ 1965;1:1333-40.
\nVareldzis BP,Grosset J,de Kantor,et al.Drug-resis-13.
\ntant tuberculosis, laboratory issues: WHO recom-
\nmendations.Tuberc Lung Dis. 1994;75:1-7.
\nFox W, Ellard GA, Mitchison DA. Studies on the14.
\ntreatment of tuberculosis undertaken by the Brit-
\nish Medical Research Council Tuberculosis Units,
\n1946-1986, with relevant subsequent publications.
\nInt J Tuberc Lung Dis. 1999;3:231-79.
\nWorld Health Organization: Guidelines for the15.
\nprogrammatic management of drug-resistant tuber-
\nculosis. Emergency update 2008. WHO, Geneva,
\nSwitzerland, WHO\/HTM\/TB\/2008.402.
\nLoddenkemper R, Sagebiel D, Brendel A. Strate-16.
\ngies against multidrug-resistant tuberculosis. Eur
\nRespir J. 2002;20(Suppl 36):66-77.
\nDavies PDO. The world wide increase in tubercu-17.
\nlosis: how demographic change, HIV infection and
\nincreasing numbers in poverty are increasing tuber-
\nculosis. Ann Med. 2003;35:235-43.
\nFaustini A, Hall AJ, Perucci CA. Risk factors for18.
\nmultidrug resistant tuberculosis in Europe: a sys-
\ntematic review.Thorax 2006;61:158-63.
\nAerts A, Hauer B, Wanlin M, et al.: Tuberculosis19.
\nand tuberculosis control in European prisons. Int J
\nTuberc Lung Dis. 2006;11:1213-23.
\nFrench CE, Glynn JR, Kruijshaar ME, Ditah IC,20.
\nDelpech V, Abubakar I. The association between
\nHIV and antituberculosis drug resistance. Eur Re-
\nspir J. 2008;32:718-25.
\nGlynn JR, Kremer K, Borgdorff MW, Rodriguez21.
\nMP, van Soolingen D. Beijing\/W genotype My-
\ncobacterium tuberculosis and drug resistance:
\nEuropean concerted action on new generation ge-
\nnetic markers and techniques for the epidemiolo-
\ngy and control of tuberculosis. Emerg Infect Dis.
\n2006;12:736-43.
\nNunn P, Reid A, De Cock KM. Tuberculosis and22.
\nHIV infection: the global setting. J Infect Dis.
\n2007;196:5-14.
\nGandhi NR, Moll A, Sturm AW, et al.: Extensive-23.
\nly drug-resistant tuberculosis as a cause of death in
\npatients co-infected with tuberculosis and HIV in a
\nrural area of South Africa. Lancet 2006;368:1575-
\n80.
\nScholten JN, de Vlas SJ, Zaleskis R. Under-report-24.
\ning of HIV infection among cohorts of TB patients
\nin the WHO European Region, 2003-2004. Int J
\nTuberc Lung Dis. 2008;12:85-91.
\nSchwalbe N,Harrington P.HIV and tuberculosis in25.
\nthe former Soviet Union. Lancet 2002;360:19-20.
\nRichter E, R\u00fcsch-Gerdes S, Hillemann D. Drug-26.
\nsusceptibility testing in TB: current status and fu-
\nture prospects. Expert Rev Resp Med. 2009;3:497-
\n510.
\nPai M, O\u2019Brien R. New diagnostics for latent27.
\nand active tuberculosis: state of the art and fu-
\nture prospects. Semin Respir Crit Care Med.
\n2008;29:560-8.
\nChiang C-Y, Yew WW. Multidrug-resistant and28.
\nextensively drug-resistant tuberculosis. Int J Tuberc
\nLung Dis. 2009;13:304-11.
\nRaviglione MC, Smith IM. XDR tuberculosis \u201329.
\nimplications for global public health.N Engl J Med.
\n2007;356:656-9.
\nWorld Health Organization.Treatment of tubercu-30.
\nlosis: guidelines (4th ed.). WHO, Geneva, Switzer-
\nland. WHO\/HTM\/TB\/2009.420.
\nMak A, Thomas A, del Granado M, Zaleskis R,31.
\nMouzafavora N,Menzies D.Influence of multidrug
\nresistance on tuberculosis treatment outcomes with
\nstandardized regimens.Am J Respir Crit Care Med.
\n2008;178:306-12.
\nCaminero JA. Treatment of multidrug-resistant tu-32.
\nberculosis: evidence and controversies. Int J Tuberc
\nLung Dis. 2006;10:829-37.
\nBlaas SH, M\u00fctterlein R, Weig J, et al.: Extensively33.
\ndrug resistant tuberculosis in a high income coun-
\ntry: a report of four unrelated cases. BMC Infect
\nDis. 2008;8:60.
\nKwon YS, Kim YH, Suh GY, et al.: Treatment out-34.
\ncomes for HIV-uninfected patients with multidrug-
\nresistant and extensively drug-resistant tuberculosis.
\nCID 2008;47:496-502.
\nMitnick CD, Shin SS, Seung KJ, et al.: Compre-35.
\nhensive treatment of extensively drug-resistant tu-
\nberculosis. N Engl J Med. 2008;359:563-74.
\nEker B, Ortmann J, Migliori GB, et al. Multidrug-36.
\nand extensively drug-resistant tuberculosis, Ger-
\nmany. Emerg Infect Dis. 2008;14:1700-6.
\nGandhi NR, Shah NS, Andrews JR. HIV coinfec-37.
\ntion in multidrug- and extensively drug-resistant
\n67
\nRegional and NMA news
\ntuberculosis results in high early mortality. Am J
\nRespir Crit Care Med. 2010;181:80-6.
\nChiang C-Y, Caminero JA, Enarson DA. Report-38.
\ning on multidrug-resistant tuberculosis: a proposed
\ndefinition for the treatment outcome \u2018failed\u2019. Int J
\nTuberc Lung Dis. 2009;13:548-550.
\nKim HJ, Kang CH, Kim YT, et al.: Prognos-39.
\ntic factors for surgical resection in patients with
\nmultidrug-resistant tuberculosis. Eur Respir J.
\n2006;28:576-580.
\nKim DH, Kim HJ, Park S-K, et al.: Treatment40.
\noutcomes and long-term survival in patients with
\nextensively drug-resistant tuberculosis. Am J Respir
\nCrit Care Med. 2008;178:1075-82.
\nDravniece G, Cain KP, Holtz RH, Riekstina V,41.
\nLeimane V, Zaleskis R. Adjunctive resectional lung
\nsurgery for extensively drug-resistant tuberculosis.
\nEur Respir J. 2009;34:180-3.
\nKeshavjee S, Gelmanova I, Farmer PE, et al. Tre-42.
\natment of extensively drug-resistant tuberculosis in
\nTomsk, Russia: a retrospective cohort study. Lancet
\n2008;372:1403-9. Epub 2008 Aug 22.
\nWorld Health Organization. The global MDR-TB43.
\n& XDR-TB response plan 2007-2008. WHO, Ge-
\nneva, Switzerland, WHO\/HTM\/TB\/2007.387.
\nBrown RE, Miller B,Taylor WR, et al. Health-care44.
\nexpenditures for tuberculosis in the United States.
\nArch Intern Med. 1995;155:1595-1600.
\nRajbhandary SS, Marks SM, Bock NN. Costs of45.
\npatients hospitalized for multidrug-resistant tuber-
\nculosis. Int J Tuberc Lung Dis. 2004;8:1012-6.
\nWorld Health Organization.The Stop TB Strategy.46.
\nBuilding on and enhancing DOTS to meet the TB-
\nrelated Millennium Development Goals. WHO,
\nGeneva, Switzerland, WHO\/HTM\/STB\/2008.
\nFloyd K, Pantoja A. Financial resources required for47.
\ntuberculosis control to achieve global targets set for
\n2015. Bull World Health Organ. 2008;86:568-76.
\nRaviglione MC, Uplekar MW. WHO\u2019s new Stop48.
\nTB Strategy. Lancet 2006;367:952-5.
\nWorld Health Organization. Guidelines for esta-49.
\nblishing DOTS-Plus projects for the manage-
\nment of multidrug-resistant tuberculosis (MDR-
\nTB). WHO, Geneva, Switzerland, WHO\/CDS\/
\nTB\/200.278.
\nGupta R, Cegielski JP, Espinal MA, et al. Increa-50.
\nsing transparency in partnerships for health \u2013 intro-
\nducing the Green Light Committee. Trop Med Int
\nHealth 2002;7:970-76.
\nMigliori GB, Sotgiu G, Jaramillo E, et al.: Deve-51.
\nlopment of a standardized multidrug-resistant\/
\nextensively drug-resistant tuberculosis assessment
\nand monitoring tool. Int J Tuberc Lung Dis.
\n2009;13:1305-9.
\nCobelens FGJ, Heldal E, Kimerling ME, et al.:52.
\nScaling up programmatic management of drug-
\nresistant tuberculosis: a prioritised research agenda.
\nPlos Medicine 2008;5:1037-42.
\nBaumann S, Eddine AN, Kaufmann SHE. Progress53.
\nin tuberculosis vaccine development. Curr Opin
\nImmunol. 2006;18:438-48.
\nTuberculosis Coalition for Technical Assistance.In-54.
\nternational Standards forTuberculosis Care (ISTC).
\nThe Hague: Tuberculosis Coalition for Technical
\nAssistance, 2006.
\nwww.euro.who.int\/tuberculosis\/TBForum55.
\n\/20070621_1
\nR. Loddenkemper, German Central
\nCommittee against Tuberculosis
\nStralauer Platz 34,10243, Berlin,Germany
\ne-mail: rloddenkemper@dzk-tuberkulose.de
\nS. Castell, German Central
\nCommittee against Tuberculosis
\nB. Hauer, Robert Koch Institute
\nAs the Medical Association of Thailand is
\nhosting the WMA Congress and General
\nAssembly in 2012, we would like to intro-
\nduce the overview to you in brief about
\nThailand and some aspects of the works of
\nthe Medical Association of Thailand.
\nBrief Introduction
\nof Thailand
\nThailand is the world\u2019s 50th largest coun-
\ntry in terms of total area (slightly small-
\ner than Yemen and slightly larger than
\nSpain), with a surface area of approxi-
\nmately 513,000 km2
\n(198,000 sq mi), and
\nthe 21st most-populous country, with
\napproximately 64 million people. About
\n75% of the population is ethnically Thai,
\n14% is of Chinese origin, and 3% is eth-
\nnically Malay; the rest belong to minority
\ngroups including Mons, Khmers and var-
\nious hill tribes. There are approximately
\n2.2 million legal and illegal migrants in
\nThailand. Thailand has also attracted a
\nnumber of expatriates from developed
\ncountries. The country\u2019s official language
\nis Thai.
\nThailand has a prevalence of Buddhism that
\nranks among the highest in the world. The
\nnational religion is Theravada Buddhism
\nwhich is practiced by more than 94.7% of all
\nThais. Muslims make up 4.6% of the popu-
\nlation and 0.7% belong to other religions.
\nThai culture and traditions are mainly in-
\nfluenced by Chinese, and to a lesser degree,
\nby Indian culture, along with Burma, Laos
\nand Cambodia. Thailand experienced rapid
\neconomic growth between 1985 and 1995
\nand is a newly industrialized country with
\ntourism, due to well-known tourist destina-
\ntions such as Pattaya, Bangkok, and Phuket,
\nand exports contributing significantly to the
\neconomy
\nFollowing the decline and fall of the Khmer
\nempire in the 13th\u201314th century, the Bud-
\ndhist Tai kingdoms of Sukhothai, Lanna
\nand Lan Chang were on the ascension.
\nHowever, a century later, the power of
\nSukhothai was overshadowed by the new
\nkingdom of Ayutthaya, established in the
\nmid-14th century in the lower Chao Phraya
\nRiver or Menam area.
\nAyutthaya\u2019s expansion centered along the
\nMenam while in the northern valley the
\nLanna Kingdom and other small Tai city-
\nstates ruled the area.Thailand retained a tra-
\ndition of trade with its neighbouring states,
\nfrom China to India, Persia and Arab lands.
\nAyutthaya became one of the most vibrant
\ntrading centres in Asia. European traders
\narrived in the 16th century, beginning with
\nthe Portuguese, followed by the French,
\nDutch and English.
\nAfter the fall of Ayutthaya in 1767 to the
\nBurmese, King Taksin the Great moved the
\ncapital of Thailand to Thonburi for approxi-
\nmately 15 years. The current Rattanakosin
\nera of Thai history began in 1782, following
\nHost of the 2012 WMA Congress and
\nGeneral Assembly
\n68
\nRegional and NMA news
\nthe establishment of Bangkok as capital of
\nthe Chakri dynasty under King Rama I the
\nGreat.
\nDespite European pressure, Thailand is the
\nonly Southeast Asian nation that has never
\nbeen colonized. Two main reasons for this
\nwere that Thailand had a long succession of
\nvery able rulers in the 19th century and that
\nit was able to exploit the rivalry and tension
\nbetween French Indochina and the British
\nEmpire. As a result, the country remained
\na buffer state between parts of Southeast
\nAsia that were colonized by the two powers,
\nGreat Britain and France.
\nWestern influence nevertheless led to many
\nreforms in the 19th century and major con-
\ncessions, most notably being the loss of a
\nlarge territory on the east side of the Me-
\nkong to the French and the step-by-step
\nabsorption by Britain of the Shan (Thai Yai)
\nStates (now in Burma) and the Malay Pen-
\ninsula.
\nGeography of Thailand
\nTotalling 513,120 square kilometres
\n(198,120 sq mi), Thailand is the world\u2019s
\n50th largest country in land mass, while it is
\nthe world\u2019s 20th largest country in terms of
\npopulation. It is comparable in population
\nto countries such as France and the Unit-
\ned Kingdom, and is similar in land size to
\nFrance and California in the United States;
\nit is just over twice the size of the entire
\nUnited Kingdom, and 1.4 times the size of
\nGermany. The local climate is tropical and
\ncharacterized by monsoons.There is a rainy,
\nwarm, and cloudy southwest monsoon from
\nmid-May to September, as well as a dry,
\ncool northeast monsoon from November to
\nmid-March.The southern isthmus is always
\nhot and humid.
\nThailand is home to several distinct geo-
\ngraphic regions, partly corresponding to the
\nprovincial groups. The north of the country
\nis mountainous, with the highest point be-
\ning Doi Inthanon at 2,565 metres above sea
\nlevel (8,415 ft).The northeast, Isan, consists
\nof the Khorat Plateau, bordered to the east
\nby the Mekong River. The centre of the
\ncountry is dominated by the predominantly
\nflat Chao Phraya river valley, which runs
\ninto the Gulf of Thailand.The south consists
\nof the narrow Kra Isthmus that widens into
\nthe Malay Peninsula.Politically,there are six
\ngeographical regions which differ from the
\nothers in population, basic resources, natu-
\nral features,and level of social and economic
\ndevelopment. The diversity of the regions is
\nthe most pronounced attribute of Thailand\u2019s
\nphysical setting.
\nThe Chao Phraya and the Mekong River
\nare the sustainable resource of rural Thai-
\nland. Industrial scale production of crops
\nuse both rivers and their tributaries. The
\nGulf of Thailand covers 320,000 km\u00b2 and is
\nfed by the Chao Phraya, Mae Klong, Bang
\nPakong and Tapi Rivers. It contributes to
\nthe tourism sector owing to its clear shal-
\nlow waters along the coasts in the Southern
\nRegion and the Kra Isthmus. The Gulf of
\nThailand is also an industrial centre of Thai-
\nland with the kingdom\u2019s main port in Sat-
\ntahip along with being the entry gates for
\nBangkok\u2019s Inland Seaport. The Andaman
\nSea is regarded as Thailand\u2019s most precious
\nnatural resource as it hosts the most popular
\nand luxurious resorts in Asia.Phuket,Krabi,
\nRanong, Phang Nga and Trang and their
\nlush islands all lay along the coasts of the
\nAndaman Sea and despite the 2004 Tsu-
\nnami, they continue to be and ever more so,
\nthe playground of the rich and elite of Asia
\nand the world
\nBrief Introduction of
\nthe Medical Association
\nof Thailand
\nThe Medical Association of Thailand un-
\nder his Majesty the King\u2019s patronage is a
\nnongovernmental non-profit making orga-
\nnization aiming at
\n2.1. Promoting and coordinating medical\u2022
\nprofessions under ethical integrity.
\n2.2. Promoting relationship amongst\u2022
\nmembers.
\n2.3. Promoting education, researches and\u2022
\nmedical services
\n2.4. Promoting member\u2019s welfares.\u2022
\n2.5. Coordinating and collaborating with\u2022
\nother medical organizations in both gov-
\nernmental and private sectors to improve
\nbetter standard of medical provision and
\npublic health to meet the international
\nstandard.
\n2.6. Advocating health promotion, pre-\u2022
\nvention and medical services to public.
\n2.7. Collaborating with international\u2022
\nhealth and medical organizations to keep
\nthe global standard. The Medical Asso-
\nciation of Thailand is an active member of
\nthe Medical Associations of South East
\nAsian Nations (MASEAN), Confedera-
\ntion of the Medical Associations in Asia
\nand Oceania (CMAAO), and the World
\nMedical Association (WMA)
\nThe Medical Association of Thailand is
\npracticing a great role in bringing all health
\nand medical providers from both govern-
\nmental and private sectors to work together
\nthrough the elective executive committee
\nwhich is composed of representatives from
\nvarious sectors. The Medical Association of
\nThailand is also one of the three compo-
\nnents forming a collaborative body com-
\nposed of the Ministry of Public Health, the
\nMedical Council and the Medical Asso-
\nciation to oversee the problems within the
\nmedical profession and allies as well as to
\ndiscuss and solve the problems which may
\narise together.
\nThe Medical association of Thailand is also
\ntaking roles in providing compromises in
\n69
\nRegional and NMA news
\nthe conflicts between medical providers and
\nconsumers.
\nThe Journals of the Medical Association
\nof Thailand is a worldwide class accepted
\nmedia in distributing educational and aca-
\ndemic know-how as well as researches.
\nThe Medical Association is not only ex-
\ntending its professional consultation to
\ndoctors in the remote areas but also support
\nthem with the life insurance.
\nCMAAO \u2018S Activities on Tobacco
\nControl in the Region
\nOn February 25th
\n-28th
\n.2010, the Medical
\nAssociation of Thailand had hosted the \u201c 1st
\n.
\nInternational Summit on Tobacco Control
\nin Asia and Oceania Region\u201d at the Rose
\nGarden Riverside Hotel in Sampran dis-
\ntrict, Nakhonpathom Province, Thailand.
\nThe event was assigned by the CMAAO
\nCongress and Assembly in Bali, Indonesia,
\nNovember 5-7, 2009.Tobacco Control Pro-
\ngramme was decided and approved to be a
\nflagship programme of the Confederation
\nof the Medical Associations in Asia and
\nOceania starting this year and the progress
\nwill be reported annually at the Conference
\nand General Assembly to share experiences
\nof success and barriers amongst member
\ncountries.
\nThe Summit was participated by 12 coun-
\ntries in the region comprised of Hong Kong,
\nIndia, Indonesia, Japan, Korea, Malaysia,
\nMyanmar, Philippines, Singapore, Taiwan,
\nVietnam and Thailand. The programme
\nconsisted of presentations from experts,
\ncurrent situation in countries with the evi-
\ndence -based health hazards from tobacco
\nsmoking and it\u2019s effects on second handed
\nsmokers as a preventable epidemic, group
\ndiscussion and production of Statement and
\ndeclaration on Tobacco control in Asia and
\nOceania Region with recommendations for
\nmember countries to practice and collabo-
\nrate at three levels ie. Medical Association,
\nindividual physician and National. All par-
\nticipating NMAs had also undersigned the
\nProclamation that they will unite and work
\ntogether towards developing the regional
\nnetwork on tobacco control and contribute
\nto make tobacco control one of the highest
\npriorities.
\nThe Medical Association of Thailand is in
\ngood relationship with the government as
\nwell as the private sector. The monthly ex-
\necutive board meeting is a platform for
\ndiscussion and recommendation for stake-
\nholders to join hands together in practices
\nfor the benefit of the consumers in general.
\nMany practical initiatives have been created
\nby the committee and practiced nationwide
\nsince members of the committee are elected
\nfrom various fields of medical profession.
\nFor more information please visit our web-
\nsite at http:\/www.mat.or.th
\nContact persons are
\nPolice Lt. General Dr. Jongjate
\nAojanepong President
\nDr. Wonchat Subhachaturas
\nPresident Elect
\nProf. Dr. Somsri Pausawasdi
\nPast President
\nAssoc. Prof. Dr. Prasert Sarnvivad
\nSecretary General
\nNaval Lt. Dr. Manopchai Thamkhantho
\nInternational Relations
\ne-mail: math@loxinfo.co.th
\nTel: +66 2314 4333, +66 2318 8170
\nFax: +66 2314 6305
\nWonchat Subhachaturas MD,
\nPresident Elect of the MAT
\nThe Medical Association ofThailand has a big role in theThai Health Professionals Alliance against
\nTobacco Consumption Project (THPAAT) to create the free environment, smoke-free hospitals
\nand etc.
\n70
\nRegional and NMA news
\nI. Establishment of CMAAO
\nCurrently comprised of 18 member National
\nMedical Associations (NMAs), the Confed-
\neration of Medical Associations in Asia and
\nOceania (CMAAO) has now marked more
\nthan 50 years of history. CMAAO\u2019s estab-
\nlishment was proposed in 1956 by Dr. Rod-
\nolfo P. Gonzalez, President of the Philippine
\nMedical Association. The Japan Medical
\nAssociation (JMA) began participating in
\nprocess of establishing CMAAO as one of
\nits first international activities,after receiving
\nrecognition from the international commu-
\nnity1
\n. In 1959, CMMAO was inaugurated at
\nthe 1st Congress and Council Meeting was
\nheld at the Imperial Hotel in Tokyo [1, 2, 3].
\nThere were 11 member NMAs at the time of
\ninauguration,of which six were present at the
\nfirst meeting (Japan, Australia, Burma (now
\nMyanmar), Republic of China (Taiwan), In-
\n1 With Occupation Policy guidance, in 1951 the
\nJapan Medical Association was granted approval
\nfor membership by the World Medical Association
\nfollowing notification of member countries world-
\nwide and on the condition that the JMA was \u201can
\norganization representing the physicians of Japan\u201d
\nand \u201coperated independently of the government\u201d,
\nreceiving legitimacy as a medical organization.
\ndonesia, and Philippine). The remaining five
\nwho could not be present were the Republic
\nof Korea, Iran, Pakistan,Thailand, and India.
\nThe complete list of current membership is
\nshown in Table 1.
\nThe Asian Medical Journal, published in Eng-
\nlish by JMA since 1958, played an important
\nrole in reporting CMAAO activities and
\nserved as a forum for information exchange.
\nThe article contributed by Dr. Albert Sch-
\nweitzer in 1959 [4] represented the spirit
\nand enthusiasm of everyone involved in the
\njournal.This Asian Medical Journal has since
\nbeen succeeded by Japan Medical Associa-
\ntion Journal (JMAJ), which continues to be
\npublished bi-monthly by the JMA to this
\nday. In collaboration with World Medical
\nJournal (WMJ), JMAJ continues to present
\nCMAAO activities to the world and also
\nintroduce English translations of articles
\nand papers from Journal of Japan Medical
\nAssociation (the Japanese language journal
\nof JMA) to the world. As part of the JMA\u2019s
\ninternational mission, the JMA Interna-
\ntional Affairs Division cooperated with the
\nTakemi Program in International Health
\nat the Harvard School of Public Health in
\n2008, researching the theme \u201cthe potential
\nfor national medical associations to con-
\ntribute to global healthcare through com-
\nmunication of information,\u201d by conducting
\nsurveys among World Medical Association
\n(WMA) and CMAAO member organiza-
\ntions [5,6] . The role and contents of JMAJ
\nis hoped to expand further into the future.
\nII. History of CMAAO Activities
\nSince its inauguration in 1959, CMAAO
\nhas held regular congresses and mid-term
\ncouncil meetings \u2013 and today, it is an orga-
\nnization that is recognized by the WMA a
\ncollaborating partner representing Asia and
\nOceania. From the very beginning, it al-
\nways has been the aim of CMAAO to pro-
\nmote friendship and information exchange
\namong member NMAs. The late Dr. Taro
\nTakemi, a former JMA President and 2nd
\nPresident of CMAAO, who for many years
\ncontinued to strive to enhance CMAAO,
\nalso proposed strategic concepts like the
\n\u201cproactive concept of building a system that
\nadvantageously expands medical associa-
\ntion activities within international treaties,
\nconsidering that international controls exist
\n\u2026 no matter how free medical association
\nappear to be to conduct their activities.\u201d
\nHe also suggested that \u201cwhen the Asian
\nCMAAO, Over Fifty Years of History and
\nFuture Outlook
\nTable 1. CMAAO Members (18 National Medical Associations)
\nAustralian Medical Association, Bangladesh Medical Association, Cambodian Medical
\nAssociation, Hong Kong Medical Association, Indian Medical Association, Indonesian
\nMedical Association, Japan Medical Association,Korean Medical Association, Macau
\nMedical Association, Malaysian Medical Association, Myanmar Medical Association,
\nNepal Medical Association, New Zealand Medical Association, Philippines Medical As-
\nsociation, Singapore Medical Association, Sri Lanka Medical Association, Taiwan Medi-
\ncal Association, Medical Association of Thailand
\nMasami Ishii, Hisashi Tsuruoka
\n71
\nRegional and NMA news
\nand Pacific Region come together, we can
\nvoice our opinions more strongly within the
\nWorld Medical Association\u201d [7]. Under the
\nlatter concept, the aim of CMAAO was to
\nbuild cooperative relationships as an inter-
\nnational government organization modeled
\nafter the ILO and WHO. In that sense,
\nthe establishment of CMAAO was even
\ncalled the \u201ccreation of a new world\u201d[8]. Dr.
\nTakemi\u2019s visions to foresee the needs for so-
\ncioeconomic discussion within WMA and
\nestablishment of organization like the JMA
\nResearch Institute also show timeless wis-
\ndom, even from today\u2019s perspective.
\nThe CMAAO Secretariat, which was origi-
\nnally with Philippines Medical Association,
\nhas moved among Malaysia, Thailand, New
\nZealand. Since 2000, it has been in Japan,
\nwith the JMA International Affairs Division
\nproviding the Secretariat support. The role
\nof CMAAO Secretary General was passed
\nto the JMA simultaneously, of which I
\n(Dr. Ishii) assumed the position since 2006.
\nIII. Directionality and Roles
\nof Recent CMAAO
\nIn addition to the annual council meetings,
\nCMAAO holds a congress every two years
\nwhere officers are appointed and bylaws are
\namended in accordance with the issues dis-
\ncussed at council meetings. Also at a con-
\ngress meeting, participating NMAs present
\nannual country reports of the current status
\nof their activities, as well as giving lectures
\nat symposium on the specific theme of the
\nyear, generating lively discussions.
\nCongress activities in recent years include
\nthe presentation of the \u201cTaro Takemi Me-
\nmorial Oration\u201d that was established by the
\nTakemi family\u2019s fund since 1991, where
\na theme that reflect the time (Table 2) is
\ndiscussed. At the 2008 Mid-term Coun-
\ncil Meeting held in Manila, Philippine,
\nDr. Keizo Takemi was invited as a special
\nspeaker to present a memorial lecture com-
\nmemorating CMAAO\u2019s 50th anniversary
\nfrom the standpoint of global health. Com-
\nbining both experiences in Japan and the
\nresults of research carried out at the Har-
\nvard School of Public Health, Dr. Takemi\u2019s
\nlecture provided a visionary outlook for the
\nnext 50 years. His lecture was tremendously
\ninspiring for the audience and lead to seri-
\nous discussions to strengthen and revitalize
\nCMAAO activities toward the year 2010.
\nIn 2006, at the suggestion of WMA, JMA
\nand WMA jointly hosted the 1st WMA
\nAsian-Pacific Regional Conference in To-
\nkyo, with CMAAO being the main organiz-
\ner. The two main themes of this conference
\nwere; 1) disaster preparedness (natural disas-
\nTable 2. Taro Takemi Memorial Oration
\nYear Congress Theme, Lecturer
\n1991
\n17th
\nHong
\nKong
\nCongress
\n\u201cDirections for Health care in the 1990\u2019s\u201d
\nDr. Haruto Haneda, President, Japan Medical Association
\n1993
\n18th
\nMalacca
\nCongress
\n\u201cUse of Environment Friendly Technology in the Health
\nIndustry\u201d Dr. M.K. Ralakumar, Past President, Malaysian
\nMedical Association
\n1995
\n19th
\nNew
\nDelhi
\nCongress
\n\u201cDiabetes and Circulatory Diseases- Asian Drama\u201d
\nProf. J.B. Bajaj, Member, Planning Commission in the rank of
\nMinister of State, Government, India
\n1997
\n20th
\nBangkok
\nCongress
\n\u201cEnvironmental Health: UNEP\u2019s Perspective\u201d
\nDr. Suvit Yodmani, Director for Asia and the Pacific United
\nNations Environment Programme
\n1999
\n21st
\nWellington
\nCongress
\n\u201cManaged Care and the Future of Health Professions\u201d
\nProf. Sir. John Scott, University of Auckland and South
\nAuckland Health, Middlemore Hospital
\n2001
\n22nd
\nTaipei
\nCongress
\n\u201cMedical Education in 21st Century\u201d
\nDr. Ming-Liang Lee, Minister, Department of Health,Taiwan,
\nR.O.C.
\n2005
\n24th
\nSeoul
\nCongress
\n\u201cProgress and Problems of Health Insurance Program in Korea\u201d
\nDr.Tai Joon Moon, President Emeritus, Korean Medical
\nAssociation
\n2007
\n25th
\nPattaya
\nCongress
\n\u201c60 years of Thai Healthcare under H.M. King Bhumibol\u201d
\nDr. Prinya Sakiyalak, Professor Emeritus, Mahidol University
\n2009
\n26th
\nBali
\nCongress
\n\u201cThe roles of primary physician in achieving the MDGS\u201d
\nDr. Azurul Azwal, Professor, University of Indonesia
\nDr. Taro Takemi
\n72
\nRegional and NMA news
\nters such as earthquakes and tsunamis, and
\ninfectious disease), and 2) the present state
\nand future of the medical profession. Simul-
\ntaneous interpretation services were provided
\nfor the representatives of prefectural medical
\nassociations in Japan who also attended.The
\nspecial public lectures by international guest
\nspeakers were also held concurrently, and the
\ndetails of the conference and special public
\nlectures were published in the 50th
\nanniver-
\nsary issue of the JMAJ[9]. Considering the
\ncurrent situation of earthquakes, tsunamis
\ncaused by earthquakes, and outbreaks of in-
\nfectious disease that that have been occurring
\nrepeatedly since, it was a timely academic
\nmeeting on an extremely meaningful theme.
\nIV. Positioning of CMAAO
\nin the World
\nAt the 2009 CMAAO Congress, a proposal
\nfor cross-regional anti-smoking action was
\nadopted.The expansion of these activities is
\ncurrently under consideration.
\nLooking at the common symposium themes
\nin the past (Table 3), each theme chosen re-
\nflected the times. In particular, we can see
\nthat the 2009 \u201cWorld Medical Association
\nDelhi Declaration\u201d theme represents the
\nfruit of the past several themes, namely
\nthe 2006 Symposium \u201cMedical Ethics,\u201d
\nthe 2008 WMA \u201cSeoul Declaration,\u201d 2009
\nWMA \u201cMadrid Declaration,\u201d and 2008
\nPhilippines Symposium \u201cClimate Change.\u201d
\nReports on the advancement of social ag-
\ning and declining birthrates in many Asian
\ncountries, as if following Japan, were also
\npresented at the Thailand\/Pattaya Congress
\nin 2007. This topic is truly a current theme
\nand was regarded extremely useful in consid-
\nering the future forms of healthcare systems
\nand health policies. In addition, at the 2009
\nIndonesia\/Bali Congress with the theme of
\n\u201cImpact of Global Financial Crisis to the
\nHealth System,\u201d it was reported that, from
\nthe standpoint of health management for
\nthe general public, the economic crisis had
\nhad very little impact in countries such as
\nJapan, Korea, and Taiwan where a national
\nuniversal healthcare system was already es-
\ntablished. This suggests that, in an unfore-
\nseen economic crisis,a nation-wide universal
\nhealthcare system can act to minimize the
\ndamage to the general health of the public,
\nreconfirming the necessity and significance
\nof such universal healthcare systems.
\nIn recent CMAAO debates, problems re-
\nlated to collective capacity-building appear
\nto be clearly improving. The social structures
\nof countries in the Asia and Oceania region
\nTable 3. CMAAO Symposium \u2013 Recent themes
\nYear Congress Title of the Symposium
\n1999 21st
\nWellington Congress Health care system
\n2000 36th
\nTokyo Mid-term
\nCouncil Meeting
\nInfectious Disease Control Measures in Asian and
\nOceania Regions
\n2001 22nd
\nTaipei Congress The Impact of Health Care Reform on the Health
\nCare Delivery System
\n2002 38th
\nThai Mid-term
\nCouncil Meeting
\nRoles of Traditional Medicine in Asia and Oceania
\nCountries
\n2004
\n40th
\nKuala Lumpur Mid-
\nterm Council Meeting
\nMedical Risk Management: Improving Patient Safety
\n& Quality of Service by Controlling Medical Error
\n2005 24th
\nSeoul Congress
\nPresent Status of National Health Insurance in Asia
\n& Oceania Region
\n2006
\n42nd
\nSingaporeMid-term
\nCouncil Meeting
\nContinuing Development in Ethics and
\nProfessionalism
\n2007 25th
\nPattaya Congress Arts and Science of Healthy Longevity
\n2008
\n44th
\nPhilippines Mid-
\nterm Council Meeting
\nGlobal Warming An Alarming Phenomenon, What
\nShall We Do?
\n2009 26th
\nBali Congress
\nImpact of the Global Financial Crisis on the Health
\nSystem
\nTable 4. Office Bearers of CMAAO 2009-2011
\nPresident Fachmi Idris Indonesia
\nPresident-Elect Ming-Been Lee Taiwan
\nImmediate Past President Somsri Pausawasdi Thailand
\n1st Vice President David Kwang-Leng Quek Malaysia
\n2nd Vice President Dong Chun Shin Korea
\nChair of Council Wonchat Subhachaturas Thailand
\nVice-Chair of Council Peter Foley New Zealand
\nTreasurer Yee Shing Chan Hong Kong
\nSecretary General Masami Ishii Japan
\nAssistant Secretary General Hisashi Tsuruoka Japan
\nAdviser Tai Joon Moon Korea
\nYung Tung Wu Taiwan
\n73
\nRegional and NMA news
\nare tremendously rich and variable in terms of
\npolitics,religion,and ethnicity.However,over-
\ncoming these differences,nations have worked
\ntogether to resolve problems and undertaken
\ncooperative activities within the region in
\nmany aspects, and some results are already
\nbeing achieved. Amidst this, CMAAO has
\npromoted deeper understanding amongst the
\nmember NMAs through group presentations
\nat annual meetings for more than 50 years,
\nproposing meaningful themes to be discussed
\nin global scale, which have led the way for
\nglobal discussions in other forums. The Asia
\nand Oceania region is not only important as
\nthe center of the world population \u2013 its geopo-
\nlitical position has improved remarkably with
\nthe invigoration of the economy. Thus, the
\nexistence and significance of CMAAO have
\ngained even greater weight in recent years.
\nIn the recent WMA activities, 2008 General
\nAssembly was held in Seoul,Korea; the 2009
\nGeneral Assembly was held in New Delhi,
\nIndia; and the 2012 General Assembly is to
\nbe held in Thailand.The WMA President for
\n2006-2007 was Dr. Arumugam of Malaysia,
\nand the 2010-2011 term will be Dr. Desai of
\nIndia.These trends illustrates that the role of
\nthe CMAAO region is becoming more im-
\nportant on the global stage.
\nFurthermore, the efforts of CMAAO are in-
\nspiring other parts of the world, too. In Af-
\nrica,a movement to establish a confederation
\nof medical associations gained momentum,
\nwhich lead to the formation of the African
\nMedical Association (AFMA) in 2006, with
\nSouth Africa taking a central role in its in-
\nauguration. So far, there have been intermit-
\ntent talks between CMAAO and AFMA for
\ninternational exchange and cooperation \u2013
\nwhich surely will grow to more specific dis-
\ncussions, given the opportunity in future.
\nV. CMAAO\u2019s Board Structure
\nand Future Activities
\nThe composition of the CMAAO Board,
\ndetermined at the 2009 Indonesia Con-
\ngress, is shown in Table 4. In order to further
\nstrengthen information sharing that been
\ngrowing consistently among member NMAs
\nand to facilitate prompt actions when neces-
\nsary, it has been agreed to undertake strategic
\nrevisions with a view to the next 50 years.The
\nsignificance of the JMAJ,which uses the com-
\nmon language in the region, is bound to in-
\ncrease further. Urgent issues also include pro-
\nmoting better information exchange through
\nenhancing of information platforms on the
\ninternet and preparing online networks.There
\nis also a need to establish more effective means
\nto disseminate information, such as declara-
\ntions and other policy papers. These reforms
\nwill likely call for examinations of the style
\nand format of congress meetings as well as
\nthe constitution itself, for which exchange of
\nopinions online has already begun.
\nVI. Conclusion
\nWith more than 50 years of history, the
\nCMAAO\u2019s role within the WMA has re-
\ncently begun expanding. The purpose of this
\nbrief history of CMAAO and summary of
\nits recent activities is to familiarize all WMA
\nmembers of the current status of CMAAO
\nas we begin to focus on our next 50 years.
\nReferences
\nIshii M, Tsuruoka H. History and recent ac-1.
\ntivities of the CMAAO. World Medical Journal
\n2008; 54 (2):54-5.
\nMoon TJ.CMAAO\u2019s role and future tasks. JMA2.
\nJournal. 2008; Nov\/Dec,.
\n\u5c0f\u6c60\u9a0f\u4e00\u90ce\u300c3.\t CMAAO\uff08\u30a2\u30b8\u30a2\u5927\u6d0b\u5dde\u533b\u5e2b\u4f1a
\n\u9023\u5408\uff09\u306e\u6b74\u53f2\u3068\u6700\u8fd1\u306e\u6d3b\u52d5\u72b6\u6cc1\u300d\u65e5\u533b\u96d1\u8a8c\u7b2c
\n115\u5dfb\u7b2c2\u53f7\u30011996\u5e74Kiitirou K.CMAAO (Asia
\nPacific Federation of State Medical) History and
\nrecent activities. The Japan Medical Association
\nJournal. 1996; 115 (2).
\nSchweitzer A. Message. Asian Medical Journal.4.
\n1959;2 (4).
\nHamamoto M, Jimba M, Halstead DD, et5.
\nal. Can National Medical Association journals
\nmake greater contributions to global health?:
\nan international survey and comparison.
\nJMAJ.2009;52(4): 243\u201358.
\nHamamoto M, Ishii M.What can medical jour-6.
\nnals do for global health? World Medical Jour-
\nnal 2010; 56 (1): 26-8.
\n\u6b66\u898b\u592a\u90ce7.\t \u300c\u4e16\u754c\u306e\u4e2d\u306e\u65e5\u672c\u306e\u533b\u653f\u300d\u65e5\u672c\u533b\u4e8b
\n\u65b0\u5831, \u7b2c2368\u53f7\u3001\u662d\u548c44\u5e749\u670813\u65e5\u767a\u884cTakemi
\nTaroT.The government of Japan in the World Me-
\ndical.Medical Shimpo Japan,1969; Sept.13.
\nTakemi T. Message. Asian Medical Journal.8.
\n1959;2 (3).
\nJMAJ.2007;50(1). http:\/\/www.med.or.jp\/en-9.
\nglish\/journal\/index.html
\nMasami Ishii, MD, Executive Board Member
\nof JMA, Secretary General of CMAAO,
\nVice-Chair of Council of WMA
\nHisashi Tsuruoka,
\nInternational Manager of JMA
\ne-mail: tsuruoka@po.med.or.jp
\nDr. Rodolfo P. Gonzalez
\n74
\nRegional and NMA news
\nSamoa is a small, peaceful nation in the
\nSouth Pacific with a population of ap-
\nproximately 200,000. It experiences a se-
\nvere shortage of doctors and faces serious
\nobstacles in attaining sufficient numbers
\nof doctors to meet its health needs in the
\ndecades ahead. The Samoa Medical Asso-
\nciation (SMA) was founded in 1948 and is
\none of the oldest professional associations
\nin Samoa.
\nAlthough the SMA has provided its mem-
\nbers with continuing medical education
\nopportunities, annual scientific conferences
\nand weekly CME meetings since its foun-
\ndation, it was felt that more could be done.
\nFor many years, the Association dreamed of
\nhaving its own journal and holding interna-
\ntional conferences, but the relatively small
\nscale of medical and health care in Samoa
\nand excessive workloads of doctors meant
\nthat, until recently, this dream could not
\nbe realised. In 2009, through collaboration
\namong the Oceania University of Medi-
\ncine (OUM), the SMA, and the National
\nHealth Service, the SMA achieved one of
\nits aspirations with the launch of the Samoa
\nMedical journal (SMJ), the online version
\nof which can be read without subscription
\nat www.oceaniamed.org. In April 2010, the
\nsame collaborative group will launch the
\nfirst Medical Conference on Heart Disease
\nin Samoa with speakers from Samoa and
\nNew Zealand.
\nOceania University of Medicine was es-
\ntablished in Samoa in 2002 to serve the
\nnational and regional interests in terms of
\nmedical workforce needs. In addition to
\noffering a four-year graduate entry medi-
\ncal programme and a new five year MBBS
\nprogramme, OUM supports, encourages
\nand provides a range of opportunities for
\npractising doctors and emerging research-
\ners to carry out medical and health-related
\nresearch. This includes working with the
\nNHS, Ministry of Health and SMA to
\nprovide continuing medical education and
\nto develop a research infrastructure and
\nprovision of postgraduate training and re-
\nsearch pathways, such as diplomas in key
\nclinical areas and a masters\u2019 and doctoral
\nprogramme in clinical and health sciences.
\nThe university shared the same conviction
\nas the SMA: that it was time to have a lo-
\ncal medical journal as part of the support
\nmechanisms and linkages for local practi-
\ntioners. The University, through its faculty,
\nhas been instrumental in bringing together
\nits partners, the SMA and NHS, through
\nthe medical doctors to work collaboratively
\nin the planning and implementing of the
\nnew journal.
\nThe journal is intended to support and en-
\ncourage medical and healthcare research in
\nSamoa and the Pacific, providing a source
\nof current medical and health information
\nto practicing physicians and other health
\nprofessionals in the region. The journal has
\na focus on the many healthcare workers in-
\nvolved in delivering healthcare and not just
\non a tiny minority of clinical researchers.
\nThis interprofessional focus will facilitate
\nshared learning across and between health
\ndisciplines and services. With a focus on
\nthe South Pacific and reflecting health is-
\nsues common to the region (such as chronic
\ndisease and infections), the journal covers
\nareas such as epidemiology, public health,
\noriginal basic science and clinical research,
\ninteresting case reports, reviews of endemic
\nor emerging diseases, focal and regional
\nmedical news, research methodology, pol-
\nicy, and innovations in medical education.
\nReviews of relevant articles and books
\npublished elsewhere will also be welcome.
\nThere is a wealth of local health and medi-
\ncal information that needs to be shared and
\nmade known that not only will contribute
\nto knowledge sharing but also ultimately
\nlead to providing a health service and clini-
\ncal care that is informed and evidence based.
\nAs they say, if it is not published, it does not
\nexist!
\nThe SMJ publishes 3 issues annually includ-
\ning both online and printed copies. Sub-
\nmissions for the journal are welcome from
\nmedical health professionals and others
\nwho are interested in health issues affecting
\nSamoa and the South Pacific.The first issue
\nwas warmly received with articles covering
\nsuch diverse topics as diabetes mellitus, in-
\ntestinal infections and respiratory muscle
\ntesting. Challenges remain in the Samoan
\nmedical community to engage its members
\nPartnership Initiatives Herald a New Phase
\nfor the Samoa Medical Association
\nJudy McKimm Monalisa Punivalu Ben Matalavea Tia Vaai Surindar Cheema
\n75
\nRegional and NMA news
\nto conduct clinical research and publish
\nthe findings, however the launch of a local
\njournal, plus support from OUM and other
\neducational providers will help to develop
\nand drive local research capacity in Samoa
\nand the region instead of relying on over-
\nseas researchers. International researchers
\nwho have an interest in tropical medicine in
\nthe South Pacific can look forward to col-
\nlaboration with OUM and the energised
\nSMA to engage the international research
\ncommunity by publication of the data in the
\nSamoa Medical Journal and other interna-
\ntional publications.
\nOrganizing and holding medical confer-
\nences is another opportunity to further sup-
\nport the SMA and the university\u2019s objective
\nof promoting and developing medical re-
\nsearch,and updating and sharing of medical
\nand health information. Such conferences
\nwill highlight the health challenges and
\npriorities of Samoa and the region but also
\npresent a platform for both local present-
\ners and invited regional and international
\nexperts to share research findings and clini-
\ncal practice and become better informed on
\ncurrent,evidence-based medical knowledge.
\nA medical conference with the theme Heart
\nDisease in Samoa is planned for 23rd
\nand 24th
\nApril 2010. The second issue of the Samoa
\nMedical Journal is scheduled to be pub-
\nlished alongside the conference.
\nJudy McKimm, Professor of Oceania
\nUniversity of Medicine
\nDr. Monalisa Punivalu , Associate Professor
\nof Oceania University of Medicine
\nDr. Ben Matalavea, Editor in
\nChief, Samoan Medical Journal
\nDr. Tia Vaai, President Samoan
\nMedical Association
\nSurindar Cheema, Professor of
\nOceania University of Medicine
\nTriana Darmayanti Akbar
\nIndonesia faces the same health problems as
\nother developing countries, which are cur-
\nrently fighting against infection, malnutri-
\ntion and perinatal problems, not to mention
\nnatural disasters such as tsunami and earth-
\nquakes. Malnutrition is still a major issue in
\nIndonesia, even in its capital city, Jakarta.
\nCommon diseases such as dengue fever,
\ntuberculosis, malaria, food poisoning and
\nmalnutrition still exist in varying degrees in
\ndifferent provinces.
\nAt a national level, in 2007 there were 4.1
\nmillion cases related to nutrition and mal-
\nnutrition issues. Alongside the high preva-
\nlence of communicable diseases such as
\ntuberculosis, malaria, dengue hemorrhagic
\nfever and measles, Indonesia is also facing
\nnon-communicable diseases (NCD) such as
\ncardiovascular disease (CVD), diabetes and
\nhypertension. In 2007 the Indonesian Insti-
\ntute of Health Research and Development
\nindicated that 31.7% of Indonesians suffer
\nhypertension (the most common NCD)
\nand 7.2% suffer CVD.
\nIndonesian health levels are still below
\nthose of other Southeast Asian countries
\naccording to basic health indicators, such
\nas Infant Mortality Rates (IMR) and Ma-
\nternal Mortality Ratio (MMR). In 2007,
\nIndonesia\u2019s IMR was 34 per 1,000 live
\nbirths, and its MMR was 228 per 100,000
\nlive births. Meanwhile, Indonesia\u2019s Hu-
\nman Development Index (HDI) ranking
\nwas 107\u2014below Thailand (78), Malaysia
\nin (63), Vietnam (105) and the Philip-
\npines (90). Even though the trends for
\nboth indicators are improving, the figures
\nhave not changed significantly. In terms
\nof communicable diseases, Indonesia
\nranks third for tuberculosis after India
\nand China. This disease should have been
\neradicated.
\nA more significant issue is Indonesia\u2019s
\nhealth budget. Health expenditure in In-
\ndonesia was equivalent to 2.8% of its GDP
\nin 2003 which was considerably less than
\nthat of Thailand (3.5%) or Malaysia (4.2%).
\nThere have been no major changes in these
\nfigures since.
\nThe Indonesian Medical Association (IMA)
\nplays a very important role in improving
\nhealth status in Indonesia. The Indonesian
\nDoctors bond was founded in 1911, sur-
\nvived the period of Japanese occupation
\n(1943-1945), and has evolved into its cur-
\nrent national organization. Led by Dr. Prijo
\nSidipratomo, the newly-elected President,
\nthe IMA organizational structure also con-
\nsists of an advisory board and a number of
\ncommittees and agencies through which
\nspecialists\u2019 associations in Indonesia can
\njoin.
\nHaving a vision of making IMA a national
\nmedical professional organization which
\ncould play a very important role in the Asia
\nPacific region by 2020 and missions:
\n1) endeavouring ethical professional capa-
\nbilities;
\nA Glance at Indonesian Health and the
\nIndonesian Medical Association
\n76
\nRegional and NMA news
\n2) developing a meaningful role in im-
\nproving health status of the Indonesian
\npeople;
\n3) forwarding aspirations, seeking the
\nwelfare and providing protection to all
\nmembers;
\n4) developing professional service stan-
\ndards,ethical standards and the fight for
\nprofessional freedom which are capable
\nof aligning the professional develop-
\nment of science and medical technol-
\nogy with the demands and needs of the
\ncommunity.
\nIMA has as its main goal integrating all the
\npotential of Indonesian doctors, enhanc-
\ning dignity and honour of themselves and
\nthe medical profession, developing science
\nand medical technology, and improving the
\nhealth of the people of Indonesia to become
\na healthy and prosperous society.
\nIn order to fulfill the IMA\u2019s vision, mission
\nand goals,there are a number of changes that
\nmust be implemented in Indonesia. First,
\nthe low levels of health spending should
\nbe increased because of rapid population
\ngrowth, the need for poverty alleviation and
\nan aging population. The 2009 Indonesian
\nHealth Ministry budget was approximately
\nRp 18 trillion (approximately $1.96 mil-
\nlion). Of this total, 48.5% was allocated for
\ncurative and medicine operational costs,
\n15.8% for public health, and only 7.7%
\nfor communicable and non-communicable
\ndisease programs. Indonesia needs to shift
\nthe focus of the health platform from cura-
\ntive programs toward health promotion and
\nprevention; therefore, the IMA has been
\nendorsing the empowerment of general
\npractitioners and family doctors to practice
\nactive health promotion, the management
\nof integrated referral systems, the accel-
\neration of National Social Security System
\nimplementation,and a range of other health
\nand medical efforts,including much-needed
\nimprovements to disaster management.
\nTriana Darmayanti Akbar, MD,
\nVice Secretary General II
\nIndonesian Medical Association
\nJacques de Haller
\nCurrently in its 110th year of existence, the
\nFoederatio Medicorum Helveticorum (FMH),
\nor Swiss Medical Association,has continued
\nto show foresight in its advocacy on behalf
\nof physicians practising in Switzerland. It
\nfosters collaboration among all stakehold-
\ners in the Swiss healthcare system and has
\nconsistently, energetically, and successfully
\ndefended physicians\u2019 rights to the freedoms
\nnecessary to practice of their profession. For
\ninstance, in the summer of 2008 the FMH
\nresolutely opposed the proposed article in
\nthe Swiss constitution \u201cfor more quality
\nand cost-effectiveness in medicine,\u201d which
\nthreatened patients\u2019 freedom to choose
\ntheir physician and would have resulted in
\nhealth funds being managed exclusively by
\nhealth insurance companies.With the cam-
\npaign \u201cNEIN zum Kassendiktat\u201d (\u201cNO to
\nhealthfund supremacy\u201d), and thanks to the
\noverwhelming support of its members and
\na broad alliance of political parties, profes-
\nsional medical organisations, patients, and
\nconsumers, voters soundly rejected this
\nproposal, to the benefit of both Swiss physi-
\ncians and patients.
\nSound arguments \u2013 strong
\ncommunity of physicians
\nReliable statistical data are of paramount
\nimportance, which is why physicians\u2019 de-
\nmography has been a key priority of the
\nFMH from the outset. FMH statistics on
\nphysicians provide information on more
\nthan 30,000 doctors practising in Switzer-
\nland (status: March 2010). For many years,
\nstatistics on physicians focused exclusively
\non social attributes and qualifications; how-
\never, the working conditions of the Swiss
\nhealthcare system have changed in recent
\nyears \u2013 for example, many physicians no
\nlonger work exclusively in a practice but
\nalso part-time in a hospital. In addition,the
\nproportion of physicians with family com-
\nmitments is growing.
\nAccordingly, the FMH revised its annual
\nstatistics and since 2008 has conducted dif-
\nferent surveys among its members according
\nto their outpatient and\/or inpatient activity.
\nAs a result, the statistics now provide more
\ndetails and convey important distinctions
\nregarding place of work, full-time equiva-
\nlency and the content of the activities. This
\nenables actors in the healthcare sector to
\nmonitor developments more closely, re-
\nspond in good time to shortages of supply,
\nand offset surplus capacities.
\nSetting the agenda for
\nSwissDRG and for eHealth
\nThe FMH does more than just provide
\nplanning instruments; for example, it also
\nsupports projects such as SwissDRG and
\neHealth. Swiss hospitals have until the
\nend of 2011 to convert their billing for
\npatient hospitalisation to the SwissDRG
\nFMH \u2013 Faithful to its Motto:\u201cNo Healthcare
\nPolicy without the FMH!\u201d
\n77
\nRegional and NMA news
\ndiagnosis-based system. The organisation
\nresponsible for setting up and managing
\nthis system is SwissDRG AG, a non-profit
\ncompany co-founded by FMH. By the end
\nof 2009, FMH had worked with medical
\nassociations and experts to solicit sugges-
\ntions for improvements to the system and
\ndevelop a concept for clinical research to
\naccompany SwissDRG\u2019s launch: early
\nevaluation is necessary in order to identify
\nfalse incentives and introduce corrective
\nmeasures rapidly. In accordance with this
\nprinciple, an initial concrete, practicable
\nproposal for related research is now in
\nplace.
\nThe Swiss Confederation\u2019s eHealth strategy
\narticulates ambitious healthcare objectives:
\n\u201cBy the end of 2010, secure authentication
\nand a legally valid electronic signature will
\nbe available for all service providers [\u2026]
\nBy the end of 2012 the electronic trans-
\nfer of medical data between members of
\nthe healthcare system will be structured
\n[\u2026].\u201d Consequently, FMH activities over
\nthe past two years have been dominated
\nby the development of eHealth concepts.
\nIn this regard, FMH has positioned itself
\nas an essential partner and has channelled
\nits concerns to various actors in the health-
\ncare sector so as to ensure that the needs
\nof physicians are taken into consideration.
\nMoreover, by issuing a Health Professional
\nCard to all physicians, it made an impor-
\ntant contribution to the national eHealth
\nstrategy and set a national standard, suc-
\ncessfully asserting the independence of
\nphysicians within the national eHealth
\ninfrastructure. Thanks to close ties with its
\nmembers and good relations with policy
\nmakers, the media, and other actors in the
\nhealthcare sector, it remains a confident
\nadvocate of its members\u2019 interests in all ar-
\neas of Swiss healthcare.
\nDr. Jacques de Haller,
\nPr\u00e9sident of the Swiss Medical Association
\nMikul\u00e1\u0161 Buzg\u00f3
\nThe Slovak Medical Chamber (SMC) is an
\nindependent medical professional organiza-
\ntion whose objective is to meet the needs of
\nits members. It also supervises professional
\nand ethical performance of physicians in
\nSlovakia. Seventy-five percent of all doc-
\ntors in Slovakia (15,384 doctors) from all
\nbranches of medicine are members of the
\nSMC.
\nThe historical roots of the SMC go back to the
\nAustro \u2013 Hungarian Monarchy where a law
\non the establishment of medical chambers was
\nissued in 1891. Later on, after the establish-
\nment of the Czechoslovak Republic in 1918,
\nactivities continued until the beginning of the
\ncommunist regime. However, communists in
\nEastern Europe did not tolerate any non-gov-
\nernmental self-regulation so they suspended all
\nChambers\u2019activities. They were restarted after
\nmajor political and social changes in Czecho-
\nslovakia in 1989. The Slovak Medical Cham-
\nber was then re-established by law in 1990.
\nThe SMC is a corporate body that is inter-
\nnally subdivided into eight Regional Medi-
\ncal Chambers \u2013 each in one of the eight
\nself-governing territorial units. The Central
\nSecretariat of the SMC is located in Brat-
\nislava. It is led by Secretary General, Mrs.
\nDaniela Resutikova. The eight Regional
\nSecretariats are an integral part of the Cen-
\ntral Secretariat.
\nThe SMC is responsible for registration of
\nall physicians who wish to practice medi-
\ncine in Slovakia. At the moment there are
\n21,586 (12,466 female and 9,120 male)
\ndoctors registered by SMC. From this
\nnumber, 2,671 are not currently practicing
\nin Slovakia (due to retirement, maternity
\nleave, working abroad).
\nThe SMC acts also as a licensing body and
\ndisciplinary body. It supervises continuing
\nmedical education (CME) which is obliga-
\ntory in Slovakia for all doctors, who must
\naccrue 250 CME credits during a five-year
\nperiod. One of the major recent tasks of the
\nSMC is the E-Learning for Doctors Project
\nsupported by European Social Fund. The
\naim of this project is to make continuing
\nmedical education easier and more acces-
\nsible for all doctors.The SMC is an advisory
\nbody for all its members in legal, economic,
\nand professional issues. Moreover, the orga-
\nnization is involved in the process of eco-
\nnomical negotiations with health insurance
\nbodies and comments on legislative propos-
\nals.The SMC does not act as a trade union.
\nAccording to its statute, the highest body of
\nthe SMC is the General Assembly, which
\ndetermines SMC policies. Other impor-
\ntant elected structures are: the board, the
\ncouncil, controlling committee and disci-
\nplinary committee. The members of these
\norgans are elected for a four- year period.
\nThe SMA also elects a president and two
\nSlovak Medical Chamber
\n(Slovensk\u00e1 lek\u00e1rska komora)
\n78
\nRegional and NMA news
\nvice-presidents. In the most recent election
\nin 2008, Prof. Milan Dragula was re-elected
\nas the president.
\nInternational activities of the SMC include
\nthe membership in WMA, the Standing
\nCommittee of European Doctors (CPME)
\nand the European Association of Senior
\nHospital Physicians (AEMH). There is in-
\ntensive and fruitful communication espe-
\ncially with medical organizations in neigh-
\nbouring countries.
\nSlovakia with 5.3 million inhabitants be-
\ncame an EU member state in 2004. Since
\nthen the Slovakian health system has been
\nfacing new tasks and challenges. Consid-
\nerable migration of doctors to other EU
\ncountries has resulted in workforce shortage
\nin some specialties. Hence the SMC has a
\ngreat interest in creating a quality profes-
\nsional environment for doctors in order to
\nenhance attractiveness of the medical pro-
\nfession in Slovakia. It is the basic condition
\nfor increasing the quality and safety of Slo-
\nvak health care and thus the EU level.
\nMikul\u00e1\u0161 Buzg\u00f3, Vice-president
\nSlovak Medical Chamber
\nThe National Medical Association of the Re-
\npublic of Kazakhstan was established in Feb-
\nruary 1990. Entitled the Association of Physi-
\nciansandPharmacistsofKazakhstan(KzMA),
\nit is voluntary, self-governing, professional,
\npublic nongovernmental organization, uniting
\nphysicians. It has more than 60 branches and
\nrepresentatives in oblast (regional) centers and
\nmany large cities of Kazakhstan.
\nThe main purposes of the association are:
\nto promote the recognition of the medical
\nprofession based on the highest levels of
\nprofessionalism, humanism, and charity; to
\nparticipate in medical science development
\nand practice to ensure the health of the
\npopulation; to support development of the
\nnongovernmental health sector; and to or-
\nganize and implement charitable programs.
\nFull membership is open to the physicians
\nof Kazakhstan. Honorary members include
\nphysicians of Europe and CIS countries.
\nStudents of medical institutions of Kazakh-
\nstan are welcomed as \u201cjoining members\u201d.
\nDuring its 20-year history, the National
\nMedical Association has implemented the
\nfollowing activities:
\nInteracted with different ministries and\u2022
\ngovernmental bodies
\nRepresented the interests of the members\u2022
\nof the NMA in governmental,internation-
\nal and nongovernmental organizations
\nProtected the rights and interests of their\u2022
\nmembers experiencing conflict situations
\nand legal proceedings
\nImplemented publishing activities, in-\u2022
\ncluding issuing the medical magazine
\n\u201cAve Vitae\u201d – a collection of conferences
\nmaterials
\nPrepared and executed weekly pro-\u2022
\ngramme \u201cDensaulyk\u201d (Health) on TV for
\nfrom 1996-2000
\nInitiated establishment of the Almaty Cura-\u2022
\ntive Centre, institute of post-graduate edu-
\ncation for psychologists and physicians
\nServed as Chairs of \u201cMedical psychology\u201d\u2022
\nand \u201cMedical Rights and Bioethics\u201d to-
\ngether with the Almaty Medical Institute
\nof Advanced Studies
\nConducted local, national, and interna-\u2022
\ntional conferences on health issues
\nActively introduced independent exper-\u2022
\ntise in the health system
\ncreated Committee on Ethics and-
\nRights in 1995
\ncreated database of independent ex–
\nperts in 2000
\npassed accreditation of the Ministry of-
\nHealth (MoH) of the Republic of Ka-
\nzakhstan in 2008
\nFounded the avenue \u201cAve Vitae\u201d in Al-\u2022
\nmaty, devoted to the memory of physi-
\ncian-solders
\nDevelopment of Ethical Code of Phy-\u2022
\nsicians of the Republic of Kazakhstan,
\nhymn and oath
\nEstablished awards:\u2022
\nThe best physician of the NMA (Altyn-
\nDeriger)
\nThe best clinic of the year-
\nNMA representatives are members of the
\nNational Coordination Council on Health
\nCare under the government of the Repub-
\nlic of Kazakhstan, the MoH\u2019s Board and its
\nCommission on Attestation, Conflict Situ-
\nations, Awards and Commissions of Local
\nExecutive Bodies. They are also members
\nof the Akimat\u2019s Commissions on Narcoma-
\nnia and Narcobusiness Control, Family and
\nWomen, and Support of Small Business.
\nInternational collaboration
\nIn addition to maintaining close contact
\nwith National Medical Associations of Eu-
\nrope and Asia,our organization is a member
\nof several international groups:
\nMember of the European Forum of\u2022
\nMedical Associations (since 1994)
\nMember of the Eurasian Forum of Medi-\u2022
\ncal Associations (since 1997)
\nMember of the World Medical Associa-\u2022
\ntion (since 2003)
\nMember of the\u2022\t European Forum for
\nGood Clinical Practice (since 2003)
\nThe 2010 General Assembly of National
\nMedical Association of the Republic of Ka-
\nzakhstan, on the theme \u201cRight for Health,\u201d
\nwill take place in Almaty, 12-14 May, a date
\ncommemorating the 65th
\nAnniversary of the
\nSecond World War.
\nDr. Aizhan Sadykova,
\nPresident of National Medical Association
\nof the Republic of Kazakhstan
\nThe National Medical Association of the
\nRepublic of Kazakhstan
\n79
\nRegional and NMA news
\nHeikki P\u00e4lve
\nThe European Union (EU) has 27 member
\nstates that have common legislation in many
\nareas and cooperate closely in many others.
\nThe core principle of EU is to create a func-
\ntioning internal market and enhance the
\nfree movement of persons, goods, services
\nand capital. In the health field, the mandate
\nof the EU has substantially increased over
\nthe last two decades.Nevertheless,the man-
\ndate is still limited, taking into account the
\nsubsidiarity principle according to which
\nmatters ought to be handled by the smallest,
\nlowest or least centralized competent au-
\nthority, i.e. by sovereign countries. All in all,
\nmany decisions on public health and health
\nservices are made at the EU level, and have
\neffect on national health systems.
\nIn this context, the significance of Europe-
\nan medical organisations (EMOs) is greater
\nthan ever.There are various topics of EU co-
\noperation that influence medical profession.
\nFree movement of health care personnel is
\nalready regulated at the EU level. Currently
\nthere are discussions on the EU legislation
\non free movement of patients, safety of or-
\ngan donations, and better collaboration on
\nmedicinal products, just to mention few.
\nIncreasing EU level cooperation in the
\nhealth sector emphasises the importance of
\na unfied voice of physicians.Common views
\nhave more power and influence on the de-
\ncision making of the EU. The European
\nCommission consults widely with different
\nstakeholders when considering new initia-
\ntives. It is important for the Commission to
\nknow who to contact if it wants to hear the
\nopinion of European doctors.
\nFor many years, that contact point has been
\nthe Standing Committee of European Doc-
\ntors (CPME),which is an international,not
\nfor profit association and represents the Na-
\ntional Medical Associations (NMA) of all
\nthose EU member states who are members.
\nThe CPME aims to promote the highest
\nstandards of medical training and medi-
\ncal practice in order to achieve the highest
\nquality of health care for all patients in Eu-
\nrope. The CPME is well recognised by the
\nEU institutions.
\nIn addition to the CPME, however, there
\nare numerous specialised European medi-
\ncal organisations where the member states\u00b4
\nrepresentation is more varied. National
\nMedical Associations are not always rep-
\nresented in the specialised EMOs. In sum-
\nmary, NMAs are represented in the EMOs1
\nin the following way:
\nCPME (Standing
\nCommittee on Eu-
\nropean Doctors)
\n27
\n(NMAs)
\n\/27
\n(coun-
\ntries)
\n100 %
\nPWG (Permanent
\nworking group of
\nEuropean Junior
\nDoctors)
\n10\/20 50 %
\n1 Only full membership is taken into account in
\nthis table.
\nUEMO (European
\nUnion of General
\nPractitioners)
\n16\/21 76,2 %
\nUEMS (European
\nUnion of Medical
\nSpecialists)
\n23\/29 79,3 %
\nCEOM (Conf\u00e9-
\nrence Europ\u00e9en
\ndes Ordres des
\nM\u00e9decins)
\nMem-
\nbership
\ncannot
\nyet be
\ndefined
\nFEMS (European
\nFederation of Sala-
\nried Doctors)
\n3\/10 30 %
\nAEMH (Euro-
\npean Association
\nof Senior Hospital
\nPhysicians)
\n10\/15 66,7 %
\nEANA (European
\nWorking Group of
\nPractitioners and
\nSpecialists in Free
\nPractice)
\n5\/14 35,7 %
\nLately, the relationship among the different
\nEuropean medical organisations has been
\nunder intense discussion, especially in the
\ncontext of how best to come together to
\nmost effectively influence EU law and policy.
\nLike the majority of National Medical As-
\nsociations in Europe, the FMA\u2019s approach
\nto this objective on the national level is to
\nobtain the views of different groups, such
\nas specialists, general practitioners, young
\nand senior doctors, etc., and then develop a
\nconsensus position to represent to the gov-
\nernment. It will be a challenge to replicate
\nthis approach at the EU level, however it is
\na crucial effort we must undertake.
\nCurrently we face the threat that EU de-
\ncision-makers are able to poll the various
\ngroups individually, select the response that
\nbest suits their purpose, and then claim to
\nhave incorporated the physicians\u2019 viewpoint
\ninto their decisions\u2013even if that viewpoint
\ndoes not represent the majority perspective
\nof the NMAs but rather a subgroup of doc-
\nChallenges of the European Medical
\nOrganisations
\n80
\nCorrespondence
\nIn the October 2009 issue of World Medical
\nJournal there was a long article by Dr. Na-
\nriman Safarli entitled \u201cEthical, Moral, and
\nLegal Responsibilities of Physicians: an
\nIslamic Perspective.\u201d I wonder if I am the
\nonly reader who was dumbfounded that the
\neditors chose to print this article. I found it
\nto be woefully silent on the ways in which
\nIslamic law contradicts basic human rights,
\n(never mind the responsibilities of physi-
\ncians), inaccurate and condescending in its
\ncharacterization of secularized medicine\/
\nphysicians, a thinly veiled attempt at reli-
\ngious proselytizing, and xenophobic.
\nDr. Safarli writes that \u201cIslamic Law (Sha-
\nriat) is comprehensive and encompasses
\nmoral principles directly applicable to med-
\nicine.\u201dWhat he doesn\u2019t mention is that Sh-
\nariah law prescribes barbaric punishments
\nlike amputation of the hands, blinding,
\nflogging and stoning to death for \u201ccrimes\u201d
\nas varied as homosexuality, thief drinking
\nalcohol, and extra-marital sexual relations.
\nIndeed, in this same issue of the World
\nMedical Journal, under Human Rights, we
\nare told of two physicians who were sen-
\ntenced in Saudi Arabia to 1500 and 1700
\nlashes (and prison terms of 15 and 20 years)
\nfor allegedly facilitating the addiction of a
\npatient who was prescribed morphine for
\npain after trauma. Attention is also drawn
\nto an Iranian man who was sentenced to be
\nblinded in both eyes with acid – \u201ca process
\nthat would involve medical professionals.\u201d
\nWhat \u201cmoral principle\u201d could possibly jus-
\ntify such unspeakable cruelty, never mind
\nthe involvement of physicians?
\nShariah law perpetuates the oppression of
\nwomen. Under Shariah law a husband has
\nthe moral and religious right to beat his
\nwives and children for disobedience or for
\nperceived misconduct. A woman\u2019s testimo-
\nny in court is accorded half the value of a
\nman\u2019s.
\nDr.Safarli writes:\u201cI know that the most im-
\nportant thing for a Muslim doctor is to be
\ninterested in the basic values and principles
\nof Islam…\u201d He contrasts this with \u201csecular
\nethics\u201dwhich \u201care framed by a society which
\nis fickle, inconsistently ruled by a majority
\nvote and devoid of religious restrictions.\u201d
\nHe posits that \u201csecularized medicine has no
\nconsistent set of ethics regarding malprac-
\ntice, fraud, and bias in research.\u201d
\nHe writes that a secular physician turns \u201ca
\nblind eye to the moral and social issue of
\nthe day\u201d. Has he never heard of Drs. Lown
\nand Chazov, two secular physicians who ac-
\ncepted the Nobel Peace Prize on behalf of
\nInternational Physicians for the Prevention
\nof Nuclear War? These men, one Ameri-
\ncan, one Russian, organized hundreds of
\nthousands of physicians to oppose nuclear
\nweapons and to educate the public about
\nthe horrors of nuclear war.
\nContrast the good which these secular phy-
\nsicians accomplished with the deeds of the
\nMuslim physician Ayman al-Zwarahiri who
\nmasterminded the slaughter of thousands of
\ncivilians on September 11, 2001. Contrast
\nthem with another Muslim physician,Nidal
\nMalik Hasan, who opened fire on a group
\nof unarmed individuals at an army base in
\nTexas, killing 13 and wounding 28.
\nDr. Safarli ends his article: \u201cTo conclude,
\nthe role of the Muslim doctor is briefly to
\nput his or her profession in service of the
\npure religion Al-Islam\u2026\u201d (emphasis mine).
\nHere Dr. Safarli implies that other religions
\nare somehow not pure, or are less pure than
\nIslam. I find this offensive in the extreme,
\nand blatantly xenophobic. I remain puzzled
\nas to why the editors thought this article
\nwas appropriate for the World Medical
\nJournal which is read by people of multiple
\nfaiths and no doubt by many who have no
\nreligious faith at all. I know I am not the
\nonly reader who was offended by many of
\nthe statements in this article and I would
\nbe most interested in hearing Dr. Safarli\u2019s
\nresponse.
\nBarbara H. Roberts, MD, FACC Director,
\nThe Women\u2019s Cardiac Center at The Miriam
\nHospital Contributing Editor, Women\u2019s
\nHeart Health, ProCOR Associate Clinical
\nProfessor of Medicine Warren Alpert
\nMedical School of Brown University
\nAuthor\u2019s response
\nIt is was very annoying, at this time of con-
\nstructive and harmonious exchange of thoughts
\nand dialogue for human welfare, to encounter
\nsuch unbalanced attacks against freedom of
\nexpression of though and culture. Dr. Roberts
\nconfused between issues in a non-scientific and
\nnon-logical manner. She has mixed ethical
\nguidelines of genuine Islamic Law (Shari\u2019ah),
\nLetters to the Editor
\n\u201cEthical, Moral and Legal Responsibilities of Physicians:
\nAn Islamic perspective.\u201d World Medical Journal. 2009; 55(3): 107-8.
\ntors represented only by some individual
\ncountries. We must, therefore, strengthen
\nthe position of the NMAs on the European
\nlevel and develop an organizational model
\nfor EMOs that has a formalized structure
\nand the objective of creating a unified voice
\nfor physicians. It is through such a collabo-
\nrative structure that we will to be able to
\nmost effectively leverage our collective in-
\nfluence at the EU level.
\nHeikki P\u00e4lve, CEO
\nFinnish Medical Association
\n81
\nCorrespondence
\nwhich she describes as barbaric, with other con-
\ntemporary practices in some Muslim countries,
\nwomen\u2019s issues, polygamy, September 11\u2026.
\netc, issues that can be dissected and discussed
\nseparately in a clam, scientific and constructive
\nmanner.
\nIt is amazing how an associate clinical profes-
\nsor in a respectable medical institution allows
\nherself to tackle major issues of ethics and cul-
\nture in this narrow mended, non-scientific ap-
\nproach. Not only she allowed her self to contra-
\ndict freedom of expression of views and values,
\nwhich may differ from her\u2019s, using a language
\nloaded with dogma and hatred, she also harshly
\nattacked the editorial board of the Journal twice
\nin her Letter!.
\nOur published article tried to present the broad
\nconcept of Islamic bioethics,which was practiced
\nduring many centuries of Islamic medical civi-
\nlization. A code of medical conduct that looked
\nat the medical profession as the most noble of
\nall professions, in view of its intimate relations
\nwith human health, diseases, life and death.
\nPhysicians from other faiths could present any
\navailable systems of bioethics, in an effort to
\ndiscuss, harmonize and improve on the status
\nof bioethics which needs care and improvement.
\nAll those contributions should be looked upon
\nwith respect and should not be ridiculed or at-
\ntacked.
\nWhen we study the history of bioethics in past
\nand contemporary eras, it becomes clear that
\npeople have always cared about bioethical de-
\nviations. Ethical codes have been designed and
\nmodified in efforts to combat ethical deviations
\nand professional misconduct. The Declaration
\nof Helsinki, for example, was modified many
\ntimes since its adoption by the World Medical
\nAssociation. But with all these efforts, bioethi-
\ncal deviations continued, and proliferated un-
\nabated.
\nIn front of me, there is a multitude of many,
\nmany examples of unethical deviations. One
\nexample took place for almost 40 years in the
\ncity of Tuskegee-Alabama, where black patients
\nsuffering from syphilis, were intentionally left
\nwithout treatment from the early 1930s to the
\nlate 1970s, in order to study the natural course
\nof the disease in its various stages.
\nThe Worldwide proliferation of medical in-
\nventions and breakthroughs that took place
\nover the past several decades, have raised wide
\nhopes and expectations, but at the same time,
\nthey have posed major dilemmas from ethical,
\nreligious, social and legal points of view, which
\nshould receive attention and efforts to improve
\nethical codes.
\nIn my article, I have tried to outline the concept
\nof combining scientific medical education togeth-
\ner with proper upbringing on faith and values.
\nPast Islamic Medical Civilization was successful
\nin doing so,with a remarkable record in combat-
\ning ethical deviations.
\nSuch medical deviations usually stem from the
\nmaterialistic outlooks of physicians that mar-
\nginalize spiritual and ethical aspects of medical
\ncare.
\nThe influence of globalization and big busi-
\nness on the medical profession always pushes
\ntowards materialistic gains, waste and cost.
\nSuch ethical and behavioral aberrations have
\ntheir roots in neglecting faith and accountabil-
\nity in the hearts and minds of physicians and
\nresearchers.
\nThis is the message from the article, which was
\nwritten in good faith, to improve the current
\nstatus of bioethics. We stand for human values
\nand look for harmony and collaboration be-
\ntween cultures and other ideas.
\nSincerely yours, Dr. Nariman Safarli
\nPresident, Azerbaijan Medical Association
\nThe world medical and health games are a
\ngathering for health professionals that al-
\nlow them to compete in various sports in a
\ncongenial and fun atmosphere. Whatever
\nyour level or age,come and share with your
\ncolleagues your passion for sport !
\nMore than 30 editions,\u2022
\nAn 8 day event in an exceptional setting,\u2022
\nOver 2000 participants coming each year\u2022
\nfrom 40 countries,
\n22 sports in an Olympic spirit,\u2022
\n5 age categories,\u2022
\nAn international sports competition with\u2022
\na professional organization,
\nAn International Sports Medicine Sym-\u2022
\nposium,
\nA nations parade,followed by a spectacu-\u2022
\nlar opening ceremony,
\nAn amazing closing ceremony lasting all\u2022
\nnight long,
\nGreat entertainment every day,\u2022
\nYou have all been waiting for this for a
\nlong time: the World Medical and Health
\nGames are finally going to Croatia!
\nFrom the 3rd till the 10th of July, we will
\ntake you to the heart of the beautiful region
\nof Istria.
\nSportsmen or not,with friends or family,we
\npromise that you will experience an unfor-
\ngettable stay!
\nDo not waste any more time and come and
\nregister online on www.medigames.com!.
\nOur team is always available for further in-
\nformation, by e-mail at info@medigames.
\ncom or by phone at +33 (0) 1 77 70 65 15.
\nThe WMHG\u2019s team
\nThe World Medical and Health Games
\n82
\nWMA news
\nThe financial crisis has affected economies
\non a global scale. While some countries
\nhave experienced no more than a tempo-
\nrary decline, other countries are still in deep
\nrecession leading to practical insolvency.
\nDespite the crisis many national health care
\nsystems have maintained their stability and
\nhave been only moderately affected, while
\nothers have experienced direct budgetary
\ncuts of up to 30 % which jeopardize essen-
\ntial health care services in some areas.
\nIn order to discuss the implications of the
\nfinancial crises on health World Medical
\nAssociation in cooperation with Latvian
\nDoctor\u2019s Association is planning to hold a
\ntwo days\u2019 conference \u201cThe Financial Crisis \u2013
\nImplications for Health Care. Lessons for the
\nfuture\u201d. The Conference will take place in
\nRiga, Latvia on 10th and 11th, September,
\n2010.
\nObjectives
\nHow severely are different health care sys-
\ntems affected by the crisis? (Regional expe-
\nriences from different countries)
\nHow do health care and economy interact
\nduring a crisis? (Are health care systems no
\nmore than an economic burden,or may they
\nbe seen as playing a stabilizing role?)
\nWhat can we learn from the crisis? What
\nmakes health care systems immune against
\neconomic crisis? (Are there best practices\/
\nsolutions to keep health care systems per-
\nforming?)
\nWhat are the consequences for health care
\nreforms? How can health care systems be
\nstructured and managed to be less sensi-
\ntive to crisis and play a stabilizing role in
\neconomy?
\nParticipants
\nThe Conference is open to National Medi-
\ncal Professional organizations and. Health
\nCare Management Staff. It is expected to
\nconvene between 300 and 400 profession-
\nals from Europe, Asia and America. The
\nConference representing the views of health
\nexperts and health professionals will pro-
\nvide an overview of the major threats and
\nchallenges for health systems caused by the
\neconomic crisis based on evidence drawn
\nfrom international experience and research.
\nKey problems and challenges faced by the
\nhealth systems in Europe and globally will
\nbe identified and responses that countries
\nso far have developed in addressing these
\nproblems and challenges will be outlined.
\nThe Conference participants will look into
\nsome priority areas to assess the impacts of
\neconomic recession and to explore effective
\npolicies in resolving the major problems
\ncreated. The aim of the conference is to
\nserve as a learning tool for finding the best
\npossible solutions in order to lead health
\ncare systems out of the crisis and achieve
\nbetter progress in improving public health
\nand faster recovery of economies.
\nMore information about the conference will
\nbe available at www.riga-wma.lv .
\nWe are looking forward to meeting you in
\nRiga and we promise you a great seasonal
\nexperience in Latvia.
\nWelcome to Riga!
\nFinancial Crisis \u2013 Implications for Health
\nCare Lessons for the Future
\nConference of the World Medical Association
\nSeptember 10\u201311, 2010, Riga, Latvia
\n83
\nIn memoriam
\nDr. Jo Asvall, former WHO Regional Di-
\nrector for Europe, died on 10th
\nFebruary
\n2010.
\nDr. Asvall had a long and distinguished
\ncareer qualifying in medicine in 1956, and
\nvery early in his career, headed up WHO\u2019s
\nmalaria team in Benin, Cameroon and
\nTogo. Returning to Norway in 1963, he
\ntook up a hospital post, becoming increas-
\ningly engaged in clinical management and
\nhospital administration, in 1973 becaming
\ndirector of the Hospital department in the
\nNorwegian Ministry of Social Affairs He
\njoined the WHO European Regional Of-
\nfice in 1976 as Officer for Country Health
\nPlanning, becoming Director Programme
\nManagement in 1979 he was appointed
\nRegional Director in 1985,serving in this
\npost for the next 15 years.
\nDr. Asvall particularly recognised the im-
\nportance of engaging the medical profes-
\nsion in understanding and implementing
\nthe \u201cHealth For All\u201d initiative. The initia-
\ntive to engage the profession started in
\n1984 with a meeting in Copenhagen un-
\nder Dr. Caprio his predecessor. In the fol-
\nlowing months when he became Regional
\nDirector in 1985 Dr. Asvall pursued this
\ninitiative, although in the initial years it
\nwas greeted with some scepticism by a
\nfew western European National Medical
\nAssociations\u2019(NMAs) leaders . This was
\nsubstantially due to misunderstanding and
\nfailure to recognise the political constraints
\nwithin which the RD worked at that time.
\nHowever, it ultimately led to a mutual un-
\nderstanding, respect and to increasingly
\nfruitful engagement between EURO and
\nNMA\u2019s in meetings right across the region
\ndefined as the European Forum of Medical
\nAssociations and European Region office
\nof WHO( EFMA\/WHO) Subsequently
\nsimilar bodies were created for Nurses
\nand Midwives, and for Pharmacists, all of
\nwhich still are active.
\nThrough these meetings NMA\u2019s not only
\nlearnt and clarified their knowledge of
\nWHO policies agreed at Regional Com-
\nmittee Meetings by regional member
\nstates governmental representatives,as well
\nas their relevance to physicians at national
\nlevel. This also led to a better understand-
\ning of various aspects of the \u201cHealth for
\nAll\u201daims in the Regional plan and to some
\nsuccessful collaborative efforts. The other
\ngreat benefit derived from the EFMA\/
\nWHO meetings were that especially in
\nthe,1980\u2019s and early 1990\u2019s they provided
\nan opportunity for physicians from both
\neast and west of the European Region to
\nmeet and understand the strengths and
\nweaknesses of their various health care
\nsystems and their problems,While Dr.As-
\nvall\u2019s remarkable dynamism, genuineness
\nand enthusiasm which were always clear in
\nhis presentations at the Forum, sometimes
\nthey led to differences of opinion, strongly
\nexpressed by both parties. However this in
\nno way diminished the respect in which
\nhe was held by even the most critical of
\nhis opponents and often differences were
\nresolved by positive compromise and sup-
\nport. His approach to engaging National
\nMedical Associations was but one example
\nof his foresight in pursuing the aims of
\nWHO in the region, not only in devising
\nand pursuit of policies by also informing,
\neducating and engaging doctors and other
\nhealth professionals.,both individually and
\ncollectively in their application\u2026
\nUnsurprisingly, his retirement was a no-
\ntional one and he continued to be very
\nactive in many fields not only in public
\nhealth and health policy, but also as Direc-
\ntor of the Rehabilitation of Torture Vic-
\ntims in Copenhagen and many other areas
\nof activity The European Region,its medi-
\ncal and other health professions are greatly
\nin his debt and will miss the qualities of
\nleadership ,inspiration and the personality
\nof this physician.
\nDr. Alan J. Rowe
\nIn memoriam
\nJo E. Asvall (1931-2010)
\nWMA news
\n100th
\n-anniversary-festivities of the Finnish Medical Association
\nSports at all ages \u2013 for a healthy population . . . . . . . . . . 43
\nExploring Sustainable Systems to Document Torture \u2013
\nthe Role of Health Professionals . . . . . . . . . . . . . . . . 44
\nPhysicians Call for Elimination of Female Genital Mutilation 46
\nHealth Professions Consider the Future of Regulation . . . . 46
\nRevolutionary Transplant in University College London \u2013
\na world first. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
\nPfizer Launches Speaking Book in China
\non Dangers of Smoking . . . . . . . . . . . . . . . . . . . . 49
\nAccountability and Transparency: Two Pillars
\nof the Health Professions in the 21st
\nCentury . . . . . . . . . 50
\nPlacebo Controls in Clinical Trials . . . . . . . . . . . . . . 53
\nThe Climate Crisis, Global Health,
\nand the Medical Response . . . . . . . . . . . . . . . . . . . 56
\nKeeping the Lines of Communication Open \u2013
\nand Patient Safety First . . . . . . . . . . . . . . . . . . . . 59
\nEnd Water Poverty. . . . . . . . . . . . . . . . . . . . . . . 59
\nMultidrug-resistant Tuberculosis:Problems and Responses . . 60
\nHost of the 2012 WMA Congress and General Assembly . . 67
\nCMAAO, Over Fifty Years of History and Future Outlook . . 70
\nPartnership Initiatives Herald a New Phase
\nfor the Samoa Medical Association . . . . . . . . . . . . . . 74
\nA Glance of Indonesian Health
\nand the Indonesian Medical Association. . . . . . . . . . . . 75
\nFMH \u2013 Faithful to its Motto:
\n\u201cNo Healthcare Policy without the FMH!\u201d . . . . . . . . . . 76
\nSlovak Medical Chamber (Slovensk\u00e1 lek\u00e1rska komora) . . . . 77
\nThe National Medical Association
\nof the Republic of Kazakhstan . . . . . . . . . . . . . . . . . 78
\nChallenges of the European Medical Organisations . . . . . . 79
\nDiscusion about the article. . . . . . . . . . . . . . . . . . . 80
\nThe World Medical and Health Games . . . . . . . . . . . . 81
\nFinancial Crisis \u2013 Implications for Health Care
\nLessons for the Future . . . . . . . . . . . . . . . . . . . . . 82
\nIn memoriam . . . . . . . . . . . . . . . . . . . . . . . . . 83
\nContents<\/p>\n"},"caption":{"rendered":"

wmj26 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, Inc G20438 Nr. 2, April 2010 Placebo Controls in Clinical Trials\u2022 The Climate Crisis and Global Health\u2022 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv editorin-chief@wma.net Co-Editor Dr. Alan J. Rowe […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":940,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj26.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3597"}],"collection":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/comments?post=3597"}]}}