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wmj27<\/a><\/p>\n

vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, Inc
\nG20438
\nNr. 3, June 2010
\nWMA Secretary General\u2019s Report to 185\u2022 th
\nCouncil
\nThe History of the Placebo\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:
\nEmiliano Di Cavalcanti, Maternidade –
\n\u201cMotherhood\u201d, 1942, Oil Painting.
\nEmiliano Augusto Cavalcanti de Albuquerque
\nMelo (1897 \u2013 1976), known as Di Cavalcanti,
\nwas a Brazilian painter. He in 1926 adopted the
\nnational issue as the main theme of his work,
\nspecially the social problems. As a defensor
\nof figurative art, in 1942 he paints the picture
\nMotherhood. At that time he also positions
\nhimself against the abstrac art that is starting to
\ngrow in Brazil.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
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\nAlexander Krauth
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\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
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\nSubscription fee \u20ac 22,80 per annum (incl.
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\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
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\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.Torunn Janbu
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNorway
\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. 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
\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
\n87
\nWMA news
\nPolicy & Advocacy
\n1.1 Multi Drug Resistant
\nTuberculosis Project
\nDuring the third phase of the Lilly
\nMDR-TB partnership we finalised the
\nTB refresher course for physicians and
\nlaunched it during the GA 2009 in Delhi.
\nThe purpose of the TB refresher course
\nis to set the baseline for basic knowledge
\non the subject, with the existing Multi-
\nDrug Resistant TB course providing more
\nadvanced knowledge. However, because
\nthe refresher course was developed after
\nthe more advanced MDR-TB course, the
\nlayout of the MDR-TB required some
\nadaptation to conform more closely with
\nthe layout of the refresher course. The TB
\nrefresher course was nominated by the
\nUnited States Centre of Disease Control
\n(CDC) as educational highlight. Over
\ntime, both courses will be translated into
\ndifferent languages.The Georgian Medical
\nAssociation kindly offered to translate the
\nTB refresher course.
\nTo increase the outreach of our TB and
\nMDR TB educational activities WMA
\nheld train-the-trainer courses in TB and
\nMDR-TB based on the 2 existing train-
\ning materials in South Africa and India. In
\nApril of this year, WMA and the Chinese
\nMedical Association (ChMA) organised
\na third workshop in Hangshuang with the
\nhelp of the Chinese Thoracic Society. Thirty
\nleaders of TB hospitals from all over Chi-
\nna took part in the training and will pass
\non their knowledge to their colleagues. In
\nChina, TB hospitals and CDC Centres are
\nthe only facilities that treat TB patients.The
\ngovernment and the provincial health de-
\npartment honoured the activities of WMA
\nand ChMA.
\nThe WHO is in the final process of devel-
\noping a policy on ethics in the TB setting,
\nand will launch the policy during a confer-
\nence and workshop in Athens just prior to
\nthe 185th
\nCouncil Session in Evian. The
\nWMA was invited to address the issues in
\nthe policy related to health professionals
\nand Dr. Jeff Blackmer from the Canadian
\nMedical Association kindly offered to draft
\nSecretary General\u2019s Report
\n(October 2009-April 2010) to 185th
\nCouncil
\n88
\nWMA news
\nthis part of the policy, which addresses the
\nduty to treat, risks, and obligations to pa-
\ntients. It also elaborates obligations related
\nto facilities, patient support, training and
\nsupervision as well as capacity building.
\nWhile there are many TB programmes and
\nactivities taking place in English speaking
\nparts of Africa, there is far less involvement
\nby French speaking areas in international
\nhumanitarian activities related to
\nTB. During the Lilly MDR-TB
\nPartnership meeting in Mexico,
\na workshop was organized to
\nincrease activities in this part of
\nthe world and connect the part-
\nnership members with the na-
\ntional governments, WHO and
\nlocal NGOs. During the meet-
\ning WMA, together with the
\nInternational Council of Nurses
\n(ICN), International Hospital
\nFederation (IHF) and Interna-
\ntional Committee of the Red
\nCross (ICRC) decided to con-
\ntinue their series of inter-pro-
\nfessional workshops on health
\ncare worker safety and infection
\ncontrol in the context of drug
\nresistant TB. A third workshop
\nwill be organised in Benin in
\nJune 2010, involving health pro-
\nfessionals from Burkina Faso,
\nMali, and Senegal, Through this
\nworkshop we hope to engage our
\nfrancophone African Members
\nmore and try to connect with or-
\nganisations in other countries.
\n1.2 Tobacco project
\nThe WMA joined the imple-
\nmentation process of the WHO
\nFramework Convention on To-
\nbacco Control (FCTC) http:\/\/
\nwww.who.int\/tobacco\/framework\/
\nen. The FCTC is an international
\ntreaty that condemns tobacco as an
\naddictive substance, imposes bans
\non advertising and promotion of
\ntobacco,and reaffirms the right of all people to
\nthe highest standard of health.The first inter-
\nnational treaty negotiated under the auspices
\nof the WHO, the FCTC entered into force
\nin 2005.It is the most widely embraced treaty
\nin UN history, with 168 signatories and 154
\nratifications to date.
\nWHO FCTC held a workshop on Article
\n14: \u201cMeasures Concerning Tobacco De-
\npendence and Cessation\u201d in New Zealand
\nin February 2009 to finalise the draft article
\nfor the next Conference of the Parties in
\nNovember 2010. The New Zealand Medi-
\ncal Organisation participated in this meet-
\ning on behalf of WMA.The working group
\nstated again how important physicians are
\nin the cessation, support and the education
\nof patients.Therefore, countries should em-
\nphasize smoke free health care settings in
\nwhich physicians and other health profes-
\nsionals can serve as role models.
\n1.3 Health Workforce
\nWMA continues its close involvement in
\nthe Positive Practice Environment Cam-
\npaign (PPE). This global 5-year campaign
\n– spearheaded by World Health Professions
\nAlliance members together with the World
\nConfederation for Physical Therapy and the
\nInternational Hospital Federation – aims to
\nensure high-quality workplaces for quality
\ncare. The first activities on a country level
\nstarted in Uganda, Morocco, Zambia and
\nTaiwan. A national PPE secretariat was set
\nup to link the national member organisa-
\ntions and develop cooperation with the
\ngovernment. National researchers began
\nconducting studies about the working con-
\nditions of health professionals. The first is-
\nsue of the newsletter reporting the various
\nactivities of the campaign was circulated in
\nFebruary. A workshop bringing together
\nnational\/local health professionals took
\nplace in Zambia last March, with others to
\nfollow in Morocco, Uganda and Taiwan. In
\nApril, a website was launched and the PPE
\nCampaign was highlighted during the Ge-
\nneva Health Forum 2010, on the occasion
\nof the parallel session on retention strate-
\ngies for health professionals.
\nThe Dutch Royal Tropical Institute or-
\nganised a conference on Human Research
\nfor Health in Amsterdam in March 2010.
\nDr. Julia Seyer was invited to present the
\nPPE campaign. During the conference the
\nadvantages and disadvantages of decentrali-
\nsation of health care and health care educa-
\n89
\nWMA news
\ntion were discussed and a special focus was
\nplaced on how to assure quality of care and
\neducation.Another discussion point was the
\nfinancing of national health care systems.
\nNone of the international and multilateral
\ndonors report how much money from verti-
\ncal programmes is allocated to human re-
\nsources in health and to education. Money
\nthat is not reported money cannot be moni-
\ntored and managed.
\nThe participants of the Seminar in Reykja-
\nvik on Human Resources for Health and
\nthe Future of Health Care last year defined
\nideas to facilitate WMA policy develop-
\nment in this area. The WMA Advocacy
\nWorking Group has considered the oppor-
\ntunity to collect best practices.Task shifting
\nremains as a monitoring item of the Work-
\ning Group.
\nIn March 2009, WMA was invited to take
\npart in the planning process of the next
\nConference on Workplace Violence in
\nthe Health Sector, which is scheduled
\nto take place from 27-29 October, 2010
\nin Amsterdam. The event is supported by
\nthe Global Health Workforce Alliance
\n(GHWA), WHO, International Labour
\nOrganisation (ILO), the International
\nCouncil of Nurses (ICN), Public Servic-
\nes International (PSI) and other relevant
\nhealth organizations.
\nWHO is in the final stage of the develop-
\nment of guidelines on retention strategies
\nfor health professionals in rural areas. The
\nobjective is to attract and retain
\nhealth care professionals in rural
\nareas.Theguidelineswillbebased
\non three pillars: educational and
\nregulatory incentives, monetary
\nincentives and management,
\nenvironment and social support.
\nDecision makers on the national
\nand local levels and health fa-
\ncilities should receive evidence
\non the impact and effectiveness
\nof various retention strategies
\nthat have been tried and tested.
\nIn November 2009 WHO, to-
\ngether with the Asian-Pacific
\nAction Alliance on Human
\nresources for Health (AAAH),
\nheld a conference to discuss with
\ngovernments in Asia this topic
\nin general and, in particular,
\nhow the guidelines need to be
\nadapted to be better accepted by
\ngovernments.
\nWMA participates as a member
\nof steering groups in two proj-
\nects commissioned by the Euro-
\npean Union on the Mobility and Migra-
\ntion of Health Professionals. One project
\nis led by the European Health Care Man-
\nagement Association and the other by the
\nResearch Institute of the German Hart-
\nmann Bund, a private physicians organiza-
\ntion. The general objective of the research
\nprojects is to assess the current trends in
\nmobility and migration of health profes-
\nsionals to, from, and within the European
\nUnion, including their reasons
\nfor moving. Research will also
\nbe conducted in non-European
\nsending and receiving coun-
\ntries, but the focus lies within
\nthe EU. This research project
\nis a medium-scale collaborative
\nproject with a goal of facilitat-
\ning informed policy decisions
\non health systems by develop-
\ning a scientific evidence base re-
\nlated to the impact of mobility
\nof health professionals.
\nIn January 2011 the Global Health Work-
\nforce Alliance will organise the 2nd Global
\nForum on Human Resources in Health
\n(HRH) in Thailand. WMA is part of the
\nthematic focus committee for this event. In
\nan initial meeting, two main themes were
\nproposed: improving quantity and quality
\nof health workforce for equitable access to
\nprimary health care within a robust health
\nsystem and financing HRH in the light of
\nthe global financial crisis.
\n1.4 Counterfeit Medical Products
\nCounterfeit medicines are manufactured
\nwhich are below established standards of
\nsafety, quality and efficacy. They are delib-
\nerately and fraudulently mislabeled with
\nrespect to identity and\/or source. Counter-
\nfeiting can apply to both brand name and
\ngeneric products and counterfeit medicines
\nmay include products with the correct in-
\ngredients but fake packaging, with the
\n90
\nWMA news
\nwrong ingredients, without active ingredi-
\nents, or with insufficient active ingredients.
\nCounterfeit medicinal products threaten
\npatient safety, endanger public health
\nby increasing the risk of antimicrobial
\nresistance, and undermine patients\u2019 trust in
\nhealth professionals and health systems.The
\ninvolvement of health professions is crucial
\nto combating counterfeit medical products.
\nWMA and the members of the WHPA
\ndeveloped the \u201cbe aware\u201d toolkit for health
\nprofessionals and patients to increase
\nawareness of this topic and provide practi-
\ncal advice for actions to take in case of a sus-
\npected counterfeit medical product.WHPA
\nis stepping up its activities on counterfeit
\nmedical issues with an educational grant of
\nPfizer Inc. and Eli Lilly. The toolkit will be
\nupdated based on the input of the national
\nmember organisations of the alliance. A
\nmission and NGO briefing was organised
\nin collaboration with WHO and IMPACT
\nin March and a workshop in either Africa
\nor Asia is being planned. Here
\nwe would like to ask our mem-
\nbers to inform us of possible
\nnational events where we could
\nlink in a combating counterfeit
\nmedical products event. WHPA
\ndeveloped a statement on coun-
\nterfeit medical products, setting
\nprinciples for procurement, dis-
\ntribution and reporting of coun-
\nterfeit medical products.
\n1.5 Alcohol
\nIn May 2008, the World Health Assembly
\nadopted a resolution requiring WHO to in-
\ntensify its work to curb harmful use of alco-
\nhol and to develop a global strategy for this
\npurpose. The resolution requests the WHO
\nDirector-General to consult with intergov-
\nernmental organizations, health profession-
\nals, nongovernmental organizations, and
\neconomic operators regarding ways in which
\nthey can contribute to reducing the harmful
\nuse of alcohol. In January 2010,
\nthe WHO Executive Board
\n126th Session passed the resolu-
\ntion on \u201cStrategies to reduce the
\nharmful use of alcohol\u201d which
\nrecommends to the 63rd
\nWorld
\nHealth Assembly (May 2010)
\nthe adoption of a resolution en-
\ndorsing the global strategy.
\nAs an implementation measure
\nof the WMA Statement on Re-
\nducing the Global Impact of
\nAlcohol on Health and Society,
\nthe WMA secretariat moni-
\ntors the drafting process of the
\nWHO strategy, informs WMA
\nmembers on a regular basis of
\ndevelopments in this area, and
\nhas developed contacts with rel-
\nevant WHO officials and civil
\nsociety organisations to collabo-
\nrate in the process. Such activi-
\nties include:
\n\u2022\u00a0 On\u00a0 23\u00a0 October\u00a0 2008,\u00a0 the\u00a0
\nWMA Advocacy Advisor,
\nMs. Clarisse Delorme, moderated an
\nNGO briefing on reducing the global
\nharm caused by alcohol, organised by
\nGAPA (Global Alcohol Policy Alliance).
\nThe objectives of the briefing were to un-
\nderstand the WHO process related to the
\nstrategy, to begin discussions on substan-
\ntive and political proposals to promote an
\neffective, evidence-based global strategy,
\nand, finally, to develop further working
\nrelations between civil society actors in-
\nvolved in this area.
\nOn 24 November 2008, Dr. Otmar Kloi-\u2022\u00a0
\nber and Ms. Delorme, participated in the
\nWHO roundtable meeting with repre-
\nsentatives of NGOs and health profes-
\nsionals on ways they could contribute
\nto reducing harmful use of alcohol. This
\nwas an opportunity to raise, amongst oth-
\ners issues, WMA\u2019s desire that medical as-
\nsociations and individual physicians be
\nfully involved in the WHO strategy on
\nalcohol.
\nAs a follow-up to this, Ms. Delorme, to-\u2022\u00a0
\ngether with George Hacker from GAPA,
\nmet with several Permanent Representa-
\ntives (Denmark, Sweden, Norway, Chile,
\nSouth Africa, US, New Zealand) in Ge-
\nneva to discuss countries\u2019 positions and
\ninvolvement within the WHO regional
\nconsultative process on the draft strategy.
\nDuring the 126\u2022\u00a0 th
\nSession of WHO Ex-
\necutive Board, Ms. Delorme made a
\npublic statement on behalf of the World
\nHealth Professional Alliance supporting
\nthe strategy and recommending more
\n91
\nWMA news
\nattention to the pivotal role that health
\nprofessionals can and do play in terms of
\neducation, advocacy and research.
\nWMA sponsored\u2022\u00a0 an alcoholpolicybrief-
\ning, which took place on 20 April in Ge-
\nneva during the Geneva Health Forum.
\nThe briefing was organised by GAPA and
\nother relevant civil society actors.
\nWMA members are encouraged to sup-\u2022\u00a0
\nport the adoption of WHO draft strategy
\nby the World Health Assembly in May
\n2010.
\n1.6 Public Health
\nIn 2007 Governments requested WHO
\nto prepare a Global Action Plan on Non-
\nCommunicable diseases (NCD), based on
\nthe Global Strategy that was amended at
\nthe WHA in the year 2000.
\nThe Global Strategy Action Plan aims to:
\n(i) map the emerging epidemics of NCDs
\nand analyse their social, eco-
\nnomic, behavioral, and political
\ndeterminants; (ii) reduce the
\nlevel of exposure of individuals
\nand populations to the common
\nmodifiable risk factors; and (iii)
\nstrengthen health care for people
\nwith NCDs by developing stan-
\ndards and guidelines for cost-ef-
\nfective interventions and by ori-
\nenting health systems to respond
\nmore effectively in managing
\nNCDs. To increase the aware-
\nness and the commitment of
\ngovernments and NGOs,WHO
\norganized the First NCDnet
\nGlobal Forum in Geneva in
\nFebruary 2010.
\n1.7 Patient safety
\nWHO stepped up its commit-
\nment on patient safety and de-
\nfined it as a major global prior-
\nity in health care. To deliver safe
\nhealth care, clinicians require
\ntraining in the discipline of pa-
\ntient safety,which includes an understanding
\nof the nature of medical error; how clinicians
\nthemselves can work in ways that reduce
\nthe risk of harm to patients; techniques for
\nlearning from errors; and how clinicians can
\nharness quality improvement methods to
\nimprove patient safety in their own organi-
\nzations. WHO responded to this need by
\npublishing the Patient Safety Curriculum
\nGuide for medical schools, and is now un-
\ndertaking a major consultation
\nexercise to develop a Multi-pro-
\nfessional Patient Safety Curricu-
\nlum Guide. WMA is member of
\nthe reviewing committee for the
\nmulti-professional guidelines.
\n1.8 Health care systems
\nPrimary health care
\nThe WMA advocacy workgroup
\nplans to develop an advocacy
\nbrief on Primary Health Care, as a tool
\nto influence decision-makers at the na-
\ntional and international level and for raising
\nawareness on this matter.
\nGlobal Charter on Health Data
\nGlobal health systems face the challenges of
\ndelivering high quality,accessible care under
\nincreasing budgetary pressure. Health data
\nhave a critical role to play in improving the
\nquality, accessibility and efficiency of health
\nservices \u2013 and, therefore, an important role
\nin ensuring that health systems continue to
\nimprove. However across all health systems
\nthere are situations in which accurate health
\ndata are not available.The lack of availabili-
\nty and access to health data can result in un-
\nsafe or ineffective services or lead to a waste
\nof resources. The World Economic Forum
\norganizes a working group to develop and
\ndefine the principles of a Global Charter
\non Health Data. The WMA represents the
\nphysicians\u2019 and patients\u2019 perspectives in this
\nworking group and demands the anonymity
\nand aggregation of data and the right of the
\npatient\u2019s ownership of the data.
\nRelationship between Physicians and Com-
\nmercial Enterprises
\nThe International Federation of Pharma-
\nceutical Manufactures and Associations
\nIFPMA invited Dr. Julia Seyer to present
\nthe revised WMA Statement concern-
\ning the Relationship between Physicians
\nand Commercial Enterprises during their
\n92
\nWMA news
\ncommittee meeting in February this year.
\nIFPMA would be pleased to start a dia-
\nlogue again with WMA to exchange codes
\nof conduct and share information and ex-
\nperiences.
\n1.9 Health and the environment
\nThe WMA Workgroup on Health and
\nthe Environment, chaired by the Canadian
\nMedical Association, was established in the
\nsummer of 2008. For 2009, the workgroup
\nagreed to focus its attention on health and
\nclimate change in view of the global United
\nNations conference on this topic in Copen-
\nhagen in December 2009. For 2010, the
\nworkgroup decided to continue its advocacy
\nwork on climate change in the context of
\nthe UNFCCC process and also to develop
\na proposed policy paper on environmental
\ndegradation and the built environment.
\nClimate change
\nIn January 2009, the workgroup produced
\na set of recommendations, which were ap-
\nproved by the 182nd
\nCouncil session in May
\n2009. A WMA conference on health and
\nclimate change took place on 1 Septem-
\nber, 2009 in Copenhagen, with a view to
\nfurther development of WMA recommen-
\ndations,based on the contributions from in-
\nvited experts. Following further revision of
\nthe recommendations after this conference,
\nthe WMA resolution was approved by the
\nCouncil at its pre-Assembly meeting and
\nthen adopted (as the Delhi declaration) by
\nthe 2009 General Assembly.
\nImmediately after the General Assembly,
\nthe WMA secretariat prepared an advoca-
\ncy kit for its national member organisations.
\nBased on the new WMA policy adopted,
\nmedical associations were invited to lobby
\nrelevant national decision-makers for a
\nhealth perspective to be included in the fi-
\nnal official conclusions of the UN Climate
\nChange Conference 2009 (COP15) which
\ntook place in Copenhagen in December
\n2009.
\nFurthermore, the Danish Medical Associa-
\ntion represented the WMA at the COP15
\n– as part of the delegation headed by the
\nHealth and Environment Alliance (HEAL)
\nand Health Care Without Harm (HCWH).
\nThe delegation, composed of health leaders
\nand representing a diversity of medical and
\npublic health organizations,emphasized the
\nfact that climate change profoundly impacts
\non human health. The DMA acted on the
\nbasis of the WMA Delhi Declaration and
\nin cooperation with other NGOs acting in
\nthe same area.
\nAs a follow-up to the COP15 (Bonn and
\nMexico conferences in 2010), the Work-
\ngroup on Health and the Environment has
\ndeveloped an advocacy strategy for WMA,
\nwith the aim of supporting members as-
\nsociations in lobbying their governments
\nto place health at the core of international
\nclimate change debate and to increase the
\nmedical community\u2019s voice as an important
\nstakeholder in climate discussions.
\nMercury
\nFollowing the adoption by the 2008 Gen-
\neral Assembly of the WMA Statement on
\nReducing the Global Burden of Mercury,
\nWMA joined the UNEP Global Mercury
\nPartnership in December 2008 in order to
\ncontribute to the partnership goal to protect
\nhuman health and the global environment
\nfrom the release of mercury and its com-
\npounds.
\nWith the support of Health Care With-
\nout Harm, an information session on the
\nMercury-Free Health Care initiative was
\nheld during the General Assembly 2009.
\nHealth Care Without Harm1
\nand the
\nWorld Health Organization are co-leading
\nthis global initiative (partnership) to achieve
\nvirtual elimination of mercury-based ther-
\nHealth Care Without Harm (HCWH): Global1.
\ncoalition of 473 organizations in more than 50
\ncountries working to protect health by reducing
\npollution in the health care sector \u2013 http:\/\/www.
\nnoharm.org.
\nmometers and sphygmomanometers over
\nthe next decade and substitute them with
\naccurate, economically viable alternatives.
\nMr. A.K. Sengupta, National Professio-
\nnal Officer (Sustainable Development &
\nHealthy Environment) from the WHO
\nIndia Country Office presented activities
\nundertaken in this area, with a focus on
\nactivities in India. This information session
\nconstituted concrete follow-up to the adop-
\ntion of WMA Statement on Reducing the
\nGlobal Burden of Mercury.
\nIn early March, Ms. Clarisse Delorme met
\nwith representatives of the Mercury Part-
\nnership to explore stronger involvement of
\nthe WMA in UNEP\u2019s mercury initiatives.
\nOptions discussed included the opportunity
\nto make health professionals more vocal in
\nthe context of the current drafting process
\nof a global legally binding instrument on
\nmercury. Another strategic approach for
\nWMA would be to target manufacturers of
\nproducts that contain mercury. WMA and
\nits members could have an impact in reduc-
\ning supply of these products through lobby-
\ning and awareness-raising actions.
\nChemicals management
\nIn December 2009, the WMA secretariat
\nwas approached by the Chemicals Branch
\nof the United Nations Environment Pro-
\ngramme (UNEP) in the context of the
\ndevelopment of a Strategic Approach to
\nInternational Chemicals Management
\n(SAICM). The SAICM, adopted in 2006,
\nis a multi-sectoral and multi-stakeholder
\npolicy framework aimed at promoting the
\nsound management of chemicals and haz-
\nardous waste in the context of sustainable
\ndevelopment. In 2009, the International
\nConference on Chemicals Management
\nrequested the development of a strategy
\nfor strengthening the engagement of the
\nhealth sector in the implementation of the
\nStrategic Approach, in consultation with
\nWHO. The SAICM secretariat is therefore
\nwilling to engage medical associations in
\nthe process.
\n93
\nWMA news
\nBased on this resolution, the SAICM sec-
\nretariat prepared a questionnaire for the
\nhealth professionals\u2019 community to evalu-
\nate the engagement of the health sector
\nin the management of chemicals. WMA
\nsecretariat circulated the questionnaire to
\nWMA members. A summary of responses
\nobtained were compiled and made available
\non SAICM website.
\nA consultative meeting was then organised
\non the 4\u20135 February in Ljubljana, Slov-
\nenia. Dr. Dong Chun Shin, from the Ko-
\nrean Medical Association, and member of
\nWMA workgroup on Health and Environ-
\nment, represented WMA at the meeting.
\n1.10 Human Rights
\nRight to health
\nThe WMA was actively involved in the
\npreparation of the joint Seminar on the
\n\u201cRight to Health as a Bridge to Peace in
\nthe Middle East\u201d, which took place on 27-
\n30 October 2009 in Turkey. The seminar
\nwas organised by the International Federa-
\ntion of Health and Human Rights Organi-
\nsations (IFHHRO), the Norwegian Medi-
\ncal Association (NMA), the Human Rights
\nFoundation of Turkey (HRFT), the Turk-
\nish Medical Association (TMA) and the
\nWMA. The objectives of the meeting were
\nto discuss what role the medical profession
\ncan play in securing equal access to health
\ncare for the population and to facilitate
\ncommunication among health professionals
\nin the participating nations.
\nDuring the reporting period, the WMA
\nsecretariat maintained contact with Anand
\nGrover, the UN Special Rapporteur on
\nHealth to increase the role of health profes-
\nsionals in the promotion of the human right
\nto the highest attainable standard of health.
\nPhysicians & patients in distress worldwide
\nIn November 2009, the WMA secretariat
\nsent to Iranian President, Mahmoud Ah-
\nmadinejad, and to the Iranian Minister of
\nHealth, the WMA Resolution adopted in
\nDelhi supporting the rights of patients and
\nphysicians in the Islamic Republic of Iran.
\nIn the accompanying letter signed by WMA
\nPresident Dr.Dana Hanson,the Iranian au-
\nthorities were asked to take urgent actions
\nin conformity with Medical Ethics Princi-
\nples and with International Human Rights
\nLaw principles.
\nDuring the same period, the WMA secre-
\ntariat sent the WMA Resolution on Leg-
\nislation against Abortion in Nicaragua to
\nthe President of The Republic of Nicaragua,
\nthe Minister of Health, and the President
\nof the Parliament. In February, the WMA
\nsecretariat was made aware by Amnesty In-
\nternational of a case in Nicaragua in which a
\nwoman with metastatic cancer was reported
\nto be denied adequate treatment, as she was
\n10 weeks pregnant. Doctors felt unable to
\nact because of the law prohibiting abortion,
\nalthough the woman gave her consent for
\nthe cancer treatment. A second letter was
\ntherefore sent to the Minister of Health
\nreiterating the conclusions of the WMA
\nresolution on this topic and reaffirming that
\nhealth of the patient should be the priority
\nof physicians. The letter also expresses seri-
\nous concerns that doctors might be unable
\nto proceed with treatment of their patients
\nbecause of fear that the anti-abortion law
\ncould be used to prosecute them.
\nPrevention of torture
\nIn November 2009, Ms. Clarisse Delorme
\nattended as an elected member the council
\nsession of the International Rehabilita-
\ntion Council for Torture Victims (IRCT),
\nwhich took place in Nairobi. During that
\nsession, she was elected member of the Ex-
\necutive Committee and therefore attended
\nthe Excom meeting in February in Copen-
\nhagen. It is hoped that this new position
\nwill allow WMA to develop more actively
\nits work on torture prevention. It should
\nalso allow the IRCT to integrate more sys-
\ntematically the perspective of health profes-
\nsionals in its activities.
\nOn the 9th
\nof March 2010, the WMA and
\nIRCT organised a joint side-event at the
\noccasion of the Human Rights Council,
\n13th
\nSession entitled \u201cExploring sustain-
\nable ways to document torture \u2013 The role
\nof health professionals\u201d. The event was
\n94
\nWMA news
\nmoderated by Manfred Nowak, UN Spe-
\ncial Rapporteur on torture. Dr. Poul Jaszc-
\nzak from the Danish Medical Association
\nand members of the Danish Rehabilitation
\nCouncil, presented WMA\u2019s policies and
\nhighlighted the role that physicians and
\nmedical associations can play in torture
\nprevention. Other speakers included repre-
\nsentatives from the Turkish Medical Asso-
\nciation, the UN Subcommittee on the pre-
\nvention of torture and the Association for
\nthe Prevention of Torture (APT). A press
\nrelease \u201cPhysicians call for effective measure
\nto document torture allegations\u201d was issued
\non this occasion.
\nWomen and health
\nIn October 2009 in Delhi, the WMA
\nworkgroup on violence against women
\nand children (VAWC) met for the first
\ntime. The workgroup is composed of the
\nEthiopian Medical Association (chair), the
\nCanadian Medical Association, the British
\nMedical Association, the American Medi-
\ncal Association, the Israel Medical Associa-
\ntion, the Indian Medical Association, and
\nthe ICRC. Dr. Barbara Roberts participates
\nin the WG activities as an advisor. During
\nthe reporting period, the group worked on a
\ndraft resolution on violence against women
\nand girls as well as on a proposed revision of
\nWMA resolution on family violence.
\nOn the 5th
\nof February, the WMA and
\nthe International Federation of Gynaecol-
\nogy and Obstetrics (FIGO) issued a joint
\npress release to mark the International
\nDay of Zero Tolerance to Female Geni-
\ntal Mutilation (FGM) on February 6. The
\ntwo organisations strongly condemned the
\nmedicalisation of female genital mutilation
\nand underlined the unique role that health
\nprofessionals can play in working towards
\nthe elimination of FGM to ensure that girls
\nand women enjoy the full extent of human
\nrights and freedom.
\nEarly March, the WMA was consulted on
\na draft Global strategy against health care
\nproviders performing female
\ngenital mutilation prepared by
\nWHO, UNICEF and UNFPA.
\nThis strategy is part of the imple-
\nmentation process of the WHO
\nresolution on the eradication of
\nFGM adopted in 2008. WMA
\nworkgroup on violence against
\nwomen and children made com-
\nments on the draft that were
\nthen forwarded to the WHO
\nsecretariat in charge.
\n1.11 Ethics
\nAt the General Assembly 2008,
\nthe Declaration of Helsinki was
\namended.At that time the debate
\nhad a strong focus on the use of
\nplacebo in medical research. If
\na proven effective intervention
\nexists, the Declaration of Hel-
\nsinki allows the use of placebo
\ncontrols, though only in very
\nlimited circumstances. However
\nthis opening raised some con-
\ncerns. In order to analyze the
\nuse of placebos in medical research a WMA
\nworking group was installed. The working
\ngroup invited a number of renowned ex-
\nperts to discuss the issue at a conference
\nheld in Sao Paulo, Brazil in February this
\nyear with the help of the Brazilian Medical
\nAssociation.
\nDuring the conference it became clear that
\nthe current version of the Declaration ad-
\ndresses the issue of placebo controls quite
\nwell. However, recent research on placebo
\nuse provides a much broader and complex
\nview on the role of placebos in medical re-
\nsearch then we had before.
\nFurthermore it was acknowledged that the
\nsame ethical questions might arise with any
\ncontrol group that receives a treatment less
\nthen the \u201cbest current proven intervention\u201d
\n(which is currently required by the Declara-
\ntion).The overriding question of the placebo
\ncontroversy now appears to be: \u201cTo what ex-
\ntent and under which circumstances is it eth-
\nically acceptable to provide a control group
\nwith an intervention less effective than the
\n\u201cbest current proven one\u201d in a clinical trial.
\nThis includes a placebo control as well as a
\ncontrol with a second standard or no treat-
\nment.This problem is aggravated by the fact
\nthat in many circumstances we do not know
\nfor sure which is the \u201cbest proven\u201dtreatment.
\nThis work has been scientifically supported
\nby the WMA Cooperating Centre, Insti-
\ntute of Ethics and History of Medicine at
\nthe University of T\u00fcbingen, Germany.
\n1.12 Speaking book
\nThe WMA launched the speaking book
\non clinical trials during the General As-
\nsembly in Seoul 2008. This project was a
\ncollaborative effort with the South African
\nMedical Association, the SADAG (South
\nAfrican Depression & Anxiety Group)
\n95
\nWMA news
\nand the Steve Biko Centre for Bioethics in
\nJohannesburg and the publisher \u201cBooks of
\nHope\u201d. The speaking book on clinical trials
\nin English-Hindi & Telugu was launched
\nat the 2009 General Assembly in India.The
\npurpose of the project is to provide proper
\ninformation on clinical research to illiterate
\npopulations so that they can make informed
\ndecisions about participation. The project
\nwas made possible by an unrestricted edu-
\ncational grant provided by Pfizer, Inc.
\nIn March 2010, Books of Hope, with the
\nsupport of Pfizer,the Chinese Centre of Dis-
\nease Control, the Chinese Medical Doctors
\nAssociation, the Chinese Association on To-
\nbacco Control and the World Medical As-
\nsociation presented a speaking book on the
\ndangers of smoking. It targets a low literacy
\ncommunity, which has experienced signifi-
\ncant increases in smoking rates over the last
\ndecades,yet cannot benefit from much of the
\nwritten informational products on tobacco
\nand smoking dangers and cessation.
\nEach of the impressively illustrated 16 page
\nbooks, with easy-to-read text and\/or voice
\non command, is expected to be received by
\naround 27 people as research has shown.
\nThus the first 5000 books have the potential
\nto impact 50,000 to 100,000 people. Like
\nthe other speaking books, the newest one
\nwill also be accompanied by research ana-
\nlyzing its impact on health literacy.
\n1.13 Caring Physicians of the World
\n(CPW) Initiative (Leadership Course)
\nThe CPW Project began with the Caring
\nPhysicians of the World book, published
\nin October 2005 in English and in Span-
\nish in March 2007. Regional conferences
\nwere held in Latin America, Asia-Pacific
\nand Africa regions. The CPW Project was
\nextended to include a leadership course or-
\nganized by the INSEAD Business School
\nin Fontainebleau, France, in December
\n2007, in which 32 medical leaders from a
\nwide range of countries participated. The
\nsecond Leadership Course was held at the
\nsame place in December 2008 for one-week
\nwith 30 participants, also with continued
\nsuccessful results and positive feedback.The
\nthird Leadership Course at the INSEAD
\nBusiness School was successfully held in
\nSingapore, 8\u201313 February 2010, with 29
\nparticipants. The curriculum includes train-
\ning in decision-making, policy work, nego-
\ntiating and coalition building, intercultural
\nrelations and media relations. The courses
\nwere made possible by an unrestricted edu-
\ncational grant provided by Pfizer, Inc.
\nThis work has been supported by the WMA
\nCooperating Centre at the Centre for Glo-
\nbal Health and Medical Diplomacy in the
\nUniversity of North Florida.
\n1.14 Medical and Health
\nPolicy Development
\nIn the past years the Centre for the Study
\nof International Medical Policies and
\nPractices, George-Mason-University,
\nwhich is one of our Cooperating Centres,
\nstudied the need for educational support
\nin the field of policy creation. The surveys
\nperformed with cooperation of the World
\nMedical Association found a demand for
\neducation and exchange. Finally the Cen-
\ntre invited WMA to participate in the cre-
\nation of scientific platform for the inter-
\nnational exchange on Medical and Health
\npolicy development.
\nIn the fall of 2009 the first issue of a scien-
\ntific journal the World Medical & Health
\nPolicy was published by Berkeley Electronic
\nPress as an online journal. It is accessible
\nunder http:\/\/www.psocommons.org\/wmhp.
\nExternal Relations
\n2.1 World Health Professions Alliance
\nAfter 10 years of successful collaboration,
\nthe WPHA celebrates its anniversary at
\nthe Leadership Forum in Geneva in May
\nin 2010. The four main health professions \u2013
\nphysicians,nurses,pharmacists and dentists \u2013
\nhave shown that working in collaboration
\ninstead of along parallel tracks, benefits the
\npatient and the health care system. WHPA
\namplifies the policy and advocacy messages
\nof member organisations and facilitates co-
\nherence and synergies among the messages
\nof national member organisations.
\nThe World Confederation of Physical
\nTherapies WCPT was a strong and reliable
\npartner of WHPA for several years. We are
\nproud to announce that WCPT joined the
\nWHPA in May.
\n96
\nWMA news
\n2.3 Administration
\nIn October 2009, the WMA re-launched its
\nwebsite which now provides the platform for
\ncooperation with the members of WMA,
\nallows online payments for meetings, books
\nand associate membership dues, and, most
\nof all, facilitates more timely presentation of
\ncontent on the public website.
\n3. WMA Governance
\nMembership
\nDuring the reporting period, the following
\nassociation applied for full membership to
\nthe WMA:
\nAssocia\u00e7\u00e3o M\u00e9dica de Mo\u00e7ambique\u2022\u00a0
\n(AMMo)
\n3.2 Medical organizations
\nin Arabic Countries
\nThe Secretariat is continuously reaching out
\nto Medical Associations in Arabic countries.
\nWe were pleased to have participation from
\nEgypt, Iraq and Palestine at our conference
\n\u201cRight to Health as a Bridge to Peace in
\nthe Middle East\u201d. We offered to visit the
\nmedical associations in Syria, Jordan and
\nEgypt and we hope that our offer will be
\naccepted during the year.
\nOn the initiative of the German and Nor-
\nwegian Medical Association we are explor-
\ning the possibility of holding a conference
\nor event planned and co-organized with the
\nEmirates Medical Association and possibly
\nthe Arab Medical Union.The current idea is
\nto hold this event early in 2011,hopefully in
\nDubai. We are also exploring the possibil-
\nity of holding the fourth CPW Leadership
\nCourse in the United Arab Emirates as IN-
\nSEAD has its third campus in Abu Dhabi.
\nAcknowledgment
\nThe Secretariat wishes to record its appre-
\nciation to member associations and inter-
\nnational organizations for their interest in,
\nand cooperation with, the World Medical
\nAssociation and its Council during the past
\nyear. We thank all those who have repre-
\nsented the WMA at various meetings and
\ngratefully acknowledge the collaboration
\nand guidance received from the officers, as
\nwell as the Association\u2019s editors, its legal,
\npublic relations and financial advisors, and
\nits officials.
\nDr. Alan J. Rowe
\nThe report on the 185th
\nCouncil meeting will
\nappear in the next issue WMJ 56.4.
\nThe photographs above are those of partici-
\npants at the 165th
\nCouncil meeting.
\nDr. Torunn Janbu, president of the Norwe-
\ngian Medical Association, has been elected
\nchair of the World Medical Association\u2019s
\nmedical ethics committee.
\nShe was elected unopposed at the WMA\u2019s
\nCouncil meeting in Evian, France in May
\nand succeeds Dr. Jens Jensen, from Den-
\nmark, who has taken up a post with the
\nDanish health service as medical direc-
\ntor and CEO in one of Denmark\u2019s five
\nhealthcare regions. Dr. Jensen had been
\nchair of the ethics committee for less
\nthan a year.
\nDr. Janbu has been president of the Norwe-
\ngian Medical Association since 2005 when
\nshe became the first female president in the
\n120 year history of the Association.Previ-
\nously she was chair of the Oslo Medical As-
\nsociation and vice president of the Norwe-
\ngian Medical Association .
\nShe is chief surgeon and specialist in gen-
\neral surgery and orthopaedic surgery, pres-
\nently on leave from her job at Oslo Uni-
\nversity Hospital while working full time as
\npresident. She took her medical degree at
\nthe University of Oslo in 1979.
\nSince taking over as President of the Nor-
\nwegian Medical Association, Dr. Janbu, has
\nbeen widely praised for the way she has
\nhandled several difficult issues.
\nShe has chaired the Ethics and Professional
\nCodes subcommittee in CPME (Comit\u00e9
\nPermanent des M\u00e9decins Europ\u00e9ens) until
\nit was abolished recently during the reor-
\nganisation of CPME.
\nDr. Janbu emphasizes the important role of
\nthe WMA in medical ethics worldwide,and
\nespecially mentions the Declaration of Hel-
\nsinki. She also said that health inequalities
\ncould be an important topic for future work
\nin the committee.
\nDr. Janbu was for several years an aerobic
\ninstructor in Oslo. She is married to politi-
\ncian and physician Kjell Maartmann-Moe.
\nNorwegian Doctor to Head
\nWMA\u2019s Ethics Committee
\n97
\nRegional and NMA news
\nSoon after the earthquake hit Haiti on 12
\nJanuary, the Brazilian Medical Association
\n(AMB) started to receive numerous calls
\nfrom doctors asking how they could help.
\nTwo days later, a cabinet crisis was installed
\nat the AMB\u00b4s headquarters to organise
\nthe available resources. On 15 January, we
\nstarted an online application at our web-
\nsite to register all the volunteers to help the
\nvictims of the tragedy. In 15 days, we had
\n976 healthcare workers volunteering to go
\nto Haiti.
\nWhile resources were being organised in
\nBrazil, Ricardo Affonso Ferreira, leader of
\n\u201cExpedicion\u00e1rios da Sa\u00fade\u201d (a NGO part-
\nner of the AMB), went to Haiti to access
\nthe situation. He found the Brenda Straf-
\nford Hospital, in Les Cayes, a small town
\nsituated 192 kilometres from Port au Prince
\nthat was not affected by the disaster.Within
\na few days the local population doubled af-
\nter the arrival of 60 000 refugees.The Bren-
\nda Strafford Institute is an ophthalmology
\nand otolaryngology hospital that later was
\nadapted to treat orthopaedic trauma pa-
\ntients.
\nIn 45 days the AMB sent three teams to
\nHaiti, 28 doctors (among them our presi-
\ndent), 12 nurses and 4 radiology techni-
\ncians. A lot of equipment, donated by pri-
\nvate companies and public institutions, was
\ncarried by the three teams to treat patients.
\nTo give an idea, the second team alone,
\ntook 1500 kilos of equipment with them.
\nThe first two teams used regular commer-
\ncial flights to go to Haiti, arriving at Santo
\nDomingo, Republica Dominicana and then
\nthey travelled by bus to Les Cayes. The last
\nteam was taken straight to Port au Prince by
\nthe Brazilian Air Force.
\nThe three teams performed 219 surgeries in
\n148 patients, mostly in men, the mean age
\nwas 31 years. Lower limbs were the most
\naffected segments and the use of external
\nfixator was the most common type of treat-
\nment. At the outpatient clinic, over 1500
\npeople were treated.
\n\u201cI consider that all three missions were
\nsuccessful. We felt privileged to be able to
\nrepresent all physicians who could not go.
\nThe continuity of this work will be done in
\ndifferent ways and one of them is the cre-
\nation of a task force trained for disasters\u00ab,
\nsaid Jos\u00e9 Luiz Gomes do Amaral, president
\nof AMB. \u201cWe also look forward to estab-
\nlishing a worldwide network of physicians,
\nnational medical associations and resourses
\nready to be used after a disaster of this pro-
\nportion.\u201d
\nHelena Fernandes,
\nCommunication Department,
\nBrazilian Medical Association
\nBrazilian Medical Association \u2013 SOS Haiti
\n98
\nRegional and NMA news
\nSao Tome is one of the world\u2019s most iso-
\nlated countries, located 300 miles west of
\nthe African continent. With 160 000 in-
\nhabitants and very few medical doctors, the
\ncountry has difficulty providing basic health
\nservices.This need inspired Taiwan Medical
\nUniversity, partly supported by the Taiwan
\nInternational Corporation and Develop-
\nment Foundation, to send in more than a
\ndozen health professionals since last De-
\ncember.Prior to their dispatch to Sao Tome,
\nmany of the Taiwan doctors and nurses did
\nnot know of this island country.
\nDuring routine rounds in local hospitals,
\nTMU\u2019s Dr. Yu-Tai Chang was troubled by
\nthe cases of three children with burns over
\nlarge areas of their bodies. He emailed pho-
\ntos of the burns to Taipei and asked about
\na timely consultation while working with
\nhis team in a shanty clinic.The chief plastic
\nsurgeon in Taipei, Dr. Cliff Chen, suggested
\na videoconference on treatment options in
\nMarch.
\nHowever, most Sao Tome internet service
\nwas too limited to carry real-time images
\nand voices to Taiwan. Dr. Chang persuaded
\nTaiwan\u2019s ambassador in Sao Tome to offer
\nhis embassy office, complete with satellite
\ncommunication system, to serve as the vid-
\neoconference site. During this examination,
\nthe scars over the burned areas were seen to
\nhave already contracted the children\u2019s bod-
\nies. Dr. Chen advised that the scars would
\ncontinue to limit them, and recommended
\ntimely reconstructive surgery to protect the
\npatients from irreversible lifetime defor-
\nmity.
\nThe decision to bring the children to Tai-
\nwan was a difficult one for the university
\nand hospital doctors. The Taiwan Medical
\nUniversity team faced daunting financial
\nand technical challenges in transferring the
\npatients,but within days of publicising their
\ncases generous pledges were made to sup-
\nport the children\u2019s treatment.
\nDr. Chang drove to the patients\u2019 villages
\nand helped the families with paperwork
\nand reassured the mothers, who had never
\nleft their villages before, about the voyage of
\nmore than 10 000 miles.They had not heard
\nabout Taiwan before learning that their in-
\njured children might receive treatment here
\nthat would enable them to lead normal lives
\nagain. Unfortunately, before they could de-
\npart the youngest patient, a 5-year-old girl,
\ndied of infection.
\nThe two boys, both 7 years old, ar-
\nrived from SaoTome & Principe atTaoyuan
\nInternational Airport on 11 April, accom-
\npanied by their mothers and a doctor from
\ntheir country. They arrived exhausted and
\ncould hardly walk without assistance due to
\ncontractures from scarring over large areas
\nof their bodies as well as 36 hours of flights
\nand transfers from Africa via Lisbon, Am-
\nsterdam and Bangkok.
\nThe doctors and nurses of the university\u2019s
\naffiliated Wanfang Hospital conducted
\nseveral operations and logged more than a
\nhundred consultations and procedures to
\nrebuild the skin over the children\u2019s scars, re-
\nplacing areas from scalp to torso. One child
\ncould again close his eyelids and mouth af-
\nter months when that had been impossible.
\nBoth patients\u2019elbows could again reach nor-
\nmal extension, and the boys enjoyed their
\nnew freedom of motion by playing football
\nand jumping around during their weeks of
\nreconstruction and rehabilitation.
\nNow the two young burn patients are get-
\nting ready to go home.As the university and
\nhospital receive calls from around Taiwan
\npledging assistance and donations, people
\nin the African children\u2019s home villages are
\nlearning about their expected recovery and
\nreturn. We salute the bravery of these in-
\njured children who came so far to stay with
\nus. Because of their courage, hundreds of
\npeople in very different countries have
\nshared medical knowledge and our com-
\nmon humanity. Everyone can celebrate this
\nhappy outcome of Taiwan\u2019s medical diplo-
\nmacy.
\nPeter Chang, MD, MPH, ScD
\nProfessor and International Dean
\nTaipei Medical University
\nAdvisor, Taiwan Medical Association
\nPeter.chang3@gmail.com
\nBurn Victims Bring Taiwan,
\nSao Tome Closer Together
\n99
\nRegional and NMA news
\nGeneva, 18 May, 2010
\nThe World Health Professions Alliance
\n(WHPA www.whpa.org) today urged fur-
\nther action against counterfeiting of medical
\nproducts, a vile and serious criminal offense
\nthat puts human lives at risk and under-
\nmines the credibility of health systems.
\nSpeaking for more than 26 million health
\nprofessionals in more than 130 countries,
\nWHPA is extremely concerned that the
\ninfiltration and sale of counterfeit medical
\nproducts in the legitimate supply chain can
\ncause death and misery to tens of thousands
\nof patients around the world. The only rea-
\nson to combat counterfeit medicines is the
\nprotection of public health \u2013 disputes in
\ntrademark infringement and other intel-
\nlectual property related crimes should never
\never be the basis on which to define if a
\nmedical product is counterfeit or not.
\n\u201cFalsely labelled, fake, spurious or counter-
\nfeited medical products which misrepresent
\nan otherwise legitimate medical product
\npose a very serious public health threat
\nwhich demands sustained and co-ordinated
\ninternational action to control. Failure to
\nact against this criminal activity would be
\na fundamental breach of the trust placed
\nin public health structures by patients,\u201d
\nsaid Mr Ton Hoek, General Secretary and
\nCEO, International Pharmaceutical Fed-
\neration (FIP) and WHPA spokesperson.
\nWHPA represents more than 26 million
\nHealth Professionals worldwide.
\nSo that health care professionals are bet-
\nter equipped to combat counterfeits, the
\nWHPA announced that it is stepping up its
\ncommitment to this issue, with the launch
\nof the \u2018Be Aware, Take Action\u2019 campaign
\nwww.whpa.org\/counterfeit_campaign.htm
\nagainst counterfeiting of medical products.
\nThis campaign focuses on public health and
\npatient safety issues and enhances the role
\nof health professionals and associations.
\nThrough regional workshops dedicated to
\nanti-counterfeiting, the WHPA aims to
\nstrengthen advocacy for appropriate in-
\nvestments in the education and capacity of
\nhealth professionals to detect, report and
\nprevent counterfeit medical products.In ad-
\ndition, the WHPA Be Aware, Take Action
\ntoolkit and other campaign resources are
\nprovided for health professionals, health-
\ncare advocates and patients
\nThe main channels for fake medical prod-
\nucts supply include street markets in devel-
\noping countries and the Internet. The harm
\ncaused by counterfeit medicines is greatest
\nin those communities least able to afford
\neffective regulatory systems and quality
\nhealth care.
\nSaid Ton Hoek, \u201cPublic health and patient
\nsafety are being put at risk and now is the
\ntime to act.
\nIncreased vigilance by health care profes-
\nsionals and patients can help make public
\nand individual health safer. Health pro-
\nfessionals need to increasingly consider
\ncounterfeit medicines as a reason for non-
\nresponse or unexpected response in phar-
\nmacotherapy in the patients they care for.\u201d
\nEducation of health professionals is crucial
\nfor detection and prevention of counterfeit
\nmedical products and is required in order
\nfor them to educate patients and popula-
\ntions about the risks of buying counterfeit
\nmedical products from unknown and unre-
\nliable sources.
\nWHPA recognizes also that for health pro-
\nfessionals to be able to effectively play their
\nrole, national authorities must set up effec-
\ntive systems for the collection of informa-
\ntion and increase national drug and medical
\ndevice regulatory capacity to support the
\nenforcement of pharmaceutical guidelines.
\nAbout WHPA www.whpa.org
\nThe World Health Professionals Alliance
\nWHPA is a unique alliance of The Interna-
\ntional Council of Nurses (ICN) www.icn.ch,
\nthe International Pharmaceutical Federation
\n(FIP) www.fip.org,
\nThe World Confederation for Physical
\nTherapy (WCPT) www.wcpt.org, the FDI
\nWorld Dental Federation (FDI) www.fdi-
\nworldental.org and the World Medical As-
\nsociation (WMA) www.wma.net. WHPA
\naddresses global health issues striving to
\nhelp deliver cost effective, quality health
\ncare worldwide. Together, the partners of
\nthe WHPA include more than 600 national
\nmember organizations, making WHPA the
\nkey point of global access to health care
\nprofessionals within the five disciplines.
\nMember Organisations
\nThe International Council of Nurses (ICN)
\nis a federation of national nurses associa-
\ntions,representing the more than 13 million
\nnurses working worldwide. www.icn.ch
\nThe International Pharmaceutical Federa-
\ntion (FIP) is the global federation of na-
\ntional organisations of pharmacists and
\npharmaceutical scientists representing more
\nthan two million pharmacists around the
\nworld. www.fip.org
\nThe World Confederation for Physical
\nTherapy (WCPT), the global voice for
\nphysical therapists \/ physiotherapists, has
\n101 national member organisations repre-
\nsenting over 350,000 members of the pro-
\nfession. www.wcpt.org
\nThe FDI World Dental Federation (FDI) is
\na federation of approximately 200 national
\nWorld Health Professions Alliance calls for
\nincreased action against counterfeits
\n100
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\ndental associations and specialist groups
\nrepresenting more than one million dentists
\nworldwide. www.fdiworldental.org
\nThe World Medical Association (WMA)
\nis the global federation of national medi-
\ncal associations from around the world,
\ndirectly and indirectly representing the
\nviews of more than nine million physicians.
\nwww.wma.net
\nFor more information about Be Aware,
\nTake Action, please see www.whpa.org\/
\ncounterfeit_campaign.htm
\nor send an email to whpa.campaign@wma.
\nnet
\nThe World Health Profession Alliance
\nWHPA
\nWHPA\u00a0Secretariat\u00a0\u2022\u00a013,\u00a0Chemin\u00a0du\u00a0Levant\u00a0
\n\u2022\u00a0BP\u00a063\u00a0\u2022\u00a001210\u00a0Ferney\u00a0Voltaire,\u00a0France
\nTel.:\u00a0+33\u00a0(0)\u00a0450\u00a040\u00a075\u00a075\u00a0\u2022\u00a0Fax:\u00a0+33\u00a0(0)\u00a0450\u00a0
\n40\u00a059\u00a037\u00a0www.whpa.org\u00a0\u2022\u00a0
\nE-mail: whpa@wma.net
\nHuge potential exists to improve pub-
\nlic health by reducing exposure to harm-
\nful environmental pollutants and through
\ncertain measures to tackle climate change,
\naccording to G\u00e9non K. Jensen, Director
\nof the Health and Environment Alliance
\n(HEAL). HEAL advocates changes in Eu-
\nropean policy that could reduce the burden
\nof chronic disease in Europe.
\nIn the world\u2019s wealthy countries, the burden
\nof disease is dominated by chronic, long-term
\nconditions. According to the World Health
\nOrganisation, 77% of the burden of disease in
\nhigh income countries is attributable to non-
\ncommunicable conditions,with only 8% of life
\nyears lost to communicable disease [1].
\nThe incidence of certain cancers,chronic re-
\nspiratory disease, diabetes and obesity is ris-
\ning. Many leading European scientists say
\nthat part of this growing burden of chronic
\ndisease is due to harmful contaminants in
\nthe everyday environment.
\nGiven that the European Union is respon-
\nsible for setting about 80% of the environ-
\nmental policy that is later applied in Mem-
\nber States, European institutions play a very
\nsignificant role in public health protection.
\nHow can changes in environmental
\npolicy reduce cancer rates?
\nIn the European Union, one in three people
\nwill develop some form of cancer during
\ntheir lifetime.Although genetics are respon-
\nsible for a proportion of cancer incidence,
\nsome cancer rates are increasing so rapidly
\nthat genetics alone cannot be the driver.
\nOther explanations for rising rates of can-
\ncer incidence include an aging population
\nor better screening programmes, or changes
\nin \u201clifestyle\u201dfactors,such as smoking and al-
\ncohol consumption. But such explanations
\ncannot account for all the increases. For ex-
\nample, the number of cancer cases among
\nchildren is increasing by at least 1% every
\nyear [2].
\nMany researchers and policy makers in-
\ncreasingly point to the connection with en-
\nvironmental factors, at least in part.
\nThe Health and Environment Alliance
\n(HEAL) has brought two recent scientific
\nreviews addressing the links between en-
\nvironmental chemical contamination and
\ndiseases to the attention of European policy
\nmakers. Substances known as \u201cendocrine
\ndisrupting chemicals\u201d(EDCs), which inter-
\nfere with or damage the human hormone
\nsystem, have been shown to produce \u201cgen-
\nder bending\u201d effects in animal studies, with
\nsignificant implications for human health
\neffects.
\nThe literature and analytical reviews link
\nEDCs with rising rates of breast cancer and
\nHow Can Changes in Environmental Policy
\nHelp Reduce Rates of Chronic Disease?
\nOpportunities for prevention in the European Union
\nGenon Jensen Diana Smith
\n101
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nwith testicular dysgenesis syndrome (TDS)
\n[3, 4]. TDS is a grouping which comprises
\nmale genital defects at birth (cryptorchid-
\nism, hypospadias), impaired semen quality,
\nand a type of testicular cancer (testicular
\ngerm cell tumours). Like breast cancer,
\nTDS has been linked with fetal exposure to
\nEDCs. Some leading European toxicolo-
\ngists are convinced that breast cancer rates
\nwill not be brought down until the issue
\nof everyday exposure to harmful synthetic
\nchemicals is addressed.
\nExamples of endocrine disrupting chemi-
\ncals mentioned in the reviews include: Bis-
\nphenol A \u2013 used in plastics and resins in
\nbaby bottles and can linings that may leach
\ninto drinks and foods; insecticides and pes-
\nticides, such as DDT and methoxychlor,
\nwhich have been banned in Europe since
\n1978 and 2003 respectively, but are still
\nfound in people\u2019s bodies; UV filters, such
\nas benzophenone and 4-MBC, which may
\nbe used in sun screens, are another example
\n[5].
\nBecause of concerns, France and Sweden
\nare currently considering banning Bisphe-
\nnol A for use in baby bottles as evidence
\nincreases on the need to protect biologi-
\ncally vulnerable groups such as babies and
\ntoddlers.
\nAlthough the EU has not yet banned
\nBisphenol A and many other important
\nEDCs, some European policy is already
\nbeginning the process of protecting human
\nhealth through stricter regulation of uses of
\nharmful chemicals. In 2007, a new law on
\nchemicals called REACH (Registration,
\nEvaluation, Authorisation and restriction
\nof chemical substances) was agreed to en-
\nsure that all chemicals on the EU market be
\nregistered. Those considered to be \u201cof very
\nhigh concern\u201d to human health are gradu-
\nally being put through a market authorisa-
\ntion process.
\nTwo years later, the so-called \u201cpesticides
\npolicy package\u201d was agreed. One of its ob-
\njectives was to reduce the impact of pesti-
\ncides and harmful effects on human health
\nand the environment. It will remove the
\nsale and use of pesticides linked with can-
\ncer, DNA mutation, reproductive toxicity,
\nand hormonal disruption. It also recom-
\nmends that pesticide use in parks, schools
\nand gardens around hospitals is minimised
\nor avoided. For the implementation of this
\npackage the national level is crucial as EU
\nMember States have to set up their own
\nNational Action Plans by 2012.
\nHEAL is currently involved in looking at
\nhow the review of the EU\u2019s biocide law can
\nlead to better health protection.Biocides are
\ndefined as \u201cchemical substances capable of
\nkilling living organisms, usually in a selec-
\ntive way\u201d. They include rodenticides, wood
\npreservatives,insecticides and anti-microbi-
\nal, such as disinfectants. A particular con-
\ncern is that the growing use of biocides is
\ncontributing to antibiotic resistance.
\nRecently the European Parliament passed
\na resolution which strongly underlines the
\nimportance of dealing with environmental
\nfactors when working to prevent cancer.
\nThe report responds to the EU \u201cCom-
\nmunication\u201d on Action against Cancer,
\nwhich already acknowledged that cancer
\nprevention should address environmental
\nand occupational causes on an equal foot-
\ning with lifestyle considerations, such as
\nsmoking, alcohol consumption and lack of
\nexercise.
\nA second example: chronic respiratory ill-
\nnesses
\nEnvironmental policy can also play an im-
\nportant role in reducing chronic health
\nproblems associated with lung disease.
\nLung disease is rising worldwide and its to-
\ntal financial burden in Europe amounts to
\nnearly \u20ac102 billion. Chronic Obstructive
\nPulmonary Disease (COPD) contributes
\nalmost one-half of this figure followed by
\nasthma, pneumonia, lung cancer and TB.
\nAlthough air quality has improved over the
\npast 20 years, it is still responsible for some
\n310,000 premature deaths within the Eu-
\nropean Union, according to a report by the
\nEuropean Commission [6].
\nResearch commissioned by the Health and
\nEnvironment Alliance (HEAL) and others
\nin 2008 showed the extent to which better
\nair quality through strong climate change
\npolicy would benefit health as a side effect
\n[7]. This would happen because reaching
\nclimate change targets involves moving to
\nenergy sources with lower of emissions of
\ncarbon dioxide and other air pollutants,
\nwhich would result in cleaner air.
\nThe review showed that if the EU moved
\nto a 30% target on greenhouse gas emission
\nreductions (compared with the EU\u2019s current
\ntarget of 20% by 2020), 100,000 fewer years
\nof life would be lost to air pollution among
\nEuropeans (over 30 years of age) every year
\nfrom 2020. In monetary terms, the overall
\npublic health benefits of the 30% reductions
\nclimate policy was estimated to be up to 25
\nbillion Euros per year by 2020 [7].
\nThe World Medical Association helped to
\nbring the message of these health co-ben-
\nefits of climate change policy to the atten-
\ntion of policy makers and the media, both
\nin Brussels and at the Copenhagen climate
\nsummit at the end of 2009. WMA joined
\n102
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nHEAL and Health Care Without Harm
\n(HCWH) in an initiative known as the
\n\u201cPrescription for a Healthy Planet\u201d, which
\naims to bring health to the centre of climate
\nchange negotiations.
\nLooking ahead
\nOver the coming months there will also
\nbe opportunities to influence EU policy
\non REACH, biocides, the Community
\nStrategy for Endocrine Disruptors, and the
\nimplementation of air quality legislation,
\nwhich includes for the first time a require-
\nment for governments to better inform re-
\nspiratory and asthma patients on poor air
\nquality. HEAL and HCWH Europe are
\nalso planning further research into how an
\nambitious greenhouse gas emission target
\ncan benefit public health in different EU
\nMember States. We hope that the WMA
\nand its member organisations will continue
\nto play its effective and prestigious role in
\nsupporting advocacy work to improve pub-
\nlic health in Europe. We very much wel-
\ncome your input into our work.
\nThe Health and Environment Alliance aims to
\nraise awareness of how environmental protec-
\ntion improves health. The membership includes
\na diverse network of organisations of citizens,
\npatients, women, health professionals and en-
\nvironmental experts across Europe. HEAL has
\na strong track record in increasing public and
\nexpert engagement in both EU debates and the
\ndecision-making process. The author has been a
\nmember of the WHO steering group the Eu-
\nropean Environment and Health Committee
\nand sits on several EU expert and research ad-
\nvisory groups as a policy advisor.
\nHEAL projects
\nHEAL has a variety of collaborative projects
\nrunning in several languages, which allow us
\nto focus on specific areas of priority.
\nChemicals Health Monitor \u2013 ensuring
\nthat scientific evidence on the links between
\nchemicals and ill-health are translated into
\npolicy as quickly as possible. www.chemi-
\ncalshealthmonitor.org
\nSick of Pesticides \u2013 advocating for strong
\nregulation of pesticide use for better health,
\nespecially to protect the most vulnerable
\ngroups in society. www.pesticidescancer.eu
\nPrescription for a healthy planet \u2013 bring-
\ning public health to the centre of the cli-
\nmate change debate, and uniting the in-
\nternational health community behind four
\nprinciples: protect public health; set strong
\ntargets on emission reductions; promote
\nclean energy; and fund global action. www.
\nclimateandhealthcare.org
\nHealthier Environments for Children \u2013
\nshowcasing examples of good practice proj-
\nects in children\u2019s environment and health
\nthroughout the 53 countries of the WHO
\nEuropean region. http:\/\/cehape.env-health.org
\nStay Healthy, Stop Mercury – raising
\nawareness of the potential health risks of
\nenvironmental mercury pollution. Calling
\non the EU to show leadership in efforts to
\ncontrol environmental mercury pollution
\nby securing a global ban on mercury. www.
\nenv-health.org\/stopmercury
\nReferences
\nWorld Health Statistics, 2009,Table 2.1.
\nCancer rates in children, source: IARC paper2.
\nThe Lancet, 11-17 December 2004
\nFactors influencing the risk of breast cancer -3.
\nestablished and emerging, ChemTrust, April
\n2008, http:\/\/www.chemicalshealthmonitor.
\norg\/spip.php?rubrique100
\nMale Reproductive Health Disorders and4.
\nthe Potential Role of Exposure to Environ-
\nmental Chemicals, ChemTrust, 2009, http:\/\/
\nwww.chemicalshealthmonitor.org\/spip.
\nphp?rubrique16
\nFactors influencing the risk of breast cancer -5.
\nestablished and emerging, ChemTrust, April
\n2008, http:\/\/www.chemicalshealthmonitor.
\norg\/spip.php?rubrique100 (page8)
\nInformation on the impacts of air pollution6.
\non human health up to 2020 www.duh.de\/
\nuploads\/media\/EU_2005__02.doc (Assess-
\nment of air quality in the EU, 21-22 February
\n2005, Clean Air for Europe (CAFE) Steering
\nGroup, European Commission.)
\nHEAL, CAN Europe, WWF, 2008, The7.
\nCo-benefits to health of a strong EU climate
\nchange policy, http:\/\/www.env-health.org\/
\nIMG\/pdf\/Co-benefits_to_health_report_-
\nseptember_2008.pdf
\nGenon Jensen, Executive Director,
\nHealth and Environment Alliance
\nDiana Smith, Communications and Media
\nAdvisor, Health and Environment Alliance
\n103
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nIntroduction
\nAt the Inauguration Ceremony of the new
\nmembers of Nigerian National Assembly
\nin Abuja, the nation\u2019s capital on 5th
\nJune,
\n2003, the President, Olusegun Obasanjo
\ndeclared:
\n\u201cNigerians have for too long been feeling short-
\nchanged by the quality of our Public Service.
\nOur Public offices have for too long been a
\nshowcase for the combined evils of inefficiency
\nand corruption, whilst being impediments to
\neffective implementation of government poli-
\ncies. Nigerians deserve better. We will ensure
\nthat they get what is better!\u201d [1]
\nPrior to this, most of these government
\nagencies had been pronounced inefficient
\ncompared to their privately run counter-
\nparts, and the Federal Government had
\nresolved to and undertook the process of
\nprivatization and commercialization of pub-
\nlic enterprises in order to improve service
\ndelivery to the nation\u2019s citizens. The health
\nsector was no exception.
\nNigeria\u2019s peculiar health sector has been
\ndiscussed at various fora over the past
\n30 years since the military coup of 31st
\nDe-
\ncember, 1983, which actually gave as one of
\nthe reasons for that putsch as \u201cour hospitals
\nhave become mere consulting clinics\u201d [2, 3].
\nThe World Health Organization (WHO),
\nfor these past decades, has rated the Nige-
\nrian health sector very low,more so with the
\nconsistently low budgetary allocation to the
\nsector by successive government administra-
\ntions. Nigeria is classed among the \u201cLow-
\nExpenditure, Low-Growth Health Econo-
\nmies\u201d, a group of underdeveloped countries
\nwhich despite comprising a population of
\n2.6 billion people (about 40% of the world\u2019s
\npopulation), is unfortunately credited with
\nless than 5% of the world\u2019s health expendi-
\nture [4]. Countries in this group suffer from
\nan absolute under-funding of their health
\nsector, along with a disproportionally high
\ndisease burden.
\nFrom 1997 to 2001, Nigeria\u2019s total an-
\nnual budgetary allocation to health tot-
\ntered around 1.7 \u2013 2.1% (2.1%, 2.3%, 1.7%,
\n1.7% and 1.9%, respectively), compared to
\nCameroon 4.1 \u2013 7.9%, South Africa 10.9 \u2013
\n12.4%, Namibia 12.4 \u2013 13.1%, Canada
\n13.9 \u2013 16.2%, and USA 16.8 \u2013 17.6%, in
\nthe same period; and the WHO prescrip-
\ntion is 15% of the Annual National Budget
\n[5,6]. Since health equated life, it was no
\nsurprise that as the budgetary allocation to
\nthe health sector, and consequently govern-
\nment investment on health, dwindled, Ni-
\ngeria\u2019s average life expectancy dropped from
\n54 years in 1998 to 43.4 years in 2004 (166th
\nout of 177 countries). And till now, there
\nis no evidence on ground that these indices
\nare improving [7, 8].
\nThe 2003\/2004 Nigerian Living Standards
\nSurvey (NLSS) conducted by the Nigerian
\nNational Bureau of Statistics, with inter-
\nnational technical assistance, documented
\na national poverty rate of 54.4%, implying
\nthat more than half of Nigerians live on
\nless than $1 per day (contrary to the WHO
\nstipulation of $5) [9]. Subjectively, 75.5%
\nof Nigerians regard themselves as poor,
\nwith most of them situated in the agricul-
\ntural and informal sectors particularly at
\nthe village levels.The picture could be scary
\nRe-Positioning of Service Delivery in the Nigerian Health System \u2013
\nthe Impact of SERVICOM on Emergency and Other Services in a
\nTertiary Health Facility
\nEmejulu, Jude-Kennedy C. Igwegbe, Anthony O. Eleje, George U.
\nOfiaeli, Robinson O. Nwofor, Alexander M. E. Anumonye, Charles O.
\n104
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nand gloomy, but more worrisome was the
\nattitude of administrators who appeared
\nnot to be bothered by these troublesome
\nstatistics.
\nThe poor service financing, seemingly rubs
\noff on various aspects of the health sector,
\nnot least, the emergency care services. On
\nmost of Nigeria\u2019s highways, there are no
\nreadily available or accessible emergency
\ncare units or squads equipped and prepared
\nto attend to road accident victims, rather,
\nthe job is left to traffic marshals whose
\noutposts are very few and far between, and
\ncommunication equipment and vehicles are
\nacutely in short supply. The result remains
\nthat most accident victims would not make
\nit to emergency care units even within the
\ngolden hour, and naturally, this would im-
\npact negatively on the outcome of most of
\nthe cases.
\nWith the unavailability of basic work tools
\ncoupled with a low morale due to sub-opti-
\nmal remunerations, Nigeria\u2019s public health
\ncare providers are not usually as enthusi-
\nastic in discharging their duties as would
\nbe expected of them in providing standard
\nservices to combat the constant challenge
\nof avoidable deaths and long term debility.
\nThis attitudinal short fall, appears to affect
\nnot only the health sector but also all the
\nother sectors of Nigeria\u2019s economy viz. law
\nenforcement, civil service, electricity gen-
\neration\/supply, transportation, telecommu-
\nnications, etc. and the impact on all fronts is
\nmore visible in the government sector and
\nbureaucracy.
\nIn December 2003, a research project was
\ncommissioned to review service delivery
\nin Nigeria with a view to determining the
\ninstitutional environment for service deliv-
\nery, the citizen\u2019s views on (and experiences
\nwith) service delivery and the designing of a
\nroadmap for a service delivery programme.
\nSubsequently, a report titled \u201cService Deliv-
\nery in Nigeria: A Roadmap\u201d was published
\nin February 2004, and the conclusions and
\nrecommendations therein included:
\nservices were not serving the people: they\u2022\u00a0
\nwere inaccessible, poor in quality and in-
\ndifferent to customer needs;
\npublic confidence was poor, and institu-\u2022\u00a0
\ntional arrangements were confusing and
\nwasteful;
\nservices should be re-designed around\u2022\u00a0
\nclients\u2019 requirements;
\nthe success of the Programme would\u2022\u00a0
\nrequire committed leadership from the
\ntop;
\nministers should demonstrate their com-\u2022\u00a0
\nmitment with a leadership declaration
\nabout Service Delivery;
\nthere was need for a far-reaching trans-\u2022\u00a0
\nformation of the Nigerian society through
\na Service Delivery Programme as a step
\nin the process of moving to a govern-
\nment that was more in touch with the
\npeople.That Service Delivery Programme
\nshould:
\ncreate citizens\u2019 and customers\u2019 de–
\nmand\u2019,
\ninstill higher expectations on public-
\nservices,
\ncommunicate service entitlements and-
\nrights,
\npublish information about perfor–
\nmance. [10].
\nIn March 2004, a Special Presidential Re-
\ntreat was held to deliberate on this report.
\nThe opening comment of the President
\nwas:
\n\u201cThis Retreat is to assert our ownership of the
\ninitiative to serve Nigerians better. We accept
\nfull responsibility for driving it to a successful
\nend\u2026 It is also the message of leading from the
\nfront in the battle to sanitize our system mor-
\nally, politically and economically. Above all, it
\nis the message of the leadership that the Nige-
\nrian people can trust…\u201d
\nAnd at the end of the retreat, the Federal
\nGovernment on 21st
\nMarch, 2004, resolved
\nto enter into a \u201cSERVIce COMpact\u201d
\n(SERV-ICOM) with the citizens of our
\ncountry for a commitment to their welfare
\nand satisfaction with service delivery; and
\nthus, was born the SERVICOM Charter
\n[1].
\nBy SERVICOM, it was also agreed that all
\nMinistries, Parastatals and Agencies and all
\nother Government Departments will pre-
\npare and publish,not later than the First day
\nof July 2004, SERVICOM CHARTERS
\nwhose provisions would include:
\nquality services designed around the re-\u2022\u00a0
\nquirements of their customers and served
\nby staff sensitive to the needs of their cli-
\nents;
\nset out the entitlements of the citizens\u2022\u00a0
\nclearly and in ways they could readily un-
\nderstand;
\nlist of fees payable (if any) and prohibit\u2022\u00a0
\nthe demand for any additional payments;
\ncommitment to the provision of services\u2022\u00a0
\n(including the processing of applications
\nand the answering of correspondence)
\nwithin realistic set time-frames;
\ndetails of agencies and officials to whom\u2022\u00a0
\ncomplaints about service failures may be
\naddressed;
\npublish these details in conspicuous plac-\u2022\u00a0
\nes accessible to the public;
\nperiodically conduct and publish surveys\u2022\u00a0
\nto determine levels of customer satisfac-
\ntion.
\nUnder this Charter, every government es-
\ntablishment outlined its goals and objec-
\ntives in the provision of optimal services to
\nthe satisfaction of its clients. It became an
\nagreement with and a commitment to the
\nclients,who were advised to report to specific
\nofficials when they get less than satisfactory
\nanswers to their enquiries or less than opti-
\nmum satisfaction from services rendered to
\nthem. Such reports would be treated with
\nseriousness, and sanctions meted out.
\nNigeria\u2019s health system operates on a cash-
\nand-carry basis whereby the client pays for
\nevery service and treatment received at any
\npoint in the hospital. However, a few years
\nago, a National Health Insurance Scheme
\n(NHIS) was introduced for the benefit of
\ngovernment employees, that allows each
\n105
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nemployee and four registered family mem-
\nbers to receive care at subsidized rates for
\nsome statutorily stipulated disease condi-
\ntions, but not for diseases outside the list.
\nThe NHIS does not as yet cover many dis-
\nease conditions.
\nOn 10th
\nMay, 2005, our institution fully
\nadopted and launched the SERVICOM
\nCharter in the provision of services to our
\nclientele, and we began to do everything
\nin a slightly different way. But it has been
\nknown that putting people first as the focus
\nof service delivery reforms is not a trivial
\nprinciple, as it could require significant \u2013
\neven if often simple \u2013 departures from
\n\u201cbusiness as usual\u201d [11].
\nNnamdi Azikiwe University Teaching Hos-
\npital (NAUTH) Nnewi, was a secondary
\nhealth facility (State General Hospital) in
\nthe 1970s which was upgraded to a Federal
\nGovernment training institution in 1992,
\nand since then, progressively grew into a
\n350-bed facility along with its five accredit-
\ned outposts located in Onitsha, Neni, Ukpo,
\nOba and Umunya, within Anambra State.
\nIt has facilities for service delivery and man-
\npower training in the various specialties of
\nMedicine and allied health professions.
\nNnewi is a semi-urban community with
\na population of 204,000 persons located
\nin Anambra State \u2013 one of the five states
\nthat constitute the South-East Zone of Ni-
\ngeria. Anambra State has a population of
\n4,182,032 persons (2006 National Popula-
\ntion Census), and our teaching hospital is
\nthe only tertiary health institution providing
\nservices to the State and some other States
\nin the South-East Zone,as well as in parts of
\ntwo other Zones (South-South and North-
\nCentral) of Nigeria. The total population of
\nthese potential catchment areas is estimated
\nat 40.2% of Nigeria\u2019s 140million population
\n(South-East 11.7%, South-South 15% and
\nNorth-Central 13.5%) [12, 13].
\nThis study is a prospective evaluation of
\nthe clientele turnover and outcome of
\ncases treated in NAUTH Nnewi after
\nthe introduction of SERVICOM in May
\n2005, meant to assess the impact of this
\nCharter on the provision of services in our
\ntertiary health institution, and determine
\nits usefulness, or otherwise, in the im-
\nprovement of the health of our catchment
\npopulation.
\nThe question is: Has SERVICOM made
\nthe desired impact on care delivery in our
\nhealth institution?
\nMethods\/Patients\/Materials
\nData collection for this study started pro-
\nspectively as soon as the SERVICOM
\nprotocol was introduced in May 2005, us-
\ning the Microsoft excel broadsheet, and
\ncollated on a monthly basis. The electronic
\nand hardcopy registers of the Department
\nof Health Records were used to crosscheck
\nthe collected data of the different Units and
\nDepartments. Statistical analysis was done
\nusing the chi-square; with the significant p-
\nvalue taken as \u22640.05.
\nBecause SERVICOM was introduced in
\nthe second quarter of 2005, we agreed that
\ndata from 2006 represented the transition
\nperiod, while 2007 onwards would more
\nappropriately reflect the impact of this pro-
\ngramme in the post-SERVICOM period,
\nand 2005 would be more representative of
\nthe pre-SERVICOM status of service de-
\nlivery in our Institution.
\nResults
\nBy the end of 2006, numerical data began
\nto show a change in all facets of care deliv-
\nery compared to the figures in the preced-
\ning year in the hospital and quite remark-
\nably, in the Accident and Emergency Unit,
\nas well.
\nFor 2005, 2006, 2007, 2008 and 2009 at-
\ntendance at Consultant Out-patient Clin-
\nics were 36032, 48703, 58530, 64931 and
\n66831 clients, respectively (Figure 1); Gen-
\neral Out-patient Clinics for the same pe-
\nriod were 35866, 51520, 57830, 60056 and
\n62055 (Figure 2); Children\u2019s Out-patient
\nClinics 36032, 48703, 58530, 64931 and
\n66831 (Figure 3); Accident and Emergency
\nUnit 3988, 7034, 10503, 12224 and 14118
\n(Figure 4); Hospital In-patient Admissions
\n4718, 6067, 11874, 13750 and 15650 (Fig-
\nure 5); Laboratory Services 58039, 62007,
\n81196, 93300 and 115301 (Table 1); Surgi-
\ncal Operations in the Theatres 1001, 1321,
\n3706, 4142 and 5642 (Table 2), and Baby
\nDeliveries in the Labour Room 596, 627,
\n1611, 2936 and 2123 (Table 3).
\nThe gross clientele turnovers for the whole
\nHospital in each of these five years (2005 \u2013
\n2009) were 76452, 107884, 128474, 140147
\nand 145127 (Figure 6), while mortalities
\nfrom in-patients for the corresponding
\nyears were 284 (6% of in-patients), 221
\n(3.64%), 200 (1.68%), 143 (1.04%) and 127
\n(0.81%) (Figure 7).Within the same period,
\nthe maternal mortalities were 11 (1.84%), 9
\n(1.43%),7 (0.43%),8 (0.27%) and 3 (0.14%),
\nrespectively (Table 3).
\nDiscussion
\nAt the inauguration of the SERVICOM
\nCharter, the management of our Hospital
\nidentified key areas that required re-evalua-
\ntion and attention based on the submissions
\nof every service Unit and Department, after
\nan analysis of the Strengths, Weaknesses,
\nOpportunities and Threats (SWOT) of
\neach. A pre-SERVICOM workshop which
\nwas supervised by the Federal Government
\nwas held in the various institutions na-
\ntionwide to enable care providers enumer-
\nate their current service capacity, and then,
\nbased on their stated ideal objectives, risks,
\nshortcomings and strengths, identify the in-
\nstitutional needs that would enable them to
\nachieve their set objectives. With the reso-
\nlutions from the workshop, human and ma-
\nterial resources were upgraded in order to
\naddress the identified risks and enhance the
\ncapacity of each institution to attain these
\nset goals.
\n106
\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
\nFor example, changes employed in the Ac-
\ncident and Emergency Unit of NAUTH
\nNnewi included:
\nthe employment of more medical officers,\u2022\u00a0
\nnurses and other health personnel;
\nprocurement of more diagnostic and\u2022\u00a0
\ntherapeutic equipment;
\navailability of adequate supply of medica-\u2022\u00a0
\ntions;
\nappointment of a new Head of Unit with\u2022\u00a0
\na brief to enforce discipline and compli-
\nance with all the activities in the Unit;
\ndaily morning audit of the clientele turn\u2022\u00a0
\nover and treatment outcome in the Unit
\nfor the preceding 24hours, by the hospital
\nmanagement;
\ninstallation of free communication lines\u2022\u00a0
\nfor health personnel to easily make con-
\ntact with their colleagues, superiors or
\nhospital management round-the-clock
\nwhenever there is an urgent need arising
\nfrom care delivery;
\nwaiver on all hospital bills for all emer-\u2022\u00a0
\ngency cases until resuscitation\/salvage is
\nachieved or relatives who would make
\npayment arrive;
\ndirect line for feedback from the clients\u2022\u00a0
\nto the hospital management for whatever
\nimpression they make of the care they re-
\nceived;
\n24-hour electric power supply; structural\u2022\u00a0
\nrenovation of sections of the Unit.
\nFollowing these reforms, the time lapse be-
\ntween the arrival of a client, in our Accident
\nand Emergency (A&E) Unit, and review
\nby the doctor on call in the A&E Unit was
\nshortened to a maximum of 5minutes com-
\npared to the previous scandalous records
\nthat got as long as 2 hours in some instanc-
\nes. Also, the maximum time lapse between
\nreview of the client by the doctor in the
\nA&E Unit and arrival of any specialist Unit
\non call that is required to attend to the same
\nclient was statutorily fixed at 30 minutes.
\nFor the rest of the institution itself, a log
\nregister was introduced and strictly en-
\nforced to monitor the movement of Staff
\nright from the moment of arrival for duties
\ntill the commencement of duty and time of
\ndeparture, and appropriate sanctions were
\nspelt out on erring Staff. Similar changes as
\nin the A&E Unit were also introduced in
\nthe Labour Room and Children\u2019s Emergen-
\ncy Room, all of which we regarded as emer-
\ngency flashpoints in our service delivery.
\nAs soon as the protocols of SERVICOM
\nwere put in place, the attitude of our Staff
\nbegan to change remarkably. Every em-
\nployee rushed to make it to the duty post
\nevery day before the attendance register was
\nclosed, and at the various service points,
\nclients were given timely and polite atten-
\ntion, medications were readily available and
\nno client was left unattended to merely on
\naccount of lack of funds. Most importantly,
\npeople felt that they were being listened to
\nand respected \u2013 a key aspect of what people
\nvalue about health care, similar to the expe-
\nrience reported in 2007 from Alaska, USA
\nand other parts of the world where some
\nhealth reforms were undertaken [14, 15,
\n16, 11].
\nWith the gross annual clientele turnovers
\nof 107884, 128474, 140147 and 145127
\nfrom 2006 to 2009 in NAUTH Nnewi, it
\nwas evident that there were geometrically
\nincreasing patronage of 41% (p <0.05),\n68% (p <0.05), 83.3% (p <0.05) and 89.8%\n(p <0.05), respectively, over the 2005 an-\nnual figure of 76452. In the A&E Unit,\nthe clientele attendance of 3988, 7034,\n10503, 12224 and 14118 for the same pe-\nriod equally translated to rises of 76.4% (p\n<0.05), 163.4% (p <0.05), 206.5% (p <0.05)\nand 254% (p <0.05), respectively over the\n2005 figures. Both the difference in gross\nclientele turnover and A&E attendance\nwhen subjected to analysis were found to\nbe statistically significant (p <0.05) in each\nof the years.\nTable 1. Laboratory services\nYear Total Laboratory Clientele Patronage (Total No. for\n2005 = 58039)\nIncrease over 2005\n2006 62007 (3968) 6.83%\n2007 81196 (23157) 39.9%\n2008 93300 (35261) 60.8%\n2009 115301 (57262) 98.7%\nTable 2. Surgical operations in the theatres\nYear Total No. of Operations (Total No. for 2005 = 1001) Increase over 2005\n2006 1321 (320) 32%\n2007 3706 (2705) 270.2%\n2008 4142 (3141) 313.8%\n2009 5642 (4641) 463.6%\nTable 3. Baby deliveries and maternal mortality\nYear Total No. of Deliveries (Total\nNo. for 2005 = 596)\nIncrease over 2005 Maternal Mortality (%)\n2005 = (11) 1.84%\n2006 627 (31) 5.2% (9) 1.43%\n2007 1611 (1015) 170.3% (7) 0.43%\n2008 2936 (2340) 392.6% (8) 0.27%\n2009 2123 (1527) 256.2% (3) 0.14%\n107\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\nPrior to 2005, the impression of our clients\nand their relatives was that prompt and op-\ntimal care was more likely to be obtained\nin private clinics in our locality than in the\nTeaching Hospital; and their reasons both-\nered mostly on the attitude of health per-\nsonnel and non-availability of medications\nin government-run health facilities. The\nWHO had noted that people are increas-\ningly impatient with the inability of health\nservices to deliver levels of national cover-\nage that meet stated demands and chang-\ning needs, and with their failure to provide\nservices in ways that correspond to their\nexpectations [4]. As a result, patronage of\nour government institutions remained very\nlow and in most cases,was confined to those\nclients who could not afford the bills of pri-\nvate facilities, or victims of accidents whose\nidentities and relatives were not known in\nthe immediate post-ictal period.\nBut, Nigeria was not alone in her inadequa-\ncies because studies by Halman, et al, Mil-\nlenson and Davies, had shown that in many\nparts of the world, there were considerable\nscepticism about the way and the extent\nto which health authorities assume their\nresponsibilities for health [17, 18, 19, 20].\nSurveys have shown a trend of diminish-\ning trust in public institutions as guarantors\nof the equity, honesty and integrity of the\nhealth sector because on the whole, people\nexpect their health authorities to work for\nthe common good, do this well, and do so\nwith foresight [21].\nThe increased patronage noted after the\nintroduction of SERVICOM appeared,\ntherefore, to indicate a restoration of public\nconfidence in the capacity of the hospital to\nprovide desirable services. And this seemed\nto cut across the entire service points of our\nhospital. In the Operating Theatre, some of\nwhose clients pass through the A&E Unit,\nfigures rose by 32% (p <0.05), 270.2% (p\n<0.05), 313.8% (p <0.05) and 463.6% (p\n<0.05), when compared to the 2005 sta-\ntistics, just as in the Labour Room where\ndelivery of new babies rose remarkably by\nFigure 1. Attendance to Consultant Out-Pa-\ntient Clinics\nFigure 2. Attendance to General Out-Patient\nClinics\nFigure 3. Attendance to Children\u2019s Out-Pa-\ntient Clinics\nFigure 4. Accident and Emergency Cases\nFigure 5. In-Patient Admissions\nFigure 6. Gross Clientele Turnover\nFigure 7. In-Patient Mortality\n108\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\n170.3% (p <0.05), 392.6% (p <0.05) and\n256.2% (p <0.05), respectively for 2007,\n2008 and 2009. The 5.2% rise recorded in\n2006 was, however, not statistically signifi-\ncant on analysis (p >0.05).
\nPerhaps, even more compelling than the
\nabsolute figures of patronage were the mor-
\ntality rates of our In-patients and pregnant
\nmothers, both which were on a persistent
\ndecline despite the rise in total clientele
\nturnover. Mortality rates for In-patients in
\nthe five years 2005 \u2013 2009 were 284 (out
\nof 4718 admissions), 221 (6067 admis-
\nsions), 200 (11874), 143 (13750) and 127
\n(15650), which translated to 6%, 3.64%,
\n1.68%, 1.04% and 0.81% of all admitted
\ncases, respectively. When the post-SER-
\nVICOM mortality rates were compared
\nto 2005 (6% of 4718), the mortality rates
\nshowed a marked progressive reduction by
\n39.3% (p <0.05) in 2006, 72% (p <0.05) in\n2007,82.7% (p <0.05) in 2008 (p <0.05) and\n86.5% (p <0.05) in 2009, respectively, all of\nwhich were statistically significant.\nAfter an assessment of the available data,we\ndiscovered that from 2006, when compared\nto the pre-SERVICOM era, there was:\na progressive increase in clientele patron-\u2022\u00a0\nage \/ turnover in all our service sectors \u2013\nA&E,Out-patient,In-patient,Operating\nTheatre, Labour Room, Laboratories, etc;\na progressive decrease in absolute mortal-\u2022\u00a0\nity rates of the In-patients per annum;\na progressive decrease in maternal mor-\u2022\u00a0\ntality rates per annum;\na much greater decline in relative mortal-\u2022\u00a0\nity rates for all the in-patients and preg-\nnant mothers per annum.\nThese findings strongly supported the fact\nthat the introduction of the SERVICOM\nCharter stimulated several positive chang-\nes, and thereby, re-positioned our tertiary\nhealth institution towards a much better\nsatisfaction of the demands of our clientele.\nThey provided the answer to the question,\nthus: SERVICOM has made the desired\nimpact on care delivery in our health insti-\ntution; even though it should be stated un-\nequivocally that there is still a lot of room\nfor more improvement.\nIt is worth noting that beyond attitude, the\nrole of quality personnel,modern diagnostic\nand therapeutic equipments, and adequate\nremuneration of workers, would never be\nover-emphasized. Attitude alone may not\nbe enough to sustain these massive gains\nfor too long because it is only a portion of\nthe whole armamentarium for a successful\nhealth care delivery system. Increasing Ni-\ngeria\u2019s annual budgetary allocation to health\nfrom the present 2% to the WHO recom-\nmended 15% as affirmed at the Abuja Ac-\ncord holds the surest key.\nRegular quality assurance of the human\nand material resources should be a comple-\nmentary aspect of the project of better ser-\nvice delivery in all sectors of the Nigerian\neconomy, most importantly, the health sec-\ntor. More so, a host of other fairly low-cost\npolicies (e.g. enhanced provision of water,\nmedical drugs, or AIDS education\/care)\nhave been reported to lead to dramatic im-\nprovements in life expectancy in developing\ncountries,and these should be given priority\nby the various governments in Nigeria, as\nwell [22].\nConclusion\nIt is obvious that the structural and attitu-\ndinal changes introduced by SERVICOM,\nbrought a very significant improvement in\nall our performance indices, and thus, con-\ntributed to the improved care delivery to\nour clients. Perhaps, one of the most likely\nhandicaps that could stall or reverse these\ngains is the non-sustenance of the current\nmomentum, but if this is sustained and in-\ntroduced changes improved upon, health\ncare delivery despite its various challenges\nwould most likely continue to improve, and\nthe life expectancy of the average Nigerian\nwould record a change, from the appalling\n43.4 years.\nReferences\nKuru Declaration, 2003 National Assembly1.\nInaugural Speech Service Delivery In Nigeria:\nA Roadmap - Time To Deliver; President\u2019s\nRemark, Memorandum by the President of the\nFederal Republic of Nigeria; Federal Executive\nCouncil Report on the Establishment of Min-\nisterial SEVICOM Units. SERVICOM Office,\nhttp:\/\/www.servenigeria.com\/misc\/wendyre-\nport.pdf.\nGlobal Security: 1983 Buhari Coup. http:\/\/2.\nwww.globalsecurity.org\/military\/world\/war\/ni-\ngeria2.htm\nTHIS DAY NEWSPAPERS: Osotimehin3.\nCanvasses Health Sector Reform. http:\/\/www.\nthisdayonline.com\/nview.php 05.16.2009.\nWHO. The 2008 World Health Report: \u201cPri-4.\nmary Health Care \u2013 Now More Than Ever\u201d 14\nOctober 2008, Geneva.\nWorld Health Organization. World Health Re-5.\nport 2004: Selected National Health Accounts\nIndicators for all Member States http:\/\/www.\nwho.int\/whr\/2004\/annex\/en\/index.html\nNational Health Accounts. World Health Or-6.\nganization, Geneva 2008. http\/\/www.who.int\/\nnha\/country\/en\/index.html, accessed May 2008.\nUNDP. Human Development Report, Human7.\nDevelopment Indicators, Country Fact Sheet:\nNigeria 2006. P. 29\u2013212.\nVanguard Media Limited. Vanguard Comment8.\nNigeria\u2019s Lower Life Expectancy 1998\u20132005.\nhtm. Monday, September 26, 2005.\nU.S. Ambassador Robin Rene\u00e9 Sanders : Isaac9.\nMoghalu Foundation Leadership Lecture Ni-\ngerian Institute of International Affairs. Lagos,\nApril 23, 2008.\nWendy Thomson.10. Delivering Service in Nigeria:\nA Roadmap; Office for Public Service Reform,\nUnited Kingdom. http:\/\/www.servenigeria.com\/\nmisc\/wendyreport.pdf\nEby D. Primary care at the Alaska Native Medi-11.\ncal Centre: a fully deployed \u201cnew model\u201d of pri-\nmary care. International Journal of Circumpolar\nHealth. 2007; 66(Suppl. 1): 4\u221213.\nEmejulu JKC, Osuafor CNC, Ogbuagu CN.12.\nAudit of the Demographic Patterns of Neuro-\nsurgical Cases in a Tertiary Health Institution:\nthe need to relate service delivery to disease pro-\nfile in dwindling resources and manpower short-\nage. African Journal of Neurological Sciences. 2009;\n28 (2). http:\/\/ajns.paans.org.\nAFRICA\/NIGERIA MASTERWEB Spe-13.\ncial Feature: Nigeria 2006 Census Figures\n109\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\nhttp:\/\/www.africamasterweb.com & http:\/\/\nwww.nigeriamasterweb.com\nEby D. Integrated primary care.14. International\nJournal of Circumpolar Health. 1998; 57 (Suppl.\n1): 665\u22127.\nGottlieb K, Sylvester I, Eby D. Transforming15.\nyour practice: what matters most? Family Prac-\ntice Management. 2008; 15: 32\u20138.\nKerssens JJ,16. et al. Comparison of patient evalua-\ntions of health care quality in relation to WHO\nmeasures of achievement in 12 European coun-\ntries. Bulletin of the World Health Organization.\n2004; 82 : 106\u201314.\nHalman L et al.17. Changing values and beliefs in\n85 countries. Trends from the values surveys from\n1981 to 2004. Leiden and Boston, Brill, 2008\nEuropean values studies 11; http:\/\/www.world-\nvaluessurvey.org, accessed 2 July 2008.\nMillenson ML. How the US news media made18.\npatient safety a priority. BMJ. 2002; 324: 1044.\nDavies H. Falling public trust in health services:19.\nImplications for accountability. Journal of Health\nServices Research and Policy. 1999; 4: 193\u20134.\nMullan F, Frehywot S. Non-physician clinicians20.\nin 47 sub-Saharan African countries. Lancet.\n2007; 370 : 2158\u201363.\nGilson L. Trust and the development of health21.\ncare as a social institution. Soc Sci Med. 2003;\n56: 1453\u201368.\nAudrey B, Graves PE. Predicting Life Expect-22.\nancy: A Cross-Country Empirical Analysis.\nEmejulu, Jude-Kennedy C, MBBS, FWACS\nNeurosurgery Unit, Department of Surgery\n& Accident and Emergency Unit\nE-mail: judekenny2003@yahoo.com\nIgwegbe, Anthony O, MBBS, FWACS, FICS\nDepartment of Obstetrics and Gynaecology\nEleje, George U, MBBS\nDepartment of Obstetrics and Gynaecology\nOfiaeli, Robinson O, MBBS,\nFMCS, FICS, FWACS\nOrthopaedic Surgery Unit,\nDepartment of Surgery\nNwofor, Alexander M E, MBBS,\nFMCS, FICS, FWACS\nUrology Unit, Department of Surgery\nAnumonye, Charles O, BSc, FHR\nDepartment of Health Records and Statistics\nRobert J\u00fctte\nEtymology\nThe term \u201cplacebo\u201d has not been part of\nmedical usage for very long, but the phe-\nnomenon we refer to as the \u201cplacebo effect\u201d\nhas been known in medical as well as lay\ncircles for a long time. The French phi-\nlosopher and writer Michel de Montaigne\n(1533\u20131592) described the powerful effect\nof imagination on the human by using the\nexample of a patient who received regular\nnon-medical enemas given by his doctor\nand experienced the same effect from them\nas from enema that actually contained me-\ndicinal substances rather than just warm wa-\nter [38]. It was not until the second third of\nthe 18th\ncentury that the phenomenon, or at\nleast a partial aspect of it, was first referred\nto as \u201cplacebo\u201d.It was the Scottish physician\nand pharmacologist William Cullen (1710\u2013\n1790) who coined the expression. In 1772\nhe demonstrably used the term for the first\nThe History of the Placebo1\nThis historical study is part of a larger project on1.\nthe placebo effect undertaken by a group of ex-\nperts on behalf of the Wissenschaftlicher Beirat\nder Bundes\u00e4rztekammer (Scientific Board of the\nGerman Medical Association)\n110\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\ntime in his Clinical Lectures in connection\nwith a patient to whom he gave an external\napplication of mustard powder although he\nwas not convinced of its specific effect: \u201cI\nown that I did not trust much to it, but I\ngave it because it is necessary to give a med-\nicine, and as what I call a placebo. If I had\nthought of any internal medicine it would\nhave been a dose of the Dover\u2019s powders.\u201d\n[10]. In another case that he considered to\nbe hopeless he also prescribed a medicine\nthat was ineffective in his view and justified\nhis decision as follows: \u201cI prescribed there-\nfore in pure placebo, but I make it a rule\neven in employing placebos to give what\nwould have a tendency to be of use to the\npatient\u201d [9].\nCullen\u2019s \u201cplacebo\u201d was not yet an inert sub-\nstance. He tended to use low doses of drugs\nwhich he thought to be ineffective given the\nseverity of the disease. His main concern\nwas not what to prescribe but how to fulfil\nthe patient\u2019s desire for a medicament, even\nthough he did not personally believe in its\npharmacological effectiveness (according to\nthe state of knowledge at the time) [28].\nAt the time when Cullen introduced the\nterm \u201cplacebo\u201d into medicine it had a dif-\nferent meaning in the English language.\nSince the 14th century \u201cto sing a placebo\u201d\nhad meant as much as \u201cflattering a person of\nhigh rank\u201d[7]. It was an ironical application\nof a medieval antiphon from the mass for\nthe dead. An antiphon is a short, memora-\nble response in the liturgy, in this case the\nlast verse of psalm 116, which in the origi-\nnal Hebrew reads: \u202b\u05b6\u05d0\u202c\u202b\u05ea\u202c\u05b0\u202b\u05d4\u202c\u05b7\u202b\u05dc\u202c\u05bc\u05b5\u202b\u05da\u202c\u05b0, \u202b\u05b4\u05dc\u202c\u202b\u05e4\u202c\u05b0\u202b\u05e0\u202c\u05b5\u202b\u05d9\u202c \u202b\u05b0\u05d9\u202c\u202b\u05d4\u202c\u202b\u05b8\u05d5\u202c\u202b\u05d4\u202c- \u202b\u05bc\u05d1\u202c\u05b0\u202b\u05d0\u202c\u05b7\u202b\u05e8\u202c\u05b0\u202b\u05e6\u202c\u202b,\u05ea\u05b9\u05d5\u202c\n\u202b\u05b7\u05d4\u202c\u202b\u05d7\u202c\u05b7\u202b\u05d9\u202c\u05bc\u05b4\u202b\u05d9\u202c\u202b-\u05dd\u202c [24, 3, 40, 2]. In the King James Bi-\nble it is translated as \u201cI will walk before the\nLord in the land of the living\u201d. This version\ncorresponds to the Latin translation by the\nchurch father Jerome (Vulgate) which fol-\nlows the Hebrew text (Ps 114.9): \u201cDeambu-\nlabo coram Domino in terram viventium\u201d.\nIn the Septuagint,the classical Greek trans-\nlation of the Old Testament, the Hebrew\nverb for \u201cgo\u201d or \u201cwalk\u201d is not rendered liter-\nally but figuratively as \u03b5\u03c5\u03b1\u03c1\u03b5\u03c3\u03c4\u03b9\u03c3\u03c9. Jerome\u2018s\nLatin translation (the Gallicana version) of\nthe Greek correspondingly uses the verbal\nphrase \u201cplacebo\u201d. Translated into English\nthe verse then reads: \u201cI shall be pleasing in\nthe sight of the Lord in the land of the liv-\ning\u201d [21].\nEarly uses of placebo\nNext to the Scottish physician and pharma-\ncologist William Cullen it was a German\ndoctor who used the placebo effect in his own\npractice: Samuel Hahnemann (1755\u20131843),\nthe founder of homoeopathy. He translated\nCullen\u2019sMateriaMedicaintoGermanwhich\ngave him the idea for his famous experiment\nwith Peruvian Bark. Hahnemann was obvi-\nously not familiar with the term \u201cplacebo\u201dal-\nthough he knew the principle which for him\nmeant giving \u201csomething non-medicinal\u201d\nsuch as raspberry juice or lactose. Early on\nin his homeopathic practice he encountered\nthe problem that his patients were used to\ntaking medicine on a daily basis as was cus-\ntomary in orthodox medicine at the time,\nwhile in homeopathy it was important, in\nhis view, to allow the remedies to fully un-\nfold their action.In an essay that was printed\nin the Allgemeine Anzeiger der Deutschen in\n1814 Hahnemann offered the following\nrecommendation to his colleagues: \u201cIn the\nmeantime, until the second medicament is\ngiven,one can soothe the patient\u2019s mind and\ndesire for medicine with something incon-\nspicuous such as a few teaspoons a day of\nraspberry juice or sugar of milk\u201d [18]. In his\nwork on the chronic diseases he advised: \u201cIf\na homeopathic physician, doubtful without\noccasion,asks me how,during the many days\nafter giving a dose of medicine that should\ncontinue to act undisturbed, to satisfy the\npatient who demands medicine every day,\nwithout harming him I reply in two words:\n\u201cgive him a daily dose of lactose, about three\ngrains, at the usual time marking it with the\ncontinuous number\u201d[17].\nHahnemann already experienced that the\nblinding was not always successful. One\nof his patients, also an eager reader of his\nwritings, had seen through the deception\nbut still remained loyal to Hahnemann:\n\u201cThe powder I took regularly although I am\nwell aware that only number (figure illeg-\nible, R.J.) is a medicine as instructed in your\nworship\u2019s books which I looked into\u201d [23].\nIn Hahnemann\u2019s case journals, which are\nalmost fully preserved, he marked placebos\nwith the paragraph symbol (\u00a7). After first\nexperimenting with ground oyster shells\n(Conchae) as placebo at the beginning of\nhis homeopathic practice he later on al-\nmost exclusively gave lactose in these cases\nto which the homeopathic Materia Medica\ndoes not attribute a medicinal effect [39].\nOn 21 June 1807 the then US president\nThomas Jefferson (1743\u20131826) wrote to a\nDr. Caspar Wistar: \u201cOne of the most suc-\ncessful physicians I have ever known, has\nassured me, that he used more bread pills,\ndrops of colored water, powders of hickory\nashes, than of all other medicines put to-\ngether. It was certainly a pious fraud. But\nthe adventurous physician goes on, substi-\ntutes presumption for kno[w]le[d]ge\u201d [25].\nIt cannot be fully ascertained but we can as-\nsume that the successful physician in ques-\ntion was Benjamin Rush (1745\u20131813), a\nJames Lind\n111\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\nfriend of Jefferson\u2019s. The letter proves that,\nas early as the beginning of the 19th\ncentury,\nphysicians consciously used the placebo ef-\nfect while being aware of the ethical impli-\ncations (\u201cpious fraud\u201d). During World War\nI a Jesuit priest employed as a nurse in a\nbattlefield hospital,knowingly administered\nsodium chloride injections as placebos:\n\u201cEvery evening there was the fight about\nthe morphine that the patients demanded.\nThey begged and pleaded. But we used it\nsparingly and, if it was at all possible, we\ndid not give them any. [...] If the lamenting\ndid not cease we often had no choice but\ndeceive them with a sodium chloride injec-\ntion. The moaning and groaning often con-\ntinued all through the night [...].\u201d[Archives\nof the German Jesuit Province in Munich,\n00\/752vl, Kriegslazarett 8, vol. 1-2. P. 126]\nThe placebo in clinical research\nThe beginnings of the controlled trial\n(with simple, double and triple blinding)\ndate back to the 18th\ncentury, though no\nplacebo was used to start with. It began\nwith the Scottish Naval Surgeon James\nLind (1716\u20131794) [43]. In his Treatise on\nthe Scurvy (1753) he described how he per-\nformed the first clinical drug testing on 20\nMay 1747 on board a British Navy vessel.\nOf 12 scurvy patients (\u201cas similar as I could\nhave them\u201d) two were given cider, two vit-\nriol, two vinegar, two sea water, two orang-\nes and lemons, two an electuary of garlic,\nmustard seeds, balsam of Peru and gum\nmyrrh. The patients who were fed citrus\nfruit recovered within six days. The com-\nparison group remained without treatment\napart from \u201ca little lenitive electuary\u201d[32].\nWe know today that citrus fruits are the\ntreatment of choice because they contain\nvitamin C the lack of which causes scurvy.\nAs the vitamins had not been discovered\nyet at the time, lemon juice was seen as a\ncleansing agent that could rid the body of\ntoxic particles. In 1784, a commission of\nexperts that was appointed by the French\nking, Louis XVI (1754\u20131793), and includ-\ned Benjamin Franklin (1706\u20131790),carried\nout simple blind trials to ascertain whether\nFranz Anton Mesmer (1734\u20131815) was\nright in claiming that the magnetic fluid\n(animal magnetism) had a healing effect.\nFor the trial, the test candidates were sepa-\nrated from the physician, who was to mes-\nmerize them, by a screen. The fluid transfer\nonly worked if the test person knew about\nthe treatment which led the commission to\nconclude in 1785: \u201cthis agent, this fluid has\nno existence\u201d[27]. This by no means put\nan end to the debate about the effective-\nness and effect of mesmerism. It continued\nright into the 19th\ncentury and there are\nstill magnetisers today who see themselves\nas continuing Mesmer\u2019s legacy [26, 42].\nIn 1799, the British physician Dr John\nHaygarth (1740\u20131827) tested in a simple\nblinded trial the controversial healing ap-\nproach of the American doctor Elisha Per-\nkins (1741\u20131799) who claimed he could\ndeviate harmful energy (electroid fluid)\nfrom the sick body by means of a \u201ctractor\u201d\nmade from two metal rods [19]. The test\nwas performed in the following way: there\nwere two groups, one of which was treated\nwith the metal tractors and the other with\nwooden rods that were made to look exactly\nlike the \u201cgenuine\u201d ones. The treatment was\nsimilarly successful in both groups.\nThe first controlled clinical trials with \u201cin-\nert\u201d substances were developed by physi-\ncians who either sought to prove the ef-\nfectiveness of homeopathy or to expose this\nnew healing system as \u201chumbug\u201d [11, 12].\nThe first was the German-Russian physician\nDr J. Hermann who, in 1829, performed a\nkind of outcome study in a military hospi-\ntal in Tulchin, now Ukraine. He compared\nthe treatment of malaria patients in a ho-\nmeopathic and an allopathic ward [20]. In\na follow up trial, which he was able to con-\nduct shortly after in a military hospital in\nSt Petersburg under the supervision of a\nDr Gigler, a third trial arm was added. The\npatients allocated to this group basically\nreceived only general care (baths, sufficient\nfood and rest):\n\u201cDuring that time the patients were kept\nin a state of innocent deception. In order to\navoid the suspicion that they did not receive\nany medicine, they were prescribed pills\nmade from white bread crumbs or cocoa, or\nsugar of milk powder, or salep decoctions as\nwas also the case in the homeopathic ward\u201d\n[31].\nInterestingly, the best results were achieved\nin the group that was given no treatment\napart from loving care.\nThe first double blind trial with a placebo\narm also served the assessment of homeop-\nathy. The initiative by physicians who were\nsceptical about homeopathy took place in a\nNuremberg public house in 1835 [Stolberg,\n1996]. The trial was performed as follows:\nA C30 solution of purified salt and distilled\nsnow water was prepared. 100 vials were\nmeticulously cleaned and numbered, then\nwell shuffled and spread on two tables. Half\nof them were filled with the homeopathic\nsolution, the other with pure distilled snow\nwater. After a list of the vials and their con-\n112\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\ntent had been made and sealed, the vials\nwere again thoroughly shuffled. Then the\nprincipal investigator gave each participant\na vial which was also registered with the\nnumber and the participant\u2019s name. Neither\nparticipants nor investigators knew who\nhad been given which vial but this could be\ndiscovered with the help of the sealed lists.\nThe outcome was not unambiguous. The\nhomeopaths in particular were critical of\nthe fact that the drug had been tested on\nhealthy subjects. Still, the experiment was\nground-breaking in one respect: it consti-\ntuted the beginning of the modern clinical\ntrial, not yet randomised, but double blind.\nHow progressive the study design was is\nshown by the forward-thinking comment\nmade by the leading investigator: \u201cAvoid\nanything that would enable the individual\nprobands to surmise whether they have re-\nceived distinctly homeopathic or distinctly\nnon-medicinal test substances. Even the\nproducers and distributors of the doses must\nnot know, as was the case in our trial, what\nthis or that person was given\u201d [33].\nIn the course of the 19th\ncentury more pla-\ncebo controlled studies into homoeopathy\nwere carried out [13], one of them in 1877\nat Boston University Medical School in the\nUnited States by Conrad J. Wesselhoeft, sr\n(1834\u20131904) who tested Carbo vegetabilis\nusing simple blinding [45]. Other treat-\nments were also assessed in clinical stud-\nies up to the outbreak of World War I, but\nthey did not yet meet modern RCT criteria\n[27].\nDespite a few pioneering efforts, more than\na century went by before placebo controlled\ntrials became the standard of clinical re-\nsearch, which was partly due to the lack of\na methodology. Only in 1932, the Bonn cli-\nnician Paul Martini (1889\u20131964) submitted\nhis Methodenlehre der therapeutischen Unter-\nsuchung (Methods of Clinical Investigation)\nwhich saw four editions and was the first\ntext book of its kind. Even though the term\n\u201cplacebo\u201d was only introduced in the later\neditions, Martini was doubtlessly familiar\nwith the problems surrounding the placebo\neffect as we can see from his preface: \u201cThe\nbest way to exclude suggestive or other sub-\njective factors is to keep the trial set-up un-\nknown. Applied to the main group of our\ntherapeutic armamentarium this means: the\nmedicines must be offered to the patients in\na form or disguise that does not reveal their\nspecial character or purpose; they must be\nmasked\u201d[36] . The medicine and the non-\nmedicinal substance selected for compari-\nson had to be identical in form, colour and\ntaste. Martini saw greater difficulties in the\ncase of non-medicinal therapies. There it\nwas important, he pointed out, \u201cto com-\npensate as much as possible through strict\navoidance of any suggestion, even by using\ncounter-suggestion\u201d [36]. Between 1936\nand 1939 Martini evaluated individual ho-\nmeopathic medicines such as bryony, secale\ncornutum (ergot), sulphur and sepia (cuttle-\nfish) [34, 35]. From a modern point of view\nthese trials can be criticised because of their\nambiguous design with different verum and\nplacebo phases, an insufficient number of\nprobands, heterogeneous dosages, lacking\ncontrol of carry-over-effects, simple blind-\ning that allows manipulation through the\nexaminer [44]. Compared to the drug re-\nsearch carried out by the Leipzig homeo-\npaths Martini\u2019s studies were certainly more\nprogressive in one respect: they were based\non intra-individual placebo control.\nAt almost the same time, the understanding\ngrew in Britain and the USA that the factor\n\u201csuggestion\u201d had to be neutralised through\nblinding if at all possible.The work of Har-\nry Gold (1899\u20131973) at Cornell University\nMedical School must be mentioned in this\ncontext, including his highly regarded study\non methylxanthine in the treatment of an-\ngina pectoris [16]. One of his colleagues re-\ncalled later that the term \u201cblind test\u201dused by\nthe study authors was inspired by a cigarette\nadvertisement from the 1930s [40].\nWhile the placebo controlled double blind\ntrial had been known for some time many\nscientists did not see the necessity for ran-\ndomisation. It was a statistician who first\nadvocated it: R. A. Fisher (1890\u20131962) [47,\n8]. In his book The Design of Experiments\n(1935) he emphasised the importance of\nrandomised trials [14]. Most clinicians did\nnot support randomisation at first because\nthey felt it restricted them in their autono-\nmous therapeutic decision-making. Austin\nBradford Hill (1897\u20131991) was an excep-\ntion. He carried out the first randomised\ndouble blind trial in 1948 to assess the ef-\nfect of streptomycin. In his memories he\ndescribed to what length he had gone at\nthe time to avoid the word \u201crandomisation\u201d\nin the study design so that he would not\nalienate his medical colleagues [22]. When\nasked in an interview in 1970 which fac-\ntors had contributed to the introduction of\nRCTs in medicine, Hill mentioned next to\nthe development of a number of new,prom-\nising medicines (sulfonamides, analgesics,\nantibiotics, cortisone preparations) also the\nresearch in military medicine during World\nWar II, when new methods and study de-\nsigns had been put to the test [40].\nIn 1955, the Journal of the American Medi-\ncal Association published a paper by Henry\nKnowles Beecher (1904\u20131976) titled \u201cThe\nPowerful Placebo\u201d [5] in which he reviewed\n15 different placebo studies on the treatment\nof headaches, nausea or post surgery pain.\nHe arrived at the conclusion that of the 1082\npatients who participated, an average of 35%\nreacted to placebos. For the first time the\nplacebo effect was quantified and scientifi-\ncally documented on a relatively broad basis\n[critical: 29]. Today \u201cThe Powerful Placebo\u201d\nis one of the most frequently quoted papers\n113\nMedical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy\non the topic of placebos. Its publication in\na reputable specialist journal contributed to\nplacebo controlled double blind studies grad-\nually becoming the standard in pharmaceuti-\ncal research from the 1950s onwards.\nIn the early 1970s, placebo research took a\nnew direction when the responder concept\nwhich claims that some people are more sus-\nceptible to placebos than others. A milestone\non the way to the epistemic shift was Jerome\nD.Frank\u2019s book Persuasion and Healing (1973)\nwhich focused on what is called the therapeu-\ntic setting [15].The change in expectations is\nseen as a crucial mechanism with the placebo\neffect. According to Frank, it was simply a\nmatter of inducing hope for improvement in a\npatient who was seeking help.\nAt the end of the 1970s, placebo research\nmoved a step further after the discovery of\nendorphins. An American group of scien-\ntists showed that it was possible to stimu-\nlate the release of endorphins with placebos\nand thus override pain receptors [30]. They\nwere convinced that they had found the pla-\ncebo effect\u2019s mechanism of action. Almost\nat the same time Robert Ader and Nicholas\nCohen experimented with a strain of mice\nthat spontaneously became sick due to an\noverreaction of the immune system which\nis usually treated with immunosuppressives\n[1]. The two researchers were able to dem-\nonstrate that conditioning made it possible\nto replace the verum with sugared water,\nthus proving that the placebo effect cannot\nbe reduced to a particular human interac-\ntion.\nAt the beginning of the 1980s there was\na new development. In 1983, the Ameri-\ncan anthropologist Daniel E. Moerman of\nMichigan University suggested replacing\nthe term \u201cplacebo effect\u201d by \u201cmeaning re-\nsponse\u201d [37].\n1985 saw the first endeavours to bring\nthe various research strands together. The\nAmerican authors L. White, B. Tursky and\nG.E. Schwartz advocated an \u201cintegrative\nsynthesis of all relevant views and factors\u201d 1\n.\nDespite some initiatives [40, 6] this synthe-\nsis remains a desideratum.\nReferences\nAder RA, Cohen N. Behaviorally conditioned im-1.\nmunosuppression. Psychosomatic Medicine. 1975;\n37: 333\u201340.\nAndersen LO, Cla\u00ebsson MH, Hr\u00f3bjartsson A,2.\nS\u00f8rensen AN. Placebo. Historie, biologi og effekt.\nKopenhagen: Akademisk Forlag; 1997.\nAronson J.When I use a word\u2026Please,please me.3.\nBMJ. 1999; 318 : 716.\nBeecher HK. Die Placebowirkung als unspezi-4.\nfischer Wirkungsfaktor im Bereich der Krankheit\nund der Krankenbehandlung. In: Placebo \u2013 das\nuniverselle Medikament? Mainz: Paul-Martini-\nStiftung; 1984. P. 25\u201342.\nBeecher HK. The powerful placebo. JAMA. 1955;5.\n159 :1602\u20136.\nBenedetti F. Placebo effects : understanding the6.\nmechanisms in health and disease, New York: Ox-\nford University Press; 2009.\nBolte J. Placebo singen. Korrespondenzblatt des7.\nVereins f\u00fcr niederdeutsche Sprachforschung.\n1885; 10 :19\u201320.\nCraen T. Placebo and placebo effects in clinical8.\ntrials. Academisch proefschrift Universiteit van\nAmsterdam; 1998.\nCullen W. Clinical Lectures 1772 Feb\/Apr9.\nRCPE Manuscript Cullen 4\/4 218\u20139 (Fak-\nsimile: http:\/\/www.jameslindlibrary.org\/trial_\nrecords\/17th_18th_Century\/cullen\/culle\/n-kp.\nhtml, letzter Zugriff 17.10.2007)\nCullen W.Clinical Lectures 1772-3 RCPE Manu-10.\nscript Cullen 4\/2 299-300 (Faksimile: http:\/\/www.\njameslindlibrary.org\/trial_records\/17th_18th_\nCentury\/cullen\/cullen-kp.html, letzter Zugriff\n17.10.2007)\nDean ME. A homeopathic origin for placebo con-11.\ntrols: An invaluable gift of God. Alternative Ther-\napies in Health and Medicine. 2000;6 : 58\u201366.\nDean ME. An innocent deception: placebo con-12.\ntrols in the St Petersburg homeopathy trial, 1829-\n30 (2003). The James Lind Library (www.james-\nlindlibrary.org, letzter Zugriff 17.10. 2007).\nDean ME. The trials of homeopathy: origins,13.\nstructure and development. Essen: KVC-Verlag;\n2004.\nFisher RA.The design of experiments. Edinburgh:14.\nOliver and Boyd; 1935.\nFrank JD. Persuasion and healing: a comparative15.\nstudy of psychotherapy. Rev. ed. Baltimore: Johns\nHopkins University Press; 1973.\nWhite LB, Tursky B, Schwartz GE. Placebo.1.\nTheory, Research and Mechanisms. New York:\nGuilford Press; 1985. P. 446.\nGold H, Kwit NT, Otto H. The xanthines (theo-16.\nbromine and aminonphylline) in the treatment of\ncardiac pain. JAMA. 1937; 108: 2173\u201379.\nHahnemann S. Die Chronischen Krankheiten. 2.17.\nAufl., Bd. 1. Leipzig: Arnold; 1835.\nHahnemann S. Heilart des jetzt herrschenden18.\nNerven- oder Spitalfiebers (1814). In: Hahne-\nmann S. Kleine Medizinische Schriften, hrsg. von\nSchmidt J M., Kaiser D. Karl F. Haug. Stuttgart:\nVerlag; 2001.\nHaygarth J. Of the Imagination, as a Cause and19.\nas a Cure of Disorders of the Body; Exemplified\nby Fictitious Tractors and Epidemic Convulsions.\nBath: R. Cruttwell; 1801.\nHerrmann J.Amtlicher Bericht des Herrn D.Her-20.\nrmann \u00fcber die hom\u00f6opathische Behandlung im\nMilit\u00e4rhospitale zu Tulzyn in Podolien, welche er\nauf Befehl Sr. Maj. des Kaisers Nicolaus I. unter-\nnommen; nebst einer Abhandlung \u00fcber die Kur\nder Wechselfieber. Annalen der hom\u00f6opathischen\nKlinik. 1831; 2: 380\u201399.\nHieronymus. Epistola CVI Ad Sunniam et Frete-21.\nlam: \u201cPlacebo Domino in regione vivorum [..] pro\nquo in Graeco legisse vos dicitis: Placebo in con-\nspectu Domini. Sed hoc superfluum est.\u201d (http:\/\/\npatrologia.narod.ru\/patrolog\/hieronym\/epist\/\nepist04.htm, letzter Zugriff 19.10.2007)\nHill AB. Suspended judgment: memories of the22.\nBritish streptomycin trial in tuberculosis. the first\nrandomized clinical trial. Controlled Clinical Tri-\nals. 1990;11: 77-9.\nHoltz [Ziegeleibesitzer] an Dr. Samuel Hahne-23.\nmann, Brief vom 8.9.1832, Archiv des Instituts f\u00fcr\nGeschichte der Medizin der Robert Bosch Stif-\ntung, Stuttgart, Bestand B 321150.\nJacobs B. Biblical origins of placebo. Journal of the24.\nRoyal Society of Medicine. 2000; 93: 213\u20134.\nJefferson T. Brief vom 21.6.1807 an Dr. Caspar25.\nWistar. http:\/\/www.iupui.edu\/~histwhs\/h364.dir\/\njeffwistar.html (letzter Zugriff 8.11.2007).\nJ\u00fctte R. Geschichte der alternativen Medizin. Von26.\nder Volksmedizin zu den unkonventionellen Ther-\napien von heute. M\u00fcnchen: C. H. Beck; 1996.\nKaptchuk T J. Intentional ignorance: a history of27.\nblind assessment and placebo controls in medi-\ncine. Bulletin of the History of Medicine. 1998;\n72: 389\u2013433.\nKerr CE, Milne I, Kaptchuk TJ. William Cullen28.\nand a missing mind-body link in the early history\nof placebos.The James Lind Library (www.james-\nlindlibrary.org, letzter Zugriff 8.10.2007).\nKienle GS. Der sogenannte Placeboeffekt. Illu-29.\nsion, Fakten, Realit\u00e4t. Stuttgart; New York: Schat-\ntauer; 1995.\nLevine JD, Gordon NC, Fields HL. The Mecha-30.\nnism of Placebo-Analgesia. Lancet. 1978; 2:\n654\u20137.\nLichtenst\u00e4dt J. Beschluss des Kaiserl. Russ. Men-31.\nicinalraths [sic] in Beziehung auf die hom\u00f6opa-\nthische Heilmethode. Litterarische Annalen der\ngesammten Heilkunde. 1832; 24: 412\u201320.\n114\nRegional and NMA news\nLind J. A treatise on the scurvy [\u2026]. 2. Aufl. Lon-32.\ndon: Millar ;1757.\nL\u00f6hner G. Die hom\u00f6opathischen Kochsalzver-33.\nsuche zu N\u00fcrnberg. N\u00fcrnberg: G. L\u00f6hner; 1835.\nMartini P, Br\u00fcckmer M, Dominicus K, Schulte34.\nA, Stegemann A. Hom\u00f6opathische Arzneimittel-\nNachpr\u00fcfungen. Naunyn-Schmiedebergs Archiv\nf\u00fcr experimentelle Pathologie und Pharmakologie.\n1938; 191: 141\u201371.\nMartini P. Die Arzneimittelpr\u00fcfung und der Be-35.\nweis des Heilerfolges. In: Allgemeine hom\u00f6opa-\nthische Zeitung. 1939; 187: 154\u201367.\nMartini P. Methodenlehre der therapeutischen36.\nUntersuchung. Berlin: Julius Springer; 1932.\nMoerman DE. Physiology and Symbols: the an-37.\nthropological implications of the placebo effect.\nIn: Romanucci-Ross L, Moerman DE, Tancredi\nLR,eds.The anthropology of medicine.New York:\nJ. F. Bergin Publishers. P. 156\u201367.\nMontaigne M. Essays, \u00fcbersetzt von Stilett, H.38.\nFrankfurt\/Main: Eichborn; 1998.\nPapsch M. Krankenjournal D 38 (1833\u20131835).39.\nKommentarband zur Transkription. Stuttgart:\nKarl Haug Verlag; 2007.\nShapiro AK, Shapiro E. The powerful placebo:40.\nfrom ancient priest to modern physician. Balti-\nmore: Johns Hopkins University Press; 1997.\nStolberg M. Die Hom\u00f6opathie auf dem Pr\u00fcfstein.41.\nDer erste Doppelblindversuch der Medizinges-\nchichte im Jahr 1835. M\u00fcnchner Medizinische\nWochenschrift. 1996; 138: 364\u20136.\nTeichler JU. \u201cDer Charlatan strebt nicht nach42.\nWahrheit, er verlangt nur Geld.\u201c Zur Ausein-\nandersetzung zwischen naturwissenschaftlicher\nMedizin und Laienmedizin am Beispiel von Hyp-\nnotismus und Heilmagnetismus. Stuttgart: Franz\nSteiner Verlag; 2002.\nTr\u00f6hler U.\u201cTo improve the evidence of medicine\u201c.43.\nThe 18th century British Origins of a critical ap-\nproach.Edinburgh: Royal College of Physicians of\nEdinburgh; 2000.\nWalach H. Die hom\u00f6opathischen Arzneimittel-44.\npr\u00fcfungen von Martini (1936\u20131939). Allgemeine\nhom\u00f6opathische Zeitung. 1991; 236: 137\u201342,\n186\u201397.\nWesselhoeft C Sr. A reproving of Carbo vegeta-45.\nbilis. Made for the purpose of demonstrating the\nnecessity of countertests in drug-proving. Trans-\nactions of the Thirthieth Session of the American\nInstitute of Homoeopathy. Philadelphia: Sher-\nman; 1877. P. 184\u2013280.\nWhite LB,Tursky B, Schwartz GE. Placebo.The-46.\nory, Research and Mechanisms. New York: Guil-\nford Press; 1985.\nYates F. Sir Ronald Fisher and the design of ex-47.\nperiments. Biometrics. 1964; 20: 307\u201321.\nProf.Robert J\u00fctte,\nDirector of the Institute for the\nHistory of Medicine of the Robert\nBosch Foundation, Stuttgart.\nKroo Florent\nAt the invitation of the Commission of the\nWest African Economic and Monetary Un-\nion (UEMOA), the administrative and pro-\nfessional medical authorities of eight African\ncountries (seven French-speaking and one\nPortuguese-speaking) met in Ouagadougou,\nBurkina Faso in March 2010. The purpose\nof the meeting was to reflect, analyze and\nconsider the reduction of the medical evacu-\nations out their regional space through better\norganization and medical collaboration.\nContext and justification\nThe Member States of the UEMOA have\nthe ambitious objective to develop their sys-\ntems of health.To this end, the structures of\ncare are organized according to a medical\npyramid with three levels. The first level is\nbasic healthcare at the district level, under\nthe responsibility of a general practitioner.\nThe second level is under the responsibility\nof specialist doctors, who receive patients\nthat are evacuated from the districts. The\nlast level consists of hospitals, which are\nfurther equipped and are charged with de-\nlivering even more specialized care.\nFacing a lack of resources, these West Afri-\ncan states are confronted with two difficul-\nties: to ensure the extension of basic care at\nthe first and second levels in order to serve\nthe greatest number, while also developing\nspecialized care at the third level to ensure\nthe care of the most severe cases.\nProgressively, with the consolidation of\nmedical coverage, the need for evacuations\nto specialized hospitals continues to grow\nand diversify. Unfortunately none of these\nstates has sufficient equipment to face the\ngrowing requirements.These states have thus\nrelied on the hospitals of Europe, the United\nStates, and North Africa (Morocco and Tu-\nnisia). These evacuations to facilities beyond\nthe home community constitute significant\nexpenditures (approximately 8 billion francs\nCFA per annum), without the possibility of\nimproving the local medical system.\nReduction of the Medical Evacuations\nInitiative of eight African western countries.\nMap of West Africa locating the 8 Member\nStates of the UEMOA\n115\nRegional and NMA news\nGeneral objective\nThe general objective of the recent dialogue\nwas to identify and evaluate the specialized\ncare facilities in each country that could\nfunction as regional centers of excellence in\norder to reduce the medical evacuations out\nof UEMOA space. These evaluations were\nmade by a competent authority1\nunder the\nsupervision of an international expert2\n.\nResults\nThe total number of evacuations made by\neach country\u2019s Council of Health during\nthe years 2007 and 2008 is 1547 patients for\nthe eight countries of the UEMOA.\nThe evacuations organized by category are\nas follows:\nCardiovascular system: 305 cases (22.6%)\u2022\u00a0\nMusculoskeletal system: 245 cases (16%)\u2022\u00a0\nUrinary tract: 237 cases (15.3%)\u2022\u00a0\nNervous system: 151 cases (10%)\u2022\u00a0\nOcular system: 142 cases (9%)\u2022\u00a0\nGynecological system: 133 cases (8.6%)\u2022\u00a0\nPathologies of these six systems account for\n81% of the medical reasons for evacuations.\nThese 1547 patients are distributed by coun-\ntry as follows:\nBenin: 217 cases\u2022\u00a0\nBurkina Faso: 182 cases\u2022\u00a0\nC\u00f4te d\u2019Ivoire: 29 cases\u2022\u00a0\nGuinea Bissau: 747 cases\u2022\u00a0\nMali: 108 cases\u2022\u00a0\nNiger: 203 cases\u2022\u00a0\nSenegal: 28 cases\u2022\u00a0\nTogo: 3 cases\u2022\u00a0\nAmong six countries (excluding Togo,\nwhose Council of Health did not sit and\nconsequently did not evacuate any patient\nduring the period, and Guinea Bissau), 767\npatients were evacuated by the Councils of\nHealth out of the region in 2007 and 2008.\nThe case of Guinea Bissau is to be taken\nseparately because it evacuated nearly as\nmany patients as all of the other UEMOA\ncountries combined.Its 747 cases were evac-\nuated principally due to urinary pathologies\n(e.g., urolithiasis, hydronephrosis), which\nare dealt with successfully in almost all the\nUEMOA countries.\nAmong the pathologies listed for the evacu-\nations, most frequent are:\ncardiovascular: congenital cardiopathies,\u2022\u00a0\nvalvular diseases, auriculo-ventricular\nblock\nmusculoskeletal system: osteoarthritis of\u2022\u00a0\nthe hip and arthrosis of the knee\ncancerology (radiotherapy): uterine collar\u2022\u00a0\nand breast cancer\nnervous system: encephalic tumour, men-\u2022\u00a0\ningioma, slipped disc\nophthalmology: retinopathy repair, lesion\u2022\u00a0\nof glazed, glaucoma\nReasons given for evacuations are as fol-\nlows:\ninsufficient materials\u2022\u00a0\ninsufficient human resources\u2022\u00a0\npolitical or administrative pressure\u2022\u00a0\nthe kindness of the doctors\u2022\u00a0\ninsufficient hygiene in local health facili-\u2022\u00a0\nties\nParticipants of Burkina Faso and C\u00f4te d\u2019Ivoire surrounding the Head of the Department of Social\nand Cultural Development (March 2010)\nParticipants of the Ouagadougou UEMOA meeting (March 2010)\n116\nRegional and NMA news\nThe direct cost of these evacuations was\nevaluated at 13, 445, 421, 453 FCFA, or ap-\nproximately 7 billion francs per annum.\nRecommendations\nA list of one to four centers of special-\nized care, based on facility and not specific\npathologies, was proposed and validated.\nThese centers will be the subject of a thor-\nough evaluation,which will make it possible\nto classify them and to obtain a final list of\ncenters of high-level care eligible to profit\nfrom the support necessary to become cen-\nters of excellence in the UEMOA region.\nThe recommendations are as follows:\nTo work out a regional medical map of\u2022\u00a0\nthe centers of specialized care\nTo educate and inform the decision mak-\u2022\u00a0\ners, health personnel, and the population\nTo motivate health personnel\u2022\u00a0\nTo increase material resources\u2022\u00a0\nTo organize regular specialist missions in\u2022\u00a0\nUEMOA countries for the local assump-\ntion of responsibility of certain prior-\nity pathologies in Guinea Bissau and in\nother countries\nTo plan the initial and continuing spe-\u2022\u00a0\ncialized trainings of the health personnel\nand managers of these centers\nTo create training structures for the main-\u2022\u00a0\ntenance of medical material\nTo establish the institutional environment\u2022\u00a0\n(equipment,maintenance,administration,\nmanagement, control, quality assurance)\nTo institute a universal system of address-\u2022\u00a0\ning disease risk\nConclusion\nThis regional initiative requires the initia-\ntive of local actors and decision-makers in\nthe health field to be coordinated with the\nintegrated efforts of all countries concerned.\nRealizing this approach to medical col-\nlaboration requires overcoming the difficul-\nties inherent in any project in a developing\ncountry and making an effort to procure ad-\nequate technical material. National medical\nassociations as well as institutional profes-\nsional organizations must be invested in the\ninitiative in order to successfully address the\nchallenge of integration.\nKroo Florent AKA, MD\nPresident of National Order of Physicians.\nPresident of Ivorian Medical Association\nE-mail; onmci@yahoo.fr\nC\u00f4te d\u2019Ivoire\nJaroslav Blaho\u0161\nThe CzMA is a voluntary and independent\norganization of medical doctors, pharma-\ncists and workers in the healthcare services\nand related fields. Our membership has\nbeen gradually increasing since 1989 when\nthe CzMA became a democratic institution\nwith a democratically elected president and\ncouncil members. Similarly, the chairs and\ncouncils of individual scientific societies are\nelected by secret ballot.The members of the\nCzMA are affiliated on the basis of their\nspecialities in individual scientific societies.\nIn larger cities the doctors organize the lo-\ncal medical clubs. Currently, 107 scientific\nsocieties and 40 local clubs are registered\nwithin the CzMA.\nThe history of the CzMA dates from the\nmiddle of the 19th century and is closely lin-\nked with the propagators of national Czech\nmedical science. Their main representative\nwas Jan Evangelista Purkyne (1787 \u2013 1869),\nthe world-renowned scientist,physician and\nhumanist. In 1862, Purkyne and his collea-\ngues founded the \u201cClub of Czech Doctors,\u201d\nthe predecessor of the CzMA. His name\ngives prestige to the title of our Association.\nBy associating ourselves with this great\npersonality we express our continuity with\nthe tradition and his human and scientific\nlegacy.The aim of J. E. Purkyne and his col-\nleagues was, above all, the development and\npropagation of knowledge of medical scien-\nce and related fields and their application in\nhealthcare for the people. These fundamen-\ntal aims remain unchanged to this day.\nThe CzMA is the major representative body\nof scientific medical activities in the Czech\nRepublic. It initiates and supports science\nand specialist work in a broader sense, not\nonly within its own ranks, but also by of-\nfering its experience to other healthcare\norganizations, e.g., the Ministry of Heal-\nth, Ministry of Labour and Social Affairs,\nprofessional chambers, health insurance\ncompanies, and other domestic institutions,\nincluding organizations concerned with\nethical, pastoral, and ecological issues, the\nenvironment, safety and health, and welfare\ninstitutions.\nThe Association is strongly involved in post-\ngraduate and continuing medical education\nin almost all fields of medicine, and orga-\nnizes many national and international con-\ngresses, symposia, and courses. The CzMA\nalso takes an active part in organizing scien-\nThe Czech Medical Association (CzMA)\n117\nRegional and NMA news\ntific meetings connected with the most im-\nportant medical and pharmaceutical exhibi-\ntions in the Czech Republic.\nThe CzMA is editor of 29 medical journals,\nwhich are distributed in the country and\nabroad. The CzMA also has close relations\nwith European and international medical\nassociations. Of these, the most impor-\ntant are the World Medical Association\n(WMA), the Forum of European Medi-\ncal Associations, the WHO (in which the\nCzMA is represented in the Council), and\nthe Council for the International Organi-\nzations of Medical Sciences (CIOMS). We\nwork closely with our friends and collea-\ngues in the Slovak Republic even after the\nseparation in 1993 from the Czechoslovak\nMedical Association.\nOur scientific societies are members of va-\nrious international organizations. Many of\nthem are representatives in the committees\nand councils. The CzMA awards honours\nand prizes, which are received with gre-\nat respect. The most prestigious of these is\nthe J. E. Purkyne Prize, which is awarded\nonce a year to one distinguished medical\npersonality, with the ceremony taking place\nat the castle of Libochovice (near Prague),\nPurkyne\u00b4s birthplace.\nProfessor Jaroslav Blaho\u0161, MD, DSc.\nPresident, Czech Medical Association\nFormer President, World Medical Association\nThe mission of the Brazilian Medical As-\nsociation (AMB),founded in 1951,is to ad-\nvocate for the professional dignity of physi-\ncians and for quality health assistance to the\nBrazilian population. AMB is composed\nof 27 State Medical Associations and 396\nRegional Associations. Moreover, AMB\u2019s\nScientific Council is composed of 48 Medi-\ncal Societies, representing the 53 specialties\nrecognized in Brazil. AMB is a member of\nthe World Medical Association and is co-\nfounder of the Portuguese Language Medi-\ncal Community.\nAreas of Action\nProfessional Qualification\nUndergraduate Studies: AMB has been\nfighting against low quality medical schools\nsince its foundation. Advocating for better\nmedical professionals.\nBoard Certification: Since 1958, AMB\nhas been pursuing scientific improvement\nand professional recognition for physicians\nthrough board certification after approval in\nrigorous examinations. AMB also manages\nthe credits required for updating the board\ncertification through the National Accredi-\ntation Committee (CNA).\nContinuing Medical Education (CME):\nPhysicians\u2019 scientific knowledge is updated\nthrough the CME program. Developed in\npartnership with the Brazilian Council of\nMedicine, the program is online, free of\ncharge and available for all Brazilian physi-\ncians.\nGuidelines Program: Since 2000, AMB\ndesigns medical guidelines based on scien-\ntific evidences in order to standardize prac-\ntices and support physicians on diagnosis\nand treatment. More than 300 guidelines\nhave been created since then, all of them\navailable at www.projetodiretrizes.org.br.\nProfessional Recognition\nRegulation of the Medical Profession:\nAMB is actively involved in the discussions\nconcerning Bill No 7703\/06 (Medical Act),\na proposal to regulate Medical practice.\nBrazilian Classification of Medical Pro-\ncedures (CBHPM): Developed and con-\ntinuously updated by AMB, the Brazilian\nCouncil of Medicine (CFM), the Physi-\ncians National Federation (Fenam) and the\nSocieties of Medical Specialties, the Brazil-\nian Classification of Medical Procedures\n(CBHPM) lists all medical procedures sci-\nentifically proved and became a reference of\nhealth quality for the population.\nPosition, Career and Wages Plan: AMB\nis member of the Committee in charge of\ndeveloping a medical career and wages plan\nfor doctors working at the Brazilian Unified\nHealth System (SUS).\nDr. Pedro Wey B. Oliveira,\nInternational Affairs Division\nBrazilian Medical Association\nBrazilian Medical Association (AMB):\nObjective and Actions\n118\nRegional and NMA news\nThe Republic of Macedonia is situated in\nthe southern part of the Balkan Peninsula.\nWon independence after World War II, in\nwhich its citizens took an active part on the\nside of the antifascist coalition. After the\nwar, Macedonia was part of Yugoslavia, as\none of the six equal federal republics. With\nthe dissolution of the federation, in 1991\nthe Republic of Macedonia gained its inde-\npendence and sovereignty.\nMacedonia covers an area of 25,713 square\nkilometres, populated with 2,048,619 in-\nhabitants, according to the data from 31\nPoor Health System and Active Macedonian\nMedical Chamber\nThe Medical Chamber of Serbia was revived\nin 2006, drawing upon the tradition of the\nMedical Chamber established in 1901 in\nthe Kingdom of Serbia.The original Cham-\nber played a very significant role in the work\nand life of physicians of that time, however,\nthe functioning of the Chamber was banned\nafter World War II by the new communist\nauthorities, as was the case in all the coun-\ntries in our neighbourhood.\nWithin the framework of the reform of\nthe health sector in 2005, the Ministry\nof Health initiated the establishment of a\nmedical chamber by virtue of the Law on\nthe Chambers of the Medical Profession.\nElections were organised to this effect, and\nMDs from both the public sector and the\nprivate sector were appointed to the Assem-\nbly of the Medical Chamber of Serbia thus\nestablishing an integrated chamber of doc-\ntors of medicine in 2006.\nThe beginning of the functioning of the\nMedical Chamber was not simple; we in-\nvested a lot of effort in the endeavour, and\nwe did not hesitate to seek and accept advice\nfrom chambers with a longstanding experi-\nence. Very shortly we drew up our Statute,\nand then, acting on the basis of the public\nauthority we were vested with on the basis\nof the Law, we drew up our Code of Profes-\nsional Ethics, and proceeded with drawing\nup the full list of MDs and relevant records,\nand issuing licences and ID cards to eligible\nMDs, including the drafting of the neces-\nsary codes of rules for the functioning of the\ncommittees, and organising of our courts of\nhonour, and all the other aspects necessary\nfor ensuring continuous medical training.\nOur Chamber is a self-sustained and politi-\ncally and economically independent profes-\nsional organisation, financed from its own\nsources. All the MDs working in the bodies\nof the Chamber provide their services with-\nout any remuneration, being assisted in that\nprocess by the relevant support services in-\nvolving lawyers, economists, IT experts, and\nothers, who receive appropriate fees.\nOnthebasisoftheLawonHealthCareissued\nby the Ministry of Health of the Republic of\nSerbia, membership in our Chamber is man-\ndatory, and membership fee is proportionate\nto the member\u2019s monthly income. Currently,\nthere are 29 500 doctors of medicine in Serbia,\n26 200 of whom are public employees, while\n3300 are in the private sector.\nUnfortunately, MDs from the private sector\nare not included in the health care system\nof our country, as a result of which patients\nhave to pay for the relevant medical services\nfrom their own resources.\nThe Medical Chamber is an institution\nperforming the tasks delegated to it as well\nas other activities from the purview of the\nmedical profession, and since we dispose\nof the professional potential of our mem-\nbers \u2013 MDs, as well as that of our support\nservices, our objective is to become part of\na health care system accessible to all MDs,\nthrough which they will be able to influence\nthe resolution of issues relating to the medi-\ncal profession. We have a vision, and we are\naspiring for becoming a significant factor\nin the decision taking process affecting the\nhealth care system of our country, as well as\naiming to influence the content of all the\nlaws relating to the medical profession.\nWe take great pride in all that we have\nachieved over the past four years, particu-\nlarly stressing the establishment of contacts\nand friendships with numerous chambers in\nEurope, the gathering together of the rep-\nresentatives of 15 chambers at the ZEVA\nMeeting in Belgrade, in September 2009, as\nwell as the fact that we have been keeping\nabreast of all the developments at the level\nof CPE and EFMA, and most importantly,\nthe fact that the procedure for the admis-\nsion of our Medical Chamber to the WMA\nis in process.\nDr. Nada Radan-Milovan\u010dev\nPresident of subcommitee for international\ncooperation of the Medical Chamber of Serbia\nThe Medical Chamber of Serbia\nNada Radan-Milovan\u010dev\n119\nRegional and NMA news\nDecember 2008. The capital is Skopje,\nknown as a city of solidarity, the name it\ngot after the disastrous earthquake in 1963,\nwhen many countries around the world\nhelped to build what was crashed by the\nnatural disaster.\nAfter the liberation of Macedonia in 1945 it\nwas not sufficiently built,without significant\nindustrial facilities and with general poverty.\nThe country was extremely poor, agrarian,\nwith a developed trade production. Evident\nwas the high mortality of the population\nthat reached up to 21 per mille and mortal-\nity of infants of 154 per mille. Sixty years\nlater, the overall mortality rate decreased\nto 9 per mille, and the mortality rate of in-\nfants to 12.8 per mille (data from 2005). In\n1945 there were in total, 123 physicians and\ndentists, 92 pharmacists and 120 nurses.\nThere was no significant health infrastruc-\nture. In addition to several hospitals, others\nwere mostly small makeshift ambulances\nand health clinics. During this period the\ncountry faced major epidemics of malaria\nand tuberculosis. This situation changed\nover the years in former Yugoslavia and a\nsignificant improvement was the result of\nbuilding health facilities supplied with new\nequipment and education and training of\nthe medical personnel abroad (not only in\nmore developed Yugoslav cities and hospi-\ntals, but in foreign countries as well).\nThe first Medical School (Medical Faculty)\nwasestablishedinNovember1947,whenthe\nfirst generation of doctors began their stud-\nies.The teachers of the first Medical School\nwere not only Macedonians, but were most-\nly from Croatia, Serbia, Russia and other\ncountries. On the other hand, in the period\nbetween the two world wars many Macedo-\nnians studied medicine in several countries\nin Europe, mainly in France, in Bordeaux\nand Paris, in Switzerland, in Geneva, and in\nseveral universities in Italy.\nThe state currently has three Medical Fac-\nulties that educate medical staff. After the\nlast complete independence of the country\n(1991), the state found itself in a poor situa-\ntion, as a result of the need for construction\nof the new state infrastructure, economic\nblockades, military conflict in the country\nin 2001, ongoing privatisation of commer-\ncial enterprises that produced many unem-\nployed people and so on.\nUnder such conditions, in 1995 the Parlia-\nment adopted a new Law on health care\nthat was supposed to follow new trends in\nhealth care in Europe,setting conditions for\na modern health care system. Over the past\nfifteen years the law has experienced a total\nof 11 changes that harmonised the system\nwith new experiences and achievements in\nthe country and abroad. However, the low\ngross social product doesn\u2019t allow develop-\ning of the system that will fully meet the\nmodern experience.\nToday in the Republic of Macedonia there\nare over 8000 active physicians in all spe-\ncialties. Most of them are doctors of general\npractice. Their number is around 2500. The\nnumber of unemployed doctors in the coun-\ntry is around 350,so we are not in a shortage\nof doctors, on the contrary. Many of them\nare in specialisation training abroad, or they\nwork abroad, and in the state are registered\nas unemployed. There are also trends in\ntemporary employment abroad. Also, there\nare doctors that seek permanent employ-\nment with the departure to other countries.\nWhat concerns, is the high age of doctors\nand uneven distribution in the country.\nThe reform of the health system was started\nby the process of privatisation in the health\ncare. All the doctors in primary care are pri-\nvatised, except a small number of them that\ntake care of immunisation of the popula-\ntion. Doctors are paid through the so-called\nsystem according to the number and age of\nthe patients attached.\nSimilar processes are planned for consul-\ntative and specialist care. The next stage\nshould be the transformation of hospital\ncare, planned to function as public private\npartnership.\nCurrently in Macedonia health care provid-\ners are about 8000 doctors, 2500 of whom\nare primary care physicians, 2000 are spe-\ncialists in specialist consulting health care,\nor 2.5 doctors per 1000 inhabitants. The\nstate has about 9500 hospital beds or one\nbed per 219 residents.\nAt present time there is an ongoing process\nof building modern private health care fa-\ncilities \u2013 modern hospitals, organised with\nprivate venture capital from the country and\nabroad. They manage to survive by practis-\ning medicine in areas not requiring lengthy\nand costly procedures for treatment. Thus,\nthey are competitive on the market for\nhealth services and can afford to purchase\nmodern equipment and high salaries paid\nto physicians. That\u2019s why there is an ongo-\ning process of migration of physicians from\npublic to private hospitals. In contrast, state\nhospitals and university clinics as part of the\npublic health, are suffering from insufficient\nfunds with resulting constant problems to\nmaintain the system. Obvious is the poor\ncondition of many facilities equipped with\noutdated equipment, providing health care\nin the public health area.\nThis is a basic situation that served as a\nbackground for foundation, organisation\nand operationalisation of the Macedonian\nJosif Dzockov\n120\nRegional and NMA news\nMedical Chamber. It was restored in 1992,\neven though, the first association of doctors\nin a chamber in the region of present-day\nMacedonia,which before World War II was\ncalled Vardarska Banovina \u2013 as a part of\nthe Kingdom of Yugoslavia, was formed on\n15December 1929. The Chamber has been\nactive until the beginning of the Second\nWorld War.\nToday the activities of the Medical Cham-\nber are going in two directions. The first is\nthe scope of work arising from the Statute,\nCode of Medical Ethics and Deontol-\nogy and the annual work programme, and\nthe second is the public authority that the\nChamber received on the basis of the Law\non Health Protection.\nMacedonian Medical Chamber,in the place\nit has in the health system and organisa-\ntional structure,has adopted the work of the\nentities that make up the system. Besides\nthe organisational activities arising from\nthe work of the Chamber, through its rep-\nresentatives it actively participates in many\nbodies where health, health policy and re-\nlated professional activities are discussed. In\nthis regard,we can say that there is relatively\ngood co-operation with state authorities,\nthe Parliament of the Republic of Mace-\ndonia and its Ministry on Health, Health\nInsurance Fund and other institutions. Al-\nthough representatives of the Chamber tend\nto be extremely co-operative, only an insig-\nnificant number of proposals are adopted by\nthe competent authorities. In this direction,\nthe Chamber frequently makes remarks to\nthe public that it wants to be a part of the\nsolution of the problem, but only if there is\na respect to its proposals.\nThe Chamber received public authority on\nthe basis of the Law on Health Protection\nof 2004. Those were the Chamber\u2019s sugges-\ntions dated back in the past. Unfortunately,\nthe state authorities had no hearing on the\nproposals from the Chamber, although the\nproposals were based on international expe-\nriences. Although the Macedonian Medical\nChamber was very ahead of the surround-\ning countries, public authority was won and\nimplemented much later, when these things\nwere operating for many years in those sur-\nrounding countries.\nPublic powers can be divided into three ar-\neas. First, the Medical Chamber is leading\nthe process of internship and exam taken by\ndoctors who have completed medical school,\nafter which they have the right to apply for a\nlicense to work. Second, the Chamber is au-\nthorised for the issue, continuance, renewal\nand the taking of the licenses for working.\nIn connection with the licenses process, in\nthe second phase, the Minister of Health is\nauthorised to make the final decision.Third,\nthe Chamber maintains a registry of doctors\nin the Republic of Macedonia, who have a\nlicense for working or general license.\nAchieved results confirm the correct move by\nthe deviation of the Chamber\u2019s authorities to\nthe public powers. The exam is noted to be\nconsistent with the educational process, es-\npecially in the area of governance skills. Also\nthe extension of the licenses triggered the\nprocess of continuous medical education and\npermanent professional development.\nDoctors\u2019 Chamber permanently required\nbeing an active partner of the government\nin making the health policy in the state.\nAlthough this definition was introduced in\nthe legislation, after a certain period, with\nchanges in the law, it was withdrawn. Cur-\nrently the Chamber is on track to restore that\nright. The Medical Chamber seeks and ex-\npects to receive request to be consulted when\nmaking decisions in the Health Fund. What\nin particular will the Medical Chamber con-\ntribute if getting the right place in the health\ncare system,is the adoption of a Law for doc-\ntors\u2019work, which has been in preparation for\nalmost 15 years. Despite numerous attempts\nto enter the legal legislation, authorities have\nnot accepted it untill now.\nBesides these high priorities, Medical\nChamber has set many goals to get its valo-\nrisation. Among other things, that is: pro-\nviding working conditions, receiving mod-\nern equipment in public hospitals, a real\nappreciation of the work of doctors, etc.\nMedical Chamber has its own web page:\nwww.lkm.org.mk and the periodical \u201cVox\nMedici\u201d, which comes out every three\nmonths, printed in 6500 copies, and deliv-\nered to all the doctors in the country. The\njournal publishes information of the Cham-\nber\u2019s work, and beyond, about the situation\nand problems in health care, educational\nmaterials and professional papers that are\nmandatory to review.\nThere is also the Macedonian Medical As-\nsociation, as an association of specialist as-\nsociations in the state.\nMacedonia is a small and underdeveloped\ncountry. With the gross national income in\n2008 of 2980 dollars per capita, Macedo-\nnian citizens were annually allocated 7.2 per\ncent of salaries or 160 Euros per capita.The\nreal situation can be seen considering that\nthe state has about 600,000 employees and\nthe unemployment rate of 37.3 per cent \u2013\none of the highest in Europe. Despite this\ngeneral condition, health care is delivered to\nall residents of the state. If one had in mind\nall this information, it would be clear that it\nis difficult to support a modern and quality\nhealth system in Macedonia, but we are do-\ning everything we can.\nAs a result of our tendency to be integrated\nin the general European medical processes,\nthis year from 30 September untill 2 Octo-\nber we will be the host for a ZEVA meet-\ning \u2013 the Symposium of the Central and\nEastern European Chambers of Physicians\n(for the second time).\nSincerely we are hoping to meet as much\nparticipants from these countries, and also\nguests that are not in this group as we can.\nJosif Dzockov,\nMedical Chamber of Macedonia\n121\nRegional and NMA news\nSince 1990, after the changing of the po-\nlitical and social regime, the health system\nin Albania encounters a lot of difficulties\nrelated to:\nvery limited technical capacities to es-\u2022\u00a0\ntablish policies, strategies and national\nplans;\nthe insufficiency in the health care system\u2022\u00a0\nfinancing and weak capacities in the field\nof health management;\nnot yet applied institutional and individ-\u2022\u00a0\nual professional accreditation;\nthe missing decentralisation of compe-\u2022\u00a0\ntences ranging from government authori-\nties to health institutions and public enti-\nties and, as a result, not quite appropriate\nfunctioning of the orders and professional\norganisations;\nthe lack of experience in monitoring and\u2022\u00a0\ncontrolling the private activity;\nthe lack of diagnostic equipment and cu-\u2022\u00a0\nrative services.\nOne of the acute problems is the unequal\ndistribution of medical staff. Many com-\nmunities are left uncovered by the health\nservice. As a result of free movement and\nthe migration towards big cities or abroad,\nthe physicians have abandoned their work-\ning places in remote rural areas.\nTaking into consideration the above-\nmentioned problems, the health reform in\nAlbania was concentrated in an ambitious\nstrategy that introduced many challenges to\nbe faced.\nFacing these challenges,Albania has already\ngained advancements in many sectors, set-\nting up of necessary structures in the sec-\ntors of Health Insurance Policies and Man-\nagement, Quality Control, Accreditation,\nLicensing, Monitoring, CME, Standardi-\nsation and Maintenance of medical equip-\nment and others.\nActually, the reforming policies concern-\u2022\u00a0\ning the health care system in Albania are\ndirected towards:\nImprovement of the quality of health care.\u2022\u00a0\nAugmentation of access and possibilities\u2022\u00a0\nto offer health services nearer to the com-\nmunities.\nImprovement of the budgetary and man-\u2022\u00a0\nagerial capacities in the health care sys-\ntem.\nInclusion in the health insurance scheme\u2022\u00a0\nof all health services and liberalisation of\nhealth insurance trading.\nImprovement of the infrastructure and\u2022\u00a0\nequipment of health institutions by intro-\nducing contemporary technologies.\nExtending information technology to all\u2022\u00a0\nof the system.\nInstitutionalisation of the continuous\u2022\u00a0\nmedical education with accredited pro-\ngrammes and, in relation to this, pro-\nfessional revalidation, recertification and\nperiodic relicensing of health care system\nprofessionals.\nAccreditation and licensing of health in-\u2022\u00a0\nstitutions, management of the risk and\nimprovement of the quality of health in-\nstitutions, introduction of indicators for\nperformance, efficacy and effective mea-\nsurement.\nConnected to these, the National Centre\nfor Continuous Medical Education and\nthe National Centre for Quality, Assurance,\nand Accreditation of Health Institutions are\nestablished in Albania. Regarding this, spe-\ncial attention has been focused on the col-\nlaboration and inclusion of the professional\norders and associations.\nIn this regard, after the changes in the so-\ncio-economic and political system, in 1994,\nby a law of the Albanian Parliament the\nOrder of Physicians of Albania, as a new\nbody without any precedent in the Albanian\nmedical history, was created.This entity be-\ngan the activity in the circumstances of a\nvery difficult transition in all sectors of the\nAlbanian social life.\nUntil 2000,the Order for reasons of a hand-\nicap to the first law was completely depend-\ning on the Ministry of Health; its activity\nand competence were very restrained. In\n2000,the new Law No.1615 \u201cOn the Order\nof Physicians in the Republic of Albania\u201d,\nwhich considered the Order an indepen-\nHealth Policy Reform in Albania and\nDevelopment of the Order of Physicians of\nAlbania\nDin AbazajShaqir Krasta\n122\nRegional and NMA news\ndent \u201cpublic entity\u201d, was promulgated. Just\nfrom this time the Order began to develop\nand enforce the institutional capacities and\nfunctioning as an effective, independent,\nprofessional body.\nThe Law assigns the mission of the Order\nof Physicians, stimulation and preserving\nof high standards of practising, formation\nand professional education of the doctors,\nand protects patients and the public from\nthe misuse and malpractice of health ser-\nvices.\nFor the implementation of this mission, the\nNational Council of the Order has oriented\nits work towards these main objectives:\nRaising the institutional capacity and ef-\u2022\u00a0\nfectiveness of the Order.\nEstablishing its indipendent budget.\u2022\u00a0\nCreating the normative acts based on the\u2022\u00a0\nLaw, Statute, Code of Ethics and Medi-\ncal Deontology,and the regulations of the\nOrder.\nEstablishing the National and Regional\u2022\u00a0\nRegister of doctors, provision of its infor-\nmatisation and updating;.\nAssigment of the medical practise stan-\u2022\u00a0\ndards and the professional education of\ndoctors.\nFitness to practice.\u2022\u00a0\nRelations and communication with the\u2022\u00a0\npublic.\nInternational relations.\u2022\u00a0\nPartnership with the Ministry of Health,\u2022\u00a0\nFaculty of Medicine and other health sy-\nstem actors.\nThe progress during these years has been\nremarkable. The Order has raised the ad-\nministrative capacity for all its stuctures.\nNowadays the Order is functioning as an\nindependent body and effective partner of\nthe Ministry of Health.\nThe new Code of Ethics and Medical De-\nontology,as a data base of professional stan-\ndards, compulsory to be applied during the\nmedical practice, is available to every doctor\nand stomatologist.\nThe establishing of the National and Re-\ngional Register of the members of the\nOrder and the inauguration of a website\n(www.urdhrimjekve.org) were the most\nimportant accomplishments during these\nyears. This register, compiled as a data base,\nserves for the periodic professional revalida-\ntion of doctors and their relicensing to prac-\ntise profession.\nFor the doctors, who are not fit to practice,\ndisciplinary commissions of the first degree\nat the Regional Councils and the National\nCommission for Disciplinary Judgment of\nthe second degree (appeal) are established.\nNew regulations for the functioning of\nthese commissions has been approved by\nthe National Council.\nThe Order of Physicians is a new body\nwithout experience, tradition and prec-\nedents in the Albanian Medicine. These\ncircumstances dictate widening of the\nrelations with homologous bodies of\nother countries and international forums.\nExcept bilateral relations, the Order of\nPhysicians of Albania is a member of a\nnumber of international organisations,\nsuch as: IAMRA (International Associa-\ntion of Medical Regulatory Authorities),\nWMA (World Medical Association),\nEFMA (European Forum of Medical\nAssociations), CEOM (Conference des\nOrdres des M\u00e9decins), G.I.P.E.F. (Asso-\nciation of the Medical Orders and Cham-\nbers of Mediterranean Countries), ZEVA\n(Symposium of the Medical Orders and\nChambers of the Central and East Euro-\npean Countries), etc.\nThe extension and improvement of interna-\ntional relations aim at drawing the Albanian\nmedicine nearer to and intergrating it with\nthe European medicine. These initiatives\nhave a positive impact and have \u201callowed\nthe Order of Physicians of Albania to stand\nitself as a credible partner towards patients,\nthe Ministry of Health and other factors and\nactors of the health system\u201d.\nA positive influence on the increasing of\ncredibility and recognition of the Order by\nthe state structures as an independent body\nof medical self-regulation and on the con-\nsolidation of partnership with these struc-\ntures have visits of many delegations of ho-\nmologous bodies and international forums\nand their meetings with the state authori-\nties of our country.\nActually the Order\u2019s activity is aimed at\nthese priorities:\nPerfection of the activity for increasing\u2022\u00a0\nand consolidating the acknowledgment\nand credibility of the Order.\nConsolidation and the holding of a firm\u2022\u00a0\nfinancial budget.\nActivities vitality and agility for standards\u2022\u00a0\nof medical educations and everyday med-\nical practices stimulation and iprovement\nMaintain the Code of Ethics and Medi-\u2022\u00a0\ncal Deontology, and upwarding the moral\nimage of doctors toward the society.\nThe membership and registration to the\nOrder of Physicians of Albania is compul-\nsory and a condition for practising the pro-\nfession.\nThe constitutional bodies of the Order are:\nOrder\u2019s assemblies (National Assembly\u2022\u00a0\nand Regional Assemblies).\nOrder\u2019s councils (National Council and\u2022\u00a0\nRegional Councils).\nThe Order\u2019s councils are elected by the as-\nsemblies, respectively the National Council\nby the National Assembly and the Regional\nCouncils by the Regional Assemblies.\nThe Regional Councils of the Order are set\nup and operated according to the adminis-\ntrative division of the country in 12 dis-\ntricts. The assembly meetings and council\nelections are held every 5 years.\nDr. Din Abazaj, President of the\nOrder of Physicians of Albania\nDr. Shaqir Krasta, General Secretary of\nthe Order of Physicians of Albania\n123\nRegional and NMA news\nStefan Konstantinov\nThe Bulgarian Medical Association\n(BuMA) is a legal representative of doctors\nin Bulgaria. Membership is obligatory for\neveryone who wants to practice medicine in\nthe country. The organisation was founded\nin 1901. During the communist regime it\nwas banned.\nBuMA is comprised of 28 regional colleges\nof physicians with large autonomy. Every\nregional college maintains a registry of doc-\ntors with unique identification numbers\ngiven by the central office. At the begin-\nning of 2010 the registry comprised about\n34 000 doctors, the number of practicing\ndoctors being about 30 000.\nEach regional structure appoints dele-\ngates who every 3 years elect the Board of\nBuMA.\nBesides the typical tasks of a medical cham-\nber, such as preparation and surveillance of\nProfessional Ethics Code, good medical\npractice, registry of doctors and continu-\nous medical education, BuMA has specific\ntasks concerning professional interests of\nits members. The most important among\nthem are the negotiations with the National\nHealth Insurance Fund (NHIF) and sign-\ning the annual frame agreement. In Bulgar-\nia the National Health Insurance Fund is\nthe major player in health insurance. Private\nfunds hold a very small part of the market\nalthough their number is 21. The negotia-\ntions with NHIF quite often dominate over\nother functions of BuMA.\nWhat happened in health care in Bulgaria\nlast year?\nThere were two landmarks affecting it: the\nfirst \u2013 the general election held in 2009 and\nthe second \u2013 the economic crisis.\nThe centre-right GERB party,which won the\ngeneral election last July,was expected to start\nthe health reform. The list of the problems\nthat had not been solved for years was quite\nlong: chronically underfinanced health sector,\nlow level and inefficacy of public expenses,in-\ncrease of informal payments and decrease of\npatients\u2019 satisfaction, young doctors leaving\nthe country,heavy administration.But instead\nreforms the major changes which the Parlia-\nment made were associated with a substantial\nreduction of the budget \u2013 especially concern-\ning \u2013 from 476.192 million Euros (BGN\n931.432 million) in 2009 to 362.439 million\nEuros (BGN 708.932 million) in 2010, i.e.\napproximately 222 million Euros less. At the\nsame time the state presence in the otherwise\nindependent NHIF was reinforced. And fi-\nnally and probably the most important \u2013 its\nfinancial reserve was included in the fiscal re-\nserve of the country in order to keep the bud-\nget deficit to an acceptable level.\nThe financial restrictions led to significant\ndelays of fund disbursements to doctors and\nhospitals by NHIF and resulted in wide-\nspread discontents which found expression\nin closure of medical offices in the period\nbetween 8th\nand 10th\nMarch 2010 and more\nfeeble protests at the hospitals on 7th\nApril.\nAt the same time attempts to restructure\nand decrease the number of hospitals in\nBulgaria failed.At present we have 331 hos-\npitals in contracts with NHIF.This number\nis quite high for a country with a population\nof 7.607 million.\nAs a whole, the task to implement a health\nreform under the conditions of an economic\ncrisis and severe financial restrictions is left\nto the newly appointed minister of health\ncare. Still the major challenges are open.\nSuch as the way of financing hospital care.\nAt present Bulgaria uses the so-called clini-\ncal paths. In the course of years the data of\nmorbidity were distorted. Generally low\nprices and lack of efficient control led to\nthe increase of hospitalisations on national\nlevel. There is a considerable disproportion\nbetween prices of different clinical paths\ndue to lobbying. Despite the long-running\ndiscussion about the introduction of DRGs\nthere still is no such decision.\nThe problems of outpatient care are also\nimportant. Bulgaria has a system of GPs\nacting as gatekeepers. Access to a specialist\nis only by a referral from GP. Yet again fi-\nnancial restrictions make maintaining good\nlevel of health care difficult. The change\nof the way of regulation is necessary more\nthan ever, but politicians are reluctant. Fears\nfrom unpopular measures like co-payment\nare stronger than the will for reforms.\nThe membership of Bulgaria in the EU had\nno direct impact on health care because the\ncountry suffered to take advantage of Euro-\npean funds.\nThat is the environment in which BuMA\nworks. Besides the internal affairs to deal\nwith BuMa has representation in several in-\nternational organisations \u2013 CPME, FEMS,\nAEMH \u2013 and closely monitors what hap-\npens with the common problems of doctors\nin Europe.\nDr. Stefan Konstantinov,\nVice Chairman of the Bulgarian\nMedical Association\nBulgarian Medical Association\n124\nRegional and NMA news\nMWIA is an association of medical women\nrepresenting women doctors from 76 coun-\ntries in all five continents. MWIA is non-\npolitical, non-sectarian, non-profit-making.\nThe different cultural backgrounds, medi-\ncal traditions and problems of its members\nprovide a stimulating forum. There are four\ntypes of membership within the associa-\ntion:\na) affiliated national associations,\nb) individual members,\nc) honorary members,\nd) members of honour.\nAll medical women, qualified accord-\ning to the accepted standard of the medi-\ncal profession in their country, are eligible\nfor membership. It is also a requisite that\nall qualified medical women of the country\n(the National Association) must be eligible\nfor membership irrespective of race, religion\nor political opinion.\nThe powers of the association are vested\nin the delegates of the membership, which\nelect an Executive Committee to facilitate\nand expedite the handling of affairs of the\nassociation in the intervals between the tri-\nennial meetings of the General Assembly.\nThe legal Head Office of the association is\nin Geneva, Switzerland. The Administra-\ntive Headquarters are at the present time in\nVancouver, Canada, where the activities of\nthe member national associations and indi-\nvidual members are coordinated.\nThe organisation is composed of 8 geo-\ngraphical regions. Each region is repre-\nsented on the Executive Committee by its\nvice-president. The president, president-\nelect, treasurer, secretary-general and vice-\npresidents are elected by the members.\nThe present aims of MWIA are: To offer\nmedical women the opportunity to meet so\nas to confer upon questions concerning the\nhealth and well-being of humanity. To pro-\nmote the general interest of medical women\nby developing cooperation, friendship and\nunderstanding without regard to race, reli-\ngion or political views.To overcome gender-\nrelated inequalities in the medical profes-\nsion. To promote health for all throughout\nthe world with particular interest in women,\nhealth and development.\nInternational congresses and general assem-\nblies are held every 3 years in various coun-\ntries of the world, e.g. 1998 in Sao Paulo,\n2001 in Sydney, 2004 in Tokyo, 2007 in\nGhana. This year the MWIA congress will\ntake place in Muenster\/Germany 28\u201331\nJuly 2010. Topic: Globalisation in Medi-\ncine \u2013 Challenges and Opportunities.\nWe as women and particularly women phy-\nsicians need to continue to make our voices\nheard, as we fight for the rights of women\nand women\u2019s health care.\nIn 2001, the Medical Women\u2019s Internation-\nal Association wrote a Training Manual on\nGender Mainstreaming to educate medical\npersonnel on the importance of considering\ngender when providing health care. It can\nbe accessed at www.mwia.net and speaks\nin language understandable by medical per-\nsonnel and gives case examples.\nMWIA was founded in New York, 1919.\nThe various committees within the organi-\nsation provide the executive board with\nideas and impulses for activities, be it topics\nfor discussion, future projects or active par-\nticipation with organisations sharing areas\nof common interest.\nThe association has consultative status with\nthe Economic and Social Council of the\nUnited Nations and is in official relations\nwith the World Health Organisation. The\nactivities of the association are supported\nby its members through dues and honorary\nservice.\nDr. Waltraud Diekhaus, 9 years Secretary-\nGeneral of the organisation, since 2007\nVice-President Central Europe\nMedical Women\u2019s International Association\n(MWIA)\nCruise 2004, Tokyo, Mallorca,Schweden, ExCo, Sri Lanka\n125\nRegional and NMA news\nMinke van Minde\nFor almost sixty years, medical students are\njoining forces to improve health all over the\nworld. They organise projects and run ex-\nchange programs coordinated on a local and\nnational level. The national members are\nunited by the International Federation of\nMedical Students\u2019 Associations (IFMSA),\none of the largest student organisations in\nthe world. Currently IFMSA represents\nover 1.2 million medical students, in 2010\n97 national organisations are members in\n92 countries across the globe, covering all\ncontinents.\nThe IFMSA is an independent, non-polit-\nical organisation founded in 1951, officially\nrecognised by the United Nations as a non-\ngovernmental organisation, by the World\nHealth Organisation (WHO) and the\nWorld Medical Association (WMA) itself.\nThe partnership with the WMA is a long-\nlasting and fruitful one. IFMSA\u2019s General\nSecretariat is based in the WMA\u2019s office and\nmany IFMSA alumni are members of the\nWMA.\nAfter 59 years, IFMSA has now an ex-\ntremely large network due to its many active\nmembers from different backgrounds. The\nmandate of the IFMSA is to train medical\nstudents at an early age to become advocates\nfor health issues that they will face after as\npractitioners. This is executed throughout\ndifferent fields such as Medical Education,\nProfessional and Research Exchange, Hu-\nman Rights and Peace, Public Health and\nReproductive Health. Every year, around\n10 000 students participate in the exchange\nprograms of IFMSA abroad \u2013 gaining ex-\nposure to patients in an international set-\nting, learning about new types of disease\nprocesses endemic to a different region, and\nexperiencing first hand the cultural and eth-\nnic diversity of our planet.\nIFMSA national member organisations\norganise numerous projects in the fields\nmentioned above. 47 of them are IFMSA-\nrecognised projects, which receive IFMSA\ninternational support and are often or-\nganised in more than one country. Part-\nnerships are established between different\norganising countries as well as with other\nNGOs and organisations, which strength-\nens the project and its cause.\nThe IFMSA would like to encourage part-\nnerships between its national member or-\nganisations and the national members of\nthe WMA, which could have a beneficial\noutcome for both. Collaboration between\ndoctors and medical students in one coun-\ntry unifies the voice of the medical sector\nand empowers future doctors and medical\nprofessionals to develop themselves in their\nprojects and resources. Medical students are\nalways very eager to get into contact with\nmedical professionals and learn from their\nexperience. The same applies to medical\nstudents who would love to benefit from\nthe knowledge of the medical association in\ntheir country.\nOne of the projects that is organised by a\nmajority of the IFMSA members is the\nTeddy Bear Hospital. Primary school chil-\ndren are invited to come to the hospital\nwith their dolls or teddy bears who are ill\nand take them to the medical students who\nact like the \u201cteddy bear doctors\u201d. Children\nare introduced to wearing hospital clothes,\nx-rays, medicine and treatment. The focus\nof this project is the children dealing with\nthe topic \u201chospital and illness\u201d. Impressions\nand ideas, which children have acquired in\nfamily and from media, should be critically\nlooked at and corrected in playing if neces-\nsary. The topical center lays in the meeting\nbetween child and future doctor. Aim of\nevery medical work should not only be the\ntreatment, but also the building of a solid\nfoundation of confidence between the doc-\ntor and his little patient. Aim is to show the\nchildren that illness and the fight against it\nis part of everydaylife and does not neces-\nsarily have to be experienced as threatening\nor frightening. The medical students prac-\ntice in dealing with children in a hospital\nenvironment and are trained to develop\nskills in children\u2019s communication.\nIFMSA has a range of donation-focused\nprojects concerning organ donation, blood\ndonation and marrow. One of the aims is\nto teach medical students about the aim of\ndonation, while the other aim is to recruit\nnew donors and educate the public using\ndifferent methods. Medical students give\npeer education in high schools, organise\nstreet actions or active donations days. All\nthis should meet the ultimate goal: decrease\nthe list of patients waiting for organs, blood\nor marrow and improve their lives.\nIn some countries a first aid course or train-\ningisnotincludedinthemedicalcurriculum.\nThat motivated many IFMSA members to\norganise this training to teach medical stu-\ndents the general skills they should be able\nto acquire as medical students. Workshops\ninclude reanimation, basic life support\ntraining, taking blood, and physical exams.\nAfter the course students have to take an\nexam to evaluate whether they possess the\nskills taught. In some faculties they liked\nthe course so much that it is now included\nin the medical curriculum!\nMedical Students in Action\n126\nRegional and NMA news\nApart from projects IFMSA organises\nseveral advocacy events. Major events are\nheld in IFMSA member countries, such\nas World AIDS Day, Tobacco Campaign\nand World Tuberculosis Day. During these\nevents medical students actively advocate in\nthe benefit of reducing AIDS, tobacco use\nand tuberculosis. This is done by organising\nadvocacy events and joint ventures all over\nthe world. For example World AIDS Day\nis now organised in 40 member countries\nand more than 10 000 young people are\nreached.\nThe IFMSA Exchanges are the biggest\nproject run in the IFMSA. As mentioned\nover 10 000 participate each year.This needs\na lot of coordination effort on a local, na-\ntional and international level. Luckily there\nare many doctors and professors willing to\ncollaborate and invite an exchange student\nto their department, in order to give the\nstudent an amazing experience in a foreign\nhospital. Because of this collaboration IF-\nMSA can successfully organise its exchang-\nes for years now.\nThe IFMSA is still working to improve\nitself and to move forward in this rapidly\nchanging world.\nIn order to do so and to execute our aims we\nare more than eager to work together with\nmedical professionals to teach us skills and\nto enrich us with their knowledge.\nLet\u2019s work together for a healthier tomorrow!\nFor more information about IFMSA,please\nvisit www.ifmsa.org\nMinke van Minde, IFMSA Vice President\nfor External Affairs 2009\/2010\nCMA President warns \u201cIf we want to save\nMedicare we have to change it \u201c\nAt its annual meeting in August this year\nthe CMA annual meeting will debate a plan\nfor transfiguration of the healthcare system.\nCMA President Dr. Anne Doig, speaking\nto the Canadian Club of Ottawa recently\ngave the above warning, saying that trans-\nformation is needed to ease pressure that is\nincreasing in all health sectors. Illustrating\nthis by referring to the fact that Canada has\nthe highest bed occupancy among members\nof OECD at 91%, she pointed out that 25-\n30% of those whose acute beds are filled by\npeople who should even not be in hospital\n\u201cThose patients need 24 hour supervised\ncare, not hospital care\u201d.\nShe said that time had caught up with the\nfive medicare principles outlined in the\nCanada Health Act (CHA). e.g. The CHA\npromised universality, but essentially, this\napplies only to hospital and physician serv-\nices, at a time when demand for other types\nof care that are not covered is mushroom-\ning. As a result, the burden of continuing\ncare is falling on informal, unpaid caregiv-\ners whose needs were not foreseen by the\nCHA. Because people are living longer,\nroughly one in five Canadians aged 45 and\nover are now providing such care. Dr. Doig\nsaid the CMA act of 1984 may have prom-\nised comprehensive care, but in 2010 is un-\nable to deliver it.\nWhen the CHA became law in 1984,physi-\ncians and hospital services represented 57%\nof total health spending, and this had de-\nclined to 41% by 2008.\u201cToday, programmes\nsuch as seniors\u2019 drug coverage and home\ncare that are not subject to CHA criteria\nconsume over 25% of total public spending\non health\u201d.\nShe concluded on a more optimistic note,\npointing to innovations such as Quebec\u2019s\nplan to introduce a personal annual health\naccount to promote accountability and\ntransparency, and the establishment of\nhealth \u201cquality councils\u201d in six provinces.\n\u201cInnovation is happening across the coun-\ntry \u2026.. not by sacrificing the principles of\nthe CHA, but by building on them. \u201cWe\nneed to capture the momentum for change\ngrowing across the country and marshal\nthat energy into a new national vision for\nhealth care\u201d\nEuthanasia Bill crushed\nA private member\u2019s bill seeking to legalise\neuthanasia and assisted suicide by amending\nCanada\u2019s Criminal Code has been defeated\nin Canada\u2019s Parliament.The bill would have\nallowed doctors to help people aged 18 or\nolder \u201cdie with dignity\u201d.The changes would\nhave applied to those \u201cexperiencing severe\nphysical or mental pain without any prospect\nof relief \u201d or who were suffering from a ter-\nminal illness after they had expressed \u201cfree\nand informed consent to die\u201d. The bill was\ndefeated by 228 to 59 in a vote that crossed\nparty lines. In a letter sent to all members\nof Parliament before the vote, CMA Presi-\ndent Anne Doig said \u201cthe CMA supports\nenhancing access to palliative cared and\nsuicide prevention programmes and under-\ntaking a study of medical decision making\nduring dying,\u201d but it was worried that the\nbill would create \u201ca slippery slope\u201d.\n(by kind permission of CMA Bulletin)\nNews from Canada\n127\nRegional and NMA news\nwww.KnowYourAirForHealth.eu\nHelping communicate EU air quality information and alerts to\nallergy, asthma and COPD patients in Europe.\nAvailable in English, Suomi, Italiano, Lietuviu Kalba.\nA Joint EFA and Health and Environment Alliance Project.\nHealth & Environment Alliance (HEAL)\nFormerly EPHA Environment Network (EEN)\n28 Boulevard Charlemagne\nB-1000 Brussels\nTel: +32 2 234 3646 Fax : +32 2 234 3649\nE-mail:gill@env-health.org\nWebsite: www.env-health.org\nEuropean Federation of Allergy and Airways\nDiseases Patients\u2019 Associations (EFA)\n35 Rue du Congr\u00e8s\n1000 Brussels\nBelgium\nemail: info@efanet.org\nWebsite: www.efanet.org\n128\nWMA news\nWorld Health Professions Alliance, Geneva, May 2010\nSecretary General\u2019s Report (October 2009-April 2010)\nto 185th\nCouncil .........................................................................87\nNorwegian Doctor to Head WMA\u2019s Ethics Committee............96\nBrazilian Medical Association \u2013 SOS Haiti...............................97\nBurn Victims Bring Taiwan, Sao Tome Closer Together............98\nWorld Health Professions Alliance\ncalls for increased action against counterfeits .............................99\nHow Can Changes in Environmental Policy Help\nReduce Rates of Chronic Disease? ..........................................100\nRe-Positioning of Service Delivery in the Nigerian Health\nSystem \u2013 the Impact of SERVICOM on Emergency and\nOther Services in a Tertiary Health Facility.............................103\nThe History of the Placebo.......................................................109\nThe Czech Medical Association (CzMA) ...............................116\nBrazilian Medical Association (AMB):\nObjective and Actions ..............................................................117\nThe Medical Chamber of Serbia...............................................118\nPoor Health System and\nActive Macedonian Medical Chamber.....................................118\nHealth Policy Reform in Albania and Development\nof the Order of Physicians of Albania ......................................121\nBulgarian Medical Association.................................................123\nMedical Women\u2019s International Association (MWIA) ............124\nMedical Students in Action......................................................125\nNews from Canada...................................................................126\nContents\n\n<\/p>\n"},"caption":{"rendered":"

wmj27 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, Inc G20438 Nr. 3, June 2010 WMA Secretary General\u2019s Report to 185\u2022 th Council The History of the Placebo\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 […]<\/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\/wmj27.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3600"}],"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=3600"}]}}