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wmj32<\/a><\/p>\n

UNITED STATES
\nvol. 57
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 2, April 2011
\n\u2022 Council Session in Sydney
\n\u2022 TaskD elegation Versus Task Shifting in the Indonesian
\nHealth Service
\n\u2022 Infectious Diseases
\nwmj 2 2011 5CS.indd I 4\/29\/11 11:13 AM
\nCover picture from Japan
\nii
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.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 Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by P\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas\u00a0apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nThe printing depicts the Ikaho Onsen
\n(hotspring) in Japan. It is said that the hotspring
\nwas found in the 2nd
\nCentury or 7th
\nCentry, good
\nto digestive diseases, rheumatism, neuralgia,
\nparalysis, bruises, etc. A westerner on the
\nright edge may be Dr. Erwin Von Baelz, a
\nGerman medical doctor, who was said to have
\npraised the Ikaho Onsen for its health benefits.
\nThis printing was made by an ukiyo-e artist,
\nKunichika Toyohara (1835\u20131900).
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 Cologne\/Germany
\nPhone (0 22 34) 70 11-0
\nFax (0 22 34) 70 11-2 55
\nProducer
\nAlexander Krauth
\nBusiness Managers J. F\u00fchrer, N. Froitzheim
\n50859 K\u00f6ln, Dieselstr. 2, Germany
\nIBAN: DE83370100500019250506
\nBIC: PBNKDEFF
\nBank: Deutsche Apotheker- und \u00c4rztebank,
\nIBAN: DE28300606010101107410
\nBIC: DAAEDEDD
\n50670 Cologne, No. 01 011 07410
\nAdvertising rates available on request
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7%\u00a0MwSt.). For members of the World Medical
\nAssociation and for Associate members the
\nsubscription fee is settled by the membership
\nor associate payment. Details of Associate
\nMembership may be found at the World
\nMedical Association website www.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Wonchat SUBHACHATURAS
\nWMA President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Dana HANSON
\nWMA Immediate Past-President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA President-Elect
\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 Brazil
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNorway
\nDr.Frank Ulrich MONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\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\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\nwmj 2 2011 5CS.indd Sec1:ii 4\/29\/11 11:13 AM
\n41
\nCouncil Down Under
\nFor many years, the mid-year WMA Council session of the year
\n(held in April or May of each year) has been held in the Geneva
\narea, for reasons of economic prudence and the will to connect it
\nto the World Health Assembly (WHA). However the results have
\nbeen mixed. Yes, it has been more economic to stay close to the
\nWMA office in the Geneva area, but not substantially so \u2013 either in
\nterms of price or value for the money.The Geneva area is known for
\nits very high prices, and when it comes to meeting services, there is
\nample room for improvement.The opportunity for WMA delegates
\nto take advantage of being in Geneva for the Council session in or-
\nder to attend the WHA has not generally been a huge success. Over
\nthe last several years, not more than a handful of Council attendees
\nhave stayed on for the WHA.
\nMost important,we have learned that remaining in the Geneva area
\nwhere dozens of associations and organizations are holding meet-
\nings at the same time limits the amount of visibility of the WMA
\nCouncil session. Starting in 2007, the WMA ended the stationary
\nstatus of the Council Session, venturing back out into the world
\nagain in alternating years, first to Berlin, then to Tel Aviv in 2009,
\nand this year to Sydney. These venues generated increased atten-
\ntion to the Council sessions,attracting more members and observers
\nthan those held in the Geneva Area.
\nFor a membership-based organization this active participation is
\ncrucial. Returning the hosting role to our member associations has
\nraised their interest and commitment to our Council meeting and
\nhas attracted public attention as well. The Australian Minister of
\nHealth,Nicola Roxon,leveraged the occasion of the Council session
\nto launch her new law proposal on plain packaging of cigarettes\u00a0\u2013
\nand this on World Health Day, April 4th
\n. There was no better place
\nfor this ambitious health initiative than a stage prepared by the
\nglobal organization of physicians.A brave new concept,and the first
\neffort to legally codify a requirement for plain packaging, the initia-
\ntive was immediately backed by the Council, which is recommend-
\ning that General Assembly make this part of the WMA policy.
\nThe Australian and the New Zealand Medical Association used the
\nmeeting to stage a Leadership Day immediately before the Coun-
\ncil, taking advantage of the presence of a large number of medical
\nleaders from around the world who had come to attend the WMA
\nCouncil Session. And, last but not least, the Governor General is-
\nsued a rare invitation for a reception to WMA Council Members,
\nhighlighting the importance Australia places on the work of its phy-
\nsicians.
\nReturning to Australia after 15 years was also a tribute to our col-
\nleagues in Australia, New Zealand and the Pacific. Despite the fact
\nthat they must travel the farthest for most of our meeting venues,
\nthey have proven among our most faithful, committed members,
\nwith many delegates from the Pacific region serving the WMA as
\nCouncil members, officers, advisors and volunteers. The election in
\nhis home country of Dr. Mukesh Haikerwal as WMA\u2019s new Chair
\nof Council was a happy coincidence, and the natural result of his
\nexceptional engagement in the WMA during the past years.
\nFinally, the WMA got its junior doctors network going. With an
\nactive group, strongly backed by young physicians from the region,
\nthis is a promising initiative to keep the WMA inter-generational.
\nWhat has been missing \u2013 a global platform for doctors in training\u00a0\u2013
\nis now available within the Associate Membership of the WMA.
\nThe WMA is proud to have this new platform under its roof.
\nDr. Otmar Kloiber WMA Secretary General
\nwmj 2 2011 5CS.indd 41 4\/29\/11 11:13 AM
\n42
\nIt gives me great pleasure to welcome you
\nto Sydney and to Australia and to address
\nyour conference.
\nYou\u2019ve come to a wonderful country for this
\ncouncil meeting and you\u2019ve come at an ex-
\nciting time.\u00a0 Australia is not just a beauti-
\nful and welcoming country, it has a strong
\nhealth system too.\u00a0
\nBut we acknowledge the strength of our
\nhealth system will not last, faced with the
\nchallenges of demography and chronic dis-
\nease without reforming key parts of the sys-
\ntem.
\nNo doubt many of these challenges are
\nshared in your countries too, and will be
\ncovered at length in your conference.
\nAt the start of my second term as Austra-
\nlian Health Minister I can share with you
\nhow the Gillard Government is facing these
\nchallenges and how some of our reforms are
\nbeing implemented.
\nI\u2019d like to focus first on three areas that pro-
\nvide a sample and flavour of our reforms:
\n(1) our determination to shift the centre of
\ngravity in our health system more heav-
\nily to primary care;
\n(2) financing and accountability\u00a0\u2013 particu-
\nlarly in a federated country to benefit
\nconsumers; and
\n(3) modernising health service delivery
\nthrough technology.
\n(1) Our Government has put a lot of focus
\non heavily supporting our GPs,and primary
\ncare more broadly.\u00a0 We strongly believe this
\nis better for patients but also helps us better
\nmanage the growing cost of high tech and
\nexpensive interventions.
\nThe OECD reports that Australia has an
\novernight hospitalisation rate of 163.4 per
\n1,000 population compared to half that\u00a0at 84
\nper 1,000 population in Canada, 137 in New
\nZealand and 134 in the United Kingdom.
\nAnd in the decade to 2007\u201308, the number
\nof hospital admissions in Australia rose by
\n37 per cent\u00a0\u2013 that is an unsustainable figure.
\nSo doubling our GP training numbers,
\nincentivising general practice in commu-
\nnities that are undersupplied, providing
\ninfrastructure funding through GP super
\nclinics and to existing practices to expand
\nmultidisciplinary work and training in pri-
\nmary care are all part of our drive to boost
\nprimary care.
\nOur next steps are establishing Medicare
\nLocals\u00a0\u2013 to help co-ordinate disparate and
\ndispersed private practices and to identify
\nand fill gaps within those local communi-
\nties.\u00a0 Our vision is that primary care with-
\nin local communities will grow a voice to
\nmatch the strength and voice of local hos-
\npitals.
\n(2) Another big area of our reform focuses
\non better financing and better accountabil-
\nity for health expenditure across all jurisdic-
\ntions\u00a0\u2013 but also better information for con-
\nsumers that can flow from this.\u00a0
\nWhilst some of our financing problems are
\nunique to the Australian federal system\u00a0 \u2013
\nour determination to establish an national
\nefficient price and to have national perfor-
\nmance benchmarks are not.\u00a0
\nWe already launched our \u201cMyHospitals\u201d
\nwebsite which advises, hospital by hospital,
\nemergency department waiting time and
\nelective surgery waits.\u00a0 These are two areas
\nwhere we are investing more to change the
\nway we do things and get improved and
\ntimely access for consumers.
\n(3) Our Government has been very deter-
\nmined to unleash the potential of technol-
\nogy \u2013 to become one of the world\u2019s leading
\ndigital economies by 2020.\u00a0 Our national
\nbroadband network will allow users internet
\naccess at speeds the envy of the world.\u00a0 This
\nnetwork will enhance the care we can pro-
\nvide, especially in remote parts of the coun-
\ntry or where our specialists are distant from
\nthose who need their care.
\nWe\u2019ve committed to a personally controlled
\nelectronic health record for all Australians.\u00a0
\nThis will mean that patients won\u2019t have
\nto tell their medical history to every new
\nhealth professional that they see when they
\nare travelling across the country or when
\nthey move.\u00a0 And, by the way, we\u2019re pretty
\nmobile\u00a0 \u2013 more than 331,400 Australians
\nmoved interstate in 2009\u201310.
\nPublic Health AUSTRALIA
\nNicola Roxon
\nNew Policy Against the Tobacco
\nSpeech during World Medical Association Council Meeting,
\nSydney 7th
\nApril 2011
\nby The Hon. Nicola Roxon,
\nAustralia\u2019s Federal Minister for Health and Ageing
\nwmj 2 2011 5CS.indd 42 4\/29\/11 11:13 AM
\n43
\nPublic HealthAUSTRALIA
\nWith patient permission,health profession-
\nals that they consult will be able to access
\ntheir history\u00a0\u2013 not just saving a lot of time
\nbut also preventing errors and saving lives.\u00a0
\nFor example, medication errors alone cur-
\nrently account for 190,000 admissions to
\nhospitals in this country each year. Avoid-
\ning mistakes on medications, allergies and
\nreactions will be a huge benefit, especially
\nfor older people.
\nIn a similar vein, from 1 July this year we
\nwill have a national after hours GP hot-
\nline\u00a0\u2013 initially by phone,but with the poten-
\ntial to grow to an online video conference
\nfrom July 2012, talking to a doctor from
\nyour own home.\u00a0
\nAlso from 1 July 2011 Medicare rebates
\nwill be payable for specialists consultations
\nacross the internet\u00a0 \u2013 for those unable to
\naccess face to face consultations, this will
\nliberate them from the tyranny of distance.\u00a0
\nWe want to tackle the brutal truth that too
\nmany rural and regional Australians don\u2019t
\nget the care they need if it involves hours, or
\noften days, of travel.\u00a0
\nI hope these few examples of our broad re-
\nforms are of interest and give you a sense of
\nthe breadth and flavour of reforms that are
\ndesigned to significantly improve the health
\nof Australians and reinforce our system for
\nthe future.
\nThe main focus of my presentation today,
\nthough, is on our Government\u2019s passionate
\ndetermination to tackle preventable disease.\u00a0
\nThis is a clear challenge of the future, and a
\nclear component of our need to help make
\nthe health system sustainable.
\nAs you know in this audience, many of the
\nmajor diseases\u00a0\u2013 cancer, cardiovascular dis-
\nease and diabetes\u00a0\u2013 are potentially avoidable.
\nIn fact it\u2019s reliably estimated that risk fac-
\ntors contribute to more than 30 per cent
\nof Australia\u2019s total burden of death, disease
\nand disability.
\nA particular challenge is that a vast and
\nrising proportion of our burden of illness
\nand mortality is due to conditions which
\ndevelop over some time and which could
\nbe avoided or prevented, often by relatively
\ncheap and low-tech interventions.
\nIt needs local and national initiatives to
\neducate the public about health risks and to
\nsupport healthy lifestyles and disease pre-
\nvention.
\nThe Government is making the nation\u2019s
\nlargest investment in preventative health\u00a0\u2013
\n$872 million over 6 years.\u00a0 These invest-
\nments stretch from work in local commu-
\nnities such as cooking classes, community
\ngardens and walking groups that are par-
\nticularly disadvantaged, to workplace ini-
\ntiatives, a focus on children, and our new
\ncampaign \u201cswap it, don\u2019t stop it.\u201d
\nAs part of this work, I want to focus on one
\narea where Australia has made good prog-
\nress, where we are committed to the long
\nhaul and have important news to share.
\nThe area is tobacco control
\nSmoking is one of the most damaging pre-
\nventable causes of ill health and death in
\nAustralia.
\nIt causes a range of cancers and chronic dis-
\neases well known to you all\u00a0\u2013 because you
\nhave to treat them.
\nIt currently kills about 15,000 Australians
\neach year,and costs Australia\u2019s economy and
\nsociety about $31.5 billion dollars a year.
\nGlobally, the World Health Organisation
\nestimates that 5 million people die from
\ntobacco-related illness each year, most of
\nthem in low- and middle-income countries.\u00a0
\nThis is expected to reach 9 million by 2030.
\nAs you all know the message is blatantly
\nclear: if we reduce smoking rates we can
\nradically reduce the burden of cancer and
\nchronic disease.
\nAustralia has had success over the years.
\nAustralia recognised the malign influence
\nof cigarettes early and has made signifi-
\ncant progress in reducing the smoking rate.\u00a0
\nOver the years the Commonwealth, State
\nand Territory Governments together have
\nprohibited advertising, removed sponsor-
\nships, restricted point of sale displays, and
\noutlawed smoking in restaurants and many
\npublic places.
\nThanks to increasing efforts by govern-
\nments, the proportion of Australians aged
\n14 years and over who smoke each day has
\nfallen from 30.5 per cent in 1988 to 16.6 per
\ncent today\u00a0\u2013 one of the lowest in the world.
\nHowever about 3 million Australians con-
\ntinue to smoke every day\u00a0\u2013 so there is more
\nthat can and will be done.
\nSmoking is also more concentrated among
\npeople in disadvantaged groups, and en-
\ntrenches disadvantage by entrenching ill
\nhealth.\u00a0 Naturally a Labor government
\nis concerned by the hard caused in these
\ngroups.
\nFor example, the adult daily smoking rate
\namong Australia\u2019s Aboriginal and Torres
\nStrait Islander people \u2013 at 47 per cent\u00a0\u2013 is
\nmore than double the whole of population
\nsmoking rate and is estimated to contrib-
\nute 17 per cent of the large life expectancy
\ngap between Indigenous and other Austra-
\nlians.
\nWhen we first came to office our Govern-
\nment committed to closing the gap in life
\nexpectancy between Indigenous and non-
\nIndigenous, but we cannot do that without
\nreducing their smoking rates.
\nThat\u2019s why the government is making a re-
\ncord investment in helping Aboriginal and
\nTorres Strait Islander communities to tack-
\nwmj 2 2011 5CS.indd 43 4\/29\/11 11:13 AM
\n44
\nPublic Health AUSTRALIA
\nle smoking\u00a0 \u2013 through indigenous tobacco
\nworkers and the first ever advertising cam-
\npaign for the indigenous community.
\nThe daily smoking rate among other dis-
\nadvantaged groups also remains unaccept-
\nably high.\u00a0 It is around 32 per cent among
\nunemployed people and a similar rate for
\npeople with mental illness.\u00a0
\nAround 50 per cent of men in some cultur-
\nally and linguistically diverse communities
\nsmoke.\u00a0 And tragically, over 40 per cent of
\npregnant teenagers.
\nI am very strongly of the view that we in
\ngovernment and you in the medical profes-
\nsion have a responsibility to do all that we
\ncan to reduce smoking and reduce the pain
\nand suffering it causes.
\nThat is why the Labor Government has
\ntaken the lead, at home and internationally,
\non this important issue.
\nWe have set targets to reduce the national
\ndaily smoking rate to 10 per cent or less of
\nthe population by 2018 and halve the smok-
\ning rate for Indigenous Australians.
\nWe are approaching these targets by mov-
\ning simultaneously on a comprehensive
\nrange of fronts\u00a0\u2013
\n\u2022 In April last year we increased the excise
\non tobacco products by 25 per cent, ef-
\nfectively increasing the price of a packet
\nof 30 cigarettes by over $2.
\n\u2022 We have legislation in the Parliament to
\nrestrict internet tobacco advertising in
\nAustralia, bringing it in line with restric-
\ntions on advertising in other media.
\n\u2022 We are making record investments in an-
\nti-smoking social marketing campaigns,
\nincluding tough new advertisements
\nlinking smokers\u2019 cough with lung cancer
\nand the first ever national indigenous
\nanti-smoking advertisement.\u00a0 These cam-
\npaigns are being extended to specifically
\ntarget high risk and hard to reach groups
\nincluding pregnant women, people with
\nmental illness, prisoners and people from
\nculturally and linguistically diverse back-
\ngrounds.
\n\u2022 In February we provided heavy subsidies
\nfor nicotine replacement therapies, as an
\naid to quitting smoking, on the Pharma-
\nceutical Benefits Scheme.
\nThese are important initiatives to keep Aus-
\ntralians healthy, but there is more that we
\ncan do.
\nPlain Packaging
\nSo, today I am pleased to announce a world
\nfirst initiative.
\nToday I am releasing the world\u2019s first plain
\npackaging laws.\u00a0 I\u2019m releasing a consulta-
\ntion paper and the exposure draft of the
\ngovernment\u2019s legislation on plain packag-
\ning\u00a0 \u2013 the world\u2019s toughest legislation on
\ntobacco promotion.
\nPlain packaging will remove one of the last
\nremaining forms of tobacco advertising. It
\nwill restrict tobacco industry logos, brand
\nimagery, colours and promotional text.
\nThe packaging will be mandated to appear
\nin a standard dark olive brown colour which
\nhas been chosen based on research for the
\nlowest appeal to smokers.
\nThe only thing to distinguish one brand
\nfrom another will be the brand and product
\nname in a standard colour,standard position
\nand standard font size and style.
\nMost of the front of the package\u00a0\u2013 75 per
\ncent, up from the current 30 per cent\u00a0\u2013 will
\nbe covered with updated graphic health
\nwarnings, adding to the current 90 per cent
\ncoverage on the back of the pack.
\nAs you see from these examples, all vestiges
\nof marketing messages have disappeared;
\nthe pack now becomes a stark reminder of
\nthe health effects of smoking.
\nManufacturers will also be permitted to
\ninclude certain anti-counterfeiting design
\nfeatures that do not run counter to the
\npublic health objectives of the measure, to
\nminimise any impact on the illicit trade in
\ntobacco products.
\nThere is strong evidence to support this
\ntough approach.
\nThe National Preventative Health Task-
\nforce, commissioned by the Australian
\nGovernment in 2008 as a key part of our
\nreform plans examined the growing body of
\nevidence on plain packaging and conclud-
\ned\u00a0\u2013 \u201cthere can be no justification for allow-
\ning any form of promotion for this uniquely
\ndangerous and addictive product which it is
\nillegal to sell to children\u201d\u00a0\u2013 including on the
\npackaging.
\nThe taskforce said plain packaging would:
\n\u2022 increase the impact of health warning
\nmessages;
\n\u2022 reduce the ability of tobacco companies
\nto mislead consumers into believing that
\nsome cigarettes are less harmful than oth-
\ners;
\n\u2022 make cigarettes look less attractive\u00a0\u2013 for
\nadults and children;
\n\u2022 and reduce the appeal and desirability of
\nsmoking generally.
\nBut it\u2019s not just our national taskforce
\nwhich believes this. Plain packaging has
\nbeen discussed in various countries and fo-
\nrums over the past 25 years, and is backed
\nby the World Health Organisation.
\nOur legislation will give effect to commit-
\nments under the WHO Framework Con-
\nvention on Tobacco Control, which was
\nadopted by the World Health Assembly on
\n21 May 2003 and entered into force on 27
\nFebruary 2005.
\nThe Framework Convention has since be-
\ncome one of the most widely embraced
\ntreaties in UN history. To date, more than
\n170 countries have ratified it.
\nwmj 2 2011 5CS.indd 44 4\/29\/11 11:13 AM
\n45
\nThe Conference of the Parties to the Frame-
\nwork Convention agreed in 2009 that plain
\npackaging should be considered as part of
\ncomprehensive bans on tobacco advertising
\nand as a way of ensuring that consumers are
\nnot misled about the dangers of smoking.\u00a0
\nAustralia is the first signatory and the first
\ncountry in the world to commit to imple-
\nmenting these recommendations on plain
\npackaging.
\nWe intend the legislation to commence on
\n1 January next year, with the requirement
\nthat all products on sale comply with the
\nnew laws within six months.
\nTo meet these timelines, I am today releas-
\ning a consultation paper together with the
\nplain packaging design and an exposure
\ndraft of the legislation for 60 days of public
\nconsultation.
\nI will then introduce the Tobacco Plain Pack-
\naging Bill 2011 during the winter sitting of
\nParliament.
\nI expect Big Tobacco to fight these steps
\ntooth and nail.
\nThey are already doing everything in their
\npower to fight the Government politically
\nand legally.This legislation will be no excep-
\ntion.
\nThey have established a group to front their
\nactivities\u00a0\u2013 The Australian Retailer\u2019s Asso-
\nciation.
\nThe Association ran a multi-million dol-
\nlar advertising campaign in the last Federal
\nelection against the Government.
\nThey claim plain packaging \u201cwon\u2019t work\u201d\u00a0\u2013
\nbut if it won\u2019t work, why would they pour
\nmillions of dollars into opposing it?
\nIt\u2019s simple\u00a0\u2013 a reduction in smoking rates
\nis a reduction in profits, a reduction in bo-
\nnuses.
\nMoney is no object to them because they
\nare fighting to keep a very profitable global
\nfront\u00a0\u2013 hawking their killer products across
\nthe developing world.
\nThey know that if Australia is the first, we
\nwill not be the last.
\nWe might be breaking ground, but we are
\non firm ground.\u00a0 Others will follow.
\nThen tobacco companies will be forced to
\nscurry around the world targeting other
\ncountries with their insidious products.
\nA global business, causing global hard de-
\nserves a global response.
\nI believe therefore that Governments and
\nthe medical profession must continue to
\nwork together to fight tobacco.
\nI believe there is an imperative on people
\nlike me, in government, and people like you,
\nin the medical profession,to act to do what-
\never we can to reduce the smoking rate.
\nI therefore ask you when you return to your
\nown country, to urge your government to
\nact in the fight against tobacco\u00a0 \u2013 to take
\nfurther steps to implement\u00a0 commitments
\nunder the WHO Framework Convention.
\nIt\u2019s true that our nation and the world have
\nother important health issues, all of which
\nrequire attention.
\nBut reducing smoking\u00a0\u2013 compared to most
\nof those problems\u00a0\u2013 is relatively simple and
\nincredibly cost effective.
\nIt doesn\u2019t require a new workforce, huge in-
\nvestment of dollars or new health techno-
\nlogy.
\nIt does require a great deal of political will
\nand determination to withstand the tobacco
\nlobby.
\nI consider myself very fortunate to be part
\nof a government that has that determina-
\ntion.\u00a0 But I can also assure you that it feels a
\nlot less lonely when you have strong support
\nfrom people like yourselves.
\nI hope that when your return home you will
\npress for plain packaging in your country
\nand for it to become commonplace around
\nthe world.
\nBecause tobacco smoking is one health di-
\nsaster that we can stub out, if we have the
\nwill.
\nPublic HealthAUSTRALIA
\nwmj 2 2011 5CS.indd 45 4\/29\/11 11:13 AM
\n46
\nWMA news
\nCouncil Meeting
\nThe 188th
\nCouncil session (7\u20139 April) was
\nopened by the Secretary General, Dr. Ot-
\nmar Kloiber at the Westin Hotel, Sydney,
\nAustralia. He welcomed new members of
\nCouncil and said apologies had been re-
\nceived from the Japanese physician mem-
\nbers,who were heavily involved in the after-
\nmath of the Japan earthquake.
\nThe first business was the election of the
\nChair of Council, the Vice Chair and the
\nTreasurer. Dr. Mukesh Haikerwal (Aus-
\ntralia) was elected unopposed as Chair
\nof Council, replacing Dr. Edward Hill
\n(America) who stood down after four years
\nin the post. Dr. Masami Ishii (Japan) was
\nre-elected Vice Chair of Council and Dr.
\nFrank Ulrich Montgomery (Germany) was
\nelected Treasurer.
\nDr. Wonchat Subhachaturas, the President,
\ngave a report on his activities and his vis-
\nits since October. He referred to the various
\nnatural disasters around the world and the
\nwork that medical professionals were doing
\nto treat the victims,and he asked delegates to
\nstand in silence in respect of those who had
\nlost their lives. He also spoke about attacks
\non physicians in conflict zones and said that
\nmedical professionals must be protected at
\nall times, although the profession must not
\ntake sides or be part of these conflicts.
\nThe WMA then welcomed the Hon. Nic-
\nola Roxon, Australia\u2019s Federal Minister for
\nHealth and Ageing, to open the conference.
\nIn her address, she spoke about the health
\nchallenges facing the world and current
\nreforms being undertaken in Australia\u00a0 \u2013
\nshifting the centre of gravity to primary
\ncare, addressing the issues of finance and
\naccountability and modernising the health
\nservice through new technologies.
\nShe then announced a major new policy
\non tobacco control with proposed legisla-
\ntion for plain packaging for cigarettes. This
\nwas the latest step in the fight to reduce the
\nnumber of smoking related deaths in Aus-
\ntralia,which currently totalled 15,000 lives a
\nyear. She said this development was a world
\nfirst and the proposed new plain packs had
\nbeen designed to have the lowest appeal to
\nsmokers. She appealed to WMA delegates
\nto urge their governments to take similar
\naction.
\nDr. Kloiber then presented the secretariat\u2019s
\nreport on the WMA\u2019s activities since the
\nlast meeting.
\nAntimicrobial Resistance
\nSpeaking on what was World Health Day,
\nwith its theme of antimicrobial resistance,
\nDr. Kloiber said that WMA policy on the
\nissue was far ahead of its time and every-
\nthing forecast in its 15-year-old Statement
\nhad come true. The world was now facing a
\ndisaster, dealing with resistance on a large
\nscale, killing many people round the world.
\nHe announced that, together with the Cen-
\nter for the Study of International Medical
\nPolicy and Practices at the George Mason
\nUniversity, USA, and the International So-
\nciety for Microbial Resistance, an online
\ntraining course on antimicrobial drug resis-
\ntance had been set up and could be accessed
\non the George Mason University website.
\nNon Communicable Diseases
\nAs part of the WHO\u2019s Global Action
\nPlan on Non Communicable Diseases
\nthe WMA, together with the members of
\nthe World Health Professions Alliance
\n(WHPA), had developed a campaign to
\n188th
\nWMA Council Meeting
\nSydney, Australia 7th
\n\u20139th
\nApril 2011
\nRosanna Capolingua
\nWonchat Subhachaturas
\nDana Hanson
\nJ. Edward Hill
\nMukesh Haikerwal
\nOtmar Kloiber
\nJose Luiz
\nGomes Do Amaral
\nFrank Ulrich
\nMontgomery
\nSir Michael Marmot
\nJ\u00f3n Sn\u00e6dal
\nwmj 2 2011 5CS.indd 46 4\/29\/11 11:13 AM
\n47
\nWMA news
\nprevent NCDs by targeting the common
\nrisk factors and the social determinants of
\nhealth.In the run up to the United National
\nSummit on NCDs in September 2011, the
\nWHPA would begin with an advocacy and
\nawareness raising campaign aimed at health
\nprofessionals, patients and government.
\nMulti Drug Resistant
\nTuberculosis Project
\nAs part of the Lilly MDR-TB partnership,
\nthe WMA had printed a version of the TB
\nrefresher course for physicians and trans-
\nferred it into an interactive TB refresher
\nonline course available free of charge from
\nthe webpage.The course had been nominat-
\ned by the United States Center of Disease
\nControl (CDC) as an educational highlight
\nand had received an award.To complete the
\nonline tools two virtual patient cases on TB
\nand MDR-TB had been developed with
\nINMEDIA.
\nThe WMA had also become a member of
\nthe Stop TB Partnership Human Rights
\nTask Force.
\nAlcohol
\nIn line with the WMA Statement on Re-
\nducing the Global Impact of Alcohol on
\nHealth and Society, the secretariat had
\nmonitored the drafting process of the
\nWHO\u2019s Global Strategy.
\nCounterfeit Medical Products
\nThe WMA and the members of the World
\nHealth Professions Alliance had stepped
\nup their activities on counterfeit medical
\nissues and developed an Anti-Counterfeit
\ncampaign with an educational grant from
\nPfizer Inc. and Eli Lilly. The basis of the
\ncampaign was the \u2018Be Aware\u2019 toolkit for
\nhealth professionals and patients to in-
\ncrease awareness of this topic and provide
\npractical advice for actions to take in case
\nof a suspected counterfeit medical product.
\nTwo regional WHPA Counterfeit Medical
\nProducts workshops had been organised in
\nCosta Rica and Nigeria.
\nHealth and the Environment
\nOn climate change, lobbying activities had
\nbeen undertaken following the Cancun
\nSummit in 2010, inviting medical associa-
\ntions to write to their governments to ask
\nthat health be brought to the forefront of
\nthe global warming debate.
\nJoint action was also being explored to pro-
\ntect human health and the global environ-
\nment form the release of mercury.
\nSocial Determinants of Health
\nFollowing the decision in Vancouver, a
\nWorkgroup had been established to draw
\nup a draft policy on the initiative of the
\nBritish Medical Association. The group
\nwas also monitoring the preparation of the
\nWorld Conference on Social Determinants
\nof Health organised by WHO in Rio de Ja-
\nneiro from 19 to 21 October 2011.
\nHealth systems
\nAn international conference to review the
\neffect of the global economic crisis had
\nbeen held in Riga, Latvia in September
\n2010. Entitled \u201cFinancial Crisis \u2013 Implica-
\ntions for Health Care \u2013 Lessons for the Fu-
\nture\u201d, the conference revealed, on one hand,
\na staggering vulnerability of some health
\ncare systems to the economic situation and
\ndocumented that it was the weakest mem-
\nbers of society that suffered the most when
\na crisis hit the health care system. On the
\nother hand, examples demonstrated that
\nhealth care systems, when appropriately
\nprotected, did actually support the overall
\neconomy.
\nHisashi Tsuruoka
\nYoram Blachar
\nRobin J. Menes
\nRobert Ouellet
\nDongchun Shin
\nCecil B. Wilson
\nPaul-Emile Cloutier
\nVivienne Nathanson
\nTorunn Janbu Heikki P\u00e4lve
\nwmj 2 2011 5CS.indd 47 4\/29\/11 11:13 AM
\n48
\nWMA news
\nThe WMA had contributed to WHO ac-
\ntion in helping governments to monitor and
\nreport about their health workforce and had
\nbeen represented at the World Economic
\nForum\u2019s Industry Partnership Strategists
\nMeeting for Health in New York in Sep-
\ntember 2010.
\nPrior to the OECD Health Ministerial
\nmeeting in October, the OECD Forum on
\nQuality of Care took place and the WMA
\nwas invited to present the physicians\u2019 per-
\nspective on this issue.
\nPositive Practice Environment
\nCampaign (PPE)
\nThe WMA continued its close involve-
\nment in the Positive Practice Environment
\nCampaign, the global five-year campaign
\nspearheaded by WHPA members together
\nwith the International Hospital Federation,
\nto ensure high-quality health workplaces
\nfor quality care. The PPE Partners and sec-
\nretariat were working with national health
\nprofessional and hospital organisations in
\nUganda, Morocco and Zambia to develop
\ncountry projects and improve their practice
\nenvironments. The campaign had organised
\na workshop during the 2nd
\nGlobal Forum
\non Human Resources for Health in Bang-
\nkok in January 2011 with participants from
\nmore than 25 countries.
\nMigration & Retention
\nThe WMA had taken part in drafting the
\nWHO Guidelines on Retention Strategies
\nfor Health Professionals in Rural Areas,
\naimed at attracting and retaining health
\ncare professionals in rural areas. And in
\nJanuary 2011, the Global Health Work-
\nforce Alliance had organised the 2nd
\nGlobal
\nForum on Human Resources in Health in
\nThailand, where the WMA helped organise
\na highly successful skills-building workshop
\non Enhancing Personal Resilience for a
\nSustainable Health Care Workforce.
\nWorkplace Violence in
\nthe Health Sector
\nThe WMA had taken part in the planning
\nprocess of the Conference on Workplace
\nViolence in the Health Sector, held on
\n27\u201329 October 2010 in Amsterdam. Ms.
\nLeah Wapner, Secretary General of the Is-
\nrael Medical Association, presented a paper
\non the issue.
\nEducation & Research
\nThe World Federation for Medical Educa-
\ntion had started a discussion process about
\nthe future role of the physician, starting
\nwith an expert panel in March that in-
\ncluded representatives of academia, WHO,
\nthe WMA and international and regional
\nmedical organisations.
\nPatient Safety
\nThe WMA was a member of the WHO
\nreviewing committee to develop a Multi-
\nProfessional Patient Safety Curriculum
\nGuide, after the WHO had defined patient
\nsafety as a major global priority in health
\ncare. To deliver safe health care, clinicians
\nrequired training in the discipline of patient
\nsafety, which included an understanding of
\nthe nature of medical error, how clinicians
\nthemselves could work in ways that reduced
\nthe risk of harm to patients, techniques for
\nlearning from errors, and how clinicians
\ncould harness quality improvement meth-
\nods to improve patient safety in their own
\norganisations.
\nCaring Physicians of the World
\nInitiative Leadership Course
\nInvitations would be sent out to NMAs for
\nthe fourth Leadership Course planned to
\nbe held in Singapore on 20\u201325 November
\n2011. The curriculum included training in
\ndecision-making, policy work, negotiat-
\nRamin Parsa-Parsi
\nFiona Davies
\nAlex Mark Well
\nDavid Mountain
\nPeter Foley
\nRoderick McRae
\nMichael Bonning
\nMark Peterson
\nArdis D. Hoven Julio Trotchansky
\nwmj 2 2011 5CS.indd 48 4\/29\/11 11:13 AM
\n49
\nWMA news
\ning and coalition building, intercultural
\nrelations and media relations. The courses
\nwere made possible by an unrestricted edu-
\ncational grant provided by Pfizer, Inc. This
\nwork has been supported by the WMA Co-
\noperating Center \u2013 the Center for Global
\nHealth and Medical Diplomacy at the Uni-
\nversity of North Florida.
\nSpeaking Book
\nThe WMA launched the speaking book on
\nclinical trials during the General Assembly
\nin Seoul 2008, as part of a collaborative ef-
\nfort with the South African Medical As-
\nsociation, the SADAG (South African De-
\npression & Anxiety Group) and the Steve
\nBiko Center for Bioethics in Johannesburg
\nand the publisher \u201cBooks of Hope\u201d. The
\nspeaking book on clinical trials in English-
\nHindi & Telugu was launched at the 2009
\nGeneral Assembly in India.The project was
\nmade possible by an unrestricted education-
\nal grant provided by Pfizer, Inc. In March
\n2010, Books of Hope presented a speaking
\nbook on the dangers of smoking, targeting a
\nlow literacy community. Each of the books
\nwas expected to be received by an average of
\n27 people as a study had shown. Thus the
\nfirst 5000 books had the potential to impact
\n50,000 to 100,000 people.
\nHuman Rights
\nA seminar took place on 1\u20132 November
\n2010 in Turkey aimed at contributing to
\nthe implementation of the right to health
\nand strengthening the independence of
\nthe medical profession in Middle East
\ncountries. The seminar was organised by
\nthe Norwegian Medical Association, the
\nHuman Rights Foundation of Turkey, the
\nTurkish Medical Association, the WMA
\nand the International Federation of Health
\nand Human Rights Organisations. Partici-
\npants included representatives from health
\norganisations from Egypt, Iraq, Israel, and
\nPalestine together with the organisers of
\nthe event. Issues raised during the event
\nwere related to access to health care, such
\nas health care for undocumented migrants,
\nproblems in accessing health care facilities
\nin occupied territories, lack of resources and
\nmigration of health care personnel due to
\nviolence.
\nDuring the year the WMA had written to
\nthe Iranian authorities about the cases of
\nDr. Arash Alaei and Dr. Kamiar Alaei who
\nwere sentenced to six and three years\u2019 im-
\nprisonment respectively, for \u201ccooperating
\nwith an enemy government\u201d.
\nIn February 2011, the WMA had sent let-
\nters to the ministers of health and of inte-
\nrior in Bahrain expressing deep concerns
\nabout attacks on health professionals that
\nwere unprovoked and in breach of interna-
\ntional law enforcement standards.
\nWomen and Children
\nand Health
\nThe WMA had been invited to be involved
\nin a WHO initiative to develop \u201cguidelines
\nfor a health-care response to intimate part-
\nner and sexual violence\u201d. The overall aim
\nof this initiative was to elaborate a policy
\nframework intended to improve health sec-
\ntor responses to sexual violence by assisting
\ndecision-makers to design health policy and
\nservice measures that would provide com-
\nprehensive, sensitive and quality care to vic-
\ntims of sexual violence.
\nMedical Ethics
\nAt the 2008 General Assembly, the Decla-
\nration of Helsinki had been amended and
\nthere was a debate on the use of placebo in
\nmedical research. If a proven effective inter-
\nvention existed, the Declaration of Helsinki
\nallowed the use of placebo controls, though
\nonly in very limited circumstances. How-
\never this opening raised some concerns.
\nIn order to analyse the use of placebos in
\nSerafin Romero
\nJose Manuel Silva
\nLuis Mazzuoccolo
\nJoel Hellstrand
\nPaul Ockelford
\nMarcos Gomez-Sancho
\nIgnacio Carrasco
\nDe Paula
\nRuben Tucci
\nThomas Flodin
\nKate Baddock
\nwmj 2 2011 5CS.indd 49 4\/29\/11 11:13 AM
\n50
\nWMA news
\nmedical research a WMA working group
\nwas formed. It was acknowledged that the
\nsame ethical questions might arise with
\nany control group that received a treatment
\nless than the \u201cbest current proven interven-
\ntion\u201d (which was currently required by the
\nDeclaration). The overriding question of
\nthe placebo controversy appeared to be: To
\nwhat extent and under which circumstances
\nwas it ethically acceptable to provide a control
\ngroup with an intervention less effective than
\nthe best current proven treatment in a clini-
\ncal trial? This included a placebo control as
\nwell as a control with a second standard or
\nno treatment. The problem was aggravated
\nby the fact that in many circumstances it
\nwas not conclusively known which was the
\n\u201cbest proven\u201d treatment. Furthermore the
\nquestion remained, whether the different
\neconomic circumstances in the different
\nparts of the world had to be considered in
\nthe Declaration or not. Most prominent
\nwere the questions: Whether the use of place-
\nbos, or interventions less effective than the best
\ncurrent proven treatment had to be seen dif-
\nferently on the existence of different economic
\nbackgrounds? and What were the requirements
\nto post-trial access to care and how should they
\nbe dealt with?
\nThe workgroup would discuss these ques-
\ntions at a conference to be held in July 2011
\nin Sao Paulo, Brazil.
\nMedical and Health
\nPolicy Development
\nThe Center for the Study of International
\nMedical Policies and Practices, George-
\nMason-University, one of the WMA\u2019s Co-
\noperating Centers, had invited the WMA
\nto participate in the creation of a scientific
\nplatform for international exchange on
\nmedical and health policy development and
\nin 2009 the first issue of a scientific journal,
\nthe World Medical & Health Policy was
\npublished by Berkeley Electronic Press as
\nan online journal. It could be accessed at:
\nhttp:\/\/www.psocommons.org\/wmhp.
\nWorld Health Professions
\nAlliance
\nAfter ten years of successful collaboration,
\nthe four main health professions \u2013 physi-
\ncians,nurses,pharmacists and dentists \u2013 had
\nshown that working in collaboration instead
\nof along parallel tracks,benefited the patient
\nand health care system. Now the WHPA
\nwas seeking to find best practice models of
\nsimilar inter-professional cooperation on a
\nnational and local level. A working group
\nwould research how a best practice model in
\ncollaborative practice could be defined and
\nwas looking for examples worldwide.
\nMedical Organisations in
\nArabic Countries
\nThe WMA was continuing to reach out to
\nmedical associations in Arabic countries
\nand was pleased to have participation from
\nEgypt, Iraq and Palestine at its conference
\n\u201cRight to Health as a Bridge to Peace in the
\nMiddle East\u201d.
\nDr. Ramin Parsa-Parsi (Germany) reported
\non discussions that had taken place in Bah-
\nrain, which were now on hold as a result of
\nthe unrest in that country.The Council then
\nheard two oral reports about the natural di-
\nsasters in Japan and New Zealand.
\nMr Hisashi Tsuruoka, a staff member from
\nthe Japan Medical Association, reported on
\nthe earthquake, tsunami and nuclear plant
\naccident in Japan. He said it was very dif-
\nficult to obtain accurate information about
\nthe disaster and its victims, as it was esti-
\nmated that about 240,000 evacuees were
\nstaying in about 2,600 shelters over a wide
\narea. No-one knew how many people were
\nmissing.The number of dead was estimated
\nat that time to exceed 30,000. In addition,
\nmany medical institutions had collapsed.
\nHe spoke about the work of medical disas-
\nter teams and the help being offered by the
\nJapan Medical Association and teams from
\nmany other countries.
\nMing-Been Lee
\nYung Tung Wu
\nMads Koch Hansen
\nCristina Lumby
\nRasmussen
\nMarie Wedin
\nChung-Shao Lin
\nBente Fogh
\nPoul Jaszczak
\nJeff Blackmer
\nHakan Wittgren
\nwmj 2 2011 5CS.indd 50 4\/29\/11 11:13 AM
\n51
\nWMA news
\nThe nuclear power plant accident in Fu-
\nkushima was aggravating the situation and
\nefforts to contain and resolve the problem
\nwould be ongoing over the coming months
\nand years.
\nMr Tsuruoka said, however, that he believed
\nJapan would recover in a much shorter pe-
\nriod that they were currently expecting.
\nDr. Peter Foley (New Zealand) reported
\nabout the earthquake which he said had
\nwiped out the core of Christchurch, New
\nZealand. He thanked international col-
\nleagues for their help.
\nMedical Ethics Committee
\nDr. Torunn Janbu (Norway) was re-elected
\nChair of the committee.
\nEthical Organ Procurement
\nDr. Vivienne Nathanson (United Kingdom),
\nChair of the Workgroup,gave an oral report
\non work in progress. She said the group had
\nconsidered a first draft of possible principles
\nand had decided that the British Medical
\nAssociation would review existing policy to
\nsee if it was up to date and fit for purpose,
\nand if there were gaps.
\nIt hoped to present to the next meeting a
\nset of principles in terms of the ethical pro-
\ncurement of organs and a background docu-
\nment explaining the principles.
\nOther issues to be covered would include
\ncommercialisation, trading in organs, pay-
\ning donors, international transport of or-
\ngans, and sending patients abroad for treat-
\nment that was illegal.
\nEnd-of-Life Medical Care
\nIn a lengthy debate, the committee consid-
\nered and amended a Proposed Declaration
\non End-of-Life Medical Care and back-
\nground document.
\nDr. William Silvester (Australia), an inten-
\nsive care specialist and national director of
\nthe Respecting Patient Choices Programme
\nin Australia, introduced the debate, speak-
\ning about the importance of advance care
\nplanning. He said this was not about eutha-
\nnasia but about giving patients a say about
\ntheir care, and advanced care planning em-
\npowered people.
\nThe committee agreed to include in the
\nintroduction to the document the phrase
\n\u2018palliative care at the end of life is part of
\ngood medical care\u2019 and in a discussion on
\npain and symptom management, it agreed
\nto insert the words \u2018the primary aim is to
\nmaintain patients\u2019dignity and their freedom
\nfrom distressing symptoms\u2019.
\nFurther amendments were agreed follow-
\ning a detailed debate on the development
\nof care plans for patients approaching the
\nend of life and the way in which a patient\u2019s
\npreferences should be initiated and han-
\ndled.
\nThe committee approved the amen-
\nded Declaration for consideration by
\nCouncil, which later agreed to for-
\nward it to the General Assembly for
\nadoption.
\nIt was decided to \u2018file\u2019the background docu-
\nment to the policy.
\nThe Ethics in Palliative Sedation
\nA Proposed Declaration on the Ethics
\nin Palliative Sedation was introduced by
\nthe Spanish Medical Association (Consejo
\nGeneral de Colegios M\u00e9dicos de Espa\u00f1a)
\nexploring the boundary between palliative
\nsedation and active euthanasia. Following a
\nbrief debate it was agreed to circulate the
\ndocument to NMAs for comment.
\nBo Kyung Kang
\nW. Paul Rijksen
\nA.C. Nieuwenhuijzen
\nKruseman
\nAjay Kumar
\nMervi Kattelus
\nBrendan Shaw
\nDeon Schoombie
\nTatjanna
\nRadosavljevic
\nPrijo Sidipratomo
\nJaroslav Blahos
\nwmj 2 2011 5CS.indd 51 4\/29\/11 11:13 AM
\n52
\nWMA news
\nThe Ethics of Placebo Control
\nin Clinical Trials
\nDr. Ramin Parsa-Parsi (Germany), Chair
\nof the Workgroup on Placebo in Medical
\nResearch, gave a report from Workgroup
\nand said that the planned expert conference
\n(13\u201315 July) would now be relocated from
\nTokyo, Japan to Sao Paulo, Brazil because
\nof the Japanese earthquake. The conference
\nwould debate the general wording of para-
\ngraph 32 of the Declaration of Helsinki, the
\nuse of placebos in resource poor settings,the
\npositions of international organisations and
\nthe \u2018reasonable availability\u2019 approach.
\nThe Declaration of Tokyo
\nA proposal was discussed to revise the Dec-
\nlaration of Tokyo on Guidelines for Phy-
\nsicians Concerning Torture to include the
\ndevelopment of a monitoring and reporting
\nmechanism to permit auditing states\u2019 ad-
\nherence to the guidelines. Delegates sug-
\ngested that NMAs should offer support for
\nphysicians in difficult situations, including
\nhelping individuals to report violations of
\npatients\u2019 health rights and physicians\u2019 pro-
\nfessional ethics in custodial settings.
\nThe committee approved the docu-
\nment, which Council later agreed
\nto send to the General Assembly for
\nadoption.
\nChild Subjects
\nA Proposed Statement on Ethical Prin-
\nciples for Medical Research on Child
\nSubjects, produced by Dr. James Appleyard
\n(UK), was considered and after a brief de-
\nbate it was decided to file the document.
\nSocial Media
\nA Proposed Statement on the Profession-
\nal and Ethical Usage of Social Media, pre-
\npared by Dr.Marianne Maman,an associate
\nmember, was considered.
\nDr. Kloiber said the WMA currently had no
\npolicy on the use of social networks. Physi-
\ncians were using social networks, sometimes
\nfor communicating with their patients.
\nAlthough everyone was in favour of using
\ntechnology to improve health care and com-
\nmunications, social networks had a number
\nof problems. For instance, the information
\nbeing exchanged was being exploited for
\ncommercial purposes.
\nSo physicians had to take special caution.
\nMany NMAs were now using these social
\nnetworks to communicate with their mem-
\nbers. But the WMA had to examine these
\nissues more closely. He suggested that the
\nWMA should use the expertise of the new
\njunior doctors\u2019 network to consider this is-
\nsue.
\nDr. Michael Bonning, a junior doctor from
\nAustralia,said that if they as doctors wanted
\nto be able to reach their patients and work
\nmore effectively among themselves, then
\nthe social media networks were some of the
\nchallenges they had to deal with. He said
\nthe junior doctors\u2019 network would be happy
\nto help the WMA draw up a policy on this
\nissue.
\nDr. Peteris Apinis (Latvia) said that in his
\ncountry pharmaceutical companies were
\nusing these networks to approach doctors
\nabout their products.
\nIt was agreed to circulate the proposed
\nStatement and to set up a working party,
\ncomprising members of the Committee and
\nthe junior doctors\u2019 network, to draft a new
\npolicy. Council later approved this recom-
\nmendation.
\nBio Banks
\nA Proposed Resolution on Physicians\u2019
\nEthical Responsibilities Regarding Bio
\nMiguel Roberto Jorge
\nRoberto Luiz d\u2019Avila
\nPeter W. Carmel
\nElie Chow-Chine
\nPedro Barbosa
\nWay Oliveira
\nMichael D. Maves
\nHernan Reyes
\nGilbert Pioud
\nTrond Markestad
\nAlarico Rodriguez
\nde Leon
\nwmj 2 2011 5CS.indd 52 4\/29\/11 11:13 AM
\n53
\nWMA news
\nBanks was briefly considered and it was
\ndecided to postpone the issue until the re-
\nvision of the WMA policy on health data-
\nbases.
\nMisuse of Drugs for Execution
\nAn emergency Resolution expressing deep
\nconcern about the misuse of drugs for the
\npurpose of capital punishment was pro-
\nposed by Dr. Ulrich Montgomery (Ger-
\nmany).
\nHe said this followed various approaches
\nthat had been made to countries for the
\nexport of thiopental to the USA for capital
\npunishment.
\nDr. Peter Carmel (USA) said the Ameri-
\ncan Medical Association had clear policy
\npreventing physicians from participating
\nin executions, but he suggested that this
\nspecific matter concerning drugs be post-
\nponed until the AMA had investigated the
\nsituation.
\nAfter a debate it was decided to postpone
\nconsideration of the Resolution and estab-
\nlish a Workgroup to examine the question
\nof whether the WMA should develop a
\npolicy statement opposing the use of capital
\npunishment.
\nFinance and Planning
\nCommittee
\nAfter the committee had approved the
\nminutes of the last meeting, an election
\nfor Chair took place to fill the vacancy
\nleft by Dr. Haikerwal\u2019s election as Chair
\nof Council. Two candidates were nomi-
\nnated \u2013 Dr.\u00a0Leonid Eidelman (Israel) and
\nDr. Robert Ouellet (Canada) \u2013 and after
\na ballot, Dr. Eidelman was elected. How-
\never he was not able to be present because
\nof his leadership of a physicians\u2019 strike in
\nIsrael, and so the meeting was chaired by
\nDr. Haikerwal.
\nMembership Dues
\nA report on Membership Dues Payments
\nfor 2011 was tabled and agreed. Dr. Kloi-
\nber proposed a new baseline of membership
\ndues to create a stable income situation and
\nto have a concrete means of determining
\nwhether a constituent member was in good
\nstanding.
\nThe committee accepted the proposal and
\nrecommended it to Council, which later
\nforwarded it to the General Assembly for
\napproval and adoption.
\nFinancial Statement
\nMr A. H\u00e4llmeyer, the Finance Advisor, gave
\na detailed presentation on the pre-audited
\nfinancial statement for 2010,stating that the
\npositive trend of recent years had continued.
\nThe audited Financial Statement was rec-
\nommended for approval by Council, which
\nlater also adopted it.
\nStrategic Plan
\nThe committee received an oral report from
\nDr. Ouillet, who led a Workgroup on the
\nformat for a strategic plan for 2011\u20132015.
\nHe emphasised how important it was for
\nmembers to respond to the survey sent out
\nto them and he also referred to surveys be-
\ning sent to outside bodies.
\nWMA Meetings
\nThe committee reviewed future meetings
\nand dates \u2013 Prague, Czech Republic for the
\nCouncil meeting in April 2012 and Bang-
\nkok, Thailand for the General Assembly in
\nOctober 2012. It was agreed that the theme
\nof the scientific session for the General As-
\nsembly in Bangkok should be \u2018Megacity \u2013
\nMegahealth\u2019.This was later approved by the
\nCouncil.
\nGeir Riise Bjorn Oscar Hoftvedt
\nSteven Hambleton
\nAndrew Pesce
\nNikolay Izmerov
\nEvgeny Achkasov
\nM W Sonderup
\nEvgeny Mashkovskiy
\nSergey Puzin
\nNorman Mabasa
\nwmj 2 2011 5CS.indd 53 4\/29\/11 11:13 AM
\n54
\nWMA news
\nNetwork in Disaster Medicine
\nand Public Health
\nA proposed new Statement on Disaster
\nPreparedness and Medical Response was
\nconsidered. During the debate that fol-
\nlowed it was recognised that the role of the
\nWMA was not to provide or co-ordinate
\npractical assistance in the event of disasters,
\nwhich was complex work being done by
\nspecialised relief organisations.
\nRather it was to provide policy support and
\nopportunities for information exchange and
\nlearning for national medical associations
\nand to engage in advocacy for disaster pre-
\nparedness on a national level.
\nDr.Ardis Hoven (US) said the WMA should
\nbuild on the platforms already in place
\naround the world and perhaps use its web-
\nsite to link to existing resources throughout
\nthe world, while Dr. Janbu (Norway) said
\nthe Workgroup should look at possibility
\nof facilitating a network, with information
\nabout courses and existing organisations
\nthat physicians might join.
\nDr. Nathanson (UK) suggested the WMA
\nmight put online a document to help doc-
\ntors understand the kinds of skill sets and
\nqualifications they needed for work in di-
\nsaster zones. Often doctors were not sure
\nwhether their skills would be useful. It was
\nagreed that the mandate of the Workgroup
\nshould be extended to take these issues into
\nconsideration and that the Statement be
\ncirculated to NMAs for comment.
\nGreening of WMA Meetings
\nDr. Mads Koch Hansen (Denmark), leading
\na Workgroup on greening WMA meet-
\nings, gave an oral report on the need for the
\nWMA to reduce its carbon footprint,saving
\nboth money and human resources.
\nHe suggested reducing the use of paper
\nby using the WMA website for accessing
\ndocuments, making more use of buses and
\nsharing taxis for travelling to conferences
\nand greening the WMA building with bet-
\nter use of energy.
\nHis report was supported by several speak-
\ners and Dr. Nathanson (UK) said the British
\nMedical Association had saved a six figure
\nsum by reducing photocopying.
\nDr. Kloiber said the time had come to go pa-
\nperless,but having both paper and web access
\nwould not be a cost saving. It was decided to
\nask Council to take action on the issue.
\nMembership
\nAn application was received from the Trini-
\ndad and Tobago Medical Association to be
\nadmitted into WMA membership and it
\nwas decided to recommend this to Council,
\nwhich later agreed to forward the applica-
\ntion to the General Assembly for adoption.
\nGovernance
\nThe committee discussed further consolida-
\ntion of the bylaws, including issues such as
\nvoting rights for the President, President-
\nelect and immediate Past President and the
\ntermination of a President\u2019s office.
\nJunior Doctors\u2019 Network
\nDr. Kloiber reported that the first draft had
\nbeen drawn up of terms of reference for set-
\nting up a junior doctors\u2019 network as part of
\nthe Associate Membership. He said further
\nwork on the terms of reference was required,
\nbut he was pleased with the progress that
\nhad been made.
\nDr. Bonning said there was no current for-
\nmal process for junior physicians to interact
\nglobally. He and his colleagues believed that
\nthe WMA was the best vehicle for achiev-
\ning this.
\nAnnabel Seebhom
\nLamine Smaali
\nJulia Seyer
\nNigel Duncan
\nSunny Park
\nJoelle Balfe
\nElmar Doppelfeld
\nRoderic Dennett
\nClarisse Delorme
\nTania Goodacre
\nwmj 2 2011 5CS.indd 54 4\/29\/11 11:13 AM
\n55
\nWMA news
\nWorld Medical Journal
\nThe editor of the Journal, Dr. Apinis, pre-
\nsented his report and said he had three pro-
\nposals \u2013 to promote and publicise the WMJ
\nto the members of NMAs,to be more active
\nin writing articles about the NMAs\u2019 activi-
\nties and to encourage Council members to
\nbecome involved in writing articles.
\nSocio-Medical Affairs\u00a0Committee
\nThe committee approved the minutes of
\nthe last meeting, and then elected unop-
\nposed Sir Michael Marmot (UK) as the
\nnew Chair.
\nHealth and the Environment
\nThe committee considered an oral report
\nfrom Dr. Ouellet (Canada), Chair of the
\nworkgroup on health and the environment.
\nHe said the group had consulted Dr. Larry
\nFrank, a Canadian expert on the area of
\nthe built environment, based on a docu-
\nment provided by the WMA office. The
\ngroup had decided that for the time being
\nthe WMA was not in a position to draw
\nup policy in this specific area for lack of ex-
\npertise. The document was based on North
\nAmerican situations and did not meet the
\ninternational requirements of the WMA,
\nincluding in developing countries. The
\ngroup decided to send the document to the
\nWorkgroup on social determinants for re-
\nview and incorporation in a broader social
\ncontext.The document would then be circu-
\nlated and posted on the website. It was then
\ndecided that the group had accomplished
\nits work and should now be dissolved.
\nDeclaration of Edinburgh
\nA Proposed Revision to the Declaration
\non Prison Conditions and the Spread of
\nTuberculosis and Other Communicable
\nDiseases was considered.
\nDr. Janbu (Norway) asked whether the
\nphrase \u2018physicians working in prisons have
\na duty to follow national public health
\nguidelines, particularly concerning the
\nmandatory reporting of infectious and
\ncommunicable diseases\u2019, could be a problem
\nwhere national guidelines were not in ac-
\ncordance with WMA policy. Dr. Nathanson
\nsaid the workgroup had assumed that any
\nNMA which believed their national guide-
\nlines were unacceptable would be lobbying
\ntheir government to get those guidelines
\nchanged. The committee agreed that the
\ndocument should be amended and sent
\nto Council for forwarding to the General
\nAssembly for adoption.
\nChronic Disease
\nThe committee considered a Proposed
\nStatement on the Global Burden of
\nChronic Disease, which Sir Michael Mar-
\nmot said was a hugely important issue.It was
\non the WHO agenda and the UN General
\nAssembly would debate the issue later in
\nthe year. Dr. Cecil Wilson (US), Chair of the
\nWorkgroup, said this lent urgency to get-
\nting the paper approved.
\nThe paper had been circulated and includ-
\ned solutions on prevention, primary care,
\nmedical care and health infrastructure,
\nwith recommendations for governments,
\nNMAs, medical schools and individual
\nphysicians.
\nIt was agreed to send the document to
\nCouncil, who later agreed to forward
\nit to the General Assembly for adop-
\ntion.
\nViolence in the Health Sector
\nA Proposed Statement on Violence in the
\nHealth Sector was proposed by Dr. Yoram
\nBlachar (Israel), who said that violence
\nagainst physicians was becoming a real
\nproblem.
\nThis was caused in part by understaffing
\nproblems, unreal expectations, dissatisfac-
\ntion with health services and the role of the
\nmedia and television in creating imaginative
\nexpectations for the best medical result. He
\nsaid it was vital to adopt a policy of zero tol-
\nerance accompanied by relevant legislation.
\nDr. Nathanson said that violence in the
\nhealth sector was a problem in all parts of
\nthe world and she suggested expanding the
\ndocument to add in more areas to help less
\ndeveloped parts of the world.
\nDr. Janbu questioned the document\u2019s pro-
\nposal that physicians should have the right
\nto refuse to treat previously violent patients,
\nexcept in emergency situations. She found
\nthis a very difficult statement.
\nDr. Nathanson said that the UK had a zero
\npolicy to violence. But it was important that
\nalternative provisions were available before
\nphysicians were able to refuse to treat a vio-
\nlent patient.
\nIt was agreed to send the document to
\nCouncil.
\nSocial Determinants of Health
\nA debate took place about the Proposed
\nStatement on Social Determinants, de-
\nscribed as the conditions in which people
\nare born, grow, live, work and age and the
\nsocietal influences on these conditions. Sir
\nMichael Marmot, Chair of the Workgroup
\non the issue, said the World Conference on
\nSocial Determinants, organised by WHO,
\nwould take place in October in Rio de Ja-
\nneiro, Brazil. He was part of the organising
\ncommittee and the WMA would be part of
\nthe conference.
\nIt was agreed to send the document
\nto Council, which later agreed to for-
\nward it to the General Assembly for
\nadoption.
\nwmj 2 2011 5CS.indd 55 4\/29\/11 11:13 AM
\n56
\nWMA news
\nArmed Conflicts
\nThe Norwegian Medical Association pre-
\nsented a Proposed Statement on the Pro-
\ntection and Integrity of Medical Personnel
\ninArmedConflicts.Dr.Janbu said the paper
\nhighlighted the lack of a systematic reporting
\nof violent incidents concerning physicians.
\nThis made it very difficult to know what
\nstrategy to adopt to prevent attacks if they
\ndid not know the extent of the problem. She
\nsaid she was surprised that no international
\nbody had this responsibility. It was agreed to
\ncirculate the document for discussion.
\nTobacco-Derived Products
\nThe American Medical Association brought
\nto the meeting a Proposed Revision of the
\nWMA Statement on Health Hazards of
\nTobacco and Tobacco-Derived Products.
\nDr. Ardis Hoven (US) said the tobacco in-
\ndustry were heavily marketing new forms
\nof tobacco-derived products with sticks,
\nmints and other nasty things to make their
\nproducts more appealing and acceptable.
\nSmokeless tobacco was also being aggres-
\nsively marketed and targeted towards young
\npeople. There were also electronic cigarettes
\navailable in convenience stores and on the
\ninternet. The WMA had to address these
\nnew forms of tobacco by revising its policy.
\nThere needed to be a stronger statement
\nrecommending banning the production,
\ndistribution and sale of tobacco-derived
\nproducts that resembled candy.
\nShe said that a separate policy statement
\nwould be drafted by the American Medical
\nAssociation on electronic cigarettes follow-
\ning further investigation about their status.
\nDr. Nathanson wanted to see something
\nadded on plain packaging following the an-
\nnouncement made that week by the Austra-
\nlian Government.
\nDr. Peteris Apinis (Latvia) presented another
\nproposed revision to classify smoking in the
\nvicinity of children and pregnant women as
\nviolence against children, as smoking sig-
\nnificantly reduced children\u2019s life expectancy
\nand impaired their quality of life.
\nDr. Rosanna Capolingua (Australia) said that
\nin her home state of West Australia they had
\nbanned smoking in cars where children were
\npresent, and the police actually policed that.
\nBut several speakers were unsure about us-
\ning the language of \u2018violence against chil-
\ndren\u2019 in the document and the Latvian
\nMedical Association was invited to come
\nback with a further proposal. It was agreed
\nto send the document to Council, which
\nlater agreed to forward it to the General
\nAssembly for adoption.
\nPain Relief
\nDr. Nathanson presented a Proposed Reso-
\nlution on the Access to Adequate Pain
\nTreatment. She said that around the world
\na lot of patients in pain were being denied
\naccess to adequate pain killers because of
\ngovernment policies and lack of availability.
\nShe asked that the document drafted by the
\nBritish Medical Association and others be
\nsent out for consultation.This was agreed.
\nIvory Coast
\nAn emergency resolution on the situation in
\nthe Ivory Coast was presented by Dr.Kloiber
\nat the request of the Ivory Coast Medical
\nAssociation. He said that as a result of civil
\nwar in the country the European Union had
\ndecided to implement sanctions which were
\naffecting the import of drugs leading to a
\nshortage. The Resolution (see separate box)
\nurged the EU to take steps immediately to
\nensure the delivery of medical supplies to
\nthe Ivory Coast in order to protect the life
\nand health of the population.
\nThe committee agreed to forward the Reso-
\nlution to Council for approval.
\nResumed Council Meeting
\nThe Council considered the Medical Ethics
\nCommittee report.
\nSocial Media
\nIt was agreed that the proposed Statement
\non the Professional and Ethical Usage of
\nSocial Media be referred to a Workgroup
\ncomprising members of the Junior Doc-
\ntors\u2019Network and two representatives of the
\nMedical Ethics Committee.
\nCapital Punishment
\nThe Council agreed that a Workgroup be
\nset up to examine the question of whether
\nthe WMA should develop a policy state-
\nment opposing the use of capital punish-
\nment. Included on the Workgroup will be
\nDr. Haikerwal, Dr. Dana Hanson, Dr. Yor-
\nam Blachar, Dr. Cecil Wilson, Dr. Otmar
\nKloiber and representatives from Denmark,
\nthe UK and Uruguay.
\nDr. Wilson (US) referred to the earlier de-
\nbate in the committee which indicated that
\nthe US Government had solicited the drug
\nthiopental. On a preliminary investigation
\nhis understanding was that the issue of thio-
\npental used came to light because the US
\nGovernment\u2019s drug enforcement agent had
\nseized supplies of thiopental from two states,
\nTennessee and Kentucky, because of the as-
\nsumption they had been illegally obtained.
\nSo these were supplies that were already in
\nthe state and they had not been solicited.
\nThey were just sold to these two states and
\nthe US Government had not solicited their
\nimport.
\nThe Council approved the Medical Ethics
\nCommittee report
\nThe Council considered the Finance and Plan-
\nning Committee report.
\nwmj 2 2011 5CS.indd 56 4\/29\/11 11:13 AM
\n57
\nWMA newsUNITED STATES
\nDisaster Medicine and Public Health
\nThe Council agreed to expand the mandate
\nof the Workgroup.
\nPrimary Care Conference
\nDr. Rosanna Capolingua spoke about hold-
\ning a conference on primary care to show-
\ncase the primary care physician and empha-
\nsise the general practitioner being the leader
\nof the health care team.This was cost effec-
\ntive and efficient for the patient. Dr. Hanson
\nsaid that the term \u2018primary care\u2019 should go
\nwider than just family practice. Council
\nnoted the comments.
\nRussian Conference
\nThe Council debated a proposal by the Rus-
\nsian Medical Society for a WMA Confer-
\nence to be held in Moscow in 2012 on the
\nrelationship between physicians and the
\npharmaceutical industry. Several speakers
\nquestioned who would pay for the confer-
\nence, while others expressed reservations
\nabout the suggested topic and proposed
\ntheir own ideas.
\nThe Council decided that the secretariat
\nshould discuss the proposal further with the
\nRussian Medical Society and report back to
\nthe General Assembly in October.
\nGeorgian Medical Association Award
\nThe Council debated a proposal from the
\nGeorgian Medical Association to sponsor
\nan annual prize for outstanding physicians
\ninternationally with the help of the WMA.
\nAfter several speakers expressed their
\ndoubts about the proposal, the Council de-
\ncided not to pursue the proposal.The Coun-
\ncil approved the Finance Committee report
\nThe Council considered the Socio-Medical Af-
\nfairs committee report.
\nDeclaration of Edinburgh
\nCouncil agreed to amend the proposed re-
\nvision to the Declaration on Prison Condi-
\ntions and the Spread of Tuberculosis and
\nOther Communicable Diseases to read
\n\u2018physicians working in prisons have a duty
\nto follow national public health guidelines
\nwhere these are ethically appropriate\u2019.
\nIt was agreed to forward the docu-
\nment to the General Assembly with
\nthe recommendation that it be ad-
\nopted.
\nViolence in the Health Sector
\nA further debate took place about the docu-
\nment\u2019s proposal that physicians should
\nhave the right to refuse to treat previously
\nviolent patients, except in emergency situ-
\nations. Several speakers questioned whether
\nthis was the right approach and the Council
\neventually decided to refer the document
\nback to the committee for further consid-
\neration.
\nGlobal Health Data Charter
\nDr. Haikerwal said that many groups were
\ninvolved in health with very little knowl-
\nedge about the subject, and they viewed
\nthe issue as one of expense. The WMA had
\nbeen asked by the World Economic Fo-
\nrum to participate in the development of a
\nGlobal Charter on Health Data and then to
\nco-sign the Charter. But he had a number
\nof concerns about the Charter which was
\nnot in line with WMA policies and was not
\nbased on a patient-centred view of the is-
\nsues.
\nHaving heard his comments, Council
\nagreed not to sign the Charter, but to fur-
\nther engage with the World Economic Fo-
\nrum to advocate for an improvement of the
\nCharter, and to report back to Council if
\nchanges occurred.
\nTobacco-Derived Products
\nDr. Apinis (Latvia) repeated the proposal he
\nput to the committee to classify smoking in
\nthe vicinity of children and pregnant women
\nas \u2018violence\u2019. Dr Ardis Hoven (US) said she
\nwas concerned about the use of the word \u2018vi-
\nolence\u2019. The objective should be not to pun-
\nish but to educate people. They needed to
\nchange the environment through parenting
\ninformation and in other ways and this op-
\nportunity would be better served by getting
\naway from using words such as \u2018violence\u2019.
\nAfter further debate, Council decided to
\namend the proposed revision of the State-
\nment on Health Hazards of Tobacco and
\nTobacco-Derived Products to add that the
\nWMA should advocate the enactment and
\nenforcement of laws to \u2018protect children
\nfrom passive smoking\u2019.
\nIvory Coast
\nCouncil voted to approve the emergency
\nmotion reaffirming WMA policy on eco-
\nnomic embargoes and health (see box).
\nAdvocacy Plan 2011\/12
\nDr. Hanson reported on the advocacy plan
\nfor 2011\/12 with its five headings \u2013 human
\nresources for health,health and the environ-
\nment, individual health, human rights and
\npatient safety. The Council approved the
\nSocio-Medical Affairs Committee report.
\nWorld Health Assembly 2011
\nMs Clarisse Delorme and Dr. Julia Seyer re-
\nported on the forthcoming World Health
\nAssembly and highlighted several topics,
\nincluding climate change, the protection of
\nhealth personnel in armed conflicts,counter-
\nfeit medicines, non communicable diseases
\nNigel Duncan, WMA Public
\nRelations Consultant
\nwmj 2 2011 5CS.indd 57 4\/29\/11 11:13 AM
\n58
\nWMA news
\nFrancis Sullivan
\nRoss Boswell
\nRichard H Osborne
\nJane Halton
\nBrendan NelsonKatie Allen
\nPeter Flaming
\nGeorge Margelis
\nRon Trent
\nMike Bainbridge
\nCouncil Resolution Reaffirming the WMA Resolution
\non Economic Embargoes and Health
\nThe World Medical Association is deeply concerned about reports of potential serious
\nhealth impacts resulting from economic sanctions imposed by the European Union
\nagainst Ivory Coast leader, Laurent Gbagbo, and numerous individuals and entities
\nassociated with his regime, including two major ports linked to Gbagbo\u2019s government.
\nThe sanctions aim to severely restrict EU-registered vessels from transacting business
\nwith these ports, which could inhibit the delivery of necessary and life-saving medi-
\ncines.
\nThe WMA Council reiterates the following position from the WMA Resolution on
\nEconomic Embargoes and Health:
\nAll people have the right to the preservation of health; and, the Geneva Convention (Article
\n23, Number IV, 1949) requires the free passage of medical supplies intended for civilians.
\nThe WMA therefore urges the European Union to take steps immediately to ensure
\nthe delivery of medical supplies to the Ivory Coast, in order to protect the life and
\nhealth of the population.
\nMedical Leadership Seminar:The view from Down Under
\nOn the Tuesday before the WMA Council opened, the Australian and New Zealand
\nMedical Associations held a joint seminar on Medical Leadership at the Westin Hotel,
\nSydney.
\nAmong the speakers were the BMA President, Professor Sir Michael Marmot, His
\nExcellency The Hon.Brendan Nelson,Australia\u2019s Representative to NATO and WHO,
\nDr Peter Foley, Chair of the New Zealand Medical Association, and Jane Halton, Sec-
\nretary of Australia\u2019s Department of Health and Ageing.
\nDr. Andrew Pesce, President of the Australian Medical Association, spoke about the
\nimportance of doctors remaining at the centre of the debate on health reform and Sir
\nMichael Marmot spoke about social justice, which he said was right at the centre of
\nwhat they as doctors were doing. He said there was much current interest in well being
\nand happiness, but health was a better definition of well being than happiness. Health
\ninequalities began at the beginning of life and that\u2019s where they had to start their in-
\nterventions.
\nHe spoke about the impact of unemployment on young people, the need for a progres-
\nsive tax system and the importance of addressing the whole of society and not just
\nfocusing on the most deprived.
\nwmj 2 2011 5CS.indd 58 4\/29\/11 11:13 AM
\n59
\nRegional and NMA news
\nWhy a GAPA Brief on NCDs?
\nIn May 2010 the UN General Assembly
\n(GA) passed Resolution 64\/265 which
\ncalled for the convening of a high-level
\nmeeting of the GA in September 2011 in
\nNew York on the prevention and control of
\nnon-communicable diseases [1]. This reso-
\nlution and related documents have stressed
\nthe need to recognise the primary role and
\nresponsibility of governments to respond to
\nthe challenges of NCDs, but also the re-
\nsponsibility of the international community
\nin assisting member states, particularly in
\ndeveloping countries, to generate effective
\nresponses [2]. Among the various NCDs,
\ncardiovascular diseases, cancers, chronic
\nrespiratory diseases and diabetes have been
\nsingled out for attention [2].
\nThis resolution reflects the growing recogni-
\ntion of NCDs as a major threat to develop-
\nment in developing countries. Furthermore,
\nthe resolution is seen as having reframed
\nthe global discussion about NCDs into em-
\nphasising broader social and environmen-
\ntal drivers of NCDs rather than unhealthy
\nchoices made by individuals [3]. It comes
\nwith the hope of garnering multi-sectoral
\ncommitment and facilitating action on an
\nunprecedented scale to address NCDs.
\nWhat is the Brief \u2019s purpose?
\n1. To put forward the case that addressing
\nharmful use of alcohol is essential in mov-
\ning forward the agenda to meaningfully im-
\npact on NCDs by highlighting the strong
\nlinkages between alcohol and several of the
\nmain NCDs of interest and also to indi-
\ncate the availability of interventions that
\nhave been documented to have an impact
\non reducing the burden of alcohol on public
\nhealth.
\n2. To highlight the relevance of the call
\nmade by the World Health Assembly in
\n2010 for countries to implement effective
\nresponses to address harmful use of alcohol
\nand to urge that greater support be given
\nto the WHO to enable it to carry out its
\nmandate in terms of the Global Strategy to
\nReduce the Harmful Use of Alcohol [4] and al-
\nlied WHO resolutions.
\n3. To specifically feed into a report being
\nprepared by the Secretary-General of the
\nUN (in collaboration with Member States
\nand WHO) by May 2011 that will serve
\nas input to the preparatory phase for the
\nSeptember 2011 high-level meeting and
\nalso feed into an informal interactive hear-
\ning with NGOs, civil society organisations,
\nthe private sector and academia that is to be
\nheld no later than June 2011 and which also
\naims to provide input into the September
\nmeeting.
\nWhat is the link between
\nalcohol use and NCDs?
\nAlcohol has been identified as a leading
\nrisk factor for death and disability globally,
\naccounting for 3.8% of death and 4.6% of
\ndisability adjusted life years (DALYs) lost
\nin 2004 [5, 6]. Alcohol was found to be the
\n8th
\nhighest risk factor for death in 2004 (5th
\nin middle-income countries and 9th
\nin high-
\nincome countries). In terms of DALYs lost
\nin 2004, alcohol ranked 3rd
\nhighest (1st
\nin
\nmiddle-income countries, 8th
\nhighest in
\nlow-income countries and 2nd
\nhighest in
\nhigh-income countries). The role of alco-
\nhol (and particularly heavy alcohol use and
\nhaving an alcohol use disorder) in NCDs
\nhas been given increasing recognition. For
\nexample, at the recent NGO conference in
\nMelbourne on health and the Millenium
\nDevelopment Goals (MDGs) during a ses-
\nsion on NCDs, along with tobacco, diet and
\nlack of exercise, alcohol was recognised as
\none of four major common risk factors [7].
\nIn terms of NCDs, alcohol has been partic-
\nularly linked to cancer, cardiovascular dis-
\neases (CVDs) and liver disease. Alcohol has
\nalso been clearly linked to mental disorders
\nand in some systems mental health is seen
\npart of NCDs. However, for the purpose
\nof this Brief we shall not comment on this
\nlinkage [5].
\nCancer
\n\u2022 Nine leading environmental and behav-
\nioural risks (higher body mass index, low
\nfruit and vegetable intake, physical inac-
\ntivity, tobacco use, alcohol use, and unsafe
\nsex, urban and indoor air pollution, and
\nunsafe health-care injections) have been
\nestimated to be jointly responsible for
\n35% of cancer deaths [6].
\n\u2022 In 2007 the International Agency for
\nResearch on Cancer asserted that there
\nwas sufficient evidence for a causal link
\nbetween alcohol and cancer of the oral
\ncavity, pharynx, larynx, oesophagus, liver,
\ncolon, rectum, and female breast [8]. All
\nthese cancers showed evidence of a dose-
\nresponse relationship, that is, the risk of
\ncancer increased steadily with greater vol-
\numes of drinking [9].
\n\u2022 The strength of this relationship varies
\nfor different cancers. For example, with
\nregard to female breast cancer, each ad-
\nAddressing Harmful Use of Alcohol is
\nEssential to Realising the Goals of the UN
\nResolution on Non-Communicable Diseases
\n(NCDs)
\nProvided by Global Alcohol Policy Alliance
\nwmj 2 2011 5CS.indd 59 4\/29\/11 11:13 AM
\n60
\nRegional and NMA news
\nditional 10 g of pure alcohol per day
\n(roughly one standard drink*
\n*) is associ-
\nated with an increase of 7% in the rela-
\ntive risk (RR) of breast cancer whereas
\nregular consumption of approximately
\n50g of pure alcohol increases the relative
\nrisk of colorectal cancer by between 10%
\nand 20%, indicating that the association
\nis stronger for female breast cancer [9].
\nThe relationship of average consumption
\nto larynx, pharynx and oesophagus can-
\ncer on the other hand would be mark-
\nedly higher than the relationship to both
\nbreast and colorectal cancer (about about
\na 100% to 200% increase for an average
\nconsumption of 50g pure alcohol per day)
\n[8].
\n\u2022 Among the causal mechanisms that have
\nbeen indicated for some cancers is the
\ntoxic effect of acetaldehyde which is a
\nmetabolite of alcohol [9].
\n\u2022 Of all alcohol-attributable deaths in
\n2004, about 20% come from cancer, 19%
\nfor males and 25% for females. When
\nconsidering both the burden from death
\nand disability,cancer is estimated to com-
\nprise approximately 9% of all alcohol-at-
\ntributable DALYs lost, 8% for males and
\n14% for females [5].
\nCardiovascular diseases (CVDs)
\n\u2022 Eight risk factors (alcohol use, tobacco
\nuse, high blood pressure, high body mass
\nindex, high cholesterol, high blood glu-
\ncose, low fruit and vegetable intake, and
\nphysical inactivity) jointly account for
\n61% of loss of healthy life years from
\nCVDs and 61% of cardiovascular deaths.
\nThese same risk factors together account
\nfor over three quarters of deaths from
\nischaemic and hypertensive heart disease
\n[6].
\n* In the UK 1 standard drink is 7.9 g of eth-
\nanol, in Australia it is 10 g, in South Africa
\n12 g and in the USA 14g. 12 g is prob-
\nably the most common mass for 1 standard
\ndrink
\n\u2022 Chronic, heavy alcohol use has been as-
\nsociated with adverse cardiac outcomes
\nincluding ischaemic heart disease (IHD),
\ndilated cardiomyopathy, cardiac dysryth-
\nmias, and haemorrhagic strokes [10].The
\ndetrimental effects of heavy drinking oc-
\ncasions on IHD are consistent with the
\nphysiological mechanisms of increased
\nclotting and a reduced threshold for ven-
\ntricular fibrillation which occur following
\nheavy drinking [9].
\n\u2022 Alcohol has been identified as the cause
\nof 30% to 60% of cases of patients with
\nnew-onset atrial fibrillation, with several
\ncausal mechanisms being put forward
\nto explain this association, including
\nincreased intra-atrial conduction time,
\nimpairment of vagal tone, hyperadren-
\nergic activity during drinking and with-
\ndrawal, and direct alcohol cardiotoxicity
\n[8]. Studies vary considerably in terms
\nof the amount of alcohol needing to be
\nconsumed and the onset of cardiac dys-
\nrhyhmias, ranging from approximately 2
\nto 5 drinks per day [9].
\n\u2022 Of all alcohol-attributable deaths in
\n2004, about 22% come from CVDs, 23%
\nfor males and 18% for females. CVDs are
\nestimated to comprise approximately 9%
\nof all alcohol-attributable DALYs lost,
\n10% for males and 8% for females [5].
\nThese estimates do not take into account
\nany beneficial effects of alcohol on CVDs.
\nHowever, it has been estimated that the
\ndetrimental effects of alcohol in terms of
\nCVDs outweigh the beneficial effects by
\na factor of 2.4 (for deaths) and 3.5 (for
\nDALYs), and these benefits typically
\nonly occur with low to moderate alcohol
\nconsumption (less than 20 g per day) and
\nthen only for selected cardiovascular out-
\ncomes (e.g. ischaemic heart disease and
\nstrokes) [5].
\nAlcoholic liver disease (ALD)
\n\u2022 Alcohol is associated with various kinds
\nof liver disease, with fatty liver, alcoholic
\nhepatitis and cirrhosis being the most
\ncommon. The likelihood of developing
\nALD is a function of both the duration
\nand the amount of heavy drinking [11].
\n\u2022 For men drinking 30 g of absolute alco-
\nhol per day is associated with a RR of 2.8
\nof dying from liver cirrhosis (7.7 for fe-
\nmales). Regarding morbidity, the RRs for
\nmales and females for drinking the same
\namount of alcohol per day were 0.7 and
\n2.4. For men drinking 54 g of alcohol per
\nday was associated with a relative risk of
\n2.3 for acquiring liver cirrhosis. For both
\nmorbidity and mortality,the RR increases
\nwith the volume consumed per day [12].
\n\u2022 Various mechanisms have been put for-
\nward for how alcohol is associated with
\nliver disease, such as the view that the
\nbreakdown of alcohol in the liver leads to
\nthe generation of free radicals and acet-
\naldehyde which individually damage liver
\ncells [13, 14].
\n\u2022 Of all alcohol-attributable deaths in 2004
\nabout 15% come from liver cirrhosis, 15%
\nfor males and 17% for females. CVDs
\nare estimated to comprise approximately
\n10% of all alcohol-attributable DALYs
\nlost, 9% for males and 13% for females.
\nAlcohol appears to have a greater impact
\non cirrhosis mortality as compared to
\ncirrhosis morbidity due to the fact that
\nheavy drinking has detrimental effects on
\nthe immune system [5].
\nOther disease
\nFor pancreatitis a threshold of about 48 g
\npure alcohol per day has been found, again
\nwith increased volume of alcohol consumed
\nper day being associated with increased risk
\n[15]. With regards to diabetes the situa-
\ntion is more complicated. A recent meta-
\nanalysis confirmed that there is a U-shaped
\nrelationship between the average amount of
\nalcohol consumed per day and the risk of
\ntype 2 diabetes [16]. There appears to be a
\nprotective effect of moderate consumption
\nof alcohol, particularly among women. Fur-
\nther research appears to be needed to make
\nstronger claims about the negative effects
\nof higher levels of consumption of alcohol
\nwmj 2 2011 5CS.indd 60 4\/29\/11 11:13 AM
\n61
\nRegional and NMA news
\nand the incidence of diabetes and to allow
\nfor greater generalisability of the findings to
\nbroader populations globally.
\nWhat response is required?
\n\u2022 As part of national efforts to address
\nNCDs countries need to give priority to
\nimplementing the Global Strategy to Re-
\nduce the Harmful Use of Alcohol approved
\nby the WHA in Geneva in May 2010 [4].
\nParticular attention should be given to
\nimplementing evidenced-based strategies
\nthat have the potential to reduce the oc-
\ncurrence of heavy drinking episodes and
\nthe prevalence of alcohol use disorders
\nthat impact on NCDs.Such strategies are
\nlikely to include regulating the availabili-
\nty,price and marketing of alcohol and im-
\nproving the capacity of health services to
\nsupport initiatives to screen for risk and
\nconduct brief interventions for hazardous
\nand harmful drinking at primary health
\ncare and other settings [17, 18, 19].
\n\u2022 While there is less evidence to support
\nthe efficacy of health education on its
\nown, it nonetheless does seem appropri-
\nate that alcohol consumers should be
\nmade aware of the risk associated with
\ndifferent levels of drinking and NCDs.
\nConsumers should, for example, be in-
\nformed that stopping or reducing alcohol
\nconsumption will reduce cancer risks, al-
\nbeit slowly over time [7].
\n\u2022 Countries must be urged to collect better
\ninformation on levels of alcohol exposure,
\ne.g. recorded adult (15 years+) per capita
\nconsumption in litres of pure alcohol and
\nheavy episodic drinking among adults
\n(15+ years) and alcohol-related harm as-
\nsociated with NCDs (e.g. age-standard-
\nized death rates for liver cirrhosis per
\n100,000 population) [20].
\n\u2022 At a global level support should be given
\nto the WHO to enable it to carry out its
\nmandate in terms of the Global Strategy
\nto Reduce Harmful Use of Alcohol and al-
\nlied WHO resolutions, in particular with
\nregard to providing technical assistance
\nto low- and middle-income countries to
\ndevelop and implement policies to reduce
\nthe burden of alcohol-related problems;
\nseeing that public health interests regard-
\ning alcohol issues are taken into account
\nin global trade agreements, the settle-
\nment of trade disputes, and decisions by
\ninternational development agencies; and
\nensuring that transnational marketing
\nor major international event marketing
\ndoes not act against national policies with
\nregard to alcohol advertising and promo-
\ntion. This needs to come in the form of
\npolitical support for action and concrete
\nresources to enable WHO to carry out its
\nmandate.
\n\u2022 Opposition from vested interest groups
\nsuch as the alcohol-beverage industry
\nand associated sectors (e.g. the advertis-
\ning industry) that benefit from the status
\nquo must be anticipated and countered
\n[3, 7]. Addressing the social determinants
\nof NCDs will also require understanding
\nand combating the role of globalisation in
\npromoting such diseases [21].
\nConclusion
\nAddressing NCDs in countries at all levels
\nof development is now seen as important in
\nensuring the achievement of MDGs [21].
\nThe way forward is to take concerted and
\ninclusive actions to address the common
\ncauses of the most prevalent NCDs. Al-
\ncohol has now been recognised as one of
\nfour major common risk factors for NCDs.
\nGAPA urges that this reality be factored
\ninto documents being prepared for the UN
\nhigh-level meeting in September 2011.
\nNot only must the causal association be-
\ntween alcohol use and NCDs be acknowl-
\nedged, but responses that address the so-
\ncial and environmental drivers of problem
\ndrinking must be included in interven-
\ntion packages that will be highlighted in
\nan Outcomes Statement to be produced
\nat the end of the UN high level meeting.
\nThis Statement should be a declaration with
\nclear, binding commitments, measurable
\ntargets and long-term agreements and pro-
\ngrammes.It should form a clear programme
\nof action for governments, the UN system,
\nand civil society.
\nThe Global Alcohol Policy Alliance (GAPA) is
\na developing network of non-governmental
\norganizations and people working in public
\nhealth agencies that share information on al-
\ncohol issues and advocate evidence-based alco-
\nhol policies. 12 Caxton Street, London, SW1H
\n0QS. gapa@ias.org.uk. www.globalgapa.org
\nReferences
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\ncommunicable disease. New York: Author.
\n2. UN. (2010b). Scope, modalities, format and
\norganization of the high-level meeting of the
\nGeneral Assembly on the prevention and con-
\ntrol of non-communicable diseases [A\/65\/L.50].
\nNew York: Author.
\n3. Alleyne, G., Stuckler, D., & Alwan, A. (2010).
\nThe hope and the promise of the UN Resolution
\non non-communicable diseases. Globalization
\n& Health, 6, 15.
\n4. HO. (2010). Global Strategy to reduce the
\nharmful use of alcohol. Geneva: Author.
\n5. Rehm., J., Mathers, C., Popova, S., Thavorn-
\ncharoensap, M., Teerawattananon, Y., Patra, J.
\n(2009). Global burden of disease and injury and
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\nalcohol-use disorders. Lancet, 373, 2223-2233.
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\nmajor risks. Geneva: Author. Available at www.
\nwho.int\/healthinfo\/global_burden_disease\/
\nGlobalHealthRisks_report_ full.pdf (accessed 7
\nFebruary 2011).
\n7. Room, R., & Rehm, J. (2011). Alcohol and non-
\ncommunicable disease \u2013 cancer, heart disease
\nand more. Addiction, 106, 1-2.
\n8. Baan, R., Straif, K., Grosse, Y., Secretan, B.,
\nGhissassi, F., Bouvard, V. Et al. (2007). Carcino-
\ngenicity of alcoholic beverages. Lancet Oncol-
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\nWorld, 21, 21-29.
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\n12. Rehm, J., Taylor, B., Mohapatra, S., Irving, H.,
\nBaliunas, D., Patra, J., & Roerecke, M. (2010).
\nAlcohol as a risk factor for liver cirrhosis \u2013 a
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\nM., Patra, J, Mphapatra, S, & Rehm, J. (2009).
\nAlcohol as a risk gactor for type 2 diabetes \u2013 a
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\nCare, 32, 2123-2132.
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\ngan, D., M\u00e4kel\u00e4, K., Marshall, M., Medina-Mo-
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\nAbuse, WHO. (2010). Report on the meeting
\non indicators for monitoring alcohol, drugs and
\nother psychoactive substance use, substance-at-
\ntributable harm and societal responses: Valencia,
\nSpain, 19-21 October 2009. Geneva: WHO.
\n21. Geneau, R., Stuckler, D., Stachenko, S., McKee,
\nM., Ebrahim, S., Basu, S., Chockalingham, A,
\nMwatsama, M., Jamal, R., Alwan, A., Beagle-
\nhole, R. (2010). Raising the priority of prevent-
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\n376, 1689-1698.
\nCharles Parry,
\nAlcohol & Drug Abuse Research Unit:
\nMedical Research Council, South Africa;
\nJ\u00fcrgen Rehm, Centre for Addiction\u00a0&
\nMental Health, Canada
\nINDONESIASocio-Medical-Affairs
\nPrior to 2001, the Indonesian government
\nconducted several programs to enchance
\nthe quality of health services at health cen-
\nters\u00a0[1]. One of these initiatives was to im-
\nprove the skill of nurses and midwives in pro-
\nviding health services by using the Clinical
\nAlgorithms (CAs). A CA is a step-by-step
\nproblem-solving procedure for clinical ser-
\nvices that guides nurses\/midwives to arrive
\nat a diagnosis and treatment.The Indonesian
\ngovernment provides CAs because doctors
\nare used in managerial roles at government
\nhealth centers. As a result nurses and mid-
\nwives must provide most of the health ser-
\nvices. For that reason, the Indonesian Medi-
\ncal Association (IMA) and the Indonesian
\nNurse Association (INA), in collaboration
\nwith the Ministry of Health and Social Wel-
\nfare and with the support of the World Bank,
\ndeveloped 15 CAs for nurses and midwives
\nto implement in government health centers
\nto improve the quality of services.
\nAfter the CAs were developed, the IMA
\nsupported the program by issuing a letter
\nof agreement for the nurses and midwives
\nto conduct some restricted medical activi-
\nties\u00a0[2].Through that letter, nurses and mid-
\nwives had the authority to diagnose and treat
\npatients using the CAs for 15 symptoms
\nof diseases, i.e.: running nose and cough,
\nfever >4 days, fever <5 days, hearing prob-\nlem, itching of skin, rash on the skin, vagi-\nnal discharge, eye redness, diarrhoea, nausea\nand vomiting, muscle and joint ache, vaginal\nbleeding, headache, burning during urina-\ntion,sore throat,epigastric pain,and difficul-\nty in breathing.The IMA letter of agreement\nmeant that certain elements of doctors\u2019 au-\nthority could be formally delegated to nurses\nand midwives. Of course, the letter of agree-\nment also had terms and conditions for nurs-\nes and midwives to follow when conducting\nthe doctor\u2019s job. First, the authority to diag-\nnose and treat using CA guidelines applied\nonly in government health centers during\nworking hours. Second, the tasks delegated\nwere given by the government health cen-\nter doctor to the government health center\nnurses and midwives only. Third, the scope\nof tasks delegated was restricted to CAs with\nwritten guidelines.Lastly,the task delegation\nrequired nurses and midwives fully record all\nprocedures in patients\u2019medical records.\nTask delegation to be\nTask Shifting\nIn the beginning,there were no major prob-\nlems in task delegation or implementing\nthe CA guidelines.For five years, from 2001\nuntil 2005, the program and relationship\nbetween doctors and nurses\/midwives was\nFachmi Idris\nTask Delegation Versus Task Shifting in the\nIndonesian Health Service\nwmj 2 2011 5CS.indd 62 4\/29\/11 11:13 AM\n63\nINDONESIA Socio-Medical-Affairs\nrun well. By the end of 2005, however, the\nsituation was out of control. The conditions\nin the letter of agreement allowing nurses\nand midwives to conduct these restricted\nmedical activities were not properly met by\nnurses in one province of Indonesia. At that\ntime, Indonesia had 33 provinces and the\ndoctors In Central Java province, the sec-\nond largest province in terms of total popu-\nlation, launched a protest to the IMA cen-\ntral executive board. They insisted the IMA\nCentral Executive Board revise the letter of\nagreement\u00a0[3].\nThe main reason for the protest was that\nthe condition of the relationship between\ndoctors and nurses\/midwives had become\nchaotic,especially in Boyolali district,where\nthe Health Authority of Central Java Prov-\nince established the Village Health Clinic\n(VHC)\u00a0[4]. The VHC was basically a com-\nmunity health service effort with the nurses\/\nmidwives serving independently as health\nservice officers.It was very different from the\nspirit of the letter of agreement that allowed\nthe nurses\/midwives to conduct diagnoses\nand treatment in government health centers\nonly. The conflict occurred between general\npractitioners and nurses\/midwives in Boyo-\nlali when nurses\/midwives campaigned to\nthe community that they could conduct the\ndoctor\u2019s job because they were trained as\nwell as a doctor using CA guidelines, which\nwere recognized by IMA. nurses\/midwives\nalso felt secure doing the doctor\u2019s job since\nthe VHC was a formal institution licensed\nby the Central Java Health Office.Task del-\negation evolved to task shifting at that time.\nCancelled Task Shifting\nAs a result, the Boyolali District IMA\nBranch office asked the IMA Central Ex-\necutive Board to take immediate action\u00a0[5].\nSince data showed that the total number of\ndoctors in Central Java was relatively high\nin proportion to the population, and trans-\nportation was generally available if there\nwas a need to find a doctor in another vil-\nlage, the need for task delegation in Central\nJava seemed less imperative. Fortunately,\nprevious to that situation occurring in\nOctober 2004, the Indonesian Parliament\nand Government had enacted the Medi-\ncal Practice Law (Law No. 29\/2004)\u00a0 [6]\nwhich states, in articles 73 & 77, that any\nperson who intentionally assumes the iden-\ntity of a registered doctor, or provides the\nimpression to the public that he or she is\na registered doctor, shall be punished with\nimprisonment of 5 (five) years or a fine of\nnot more Rp 150.000.000. With this law in\nplace, the Indonesian Medical Association\nfinally cancelled the letter of agreement.\nAfter the IMA cancelled the letter of agree-\nment,there was a need to find a way to meet\nhealth services needs when there were no\ndoctors in a particular area. Therefore, the\nIndonesian Medical Association sent rec-\nommendation letter on task delegation in\n2008\u00a0 [7]. In this letter, the IMA recom-\nmended that doctors delegate medical au-\nthority to nurses\/midwives in remote areas\nwith the following terms and conditions:\nthe delegation mechanism includes ac-\ncountability measures; the criteria of service\nis very clear; the time frame is restricted;\nonly selected doctors in the area can dele-\ngate authority to nurses\/midwives; medical\nauthority to be delegated is clear; there is a\nlimited list of drugs that can be dispensed\nby nurses\/midwives; and nurses\/midwives\ncan perform these tasks in government\nhealth facilities only [8].\nThe main difference between the prior letter\nof agreement and the new letter of recom-\nmendation is in the scope of collaboration.\nIn the letter of agreement, the Ministry of\nHealth collaborated with the IMA Cen-\ntral Executive Board directly. The terms\nand conditions of collaboration were very\ngeneral and it was difficult to control their\nimplementation. In the letter of recommen-\ndation, the IMA Central Executive Board\ndid not collaborate directly with the Minis-\ntry of Health but instead gave full author-\nity to IMA Branch offices at district levels\nto decide on collaboration with the district\nhealth office. The collaboration really de-\npends on how severe the shortage of doctors\nin that area is and requires that doctors in\nthat district accept the concept of delegat-\ning their medical authority. The IMA Cen-\ntral Executive Board was involved minimal-\nly only in determining the guidelines.\nLessons Learned\nThe World Medical Association describes\n\u201cTask Shifting\u201d as a situation where a task\nnormally performed by a physician is trans-\nferred to a health professional with a differ-\nent or lower level of education and train-\ning, or to a person specifically trained to\nperform a limited task only,\u00a0without having\na formal health education (World Medical\nAssociation)\u00a0[9]. Within the World Health\nOrganization (WHO), task shifting is a\nterm that involves the rational redistribu-\ntion of tasks among health workforce teams.\nSpecific tasks are moved, where appropri-\nate, from highly qualified health workers\nto health workers with shorter training and\nfewer qualifications in order to make more\nefficient use of the available human resourc-\nes for health\u00a0[10].\nRegardless of the differences between the\nWMA and WHO definition, the fact is\nthat the Indonesian Medical Association\nformerly supported shifting some physi-\ncians\u2019tasks to nurses and midwives, as com-\nmunicated through the letter of agreement.\nBut, given the deteriorated professional\nrelationship among physicians and nurses\/\nmidwives, and the IMA\u2019s assessment that\nthe implementation of task shifting could\nbe dangerous for patients, the Indonesian\nMedical Association cancelled the letter of\nagreement.\nReferences\n1. Setyawati, B., et all. Development of Clinical\nAlgorithm for Nurse and Midwife (Final Re-\nport). Indonesia Medical Association and In-\nwmj 2 2011 5CS.indd 63 4\/29\/11 11:13 AM\n64\nGeorgia\nGeorgia is situated in the South Caucasus,\non the southern foothills of the Greater\nCaucasus mountain range. There is a short\nborder with Turkey to the south-west and\na western coastline on the Black Sea. The\nnorthern border with the Russian Federa-\ntion follows the axis of the Greater Cauca-\nsus. To the south lies Armenia and, to the\nsouth-east, Azerbaijan.\nGeorgia has a rich history thanks to its stra-\ntegic location. Ionian Greeks colonized this\narea in the 6th\ncentury BC. At this time the\nwestern region of what is now Georgia was\nknown as Kolkhida and the eastern region\nas Iberia.In the 4th\ncentury BC Georgia was\nunited into a single kingdom, with Mtskhe-\nta as its capital.\nChristianity was introduced in the 4th\ncen-\ntury AD. The Persian and Byzantine em-\npires dominated the area until the Arab\nconquest in the 7th\ncentury.The region then\ncame under control of the Seljuk Turks in\nthe 11th\ncentury before their foray into Ana-\ntolia. A period of unification and indepen-\ndence in the 12th\ncentury, under King David\nIV, was swept aside by the Turco-Mongol\ninvasion in the 13th\ncentury.Between the re-\nturn of Timur\u2019s army to central Asia and the\n18th\ncentury, control of Georgia oscillated\nbetween the Persian and Ottoman empires.\nA short-lived Georgian kingdom was pro-\nclaimed in the mid-18th\ncentury, followed\nsoon after by annexation by the Russian\nEmpire.Initially,in 1783,this took the form\nof control of the kingdom\u2019s foreign affairs.\nIn 1801, with the abdication of the last\nGeorgian king, Georgia was fully incor-\nporated into the Russian Empire. After\nthe Russian Revolution, in 1917, Georgia\nbriefly became an independent republic.\nThis independence was short-lived, lasting\nonly until 1921, when it was incorporated\ninto the Union of Soviet Socialist Republics\n(USSR), where it remained for the follow-\ning 70 years.\nDuring the Soviet era, Georgia was a rela-\ntively prosperous republic, supplying USSR\nwith produce and services and exerting con-\nMedical History GEORGIA\nHistory of Georgia, Georgian Medicine and Medea\nOtar Toidze Nino Chikhladze Gia Lobzhanidze Zaza Khachiperadze\ndonesia Nurse Association in collaboration with\nMinistry of Health and Social Welfare. 2001.\n2. IMA Central Executive Board. The Agreement\nof Task Delegation of The Restricted Medical\nService to Nurse and Midwives. The letter No.\n380\/PB\/E.1\/05\/2001.\n3. GP Boyolali Forum. The Position Statements of\nGP for Village Health Service Training. Aorta\nMagazine. January-March edition 2006, page: 26.\n4. IMA Boyolali Branch Office. Village Health\nService. Aorta Magazine. January-March edi-\ntion 2006, page: 21.\n5. IMA Boyolali Branch Office. The proposal\nof Management of Medical Service Base on\nHealth Provider Competency. 7 Agustus,\n2006\n6. The Government of Indonesia Republic. The\nMedical Practice Act, Law Number 29, year\n2004.\n7. IMA Central Executive Board. The Revocation\nof Agreement Letter of Task Delegation of The\nRestricted Medical Service to Nurse and Mid-\nwives.The letter No. 2032\/PB\/E.1\/08\/2006.\n8. IMA Central Executive Board. The IMA Posi-\ntion on the Regulation of Medical Task Delega-\ntion.The letter No. 2392\/PB\/E.1\/12\/2008.\n9. WMA. World Medical Association Resolution\non Task Shifting from The Medical Profession.\nAdapted by WMA General Assembly, New\nDelhi, India, October, 2009.\n10. WHO. World Health Organization: Task\nShifting, Global Recommendation and Guide-\nline. Pefpar and UNAIDS. the WHO Docu-\nment Production Services, Geneva, Switzer-\nland, 2008.\nDr. Fachmi Idris, Dr (PH). President of\nCMAAO\/Immediate President of Indonesian\nMedical Association and Lecturer in Public\nHealth-Community Medicine of Medical\nFaculty of Sriwijaya University, Indonesia\nwmj 2 2011 5CS.indd 64 4\/29\/11 11:13 AM\n65\nMedical HistoryGEORGIA\nsiderable influence over internal exchange\nand cultural networks.\nThe country declared its independence from\nthe USSR in April 1991[1].\nGeorgian Medicine\n(Christian period)\nGeorgian medicine is one of the oldest in\nthe world. Georgian medicine is created\non the basis of two great traditions of East\nand West.There are more than 500 medical\nmanuscripts in Georgian and foreign librar-\nies. In the 1st\ncentury Greco-Roman medi-\ncine was closely bound to the ancient Pelas-\ngian, pre-Iberian world. The Georgians and\nthe Caucasians were always close to the\nHellenic world.It resulted from genetic,an-\nthropological, intellectual and cultural links\nbetween them\u00a0[2].\nThe level of Georgian medicine is given\nin the literary monument of the 5th\ncen-\ntury \u201cMartyrdom of Shushanic\u201d, in which\nthe author gives not only the methods of\ntreatment and care of the patient, but also\ndescribes the direct and indirect causes of\ndisease. In the work of Sabatsmindeli \u201cSin-\nanulisatvis Simdablisa\u201d together with many\ninteresting advises, the medical knowledge\nnecessary for monks and nuns is imparted.\nAn emergency situation with sending for a\ndoctor is noted here as well. It denotes that\nthe doctor\u2019s profession has existed indepen-\ndently in the 6th\ncentury in Georgia. It is\nnatural that the exceptional place of mon-\nastery medicine is especially underlined in\nreligious literary sources.\nIt is evident that monastery medicine is a\nsignificant part of the whole medicine. All\nsaints are healers, and there are no excep-\ntions. Petre Iberi, Shushaniki (5th\ncentury\nAD), Thirteen Assyrian Fathers (6th\ncen-\ntury AD), and Grigol Khandzteli (8th\n\u20139th\ncenturies AD) were the famous healers of\ntheir times. Ilarion Kartveli must be es-\npecially mentioned. He was a worldwide\nknown doctor treating patients without\nfee.\nThe first medical book, \u201cUstsoro Karaba-\ndini\u201d, which has reached our time, dates\nback to the 10th\ncentury. Last year we cel-\nebrated the 1000th\nanniversary of the book.\nIt was written by a doctor with encyclope-\ndic knowledge, who called himself Kanan-\neli. Many scientific works are devoted to the\nGeorgian golden period (11th\n\u201312th\ncentu-\nries AD). These favorable conditions were\nconducive to the early origin of remarkable\nRenaissance. Only after a few centuries\nWestern European countries could enter\nthe Renaissance. Medicine in particular\nachieved a high level of development. This\ntime was an extraordinary period in Geor-\ngian history.Georgian medicine is known as\nJoanne Petrici\u2019s and Arsen Ikaltoeli\u2019s period.\nArsen Ikaltoeli was recognized as the great-\nest anatomist of this period. He lived and\nworked in the same sociocultural environ-\nment where the genius of Shota Rustaveli\nflourished. In the 10th\n\u201313th\ncenturies many\nGeorgian institutions were created in Geor-\ngia and abroad. Building of hospitals was\nleading among these activities. The ruins of\nthese hospitals are still to be seen in Geor-\ngian cloisters in the western and eastern\nGeorgia, southwestern part Tao-Klarjeti\nand at Georgian cultural centers abroad:\nJerusalem, Khalkedon, Petrisioni, Sinai, and\nthe Black Mountains. Some hospitals had\nrich libraries.\nIn the 13th\ncentury Kojakopoli wrote the\nmedical book \u201cTsigni Saakimoi\u201d, which\nalso corresponds with the \u201cgolden period\u201d\nof Georgian history. The greatest Georgian\ndoctor and philosopher, Zaza Panaskerteli-\nTsitsishvili (15th\ncentury AD) was the first\nlay person, holding an especial place in the\nhistory of Georgian medicine. His most\nfamous medical work was \u201cSamkurnalo\nTsigni (The Book of Treatment)\u201d. It became\nextremely popular in the country.\nIn the 16th\ncentury David Batonishvili\n(Bagrationi) wrote the medical book \u201cIad-\ngar Daudi\u201d. The 17th\n\u201318th\ncenturies were\nsignificant because of the expansion of Eu-\nropean culture and knowledge in Georgian\nmedicine. The king of Georgia, Vakhtang\nVI (18th\ncentury) took some young people\nto Russia, where they received univer-\nsity medical education. Among them, Ilia\nGruzinov (Namchevadze) should be espe-\ncially mentioned as a talented person, who\nwas sent to Europe, where he became well\nknown in the scientific circles of Germany,\nFrance and England. He is considered as a\npioneer neurophysiologist. The document\nof this period of King Erekle II shows that\n\u201cEkimbashi\u201d\u2013 chief of doctors \u2013 trained his\npupils for 20\u201325 years and only after at-\ntending his course, had they a right to con-\nduct independent practice and to have their\nown trainees.\nMedea and Medicine\nIn the 18th\ncentury K. J. Sprengel\u2019s classic\nof the history of medicine begins with Cura\nMediana (Treatment by Medea) and thus\nrecognizes the antiquity of Kolkh-Iberian\nmedicine. There exists a well-founded ver-\nsion linking medicine with the name of the\nKolkhetian ruler\u2019s daughter \u2013 Medea,famed\nfor her knowledge of various remedies. She\nwas preparing remedies in different forms,\nfor respiratory, internal and external usage,\netc. There were many kinds of drugs in her\narsenal of medicaments: curing different\ndiseases, giving strength, poisoning, un-\nguents, magic, etc.\nOne of the medical treatment manipula-\ntions, among the ones Medea knew, was the\ntreatment of wounds quickly and effectively.\nThe wounded Argonauts,who were fighting\nagainst the Kolkhs, were treated by Medea\n\u201cin a few days with roots and some other\nherbs\u201d (Diodorus the Sicilian).\nMedea also knew the treatments for steril-\nity. The King of Athens \u2013 Egeos, who was\n\u201cill with sterility,\u201d was told by the healer\nwoman: \u201cYou do not even know how lucky\nwmj 2 2011 5CS.indd 65 4\/29\/11 11:13 AM\n66\nMedical History GEORGIA\nyou are as you have come up to me, I know\nthe medicine of infertility.\u201d\nThe Kolkh woman was quite educated in\ncosmetology, too. She is considered to be\nthe first in creating coloring hair. She knew\nthe secrets of skin caring.\nThe healing woman during her medical\nfunctioning used to make blood transfusion,\ntoo. She used lamb as a donor. She cured\nJason\u2019s uncle in the same way.\nMedea was making poison with special\nprocessing \u2013 boiling, thermal, mechanic,\nor chemical influence, that means getting\nthe poison by concentrating. The principle\non which nowadays medicine exists and\ndevelops, is contraria contrariis curantur,\nor the allopathic maxim. The priority falls\non this maxim now. This is the direction\nfollowed by the world\u2019s modern medicine\ntoday.\nIt is worth mentioning that this direction\nbefore Medea\u2019s epoch was not developed in\nany other countries\u2019 medicine. In the east-\nern medicine the allopathic maxim is not\nemphasized as a dominant one. It originates\nfrom Greco-Roman medicine. The roots of\nit are in Mediterranean Pelasgic and Kolkh-\nIberian medicine. The evidence to it is Ro-\ndoseli\u2019s \u201cArgonautica\u201d.\nMedea is special for her skills to find out\ncuring merits in new plants. And later,\nshe prepares the concentrates for creating\ndrugs\u00a0\u2013 poison. Seems that this is the basis\nof connection between \u201cSatsamlavi\u201d (poi-\nson) and \u201cTsamali\u201d (drug) in Georgian.\nFor effective influence of adversity on an-\nother adversity medicine needed drugs. As\nfor the medicine, it was prepared by poison\u2019s\ndilution. It became the basis of the allo-\npathic mentality system. The aunts taught\nMedea the art of poison preparation. But\nshe used this knowledge differently. As she\ngot the active concentrate from plants, she\ndiluted it in the dose, that this substance\nwas used not as poison but as a drug. She\nknew the maxim that medicine is poison\nand poison is medicine. The difference is\nonly in dosage. (Paracelsus.) Medea could\ndetermine dosage between dosis letalis mini-\nma and dosis therapeutica.\nMedea\u2019s skills are revealed in the myth\nabout the Argonauts. Facts say that Jason\narrived from Iolcus to Colchis (the old\nkingdom of Georgia) to claim his inheri-\ntance and throne by retrieving the Golden\nFleece. In the most complete surviving ac-\ncount, the Argonautica of Apollonius, Me-\ndea fell in love with him and promised to\nhelp him but only on the condition that if\nhe succeeded, he would take her with him\nand marry her. Jason agreed. In a famil-\niar mythic motif, Ae\u00ebtes promised to give\nhim the fleece but only if he could perform\ncertain tasks. First, Jason had to plough a\nfield with fire-breathing oxen that he had\nto yoke himself. Medea gave him an un-\nguent with which to anoint himself and\nhis weapons, to protect him from the bulls\u2019\nfiery breath.\nFigure 1. John William Waterhouse\u2019s paint-\ning \u201cJason and Medea\u201d (1907)\nSource: http:\/\/kevinalfred-\nstrom.com\/art\/v\/paintings\/\nFoto+2_+Jason+and+Medea_+1907+2.jpg.\nhtml\nFigure 2. The statue of Medea in Batumi\nSource: http:\/\/4.bp.blogspot.com\/_\nh4G8qWVecRo\/TFa7jmAh_2I\/\nAAAAAAAAAmg\/vhSrs23GXl0\/\ns1600\/100_9408.jpg\nThen,Jason had to sow the teeth of a dragon\nin the ploughed field (compare the myth of\nCadmus). The teeth sprouted into an army\nof warriors. Jason was forewarned by Me-\ndea, however, and knew to throw a rock into\nthe crowd. Unable to determine where the\nrock had come from, the soldiers attacked\nand defeated each other. Finally, Ae\u00ebtes\nmade Jason fight and kill the sleepless drag-\non that guarded the fleece. Medea put the\nbeast to sleep with her narcotic herbs. Jason\nthen took the fleece and sailed away with\nMedea, as he had promised [8].\nEven nowadays Medea is highly respected in\nGeorgian medicine. Georgian nation built a\nstatue of Medea in Batumi. The monument\nis a symbol of Georgia\u2019s Black Sea coast and\nis an attribute thereof.\nReferences\n1. Chanturidze T., Ugulava T., Dur\u00e1n A., Ensor\nT., Richardson E. Georgia: health system review,\n2009.\n2. Verulava T. History of Georgian medicine, 2000.\n3. Saakashvili M. History of Georgian medicine.\nTbilisi, 1956.\n4. Shengelia M. Georgian medicine in transition,\n1801-1860.Tbilisi,1968.\n5. Shengelia M. History of Georgian medicine.\nTbilisi, 1984.\n6. Shengelia M. Ancient Kolchian-Iberian medi-\ncine.Tbilisi,1979.\n7. Shengelia R. History of Georgian medicine.\nTbilisi, 1995.\n8. http:\/\/en.wikipedia.org\/wiki\/Medea\nDr. Otar Toidze MD, PhD,\nHead of the Healthcare and Social Issues\nCommittee of the Georgian Parliame\nProf. Gia Lobzhanidze MD, PhD,\nChairman of Georgian Medical Association\nNino Chikhladze MD, PhD,\nAssociated Professor Ivane Javakhishvili\nTbilisi State University\nDr. Zaza Khachiperadze MD,\nDeputy General Secretary of\nGeorgian Medical Association\nwmj 2 2011 5CS.indd 66 4\/29\/11 11:13 AM\n67\nRegional and NMA newsNETHERLANDS\nIntroduction\nPalliative care has been the subject of consid-\nerable interest in the Netherlands since the\nlate 1990s, partly because the government\nhas actively promoted it. The past few years\nhave witnessed a proliferation of expertise\nand skill in this area. The Netherlands now\noccupies the fourth place in the European\nranking for palliative care.This ranking indi-\ncates the extent to which palliative care has\nbeen developed within a country [1].\nPalliative sedation has also been discussed at great\nlength in the context of these developments.This\ndebate was triggered by the Public Prosecution\nService in 2003. This year marked criminal and\ndisciplinary proceedings against a physician due\nto the sedation of a terminally ill patient who\nwas at risk of suffocating. Partly as a result of all\nthe publicity that this story attracted,the govern-\nment highlighted the importance of the drafting\nof a national guideline for palliative sedation by\nthe profession.The guideline of the Royal Dutch\nMedicalAssociation(RDMA)forpalliativeseda-\ntion was published in 2005 and reviewed in 2009\n[2\u20134]. Besides defining the professional standard,\nthe guideline has also acquired legal significance.\nThe Public Prosecution Service has stated that it\nsees no reason to prosecute physicians who keep\ntotheguideline.Anyphysicianwhodeviatesfrom\nit,however,mustbearinmindthathisactionsmay\nbe the object of a criminal investigation.Research\nhas shown that the practice of palliative sedation\nhas improved and that the RDMA-guideline\nis being followed [5\u20138].This article discusses the\nkeypointsoftheguideline.Theguidelinehasbeen\ntranslated in full and is available on the website of\ntheRDMA[2].\nRelationship between\npalliative care, palliative\nsedation and patients\u2019 rights\nPalliative sedation forms part of a palliative\ncare process [9]. The decision-making pro-\ncess regarding whether or not to commence\npalliative sedation takes place in the Neth-\nerlands within the conditions for a palliative\ncare approach, as described by the WHO:\n\u2018Palliative care is an approach that improves\nthe quality of life of patients and their families\nfacing the problem associated with life-threat-\nening illness, through the prevention and relief\nof suffering by means of the early identification\nand impeccable assessment and treatment of\npain and other problems, physical, psychosocial\nand spiritual\u2019 [10].\nThe RDMA strongly agrees with this de-\nscription, as it centres on the needs of the\npatient and his or her family. This is crucial\nwhen caring for the terminally ill. The focus\non the patient\u2019s needs is also in line with the\nrights granted to patients in the Netherlands.\nThe Dutch \u2018Medical Treatment Contracts\nAct\u2019 stipulates that except for in emergency\nsituations, physicians must adequately in-\nform the patient and the patient must then\ngrant consent before the physician can start\nthe treatment, if possible. The starting point\nfor every treatment is therefore informed\nconsent. The consequence of this is that the\npatient may refuse the treatment, and the\nphysician must respect this decision. Aside\nfrom this, however, the RDMA considers it\nimportant for the physician and patient to\ntalk to one another in clear terms and in a\ntimely manner about feasible and unfeasible\ncare and treatment options in the last stages\nof life. Staff should be proactive in ensuring\nthat consent is sought while the patient is still\nlucid. This means that the possibility should\nbe discussed with the patient,if at all possible,\nwell before the stage when palliative sedation\nis the only remaining option. The essence of\nthis discussion is the quality of remaining life\nand the inevitable death of the patient.\nWhat does palliative\nsedation mean?\nThe RDMA has defined palliative sedation as:\n\u2018The deliberate lowering of a patient\u2019s level of\nconsciousness in the last stages of life\u2019.\nIt is a treatment administered to patients\nwho are dying and experiencing unbearable\nsuffering.The aim of palliative sedation is to\nalleviate this suffering. Lowering the level\nof consciousness is a means to that end.Pal-\nliative sedation can be administered in dif-\nferent ways: deep or superficial, temporary\/\nintermittent or continuous.\nThe RDMA considers it crucial that pal-\nliative sedation be applied proportionately\nand adequately, in response to the appropri-\nate medical indications. It is the degree of\nsymptom control rather than the degree to\nwhich consciousness must be reduced that\ndetermines the dose, combinations, and\nduration of the medication administered in\npalliative sedation. Interim evaluations and\nother decision-making processes must be\ngeared towards adequately alleviating the\npatient\u2019s suffering in order to create a tran-\nquil and tolerable situation.\nEric van Wijlick\nPalliative Sedation in the Netherlands\nThe Royal Dutch Medical Association Guideline Tries to Provide Clarity\nwmj 2 2011 5CS.indd 67 4\/29\/11 11:13 AM\n68\nNETHERLANDSRegional and NMA news\nThe word \u2018deliberate\u2019 is included in the\ndefinition in order to exclude situations in\nwhich the lowering of the patient\u2019s level of\nconsciousness is a (possibly unintended) side\neffect of treatment,for instance the lowering\nof consciousness as a result of the adminis-\ntration of morphine to relieve pain. Physi-\ncians may use or increase the dose of opioids\nor other forms of medication not usually\nused primarily as sedatives with the implicit\nor explicit aim of palliative sedation.\nEmpirical data\nThe total number of deaths in the Nether-\nlands in 2005 where the patient underwent\ndeep and continuous sedation prior to death\nwas 8.2% [11].In the international literature,\nthe reported incidence of palliative sedation\nof patients receiving clinical care (generally\nin hospices) ranges from 15% to 52%. The\ncommonest indications for palliative seda-\ntion are delirium or agitation in the terminal\nphase (57%), followed by dyspnoea (23%),\npain (17%) and vomiting (4%) [12\u201318].\nContinuous, deep sedation until death is\npractised most often by medical specialists\n(45%), followed by general practitioners\n(34%) and nursing home physicians (19%).\nOf the cases in which continuous, deep se-\ndation was administered until the time of\ndeath in the Netherlands, 47% involved pa-\ntients with cancer,17% patients with cardio-\nvascular disorders, 6% pulmonary diseases,\n4% diseases of the nervous system and 26%\n\u2018other\u2019 disorders. In about three-quarters of\nall cases, the patients were aged 65 years or\nover. The most common symptoms in 2005\nin the last 24 hours preceding death were fa-\ntigue (55%), dyspnoea (48%), reduced level\nof consciousness (47%) and pain (42%).\nThe vast majority of patients have virtu-\nally ceased eating and drinking by the time\nthat deep and continuous sedation needs to\nbe initiated and most of them die within a\nfew days of its initiation [14, 20]. Research\nshows that 47% of patients put into a state\nof continuous, deep sedation die within 24\nhours,47% within one to seven days and 4%\nwithin one to two weeks [11, 21].\nIndications for\npalliative sedation\nIn the Netherlands, indications for pallia-\ntive sedation are present if the patient is suf-\nfering from one or more refractory symp-\ntoms. A symptom is, or becomes,\u2018refractory\u2019\nif \u2018none of the conventional modes of treat-\nment is effective or fast-acting enough,and\/\nor if these modes of treatment are accompa-\nnied by unacceptable side-effects\u2019.\nIn practice, determining whether a symp-\ntom is refractory sometimes leads to dif-\nficulties. It requires knowledge and skill to\ndistinguish symptoms that are difficult to\ntreat from symptoms that are untreatable.\nThe physician will have to decide whether a\nsymptom is treatable or not on the basis of\naccepted good medical practice, bearing in\nmind the specific circumstances of a patient\nin the last stages of life. Since the guideline\nwas introduced, patients are increasingly be-\ning involved in the decision-making process\nand at an earlier stage (from 72% before to\n82% after the introduction). Determining\nwhether there are indications for palliative\nsedation is a medical decision. The decision\nto administer palliative sedation is not based\non a specific moment in time, but is a pos-\nsible outcome within the context of a pallia-\ntive care plan. Patient and physician (often\na member of a multidisciplinary treatment\nteam) have together arrived at a point where\nthey find themselves, through a complex of\nproblems, with their backs to the wall. The\nfeelings of the patient are extremely impor-\ntant,especially as regards the discomfort and\nother side-effects of any possible mode of\ntreatment. The decision-making is also in-\nfluenced by factors such as the views of the\npatient and the physician concerning a \u2018good\ndeath\u2019, the quantity and severity of symp-\ntoms, the impact of the somatic complaints\non feelings such as fear,the fear of death and\nthe actual process of dying, powerlessness,\nuncertainty, grief, anger, sadness, the dura-\ntion of the illness, the burden on informal\ncarers, and the strength and endurance of\nthe patient and of his informal carers.Physi-\ncal exhaustion (intense fatigue) may also\nplay a role at this stage, and may exacerbate\nsuffering. It is one of the factors that help to\ndetermine the patient\u2019s endurance.This may\nlead to the conclusion that there is no more\nscope for deploying any other reasonable\ninterventions aside from palliative sedation.\nThe decision to apply palliative sedation is\nmade within the context of palliative care,\nwhich characteristically relies on a multidis-\nciplinary approach. Nursing staff and other\ncare professionals can provide input for\ndrawing up the indications, and the RDMA\nadvises physicians to consult the appropriate\nexpert in good time if he or she is in any\ndoubt as to whether medical indications are\npresent. In the Netherlands, every physician\ncan enlist the assistance of a regional pallia-\ntive care consultation team.\nThe relationship between\npalliative sedation and action\nintended to terminate life\nWithin the context of palliative sedation,\nthe RDMA distinguishes between the fol-\nlowing two situations:\n\u2022 continuous sedation until the time of death;\n\u2022 temporary or intermittent sedation.\nWe take the view that on the one hand,\nthese are situations that must both be\nviewed against the wider background and\nthe process of palliative care, but that on the\nother hand also differ from one another, for\ninstance as regards the substance and word-\ning of the preconditions for good medical\npractice. The discussions that have taken\nplace over the past few years have focused\non continuous, deep sedation until the time\nof death. This form of palliative sedation,\nwhich is sometimes also known as terminal\nsedation, and its relationship to action in-\nwmj 2 2011 5CS.indd 68 4\/29\/11 11:13 AM\n69\nRegional and NMA newsNETHERLANDS\ntended to terminate life has led to medical-\nethical, legal, social and political debate.\nPalliative sedation is a normal medical proce-\ndure.The aim of palliative sedation,including\ncontinuous sedation until the time of death,\nis not to shorten or prolong life,but to allevi-\nate suffering. When applied proportionately\nand adequately, palliative sedation does not\nhasten death [22\u201329]. The patient dies as a\nconsequence of the underlying disease and\nnot as a result of palliative sedation. Pallia-\ntive sedation is a way of stopping the patient\nfrom consciously experiencing symptoms\nand thereby preventing unbearable suffering\nprior to death. Based on the view that the\npatient\u2019s remaining quality of life and death\nmust be the key focus, the RDMA considers\nit essential for the physician and patient to\ntalk to one another in clear terms and in a\ntimely manner about feasible and unfeasible\npalliative care options, including palliative\nsedation. The guideline therefore places a\nstrong focus on the decision-making process\nand dealing with the patient\u2019s family.\nIntermittent palliative sedation can be initi-\nated in consultation with the patient to re-\nstore tranquillity and then allow the patient\nto return to consciousness,but in some situa-\ntions also provides the opportunity to estab-\nlish whether a symptom is permanently re-\nfractory. This gives the physician the chance\nto assess the situation with the patient and\nhis or her family and if necessary to modify\nthe management of the case. Another op-\ntion is continuous sedation. In this situation\nthe RDMA considers that besides the pres-\nence of one or more refractory symptoms, a\nsecond precondition is the expectation that\ndeath will ensue within one to two weeks.\nThe RDMA feels that there should be no\nartificial administration of fluids and food in\nthe case of continuous sedation.The artificial\nadministration of fluids and food is viewed as\nmedical treatment in the Netherlands.When\na patient is in the last stages of life and a pal-\nliative care approach has been adopted, the\nartificial administration of fluids and food\nmust be regarded as medically futile. There\nare indications that artificially administering\nfluids and food to a patient who is dying pro-\nlongs life and exacerbates suffering (oedema,\nascites, bronchial secretions etc.). In practice,\nhowever, most patients are no longer will-\ning or able to take any fluids, because they\nare dying. Patients are frequently cachectic,\ntired and debilitated. Of all patients who are\ncontinuously sedated prior to death 47% die\nwithin 24 hours, 47% within one to seven\ndays and 4% within two weeks. In 2% of pa-\ntients, it proved necessary to administer con-\ntinuous sedation for over two weeks [11, 21].\nPalliative sedation differs from euthanasia in\nthat its aim is not to shorten life.In this case\ntoo, the patient\u2019s needs and wishes are para-\nmount. Palliative sedation is the first choice\nfor patients who no longer want to experi-\nence unbearable suffering, but who also do\nnot want to end their lives. If the patient\ndoes not want to live any longer as a result\nof his or her unbearable suffering, euthana-\nsia is an option in the Netherlands. Eutha-\nnasia is not regarded as a normal medical\nprocedure and is not accepted good medical\npractice. Euthanasia is subject to statutory\nrequirements. The patient does not have a\nright to euthanasia and the physician is not\nunder any circumstances obliged to comply\nwith the patient\u2019s request. Timely and clear\ncommunication about feasible and unfea-\nsible options is of course essential.\nMorphine and Midazolam\nIn situations where continuous, deep seda-\ntion until the time of death is being consid-\nered, morphine is often already being given\nto treat pain or dyspnoea. In these circum-\nstances, it may seem attractive to increase\nthe dose of morphine substantially in the\nhope of expediting loss of consciousness\nand death. Research into medical decisions\nrelating to the end of life has shown that\n19% of specialists, 13% of general practitio-\nners and 10% of nursing home physicians\nuse morphine for this purpose [11]. Closer\nconsideration reveals that its use in this way\noften has two different aims: first, to render\nthe patient unconscious and second, to has-\nten death. For neither of these aims, how-\never, is morphine the drug of choice. Exces-\nsively high doses of morphine frequently\nproduce drowsiness, but not always loss of\nconsciousness. Therapeutic doses of opioids\n(that is, doses tailored to the degree of pain\nor dyspnoea) are not at all likely to shorten\nlife, even if they are high. Moreover, mor-\nphine has major side-effects. For instance, it\ncan increase delirium or induce myoclonus.\nThe RDMA regards the use of morphine for\nthese purposes as bad practice. Morphine\nshould only be given or continued (alongside\nsedatives) to relieve pain and\/or dyspnoea.\nThe dose should be calculated to relieve the\nactual or assumed extent of the pain and\/or\ndyspnoea. If it is necessary to intentionally\nlower the patient\u2019s level of consciousness in\nthe last stages of life with the aim of allevi-\nating suffering,the RDMA-guideline speci-\nfies Midazolam as the drug of choice.\nRecord-keeping and evaluation\nAccurate record-keeping plays a very impor-\ntant role in helping to ensure the quality and\ncontinuity of care. Palliative care and seda-\ntion characteristically rely on a multidisci-\nplinary approach.This means that all relevant\ninformation about the patient and his or her\nsituation must be recorded in his or her file.\nFirst and foremost, the file should contain\nthe reasons why it was decided to adminis-\nter palliative sedation and how sedation was\nadministered. The problems and symptoms\nthat prompted the decision to administer\ncontinuous sedation should serve as the basis\nfor evaluation. The physician against whom\ncriminal and disciplinary proceedings were\nbrought in 2003 had failed to adequately\nupdate the patient\u2019s file. The physician was\ntherefore unable to demonstrate the patient\u2019s\nsymptoms, the aim of the treatment, which\ndrugs were used and at what doses.The phy-\nsician was eventually acquitted.However,the\ndisciplinary court found the physician guilty\nof failing to keep proper records.\nwmj 2 2011 5CS.indd 69 4\/29\/11 11:13 AM\n70\nRegional and NMA news NETHERLANDS\nConclusion\nPractice has improved following the in-\ntroduction of the RDMA-guideline for\npalliative sedation and is in line with the\nbasic principles and recommendations in\nthe guideline. The RDMA still considers\npatient involvement in the decision-making\nprocess to be a point that requires attention.\nThe essence of palliative care and therefore\nalso palliative sedation is the quality of re-\nmaining life and the inevitable death of the\npatient.The RDMA-guideline clearly states\nthat palliative sedation does not shorten life\nand must be clearly distinguished from eu-\nthanasia. The physician must include in the\nfile information on the patient\u2019s symptoms\nand complaints, the physician\u2019s envisaged\ntreatment objective, whether or not in-\nformed consent has been granted, the drugs\nadministered and at what doses. It cannot\nbe said enough that the main priority is the\nquality and continuity of care during the\npatient\u2019s remaining life and death. There is\nno room for misunderstandings or miscon-\nceptions. The RDMA-guideline provides\nclear and substantiated criteria that can be\napplied in practice in the Netherlands.\nSummary\n\u2022 In the last stage of life, palliative sedation\nconsists always of continuous administra-\ntion of the sedatives. In this stage of life\nthe patient is dying and experiencing un-\nbearable suffering.\n\u2022 Part of palliative care is that the physi-\ncian and patient talk to one another in\nclear terms and in a timely manner about\nfeasible and unfeasible options in the last\nstage of life.The essence of this discussion\nis the quality of remaining life and the in-\nevitable death of the patient.\n\u2022 The decision to apply palliative sedation\nis made within the context of palliative\ncare, which characteristically relies on a\nmultidisciplinary approach.\n\u2022 Continuous sedation differs from eutha-\nnasia in that its aim is not to shorten life.\nPalliative sedation is a normal medical\nprocedure, euthanasia is not.\nReferences\n1. See www.eapcnet.eu\n2. Royal Dutch Medical Association (KNMG).\nGuideline for Palliative Sedation 2009. Down-\nload: http:\/\/knmg.artsennet.nl\/dossiers\/Dossi-\ners-op-thema\/levenseinde\/euthanasieenpallia-\ntievesedatie.htm\n3. Verkerk M,Wijlick EHJ van, Legemaate J, Gra-\neff A de. A national guideline for palliative seda-\ntion in the Netherlands. J Pain Sympt Manage\n2007; 34: 666-670.\n4. Legemaate J,Verkerk M,Wijlick EHJ van, Gra-\neff A de. Palliative sedation in the Netherlands:\nstarting-points and contents of a national guide-\nline. Eur J Health Law 2007; 14: 61-73.\n5. Hasselaar GJ, Verhagen CAHHVM, Wolff AP,\nEngels Y, Crul JP, Vissers CP. Changed patterns\nin Dutch palliative sedation practice after the\nintroduction of a national guideline. Arch Intern\nMed 2009; 169(5): 430-437.\n6. Swart SJ, Brinkkemper T, Rietjens AC, Blanker\nH, Zuylen L van, Ribbe M, Zuurmond WA,\nHeide A van der, Perez SGM. Physicians\u2019 and\nnurses\u2019 experiences with continuous palliative\nsedation in the Netherlands. Arch Intern Med\n2010; 170(14): 1271-1273.\n7. Deijck HPD, Krijsen JC, Hasselaar GJ, Ver-\nhagen CAHHVM, Vissers CP, Koopmans\nTCM. The practice of continuous palliative se-\ndation in elderly patients: a nationwide explora-\ntive study among Dutch nursing home physi-\ncians.Journal American Geriatrics Society 2010.\n8. Brinkkemper T,Klinkenberg M,Deliens L,Eliel\nM, Rietjens AC, Zuurmond WA. Palliative se-\ndation at home in the Netherlands: a national\nwide survey among nurses. Journal of Advanced\nNursing 2011.\n9. European Association for Palliative Care\n(EAPC): recommended framework for the use\nof sedation in palliative care. Palliative Medicine\n2009; 23(7): 581-593.\n10. World Health Organization. WHO Definition\nof Palliative Care 2002.\n11. Rietjens JA, Delden JJM van, Onwuteaka-\nPhilipsen BD, Buiting H, Maas P van der,\nHeide A van der. Continuous deep sedation\nfor patients nearing death in the Netherlands:\ndescriptive study. British Medical Journal 2008;\n7648: 810-813.\n12. Wein S. Sedation in the imminently dying pa-\ntient. Oncology (Huntingt) 2000; 14: 585-592.\n13. Cherny NI, Portenoy RK. Sedation in the man-\nagement of refractory symptoms: guidelines for\nevaluation and treatment. Journal of Palliative\nCare 1994; 10: 31-38.\n14. Cowan JD, Palmer TWP. Practical guide tot\npalliative sedation. Current Oncol Rep 2002; 4:\n242-249.\n15. Cowan D, Walsh D. Terminal sedation in pal-\nliative medicine \u2013 definition and review of lit-\nerature. Support Care Cancer 2001; 9: 403-407.\n16. Chater S, Viola R, Paterson J, Jarvis V. Sedation\nfor intractable distress in the dying \u2013 a survey of\nexperts. Palliat Med 1998; 12: 255-269.\n17. Cherny NI. Sedation: uses, abuses and ethics at\nthe end of life. Jerusalem, Israel, 2003.\n18. Voltz R, Borasio GD. Palliative therapy in the\nterminal stage of neurological disease. J Neurol\n1997; 244 (Suppl 4): S2-S10.\n19. Fainsinger RL, Landman W, Hoskings M, Bru-\nera E. Sedation for uncontrolled symptoms in\na South African hospice. Journal of Pain and\nSymptom Management 1998; 16: 145-152.\n20. Rousseau P.Terminal sedation in the care of dy-\ning patients. Arch Intern Med 1996; 156: 1785-\n1786.\n21. Verhagen CAHHV. Incidence, methods and\noutcome of palliative sedation before and after\npublication of a specific guideline in the Neth-\nerlands. Aachen, EAPC 8\u201310 April 2005, P148.\n22. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen\nCY. Sedation for refractory symptoms of termi-\nnal cancer patients in Taiwan. Journal of Pain\nand Symptom Management 2001; 21: 467-472.\n23. Kohara H, Ueoka H, Takeyama H, Murakami\nT, Morita T. Sedation for terminally ill patients\nwith cancer with uncontrollable physical distress.\nJournal of Palliative Medicine 2005; 8: 20-25.\n24. Morita T, Tsuneto S, Shima Y. Proposed defi-\nnitions of terminal sedation. Lancet 2001; 358:\n335-336.\n25. Stone P, Phillips C, Spruyt O, Waight C. A\ncomparison of the use of sedatives in a hospital\nsupport team and in a hospice. Palliative Medi-\ncine 1997; 11: 140-144.\n26. Sykes N,Thorns A.The use of opioids ands sed-\natives at the end of life. The Lancet Oncology\n2003; 4: 312-318.\n27. Ventafridda V,Ripamonti C, De Conno F,Tam-\nburni M, Cassileth BR. Symptom prevalence\nand control during cancer patients\u2019 last days of\nlife. Journal of Palliative Care 1990; 6: 7-11.\n28. Wein S. Sedation in the imminently dying pa-\ntient. Oncology (Huntingt) 2000; 14: 585-592.\n29. Maltoni M, Pittureri C, Scarpi E, Piccinini,\nMartini F, Turci P, Montanari L, Nanni O,\nAmadori D. Palliative sedation therapy does not\nhasten death: results from a prospective multi\ncenter study. Annals of Oncoloy 2009; 20: 1163-\n1169.\nEric van Wijlick, senior policy advisor\nRoyal Dutch Medical Association\nE-mail: e.van.wijlick@fed.knmg.nl\nwmj 2 2011 5CS.indd 70 4\/29\/11 11:13 AM\n71\nBelgium\u2019s current law on euthanasia was\npassed on May 28th\n, 2002, shortly after a\nsecular government unseated the prevail-\ning Social-Christian party, which had held\npower almost continuously since World\nWar II. This law is very permissive since it\nallows euthanasia in circumstances where\nthe death process has begun, as well as in\ncases of long-term, often terminal illness.\nThe circumstances\nThe law was passed in 2002 following a time\nwhen rationing, cost containment and the\nsustainability of social systems were the is-\nsues that largely filled political agendas. The\nextension of life expectancy and the prohibi-\ntive cost of the last six months of life often\nwere arguments of weight in the debate.\nThe philoso\u00a0phical\u00a0basisof\u00a0the law\nThe Belgian law has been very permissive\nfrom the very start and recently there has\nbeen a movement to consider extending\nthe law to include the possibility of eu-\nthanasia for children. The current law is,\nto a large extent, founded on the patient\u2019s\nautonomy. It is the patient who decides to\nsubmit to euthanasia as long as the condi-\ntions of eligibility are met. A constraining\nanticipated declaration can be made, or a\nperson of trust can be appointed by pa-\ntients to represent themselves in the event\nthey become unable to express their will.\nThe practitioner may refuse to perform the\neuthanasia on the grounds of objection of\nconscience, but must tell the patient and\noffer to give way, immediately or when the\nmoment has come, to one of their peers\nwho is likely to comply with the patient\u2019s\nwishes. The decision must not be made by\nthe practitioner, nor may he submit it to\na committee of ethics. These possibilities\nhave been discarded by the legislator and\nit stands in the law.\nThe autonomy of the patient has naturally\nbeen supported by advocating associations\nlike \u00ab\u00a0Mourir dans la Dignit\u00e9\u00a0\u00bb (To Die in\nDignity) but often leaves the practitioner\nperplexed. It can be confusing for practi-\ntioners to witness more and more deaths\nby suicide and even more suicide attempts\nwhile trying to bring back to life and restore\na joy of living to some patients while eu-\nthanizing others . What should be done in\nthe numerous cases of depression in those\nsuffering from incurable diseases?\nThe situation prior to the law\nIt cannot be denied that euthanasia was\nperformed in Belgium before the law was\npassed, although in what numbers it is dif-\nficult to assess. Most certainly, it was done\nin some terminal cases (irreversible coma,\nunrelieved pain) and maybe also when the\ndeath did not present itself imminently but\nlife had become unbearable (locked-in syn-\ndrome). Belgium did experience a famous\ntrial at the end of the 1950\u2019s regarding the\neuthanasia of an infant born without arms\nor legs, after the intake of Thalidomide by\nthe mother while she was pregnant. The\ntrial ended with acquittals and there were\nno more trials dealing with euthanasia in\nBelgium until the subject was debated in\nthe parliament.\nWas there a need for a law?\nIn the past, when charged with the crime\nof euthanasia or medically assisted suicide,\npractitioners could raise the argument of a\nstate of necessity, which is the situation in\nwhich one has to act in opposition to the\nlaw because to obey it would lead to an\neven greater harm. However, the decision\nregarding the state of necessity belonged\nto a judge who would make it according to\ntheir own convictions.Therefore,in the past,\na physician was quite vulnerable, as the le-\ngitimacy of their decisions were subject to\nthe judgement of others. As a result, before\nthe current law was passed, euthanasia was\nhypothetically legally available to Belgian\nsociety under exceptional and justifiable\ncircumstances. However, there was little\nguarantee that even under these conditions,\na practitioner could be found who was will-\ning to risk the legal consequences if a judge\nwere to disagree with the physician\u2019s assess-\nment of what constituted an exceptional\nand justifiable case.\nThe current situation\nThe current law sought to make the situa-\ntion more consistent with the actual situ-\nation and, in doing so, it provided a very\npermissive framework within which eutha-\nnasia is permissible because patients with\nserious incurable diseases are eligible even\nif they are not threatened by imminent\ndeath. The patient is placed at the centre\nRegional and NMA newsBELGIUM\nRoland Lemye\nOpinion of the Belgian Medical Association\nAbout the Law Refering to Euthanasia\nwmj 2 2011 5CS.indd 71 4\/29\/11 11:13 AM\n72\nBELGIUMRegional and NMA news\nof the decision by his or her demand, an-\nticipated declaration, or by the demand of\nthe person of trust he or she has previous\nchosen, In addition, the family practitioner,\nif he or she accepts a request of euthana-\nsia, must have the eligibility of the patient\nchecked by a second physician and follow\nan administrative procedure that becomes\ncentral to the process. If the procedure is\nrespected, the practitioner must not be\nsued. Now the responsibility of the judge is\nto ensure that the procedural guidelines of\nthe law are followed instead of to judge the\nlegality of the performing practitioner\u2019s in-\ntent..\nThe current position of\nthe medical profession\nAt the time the current law was passed,\nthere was not a strong call from the medi-\ncal profession demanding a law to legal-\nize euthanasia. Our association was in\nopposition to any such legal initiative. In\nthe field, however, opinions were much\nmore divided and varied. Flemish doctors,\nprobably influenced by the example of the\nNetherlands, we more in favour of it than\nthe French-speaking physicians who are\nculturally bound to a more Latin vision of\nthings. Regardless, the law was voted and\npassed, taking advantage of the eviction of\nthe Catholic parties.The law has now been\nimplemented in Belgium for almost ten\nyears and, as of yet, there is no evidence of\nthe slippery slope of broadening eligibility\nthat the Netherlands has experienced. On\nthe contrary, an important opposition has\nbeen noted in the French-speaking part of\nthe country, although the Dutch-speaking\npart of the country has remained stable in\nits support of the law. Despite the law\u2019s\nhistory of non-revision, there is no guar-\nantee that changes to the law will not be\ncalled for in the future. Furthermore, the\ncomplexity of the administrative proce-\ndure and the uncertainty of the response\nto declarations of legal euthanasia suggest\nthat, even under the law, not all cases of\neuthanasia are declared. The question is\nalmost no longer mentioned in adminis-\ntrative boards since it is well known that\nopinions are even more divided since the\npublication of the law. Our association\nhas, however, refused to meet the request\nof some practitioners who, supported by\nmutual insurance companies and social se-\ncurity, have proposed to create a fee for this\nmedical act.\nRemaining questions\n1. Is life the absolute value which physi-\ncians have to protect at any cost?\n2. If there exists a hierarchy according to\nwhich life has to be sacrificed for more\nimportant values (sacrifice,suffering,\u00a0...),\nwho is able to judge? A physician has\nhis or her own hierarchy of values. His\nor her judgement may be altered by his\nown suffering or emotions. Society\u2019s\nopinon is most certainly the one that has\nto be disregarded in the individual deci-\nsion because it is the most motivated by\nmoney savings. But is the patient really\nable to judge? Does the anticipated de-\ncision really allow people to predict how\nthey will feel when faced with death?\nCouldn\u2019t it be said that people at the\nend of their life are too vulnerable and\nlikely to be swayed by the pressure of\ntheir entourage and society to be able\nto refuse such a decision? Who can ad-\nvocate for them better than their family\npractitioner in such a situation? Suicide\nand suicide attempts are such frequent\nevents in our society that it is difficult\nfor physicians who witness these situa-\ntions to leave the decision to die or not\nsolely with the afflicted patient, even\nif the decision for suicide seems to be\nbased on good reasons.\n3. To put an end to a patient\u2019s suffer-\ning when he or she is agonizing or has\nreached a stage of unconsciousness with-\nout any hope of recovering is one thing,\nbut to put an end to the life of an in-\ncurable patient who is not at a terminal\nstage is something different. If that last\nstatement is admitted, where is the bor-\nder?\n4. On the other hand, did not the physi-\ncians themselves induce a distorted im-\nage with therapeutic harassment, not\nalways misplaced. Here too, where is the\nline drawn?\n5. Is the family in a better position to de-\ncide? The family may have interests\nwhich could sway their decision. Even\nif there was no ulterior motive to decide\nfor euthanasia, is it right that the family\nbears the burden of such a decision?\n6. Some say that the family practitioner\ncould do that last duty to the patient, but\nis it really his or her role?\nConclusion\nCivil society is evolving. The rights of the\nindividual are growing while, at the same\ntime, a will for transparency threads on ev-\neryone\u2019s private life.The countries that have\nlegislated to allow euthanasia or medically\nassisted suicide have also, simultaneously,\nlegislated to define patient care to which\nall patients are entitled. By doing so, they\nalso define the patient care to which they\nare not entitled. According to the principle\nof equity, what is not affordable for every-\nbody should not be affordable for anybody.\nIs it possible to infer from all this that the\nconcepts of rationing, sustainability of pa-\ntient care, equity and euthanasia are bound\ntogether, whether the physicians accept it or\nnot? Whatever may happen in society, phy-\nsicians always have to stand on the side of\ntheir patients.\nDr. Roland LEMYE, President,\nAssociation Belge des Syndicats\nE-mail: roland.lemye@skynet.be\nwmj 2 2011 5CS.indd 72 4\/29\/11 11:13 AM\n73\nInfectious Diseases\nThe Challenge of Infectious\nDiseases: A\u00a0Historical\nPerspective \/lead of the section\nProf.\u00a0Charles Savona Ventura\/\nIt was made clear from the beginning of this\nconference that infectious diseases are still\nvery much at the top of most of the world\u2019s\nagenda. Malta\u2019s strategic importance due to\nits geographical position in the centre of\nthe Mediterranean has attracted a string of\npowers over the centuries, and with them,\ninfectious diseases.\nIn the Medieval ages it was well understood\nthat the spread of disease resulted from a\n\u201ccorruption of the atmosphere\u201d or, as it was\nknown at the time, a \u201cMiasma\u201d. By the time\nthe Knights of the Order of St John pre-\nsided over the archipelago, quarantine was\nstrictly enforced. Punishments were harsh\nif regulations were infringed but Malta had\nbeen stung by repeated outbreaks of the Bu-\nbonic Plague and every effort was made to\nstem the deaths.\nBishop Island (now Manoel Island) was\nthe site for the temporary accommodation\nof sailors entering Malta\u2019s harbours during\nthe British Period. John Howard described\nthe fumigation process, or \u201cperfuming\u201d,\nthat took place there. The worst plague to\never the hit the island occurred in 1675,\nclaiming the lives of 20% of the population.\nGozo, however, was spared. It was not un-\ntil 1894 that the causative bacterium was\nidentified and the last outbreak of plague\ntook place during the Second World War,\nthe Government setting a price on rats\u2019\nheads.\nHepatitis C: Current Standards of Care\n\/lead of the section Dr. James Pocock\/\nThe 6 genotypes of the Hepatitis C virus\nwere identified and described, as was the\nscreening process for their respectable anti-\nbodies. Hepatitis C is a chronic disease that\nleads to cirrhosis and liver failure in 30% of\npatients, with the attendant risk of Hepato-\ncellular Carcinoma.\nThe virus may be transmitted through the\nbloodstream, through contact of mucous\nmembranes, or vertically during childbirth.\n72% of cases in Malta are drug addicts.\nDrugs include PEGylated Interferon and\nRibavirin. There are numerous adverse af-\nfects of PEGylated Interferon, including\nan Influenza-like syndrome, bone-marrow\nsuppression and autoimmune diseases. Rib-\navirin also has serious side effects, namely\nteratogenicity and a tendency to induce\nhaemolysis. Contraindications for the use\nof these drugs include co-morbidities, preg-\nnancy and decompensated liver failure.\nThe Markov Model, constructed from co-\nhort studies, predicts the course of Hepa-\ntitis C in different patients, the possible\noutcomes being a breakthrough, relapse or\na sustained virological response. The im-\nportance of achieving an early virological\nresponse (EVR) is recognized. The aim is\nfor a 50% reduction in vRNA by the 12th\nweek of treatment. Genotypes 2 and 3 are\nclassified as dose-independent patients\nwhilst genotypes 1 and 4 are dose-depen-\ndent patients. A single letter genetic varia-\ntion of the IL 28B Gene on chromosome\n19, coding for interferon \u03bb3, seems to be\nresponsible for the genotypic variation.\nStudies have shown that prolonged treat-\nment for 24 weeks are beneficial for geno-\ntypes 2 and\u00a03.\nTreatment should be terminated after 72\nweeks for patients who fail to respond.\nProtease inhibitors are used after trying a\nPEGylated interferon and Ribavirin com-\nbination. There is also an ethnic variation\nin the degree of response to treatment, with\nAsians reacting well but Africans poorly.\nChallenges in Prosthetic Joint\nInfections \/lead of the section\nDr.\u00a0Charles Mallia-Azzopardi\/\nThe main sites vulnerable to developing\nprosthetic joint infections were outlined,\nwith special emphasis on the hip and the\nknee, as well as revision arthroplasties.\nAdvanced age, obesity and diabetes were\nmentioned as predisposing factors and\nCoagulase-negative Staphylococci were\nidentified as the most important causative\npathogens.\nGordon Caruana-Dingli\nReport from Infectious Diseases Conference,\nMalta 2010\nStephen Micallef-Eynaud\nwmj 2 2011 5CS.indd 73 4\/29\/11 11:13 AM\n74\nInfectious Diseases\nProsthetic joint infections may be classified\naccording to their time of onset into early,\nmiddle and late. The former occur within 3\nmonths of the operation and are generally\ncaused by more virulent organisms.They are\ncharacterized by an inflammatory response\naround the suture line. The latter may arise\n2 years after the operation, are generally\ncaused by less virulent organisms and are\noften the result of haematogenous spread\nfrom a urinary tract infection, pulmonary\ninfection or any other primary locus.\nThe \u201cArthroplasty Effect\u201d was described.\nMacrophages are known to take up debris\nfrom the prosthesis. An increase in osteo-\nclast activity then follows, possibly due to\ninflammatory mediators. Bone resorption\nultimately leads to mechanical dysfunc-\ntion. A key element in the pathogenesis is\nthe development of a biofilm. This impreg-\nnable surface offers protection to the mi-\ncrobes beneath, where they exist in a highly\norganized community and exhibit quarum\nsignaling and the development of complex\nwater channels.\nCorrect diagnosis involves the measurement\nof inflammatory markers: CRP and ESR. A\nhigh white blood cell count and procalci-\ntonin level are less sensitive tests. There are\nvarious means of imaging the joint. X-rays\noften prove to lack sensitivity. MRI and CT\nscanning are of limited use. Nuclear imag-\ning is not ideal. Sinugrams may be more\nhelpful in visualizing the site of infection.\nMicrobiological culture and sensitivity test-\ning requires organisms to be retrieved from\nthe peri-prosthetic area and not the sinus,\nwhere the flora will correlate poorly with\nthat found at the surgical site.\nThe joint is removed and placed in a vor-\ntex container. This removes the biofilm and\nallows proper investigation of the joint, in-\ncluding careful sampling and debridement\nof necrotic tissue. The patient receives long\nterm antibiotic therapy before undergoing\na joint replacement. An antibiotic-impreg-\nnated cement is used for this procedure.\nInfections in an Intensive\nCare Unit \/lead of the section\nDr. Sundaram Arulrhaj\/\nVentilator-associated pneumonias (VAPs),\ncatheter-associated urinary tract infection\n(CAUTIs), and catheter-related blood-\nstream infection (CRBSIs) are just a hand-\nful of the enormous list of infectious dis-\neases encountered in an ICU environment,\nwhere pathogens may invade the patient\n\u201cfrom the floor to the roof \u201d.\nSeveral factors contribute to the high in-\ncidence of these infections in the ICU\nand the associated poor patient outcomes.\nCompared to patients in the general hos-\npital population, patients in ICUs have\nmore chronic comorbid illnesses and more\nsevere acute physiologic derangements.\nThe use of certain drugs, such as sedatives\nand muscle relaxants also predisposes to\ninfection.\nThe high frequency of indwelling catheters\namong ICU patients provide a portal of\nentry of organisms into the bloodstream.\nThe use and maintenance of these catheters\nnecessitate frequent contact with health\ncare workers, which predispose patients to\ncolonization and infection with nosocomial\npathogens.\nMultidrug-resistant pathogens such as\nmethicillin-resistant Staphylococcus au-\nreus (MRSA) and vancomycin-resistant\nenterococci (VRE) are being isolated with\nincreasing frequency in ICUs. Infections\ncaused by these resistant pathogens are dif-\nficult to treat effectively.\nmHealth \/lead of the section\nDr. Michael Chamberlain\/\nmHealth is the practice of medical and\npublic health, supported by mobile devices.\nWhilst it certainly has a role for industrial-\nized nations, the field has emerged in recent\nyears as a major application for developing\ncountries, stemming from the rapid rise of\nmobile phone penetration in low-income\nnations. mHealth is a useful means of pro-\nviding greater access to larger segments of a\npopulation in developing countries, as well\nas improving the capacity of health systems\nin such countries to provide quality health-\ncare.\nThe motivation behind the development of\nthe mHealth field arises from two factors.\nThe first factor concerns the myriad con-\nstraints felt by the healthcare systems of de-\nveloping nations. These constraints include\nhigh population growth, a high burden of\ndisease prevalence, low health care work-\nforce, large numbers of rural inhabitants,\nand limited financial resources to support\nhealthcare infrastructure and health infor-\nmation systems.The second factor is the re-\ncent rapid rise in mobile phone penetration\nin developing countries to large segments\nof the healthcare workforce, as well as the\npopulation of a country as a whole. With\ngreater access to mobile phones, the po-\ntential of lowering information and trans-\naction costs in order to deliver healthcare\nimproves.\nThe combination of these two factors have\nmotivated much discussion of how greater\naccess to mobile phone technology can be\nleveraged to mitigate the numerous pres-\nsures faced by developing countries\u2019 health-\ncare systems.\nTrinidad and Tobago \/lead of the\nsection Dr. Soloiman Juman\/\nThe talk focused on the main infectious dis-\neases crippling this twin island state.\nHIV remains at the forefront of the popula-\ntion\u2019s health burdens. The incidence of new\ncases has remained fairly constant in recent\nyears, with a 3.2% prevalence. Only 6,000\nof the 18,000 people infected with HIV\nare receiving treatment. HIV has received\nincreasing attention over the past five years\nwith the introduction of the National AIDS\nCoordinating Committee and the Medical\nResearch Foundation in the capital, Port of\nSpain.\nwmj 2 2011 5CS.indd 74 4\/29\/11 11:13 AM\n75\nInfectious Diseases\nDengue has spread relentlessly through the\nCaribbean in the past 2 years.There is some\ndiscrepancy in identifying \u2018true cases\u2019. Tu-\nberculosis, which had been rampant up un-\ntil the early 1980s, has reared its ugly head\nagain in concordance with the rise in HIV\/\nAIDS and a trend in antibiotic resistance.\n5 deaths due to H1N1 infection were also\nnoted in the country.\nIn 1983 only 60% of children one year of\nage and younger had been immunized\nagainst measles, poliomyelitis, diphthe-\nria, pertussis, and tetanus. The implication\nof the deficient inoculation programs was\nevident in the 4.7% of total deaths result-\ning from infectious and parasitic diseases;\nthis was significantly higher than on other\nEnglish-speaking Caribbean islands.Today,\nthe pneumococcal polyvalent vaccine is only\navailable privately.\nNigeria \/lead of the section\nProf. Oluwole Ayoola Atoyebi\nand Dr. Chris Piwuna\/\nThe immensity of the impact that infectious\ndiseases have had and continue to have on\nAfrica\u2019s most populous country, with a pop-\nulation of 151 million, was outlined from\nthe beginning of this talk.\nOnly 53% of the population have constant\naccess to safe drinking water. \u201cExtreme\nPoverty\u201d is on the rise throughout the\ncountry, and with it infectious diseases. 2.6\nmillion people are living with AIDS. The\nprevalence of HIV stands at 3.1%. Non\ncommunicable diseases are also increas-\ning, particularly among the higher income\ngroups, possibly as a result of poor dietary\nhabits and unhealthy lifestyles. Poverty and\nilliteracy are becoming more widespread\nand urban slums are growing. Venereal\ndiseases are rife throughout much of the\ncountry and \u201cReligion\u201d was likened to the\nWest\u2019s way of polluting the minds of Ni-\ngeria\u2019s people.\nMalaria has greatly risen in incidence and\nthe parasite is showing resistance. The\neconomy has been severely affected by this\ndisease. The worst death rates have been in\nchildren. Faeco-oral diseases are also on the\nrise and the recent cholera epidemics have\nbeen grave.\nMeasles continues to affect many children\neach year. Other diseases widespread in Ni-\ngeria are: Leprosy, Meningococcal Menin-\ngitis, Tuberculosis, Poliomyelitis and Neo-\nnatal Tetanus.\nMalaysia \/lead of the section\nDr. Ara Nachiappan Arumugam\nand Dr. Kuljit Singh\/\nThe country lies just north of the equator\nand supports a rich tropical environment.\nThe jungles and swamps that characterize\nmuch of Malaysia provide a perfect habitat\nfor mosquitoes, as was noted by Sir Frank\nSwettenham, the viceroy of British Malaya\nduring the colonial period. Still a large per-\ncentage of the population are farmers and\nfishermen. Sustainable logging accounts\nfor a significant portion of the country\u2019s\neconomy.\nThere is a long list of notifiable diseases in\nMalaysia. Dengue has become very com-\nmon in recent years. It occurs in cities as\nwell as rural areas. Plans to release a ge-\nnetically modified mosquito to wipe out\nthe natural vector for the disease have had\nsceptical responses. Surveillance maps al-\nlow \u2018hot spots\u2019for infection to be identified.\nTuberculosis, food poisoning and Chikun-\ngunya are also high on the list. There have\nbeen sporadic cases of Avian Influenza,\nH1N1 and SARS. 3 million foreign work-\ners and 1 million illegal workers provide a\ncontinual source for the re-emergence of\ninfectious diseases.\nInfluenza \/lead of the section\nDr.Tanya Melillo\/\nInfluenza, commonly referred to as the flu,\nwas defined as an infectious disease caused\nby RNA viruses of the family Orthomyxo-\nviridae, that affects birds and mammals.The\nmost common symptoms of the disease\nwere identified: chills, fever, sore throat,\nmuscle pains, severe headache, coughing,\nweakness\/fatigue and general discomfort\nare all characteristic.\nVaccinations against influenza are usually\ngiven to people in developed countries and\nto farmed poultry. The most common hu-\nman vaccine is the trivalent influenza vac-\ncine (TIV) that contains purified and in-\nactivated material from three viral strains.\nTypically, this vaccine includes material\nfrom two influenza A virus subtypes and\none influenza B virus strain.The TIV carries\nno risk of transmitting the disease, and it\nhas very low reactivity. A vaccine formulat-\ned for one year may be ineffective in the fol-\nlowing year,since the influenza virus evolves\nrapidly, and new strains quickly replace the\nolder ones. Antiviral drugs can be used to\ntreat influenza, with neuraminidase inhibi-\ntors being particularly effective.\nInfluenza is much more severe and lasts\nlonger than the common cold. Most people\nwill recover completely in about one to two\nweeks, but others will develop life-threat-\nening complications (such as pneumonia).\nInfluenza, thus, can be deadly, especially\nfor the weak, young and old, or chronically\nill. Those who are immunosuppressed, such\nas people with advanced HIV infection or\ntransplant patients, suffer from particularly\nsevere disease. Other high-risk groups in-\nclude pregnant women and young children.\nThe flu can worsen chronic health problems.\nPeople with emphysema, chronic bronchi-\ntis or asthma may experience shortness of\nbreath while they have the flu,and influenza\nmay cause worsening of coronary heart dis-\nease or congestive heart failure. Smoking is\nanother risk factor associated with more se-\nrious disease and increased mortality from\ninfluenza.\nReference was made to the various strains\nof influenza viruses: the present H1N1 pan-\ndemic, Avian H5N1, H9N2 (China 1999)\nand H7N3 (Holland).\nwmj 2 2011 5CS.indd 75 4\/29\/11 11:13 AM\n76\nInfectious Diseases\nIt was appreciated that the threat of H1N1\nis still with us. The virus acquired its pan-\ndemic properties in Mexico. It is known\nto be more prevalent and serious amongst\nyoung and pregnant females. Because the\nmean age of death is just 34.7 years, the\nnumber of years of life lost is high. It is\nunderstood that those who have a D222G\ngene mutation are the worst affected.\nUganda \/lead of the section\nDr. Margaret Mungherera\nand Dr. Jenifer Kavuma\/\nThis equatorial country has a growing pop-\nulation of 31 million, 35% of whom are se-\nverely impoverished.Infant mortality stands\nat 76 per 1,000.At the forefront of Uganda\u2019s\nhealthcare woes are a massive \u2018brain drain\u2019\nproblem and a mushrooming of alternative\nmedicine.\nThere is a National Health Policy which\naims to provide primary healthcare de-\nlivery and financing. The majority of the\noutpatient workload is composed of infec-\ntious diseases. Malaria accounts for 40%,\nRespiratory infections\u00a0 \u2013 25% and HIV\/\nAIDS\u00a0\u2013 6.2%. Tuberculosis has re-emerged\nas an important and widespread infectious\naffliction.\nKey programs for infectious diseases in-\nclude Malaria Control, to stem the current\nupsurge in Malaria, AIDS Control, Clini-\ncal Intervention, Tuberculosis and Leprosy\nControl, Nutrition and Health Promotion.\nThe 6 traditional vaccines are offered as well\nas the Hepatitis B and Haemophilus Influ-\nenzae vaccines.\n70% of ill-health amongst children is relat-\ned to malnutrition. Breast feeding is being\npromoted. Radio and television are utilized\nfor health promotion and there is an ongo-\ning handwashing and soap campaign. The\nchallenges are varied and are financial, cul-\ntural, political and infrastructural in nature.\nHospice Africa and a Palliative Care Uni-\nversity course have been highly successful in\nUganda.\nNovel Antibiotics \/lead of the\nsection Dr. Paul Caruana\/\nWe are living in an era where infectious dis-\neases that were once notorius killers of the\npast are staging a collective comeback in the\nform of antibiotic-resistant strains of bac-\nteria. Bacteria obtain resistance genes from\nvarious sources. When it comes to natural-\nly-derived bactericidal agents, pools of re-\nsistance genes exist in the wild, in plasmids,\ntransposons and other vectors. Synthetic\nantibiotics on the other hand demand mu-\ntations of the bacterial genome in order to\nafford resistance.\nMention was made of the emergence\nof highly resistant \u201cSuperbugs\u201d such as\nMRSA,VISA and VRSA, and that bacteria\noutnumber human cells by ten to one.It was\noutlined from the start that the manufac-\nture of new antibiotics is not cost effective.\nDaptomycin is used as a last line for resis-\ntant Gram positiveve agents. It is extremely\ntoxic and was sold off by the original man-\nufacturer to a pharmaceutical company.\nThere is a small market for its use; hence its\nmanufacture may not be worth the price. It\nis used to treat VISA and VRSA, for soft\ntissue staphylococcal infections and bacter-\naemia and right sided endocarditis.\nLinezolid, which can only be given via\nthe intravenous route, is associated with\nthrombocytopaenia and optic neuritis and\nmust not be continued for over 28 days.\nQuinupristin and Dalfopristin are used to\ntreat staphylococci and streptococci. Li-\npoglycopeptides such as Televancin and\nDalbavancin are still in the third phase of\nclinical trials and have not yet been FDA\napproved.\nGram negative bacteria are equipped with\na semi-permeable membrane that drugs\nmust pass through to affect the bacte-\nrium, hence the potential for resistance\nis much greater. Strains of Pseudomonas\nand Acinetobacter have shown extreme\nmulti-drug resistance. Carbapenemase-\nproducing E.coli and Klebsiella have also\nbeen recorded. Resistance genes are easily\ntransmitted via plasmids. Tigecycline, a\nderivative of Minecycline, is used to treat\nsoft tissue infections.\nMore futuristic antibiotics include NXL\n104 and antibacterial polypeptides and\npolymyxins derived from anywhere between\nfrog\u2019s skins all the way to insect secretions.\nIt was pointed out that the situation in vet-\nerinary practice is just as bad, if not worse,\nand that species leakage of antibiotic resis-\ntance is an extremely important factor to\nconsider.\nGhana \/lead of the section\nDr.\u00a0Kwabena Opuku Adusei and\nDr. Rita Larsen-Reindorf\/\n\u2018Roll Back Malaria\u2019 is a recent incentive in\nGhana to combat the upsurge of malaria\nthat has spread relentlessly throughout the\ncountry in recent years. The severest out-\ncomes have been in children under 5 years\nold and in pregnant women. Breeding\ngrounds of the Anopheles gambiae mos-\nquito are targeted by indoor resisdual spray-\ning with insecticides. However, poor record\nkeeping and the poor quality of drugs used\nto treat the condition have limited the ef-\nfectiveness of this campaign.\nThe \u2018Hang Up Campaign\u2019has been initiated\nto increase public awareness of the benefits\nof mosquito nets in the prevention of ma-\nlaria.\nThere is a 2.9% prevalence of malaria in\nGhana,with more people in the south of the\ncountry being infected. Numbers are rising.\nThe Ghana AIDS Community strives to\nestablish good education, management and\ncontrol of the disease and those affected\nby it. Anti-Retroviral Treatment services\n(ART) are heavily subsidized and the are\nfree. They include CD4 counts. There are\nplans to set up HAART centres within the\ncountry. Challenges to adequate healthcare\nin the community are plentiful and diverse,\nwmj 2 2011 5CS.indd 76 4\/29\/11 11:13 AM\n77\nInfectious Diseases\nincluding social stigma and beliefs, funding\nand popular culture.\nBangladesh \/lead of the section\nProf. Sharfuddin Ahmed\/\nThe country is home to 162 million, the 8th\nmost populous country in the world, and is\nthe 6th\nworst Tuberculosis-affected country,\nalong with Cambodia, Ethiopia, Afghani-\nstan and India. Other infectious diseases\nthat continue to plague the country are Ma-\nlaria, Kala-Azar, Leptospirosis, Infectious\nDiarrhoea, Dengue, Nipah Virus and HIV.\nHealth and education levels remain rela-\ntively low, although they have improved re-\ncently as poverty levels have decreased.Most\nBangladeshis continue to live on subsistence\nfarming in rural villages. Health problems\nabound, springing from poor water quality\nand prevalence of infectious diseases. The\nwater crisis is acute, with widespread bacte-\nrial contamination of surface water and ar-\nsenic contamination of groundwater. There\nare high risk endemic districts for malaria.\nThe incidence of Hepatitis A is currently\n2\u20137%, that of Hepatitis B is 2\u20134% and that\nof Hepatitis C is 1\u20133%. Because 90% of the\npopulation are Muslim and are generally\nsexually disciplined, the prevalence of HIV\/\nAIDS is comparatively low (0.1%).\nFilariasis is endemic in 23 districts and 20\nmillion are already infected. Diarrhoeal dis-\neases are especially common during the sea-\nsonal cyclones which bring bad floods and\nwater pollution.There have been both dengue\nand anthrax epidemics. H1N1 and H5N1\nhave also left their mark on the country\nCyprus \/lead of the section\/lead of\nthe section Dr.\u00a0Andreas Demetirou\/\nIn stark contrast to the developing nations,\nCyprus has a very low incidence of infec-\ntious diseases. 40% of annual deaths are due\nto cardiovascular morbidity, 20% due to\nneoplasia and 10% due to diabetes.\nHowever,the country has seen large influxes\nof foreigners and tuberculosis is on the rise.\nThere have been only 3 reported cases of\nMDR resistant tubercle bacilli in 10 years.\nTuberculosis patients are isolated for 3\nweeks in a special residence in the moun-\ntains until they are sputum culture negative.\nThe question was raised as to whether or\nnot this violated human rights.\nSevere Sepsis \/lead of the\nsection Dr.Tonio Piscopo\/\nWorldwide, 18 million people die from\nsepsis every year. It carries a 25\u201330% mor-\ntality rate. Sepsis cases are set to grow at\na rate of 1.5% per annum. Sepsis was de-\nfined as a systemic inflammatory response\nsyndrome (SIRS) resulting from infection.\nInfection, in turn, was defined as an inva-\nsion by microorganisms causing inflam-\nmation.\nThe signs of sepsis were discussed. A tem-\nperature above 38\u00b0C, a heart rate above 90\nbeats\/minute, a respiratory rate above 20\nbreaths\/minute and a white cell count above\n12,000\/mm3 are all helpful diagnostically.\nThe pathological mechanism underlying\nsepsis was discussed, with reference to the\nbacterial lipopolysaccharides that trigger\nthe immune response.The role of Activated\nProtein C in counteracting the pro-coagu-\nlation pathway and of bradykinin and the\ncytokines in the production of oedema were\nalso discussed. It was noted that it is the\nbody\u2019s reaction to infection, rather than the\ninfection itself which produces most of the\nwidespread damage. The organisms become\n\u2018bystanders\u2019.\nOutcomes of sepsis include confusion,\nchange in personality, tachypnoea, jaundice\nand hepatic necrosis, fever, disseminated\nintravascular coagulation and renal failure,\namongst others. The role of antibiotics in\nlowering the infectious load, the toxic bur-\nden and the inflammatory response was\ndiscussed.The causes for delays in the man-\nagement of sepsis include logistical delays,\nfailure to give clear instructions and a failure\nto reach a correct diagnosis.\nHighly Infectious Diseases \/lead of\nthe section Dr.\u00a0Barbara Bannister\/\nThe regional importance of infectious\ndiseases throughout much of the Com-\nmonwealth was stressed. Severe disease is\ngaining ground in new threats such as bio-\nterrorism. All cause death by initiating a\nsepsis syndrome.\nViral infections were discussed. The death\nand malfunction of immune N-K phago-\ncytic cells through interferon damage in-\nduced by viruses was described.It was stated\nthat these infections are largely zoonotic.\nThe Haemorrhagic fevers, including yellow\nfever, hendra, dengue, Rift Valley virus and\ntularaemia were mentioned.\nCrimean\u2013Congo hemorrhagic fever\n(CCHF) is a widespread tick-borne vi-\nral disease, a zoonosis of domestic animals\nand wild animals, that may affect humans.\nThe pathogenic virus, especially common in\nEast and West Africa, is a member of the\nBunyaviridae family of RNA viruses. Clini-\ncal disease is rare in infected mammals, but\ncommonly severe in infected humans, with\na 30% mortality rate. Outbreaks of illness\nare usually attributable to handling infected\nanimals or people.\nSporadic infection of people is usually\ncaused by Hyalomma tick bite. Clusters of\nillness typically appear after people treat,\nbutcher or eat infected livestock, particular-\nly ruminants and ostriches. Outbreaks have\noccurred in clinical facilities where health\nworkers have been exposed to infected\nblood and fomites.\nThe causative organism is found in Asia,\nEastern Europe, the Middle East, a belt\nacross central Africa and South Africa and\nMadagascar. The main environmental res-\nervoir for the virus is small mammals (par-\nticularly European hare, Middle-African\nhedgehogs and multimammate rats). Ticks\ncarry the virus to domestic animal stock.\nSheep, goats and cattle develop high titers\nof virus in blood, but tend not to fall ill.\nwmj 2 2011 5CS.indd 77 4\/29\/11 11:13 AM\n78\nInfectious Diseases\nBirds are generally resistant with the excep-\ntion of ostriches.\nTypically, after a 1\u20133 day incubation period\nfollowing a tick bite (5\u20136 days after expo-\nsure to infected blood or tissues), flu-like\nsymptoms appear, which may resolve after\none week. In up to 75% of cases, however,\nsigns of hemorrhage appear within 3\u20135 days\nof the onset of illness in case of bad con-\ntainment of the first symptoms: first mood\ninstability, agitation, mental confusion and\nthroat petechiae, then soon nosebleeds,\nbloody urine and vomiting,and black stools.\nThe liver becomes swollen and painful. Dis-\nseminated intravascular coagulation may\noccur as well as acute kidney failure and\nshock, and sometimes acute respiratory dis-\ntress syndrome.\nPatients usually begin to recover after 9\u201310\ndays from symptom onset, but 30% die in\nthe second week of illness.\nWhere mammal and tick infection is com-\nmon agricultural regulations require de-\nticking farm animals before transporta-\ntion or delivery for slaughter. Personal tick\navoidance measures are recommended, such\nas use of insect repellents,adequate clothing\nand body inspection for adherent ticks.\nWhen feverish patients with evidence of\nbleeding require resuscitation or intensive\ncare, body substance isolation precautions\nshould be taken. The United States armed\nforces maintain special stocks of ribavirin to\nprotect personnel deployed to Afghanistan\nand Iraq from CCHF.\nTreatment is primarily symptomatic and\nsupportive,as there is no established specific\ntreatment. Ribavirin is effective in vitro and\nhas been used during outbreaks, but there is\nno trial evidence to support its use.\nThe Filoviruses were then discussed. Filo-\nviridae is the family of viruses that belong\nto the order Mononegavirales. Filoviruses\ncause viral hemorrhagic fevers, character-\nised by often fatal bleeding and coagulation\nabnormalities. The name Filovirus is de-\nrived from the Latin word filum, alluding to\nthe thread-like appearance of virus particles\nin electron microscope images.[1] Filo-\nviruses are single stranded negative sense\nRNA viruses that target primates.There are\ntwo genera: the Ebola virus and Marburg\nvirus. Mechanisms of transmission were\ndescribed, with reference to Bundibugyo, a\nsmall town in western Uganda where fruit\nbats serve as the main reservoir for filovi-\nruses and are transmitted via monkey bush\nmeat.The Arena viruses are spread by rats.\nThe Viral Haemorrhagic Fevers were then\ndiscussed.There is an acute onset of flu-like\nsymptoms with these diseases,characterized\nby abdominal pain, aches, myalgia and fever.\nBlood tests reveal a low white cell count and\na raised C-Reactive Protein level. There is\nfrank bleeding from the nose and gums. An\nescalation of AST is coupled with a pro-\nfound decrease in the platelet count.With a\npatient presenting with the early features of\nCrimean Congo Haemorrhagic Fever (pe-\ntechiae, soft tissue bleeding and bruising,\ngastrointestinal bleeding and exsanguinat-\ning nose bleeds) we must enquire about re-\ncent travel to tropical destinations. Antigen\ntesting, such as IgM ELSIA, is insensitive\nbecause the patient has a damaged immune\nsystem. Vial culture is the gold standard.\nManagement includes early Ribavirin to\nraise the platelet count and lower mortality.\nThe bleeding must then be managed. There\nis no licensed vaccine.\nWe should educate people living in endemic\nareas not to squash ticks and instruct them\non good food and farm hygiene.\nLassa Fever was next discussed. The virus\ncomes from the Arenaviridae family and its\nreservoir lies in the rat population. Spread is\nthrough rat faeces, urine and bites. There is\na Lassa Fever belt across West Africa from\nGuinea to Cameroon, but interestingly not\nin Ghana.\nThe presenting features include a non-pit-\nting swelling of the face and neck, as well\nas haemorrhagic signs. There may be neu-\nrological features and full-blown sseptic\nshock. The markers of prognosis include a\nviraemia, and incubation periods, which are\nvery helpful in risk assessment.\nRisk factors are important and include:\nTicks, handling and butchering animals,\ntraditional funeral ceremonies, needle stick\ninjuries,caring for a sick family member and\nworking around drains (where rats abound).\nChikungunya, first described in Tanzania in\n1953, is spread by the Asian Tiger mosquito\nand has led to epidemics in the tropics,most\nnotably in Mauritius.Climate may have far-\nreaching implications, with the mosquito\nbeing able to spread over winter months.\nHIV in Pregnancy \/lead of the section\nDr. Lisa Micallef Grimaud\/\nMother to child transmission of HIV\/\nAIDS is exceptionally prevalent in Sub-\nSaharan Adfrica and 40% of all cases oc-\ncur within the Commonwealth. Maternal\nfactors include the HIV viral load, genital\ninfections with ulcers and intravenous drug\nabuse. Pregnancy factors include chorioam-\nnionitis, prolonged rupture of membranes,\nthe gestational age at delivery and the mode\nof delivery.\nWhen HIV is diagnosed during Pregnancy\nthe mother is first assessed and it must be\ndecided whether she needs Anti-Retroviral\nTherapy for her own health. Is so, ART is\ninitiated. If not, ART begins in the second\ntrimester. The PACTG 076 Study showed\nthat Zinovudine prophylaxis decreased ver-\ntical transmission by 67.5%.\nAnti-Retroviral Therapy in pregnancy de-\ncreases the viral load by crossing the pla-\ncenta and by decreasing secretions. Delivery\nshould be by pre-labour caesarean section\nat 39 weeks, under intravenous zinovudine\ncover. In Malta HIV is usually diagnosed\nduring the second and third trimester.\nwmj 2 2011 5CS.indd 78 4\/29\/11 11:13 AM\n79\nInfectious Diseases\nHIV in Children \/lead of the\nsection Dr. David Pace\/\nThis is a worldwide problem, with the lat-\nest epidemics occurring in Eastern Europe,\nCentral and South-East Asia and Sub-\nSaharan Africa. Most cases are due to peri-\nnatal transmission. Management includes\ncombination ART for the mother, caesar-\nean section, avoidance of breastfeeding and\nART prophylaxis in children.\n68% of HIV cases in Malta have been in\nmigrants from Sub-Saharan Africa, 18% in\nMaltese, 9% in Eastern Europeans and 5%\nin North Africans. The majority of moth-\ners infected with HIV were unsupported.\nMost fathers accepted testing. The peak\nwitnessed in 2008 corresponded with the\npeak in illegal immigration of that year.\nThe mode of delivery was found to signifi-\ncantly affect the rates of vertical transmis-\nsion. Vaginal delivery, Elective Caesarean\nand Emergency Caesarean section resulted\nin 10%, 2% and 9% rates of transmission\nrespectively.\nBreast milk is known to contain HIV in\nboth cell form and free form.Administering\nART to infants will not only be of benefit to\ntheir own health but will benefit the general\npopulation by rendering them potentially\nless infective. Challenges faced by clinicians\ninclude language barriers, poverty (many\nare unable to afford the formula milk), im-\nproper sterilization of bottles, inappropriate\nmixing techniques and cultural stigmas.\nHIV and Hepatitis \u2013 Challenging\nInteractions \/lead of the\nsection Dr. Alistair Miller\/\nIt was stressed that if one blood-borne virus\nis diagnosed, the patient should be investi-\ngated for other blood-borne viruses, with\nsimilar routes of transmission.\nModels of care include well-equipped\ngenitourinary, hepatology and infectious\ndiseases clinics. Globally, 175 million are\ninfected with HIV, 60 million are infected\nwith Hepatitis C and amongst them, some\n10 million are suffering from a co-infection\nbetween the two viruses.\nChronic liver disease rates are known to\ncoincide with HIV epidemics and co-in-\nfection results in a much higher grade of\nHepatitis C viraemia.To add even more in-\nsult to injury, Anti-Retroviral Therapy pro-\nduces various toxic effects on the liver.Some\nof the drugs used cause hepatic fibrosis and\nnon-cirrhotic portal hypertension. A liver\nbiopsy will establish the degree of fibrosis.\nThe need to initiate immediate Antiretro-\nvirals should be questioned in view of the\nindividual patient.\nIt was pointed out that in a child the im-\nmune system is not yet mature. Infection\nwith Hepatitis B results in high levels of\nthe Hep B virus (the so called \u2018Immune\ntolerant\u2019 phase). Once the immune system\nbegins to develop resistance against the\nHep B virus, inflammatory processes begin\nto damage the liver, in contrast to Hep C\ninfection where the virus particle itself is\nresponsible for the liver damage, and end\nstage hepatic failure.\nMalaria \u2013 Counting it Out\n\/lead of the section Dr. Chantal\nGalea and Dr. Claudia Fsadni\/\nMalaria is a mosquito-borne infectious dis-\nease of humans caused by eukaryotic pro-\ntists of the genus Plasmodium. It is wide-\nspread in tropical and subtropical regions,\nincluding much of Subsaharan Africa,\nAsia and the Americas. The disease results\nfrom the multiplication of malaria parasites\nwithin red blood cells, causing symptoms\nthat typically include fever and headache,\nin severe cases progressing to coma, and\ndeath.\nFive species of Plasmodium can infect hu-\nmans: severe disease is largely caused by\nPlasmodium falciparum. Malaria caused by\nPlasmodium vivax, Plasmodium ovale and\nPlasmodium malariae is generally a milder\ndisease that is rarely fatal. A fifth species,\nPlasmodium knowlesi, is a zoonosis that\ncauses malaria in macaques but can also in-\nfect humans.\nMalaria transmission can be reduced by\npreventing mosquito bites by distribution\nof inexpensive mosquito nets and insect\nrepellents, or by mosquito-control mea-\nsures such as spraying insecticides inside\nhouses and draining standing water where\nmosquitoes lay their eggs. Although many\nare under development, the challenge of\nproducing a widely available vaccine that\nprovides a high level of protection for a\nsustained period is still to be met. Several\ndrugs are also available to prevent malaria\nin travellers to malaria-endemic countries\n(prophylaxis).\nA variety of antimalarial medications are\navailable. In the last 5 years, treatment of\nP. falciparum infections in endemic coun-\ntries has been transformed by the use of\ncombinations of drugs containing an arte-\nmisinin derivative. Severe malaria is treated\nwith intravenous or intramuscular quinine\nor, increasingly, the artemisinin derivative\nartesunate which is superior to quinine in\nboth children and adults.Resistance has de-\nveloped to several antimalarial drugs, most\nnotably chloroquine.\nEach year, there are more than 225 million\ncases of malaria, killing around 781,000\npeople each year according to the latest\nWHO Report. The majority of deaths are\nof young children in sub-Saharan Africa.\nNinety percent of malaria-related deaths\noccur in sub-Saharan Africa. Malaria is\ncommonly associated with poverty, and can\nindeed be a cause of poverty and a major\nhindrance to economic development.\nFor areas where microscopy is not avail-\nable, or where laboratory staff are not ex-\nperienced at malaria diagnosis, there are\ncommercial antigen detection tests that\nrequire only a drop of blood. Immunochro-\nmatographic tests have been developed,\ndistributed and fieldtested. These tests use\nfinger-stick or venous blood, the completed\nwmj 2 2011 5CS.indd 79 4\/29\/11 11:13 AM\n80\nInfectious Diseases\ntest takes a total of 15\u201320 minutes, and the\nresults are read visually as the presence or\nabsence of colored stripes on the dipstick,\nso they are suitable for use in the field. The\nfirst rapid diagnostic tests were using P. fal-\nciparum glutamate dehydrogenase as anti-\ngen.\nMolecular methods are available in some\nclinical laboratories and rapid real-time as-\nsays (for example, QT-NASBA based on\nthe polymerase chain reaction) are being\ndeveloped with the hope of being able to\ndeploy them in endemic areas.\nPCR (and other molecular methods) is\nmore accurate than microscopy. However,\nit is expensive, and requires a specialized\nlaboratory. Moreover, levels of parasitemia\nare not necessarily correlative with the pro-\ngression of disease, particularly when the\nparasite is able to adhere to blood vessel\nwalls. Therefore more sensitive, low-tech\ndiagnosis tools need to be developed in or-\nder to detect low levels of parasitemia in\nthe field.\nEfforts to eradicate malaria by eliminating\nmosquitoes have been successful in some ar-\neas. Malaria was once common in the Unit-\ned States and southern Europe, but vector\ncontrol programs, in conjunction with the\nmonitoring and treatment of infected hu-\nmans, eliminated it from those regions. In\nsome areas, the draining of wetland breed-\ning grounds and better sanitation were ad-\nequate. Before DDT, malaria was success-\nfully eradicated or controlled also in several\ntropical areas by removing or poisoning the\nbreeding grounds of the mosquitoes or the\naquatic habitats of the larva stages, for ex-\nample by filling or applying oil to places\nwith standing water. These methods have\nseen little application in Africa for more\nthan half a century.\nSterile insect technique is emerging as a po-\ntential mosquito control method. Progress\ntowards transgenic, or genetically modified,\ninsects suggest that wild mosquito popu-\nlations could be made malaria-resistant.\nResearchers at Imperial College London\ncreated the world\u2019s first transgenic ma-\nlaria mosquito, with the first plasmodium-\nresistant species announced by a team at\nCase Western Reserve University in Ohio\nin 2002. Successful replacement of current\npopulations with a new genetically modified\npopulation, relies upon a drive mechanism,\nsuch as transposable elements to allow for\nnon-Mendelian inheritance of the gene of\ninterest. However, this approach contains\nmany difficulties and success is a distant\nprospect. An even more futuristic method\nof vector control is the idea that lasers could\nbe used to kill flying mosquitoes.\nIndoor residual spraying (IRS) is the prac-\ntice of spraying insecticides on the interior\nwalls of homes in malaria affected areas.Af-\nter feeding, many mosquito species rest on\na nearby surface while digesting the blood-\nmeal, so if the walls of dwellings have been\ncoated with insecticides, the resting mos-\nquitoes will be killed before they can bite\nanother.\nAlthough DDT has never been banned for\nuse in malaria control and there are several\nother insecticides suitable for IRS,some ad-\nvocates have claimed that bans are responsi-\nble for tens of millions of deaths in tropical\ncountries where DDT had once been ef-\nfective in controlling malaria. Furthermore,\nmost of the problems associated with DDT\nuse stem specifically from its industrial-\nscale application in agriculture, rather than\nits use in public health.\nThe World Health Organization (WHO)\ncurrently advises the use of 12 different\ninsecticides in IRS operations, including\nDDT as well as alternative insecticides\n(such as the pyrethroids permethrin and\ndeltamethrin). One problem with all forms\nof Indoor Residual Spraying is insecticide\nresistance via evolution of mosquitoes.\nMosquito nets help keep mosquitoes away\nfrom people and greatly reduce the infec-\ntion and transmission of malaria. The nets\nare not a perfect barrier and they are often\ntreated with an insecticide designed to kill\nthe mosquito before it has time to search\nfor a way past the net. Anopheles mosquitoes\nfeed at night, the preferred method is to\nhang a large \u201cbed net\u201d above the center of a\nbed such that it drapes down and covers the\nbed completely.\nImmunity (or, more accurately, tolerance)\ndoes occur naturally, but only in response\nto repeated infection with multiple strains\nof malaria. Vaccines for malaria are under\ndevelopment, with no completely effective\nvaccine yet available. The first promising\nstudies demonstrating the potential for a\nmalaria vaccine were performed in 1967 by\nimmunizing mice with live, radiation-at-\ntenuated sporozoites, providing protection\nto about 60% of the mice upon subsequent\ninjection with normal, viable sporozoites.\nSince the 1970s, there has been a consid-\nerable effort to develop similar vaccination\nstrategies within humans. It was deter-\nmined that an individual can be protected\nfrom a P. falciparum infection if they receive\nover 1,000 bites from infected yet irradiated\nmosquitoes.\nEducation in recognizing the symptoms of\nmalaria has reduced the number of cases\nin some areas of the developing world by\nas much as 20%. Recognizing the disease\nin the early stages can also stop the disease\nfrom becoming a killer. Education can also\ninform people to cover over areas of stag-\nnant, still water e.g. Water Tanks which are\nideal breeding grounds for the parasite and\nmosquito, thus cutting down the risk of the\ntransmission between people. This is most\nput in practice in urban areas where there\nare large centers of population in a confined\nspace and transmission would be most likely\nin these areas.\nA World Without Tuberculosis \/lead\nof the section Dr. Brian Farrugia\/\nOne third of the world\u2019s population is\nthought to be infected with M. tubercu-\nwmj 2 2011 5CS.indd 80 4\/29\/11 11:13 AM\niii\nInfectious Diseases\nlosis, and new infections occur at a rate of\nabout one per second. The proportion of\npeople who become sick with tuberculosis\neach year is stable or falling worldwide but,\nbecause of population growth, the absolute\nnumber of new cases is still increasing. In\n2007 there were an estimated 13.7 million\nchronic active cases, 9.3 million new cases,\nand 1.8 million deaths, mostly in develop-\ning countries. In addition, more people in\nthe developed world contract tuberculosis\nbecause their immune systems are more\nlikely to be compromised due to higher\nexposure to immunosuppressive drugs, sub-\nstance abuse, or AIDS. The distribution of\ntuberculosis is not uniform across the globe;\nabout 80% of the population in many Asian\nand African countries test positive in tu-\nberculin tests, while only 5\u201310% of the US\npopulation test positive.\nWhen people suffering from active pulmo-\nnary TB cough, sneeze, speak, or spit, they\nexpel infectious aerosol droplets 0.5 to 5 \u03bcm\nin diameter. A single sneeze can release up\nto 40,000 droplets. Each one of these drop-\nlets may transmit the disease, since the in-\nfectious dose of tuberculosis is very low and\ninhaling fewer than ten bacteria may cause\nan infection.\nPeople with prolonged, frequent, or in-\ntense contact are at particularly high risk\nof becoming infected. Others at risk in-\nclude people in areas where TB is common,\npeople who inject drugs using unsanitary\nneedles, residents and employees of high-\nrisk congregate settings, medically under-\nserved and low-income populations, high-\nrisk racial or ethnic minority populations,\nchildren exposed to adults in high-risk\ncategories, patients immunocompromised\nby conditions such as HIV\/AIDS, people\nwho take immunosuppressant drugs, and\nhealth care workers serving these high-risk\npatients.\nDrug-resistant tuberculosis is transmitted\nin the same way as regular TB. Primary\nresistance occurs in persons infected with\na resistant strain of TB. A patient with\nfully susceptible TB develops secondary\nresistance (acquired resistance) during TB\ntherapy because of inadequate treatment,\nnot taking the prescribed regimen appro-\npriately, or using low-quality medication.\nDrug-resistant TB is a public health issue\nin many developing countries, as treat-\nment is longer and requires more expensive\ndrugs. Multi-drug-resistant tuberculosis\n(MDR-TB) is defined as resistance to the\ntwo most effective first-line TB drugs: ri-\nfampicin and isoniazid. Extensively drug-\nresistant TB (XDR-TB) is also resistant to\nthree or more of the six classes of second-\nline drugs.\nThe DOTS (Directly Observed Treatment\nShort-course) strategy of tuberculosis treat-\nment recommended by WHO was based on\nclinical trials done in the 1970s by Tubercu-\nlosis Research Centre, Chennai, India. The\ncountry in which a person with TB lives can\ndetermine what treatment they receive.This\nis because multidrug-resistant tuberculosis\nis resistant to most first-line medications,\nthe use of second-line antituberculosis\nmedications is necessary to cure the patient.\nHowever, the price of these medications is\nhigh; thus poor people in the developing\nworld have no or limited access to these\ntreatments.\nThe World Health Organization declared\nTB a global health emergency in 1993, and\nthe StopTB Partnership developed a Global\nPlan to Stop Tuberculosis that aims to save\n14 million lives between 2006 and 2015.\nSince humans are the only host of Myco-\nbacterium tuberculosis, eradication would be\npossible. This goal would be helped greatly\nby an effective vaccine.\nImmunisation \u2013 The Paradigm\nOf Prevention \/lead of the\nsection Dr. Mark Muscat\/\nImmunisation is the process by which an\nindividual\u2019s immune system becomes forti-\nfied against an agent, known as the immu-\nnogen.\nAlong with safe drinking water, vaccines\nhave had an impact on health and mortal-\nity reduction that by far surpasses any other\nhealth strategy, including antibiotics. The\n21st\nCentury has brought with it the Papil-\nloma Virus and Rotavirus vaccines.\nImmunisation imparts immense economic\nbenefits.The aim is to prevent not just indi-\nvidual infection, but infection in the popu-\nlation as a whole.\nThe approaches towards immunization\nwere discussed,including mass,selected and\nroutine (childhood) vaccination. The role\nof mass vaccination during outbreaks was\ndescribed. The history and outcomes of the\nmeasles, cholera, typhoid and meningococ-\ncal vaccines were all mentioned.\nMeasles is still prevalent in Africa and In-\ndia.The main public health strategies are to\nsustain high coverage with 2 MMR shots\nin childhood and to improve surveillance.\nA recent outbreak occurred amongst the\nRoma people of Bulgaria. Cases still occur\nwithin Traveller groups and ultraorthodox\nreligious groups in the UK and central Eu-\nrope.\nChallenges facing effective immunization\nare religious beliefs, anthroposophic groups\nand a general lack of information.Anti-vac-\ncine lobbyists made an issue out of thiomer-\nsal in the H1N1 vaccine.It was stressed that\nhealth workers must continue to educate\nthe public, enhance surveillance and under-\ngo medical training in Vaccicology.\nDr. Gordon CARUANA-DINGLI,\nPresident Commonwealth Medical Association\nE-mail: gordoncd@maltanet.net\nThe report was compiled by\nMr Stephen MICALLEF-EYNAUD\nwmj 2 2011 5CS.indd Sec2:iii 4\/29\/11 11:13 AM\niv\nA Brief History\nFounded in 1978 by \u201cLe Quotidien du Medecin\u201d (a French maga-\nzine for the medical professions) and initiated by the journalist Lil-\niane Laplaine-Montheard, the World Medical and Health Games\n(aka Medigames) have become the most important international\nathletic event exclusively for health professionals. They are open to\nall health professionals: doctors, dentists, pharmacists, nurses, vet-\nerinarians and students in those majors. The games offer a unique\nambiance where the participants can exchange both their profes-\nsional ideas and life experiences as well as compete in their favourite\nsports.\n23 Sports, One Rallying Philosophy...\nFor the baron Pierre de Coubertin, the founder of the modern\nOlympic Games, the beauty of sports and the pure joy in the ath-\nletic effort was paramount. It is in this \u201cOlympic\u201d spirit that every\nyear the participants meet in the Medigames.There is a large choice\nbetween individual sports (tennis, Judo, swimming, half marathon,\nsquash, golf, gymnastics...) and team sports (volley-ball, beach vol-\nley-ball, soccer, basket-ball...).The week that follows not only offers\nmany athletic competitions but also a variety of entertainments. It\nends with a \u201cclosing ceremony\u201d in honor of the games.\nSport... for the Neurons\nEvery year since their creation, and beyond the focus on sports, the\nMedigames have always been an international forum where several\nmedical themes are studied and discussed, thus allowing the partici-\npants to ally sport with a furthering of their professional expertise.\nThis year Dr Andr\u00e9 MONROCHE (France) will be our president.\nFinally, the Medigames offer an opportunity to discover a new part\nof the world every year. After Morroco (2007), Germany (2008),\nSpain (2009) and Croatia (2010) it is now the turn of the Canary\nIslands (Spain) to host the games.\nThe 32nd\nEdition of the Medigames will take place from July 2nd\nto\nJuly 9th\n2011 at Las Palmas De Gran Canaria.\nE-mail : presse@mundiavocat.com\nSite Internet\u00a0: www.medigames.com\nThe 2011 World Medical and Health Games\nContents\nCouncil Down Under . . . . . . . . . . . . . . . . . . . . . . . . 41\nNew Policy Against the Tobacco . . . . . . . . . . . . . . . 42\n188th\nWMA Council Meeting . . . . . . . . . . . . . . . . . 46\nAddressing Harmful Use of Alcohol is Essential\nto Realising the Goals of the UN Resolution on\nNon-Communicable Diseases (NCDs) . . . . . . . . . . 59\nTask Delegation Versus Task Shifting in the\nIndonesian Health Service . . . . . . . . . . . . . . . . . . . . 62\nHistory of Georgia, Georgian Medicine\nand Medea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64\nPalliative Sedation in the Netherlands . . . . . . . . . . . 67\nOpinion of the Belgian Medical Association\nAbout the Law Refering to Euthanasia . . . . . . . . . . 71\nReport from Infectious Diseases Conference,\nMalta 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73\nwmj 2 2011 5CS.indd Sec2:iv 4\/29\/11 11:13 AM\n\n<\/p>\n"},"caption":{"rendered":"

wmj32 UNITED STATES vol. 57 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 2, April 2011 \u2022 Council Session in Sydney \u2022 TaskD elegation Versus Task Shifting in the Indonesian Health Service \u2022 Infectious Diseases wmj 2 2011 5CS.indd I 4\/29\/11 11:13 AM Cover picture from Japan ii Editor in Chief […]<\/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\/wmj32.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3615"}],"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=3615"}]}}