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wmj33<\/a><\/p>\n

UNITED STATES
\nvol. 57
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 3, June 2011
\n\u2022 Global Forum on Human Resources for Health
\n\u2022 Leadership and the Medical Profession
\n\u2022 Physician Suicide and Resilience
\nwmj 3 2011 5CS.indd I 6\/21\/11 9:32 AM
\nCover picture from China
\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:
\n\u201cBell Sound from the Monastery\u201d by dental
\nradiologist, Dr. WANG Zhaowu from a hospital
\nin Beijing. In Chinese paintings, they try to
\ninclude all senses in one visual picture to make
\nyou hear the sound, see the moving water, feel
\nthe smell of the trees and flowers…
\nPublisher
\nThe World Medical Association, Inc. BP 63
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\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
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\nWMA Vice-Chairman of Council
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\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
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\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
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\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
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\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 3 2011 5CS.indd Sec1:ii 6\/21\/11 9:32 AM
\n81
\nA woman who uses cosmetics may cover her face with some 80\u00a0ki-
\nlograms of various protective and nourishing creams during her life-
\ntime. At least 200 different compounds used in cosmetics may have
\nharmful effects on one\u2019s health. Most perfume ingredients are based
\non oil products. As a rule, these are secret combinations that are not
\npatented. So, a woman can never be sure about what she spreads
\nover her face.
\nHousehold cleaning chemicals turn out to be much more danger-
\nous than we have thought in the past. 70.000 new components have
\nbeen introduced in the past 60 years. 15.000 of them have never
\nbeen tested for harmful side-effects. Furthermore, for 99% of these
\nagents there is no information about possible side effects on chil-
\ndren\u2019s health.
\nLaundry detergents contain surfactants that end up in our water
\nsupply.This is just another insult to our precarious water supply.
\nThis year more attention is being paid to antimicrobial resistance by
\nthe World Health Organization and the World Medical Associa-
\ntion than in the past. There is because of an obvious reason: more
\nand more antibiotic-resistant bacteria are being encountered. Al-
\nthough the main concern has been Mycobacterium tuberculosis, a
\ngreater problem exists.
\nOur focus has been on antibacterial therapy for human use. How-
\never, more than 95% of world\u2019s antibiotics are used for veteri-
\nnary purposes and zootechnics. Enormous fish farms ponds and
\nconfined sea bays are routinely scattered with fish food that also
\ncontains antibiotics and various substances that improve the fla-
\nvour and colour of fish products. The antibiotics affect not only
\nthe bacteria in the water into which they have been placed, but
\nthey spread widely by flowing water. As a result, the qualities of
\nbacteria all over the world are affected. Antibacterial medicine
\nthat has been fed to domestic birds and animals present an even
\ngreater problem in the development of antibiotic-resistant strains
\nof bacteria.
\nThe problem of antimicrobial resistance in animals is spreading to
\nbecoming a problem in human medicine. This means we have to
\ndo everything possible to reduce uncontrolled use of antimicrobial
\nsubstances in the processes of producing fish, poultry and meat.
\nAlthough we cannot anticipate chemical or nuclear catastrophes,
\nthe Hungarian aluminum refinery toxic sludge spill and the recent
\nnuclear plant disaster in Japan should heighten our concern. The
\nWorld Medical Association should raise its voice and continue
\nto speak firmly to our governments about these risks. This time it
\nshould also be about the uncontrolled use of antibiotics and the
\nwidespread use of chemicals in cleaning and washing and in cos-
\nmetics.
\nDr. P\u0113teris Apinis,
\nPresident of Latvian Medical Association
\nEditorial
\nwmj 3 2011 5CS.indd 81 6\/21\/11 9:32 AM
\n82
\nReviewing Progress and Renewing Commitment to Health Workforce
\nDevelopment: the 2nd
\nGlobal Forum on Human Resources for Health
\nSummary
\nAn adequately available and equitably dis-
\ntributed health workforce is critical in ensur-
\ning the delivery of healthcare services that
\nmeet local populations\u2019healthcare needs. Yet,
\nthe reality is that many countries are suffer-
\ning from a shortage and mal-distribution of
\ntheir health workforce. In 2008 in an effort
\nto address these issues, the Kampala Declara-
\ntion and Agenda for Global Action (KD-AGA)
\nwas adopted at the 1st
\nGlobal Forum on Hu-
\nman Resources for Health held in Kampala,
\nUganda.The KD-AGA is a set of inter-con-
\nnected strategies and policy actions that are
\nrequired at global,regional and national levels
\nto address these issues.On January 25th
\n,2011
\nin Bangkok, Thailand the 2nd
\nGlobal Forum
\non Human Resources for Health convened to
\nreview the progress made in the implementa-
\ntion of the KD-AGA and renew the com-
\nmitment to addressing human resources for
\nhealth. This paper presents the background
\nand achievements of the 2nd
\nGlobal Forum
\non Human Resources for Health in address-
\ning health workforce challenges.
\nIntroduction: global health
\nworkforce challenges
\nIt is a well-recognized fact that health-
\ncare workers are an essential component of
\nhealth systems,without which health devel-
\nopment objectives, such as the health Mil-
\nlennium Development Goals (see box\u00a0 1)
\ncannot be achieved[1]. In 2006, however,
\nthe World Health Organization (WHO)
\nwarned that 57 countries were affected by
\nsevere shortages of health workers (i.e.,,
\nfewer than 2.3 physicians, nurses, and mid-
\nwives per 1000 population), estimating the
\nglobal shortfall of health workers at 4.3
\nmillion[2]. Regional disparities in the avail-
\nability of healthcare workers are stagger-
\ning: for example, Africa alone carries 25%
\nof the world\u2019s disease burden yet has only
\n3% of the world\u2019s health workers and 1% of
\nthe world\u2019s financial resources to meet that
\nchallenge[3].Healthcare workforce gaps are
\neven greater in absolute numbers in south-
\neast Asia, as a result of the large population
\nof countries such as India,Pakistan,Bangla-
\ndesh, and Indonesia.
\nThe global health workforce crisis is not
\ncharacterized exclusively by the shortage of
\nhealthcare workers, but also by in-country
\nmal-distribution and poor motivation, per-
\nformance and quality of services rendered by
\nhealthcare personnel. These system-wide de-
\nficiencies that are prevalent in many countries
\nare caused by structural gaps due to limited
\nresources, and weak education and manage-
\nment systems.The health workers\u2019challenges
\nare compounded by and result in the interna-
\ntional migration of health workers.Shortages
\nin high-income countries exercise a \u201cpull\u201d
\nover poorly paid or poorly motivated health
\nworkers in low- and middle-income coun-
\ntries.Spanning across sectors and constituen-
\ncies, the complex nature of these challenges
\nand the international dimension of the topic
\nillustrate how all relevant stakeholders should
\ncollectively contribute to resolving these is-
\nsues within their respective roles in the health
\nworkforce. For instance, while ministries of
\nhealth are typically the primary \u201cusers\u201d and
\nemployers of health workers,the ministries of
\neducation should take the lead on pre-service
\neducation and production of health workers.
\nGlobal Health Workforce Alliance
\nGiorgio Cometto Hirotsugu Aiga Mubashar Sheikh
\nwmj 3 2011 5CS.indd 82 6\/21\/11 9:32 AM
\n83
\nGlobal Health Workforce Alliance
\nThe ministries of labour and ministries of
\npublic services should be involved in design-
\ning a possible package of additional financial
\nand non-financial incentives for those work-
\ning in remote and hardship areas. Ministries
\nof foreign affairs and ministries of interna-
\ntional trade may need to broker agreements
\nwith other countries in order to address the
\nissue of international migration of healthcare
\nworkers,. In addition, most of these measures
\nmay require the allocation of additional fi-
\nnancial resources by ministries of finance.
\nFurthermore, it is essential to engage health
\nprofessional associations and the private sec-
\ntor (both for-profit and not-for-profit), in
\nlight of the rapidly growth of private health
\nservice delivery and health workforce produc-
\ntion in the developing world [5].
\nTo address the multi-faceted and complex na-
\nture of health workforce issues through inter-
\nnationally partnering stakeholders,the Global
\nHealth Workforce Alliance (the Alliance) was
\nlaunched in 2006, with the vision that \u201cAll
\npeople, everywhere, shall have access to a skilled,
\nmotivated and supported health worker\u201d[6].
\n.The
\nAlliance has been consistently advocating for
\nthe importance and value of addressing health
\nworkforce issues in a multi-sectoral manner
\nat both global and country levels. One of the
\nkey functions of the Alliance is to bring to-
\ngether various types of stakeholders in human
\nresources for health development, in order to
\nfacilitate a shared understanding of problems
\nand a joint ownership of solutions to health
\nworkforce challenges.To this end the Alliance
\nhas been given a mandate to periodically con-
\nvene a Global Forum on Human Resources
\nfor Health.
\nThe Kampala Declaration and
\nAgenda for Global Action
\nIn March 2008, the Alliance convened the
\nfirst-ever Global Forum on Human Resourc-
\nes for Health at Kampala, Uganda, which
\nresulted in the adoption of the Kampala Dec-
\nlaration and Agenda for Global Action (KD-
\nAGA)[7].The AGA (see box 2) is composed
\nof six interconnected strategies, ranging from
\ninvestment strategies to policy, planning, or-
\nganization, education, management and in-
\nformation issues, which provide an overarch-
\ning framework for health workforce initiatives
\nand development efforts at all levels [8].
\nBox 2: The Agenda for Global Action
\n(adopted in Kampala, Uganda, in March
\n2008)
\n1. Building coherent national and
\nglobal leadership for health work-
\nforce solutions.
\n2. Ensuring capacity for an informed
\nresponse based on evidence and
\njoint learning.
\n3. Scaling up health worker education
\nand training.
\n4. Retaining an effective, responsive
\nand equitably distributed health
\nworkforce.
\n5. Managing the pressures of the in-
\nternational health workforce market
\nand its impact on migration.
\n6. Securing additional and more pro-
\nductive investment in the health
\nworkforce.
\nThe Agenda for Global Action offers an
\nambitious vision of concerted action by all
\nstakeholders,at all levels,to comprehensively
\naddress health workforce challenges. Its key
\nprovisions contain relevant policy guidance,
\nwhich has been taken up through a number
\nof other policy initiatives, including, most
\nrecently, the United Nations Global Strat-
\negy for Women\u2019s and Children\u2019s Health [9].
\nLeadership. A coherent leadership strategy
\nfor addressing the health workforce issues
\nneeds to be underpinned by national health
\nworkforce plans, which are comprehensive,
\ncosted,and evidence-based.The plans should
\nproject an appropriate scale and skills mix of
\nthe health workforce, including, where rel-
\nevant, health workers and mid-level health
\nproviders, cadres that are effective in scaling
\nup access to essential services, often with
\nlimited costs, and with a higher likelihood
\nof being retained in rural areas [10, 11].
\nEvidence and joint learning. There is a need
\nto strengthen health workforce information
\nsystems to monitor the availability, distribu-
\ntion and performance of health workers, as a
\nbasic requirement to ensure that the develop-
\nment of national health workforce plans is
\nconducted on the basis of documented needs
\nand according to an evidence-based approach.
\nBox 1: The health-related Millennium Development Goals[4].
\nThe United Nations Millennium Development Goals (MDGs) are eight goals that
\nthe 191 UN member states have agreed to achieve by 2015. The MDGs are part of
\nthe United Nations Millennium Declaration, and have specific targets and indicators.
\nWhile all MDGs directly or indirectly influence health, 3 goals were formulated in
\nhealth-specific terms.The 3 health-related MDGs and their targets are highlighted in
\nbold in the list below:
\nThe Eight Millennium Development Goals are:
\n1. to eradicate extreme poverty and hunger;
\n2. to achieve universal primary education;
\n3. to promote gender equality and empower women;
\n4. to reduce child mortality (target: reduce by two thirds the mortality rate among
\nchildren under five;
\n5. to improve maternal health (targets: reduce by three quarters the maternal mortality
\nratio; achieve, by 2015, universal access to reproductive health);
\n6. to combat HIV\/AIDS,malaria,and other diseases (targets; halt and begin to reverse
\nthe spread of HIV\/AIDS; achieve, by 2010, universal access to treatment for HIV\/
\nAIDS for all those who need it; halt and begin to reverse the incidence of malaria
\nand other major diseases);
\n7. to ensure environmental sustainability; and
\n8. to develop a global partnership for development.
\nwmj 3 2011 5CS.indd 83 6\/21\/11 9:32 AM
\n84
\nEducation and training. The absolute
\nnumber of available healthcare workers re-
\nmains insufficient in all countries affected
\nby the health workforce crisis. While other
\nfactors such as mal-distribution and quality
\nof care issues are equally important, edu-
\ncation and training should be scaled up to
\ncompensate for the workforce short-fall,
\nwhich was estimated at 3.5 million addi-
\ntional health workers for 49 low-income
\ncountries alone [12].
\nRetaining the health workforce. It is es-
\nsential to ensure adequate incentives, sup-
\nportive supervision, opportunities for pro-
\nfessional development, and an enabling
\nworking environment, in order to improve
\nretention rates, equitable workforce distri-
\nbution, and motivation and performance of
\nhealth workers. Each country has its unique
\ndirect and underlying causes of domestic
\nmigration and mal-distribution of health
\nworkers. Therefore, a package of health
\nworkforce retention strategies should be
\ncarefully customized to suit each nation\u2019s
\nindividual needs.
\nInternational migration. While admitting
\nthe freedom of international movement of
\nhealth workers as an essential human right,
\nthere is a critical need to balance this with
\nthe populations\u2019 right to quality healthcare.
\nTherefore, international labour markets
\nshould be shaped in favour of retention
\nof health workers in countries affected by
\nthe health workforce crisis. The 63rd
\nWorld
\nHealth Assembly adopted the WHO global
\nCode of practice on the international recruit-
\nment of health personnel. The Code provides
\na framework for member states and interna-
\ntional recruiters to collaborate in the ethical
\nmanagement of health professionals\u2019migra-
\ntory flows.
\nInvestment.It has been estimated that a to-
\ntal of US $62 billion (inclusive of both train-
\ning and employment) needs to be invested in
\nthe healthcare workforce until 2015,in order
\nto achieve the health-related MDGs in 49
\nlow-income countries. External assistance is
\nneeded on a long-term basis to supplement
\nthe shortfall in domestic resources, especial-
\nly in low-income countries. Such support
\nshould be provided in a well coordinated
\nmanner among donors for greater efficiency
\nand effectiveness. In parallel, governments
\nof low-income countries should maximize
\nefforts to mobilize and invest adequate do-
\nmestic resources, and ensure their account-
\nable and efficient utilization.
\nThe 2nd
\nGlobal Forum on
\nHuman Resources for
\nHealth: coming together
\nto review progress
\nThe Kampala Declaration called upon the
\nAlliance to periodically review and report
\nprogress. In compliance, almost three years
\nafter the adoption of the KD\u00a0\u2013 AGA, a 2nd
\nGlobal Forum on Human Resources for
\nHealth was convened in Bangkok,Thailand
\non January 27th
\n, 2011. The 2nd
\nGlobal Fo-
\nrum was co-hosted by the Alliance, WHO,
\nthe Prince Mahidol Award Conference
\n(PMAC), and the Japan International Co-
\noperation Agency (JICA).
\nWith approximately 1,000 participants
\nfrom over 100 countries in attendance, the
\nForum enabled all types of stakeholders
\nfrom different constituencies and sectors to
\ncome together, review progress and renew
\ntheir commitment to health workforce de-
\nvelopment. Government participants came
\nnot only from the ministries of health of
\nthe affected countries, but also ministries
\nof education, labor, and finance. Beyond the
\npublic sector, there was also a high level of
\nparticipation from the private not-for-profit
\nsector, professional associations, academic
\nand research institutes, development part-
\nners, UN agencies, civil society organiza-
\ntions, and media. The three-day Forum was
\ncomposed of four types of activities: plenary,
\nparallel, side sessions and field trips around
\nBangkok to places illustrating interesting
\naspects of healthcare service organization
\nand innovative approaches to health work-
\nforce development and management. The
\nevent also featured a marketplace for booths
\nand posters, awards for outstanding health
\nworkers, and innovative case stories on
\nhealth workforce topics.
\nExchanging experiences at the Forum
\nThe Forum provided a platform for policy
\ndialogue, sharing of research findings, and
\nexchange of best practices or promising ap-
\nproaches: a total of 67 sessions (4 plenary
\nsessions, 20 parallel sessions, and 43 side
\nsessions) were held during the 5 day pro-
\ngramme, covering all health workforce is-
\nsues of relevance to the KD\u00a0 \u2013 AGA. The
\nForum structure provided an opportunity
\nfor all constituencies and key players to
\norganize sessions and have a voice in the
\nconference, while ensuring the internal co-
\nherence of the programme. Box 3 contains
\nmore information on the focus of the ple-
\nnary sessions.
\nOne of the highlights of the 2nd
\nGlobal Forum
\nwas the discussion on the progress made in
\nimplementing the KD\u00a0\u2013 AGA. At the global
\nlevel, the last few years saw healthcare sys-
\ntem strengthening rise to greater promi-
\nnence in the international health policy
\ndiscourse, with a greater recognition of the
\nindispensable role played by the health
\nworkforce. Every major international health
\nevent and process since 2008, from G8 and
\nAfrica Union summits to the adoption of
\na WHO Global Code of Practice on the
\nInternational Recruitment of Health Per-
\nsonnel and the launch of the United Na-
\ntions Secretary-General Global Strategy
\nGlobal Health Workforce Alliance
\nwmj 3 2011 5CS.indd 84 6\/21\/11 9:32 AM
\n85
\nfor Women\u2019s and Children\u2019s Health, have
\ncalled upon countries and the international
\ncommunity to strengthen health systems
\nand accelerate progress on the path to the
\nMillennium Development Goals, universal
\naccess to HIV prevention, treatment and
\ncare, and universal health coverage. How-
\never, the extent to which this attention was
\ntranslating into action by governments,
\ndevelopment partners and other relevant
\nstakeholders at country level was unclear.
\nThe Alliance therefore undertook a survey
\non the key policy and governance elements
\nthat characterize a country\u2019s response to its
\nhealth workforce challenges. This survey
\nwas then used to analyse how well countries
\nare planning and coordinating their health
\nworkforce development including their ef-
\nforts to develop evidence and information
\nsystems, education and retention strate-
\ngies, and investment decisions. This semi-
\nquantitative analysis was complemented by
\ncase stories submitted by countries and or-
\nganizations that illustrated through a more
\nqualitative approach specific aspects in the
\nimplementation of the Agenda for Global
\nAction in the priority countries.
\nThis analysis, despite some limitations re-
\nlated to the nature of a rapid survey and
\nconstraints relative to data availability, rep-
\nresents the first attempt to track progress in
\nimplementing the KD-AGA and provides a
\nuseful snapshot of the human resources for
\nhealth policy and the governance situation
\nin priority countries. The analysis revealed
\nareas of progress co-existing with others
\nthat require increased attention. Presented
\nin the first plenary of the Forum, this re-
\nport served as an instrument for countries,
\npartners and other relevant stakeholders
\nto review progress together, to hold one
\nanother accountable, and, by informing
\nthe discussions throughout the rest of the
\nconference, to renew and strengthen their
\ncommitment to work in partnership to de-
\nvelop and implement sustainable solutions
\nto the global health workforce crisis. While
\nthe full details of the study are available in
\na separate report [13], the general picture
\nthat emerged is that the level of progress in
\nimplementing the KD\u00a0\u2013 AGA is still un-
\neven, both in relation to different areas of
\nhealth workforce development and across
\ncountries. While actions on the ground
\nin a number of countries may be starting
\nto make a difference, considerable work
\nremains to be done to fully maximize the
\nvalue of the KD & AGA [14].
\nAnother key highlight of the Forum was
\nthe awards for outstanding health work-
\ners and innovative case stories. These two
\ntypes of awards honored individuals and
\norganizations delivering healthcare services,
\ni.e., Special Recognition Awards for Individu-
\nals and Awards for Excellence for case stories.
\nThe Special Recognition Awards brought a
\nhuman element throughout the forum: the
\npersonal and emotional anecdotes from the
\ncommunity-level health workers won the
\naudience\u2019s hearts. Through the Awards for
\nExcellence, the real experiences of innovative
\nand sustainable projects were showcased
\nthrough \u2018case stories\u2019\u00a0\u2013 real life narratives on
\nwhat has worked, where and why, and shar-
\ning best practices. At the closing ceremony,
\n2 individual health workers and 6 case sto-
\nries were awarded as the final winners.
\nThe Forum was also designed to carry its
\nmessages out to the wider world through
\npress coverage, op-eds, and a dedicated
\nwebsite hosted by the UK Newspaper \u201cThe
\nGuardian\u201d [15]. Moreover, a dedicated ini-
\ntiative was supported to ensure that health
\nworkforce issues generate even greater in-
\nterest in the countries where it matters the
\nmost. To this end, ten young journalists
\nfrom HRH crisis countries were given the
\nopportunity to report on the Second Global
\nForum on Human Resources for Health.
\nExclusively selected from countries facing
\nsevere health worker shortages, the scheme
\ninspired the journalists to report on health
\nworker shortages in their national media.
\nThrough exposing the scale and seriousness
\nof the crisis, this group can stimulate dis-
\ncussion of country-level progress and chal-
\nlenges [16].
\nThe way forward: taking
\nthe momentum of the
\nSecond Global Forum
\nout to the wider world
\nThe conference participants were engaged
\nthrough a participatory, consultative pro-
\ncess in the development of an outcome
\nstatement of the Second Global Forum,
\nwhose main contents are summarized in
\nthis section. Reiterating the validity of the
\nKD-AGA as an overarching framework for
\nhealth workforce development, and recog-
\nnizing the WHO Global Code of Practice
\non International Recruitment of Health
\nBox 3. Plenary sessions at 2nd
\nGlobal Forum on Human Resources for Health.
\n1. Plenary session 1 \u201cFrom Kampala to Bangkok: Making progress, Forging solution\u201d dis-
\ncussed the progress made for the AGA and served as the essential foundation for all
\nthe subsequent sessions.
\n2. Plenary Session 2 \u201cHave leaders made a difference?: How leadership can show the way
\ntowards MDGs\u201d, examined leadership-related issues confronted when managing
\ncomplex and delicate environments, such as: competing priorities, contradictory
\npurposes and the involvement of various stakeholders.
\n3. Plenary Session 3 \u201cProfessional Leadership and Education for 21st Century\u201d addressed
\nthe key challenges of professional education, shared countries experiences on pro-
\nviding education to meet the challenges and propose recommendations of health
\nworker training in the 21st Century.
\n4. Plenary Session 4 \u201cMaking HRH Innovation Work for Strengthening Health Systems\u201d,
\nreviewed successful lessons learned in HRH innovations for scaling up training and
\nrelated country-level experiences.
\nGlobal Health Workforce Alliance
\nwmj 3 2011 5CS.indd 85 6\/21\/11 9:32 AM
\n86
\nGlobal Health Workforce Alliance
\nPersonnel as a key instrument to foster
\nHRH collaboration across countries, the
\noutcome statement was developed on the
\nbasis of the discussions in different sessions
\nand other major inputs into the Forum,
\ncondensing into a few simple words the key
\nmessages emerging from the Forum.
\nThe outcome statement [17] recognized
\nthat, despite some areas of progress, major
\ngaps persist:
\n\u2022 The supply of health workers is still in-
\nsufficient in many countries, particularly
\nin Africa and complex emergency set-
\ntings. Shortages should be addressed by
\nscaling up education and training capac-
\nity in order to meet the growing demand
\nfor health personnel.
\n\u2022 Reliable and updated information on the
\nhealth workforce is not always present,
\nhindering the monitoring of progress,and
\nplanning and decision making processes.
\nStrong national capacity is required in all
\ncountries to regularly collect, analyse and
\nuse data on health workforce availabil-
\nity, distribution, employment status, and
\nmigration, to inform policymaking and
\nmanagement.
\nWhile the health workforce challenges were
\ninitially highlighted by making reference
\nprimarily to shortages in terms of absolute
\nnumbers, new benchmarks beyond the den-
\nsity of physicians, nurses and midwives, will
\nbe required to set appropriate targets toward
\nwhich that policy makers can strive. This
\nwill, in turn, help give greater relevance to
\nother parameters such as geographic distri-
\nbution, retention, gender balance, minimum
\nstandards, competency frameworks, which
\nwill better reflect the diverse composition of
\nthe health workforce.
\nRecognizing these gaps, the Forum par-
\nticipants agreed that realizing the ambitious
\nvision of the KD-AGA will require greater
\nefforts across a number of areas.
\nLeadership by all state and non\u2010state actors
\nis required to strengthen commitment and
\nfocus action on the health workforce. Policy
\ncoherence across sectors is essential, as is
\nthe capability to plan and manage health
\nworkforce development. National health
\nworkforce coordination mechanisms should
\nbe established, or existing ones strength-
\nened, to foster synergies among stakehold-
\ners and inclusive communities of purpose
\nwhere best practices are shared. HRH de-
\nvelopment strategies and budgets should be
\nlinked with national healthcare strategies,
\npolicies and plans.
\nAt the local level, suitable policies and
\nstrategies should be adopted to attract and
\nretain health workers with an appropriate
\nskills mix in rural and other under\u2010served
\nareas, including the deployment of commu-
\nnity\u2010based and mid\u2010level health providers.
\nApproaches may include tailoring educa-
\ntion curricula and practices to work in rural
\nareas,financial and non\u2010financial incentives,
\nregulation, management support and im-
\nproved career development opportunities.
\nThe quality of care rendered by service
\nproviders should improve through ac-
\ncreditation of health workers and training
\ninstitutions and compliance with relevant
\nnational standards and regulation systems.
\nPerformance should be enhanced through
\neffective supervision, competency\u2010based
\ncurricula, enabling practice environments
\nand supportive management practices.
\nThe international migration challenges
\nshould be addressed by putting in place
\nthe necessary regulatory, governance and
\ninformation mechanisms envisaged in the
\nWHO Global Code of Practice on Inter-
\nnational Recruitment of Health Personnel.
\nAn adequate level of financial investment
\nfor health workforce development should
\nbe attained through both domestic and in-
\nternational resources. Where allocation of
\ndomestic resources is not sufficient, govern-
\nments should increase it, if necessary by re-
\nlaxing macro-economic restrictions, with the
\nhelp of International Financial Institutions.
\nWhere the shortfall in resources cannot be
\naddressed through domestic means alone,
\ndevelopment partners, global health initia-
\ntives and international agencies share the
\ncollective responsibility to provide predict-
\nable, long\u2010term and flexible support, aligned
\nto country priorities, and national health
\nplans that allow for investment in pre\u2010service
\neducation, remuneration and other recurrent
\ncosts for health personnel. Better financial
\nmanagement mechanisms can foster ac-
\ncountability and improve equity and effi-
\nciency of investments made from all sources.
\nThe Forum was an opportunity to review
\nprogress and share experiences. It re-ignited
\nmomentum for health workforce develop-
\nment, calling for joint action and renewed
\nefforts towards the vision that \u201cevery person,
\nwhoever they are and wherever they live,has
\naccess to a health worker\u201d[17] .
\nReferences
\n1. Travis P, Bennett S , Haines A, et al. Overcom-
\ning health-systems constraints to achieve the
\nmillennium development goals, Lancet 2004;
\n364:. 900\u2013906.
\n2. WHO, Working together for health\u00a0 \u2013 World
\nHealth Report 2006
\n3. Robinson M, Clark P. Forging solutions to
\nhealth worker migration. Lancet. 2008 Feb 23;
\n371(9613):691-3.
\n4. United Nations. Millennium Development
\nGoals,; 2000: Available from: http:\/\/www.undp.
\norg\/mdg\/basics.shtml accessed on March 2nd
\n2011.
\n5. The Global Health Workforce Alliance Country
\nCoordination and Facilitation (CCF) Principles
\nand process 2010. Available from: http:\/\/www.
\nwho.int\/workforcealliance\/knowledge\/resourc-
\nes\/CCF_Principles_Processes_web.pdf accessed
\nMarch 2nd
\n2011
\n6. Global Health Workforce Alliance. Alliance vi-
\nsion and mission: Available from: http:\/\/www.
\nwho.int\/workforcealliance\/about\/vision_mis-
\nsion\/en\/index.html ,accessed on March 2nd
\n2011
\n7. GHWA & WHO. The Kampala Declaration
\nand Agenda for Global Action. GHWA &
\nWHO. 2008 Available from: http:\/\/www.who.
\nint\/workforcealliance\/knowledge\/resources\/
\nkampala_declaration\/en\/index.html accessed on
\nMarch 2nd
\n2011
\n8. Cometto G, Sheikh M. Forging partnerships
\nto solve the global health workforce crisis and
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\n87
\nSocio-Medical-AffairsISRAEL
\nachieve the health MDGs. World Hosp Health
\nServ. 2010;46(3):16-9.
\n9. United Nations. Access for all to skilled, mo-
\ntivated and supported health workers\u00a0 \u2013 Back-
\nground paper to Global Strategy for Women\u2019s
\nand Children\u2019s Health; 2010. Available from:
\nhttp:\/\/www.who.int\/pmnch\/activities\/jointac-
\ntionplan\/20101007_4_skilledworkers.pdf ac-
\ncessed on March 1st
\n2011.
\n10. Global Health Workforce Alliance.Global Expe-
\nrience of Community Health Workers for Deliv-
\nery of Health Related Millennium Development
\nGoals: A Systematic Review,Country Case Stud-
\nies, and Recommendations for Integration into
\nNational Health Systems. GHWA & WHO.
\n2010 Available from: http:\/\/www.who.int\/work-
\nforcealliance\/knowledge\/resources\/chwreport\/
\nen\/index.html accessed on March 2nd 2011.
\n11. World Health Organization. Mid-level health
\nworkers The state of the evidence on pro-
\ngrammes, activities, costs and impact on health
\noutcomes A literature review; 2008. Geneva,
\nSwitzerland. Available from: http:\/\/www.who.
\nint\/hrh\/MLHW_review_2008.pdf acessed on
\nMarch 1st
\n2011.
\n12. WHO. Constraints to Scaling Up Health
\nRelated MDGs: Costing and Financial Gap
\nanalysis, 2009. Available from: http:\/\/www.who.
\nint\/choice\/publications\/d_ScalingUp_MDGs_
\nWHO_report.pdf accessed on March 2nd 2011
\n13. Global Health Workforce Alliance (2011).
\nReviewing progress, renewing commitments\u00a0 \u2013
\nprogress report on the Kampala Declaration
\nand Agenda for Global Action. Geneva, Swit-
\nzerland. Available from: http:\/\/www.who.int\/
\nworkforcealliance\/forum\/2011\/progressreport-
\nlaunch\/en\/index.html accessed on February
\n17th 2011.
\n14. Sheikh M. Commitment and action to boost
\nhealth workforce. Lancet. 2011 Jan 24. [Epub
\nahead of print]
\n15. TheGuardian,2011.GlobalHealthCheck.Avail-
\nable from: http:\/\/www.guardian.co.uk\/global-
\nhealth-workers; accessed on March 7th
\n2011
\n16. Global Health Workforce Alliance 2011. Jour-
\nnalist fellowship programme. Available from:
\nhttp:\/\/www.who.int\/workforcealliance\/fo-
\nrum\/2011\/journalist_fellowship\/en\/index.html
\naccessed on March 7th 2011
\n17. Global Health Workforce Alliance 2011. Out-
\ncome statement of the Second Global Forum
\non Human Resources for Health. Available
\nfrom: http:\/\/www.who.int\/workforcealliance\/
\nforum\/2011\/Outcomestatement.pdf accessed
\non March 7th 2011.
\nDr. Giorgio Cometto, Adviser to the
\nExecutive Director at the Global
\nHealth Workforce Alliance
\nDr. Hirotsugu Aiga, Coordinator of the
\nGlobal Health Workforce Alliance
\nDr. Mubashar Sheikh, Executive Director
\nof the Global Health Workforce Alliance
\nE-mail: comettog@who.int
\nFor physicians and allied health care work-
\ners across the globe, the experience of job-
\nrelated violence is all too common. This is
\ntrue to such an extent that many health care
\nprofessionals reportedly consider a certain
\ndegree of workplace violence to be an inevi-
\ntable part of the job.
\nThis hazardous dynamic not only endangers
\nhealth workers, but can have a devastat-
\ning impact on entire health care systems.
\nPhysical and emotional stress and strain as
\nthe result of workplace violence leads to an
\nincreased shortage of health workers due to
\nsickness, temporary leave of absence and
\npermanent loss of staff.
\nWith physician shortage already a growing
\nproblem throughout the world, additional
\nloss of staff due to workplace violence ex-
\nacerbates the crisis of the public\u2019s restricted
\naccess to health care, itself the inevitable re-
\nsult of medical manpower shortages.
\nWorkplace Violence Defined
\nTo cite a widely accepted definition of work-
\nplace violence used by the World Health
\nOrganization (WHO), workplace violence
\ncan be described as \u201cthe intentional use of
\npower, threatened or actual, against another
\nperson or against a group, in work-related
\ncircumstances, that either results in or has
\na high degree of likelihood of resulting in
\ninjury, death, psychological harm, mal-de-
\nvelopment, or deprivation\u201d[3].
\nIt is important to acknowledge that work-
\nplace violence includes both physical and
\nnon-physical (psychological) violence. Non-
\nphysical violence, including harassment,
\nthreats and verbal abuse,can have severe psy-
\nchological consequences and must be recog-
\nnized as having a potential detrimental im-
\npact comparable to that of physical violence.
\nIn fact,non-physical violence can have more
\nsevere consequences than physical violence
\nand can result in numerous health effects
\non its victims, including gastrointestinal
\ndisorders and psychosomatic symptoms.
\nPsychological violence is more prevalent
\nthan physical violence and is widespread
\nthroughout health services.
\nAccording to country surveys conducted
\nby the International Labor Organization
\n(ILO), patients are the main perpetrators
\nof physical violence, while staff members
\nseem to be the main perpetrators of psycho-
\nlogical violence against other professionals.
\nYoram Blachar
\nViolence in the Health Care Sector\u00a0\u2013
\nA\u00a0Global Issue
\nwmj 3 2011 5CS.indd 87 6\/21\/11 9:32 AM
\n88
\nISRAELSocio-Medical-Affairs
\nIt is important to highlight, however, the
\ndifficulty of establishing a profile of people
\ncommitting acts of workplace violence, and
\nto acknowledge the risks associated with
\ngeneralization and stereotyping in this area.
\nIn the United Kingdom, reports show that
\nbetween one quarter and one half of the
\nNational Health Service (NHS) staff report
\nsignificant work-related personal distress.
\nAccording to country surveys, a majority
\nof health care workers experienced at least
\none incident of physical or psychologi-
\ncal violence in the previous year: 75.8% in
\nBulgaria; 67.2% in Australia; 61% in South
\nAfrica; an average of 48% in Portugal (60%
\nin health centers and 37% in hospitals); 54%
\nin Thailand; 46.7% in Brazil [4]. Workplace
\nviolence is a recognized generator of post-
\ntraumatic stress disorder (PTSD) and ac-
\ncording to surveys, between 40% and 70%
\nof its victims report significant levels of
\nPTSD symptoms [3].
\nReasons for Escalation
\nof Violence
\nIn recent years violence in the health sector
\nhas become an increasing problem for a va-
\nriety of reasons. From a general perspective,
\ncauses of workplace violence have been iden-
\ntified in three main areas: the organizational
\nlevel,the societal level and the individual level.
\nCausative factors are intricately intertwined
\nand complex in the way they contribute to
\nemerging violence, but can broadly be at-
\ntributed to the accumulation of stress and
\ntension in health occupations under the
\nstrain of societal problems and the pressure
\nof health system reform.
\nCauses of Violence at an Organizational Level
\nAccording to the ILO, healthcare workers
\nare at high risk for experiencing violence at
\nwork, with almost one quarter of all violent
\nincidents in the workplace occurring in the
\nhealth sector [4]. The ILO reports a strong
\ncorrelation between workplace violence and
\noccupations associated with high levels of
\nstress. The ongoing restructuring of health
\ncare systems,staff shortages,low pay and shift
\nwork are all factors causing health care work-
\ners\u2019vulnerability to stress.Work strain has led
\nto high costs in terms of sickness rates and
\nloss of staff, increasing the burden on those
\nwho remain.
\nThis correlation between violence and stress
\nis significant not only in its effect on the
\nindividual worker, but also in determining
\nthe global impact of stress and resulting vio-
\nlence on health systems and organizations.
\nThe relationship between violence and
\nstress highlights the importance of address-
\ning factors on the organizational level that
\nmay contribute to workplace stress in health
\noccupations.The implementation of chang-
\nes to reduce stress will in turn minimize the
\nelevated costs and compromised efficiency
\ncaused by workplace violence.
\nCauses of Violence at a Societal Level
\nIt is significant to recognize that the pub-
\nlic\u2019s conception of the doctor\u2019s role has been
\nblurred in recent years by the many prob-
\nlems associated with modern medicine and
\nhealth care. Rather than viewing doctors as
\npublic servants dedicated to saving lives and
\nproviding treatment, the physician has be-
\ncome a scapegoat for issues such as rising
\nhealth care costs and overcrowding in hos-
\npitals and medical institutions. Resulting
\nmisguided anger directed toward doctors
\noften leads to incidents of violence.
\nPhysicians have been forced to take on the
\nrole of messengers of an inadequate health
\nsystem. They must often explain to patients
\nthat the medication they need is not cov-
\nered or authorized by their insurance. In
\naddition, doctors have their hands tied
\nwhen it comes to patient complaints of long
\nwaiting times due to inadequate staffing, re-
\nsources and treatment areas. As health care
\ncosts continue to rise and medical technol-
\nogy becomes progressively more expensive,
\ndoctors are becoming increasingly overbur-
\ndened and at greater risk for workplace vio-
\nlence due to patient dissatisfaction.
\nCauses of Violence at an Individual Level
\nAccording to the ILO, healthcare workers
\ntend to rank the personality of patients as
\nthe lead generating factor of violence. Stud-
\nies have identified the most common trig-
\ngers for acts of violence in the health sector
\nas long waiting times and dissatisfaction with
\nthe treatment provided [1].Studies have sug-
\ngested that the impatience that accompanies
\nwaiting times may have a cultural element.
\nWhen a population experiences a compro-
\nmised sense of safety and security for an
\nextended period of time, cultural norms
\nand patterns of behavior can develop that
\ntrigger a person\u2019s tendency toward violent
\nconduct. The deterioration of a country\u2019s
\neconomic and\/or security situation creates a
\ncircumstance in which physicians are caring
\nfor patients who are affected by the physi-
\ncal and mental distress of their surrounding
\nenvironment.This increased agitation in the
\npatient population can potentially expose
\nhospital and community-based physicians
\nto violent acts in the workplace.
\nFormulating a Strategy
\nWhen establishing a strategy to deal with
\nworkplace violence, it is important to ana-
\nlyze the origins and risk factors of work-
\nplace stress and violent acts in individual
\ncommunities in order to identify resource
\nallocation priorities and to develop appro-
\npriate and effective policies.
\nBased on a variety of studies,it has been rec-
\nommended by the ILO and other interna-
\ntional organizations to take a multi-faceted
\napproach which integrates interventions at
\norganizational, societal and individual lev-
\nels,with a clear focus on preventative action.
\nReform in the areas of legislation, security,
\ndata collection, training, environmental fac-
\nwmj 3 2011 5CS.indd 88 6\/21\/11 9:32 AM
\n89
\nISRAEL Socio-Medical-Affairs
\ntors, public awareness and financial incen-
\ntives is required in order to successfully ad-
\ndress this issue [1,2].
\nIn addition, collaboration amongst various
\nstakeholders is essential, including gov-
\nernments, National Medical Associations
\n(NMAs), hospital and general health ser-
\nvices, management, insurance companies,
\ntrainers and preceptors, researchers and the
\npolice. As the representatives of physicians,
\nNMAs should not only take an active role in
\ncombating violence, but should encourage
\nother key factions to act. The commitment
\nand cooperation of each entity is imperative
\nto effectively tackle the widespread issue of
\nworkplace violence in the health sector.
\nInterventions Addressing
\nViolence in the Health Sector
\nBased on the analysis of country reports, the
\nILO recommends that interventions against
\nworkplace violence in the health sector
\nshould focus on (a) general conditions in so-
\nciety and the legal framework; (b) normative
\ninterventions, such as guidelines and man-
\nagement competencies; and (c) interventions
\nat the environmental and individual levels [4].
\nIn addition,it is recommended that countries
\nstart by raising awareness of the problem
\nand building a greater understanding among
\nhealth care professionals of the causes and
\nassociated risks of workplace violence.
\nWorld Medical Association Recommendations
\nA statement on violence in the health sector,
\ncurrently being proposed for adoption by the
\nWorld Medical Association (WMA),makes
\ndetailed strategic recommendations. The
\nstatement urges National Medical Associa-
\ntions to encourage healthcare institutions to
\nimplement prevention strategies against vio-
\nlence. Prevention strategies should include,
\namong other things,the prompt reporting of
\nviolence and a designated plan of action for
\nincidents of violence.
\nThe statement further recommends that
\nnational priorities and limitations on medi-
\ncal care be clearly addressed by government
\ninstitutions in order to reduce patient dis-
\nsatisfaction. Furthermore, health care ad-
\nministrators should adopt a zero-tolerance
\nattitude to threats and acts of violence.
\nVarious forms of counseling and support
\nshould be provided to staff members who
\nhave been victims of threats of violence and\/
\nor violent assault while at work. When ap-
\npropriate, the public should be informed
\nof violent occurrences in order to increase
\nawareness.
\nNMAs should lobby for the establishment
\nof reporting systems that enable health
\ncare workers to report, anonymously and
\nwithout reprisal, any threats or incidents
\nof violence. Such systems should be used
\nto analyze the effectiveness of prevention
\nstrategies and data should be collected and
\nrecorded.
\nLaw enforcement should give high priority
\nto acts of violence in the health care sector
\nand appropriate security measures should
\nbe enforced. A routine violence risk audit
\nshould be implemented to identify high risk
\njobs and locations. Hospital staff should
\nbe well-trained in the recognition and an-
\nticipation of high risk situations and should
\nbe encouraged by management to remain
\nvigilant.The cultivation of sound physician-
\npatient relationships and effective commu-
\nnication skills should be promoted.
\nPatient waiting areas should be comfortable
\nand should provide unrestricted patient ac-
\ncess to restrooms and necessary facilities.
\nA system allowing displeased patients to
\nfile complaints and receive appropriate and
\ntimely responses may also serve to reduce
\npatient anxiety and facilitate a calm and
\nneutral environment.
\nThe statement also encourages governments
\nto allocate appropriate funds in order to
\nimplement health care system reforms.
\nConclusion
\nAs a global issue, violence in the healthcare
\nsector continues to be addressed through-
\nout the world in various ways, and by a
\nvariety of stakeholders. There is no escape
\nfrom the recognition that although each
\nparty hopes their efforts will diminish vio-
\nlence against health professionals; a large-
\nscale and comprehensive plan is more like-
\nly to lead to a significant reduction of this
\nphenomenon.
\nSuch a plan demands widespread coop-
\neration and the active involvement of all
\nconcerned. Parties must work together to
\nestablish prevention plans, which should
\nbe routinely evaluated to assess efficiency
\nand to identify areas needing improvement.
\nSufficient collaboration and the building of
\nsound policies and frameworks will assist
\nwith the significant reduction of violence in
\nthe health sector.
\nReferences
\n1. Carmi-Iliz, T., Peleg, R., Freud, T., Shvartzman,
\nP. (2005). Verbal and physical violence towards
\nhospital- and community-based physicians in
\nthe Negev: an observational study. BMC Health
\nService Research, 5(54). doi:\u00a0 10.1186\/1472-
\n6963-5-54.
\n2. Derazon, H., Nissimian, S., Yosefy, C., Peled,
\nR., Hay, E. (1999). Violence in the emergency
\ndepartment (Hebrew) Harefuah, 137(3-4):95-
\n101, 95-101. http:\/\/www.ima.org.il\/harefuah1\/
\ninpage.asp?show=article&nJournalID=94&catI
\nD=245&artID=1078
\n3. International Labour Organization (2003). ILO
\nfact sheet: Workplace violence in the health ser-
\nvices. Last accessed 28th March 2011. http:\/\/
\nwww.ilo.org\/public\/english\/dialogue\/sector\/pa-
\npers\/transport\/violence.pdf
\n4. World Health Organization (1995). Prevention
\nof violence: a public health priority. Last ac-
\ncessed 28th March 2011. http:\/\/www.who.int\/
\nviolence_injury_prevention\/resources\/publica-
\ntions\/en\/WHA4925_eng.pdf
\nDr. Yoram Blachar,
\nIsrael Medical Association
\nwmj 3 2011 5CS.indd 89 6\/21\/11 9:32 AM
\n90
\nSuicide is not spoken about openly or eas-
\nily, particularly in the medical community.
\nThere is a wall of silence surrounding this
\nmysterious topic, probably because the pain
\nis so private and the act so public. But make
\nno mistake, the suicide death of a physician
\nis very humbling\u00a0\u2013 whether we are the treat-
\ning person, a loved one left behind, a col-
\nleague or friend. John Donne\u2019s wise words
\nare so apt.\u201c…any man\u2019s death diminishes me,
\nbecause I am involved in Mankind…\u201d [1]
\nAccording to the Centers for Disease Con-
\ntrol and Prevention (CDC), there is one
\ndeath by suicide every 15 minutes in the
\nUnited States or 94 suicides per day [2] and
\naccording to the physician depression and
\nsuicide project of the American Founda-
\ntion for Suicide Prevention, every year 300-
\n400 physicians kill themselves in America
\n[3]. In an attempt to address the shock and
\ndisbelief when a physician kills himself or
\nkills herself, Jamison [4] has written: \u201cNo
\none who has not been there can compre-
\nhend the suffering leading up to suicide,nor
\ncan they really understand the suffering of
\nthose left behind in the wake of suicide\u201d.
\nAnd Nuland [5] waxes eloquent (literally
\nand metaphorically) when he explains the
\nseeming indifference to physician suicide
\nby other physicians \u201c\u2026for the uninvolved
\nmedical personnel who first view the corpse,
\nthere is another factor to consider, which
\nhinders compassion.Something about acute
\nself-destruction is so puzzling to the vibrant
\nmind of a man or woman whose life is de-
\nvoted to fighting disease that it tends to di-
\nminish or even obliterate empathy\u201d.
\nEpidemiology
\nSuicide is a disproportionately high cause
\nof mortality in physicians, with depression
\nas a major risk factor [6]. Schernhammer
\nand Colditz\u2019s [7] review and meta-analysis
\nof 25 studies on physician suicide conclud-
\ned that the aggregate suicide rate ratio for
\nmale physicians, compared with the general
\npopulation, is 1.41:1. For female physicians,
\nthe ratio is 2.27:1. Unlike almost all other
\npopulation groups,in which men die by sui-
\ncide about four times more frequently than
\nwomen,physicians have a suicide rate that is
\nvery similar for both men and women.
\nWhat do we know about
\nphysician suicide?
\nThere is no one factor that makes some-
\none suicidal.The act of suicide is a complex
\nphenomenon involving some convergence
\nof genes, psychology and psychosocial
\nstressors [8]. It is generally felt that 85-
\n90% of individuals who die by suicide have
\nbeen living with some type of psychiatric
\nillness, whether recognized and treated or
\nnot. Although all physicians have some
\nbasic knowledge about depression and its
\ntreatment, an unknown number die by sui-
\ncide each year, who seem to \u2018fall through
\nthe cracks\u2019. They have never consulted a
\nmental health professional or received any
\ntreatment by others. Some have treated
\nMichael F Myers
\nPhysician Suicide and Resilience: Diagnostic,
\nTherapeutic and Moral Imperatives
\nThis is a revised version of a keynote lecture delivered on October 4, 2010 at the International
\nConference on Physician Health in Chicago, IL
\nTable 1. Profile of a Physician at High Risk for Suicide
\nGender Male or female
\nAge 45+ years old (female); 50+ years old (male)
\nRace White
\nMarital Status Divorced, separated, single or currently with marital disruption
\nHabits
\nAlcohol or other drug abuse \u201cWorkaholic\u201d
\nExcessive risk taker (especially high-stakes gambler; thrill seeker)
\nMedical Status
\nPsychiatric symptoms (especially depression; anxiety)
\nPhysical symptoms (chronic pain; chronic debilitating illness)
\nProfessional
\nChange in status\u00a0\u2013 threat to status, autonomy, security, financial
\nstability, recent losses, increased work demands
\nAccess to means
\nAccess to lethal medications
\nAccess to firearms
\nReprinted with permission. From Silverman MM. Physicians and Suicide. In Goldman LS,
\nMyers M, Dickstein LJ, The Handbook of Physician Health. Chicago, IL, American Medical
\nAssociation, 2000
\nSocio-Medical-Affairs UNITED STATES OF AMERICA
\nwmj 3 2011 5CS.indd 90 6\/21\/11 9:32 AM
\n91
\nthemselves. Silverman [9] has concluded
\nthat there are additional factors that make
\nphysicians an at-risk group for suicide
\n(Table\u00a01).
\nReprinted with permission.From Silverman
\nMM. Physicians and Suicide. In Goldman
\nLS, Myers M, Dickstein LJ,The Handbook
\nof Physician Health. Chicago, IL, Ameri-
\ncan Medical Association, 2000
\nThe psychiatric disorders most commonly
\nimplicated in physician suicide are: Major
\ndepressive disorder, bipolar affective disor-
\nder, alcohol and other drug abuse, anxiety
\ndisorders, and borderline personality disor-
\nder [9].
\nIn addition to demographic and diagnos-
\ntic factors that put physicians at risk for
\nsuicide, there are other specifics that play
\na role. Table 2 lists some considerations to
\nkeep in mind when trying to understand
\nsuicide in physicians or when conducting a
\ncomprehensive suicide risk assessment in an
\nill physician [8].
\nA few points to remember. There are many
\nphysicians living with a mood disorder and\/
\nor substance dependence who escape at-
\ntention. Many are untreated or self-treated
\nand many who are in treatment are under-
\ntreated by their clinicians.The clinician may
\nhave little experience in treating a popula-
\ntion of sick individuals who are terrified to
\nbe totally honest and who can be cleverly
\ndeceptive. They have not been fully forth-
\ncoming with their treating clinician about
\nsuicidal ideation and a dangerous plan for
\nself-destruction. In suicidology, one of the
\nkey risk factors in people who die by suicide
\nis a previous suicide attempt. This does not
\nalways apply to physicians.Doctors who kill
\nthemselves are distinguished by the (rela-
\ntive) absence of an earlier suicide attempt.
\nOr if they have attempted suicide before,
\nwhen asked, they may lie\u00a0 \u2013 because they
\ndon\u2019t have a trusting relationship yet with
\ntheir therapist or they are terrified of being
\nforced into hospital against their wishes.
\nHow common are suicide
\nthoughts in physicians?
\nThere is very little research but there are
\nquestionnaire studies that have found clini-
\ncal depression in residents,including suicid-
\nal ideation [12,13]. In a study of burnout in
\nmedical students, Dyrbye et al. [14] found
\nsuicidal ideation in 10% of students. In a
\nstudy of female university MDs in Sweden
\nand Italy, 13.7% and 14.3% reported suicid-
\nal ideation [15]. It is generally believed that
\nwhatever research we do have is probably an
\nunderestimation of the actual frequency of
\nsuicidal thinking in doctors. There is a lot
\nof shame in reporting thoughts of self-harm
\nand when a doctor is in treatment, he or
\nshe may fear the consequences of disclos-
\ning thoughts of suicide. Some physicians
\nare comforted by thoughts of suicide which
\nmeans that they have a way out, a way of
\nescaping the pain and that they retain some
\nmeasure of control. Being in control and
\nhaving control over one\u2019s self is characteris-
\ntic of many doctors.
\nPersonality traits are significant
\nPerfectionism is not uncommon in physi-
\ncians. It is almost impossible to gain en-
\ntrance to medical school without some
\nmeasure of thoroughness and attention to
\nSocio-Medical-AffairsUNITED STATES OF AMERICA
\nTable 2. Suicide Risk Considerations in Physicians
\n\u2022 Previous history of a depressive episode. This may have occurred in adolescence or young
\nadulthood,in college or medical school and whether recognized and treated or not,this
\nis significant information
\n\u2022 Previous suicide attempt. Physician deaths by suicide are distinct from the general public
\nbecause of the relative paucity of previous suicide attempts. However, some physicians
\nhave attempted suicide before and survived. Most feel deeply embarrassed and will not
\ndisclose this matter easily to their treating physician
\n\u2022 Family history of mood disorders, including suicide. Many physicians have genetic load-
\ning for mood disorders. Suicide can be familial but it is much more complicated than
\ngenetic predisposition
\n\u2022 Professional isolation. This may be long-standing in someone who tends to be a loner,
\nvery private and\/or self-contained. But more commonly, professional isolation is the
\nresult of a geographic move or loss of some type (health, family, financial stability).
\nThese individuals lack the supports and the protective factors that militate against
\nself-destruction [10]
\n\u2022 Lawsuits and medical license investigations. Being sued for malpractice or having com-
\nplaints made to one\u2019s licensing board about professional competence, safety or ethics
\ncan be one of the most traumatic assaults to a physician\u2019s health and sense of well-
\nbeing. Such individuals, especially if alone without actual or perceived supports, are at
\nrisk of self-harm
\n\u2022 Poor treatment adherence. For whatever reason\u00a0\u2013 denial,shame,simple ignorance\u00a0\u2013 some
\nphysicians are not very good patients.They cannot accept the gravity of their illness(es)
\nand the pressing need for professional help [11].Their symptoms worsen and they lose
\nhope. If they have an associated unchecked substance abuse problem, they are espe-
\ncially at risk of killing themselves
\n\u2022 Treatment refractory psychiatric illness. Like patients in general, some physicians suffer
\nfrom \u2018malignant\u2019 psychiatric disorders that do not respond easily to state-of-the-art
\npsychiatric treatment. When one is symptomatic for long periods of time or achieves
\nvery short (or increasingly short) periods of remission, demoralization sets in and sui-
\ncide risk builds
\nwmj 3 2011 5CS.indd 91 6\/21\/11 9:32 AM
\n92
\ndetail. In fact, our work dictates a certain
\ndegree of fastidiousness in order to be accu-
\nrate, competent and safe. But this tendency
\ncan work against self-acceptance in physi-
\ncians. When it is hypertrophied, it can be
\nlife threatening. The ill physician is so self-
\nloathing and unforgiving that he\/she can
\nbecome dangerously suicidal.
\nMany physicians have a very high need
\nfor autonomy. They want to set their own
\nagenda, they eschew intrusion of others and
\nthey argue that they know what is best for
\nthemselves.This stubbornness may preclude
\ntheir seeking help from others should they
\nfall ill or if they do consult someone they
\nhave trouble trusting and fully respecting
\nthe individual as being able to assist them.
\nSometimes this is coupled with a rugged
\nindividualism that goes back to their child-
\nhood. It is their way of going through life.
\nThey hate to bother others or to need others
\nto help them.
\nAn unknown number of physicians have
\npersonality disorders or traits of one. Phy-
\nsicians who have a borderline personal-
\nity disorder or traits are at risk for suicidal
\nbehavior because of impulsivity, unstable
\ninterpersonal relationships and rejection
\nsensitivity. Physicians with narcissistic per-
\nsonality are at risk for suicide (along with
\nother factors) in the face of overwhelming
\nloss of prestige, medical license investiga-
\ntion or public humiliation (for example, be-
\ning featured in the media after charges of
\nmedical negligence, medicare fraud, sexual
\nabuse of patients).
\nThe suicide plans of doctors
\nThere is no systematized research in this
\narea. However, my experience as a clini-
\ncian and specialist in physician health has
\nyielded an important and very concerning
\nfinding. Dangerously suicidal physicians
\nhave often given self-destruction consider-
\nable thought and invested many hours into
\nresearching suicidal means. They may have
\neven rehearsed how they would do it. The
\nintent is serious, the method is highly lethal
\nand foolproof. This is captured in the state-
\nment: \u201cI\u2019m a doctor\u00a0\u2013 I know how to kill
\nmyself\u00a0\u2013 I\u2019m not going to botch it.As a neu-
\nrosurgeon (or anesthesiologist or intensivist
\nor emergency physician or thoracic surgeon
\nor psychiatrist) I have looked after too may
\nsuicidal patients who didn\u2019t die but ended
\nup permanently disabled after they tried to
\nkill themselves\u00a0\u2013 not me, I\u2019m going to do it
\nright\u201d.
\nWhat about rational
\nsuicide in physicians?
\nPhysicians who are living with chroni-
\ncally debilitating medical illnesses are those
\nmost interested in rational suicide. In other
\nwords, they are not suffering from a men-
\ntal illness that is affecting their judgment.
\nThey are very clear that their medical state
\nis unbearable and perhaps worsening and
\nthat their decision to die is carefully con-
\nsidered and best for them. Being physicians
\nthey either know or have investigated what
\ncontinuing to live will look like for them
\nand they know their prognosis.Their family
\nmembers, irrespective of their empathy and
\ncompassion and acceptance of their physi-
\ncian loved one\u2019s clarity about suicide, may
\nstruggle though. All suicides have an after-
\nmath for the family and others left behind,
\nwhether they are rational or not.
\nWhat about stigma?
\nStigma kills! This scourge is yet to be eradi-
\ncated in the house of medicine and this
\nposes one of the greatest challenges for
\nmedicine in the 21st
\ncentury. Judgmental,
\nignorant, and discriminatory attitudes to-
\nward physicians living with mental illness
\ncompound their suffering, increase their
\nsense of isolation, delay help-seeking, drive
\ndenial of illness and self-treatment, and
\nheighten the risk for suicide. The stigma
\nin physicians may be one of two types or
\na mixture. Enacted stigma is the stigma
\nthat is embedded in institutional attitudes
\ntoward illness in doctors (noted in ap-
\nplications for hospital privileges that ask
\nquestions that are not necessary to gauge
\ncompetence and safety) and in some medi-
\ncal licensing bodies (noted in the questions
\nasked on applications, questions that are
\nover inclusive and generalized, not about
\nimpairing conditions, psychiatric or other-
\nwise). Felt or perceived stigma exists in the
\nsuffering physician and is irrational, often
\ndue to his\/her mental illness that is affect-
\ning cognition and perception. The individ-
\nual fears the judgment and scorn of family
\nand colleagues who actually understand,
\nthey do care and want to help.
\nResilience
\nThere are many definitions of resilience but
\nthe following is one of my favorites and
\nvery applicable to the physician population:
\n\u201ca life force that promotes regeneration and
\nrenewal\u201d and \u201cthe ability to confront adver-
\nsity and still find hope and meaning in life\u201d
\n[16]. Individuals with good or healthy resil-
\nience face their fears and actively cope with
\nthem; have positive emotions and an opti-
\nmistic attitude toward life; possess a skill set
\nof cognitive reappraisal, positive reframing
\nand acceptance; are socially competent and
\nhave social supports in place; and have a
\npurpose in life, a moral compass, a sense of
\nmeaning and spirituality [17].
\nHow do we reconcile
\nsuicide with resilience?
\nMost physicians have good-to-excellent re-
\nsilience. Indeed without this, and given the
\ncompetition worldwide, they would never
\nhave been accepted into medical school.
\nGiven the seeming paradoxical forces of
\nembracing life on the one hand and ex-
\ntinguishing life on the other, how do we
\nexplain suicide in doctors? Do physicians
\nwho kill themselves lack resilience? Do re-
\nSocio-Medical-Affairs UNITED STATES OF AMERICA
\nwmj 3 2011 5CS.indd 92 6\/21\/11 9:32 AM
\n93
\nsilient physicians never kill themselves? Is
\nresilience a protective factor against suicide?
\nIs resilience an absolute and fixed phenom-
\nenon? Are physicians who seem to be lack-
\ning resilience over the long term at risk of
\nsuicide? How does illness affect resilience?
\nThe answers to some of these questions are
\nobvious, to others more elusive. It is though
\nprobably safe to conclude that virtually all
\nphysicians (with the arguable exception of
\nrational suicide) who kill themselves are de-
\nvoid of resilience when they make that final
\nand irreversible decision to die.
\nAnd yet when I ponder the notions of resil-
\nience and suicide in physicians, I feel torn
\nand anxious. I fear that the notion of phy-
\nsician resilience will be abused or misap-
\npropriated, that ailing physicians, who are
\nsick with any medical or psychiatric disor-
\nder, may flagellate themselves for not being
\nmore resilient. They do not need this extra
\nlayer of worry on top of their psychological
\nadjustment to their blighted health. I also
\nam concerned that physicians who die by
\nsuicide will be judged as they once were\u00a0\u2013
\nand still are, in some circles today\u00a0 \u2013 that
\nthey have given up, that they \u2018can\u2019t cut the
\nmustard\u2019, that they lack the \u2018muscle\u2019 (or the
\n\u2018balls\u2019) to cope with the rigors of a medical
\ncareer, that suicide is \u2018selfish\u2019and a \u2018cop-out\u2019.
\nAs a clinician who has treated scores of
\nphysicians over the years (I treated my first
\nphysician patient during my residency in
\n1969) and who has lost physician patients
\nto suicide, I believe that most doctors who
\nkill themselves are exhausted and demor-
\nalized, that they hurt terribly inside with
\n\u2018psychache\u2019 [18], that their thinking has be-
\ncome constricted, that they (and often their
\nloved ones) have suffered enough already
\nand do not deserve the ignominy, hostility
\nand rejection that sometimes sullies their
\ndemise. Like the attitudes toward doctors
\nwho suffer a mental illness, including sub-
\nstance abuse, the stigma attached to physi-
\ncian suicide can be shocking and chilling.
\nToo many spouses, children and parents of
\ndoctors who died by suicide describe being
\nunsupported, shunned or judged by their
\nloved one\u2019s physician colleagues.
\nJoiner\u2019s [19] conceptualizations of what
\ndrives individuals to kill themselves are
\nhelpful in understanding suicide in physi-
\ncians. He has described three inner feeling
\nstates:
\n1. \u201cPerceived burdensomeness\u201d\u00a0 \u2013 a sense
\nthat one is a burden on others.
\n2. \u201cFailed belongingness\u201d\u00a0\u2013 a sense that one
\ndoes not belong to a valued social group.
\n3. \u201cLearned fearlessness\u201d\u00a0\u2013 the acquired ca-
\npability to enact lethal self-injury.
\nJoiner goes on to explain learned fearless-
\nness: \u201c\u2026\u2026\u2026.the kind of exposure to
\npain and fear that people also might learn
\nthrough such experiences as mountain
\nclimbing, performing surgery, fighting in
\nwars or being afflicted with anorexia\u201d. This
\nsense of fearlessness about death applies to
\na segment of physicians who not only fit
\ninto this category but are also very philo-
\nsophical and accepting of death. Regarding
\nJoiner\u2019s notion of failed belongingness, it is
\ncertainly true that physicians who become
\nill and cannot practice medicine any longer
\ncan feel a sense of loss and estrangement
\nfrom their profession. For some doctors, es-
\npecially those whose principal identity has
\nbeen their work, this can be serious.
\nA model of suicide
\nrisk assessment
\nSuicide is an outcome that requires several
\nthings to go wrong all at once. There is no
\none cause of suicide and no single type of
\nsuicidal person [20]. Table 3 is a schematic
\nrepresentation from the above reference.
\nThis is a dynamic flow chart with a bidirec-
\ntional interaction between any or all listings
\nunder the four headings.
\nAlthough this is a universal model that ap-
\nplies to all suicidal people, it is very help-
\nful in assessing the degree of suicidality and
\ndangerousness risk for ill physicians. Hence,
\na physician with the following features
\nwould be deemed very high risk: a family
\nhistory of suicide; a major mood disorder
\ncoupled with alcohol abuse, both of which
\nhave been refractory to conventional treat-
\nment; recent charges of unwanted sexual
\nadvances by patients and medical students;
\nmedia exposure of the latter; a stash of tri-
\ncyclic antidepressants at home.
\nThe impact of physician suicide
\non their families and colleagues
\nOne of first and most common reactions
\nwhen a doctor kills himself or kills herself is
\nSocio-Medical-AffairsUNITED STATES OF AMERICA
\nTable 3.
\nBiological Factors
\nPredisposing
\nFactors
\nProximal Factors
\nImmediate
\nTriggers
\nFamilial Risk
\nMajor Psychiatric
\nSyndromes
\nHopelessness
\nPublic Humiliation\/
\nShame
\nSerotonergic
\nFunction
\nSubstance Use\/
\nAbuse
\nIntoxication Access to Weapons
\nNeurochemical
\nRegulators
\nPersonality Profile
\nImpulsiveness
\nAggressiveness
\nSevere Defeat
\nDemographics Abuse Syndromes
\nNegative
\nExpectancy
\nMajor Loss
\nPathophysiology
\nSevere Medical\/
\nNeurological Illness
\nSevere Chronic
\nPain
\nWorsening
\nPrognosis
\nwmj 3 2011 5CS.indd 93 6\/21\/11 9:32 AM
\n94
\nshock. Why? Is there a collective or cultural
\ndenial in the world of medicine, that doctors
\ndon\u2019t die by suicide? Are some physicians
\nmasterful at covering up their illness and
\ndesperation? Are we blind to or neglectful
\nof our colleagues\u2019 personal interior lives? Are
\nsome deaths of doctors in the 10-15% who
\ndo not have an underlying psychiatric illness
\nthat has made them suicidal? There are no
\neasy answers to these questions and yet even
\nwhen we embrace the idea that the individual
\nmust have been ill\u00a0\u2013 and desperate\u00a0\u2013 disbelief
\nis still ascendant. Those left behind struggle
\nwith confusion and a flood of unanswerable
\nquestions. Here are some reactions:
\nThe words of Dr. David Satcher (Surgeon
\nGeneral of the United States 1998-2002):
\n\u201cYour video is an important effort in get-
\nting out a message to destigmatize and de-
\nscribe this serious problem whose aftermath
\nis characterized by personal pain, social and
\nfamily disruption, and loss of such produc-
\ntivity and promise\u201d [21].
\nThe words of a doctor\u2019s widow: \u201cWe have
\nthis belief that physicians have chosen that
\nprofession to continue and sustain and
\nprotect life\u2026\u2026\u2026.and when a physician
\nkills himself or kills herself, it is very, very
\nconfusing\u2026\u2026.because it\u2019s almost as if\u2026.if
\nthey\u2019re giving up\u2026what\u2019s that mean for the
\nrest of us?\u201d [22]
\nThe words of a doctor\u2019s daughter [23]: \u201cMy
\nfather always said:\u2018If you\u2019re going to do some-
\nthing,do it right\u2019.I remember he saw a movie
\nwhere a guy killed himself in the shower. He
\nwas very impressed with that.He kept repeat-
\ning: \u2018He did it there so it\u2019d be easy to clean
\nup\u2019. But where my father killed himself, the
\nblood stains are still in the floor boards. It\u2019s
\nbeen over 20 years. When I was 17 and he
\nwas 54, my father went up into the attic and
\nshot himself in the heart. I didn\u2019t cry\u201d.
\nThe words of a doctor\u2019s physician colleague
\n[24]: \u201cToday I learned that you died and
\nnothing will ever be the same again. I re-
\nfused to believe the words I heard, that you
\ncommitted suicide. Only terribly depressed
\npeople kill themselves. You weren\u2019t terribly
\ndepressed\u2026.but then I learned that, yes, se-
\ncretly you had been. How could I not know,
\nnot realize?\u201d
\nThe words of a doctor\u2019s patient [25] spo-
\nken at the doctor\u2019s funeral: \u201cI\u2019m a patient of
\nDr ______. I\u2019m sorry I cannot say: \u2018I was
\na patient\u2019. I cannot use the past tense. My
\ndoctor saved my life\u2026.\u201d As he choked and
\nstruggled for words, he stopped and began
\nto sob uncontrollably \u2026two attendants
\nhelped him back to his seat.
\nSome diagnostic, therapeutic
\nand moral imperatives
\nHow can we lower the incidence of physi-
\ncian suicide?
\nPrimary prevention
\nWe need to continue to study and delin-
\neate risk factors in medical education and
\npractice. Do we need to change the criteria
\nused to select medical students? Is there too
\nmuch emphasis placed on MCAT scores
\nand other markers of scholastic achieve-
\nment? How standardized or incisive are
\nmedical student applicant personal inter-
\nviews? How sensitive are we to the genetic
\nand developmental vulnerabilities of our
\napplicants to medical school and residen-
\ncy? How much do we accept the elusive
\n\u2018woundedness\u2019 of some, in addition to their
\nintellectual achievements on paper and how
\nthey perform in interviews? How much
\nshould we accommodate pre-existing con-
\nditions? We have no acceptable answers to
\nthese questions and what is more, we may
\nnot be asking the right questions anyway in
\nour attempts to understand suicide in medi-
\ncal students and physicians.
\nWhat about teaching methods in medi-
\ncal school and residency? We can say with
\nsome evidence that professors and attend-
\ning physicians whose teaching style is coer-
\ncive,shaming or abusive cause psychological
\ndamage to our trainees.At best they become
\ndisillusioned and cynical; at worst, they get
\ndepressed, develop symptoms of post trau-
\nmatic stress disorder,abuse alcohol and oth-
\ner drugs, and coupled with other issues, may
\nbecome despondent and suicidal. Can we\u00a0\u2013
\nor should we\u00a0\u2013 change the culture of medi-
\ncine? I am referring to the \u2018macho\u2019mystique,
\nthe normalcy and rewarding of overwork or
\nworkaholism, the ascendancy of intellectu-
\nalization and rationalism over feeling, com-
\npassion and humanism, the competition,
\nthe materialism in some sectors, and male
\nand female sexism in our medical centers
\nand institutions.
\nHow do we protect \u2018good doctors\u2019 who are
\nused to hard work and self-sacrifice in the
\nservice of their patients, education and
\nresearch? Some of these physicians have
\namazing resilience, including personal and
\nfamily lives that are fulfilling and rich. But
\nif they are not shielded from taking on more
\nand more work, especially with diminished
\nresources, and a needy underserved patient
\npopulation, they may burnout and get sick.
\nHow do we use the findings from innumer-
\nable burnout studies implicating overwork,
\nloss of locus of control and breakthrough
\nsymptoms of exhaustion, depression and
\nsuicidal ideation? Are the public\u2019s percep-
\ntions and expectations of their doctors
\nunrealistic? Many surveys of physicians in
\npractice have noted their high levels of de-
\nmoralization and an attitude or entitlement
\nand hostility in many of their patients.
\nWhat about medical licensing boards or
\nhospital credentialing standards that are
\noutdated, unenlightened and punitive? This
\nis serious because physicians are terrified of
\nself-disclosures and discriminatory inves-
\ntigations. A study of SMB (State Medical
\nBoard) license applications noted that 13
\nof the 35 SMBs responding indicated that
\nthe diagnosis of a mental illness by itself was
\nsufficient for sanctioning physicians [26].
\nThis was without any evidence of specifics,
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\n95
\nonset, treatment or duration. These same
\nSMBs also acknowledged that they treat
\nMDs receiving psychiatric care differently
\nthan those receiving medical care. The au-
\nthors argue that physicians\u2019 perceptions of
\nthis apparent discrimination likely plays a
\nrole in delayed or absent help seeking for
\nsymptoms of a mental illness. These same
\nphysicians end up with no treatment or
\ntreat themselves, both of which put them at
\nrisk of worsening morbidity and, in some,
\npossible mortality.
\nFinally, is there anything that can be done
\nabout a litigious climate of lawsuits and soar-
\ning costs? This drives an ethos of defensive
\nmedical practice, anxiety about being sued
\nand in many doctors, a risk of developing a
\nclinical illness as a result of this assault [27].
\nSecondary prevention
\nPhysicians continue to kill themselves\u00a0 \u2013
\nworld wide\u00a0\u2013 despite research on morbidity
\nand mortality in doctors that has been avail-
\nable in the scientific literature for decades. In
\nfact, the amount of evidence-based research
\nis increasing.So given the burgeoning studies
\non burnout, substance use and abuse and de-
\npression in medical students and residents\u00a0\u2013
\nin many countries\u00a0\u2013 we must redouble our
\nefforts toward promoting self-care and mak-
\ning sure that these findings are known to
\nclerkship and training directors, deans and
\nassociate deans, department chairs, chiefs of
\nstaff and so forth.We cannot be complacent;
\nwe cannot turn the other cheek and say that
\ndoctors don\u2019t take their lives in this medical
\ncenter or this community.
\nWe need to find ways of identifying trainees
\nand licensed physicians at risk by education
\nand inculcating an accepting attitude in their
\npeers, employers and caregivers. Outreach
\nneeds to be early, timely, invitational, wel-
\ncoming, comprehensive and kind. We must
\nensure that diagnostic and treatment servic-
\nes for trainees are available and advertised\u00a0\u2013
\nfree or sliding scale, confidential and geo-
\ngraphically accessible. We all must continue
\nto fight stigma both in our words and deeds,
\nby speaking openly and discretely about our
\nown personal struggles if so inclined and by
\nsupporting our colleagues when ill.
\nLoved ones of medical students and phy-
\nsicians are key players in physician health
\nwho have a vested interest and should be a
\n\u2018protective\u2019factor. Not only are they the best
\nones to provide collaborative information
\nbut they need to be our allies in a compre-
\nhensive treatment plan and caretakers must
\nmake themselves available to them. Too
\nmany ill physicians are receiving treatment
\nfor serious mental illnesses and their fam-
\nily members are totally excluded from their
\ncare. Therapists need to understand that
\nmany physicians are masters at deception
\nand what they choose to disclose in their
\ntreatment sessions may be devoid of the
\ndysfunction and symptomatic behavior at
\nhome. Grieving spouses, parents and chil-
\ndren of doctors who have killed themselves
\nhave an enormous amount to teach us about
\nbearing witness to the anguish and pain of
\ntheir loved one prior to his or her death.
\nSelf-treatment must stop by ensuring that
\nall physicians have primary care physicians
\nwho are interested and skilled at treating
\nailing doctors. This is no easy task. Count-
\nless physicians have trouble turning over
\ntheir health care to someone else, even
\nwhen those individuals are available. They
\ndo not trust easily.And too many physicians
\nwho treat other physicians do not give them
\nthe same kind of diagnostic and therapeutic
\nexcellence that they give to their non-physi-
\ncian patients.They make too many assump-
\ntions and avoid embarrassing questions and
\nphysical examination steps that compromise
\nthe care.Unfortunately,the doctor patient is
\nput at risk of worsening illness because of
\nmissed diagnoses or inadequate treatment.
\nAll medical communities\u00a0 \u2013 world wide\u00a0 \u2013
\nneed diagnostic and treatment resources
\n(similar to state and physician health pro-
\ngrams in the USA and Canada). They have
\nbeen established to meet the needs of col-
\nleagues at risk from the stress of practicing
\nmedicine. The science is first rate and there
\nis always a continuing education compo-
\nnent to keep the knowledge base up-to-
\ndate and to make sure that compassion and
\ntreatment eclipse punitive and discrimina-
\ntory attitudes toward ill physicians.
\nTertiary prevention
\nIn addition to primary care doctors who
\ntreat physician patients with respect and
\nthoroughness, we need specialists in addic-
\ntion medicine, psychiatrists and other men-
\ntal health professionals with expertise in
\nphysician health, specialists in occupational
\nhealth and rehabilitation, psychopharma-
\ncologists, and good (and affordable) treat-
\nment resources. Physicians, like patients in
\ngeneral, may suffer from difficult-to-treat
\nmood disorders, often comorbid with sub-
\nstance abuse, that require expertise that may
\nbe beyond the generalist. Indeed, it may be
\ndangerous for a solo mental health profes-
\nsional to try to be all things to his\/her pa-
\ntient. It is best to share the responsibility
\nwith others to ensure that your patient is
\ngetting the best care.
\nWe need to continue research on (and edu-
\ncate about) recurrent and chronic illnesses
\nin physicians that need treatment and
\nmonitoring. This is not common knowl-
\nedge. Given how doctors abhor illness in
\nthemselves and each other, there is a na\u00efve
\nattitude in some dimensions of the medical
\ncommunity that all that the ill doctor needs
\nto do is go away for awhile, get treated and
\ncome back with 100% functioning. This is
\noften not the case and there are many doc-
\ntors who report feeling chided by employers
\nand colleagues if they are not able to take
\non the same case load or medical respon-
\nsibilities that they assumed before they fell
\nill. We need return-to-work plans and pro-
\ngrams that accommodate partially disabled
\ndoctors. And most important, disability
\ninsurance needs modernizing and fairness.
\nSocio-Medical-AffairsUNITED STATES OF AMERICA
\nwmj 3 2011 5CS.indd 95 6\/21\/11 9:32 AM
\n96
\nSome doctors make need to remain on par-
\ntial disability indefinitely.
\nColleagues of physicians who are away on
\nextended medical leave need to keep in
\ntouch with them via email, cards, phone
\ncalls and visits (if the person is up for being
\nvisited). Ill physicians often feel bereft of
\nthe day-to-day medical world and can feel
\nout of the loop quickly. Worse is that they
\nfeel rejected as no longer \u2018part of the club\u2019
\nif they do not hear from their work mates.
\nGestures of missing them will aid healing
\nand lift spirits. Families need support for
\ntheir central role in keeping their physician
\nloved one well\u00a0\u2013 or in some cases of refrac-
\ntory illness\u00a0\u2013 alive.
\nSome moral imperatives
\nAdvocacy is part of being a physician and
\nthis has never been more applicable than in
\nphysician health and wellness. I urge you to
\nfight the stigma associated with suicide\u00a0 \u2013
\nwhether it is for the deceased physician or
\nhis\/her family. Speak out, write letters and
\npapers, volunteer, invite experts to give in-
\nservice training, lectures, seminars and so
\nforth. Educate staff and faculty about this
\nunique type of loss. Present cases at M &
\nM rounds, critical incident debriefing af-
\nter a suicide. The American Foundation
\nfor Suicide Prevention has a Suicide Data
\nBank Project and a Physician Depression
\nand Suicide Prevention project.
\nWhen a medical colleague dies by sui-
\ncide there is a lot that you can do, both
\nfor yourself and for others who knew the
\nphysician. There are diverse reactions in the
\ncolleagues of deceased physicians [8, page
\n201]. Mourning is to be expected and this
\nincludes the full range of emotions and
\nthoughts that people experience when they
\nlose a colleague or friend to death. But it
\nmay be more intense and confusing because
\nyour colleague died by suicide. Some be-
\nreaved physicians feel anxious after a death
\nlike this. They may feel personally vulner-
\nable, that they themselves have felt stressed
\nwith their work or have been depressed.
\nAn inner question may haunt them: \u201cAm I
\nprone to suicide?\u201d or they may fear the sui-
\ncide of another colleague of the deceased
\ndoctor.This is called \u2018contagion fear\u2019.
\nSome doctors feel guilty and may blame
\nthemselves. They are upset that they didn\u2019t
\ndo more to prevent the doctor\u2019s suicide. Or
\nthey castigate themselves for missing clues
\nthat the person may have been giving. If
\nthey didn\u2019t reach out to the doctor and ask
\nhow they were feeling or try to steer him\/
\nher for care, they may be wracked with feel-
\nings of regret. Some grieving doctors will
\nblame other physicians in their group or
\nmedical setting for not doing more, for fail-
\ning the deceased physician.
\nAnger and rage at the deceased physician
\nare not uncommon. Very primitive and
\nseemingly irrational emotions and state-
\nments accompany deaths by suicide. Some
\ndoctors will blame the suicide victim for
\n\u2018giving up\u2019 or being \u2018selfish\u2019, that they didn\u2019t
\naccept treatment or give it enough time or
\nthat they were thinking only of themselves
\nand not the many people they have left
\nbehind. These same individuals will accuse
\nthe deceased of abandoning his\/her fam-
\nily, friends, medical mates and patients. In
\nsome communities where there is a shortage
\nof physicians, the doctors may feel \u2018dumped
\non\u2019, that they now have to look after the
\ndead doctor\u2019s patients. \u201cAnd what do I tell
\nthem?\u201d may be a question that they don\u2019t
\nknow how to answer. Other physicians feel
\njudged by a colleague\u2019s suicide,that our pub-
\nlic perception of being invincible is tainted
\nby the doctor\u2019s death. This is rooted in the
\nhistory of suicide through the ages, that it is
\na blight, a shameful death.
\nAnd finally some doctors carry on as if the
\nphysician simply died of natural causes.
\nTheir manner and stance is business as usu-
\nal. Inwardly such physicians may be angry,
\nhurt or devastated but they keep their feel-
\nings to themselves.
\nOrganizational initiatives
\nThe American Medical Association is in
\nthe process of forming an expert panel to
\naddress risk factors for suicide in medical
\nstudents and physicians with representation
\nfrom medical educators, mental health pro-
\nfessionals and suicidologists. The National
\nAction Alliance for Suicide Prevention was
\nlaunched on September 10, 2010 (World
\nSuicide Prevention Day). Its focus is three-
\nfold: 1) Updating and advancing the Na-
\ntional Strategy for Suicide Prevention from
\n2001; 2) Development of effective public
\nawareness and social marketing campaigns,
\nincluding targeted messages for specific
\nsegments of the population that can change
\nattitudes and norms and reduce suicidal be-
\nhaviors; and 3) Advancing suicide preven-
\ntion among high-risk groups.Physicians are
\nconsidered a high-risk group.
\nResearch imperatives
\nand the future
\nWe need evidence-based research on mood
\ndisorders and other Axis I illnesses in physi-
\ncians, especially substance use disorders.This
\nmust include treatment outcome research
\nand not just psychopharmacological studies.
\nAnother area that needs updating is research
\ninto the suicide risk factors in physicians.
\nWe know a lot but much of our data are
\nold. Given the mosaic of physicians practic-
\ning medicine currently, there must be factors
\nthat have not been studied.Early outreach by
\nthe treatment team or a suicide social agency
\nto the families of doctors who have killed
\nthemselves must happen routinely. Currently
\nit is hit and miss.There is a compelling need
\nfor postvention studies on families and col-
\nleagues of doctors who have died by suicide.
\nThis will include psychological autopsies
\non doctors who have killed themselves, in-
\nformation that is sorely lacking. Our great-
\nest challenge will be grieving families and
\nmedical colleagues of the deceased physician.
\nAccurate studies are impeded by the privacy
\nrights of families, their protective denial and
\nSocio-Medical-Affairs UNITED STATES OF AMERICA
\nwmj 3 2011 5CS.indd 96 6\/21\/11 9:32 AM
\n97
\nshame,and the collusive secrecy of the medi-
\ncal community and the family.
\nFinally, qualitative research on medical stu-
\ndents and physicians who have made suicide
\nattempts (especially near lethal and aborted
\nattempts) and who did not die is overdue.
\nThe narrative recording of their memories,
\nthoughts, thought process and feelings with
\nthe goal of understanding the \u2018why\u2019 and the
\n\u2018how\u2019of their decision to die will yield criti-
\ncal information, information that can assist
\nin prevention, especially early intervention.
\nThis research will be helpful not just for the
\nperson him\/herself in treatment planning
\nbut by extension, very helpful in identifying
\nwhich physicians might be at risk of suicide.
\nConclusion
\nI can think of no more fitting way to con-
\nclude this paper than the way I ended my
\nlecture, that is, with quotes from the eulo-
\ngies of the son and daughter of a physician
\nwho ended his life in 2010.
\nFrom his son:
\nIn the last few months,he entered his deepest and
\ndarkest struggle. I called him every day, offering
\nadvice, a different perspective, another way to
\nlook at things, suggestions of how to feel better.
\nAnd he was so thankful\u00a0\u2013 he loved my advice
\nand suggestions. I felt like we were making
\nprogress.
\nBut in the end, I didn\u2019t realize how deep his
\npain was. And despite all he told me, he was
\nin a worse place than I or anyone else realized.
\nHe\u2019s gone now, and his pain has subsided. Yet
\nhis loss will live with me every
\nday for the rest of my life. I had nearly 40
\namazing, wonderful years with him.
\nRight now, the hole in my heart is big\u00a0\u2013 it will
\nheal, but a large and permanent scar will re-
\nmain.
\nFrom his daughter, a physician herself:
\nAs many of you know already, my father took
\nhis own life. As I told the children, he had a
\nsickness in his brain, and because of the sickness
\nhe made a bad decision. And unfortunately, it\u2019s
\nnot one that can be undone. All of these things
\nwe see in him, he couldn\u2019t see in himself. We
\ntried so hard to tell him, to reassure him. But he
\ncouldn\u2019t hear it. His brain just wasn\u2019t function-
\ning properly.
\n\u2026\u2026\u2026\u2026\u2026As doctors, we feel as though we
\nare supposed to be perfect in some way, and my
\nfather embodied that sentiment. He wanted to
\nbe perfect, and when he saw that he wasn\u2019t, he
\ncouldn\u2019t tolerate it.
\nDepression is a real disease. I don\u2019t know why
\nor how it happens, but it does. And to honor my
\nfather we can bring it out from the shadows and
\nremove the shame.There is NO shame in depres-
\nsion. I want everyone in this room to hear that,
\nand I want my father to hear that, wherever he
\nis. You will always remain a smart, hardwork-
\ning,lovable mensch,regardless of what you were
\nsuffering. Your family loves you so much.
\nReferences
\n1. Donne J. Meditation Xvii.
\n2. Centers for Disease Control and Prevention.
\nSuicide Facts at a Glance. Summer 2010. www.
\ncdc.gov
\n3. American Foundation for Suicide Prevention.
\nwww.afsp.org
\n4. Jamison KR. Forward.Touched by suicide: hope
\nand healing after loss. Myers MF and Fine C.
\nNew York, Gotham\/Penguin, 2006.
\n5. Nuland SB.How we die: reflections on life\u2019s final
\nchapter.New York,Alfred A Knopf,1994,p 151.
\n6. Center C, Davis M, Detre T et al. Confronting
\ndepression and suicide in physicians: a consensus
\nstatement. JAMA 2003;289:3161-3166.
\n7. Schernhammer ES, Colditz GA. Suicide rates
\namong physicians: a quantitative and gender
\nassessment (meta-analysis). Am J Psychiatry
\n2004;161:2295-2302.
\n8. Myers MF, Gabbard GO. The physician as pa-
\ntient: a clinical handbook for mental health pro-
\nfessionals. Washington, DC. American Psychi-
\natric Publishing, Inc, 2008, p 186.
\n9. Silverman MM. Physicians and suicide. In: The
\nhandbook of physician health. Edited by Gold-
\nman LS, Myers M, Dickstein LJ. Chicago, IL,
\nAmerican Medical Association, 2000.
\n10. American Psychiatric Association: Practice
\nguidelines for the treatment of psychiatric disor-
\nders: Assessment and treatment of patients with
\nsuicidal behaviors, compendium 2004. Wash-
\nington, DC, American Psychiatric Association,
\n2004, pp 835-1027.
\n11. Jamison KR. Night falls fast: understanding sui-
\ncide. New York, Knopf, 1999, p 268.
\n12. Hendrie HC, Clair DK, Brittain HM et al. A
\nstudy of anxiety\/depressive symptoms of medical
\nstudents, house staff, and their spouses\/partners.
\nJ Nerv Ment Dis 1990;178:204-207.
\n13. Hsu K, Marshall V. Prevalence of depression
\nand distress in a large sample of Canadian
\nresidents, interns and fellows. Am J Psychiatry
\n1987;144:1561-1566.
\n14. Dyrbye LN,Thomas MR,Massie FS et al.Burn-
\nout and suicidal ideation among US medical stu-
\ndents. Ann Int Med 2008;149:334-341.
\n15. Fridner A, Belkic K, Marini M et al. Survey
\non recent suicidal ideation among female uni-
\nversity hospital physicians in Sweden and Italy
\n(The HOUPE Study): cross-sectional asso-
\nciations with work stressors. Gender Medicine
\n2009;6:314-328.
\n16. Deveson A. Resilience. Allen & Unwin. Sydney,
\n2003, pp 161, 267.
\n17. Feder A, Nestler EJ, Charney DS. Psychobiol-
\nogy and molecular genetics of resilience. Nature
\nReviews Neuroscience 2009;10:446-457.
\n18. Shneidman ES. Suicide as psychache. J Nerv
\nMent Dis 1993;181:145-147.
\n19. Joiner TE. Why people die by suicide. Cam-
\nbridge, MA, Harvard University Press, 2005.
\n20. AAS suicide risk assessment 2009.DVD.Amer-
\nican Association of Suicidology, Washington,
\nDC.
\n21. From the commentary of When Physicians Com-
\nmit Suicide: Reflections of Those They Leave Behind.
\nVideotape produced by MF Myers 1998.
\n22. Fine C. Excerpt from When Physicians Commit
\nSuicide: Reflections of Those They Leave Behind.
\nVideotape produced by MF Myers 1998.
\n23. Heckel S.Unspeakable.Documentary film.2009.
\n24. Middleton JL. Today I\u2019m grieving a physician
\nsuicide. Ann Fam Med 2008;6:267-269.
\n25. Myers MF. Physician suicides leave many vic-
\ntims in their wake. Winnipeg Free Press, Octo-
\nber 1, 2006.
\n26. Hendin H, Reynolds C, Fox D et al. Licens-
\ning and physician mental health: problems
\nand possibilities. J Med Licensure and Discipline
\n2007;93:1-6.
\n27. Charles S. Physician litigation stress resource
\ncenter. www.physicianlitigationstress.org
\nMichael F Myers, MD;
\nProfessor of Clinical Psychiatry;
\nVice-Chair Education and Director
\nof\u00a0Training Department of
\nPsychiatry\u00a0&\u00a0Behavioral\u00a0Sciences
\nSUNY Downstate Medical Center
\nE-mail: michael.myers@downstate.edu
\nSocio-Medical-AffairsUNITED STATES OF AMERICA
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\n98
\nGenome Sequencing AUSTRALIA
\nIntroduction
\nHuman genetic disorders fall into three cat-
\negories: (1) Somatic cell defects, (2) Men-
\ndelian genetic disorders and (3) Complex
\ngenetic disorders (Table 1). The latter two
\ninvolve the germline and so are heritable.
\nOur understanding of pathogenesis in the
\nsomatic cell defects is still mostly research-
\nin-progress. These usually involve sporadic
\ncancers. The Mendelian genetic disorders
\nare well characterised at the molecular level
\nalthough for many the underlying causative
\ngenes remain to be found. In contrast, we
\nknow very little of the complex genetic dis-
\norders apart from the assumption that they
\nare caused by gene-gene, gene-environment
\nor gene-environmental-epigenetic inter-
\nactions [1]. Our understanding of genetic
\ndisorders took a major step forward when
\nthese were better understood at the DNA
\nlevel.
\nThe molecular (DNA) era for medical
\ngenetics started in 1953 with the de-
\nscription of DNA\u2019s double helix structure
\nby J. Watson, F. Crick, M. Wilkins and
\nR. Franklin. For this discovery the first
\nthree were awarded the 1962 Nobel Prize
\nin Physiology or Medicine (Rosalind
\nFranklin had died by then). Subsequently,
\nthere were many more discoveries involv-
\ning DNA and RNA which provided a
\nnew molecular understanding of genetic
\ndiseases and how they arose through mu-
\ntations in genes. From this came better
\nways to investigate and then detect these
\ndisorders by DNA testing. A number of
\nimportant developments then occurred
\nleading to the potential for sequencing
\nthe whole human genome as a compo-
\nnent of patient care. These developments
\nincluded:
\n\u2022 In the 1970s, DNA genetic testing start-
\ned with a method called Southern blot-
\nting. This was cumbersome, dangerous
\n(radioactivity and carcinogenic chemicals
\nwere used) and took a few weeks to get a
\nresult. The method would predominantly
\ndetect deletions in genes which represent
\nthe less common disease-causing muta-
\ntions.
\n\u2022 DNA mutation testing took a major step
\nforward when methods were devised to
\nsequence segments of DNA. This meant
\nthe four nucleotide bases\u00a0\u2013 adenine (A),
\nthymine (T), guanine (G) and cytosine
\n(C) making up a segment of DNA could
\nbe identified. Point mutations (single base
\nchanges) which comprise the usual cause
\nfor a genetic disease were now identifi-
\nable. For work on developing DNA se-
\nquencing W. Gilbert and F. Sanger were
\nawarded a Nobel Prize in 1980.
\n\u2022 The next significant advance in genet-
\nic DNA testing was the discovery of
\na technique called PCR (Polymerase
\nChain Reaction) in 1985. For this,
\nK.\u00a0Mullis was awarded the 1993 Nobel
\nPrize in Chemistry. PCR had a signifi-
\ncant impact on DNA genetic testing in
\nmedicine as well as forensic science, in-
\ndustry and many different research ap-
\nplications because it is a technique that
\nallows a segment of DNA to be ampli-
\nfied hundreds to millions of times. In
\neffect, PCR allows a portion of DNA
\nto be cloned so it can be more easily
\nmanipulated or characterised. The latter
\nhas direct applications for DNA genetic
\ntesting.
\n\u2022 The last important development oc-
\ncurred during 1991 to 2000. This was
\nthe Human Genome Project the pri-
\nmary goal of which was to DNA se-
\nquence the first human genome. At the
\ntime, it was proposed that the Human
\nGenome Project once completed would
\nprovide a new paradigm for medical
\ncare through a thorough understand-
\ning of human genetic disorders. Un-
\nfortunately, this has not turned out to
\nbe the case because, if anything, the
\nHuman Genome Project has produced
\nmore questions than answers. For ex-
\nample, at the beginning of the Human
\nGenome Project it was generally be-
\nlieved that humans had about 150,000
\ngenes coding for proteins. Today, the
\nestimated number of these genes is
\ncloser to 20,000 [1]. This is a puzzle
\nbecause the mouse also has 20,000
\nprotein-coding genes (as has the pinot
\nnoir grape!). So, what is the difference
\nbetween humans and the mouse? The
\nHuman Genome Project has opened
\nup some new areas of understanding
\nabout the human genome, particularly
\nthe role of non-coding (nc) RNA spe-
\ncies [2].
\n\u2022 An important by-product of the Human
\nGenome Project was technology devel-
\nopment and this enabled better and fast-
\ner ways to sequence the human genome.
\nRon Trent
\nWhole Genome Sequencing\u00a0\u2013 a New
\nParadigm for Clinical Care?
\nBased in part on a presentation to the World Medical Association\u00a0\u2013 Australian
\nMedical Association meeting Medical Leadership: The View from Down Under
\non 5 April 2011 in Sydney.
\nwmj 3 2011 5CS.indd 98 6\/21\/11 9:32 AM
\n99
\nGenome SequencingAUSTRALIA
\nDNA sequencing
\nDNA sequencing is considered the \u201cgold
\nstandard\u201d for mutation detection because it
\nwill allow single base changes to be iden-
\ntified and characterised. DNA sequencing
\nis of little use for detecting unknown dele-
\ntions. During the early days of the Human
\nGenome Project, DNA sequencing became
\nincreasingly more automated so that larger
\nread lengths were possible, for example, 800
\nbase pairs (bp) became a standard length for
\na sequence trace (Figure 1). Genes would be
\nlarger than this but by incorporating PCR
\nand new approaches to sequencing, it was
\npossible to break the gene into segments and
\neach was sequenced separately. For example,
\nall exons and the exon-intron boundaries
\nof a gene could be sequenced individually
\nrather than the whole gene because it was in
\nthese regions that the more serious disease-
\ncausing mutations were likely to be found.
\nAs the Human Genome Project progressed
\nso did the technologies for DNA sequenc-
\ning until the unthinkable was proposed\u00a0\u2013 a
\nwhole genome sequence that would cost
\naround $1,000. This needs to be put into
\nthe context that the first human genome
\nreported in 2003 was estimated to have
\ncost around $3 billion to complete. From
\n2003 to 2011, the costs for a whole human
\ngenome have plummeted, and today com-
\nmercial companies can complete a whole
\ngenome sequence for about $4,000. The
\n$1,000 target is not far away [3]. By com-
\nparison, DNA sequencing for two common
\nbreast cancer genes (BRCA1, BRCA2) costs
\naround $2,000\u2013$3,000, yet all 20,000 hu-
\nman genes including these two cancer genes
\ncan be sequenced for $4,000 and likely to
\nbe $1,000 in the next 12 months. There is
\nalso talk that the technology will continue
\nto improve and $100 for a whole genome
\nsequence is achievable!
\n65 81
\nGCTAAGCTGGAATAAAATCCACTTACCTGT
\nG
\nC
\nT
\nA
\nFigure 1. DNA sequencing. Automated se-
\nquencing is now possible and it uses sophisticat-
\ned analytic platforms as well as bioinformatics
\ntools to identify changes in the DNA sequence.
\nThe four bases are distinguished by lines.
\nChanges in the DNA sequence compared to
\nnormal would signify a mutation or a neutral
\nchange which is called a DNA polymorphism.
\nThe significance of DNA changes (collectively
\ncalled DNA variants) requires analysis by
\nsoftware and reference to DNA databases and
\nthe literature. In a number of cases (up to 15%
\nwhen the breast cancer genes are sequenced),
\nthe significance of variants cannot be estab-
\nlished and these are known as VUS (variants
\nof unknown significance). Not surprisingly, the
\nlikelihood of VUS changes in a whole genome
\nsequence will be significantly greater.
\nWhole genome sequencing in humans only
\nbecame realistic when new analytic plat-
\nforms and alternative strategies were de-
\nveloped.These are called NG DNA sequenc-
\ning (NG\u00a0 \u2013 next generation) or massively
\nparallel DNA sequencing. Basically, the NG
\nDNA sequencing strategies rely on smaller
\nDNA fragment being sequenced (100 bp)
\nrather than the 800 bp described above
\nwith conventional DNA sequencing which
\nis also called Sanger sequencing. But to get
\naround the smaller fragments sequenced,
\nthe technology allows a larger number of
\noverlapping fragments to be generated\u00a0 \u2013
\nup to x30 coverage can be achieved. The
\nsmaller but overlapping fragments repre-
\nsent a giant jigsaw puzzle made up of two
\ncopies of 3.3 billion combinations of A, T,
\nG and C.These are put together in the cor-
\nTable 1. Classification of genetic disorders
\nSomatic cell defects Mendelian genetic defects Complex genetic disorders
\nAcquired Inherited as autosomal dominant,
\nrecessive or X linked disorders
\nG x G, G x E, G x G x E,
\nG x EPI, G x E x EPI and
\nother combinations pos-
\nsible1
\nNo implications for
\nfamily members
\nQuantifiable risks for family
\nmembers
\nFamilial risk can be appar-
\nent but not quantifiable in
\nthe individual case
\nCancer tissue testing
\ncurrent model dem-
\nonstrating recurring
\nmutations in key
\npathways
\nStrong high penetrance genes
\ninvolved. Can draw family tree
\ntracing disease
\nTwin studies confirm heri-
\ntability
\nDNA genetic testing
\nhelps in guiding
\ntherapies. Whole ge-
\nnetic sequencing is a
\npromising approach
\nfor new classification
\nbased on molecular
\nsignatures
\nDNA genetic testing useful for
\nmultiple applications from plan-
\nning pregnancies, screening popu-
\nlations to predicting development
\nof disease well into the future
\nWhole genome sequencing being
\nused to find new causative genes
\nDNA genetic testing not
\nuseful in clinical care.
\nWhole genome sequencing
\nnow being explored to iden-
\ntify the G and EPI compo-
\nnents in pathogenesis
\n1
\nG = genetic; E = environmental; EPI = epigenetic effects.
\nwmj 3 2011 5CS.indd 99 6\/21\/11 9:32 AM
\n100
\nrect order through bioinformatics i.e. soft-
\nware tools.
\nApplications: NG DNA
\nsequencing and somatic cell
\ngenetic testing of solid tumours
\nResearchers quickly saw the potential ben-
\nefits of NG DNA sequencing and many
\nwhole genome sequencing projects devel-
\noped. These followed the Human Genome
\nProject format which involved ambitious
\nresearch questions being asked, and the
\nanswers sought by sophisticated DNA se-
\nquencing and bioinformatics strategies. An
\nexample would be the International Can-
\ncer Genome Consortium (ICGC) [4]. This
\nstarted in 2009 and its aim is to sequence 50
\nof the most important human cancers us-
\ning DNA taken from the tumours. This is
\ncalled somatic cell DNA genetic testing be-
\ncause the mutations are only present in the
\nsomatic cells and so not passed on through
\nthe germline to other family members.
\nThe ICGC is a multinational endeavour
\nand is only in its early stages but already
\ninteresting molecular signatures for differ-
\nent tumours are being identified.These mo-
\nlecular signatures have shown that a limited
\nnumber of DNA mutations are necessary
\nfor tumour formation and the changes are
\nnot tumour specific [5]. Hence, the tradi-
\ntional histological or immunophenotypic
\nclassifications can be complemented with
\nchanges in DNA. Perhaps the molecular
\nchanges (signatures) will eventually prove
\nmore useful than the traditional ways for
\nestablishing diagnosis and prognosis.
\nAlready the molecular signatures associated
\nwith tumours are being used to guide treat-
\nment with examples including: (1) Breast
\ncancer and amplification of the HER2 gene.
\nChemotherapy with the humanised mono-
\nclonal antibody Herceptin in this tumour is
\nmore effective when it has multiple copies
\nof the HER2 gene. This type of approach is
\ncalled personalised medicine because it pro-
\nvides additional DNA based information
\nallowing better selection of drugs for any
\nparticular individual [6]. Ultimately, select-
\ning the best drug for a tumour will save
\nhealth dollars and, in the case of Herceptin,
\nwill avoid exposing patients to potential
\nserious side effects if this drug is unlikely
\nto be effective. (2) Treatment of metastatic
\ncolon with another humanised monoclonal an-
\ntibody cetuximab. In this particular example,
\nthe KRAS gene needs to be in its normal
\n(wild type) configuration for the drug to be
\neffective. (3) Treatment of metastatic mela-
\nnoma with an experimental drug PLX4032.
\nThis is showing very promising results in
\nwhat is otherwise a difficult malignancy to
\ntreat. For optimal response to PLX4032 the
\nBRAF gene must have the V600E mutation.
\nThe successes seen with somatic cell DNA
\ntesting in tumours would suggest that whole
\ngenome sequences of all tumours will soon
\nbe part of the routine clinical and patholog-
\nical workup of a tumour so that treatment
\ndecisions can be based on molecular signa-
\ntures.In other words,there will no longer be
\na drug for treating lung or colon cancer.This
\nwill be replaced by a drug(s) that target(s)
\na genetic cancer-causing mutation(s) which
\nmight be found in either or both of the
\nmentioned cancers. Combination chemo-
\ntherapy regimens would follow the same
\nrationale but target multiple mutations.
\nGermline whole
\ngenome sequencing
\nDNA changes in the germline have been
\ninherited from our parents and can be
\npassed on to our children. Hence, germline
\nDNA genetic testing is different to the so-
\nmatic cell testing described above because it
\ninvolves other members of the family who
\nshare our genes (and so will share our risks).
\nGermline DNA testing also can be used for
\npredictive genetic testing since we are born
\nwith these mutations. Therefore, looking
\nfor an inherited mutation in an asymptom-
\natic individual will allow a prediction that
\nsometime into the future a disease might
\narise. An example is Huntington disease
\n(HD) predictive DNA testing. HD is an
\nautosomal dominant disorder so children of
\nan affected parent have a 1 in 2 (50%) risk of
\ninheriting a mutated HTT gene that causes
\nHD. Onset of this invariably fatal neurode-
\ngenerative disorder is in the fourth or fifth
\ndecade and penetrance of the HD DNA
\nmutation is 100%. This means that anyone
\nwith the right mutation in the HD gene
\nwill invariably develop this disorder un-
\nless they die from some other cause before
\nthey reach the age for HD development.
\nThe HD mutation can be looked for at any
\ntime in life (or in utero or preimplantation
\ngenetic diagnosis) to predict an individual\u2019s
\nrisk, i.e., no risk or 100% risk for develop-
\ning HD. A similar test is available for breast
\ncancer when there is a strong family history
\nor other clinical features to suggest a sig-
\nnificant genetic component [7]. However,
\nin this case the penetrance for mutations in
\nthe BRCA1 or BRCA2 genes is not 100%
\nbut between 60% and 80% depending on a
\nnumber of factors.
\nAnother area of interest in DNA genetic
\ntesting is pharmacogenetics which allows
\nindividual\u2019s genetic predisposition to drug
\ntherapies to be predicted based on their
\ngenetic makeup [8]. It is proposed that the
\n\u201cright drug for the right person\u201d might be
\nachievable by taking into consideration
\nthe metabolising status of the patient and
\nin this way select a more appropriate drug
\ndosage to optimise efficacy or alternatively
\nreduce the dose to avoid side effects that oc-
\ncur because the individual\u2019s genes involved
\nin metabolising a drug into the inactive
\nforms are less effective.
\nThe delivery of personalised medicine will
\nrequire more genetic DNA testing to assist
\nin clinical decision making. This is now be-
\ning undertaken using single gene tests that
\nlook at one or two genes. Apart from the
\ncosts (illustrated above with the BRCA1
\nand BRCA2 example), it is time consuming
\nGenome Sequencing AUSTRALIA
\nwmj 3 2011 5CS.indd 100 6\/21\/11 9:32 AM
\n101
\nand potentially inefficient because the same
\ntest might be repeated a number of times
\nif results are not readily available. Since
\nchanges are in the germline,they will always
\nremain the same and so repeat tests are un-
\nnecessary. In contrast, a once-in-a-lifetime
\nwhole genome sequence can be interrogated
\non a regular basis depending on the clinical
\ncontext. Provided it can be safely stored and
\nprotected to avoid any potential ethical legal
\nsocial issues (ELSI) see below, it needs only
\nbe tested once. Since the actual test cost is
\nlikely to be cheap, it becomes a cost effec-
\ntive and efficient way to move forward the
\npersonalised medicine agenda.
\nSome future clinical
\nresearch directions for whole
\ngenome sequencing
\nA global health problem is obesity and there
\nare many traditional public health based
\nstrategies to prevent this growing epidemic.
\nTo date the results are disappointing and so
\nother strategies are being considered. Can
\ngenetics help? So far the answer is no be-
\ncause only very rare forms of obesity are of
\nthe Mendelian type and so caused by muta-
\ntions in single genes. The great majority of
\ncases are considered to represent a complex
\ngenetic disorder with genes, environment
\nand epigenetic effects all potentially play-
\ning a role. Nevertheless, twin studies which
\ncompare obesity in monozygotic twins
\n(who share essentially the same DNA) ver-
\nsus dizygotic twins (who share 50% of their
\nDNA) suggest that the heritability factor in
\nobesity is considerable at around 81% [9]. A
\nlot of work is now being undertaken to find
\nthe genes implicated in obesity (including
\nknowledge from whole genome sequences)
\nand from this use DNA testing approaches
\nto identify those particularly at risk, and
\nnew targets for drug therapies.
\nAnother interesting development in obe-
\nsity is the potential that our gut flora might
\nbe involved in pathogenesis. This has come
\nfrom metagenomics studies of the hu-
\nman gut flora (metagenomics refers to the
\ncharacterisation by DNA sequencing of all
\nmicroorganisms in an uncultured environ-
\nment). Humans have two types of DNA
\n(nuclear DNA and mitochrondrial DNA)
\nbut so far we have ignored the DNA con-
\ntent in our gut flora which is estimated to be
\nx100 our nuclear DNA and comprises over
\n500 species of bacteria [10]. Some early re-
\nsearch studies are also suggesting that the
\nmetagenome is different in the obese and
\nnon-obese individual, and perhaps more in-
\ntriguingly that germ free mice given a gut
\nmetagenome from an obese or non-obese
\nmouse will revert to the phenotype of the
\ndonor mouse [11]. It will be interesting to
\nsee how this story progresses particularly
\nthe implication that diet may influence
\nobesity via the metagenome and not calorie
\nintake alone.
\nChallenges ahead for
\nwhole genome sequencing
\nin clinical care
\nThere is little doubt that whole genome se-
\nquencing has made important contributions
\nto research proposals and will continue to
\ndo so in this area. However, there are many
\nchallenges ahead before the whole genome
\nsequence can be effectively integrated into
\nclinical care.These include:
\nTranslation of research findings: As a 2008
\nnews feature in Nature suggested, cross-
\ning over from basic medical research into
\nits clinical applications is like \u201ccrossing
\nthe valley of death\u201d [12]. There is planning
\nneeded to ensure that the beneficial research
\napplications from whole genome sequenc-
\ning can be rapidly moved into clinical care.
\nSome jurisdictions are now asking the right
\nquestions about the clinical implications for
\nwhole genome sequencing and clinical ser-
\nvice delivery.A few clinical studies are being
\ndescribed where whole genome sequencing
\nis used to inform clinical decision making
\n[13]. However, more research is needed, as
\nare new clinical decision-making tools to
\nlink genome data with appropriate inter-
\nventions.
\nBioinformatics: Few would dispute that
\nwhole genome sequencing will become
\nfaster,cheaper and easier to deliver.The road
\nblock today and for sometime into the fu-
\nture will remain our superficial understand-
\ning of the genome. The Introduction im-
\nplied that knowledge of the 20,000 human
\nprotein-coding genes will not be enough,
\nand as these only occupy about 1\u20132% of the
\ngenome there remain vast regions that will
\nbe sequenced but their significance will re-
\nmain uncertain. However, just as we found
\nwith the development of the computer, the
\nsoftware programs available for in silico
\nanalysis of whole genome sequences will
\nonly get faster and more sophisticated. As
\nour understanding of the human genome
\nimproves, it will be possible to go back to
\nan individual\u2019s whole genome sequence and
\nreinterrogate it to update the information.
\nEngaging health professionals and the com-
\nmunity: Health professionals, particularly
\nthe general (family) practitioner, are already
\nunder considerable pressure maintaining
\ncontinuing education requirements for ar-
\neas of practice with which they have some
\nfamiliarity and meet regularly. While whole
\ngenome sequencing can be predicted to play
\na key role in our understanding of disease
\nrisks and new therapies, it will take some
\ntime for familiarisation with this technol-
\nogy, particularly what it can or cannot do.
\nIn contrast, members of the community are
\nconstantly being exposed to media reports
\nof gene X or Y being able to predict disease
\nor human traits such as sporting prowess.
\nCuriosity is followed by Internet searches.
\nAs such, the community seems to be more
\nengaged in the genetics developments than
\nthe health professionals and this may be-
\ncome problematic if the doctor-patient
\nrelationship does not develop to take on
\nboard the influence that the Internet can
\nplay in patient care.
\nGenome SequencingAUSTRALIA
\nwmj 3 2011 5CS.indd 101 6\/21\/11 9:32 AM
\n102
\nGenome Sequencing AUSTRALIA
\nAddressing ELSI (ethical, legal, social issues):
\nInappropriate use of genetic information
\ncan cause problems related to privacy, dis-
\ncrimination, stigmatisation or loss of self-
\nesteem.These are issues that are under active
\nconsideration for the more straightforward
\nDNA genetic testing but will be more com-
\nplex with whole genome sequencing. On
\nthe other hand, the modern generation
\nseems to be fairly relaxed about privacy or
\nconfidentiality issues as evidenced by social
\nmedia that are increasingly popular. So the
\nimplications for ELSI and whole genome
\nsequencing may differ depending on how
\ncomfortable is the individual with the elec-
\ntronic media as whole genome sequencing
\nand interpretations of the results will rely
\nentirely on eHealth capability. While per-
\nsonalised medicine has many attributes, it
\nis the antithesis of public health medicine
\nsince the individual is the focus. This will
\nmean that new therapies developed through
\npersonalised medicine will not be available
\n(or subsidised depending on the health
\nsystem involved) for all in the community.
\nOther broader considerations include the
\npotential for unnecessary hype to be coun-
\nterproductive because promises will not be
\ndelivered, and the influence of the growing
\ndirect-to-consumer DNA testing market
\ndiscussed next.
\nDirect-to-consumer (DTC) DNA testing: The
\nprovision of DNA testing direct to the pub-
\nlic and bypassing the health professional
\nhas grown rapidly since the mid 2000s
\nwhen there were only a handful of these
\nservices. The DTC marketplace has moved
\nahead with little oversight by the regulators
\nbut this has recently changed following two
\nadverse reports from the US Government
\nAccountability Office and a paper in Nature
\nsuggesting that the actual DNA test was re-
\nliability undertaken by two of the leading
\nUS DTC DNA testing companies but the
\ninterpretation of the risks for some serious
\nmedical disorders could differ [14]. While
\nthe DTC model is attractive to consumers
\nwho are increasingly turning to the Inter-
\nnet for services, it advertises and sells DNA
\ngenetic tests as a commodity. Promises
\nmade about the implications of DNA ge-
\nnetic testing for health, well-being and even
\nlongevity are qualified by caveats. Services
\nbased offshore cannot for practical purposes
\nbe regulated or held accountable. Today,
\ncompanies are moving to DTC whole ge-
\nnome sequencing.
\nRural, remote and the disadvantaged: As
\npersonalised medicine starts to impact on
\nhealth care,it is expected that those living in
\nrare or remote regions or are disadvantaged
\nwill have access to the same genetic devel-
\nopments including whole genome sequenc-
\ning. The DTC DNA testing market has
\nalready shown that DNA is portable and
\ncan be flown from one country to another
\nso distances and transportation are not an
\nissue. Costs as indicated above are coming
\ndown and hopefully will not become a limi-
\ntation. Interpretation of the whole genome
\nsequence will continue to be a barrier but
\nthis should not relate to distance or isolation
\nwith expected developments in eHealth.
\nConclusions
\nWhole genome DNA sequencing repre-
\nsents rapidly evolving technology that will
\nimpact on clinical care particularly in rela-
\ntion to personalised medicine. There is still
\na long way to go for the development of
\nbioinformatics programs to enable a better
\nunderstanding of what the DNA sequence
\nis saying in terms of an individual\u2019s health
\nor risk for disease development. Neverthe-
\nless,software development will progress and
\nthe whole genome sequence will become a
\ncomponent of routine care or public health
\nmedicine in terms of disease prevention or
\nidentification of risks. New therapeutics
\nbased on underlying molecular signature of
\ndisease will be developed. For this technol-
\nogy to be effectively integrated into clini-
\ncal care will require engaged and educated
\nhealth professionals and members of the
\npublic. The challenges are considerable but
\nthe potential benefits are enormous.
\nReferences
\n1. Trent RJ. Molecular medicine. 3rd
\nedition. San
\nDiego, Elsevier, 2005. 4th
\nedition in 2012.
\n2. Taft RJ, Pang KC, Mercer TR, Dinger M, Mat-
\ntick JS.Non-coding RNAs: regulators of disease.
\nJournal of Pathology 2009;220:126-139.
\n3. Mardis ER. A decade\u2019s perspective on DNA se-
\nquencing technology. Nature 2011;470:198-203.
\n4. International Cancer Genome Consortium
\nwww.icgc.org\/
\n5. Hanahan D, Weinberg RA. Hallmarks of can-
\ncer: the next generation. Cell 2011;144:646-674.
\n6. US President\u2019s Council of Advisors on Science
\nand Technology report 2008 on pesonalized
\nmedicine. www.whitehouse.gov\/files\/docu-
\nments\/ostp\/PCAST\/pcast_report_v2.pdf
\n7. US National Cancer Institute\u00a0 \u2013 Genetics of
\nBreast and Ovarian Cancer www.cancer.gov\/
\ncancertopics\/pdq\/genetics\/breast-and-ovarian\/
\nHealthProfessional\/page1
\n8. Wang L, McLeod HL,Weinshilboum RM. Ge-
\nnetics and drug response. New England Journal
\nof Medicine 2011;364:1144-1153.
\n9. Bell CG, Walley AJ, Froguel P. The genet-
\nics of human obesity. Nature Reviews Genetics
\n2005;6:221-234.
\n10. Carroll IM, Threadgill DW, Threadgill DS.
\nThe gastrointestinal microbiome: a malleable,
\nthird genome of mammals. Mammalian Genome
\n2009;20:395-403.
\n11. Ley RE. Obesity and the human microbiome.
\nCurrent Opinion in Gastroenterology 2010;26:5-
\n11.
\n12. Butler D. Crossing the Valley of Death.
\n2008;453:840-842.
\n13. Ashley EA, Butte AJ, Wheeler MT, Chen R,
\nKlein TE, Dewey FE et al. Clinical assessment
\nincorporating a personal genome. Lancet 2010;
\n375:1525-1535.
\n14. Ng PC, Murray SS, Levy S, Venter JC. An
\nagenda for personalized medicine. Nature
\n2009;461:724-726.
\nRonald JA Trent, Professor of
\nMedical Molecular Genetics
\nSydney Medical School, University of Sydney;
\nHead of the Department of
\nMolecular & Clinical Genetics
\nRoyal Prince Alfred Hospital, Australia
\nE-mail: ronald.trent@sydney.edu.a
\nwmj 3 2011 5CS.indd 102 6\/21\/11 9:32 AM
\n103
\nVaccinesUNITED STATES OF AMERICA
\nThe statistics show that too many children
\nand youth become injured, maimed and
\ndie in variety of accidents, too many get ill
\nwith infectious diseases, preventable by a
\nhealthier lifestyle, hygiene and vaccinations,
\nand lack the available, reachable health care.
\nIt is important to emphasize the improved
\nhealth effects of vaccines not only on the
\nhealth of children but also on the popula-
\ntion of the country. Vaccinations not only
\nhave prevented the spread but have led to
\nthe eradication of some diseases. Discus-
\nsions about vaccination have surfaced since
\nthe population have forgotten and not seen
\nthe death, the crippling effects of poliomy-
\nelitis, the physical and emotional effects,
\neven death resulting from measles, rubella,
\nmumps and varicella, not to mention the
\nmultitude of other side effects. The primary
\ncare physicians are fully aware and trained
\nin the preventive medical approaches, in-
\ncluding vaccination.
\nThe beginning of vaccination practices in
\nthe middle of the last century was the most
\nimportant historical progress in the field of
\nchild health. It is unfortunate that currently
\nthis medical achievement has evoked major
\ndiscussions and created complex problems.
\nThe vaccine-preventable diseases are not
\nas prevalent, yet common in the countries
\nwhere the vaccination practices are poor
\nand inadequate and most of the popula-
\ntion fails to receive the recommended doses
\nof vaccines. We must always be aware that
\nthe infectious diseases are only one airline
\nflight away. Repeatedly there are cases of
\na traveler-transmitted disease, as most re-
\ncently happened in California, USA where
\na traveler with measles was in contact with
\n839 and infected 11 persons. Anyone, who
\nhas not been vaccinated or partially so, is at
\nrisk.In 1999 measles outbreak 3000 became
\nill and 3 died. In 2006, in USA mid states
\nthere were 4000 cases of mumps and across
\nthe USA repeatedly off and on, there are re-
\nported cases of pertussis and other vaccine-
\npreventable infections. Each person should
\nbe aware, parents and doctors included, of
\nthe pain, fear, and sadness, the financial
\nexpenses, lost time of work that the infec-
\ntious disease can create. Scientifically, it has
\nbeen proven that the crowd immunity of the
\nvaccinated does not necessarily protect the
\nunvaccinated unless the surrounding im-
\nmunity is greater than 95%. The hope on
\ncrowd immunity does give false security. In
\naddition,one must be aware that the tetanus
\nvaccine only protects the one who is vacci-
\nnated. Tetanus is not a person-to-person
\ntransmissible infection as the bacillus is
\npresent in soil and the animal excreta.
\nThere are 2.5 million children under the age
\nof 5, who die of vaccine-preventable dis-
\neases. The goal of vaccines is to prevent the
\ndisease, yet the ultimate goal is to exhaust
\nthe disease. In order to reach these goals, it
\nis imperative that the physicians and health
\ncare workers prioritize to vaccinate infants,
\nchildren, adolescents and adults. It is im-
\nperative that all receive preventive vaccines.
\nIn 1977, the global eradication of smallpox
\nwas achieved. Since 1991, poliomyelitis has
\nvanished in the USA.Since 2000,the ongo-
\ning measles transmission has disappeared.
\n2004 signaled the end of the appearance
\nof rubella cases and associated congenital
\nrubella syndrome in the USA. Since the
\nmumps vaccine was instituted in1968, the
\n2007 statistics show the decrease of mumps
\nby 99%. In the USA, the extensive vacci-
\nnation program has accomplished the case
\ndisappearance of diphtheria in 2007.
\nThe pertussis vaccine was developed in the
\n1920s. In the 2007 statistics, it is evident
\nthat pertussis illness has decreased by 93%,
\nunfortunately, still yearly 20 to 40 infants
\nunder 3 months of age, who have not been
\nvaccinated, die. The research has proven
\nthat the immunity against pertussis wanes
\ngradually and therefore a booster TDAP
\nis required at 11 years of age and recom-
\nmended to expectant mothers to decrease
\nthe potential transmissibility of pertussis to
\ntheir newborns. Every year in the USA ap-
\nproximately 30 become ill with tetanus and
\none of ten die. The statistics of 2009 con-
\nfirm the great success of vaccines in the de-
\ncrease of illness and death.Since 1985 when
\nHIB (Haemophilus influenzae bacterial vac-
\ncine) was licensed, the USA 2007 statistics
\nconfirmed the 99% decrease of H. influen-
\nzae illness. The health benefits are evident
\nwith the pneumococcal vaccine. Every year
\n>40,000 become ill with severe pneumo-
\ncoccal-induced infections and >4,400 die.
\nThis vaccine is designed to protect against
\nsevere infections, not for ear infection. To
\nprotect against a greater spectrum of pneu-
\nmococcal-induced infections, the original
\nPCV (pneumococcal conjugate vaccine) of
\n7 serotypes has been modified to consist of
\n13 serotypes.
\nThe pneumococcal 23 vaccine is recom-
\nmended for those ill with chronic ailments.
\nThe USA statistics confirm yearly occur-
\nrence of 78,000 new hepatitis B cases, of
\nwhom 5000 die. The annual occurrence of
\nZaiga Alksne Phillips
\nOverview of the Vaccines in Preventing
\nInfectious Diseases
\nwmj 3 2011 5CS.indd 103 6\/21\/11 9:32 AM
\n104
\nUNITED STATES OF AMERICAVaccines
\nhepatitis A is 20,000 cases, of whom more
\nthan 100 die. Varicella occurrence is 67,400,
\nof whom 54 die of the complications. Me-
\nningococcal infection occurrence is re-
\nported as 1000 to 3000, ofwhom 125 die.
\nIn contrast, every year there are 31 million
\nill with influenza and 30,000 cases of death
\nare reported. Keeping statistics is essential
\nto report the cases of disease occurrence,
\nthe deaths and the benefits derived from
\npreventive vaccinations in the surveillance
\nof infectious diseases and health care of the
\ncountry. BCG vaccine is not used in the
\nUSA since,based on the statistical evidence,
\ntuberculosis is not widespread, yet cases of
\noccurrence must and are reported to Public
\nHealth Departments and the contacts are
\nidentified and tested.
\nReviewing the above disease statistics and
\nthe benefits reached from vaccinations, it
\nis difficult to understand why the parents
\nwould refuse to vaccinate their children.
\nThe infectious diseases mentioned above
\nare widespread in countries where there is
\nlack of governmental support for health,
\nlack of understanding, presence of fear, ex-
\nisting misinformation and lack of science-
\nbased information. Unfortunately, many of
\nthe health workers, including physicians
\nand nurses, are themselves misinformed
\nand lacking the knowledge and the belief
\nin the benefits of the immunizations that
\nwould also reduce the nation\u2019s health care
\nexpenses.The effects are far reaching, affect-
\ning not only the nation\u2019s health but leading
\nto increased health expenses.
\nIt is important how the vaccination practices
\nhave developed in countries where health is
\nconsidered a priority. In the USA, as an ex-
\nample dependent on the laws and the health
\ncare in each of the 50 states, the number of
\nthe vaccinated vary to some degree, yet on
\naverage 9 out of every 10 children and ado-
\nlescents are fully vaccinated. It is of extreme
\nimportance to document the cost and com-
\npare the nation\u2019s vaccination expenses with
\nthe expenses incurred from the care of the
\nill with infectious, vaccine-preventable dis-
\neases, the crippled and mentally affected by
\nthe disease, the public measures to curb the
\nspread of disease and loss of the work force
\nof the ill. The cost of infectious diseases is
\nmajor not only to the government, but also
\nto the country\u2019s health and well-being.
\nOngoing research and discoveries in im-
\nmunology, molecular biology and genetics
\nhave enhanced the development of new
\nvaccines and improved the safety of famil-
\niar vaccines. The science requests the expert
\nand common scientific balance between
\nthe risks, side effects and the effectiveness
\nof vaccines. It takes years of extensive test-
\ning to carefully evaluate the new, improved
\nor combined vaccine and only then when
\nthere is a guarantee in safety and effective-
\nness, the newly licensed vaccine is to find
\nits place in the pharmaceutical marketplace.
\nThe newly licensed vaccine continues to be
\nclosely monitored. Its use, the reactions, if
\nany, are well documented. The specific field
\ntrial analysis is continuous. On the rare oc-
\ncasions, when the vaccine has been received
\nby many, the rare side effects may be ob-
\nserved. Increased cases of intersection were
\nnoted to be associated with the initial\u00a0\u2013 li-
\ncensed in August 1998\u00a0\u2013 tetravalent rotavi-
\nrus oral vaccine (RotoShield). This product
\nwas voluntarily withdrawn from market
\nin October 1999 and the production was
\nstopped. In February 2006, a live oral hu-
\nman-bovine heptavalent rotavirus vaccine
\n(RotaTeq) was licensed and in April 2008, a
\nlive oral human attenuated rotavirus vaccine
\n(Rotarix) was licensed. It is imperative that
\nthe physicians and health care workers have
\nthe newest vaccine\/vaccination information
\nand are updated with information regarding
\nchanges and safety.
\nIn a cooperative relationship with FDA
\n(Food and Drug Administration) and the
\nCenters for Disease Control and Prevention
\nin the USA, vaccine safety is monitored by
\nVAERS (Vaccine Adverse Event Report-
\ning System). VAERS is tasked to collect
\nand systemically review adverse effects and
\nreactions that may be associated with vacci-
\nnations, assess the risks and pinpoint which
\nvaccine, constituent or substrate has pro-
\nduced the unexpected symptoms. With set
\nspecific guidelines in place, the physicians
\nare obligated to provide VAERS with the
\ninformation regarding the vaccine side ef-
\nfects or post vaccine symptoms.The vaccine
\nadministered is tracked by the production
\nand date numbers, the date administered,
\nthe person administering and parental\/
\nguardian consent. All of the above must be
\ncarefully recorded. The National Vaccine
\nInjury Compensation Program is involved
\nin evaluation and may as needed set up
\ncompensation for vaccine-related injuries.
\nvPhysicians and health workers should be
\nexpecting questions from the parents and
\nbe able to provide the answers and the ex-
\nplanations regarding vaccination, safety,
\nefficacy and risks involved. Some parents
\nhave strong personal and religious beliefs
\nregarding vaccination. The following ques-
\ntions need to be understood: do patients
\nlack timely and up-to-date information; are
\nthere organizations and persons that op-
\npose immunization by personal, religious
\nand alternative medicine principles that
\nare not scientifically based; is there a lack
\nof trust in modern medicine, health care
\nand physicians; and is there a lack of un-
\nderstanding the disease, the complications
\nfrom infections, the risks and the inabil-
\nity to value the protection from disease or
\ndiseases that combined vaccines provide?
\nWhen one sees parental opposition to vac-
\ncinations, it is imperative to clarify whether
\nthe fears and reasons for concern are regard-
\ning one or all vaccines. A recent nationwide
\nUSA questionnaire involving 1552 parents
\nrevealed the following: 90% of parents feel
\nthat the vaccines are a great way to protect
\nfrom certain infectious diseases, 54% are
\nconcerned about post vaccination reac-
\ntions, 25% believe that there is a vaccina-
\ntion and autism association and 11.5% have
\nrefused one to several vaccines for variety of
\nreasons. It is a known fact that the current
\nvaccines since 1930 are the most researched
\nand scientifically evaluated medication that
\nwmj 3 2011 5CS.indd 104 6\/21\/11 9:32 AM
\n105
\nUNITED STATES OF AMERICA Vaccines
\nis introduced into the human body, yet it is
\nacknowledged that vaccines are not 100%
\nsafe. Fever and vaccine site reactions remain
\nthe most common side effects. Severe com-
\nplications occur in approximately 1 out of
\n1,000,000 vaccinations.
\nAs progress continues with the develop-
\nment of new vaccines, such as those against
\nrotavirus and HPV (human papillomavi-
\nrus), it is imperative to accept the fact that
\ncertain vaccine recipients do not develop
\nthe expected full immunity, yet vaccines
\nare effective in 90% of cases. The parents
\nfrequently express the following concerns
\nand questions whether there are too many
\nvaccines given at one time, together or at
\ntoo young an age. Is the immune system
\nof an infant able to handle so many vac-
\ncines? What about the development of
\nautism, allergy, diabetes and other autoim-
\nmune diseases in future? Is it scientifically
\nproven that the immune system of an infant
\nis well developed and can process multiple
\nantigens and respond well with immunity?
\nCurrent vaccines in the United States pro-
\ntect against 16 infectious diseases, and pro-
\nvide the effect of 177 individual antigens.
\nTo compare, the vaccinations in 1980 were
\nprotective against 8 diseases, yet there were
\n3041 varied antigens. Here we see the prog-
\nress in the refinement of the vaccine bio-
\nlogical ingredients. Combination vaccines
\nhave lead to more efficient and complete
\nvaccination practice, less stress to the pa-
\ntient and time loss to parents. Psychiatrists
\nhave noted that children who have received
\ntheir vaccinations in combined forms and at
\nthe commended time intervals perform bet-
\nter on psychological testing.
\nDuring the past 10 years,attention has been
\ndirected towards the debunked association
\nbetween vaccines and autism. It started
\nwith Andrew Wakefield\u2019s 1998 publica-
\ntion in \u201cLancet\u201d.The extensive research that
\nfollowed failed to prove any association of
\nvaccines and the minute amount of mercury
\nthat is used as preservative in vaccines. The
\nWakefield study has now been discredited
\nand proven to be fraudulent. Fortunately,
\nthe diagnostic studies and the identification
\nof autism have progressed and currently ap-
\nproximately 1 of every 100 children in the
\nUSA has been diagnosed to have an autism
\nspectrum disorder. Genetic and environ-
\nmental association is implied.
\nThe antivaccination campaigns are very ac-
\ntive. The news and the internet information
\nthat parents access provide scary unrealistic
\nstories of vaccine-associated complications.
\nIt is very important to achieve a greater trust
\nin medical area and in the individual physi-
\ncian. It is important to have an open dis-
\ncussion about vaccines, the side effects and
\nthe benefits of infectious disease prevention.
\nThe physician must be well informed, be-
\nlieve in immunizations, be a good listener
\nand understand the parental needs and con-
\ncerns.It is imperative that we protect our-
\nselves, the population of Latvia, and the fu-
\nture of Latvia against preventable diseases.
\nThe infants, children and the adolescents
\nwill travel and are traveling anywhere in
\nworld and the health worker responsibilities
\nare to keep the nation healthy.
\nReferences
\n1. AAP Red Book: 2009 report of the Committee
\non Infectious Diseases.
\n2. Smith PJ, Kennedy AM, Wooten K, Gust DA,
\n3. Pickering LK. Association between health care
\nproviders\u2019 influence on parents who have con-
\ncerns about vaccine safety and vaccination cov-
\nerage.
\n4. Pediatrics 2006; 118.Benin AL, Wisner-Scher
\nDJ, Colson E, Shapiro ED,
\n5. Holmboe ES. Qualitative analysis of mothers\u2019
\ndecision-making about vaccines for infants: the
\nimpotence of trust. Pediatrics 2006; 117.
\n6. Dunn J. Immunization myths: \u201cThe facts about
\nFAQs\u201d.
\n7. Department of Pediatrics & Preventive Health-
\nGroup Health Vaccine Advisory Committee,
\nWashington State Department of Health, Au-
\ngust 2010.
\n8. Recommendations for identification and pub-
\nlic health management of persons with chronic
\nhepatitis B virus infection. CDC Morbidity and
\nMortality Weekly Report. September 19, 2008.
\n9. CDC Online Source for Credible Health Infor-
\nmation cdcinfo@cdc.gov
\n10. Vaccine safety\u00a0 \u2013 frequently asked questions
\nabout multiple vaccinations and the immune
\nsystem.
\n11. CDC Online Source for Credible Health Infor-
\nmation cdcinfo@cdc.gov
\n12. Vaccine safety\u00a0\u2013 sudden infant death syndrome
\n(SIDS) and vaccines.
\n13. Syncope after vaccination\u00a0 \u2013 in United States,
\nJanuary 2005\u2013July 2007.
\n14. MMWR 2008;57(17):457-460.
\n15. Duchin JS. Communications with patients and
\nparents about immunizations. Public Health,
\nSeattle & King County, Washington State Bul-
\nletin, King County Medical Association, Sep-
\ntember\/October 2010.
\n16. Kaplan SL. Partnering with parents to achieve
\nimmunization goals. Summer 2009 PRI health
\ncare solutions.
\n17. Centers for Disease Control and Prevention
\n(CDC) www.cdc.gov\/vaccines\/hcp.htmNational
\nNetwork for Immunization Information www.
\nimmunizationinfo.org
\n18. Children\u2019s Hospital of Philadelphia Vaccine
\nEducation Center
\n19. www.chop.edu\/service\/vaccine-education-cent-
\ner\/home.htm\/
\n20. Immunization Action Coalition www.immu-
\nnize.org
\nZaiga Alksne Phillips,
\nF.A.A.P. USA
\nwmj 3 2011 5CS.indd 105 6\/21\/11 9:32 AM
\n106
\nHealth and Enviroment Alliance
\nThere is a growing global consensus regard-
\ning a missing key element of cancer pre-
\nvention. Increasing numbers of experts are
\nconvinced that the current focus on lifestyle
\nchanges related to alcohol and tobacco use,as
\nwell as maintaining healthy diet and exercise
\nhabits, needs to shift to emphasize govern-
\nment action to reduce harmful environmen-
\ntal exposures. A particular concern is the
\ninvoluntary and unwitting exposures of indi-
\nviduals to harmful chemicals in everyday life.
\nThe World Medical Association has added
\nits weight to the argument in its \u201cStatement
\non Environmental Degradation and Sound
\nManagement of Chemicals\u201dagreed in 2010.
\nIt highlights the growing use of industrial
\nchemicals and pesticides and calls for a
\nmore comprehensive approach to the safe
\nregulation of harmful domestic and indus-
\ntrial substances [1].
\nThe European Union is a recognised global
\nleader on addressing this issue. It responded
\nto the scientific evidence on human expo-
\nsure to carcinogens with the introduction of
\nlegislation pertaining to chemical manage-
\nment known as REACH in 2007 [1], and
\nlater with legislation that supported a range
\nof changes on pesticide use [2].
\nThe US scientific community is echoing the
\nEU\u2019s concerns. In May of 2010, recommen-
\ndations by the US President\u2019s Cancer Panel
\nReport called for stronger government regu-
\nlations for better cancer prevention [3]. An
\narticle in the New England Journal of Med-
\nicine in March, 2011 has gone a step further
\nby identifying environmental carcinogens as
\nthe number one threat to cancer prevention..
\nThe article states: \u201cThe most valuable ap-
\nproaches to reducing cancer morbidity and
\nmortality lie in avoiding the introduction of
\ncarcinogenic agents into the environment
\nand eliminating exposure to carcinogenic
\nagents that are already there\u201d[5].
\nThe World Health Organization\u2019s specialist
\nagency on cancer, IARC, noted the contri-
\nbution of exposure to synthetic chemicals as
\na contributor to cancer in a report in 2008.
\nIt recognised as important \u201cthe potential
\ncancer burden from exposure to hundreds of
\nprobable and possible human carcinogens
\nthat have been identified and from thou-
\nsands of new chemicals that have not been
\ntested for their cancer potential\u201d [6]. A re-
\ncent WHO review of evidence on the bur-
\nden of disease from chemicals has conclud-
\ned that, \u201cthe known burden of chemicals is
\nconsiderable\u201d and supports further action.
\n\u201cEffective public health interventions are
\nknown to manage chemicals and limit their
\npublic health impacts and should be imple-
\nmented at national and international levels\u201d
\n[7]. Discussions on the required response
\nwere set to be addressed at a WHO meeting
\nin Spain in March 2011 on \u201cEnvironmental
\nand occupational determinations of cancer,
\nInterventions for primary prevention\u201d. A
\ncollective \u201ccall to action\u201d for the primary
\nprevention of cancer was planned [8].
\nWhat is primary prevention?
\nPrimary \u201cenvironmental and occupa-
\ntional\u201dprevention could be defined as re-
\nducing involuntary exposure to harmful
\nchemicals by removing carcinogens and
\nother chemicals linked to cancer, such as
\nendocrine disruptors, from the environ-
\nment and the workplace. It is separate
\nfrom early detection (such as breast can-
\ncer screening) and would benefit from
\nbeing distinctly separated into systemic
\nversus individual lifestyle measures.
\nAre chemicals to blame?
\nAs noted in the WMA Statement [1], In
\nrecent decades there has been a rapid in-
\ncrease in the use of pesticides and fertilis-
\ners in agriculture and synthetic chemicals
\nin consumer and industrial goods. During
\nthe same 50 years, the incidence of cancer
\nhas increased, despite some reductions in
\nmortality rates due to improved treatments.
\nCurrently, in Europe, one in two men and
\none in three women is or will be affected
\nby cancer. The increase in cancer incidence
\ncan only be partly attributed to an aging
\nLisette van Vliet
\nWhy Cancer Prevention isn\u2019t Working Well
\nEnough
\nGenon Jensen
\nwmj 3 2011 5CS.indd 106 6\/21\/11 9:32 AM
\n107
\nHealth and Enviroment Alliance
\nEuropean population. The rest \u2013 around
\n52% for men and 55% for women \u2013 must be
\nattributed to environmental causes, which
\ninclude the natural environment, work and
\nindoor environments, food and so on.
\nTobacco and alcohol cannot be blamed for
\nthe rising rates because their use is stagnat-
\ning or declining in many European coun-
\ntries. This is confirmed in some European
\ncountries by the decrease in cancers that are
\nmostly related to these substances, such as
\nlung and oesophageal cancer. On the other
\nhand, breast cancer rates have reached epi-
\ndemic proportions in Europe.In France,the
\nnumber of cases of breast cancer increased
\nby an astronomical 97% between 1980 and
\n2000,according to a French national agency
\nreport [9]. New figures in the UK show that
\none in eight British women can expect a
\nbreast cancer diagnosis during her lifetime.
\nCancer amongst children is also rising. The
\naverage childhood cancer incidence has in-
\ncreased by 1% per year in Europe over the
\npast 30 years. [10]. This worrying trend
\nunderlines again that risk factors associ-
\nated with life style, such as alcohol, tobacco,
\ndiet and exercise, cannot be relied upon too
\nheavily in cancer prevention.
\nUnsafe exposure
\nIn the European Union, approximately
\n100,000 different synthetic chemicals are
\non the market, around 30,000 of which are
\nproduced at volumes of more than one ton
\nper year.
\nIn the last 25 years, less than 3% of these
\nchemicals (1% in terms of volume) has
\nbeen thoroughly analysed for their haz-
\nardous properties and given a formal and
\nquantified assessment of their toxicologi-
\ncal and eco-toxicological risks. The recent
\nEU REACH and pesticides legislation are
\nimportant steps in the right direction but
\nimplementation is very slow and many car-
\ncinogens and endocrine disrupting chemi-
\ncals remain in everyday use.
\nIf breast cancer rates are to be brought
\ndown, prohibitions and phase-outs of car-
\ncinogenic and endocrine-disrupting chemi-
\ncals, such as Bisphenol A, need to be expe-
\ndited to reduce everyday exposure.Professor
\nAndreas Kortenkamp, a leading scientist on
\nseveral EU research projects on endocrine
\ndisrupting chemicals and a signatory of the
\nPrague Declaration on endocrine disrupting
\nchemicals, says that the risk of breast cancer
\nwill not be reduced until preventable causes,
\nparticularly exposure to chemicals, are ad-
\ndressed [11]. Childhood cancer incidence
\nmay best be addressed by reducing exposure
\nto pesticides. A comprehensive review of
\nthe human health effects of pesticides by
\nthe Ontario College of Family Physicians
\nhighlights several studies implicating pesti-
\ncides as a cause of non-Hodgkin\u2019s lympho-
\nma and leukaemia in children [12].
\nFor all cancers, the potential impact of
\nprimary prevention is probably underesti-
\nmated rather than overestimated. Although
\nevidence of some direct correlation exists,
\nlittle is known at the present time about
\nthe risks from combinations of exposures
\nat levels found in the environment. Equally,
\ntoo little is known about exposures during
\ncritical time windows of development or in
\nsusceptible populations. As a report from
\nthe IARC pointed out: \u00abCancers may have
\nmultiple causes, so that environmental fac-
\ntors may contribute to cancers that are at-
\ntributed to occupational or lifestyle factors\u00bb
\n[4].
\nWhat needs to happen?
\nCountries around the world can draw on
\nthe findings of the US President\u2019s Panel on
\nCancer, which include the call for a remov-
\nal of carcinogens, mutagens, chemicals tox-
\nic to reproduction and endocrine disruptors
\nfrom the market. HEAL and others at the
\nWorld Health Organization meeting in
\nAsturias, Spain in March, 2011 intended
\nto present the President\u2019s Panel recom-
\nmendations for inclusion in a planned call
\nto action for the primary prevention of
\ncancer, which is also likely to address the
\nmore traditional exposures, such as passive
\nsmoking and radon. The recommendations
\nof the US President\u2019s Panel will also be use-
\nful to WMA members who are taking the
\nStatement on Environmental Degradation
\nto the national level.
\nIf major inroads into cancer prevention
\nare to be made, national and EU cancer
\nprevention plans should take into account
\nthese recommendations on primary envi-
\nronmental prevention, including carcino-
\ngen and EDC exposure. The EU\u2019s \u201cAction
\nagainst Cancer: European Partnership\u201d
\ndoes not currently address environmental
\nand occupational dimension in preventing
\ncancer. In an effort to correct this omission,
\nHEAL has brought together 21 groups, in-
\ncluding the European Respiratory Society
\nand the International Society of Doctors
\nfor the Environment, to support the need
\nto address primary environmental and oc-
\ncupational carcinogen exposure in cancer
\nprevention [13]. Spain has already incor-
\nporated environmental prevention into its
\nnational plan. It needs to be ensured that
\nthe national cancer action plans that all EU
\nmember states are preparing or implement-
\ning also highlight the environmental di-
\nmension.
\nWMA national leaders can also help make
\ninformation materials available for fellow
\ndoctors. US doctors have already produced
\na fact sheet on \u201cCancer and the Environ-
\nment: What health care providers should
\nknow\u201d[14]. A training programme for doc-
\ntors themselves is planned in Paris immedi-
\nately after the Paris Appeal 2011 meeting
\non children\u2019s health and the environment in
\nApril [15]. The role of WMA, doctors and
\nscientists in supporting this shift in cancer
\nprevention cannot be underestimated. Gov-
\nernments need the support of public health
\narguments from medical professionals to
\nmake the necessary policy changes that will
\nbring major reductions in cancer incidence
\nworldwide.
\nwmj 3 2011 5CS.indd 107 6\/21\/11 9:32 AM
\n108
\nAUSTRALIASocio-Medical-Affairs
\nThe Health and Environment Alliance aims to
\nraise awareness of how environmental protec-
\ntion improves health. It achieves this by cre-
\nating opportunities for better representation
\nof citizens\u2019 and health experts\u2019 perspectives in
\nthe environment and health-related European
\npolicy-making. Our membership includes a
\ndiverse network of more than 65 citizens\u2019, pa-
\ntients\u2019, women\u2019s, health professionals\u2019 and envi-
\nronmental organisations across Europe and has
\na strong track record in increasing public and
\nexpert engagement in both EU debates and the
\ndecision-making process.
\nReferences
\n1. What will new EU chemicals legislation deliver
\nfor public health? Leaflet from HEAL\u2019s Chemi-
\ncals Health Monitor project, available in seven
\nlanguages at http:\/\/www.chemicalshealthmoni-
\ntor.org\/spip.php?article148
\n2. A review of the role pesticides play in some can-
\ncers, CHEMTrust, includes section on regula-
\ntory issues, www.chemtrust.org.uk
\n3. IARC World Cancer Report 2008 http:\/\/www.
\niarc.fr\/en\/Publications\/PDFs-online\/World-
\nCancer-Report
\n4. World Medical Association, Statement on En-
\nvironmental Degradation and Sound Manage-
\nment of Chemicals, www.wma.net
\n5. Pruss-Uston A et al, Knowns and unknowns on
\nburden of disease from chemicals; a systematic
\nreview, Environmental Health, Environmental
\nHealth 2011, 10:9doi:10.1186\/1476-069X-10-9
\nhttp:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/
\nPMC3037292\/
\n6. WHO meeting entitled \u201cEnvironmental and
\noccupational determinations of cancer, Inter-
\nventions for primary prevention\u201d, March 2010
\nhttp:\/\/www.who.int\/phe\/news\/events\/interna-
\ntional_conference\/en\/index.html
\n7. US President\u2019s Cancer Panel: \u201cReducing the
\nEnvironmental Causes of Cancer\u201d (200 pages);
\nArticle: Environmentally caused cancers are
\n\u2018grossly underestimated\u2019 and \u2018needlessly dev-
\nastate American lives\u2019 available at http:\/\/www.
\nenvironmentalhealthnews.org\/ehs\/news\/presi-
\ndents-cancer-panel.
\n8. Christiani DC, Combating Environmen-
\ntal Causes of Cancer, New Engl J Med 2011;
\n364:791-793March 3, 2011
\n9. \u201cEvolution de l\u2019incidence et de la mortalit\u00e9 de
\n1978 2000\u201d, 2004, Institut de veille sanitaire
\n(InVs), France.
\n10. IARC study shows increasing cancer rates in
\nchildren in Europe, Press release 155, 10 De-
\ncember 2004.
\n11. Scientists deliver wake-up call: \u201cReduce chemi-
\ncal exposure to reduce breast cancer\u201d, HEAL,
\nCHEMTrust press release, 2 April 2008.
\n12. Sanborn, M et al, Systematic Review of Pesti-
\ncide Human Health Effects, Ontario College of
\nFamily Physicians, Toronto. Available at: www.
\nocfp.on.ca
\n13. Letter to the European Parliament\u2019s Environ-
\nment committee, on Commission Communica-
\ntion on Action against Cancer: European Part-
\nnership, 7 April 2010, see
\n14. http:\/\/www.env-health.org\/a\/3554
\n15. Fact sheet, Cancer and the Environment, What
\nhealth care providers should know. http:\/\/www.
\npsr.org\/assets\/pdfs\/cancer-and-the-environ-
\nment.pdf
\n16.Intensive Course in Environmental
\nMedicine, 14-16 April 2011, Paris, France,
\nwww.artac.info
\nUseful documents
\n1. WMA Statement on Environmental Degrada-
\ntion and Sound Management of Chemicals
\n2. https:\/\/www.wma.net
\n3. CPME Statement on Environment and Health,
\n2005
\n4. http:\/\/cpme.dyndns.org:591\/adopted\/CPME_
\nAD_Brd_030905_100_EN.pdf
\n5. Collaborative on Health and the Environment
\nconsensus statement
\n6. http:\/\/www.healthandenvironment.org\/about\/
\nconsensus
\n7. Living with chemicals, Danish Ministry of the
\nEnvironment
\n8. http:\/\/www.mst.dk\/English\/Focus_areas\/Liv-
\ningWithChemicals\/default.htm
\n9. Fact sheet on \u201cGood chemistry to pregnant and
\nnursing mothers\u201d at
\n10.http:\/\/www.mst.dk\/English\/Chemicals\/Con-
\nsumer_Products\/Good_Chemistry_to_preg-
\nnant_and_nursing_mothers.htm
\nGenon Jensen, Executive Director,
\nHealth and Environment Alliance
\nLisette van Vliet, Toxics Policy Advisor,
\nHealth and Environment Alliance
\nThe World Medical Association Council
\nrecently held its 188th
\nsession in Sydney.
\nThe previous occasion was its 138th
\nsession
\nwhich I attended as vice president of the
\nAustralian Medical Association.
\nOn that occasion, the Finnish represen-
\ntative asked of the Council, \u201cShould the
\nWMA have a policy on nuclear weapons?\u201d
\nThe representative of a large European
\ncountry replied, \u201cWe should involve our-
\nselves only in matters of a strictly medical
\nnature\u201d. Really? Can the responsibilities of
\nphysicians to the health and integrity of hu-
\nman life, and the causes embraced by their
\nrepresentative bodies, be restricted to those
\nof a \u2018strictly medical nature\u2019?
\nIn answering this fundamental question lies
\nthe relevance or otherwise of the profession
\nin a world so desperately in need of lead-
\nership. The qualities of leadership cannot
\nbe taught, but they can be understood. The
\npower is in the story.
\nHanging on the wall of my Brussels office is
\na large black and white photograph. I have
\nalways hung it opposite my desk. It reminds Brendan Nelson
\nLeadership and the Medical Profession
\nwmj 3 2011 5CS.indd 108 6\/21\/11 9:32 AM
\n109
\nAUSTRALIA Socio-Medical-Affairs
\nme every day of what is really important. It
\nis of the late Neville Bonner, the first Ab-
\noriginal Australian elected to the Australian
\nparliament (Senate) in 1971. But that alone
\nis not why it is there.
\nNeville was born in 1922 on Ukerabagh
\nIsland in the mouth of the Tweed River
\nin northern New South Wales. A Jagera
\nman, he was born there because Aboriginal
\npeople were not allowed to be in town after
\nthe sun had gone down. Raised first by his
\nmother in a hollow carved by his grandfa-
\nther under Lantana bushes, he was born
\ninto a world of great adversity.
\nAt the age of nine,the year before his moth-
\ner\u2019s death, Neville was sent to the school in
\nLismore.He lasted only two days before the
\nnon Aboriginal parents forced him out.
\nIt was to Ida Bonner, his grandmother,
\nthat Neville attributed his final success.
\nAt the age of fourteen, she insisted he go
\nto school. He did, attending Beaudesert
\nSchool in Queensland for one year. Ida had
\nsaid, \u201cNeville, if you learn to read and write,
\nexpress yourself well and treat people with
\ndecency and courtesy, it will take you a long
\nway\u201d.
\nAnd it did. It took him through a life of
\nbeing a stockman, labourer and scrub clear-
\ner. He spent eleven years on the infamous
\nPalm Island and then worked as a bridge
\ncarpenter. Finally in 1971, the Liberal
\nParty of Australia selected him to represent
\nthe people of Queensland in the Australian
\nSenate.
\nHe had said to those who chose him, \u201cIn
\nmy experience of this world, there are two
\nhuman qualities of which we are always in
\ngreater need\u00a0\u2013 human compassion and un-
\nderstanding\u201d. He served for eleven years,
\nembracing many causes with conviction and
\nprinciple.Even as a Senator he endured dis-
\ncrimination, but always argued that in deal-
\ning with injustice, his people should seek to
\nchange laws, not break them.
\nIn 1992, asked to nominate his greatest
\nachievement, he replied, \u201cIt is that I was
\nthere. They no longer spoke of boongs or
\nblacks, they spoke instead of Aboriginal
\npeople\u201d. His life is testimony to the trans-
\nformative, liberating power of education
\nand above all human virtues stands the
\npower of character. The Jesuits laid a foun-
\ndation for me, teaching me four things es-
\nsential for a \u2018successful\u2019 life. Commitment.
\nNothing would be achieved without consis-
\ntent application to that in which you believe.
\nConscience. Beneath every decision lies the
\nquestion, \u201cwhat is the right thing to do?\u201d
\nCompassion. In a literal sense it means to
\nshare another person\u2019s pain. In leadership,
\nit is to be imbued with the imaginative ca-
\npacity to see the world through the eyes of
\nsomeone else. Knowing what someone else
\nthinks is important, but understanding how
\nthey think is the key to effecting change.
\nCourage. Everything of value worth achiev-
\ning demands taking a risk for others. An-
\nother major influence in my life is the for-
\nmer AMA president, Dr. Bruce Shepherd.
\nIt was upon his shoulders and through his
\ncourageous vision that the modern Austra-
\nlian Medical Association has been built.
\nAt my first encounter with Dr. Shepherd
\nwho had enjoyed a high, combative profile
\nin Australia through the 1980s, I told him
\nI didn\u2019t like him. He responded, \u201cI am go-
\ning to give you a lot of advice.The first is to
\nnever pass an opinion on someone you have
\nnot met\u201d.
\nBruce Shepherd later taught me the im-
\nportance of having people around you pos-
\nsessed of two qualities. The first was that
\nthey had to be \u2018overenthusiastic\u2019to the point
\nof having to be \u2018hosed down\u2019 a couple of
\ntimes a day.
\nThe second quality was belief. \u201cSurround
\nyourself,\u201d he said, \u201cwith people who have
\nbeen prepared to bleed for a cause in which
\nthey believe. That you share that cause is
\nless important than that they have been
\nprepared to give their all for their beliefs\u201d.
\nWhen I assumed the presidency of the Aus-
\ntralian Medical Association in 1993, it was
\na different time. Australia was emerging
\nfrom a period of virulent anti doctor sen-
\ntiment in which the motives and incomes
\nwere questioned as the fodder of daily polit-
\nical discourse. Doctors had been embraced
\nas the enemy in a class struggle.
\nConsumerist movements\u00a0\u2013 many in receipt
\nof government funding\u00a0\u2013 were demanding
\n\u2018equity and justice\u2019 as the nascent push to
\nde-medicalise the health care system gath-
\nered momentum.Health financing was seen
\nas an instrument of control.
\n\u2019Free\u2019 healthcare was equated to \u2018good\u2019
\nhealthcare. One half of Australia\u2019s health-
\ncare system funded its endless wants in out-
\npatient services The other half, catering for
\nour needs\u00a0\u2013 hospital care, was seriously ra-
\ntioned as governments systematically with-
\ndrew political and financial support for the
\nprivate sector.
\nIntra professional rivalries and resentment
\nof medical groups to one another with
\nwidening income differentials concluded a
\ngloomy scenario. The early priorities were
\npolicy, personnel\u00a0\u2013 bringing people togeth-
\ner, organisational structure and the political
\ndimensions of the challenges ahead.
\nHow, I asked myself, could we harness the
\nidealism in members of the profession to
\npractical achievements serving others? Ex-
\nternally, we had to actively engage the po-
\nlitical process at all levels and in doing so,
\nform coalitions with unlikely groups.
\nThe AMA would have to go where it had
\nrarely ventured\u00a0 \u2013 so called \u2019social policy\u2019.
\nTo abandon idealism was to not only court
\nirrelevancy, but would diminish the profes-
\nsion\u2019s authority and influence in its pursuit
\nof its legitimate professional and industrial
\ninterests.
\nwmj 3 2011 5CS.indd 109 6\/21\/11 9:32 AM
\n110
\nAlthough many of its members had dedi-
\ncated their lives to improving the health of
\nindigenous Australians, the AMA had done
\nlittle in the public policy space to address
\nthe appalling health, premature deaths and
\nexistential despair of the first Australians.
\nSpurred on by the AMA\u2019s advocacy, the
\nhealth minister repeated to a Sixty Minutes
\njournalist whilst touring remote Australia,
\nwhat he had said to me privately when I
\nfirst nominated Aboriginal health as an ur-
\ngent, national health priority.
\nThe journalist asked, \u201cWhy, after eleven
\nyears in government is the situation still so
\nbad?\u201dThe Minister replied,\u201cI\u2019ve spent a life-
\ntime reading polls,and concern for Aborigi-
\nnal people has not been in the top million
\nissues worrying the voters\u201d.
\nI travelled the length and breadth of Ab-
\noriginal Australia, bringing to the con-
\nsciousness of middle Australia\u00a0 \u2013 the
\n\u2018voters\u2019\u00a0\u2013 the shocking circumstances of in-
\ndigenous Australia, what should be done to
\naddress it and admitting the prior neglect of
\nthe profession at its representational level.
\nWhen standing in a pit of poisoned dog
\ncarcasses to illustrate a point about a process
\nthat had led to sick Aboriginal children, an
\nofficial hurled abuse, \u201cthat\u2019s not the sort of
\nthing the president of the AMA should be
\ndoing!\u201d I firmly replied, \u201cYes, it is precisely
\nwhat the president of the AMA should be
\ndoing\u201d.
\nSimilarly in tobacco control, it\u2019s not good
\nenough to pass a motion, tuck it under the
\nprofession\u2019s collective pillow, go to sleep and
\nexpect someone else to take up the fight. It
\nrequired leadership at public demonstra-
\ntions to get the industry out of sport and
\ndebate credible business and sporting iden-
\ntities to have its media promotion banned.
\nAt one point I had to hold up to Austra-
\nlia\u2019s National Press Club a packet of ciga-
\nrettes with a barely readable health warn-
\ning. Alongside it I held a packet of Ratsak
\nwhich boldly stated in black on gold, \u201cKills
\nRats and Mice\u201d.
\nThat act resulted in the then government
\nmoving the same day on new, graphically
\npowerful health warnings.
\nThe health and human effects of unem-
\nployment, aid programmes and rights for
\nwomen in the developing world, repeal of
\nlaws banning homosexuality, population
\nand environment, boxing, gun control, fe-
\nmale genital mutilation, illicit drugs, youth
\ndespair, euthanasia and many other issues
\nwere driven by the AMA.
\nThe AMA\u2019s political influence rose as did
\nits membership. But it was not supported
\nby all. One physician wrote, \u201cThe health
\nproblems of Aboriginal people are social is-
\nsues beyond the scope and responsibilities
\nof doctors. Get back to health\u201d. Another
\nwas blunter, \u201cAs you are no longer inter-
\nested in my income, I hereby tender my
\nresignation\u201d.
\nA recently qualified anaesthetist argued that
\nshe saw no reason to join the AMA. She
\nhad \u201clittle in common with other doctors\u201d
\nand, \u201cunemployment and tobacco advertis-
\ning had little to do with her\u201d.
\nMore than a few politicians told me that the
\nmedical profession was in danger of \u2018los-
\ning its credibility\u2019 because of its increasing
\noutspokenness on social issues that in their
\nopinion had nothing to do with health.
\nWhy does any medical practitioner study
\nmedicine, engage in research, teach and
\ngenerally strive for excellence? Surely it
\nis because our commitment to an ethic of
\nservice to other human beings, as individu-
\nals and a community, overrides notions of a
\npreoccupation with our own influence and
\nimportance.
\nYes, we have obligations to individual pa-
\ntients, uberrima fides\u00a0\u2013 to always act in the
\nutmost good faith. But we also have two
\nothers. In joining the profession we assume
\nresponsibilities for the broad, epidemiologi-
\ncal aspects of health.
\nWe also have a responsibility to society
\nitself. Doctors must be agents of change,
\nchallenging and changing the way our
\ncountry and world thinks about a range of
\nhealth and social issues. We must also be a
\nvoice for those who have neither power nor
\ninfluence.
\nThe Australian government is proposing
\nto legislate generic packaging of cigarettes.
\nIn doing so, it will break the link between
\nthe packing and the sophisticated market-
\ning created by the industry that entices
\npubescent young people. As they cross the
\nthreshold to what is frequently a lifetime of
\npitiable addiction, ill health and premature
\ndeath, they are drawn to an aspirational im-
\nage created for them.
\nWhy should a product injurious to human
\nhealth at any level of consumption recom-
\nmended by the manufacturer be packaged
\nas if it were chocolate or perfume? Will
\nthe WMA take up the cause knowing that
\nif Australia prevails over the industry, the
\nrest of the world will inevitably follow with
\ngeneric packaging? Another issue that the
\nWMA could embrace is that of newborn
\ndeafness.
\nHearing is the primary sense for commu-
\nnication. Today, with early screening, a co-
\nchlear implant and audio verbal therapy, a
\nbaby born profoundly deaf can, by the age
\nof five be fully integrated into the hearing,
\nspeaking world attending normal schools.
\nYet there are those who think deafness is a
\n\u2018gift\u2019,who consign these children to the deaf
\nworld. Does the WMA not see a role for
\nitself in transforming the lives of the deaf
\nthroughout the world as a respected, pow-
\nerful advocate? Gestures of intellectual in-
\ndependence from professional organisations
\nand associations mean that whatever you
\nstand for will remain in obscurity.
\nMedicine is not confined to textbooks and
\njournals, but extends into the life and fabric
\nof society itself. As such, we have an obliga-
\nAUSTRALIASocio-Medical-Affairs
\nwmj 3 2011 5CS.indd 110 6\/21\/11 9:32 AM
\n111
\nCollaborationNETHERLANDS\/INDONESIA
\nUniversitas Gadjah Mada (UGM) in Yo-
\ngyakarta on the island of Java, Indonesia
\ntraces its origins to 1949 when a group of
\nIndonesian intellectuals established a foun-
\ndation which subsequently gave birth to the
\nUniversitas Gadjah Mada.
\nUGM is the oldest and leading university
\nin Indonesia striving to stay on the cutting
\nedge of educational affairs and scientific de-
\nvelopment. In addition, it has always been a
\ngoal of UGM to give something back to the
\ncommunity, both providing social services, as
\nwell as producing students who are dedicated
\nto the greater Indonesian population. UGM
\nFaculty of Medicine was founded earlier
\nin 1946 when during the war, the medical
\nschool in Jakarta was moved to Klaten.
\nThe cooperation between the Universitas
\nGadjah Mada (UGM) and Maastricht Uni-
\nversity (UM), Maastricht, The Netherlands
\nhas a long history which can be traced back
\nto 1980s. Both universities have shared a
\nstrong interest in innovation of its health
\nprofessions education, with the ultimate
\npurpose of making the education more rel-
\nevant for the societies that they serve.UGM
\nFaculty of Medicine
\n(UGMFM) has been a pioneer in educa-
\ntional innovation, in Indonesia and inter-
\nnationally, especially in community-based
\neducation and in introducing innovative
\nlearning formats. The Faculty was the first
\nto introduce small group tutorials applying
\nproblem-based learning (PBL) methodol-
\nogy in Indonesia since 1985.
\nIn 2002, the whole curriculum was changed
\ninto a PBL curriculum using block system,
\nfirst in its international program in medi-
\ncine, later also in the regular medical pro-
\ngram. Already in the early 1990s UGMFM
\nestablished the so-called \u2018skillslab\u2019 to train
\nits undergraduate students\u00a0 \u2013 a develop-
\nment supported by a co-operation with
\nMaastricht University. New government
\nlaws in 2002 obligate all medical schools
\nin Indonesia to develop and implement
\ncompetence-based medical education with
\na family medicine orientation. Standards of
\nCompetence for Indonesian Medical Doc-
\ntor was issued by the Indonesian Medical
\nCouncil in November 2006.
\nCapacity Building Collaboration in the
\nArea of Undergraduate Medical Education:
\nan experience from Gadjah Mada and
\nMaastricht University
\nGeraldine van Kasteren Titi Savitri P Damardjati
\ntion to demonstrate an activism of caring.
\nIn this, the WMA remains an untapped
\nagent of change for good.
\nThe key is to keep an open mind, nurture
\nthe inner integrity of your intellect and rec-
\nognise that your ultimate success will derive
\nfrom the humanity shown to others.
\nIt seems we live in a world of fundamental-
\nist intolerance, in vast ignorance of the long
\nterm consequences of decisions we make
\nand that are made for us. With global eco-
\nnomic uncertainty,tectonic shifts in geopol-
\nitics and rapid technological change, what
\nwe need most is\u00a0\u2013 one another.
\nThe world needs a strong,coherent medical
\nvoice on much more than issues of a \u2018strict-
\nly medical nature\u2019. The extent to which it
\ndoes so will determine its influence and
\nrespect. The profession has a responsibility
\nto shape those polls so studiously read by
\nour politicians. In doing so, it can change
\nthe world.
\nThe Hon Brendan Nelson,
\n13th President, AMA;
\nAustralia\u2019s Ambassador to Belgium,
\nLuxembourg and the European Union;
\nAustralia\u2019s Representative to NATO & WHO
\nwmj 3 2011 5CS.indd 111 6\/21\/11 9:32 AM
\n112
\nThanks to previous innovations, UGMFM is nationally a leader in
\nthis important change process. In order to be able to develop its
\nmedical education further in these directions, UGMFM intended
\nto do a major curricular reform of which external support is needed,
\nespecially to strengthen the knowledge and skills of staff, to monitor
\nthe progress as well as to improve the management system which is
\nmore compatible with the competence-based philosophy.
\nIn the current collaboration project with Maastricht and Groningen
\nUniversities, specific attention is given to clinical education, which
\nhas not been standardized in Indonesia and often is of low quality.
\nNext to GMUFM, several teaching hospitals, district hospitals and
\ncommunity health centres in the region surrounding the city of Yo-
\ngyakarta got supports from the project in relation to the strengthen-
\ning of clinical teaching.
\nThis includes training of hospital staff involved in clinical teach-
\ning and provision of books, educational equipment and skills lab.
\nAnother focus is continued support for developing and refining the
\nnew curriculum, in which PBL and skills training are more con-
\nsistently applied and a family medicine orientation are developed.
\nThis involves staff training, both on the spot, but also some graduate
\ntraining (masters and PhDs in medical education) in the Nether-
\nlands. Furthermore, it supports the development and production of
\nteaching materials (like so-called \u2018block books\u2019, skills lab manual,
\nliterature references, study guide, etc) for the whole undergraduate
\ncurriculum.
\nAttention has also been given to the sharing of GMUFM\u2019s experi-
\nences in medical education innovation with other 52 medical schools
\nthroughout Indonesia through sharing of expertise in national semi-
\nnars, training, and study visits. Also this project contributes to the
\nIndonesian Medical Council (IMC) as a national regulatory body,
\nto be able to develop a national assessment and accreditation system
\nthrough sharing of expertise.
\nThe overall aim of this project is to strengthen competence-based
\nclinical education using a Problem Based Learning strategy, to en-
\nhance the competencies of Indonesian medical graduates, who will
\nsubsequently provide better quality health care.
\nMaastricht University,through the office of MUNDO,in collabora-
\ntion with Groningen University supports capacity development in
\nhigher education in general and in medical education in particular,
\nthrough facilitating innovation of educational methods, curriculum
\ndevelopment, training of staff, improvement of teaching and learn-
\ning resources, the establishment of new courses etc.
\nWhenever there is a clear demand for the expertise that Maastricht
\nUniversity and its network can provide MUNDO is willing to sup-
\nNETHERLANDS\/INDONESIACollaboration
\nwmj 3 2011 5CS.indd 112 6\/21\/11 9:32 AM
\n113
\nCPME
\nCPME Spring Board meeting
\nand General Assembly in
\nBrussels on 30 April
\nAt its Spring Board meeting and General
\nAssembly held in Brussels on 30 April and
\nchaired by CPME President Dr. Konstanty
\nRadziwill, the CPME members came to-
\ngether to discuss latest items of interest for
\nthe European Medical Profession, includ-
\ning policies which look at the bigger pic-
\nture of public health. The CPME inter alia
\napproved a document addressing health
\ninequalities and outlining main actions,
\nfurthermore a position on the Innovation
\nPartnership for Active and Healthy Ageing,
\nand also a policy on climate change and its
\nrelevance for health. However, CPME po-
\nsitions regarding the core business of pro-
\nfessional policy, like the European Working
\nTime directive, the Professional Qualifica-
\ntion directive and European Health Work-
\nforce were discussed as well. The day before
\nthe meeting, national experts from the
\nNational Medical Associations addressed
\npolicy subjects in specific working groups.
\nport. MUNDO is facilitating the process
\nand connects the experts from both sides in
\nteams with a shared vision of what needs to
\nbe accomplished. In MUNDO we believe
\nthat real capacity development, especially
\nin higher education, is more than doing a
\nproject. It is about establishing open mind-
\ned partnerships based on equity, reciprocity
\nand mutual respect.
\nSuch partnerships enable academics and
\nstudents to step over institutional and coun-
\ntry borders, and engage in a free flow of
\nknowledge and ideas for the advancement
\nof their own country as well as the global
\nsociety.This we believe is sustainable capac-
\nity development.
\nDuring the course of this Project funded by
\nthe Dutch Government, trust and sincer-
\nity have grown out of those involved which
\nhave overcome some obstacles.
\nLessons learnt from this long collaboration
\nbetween the universities are first of all that
\na strong basis of mutual trust and respect
\nis required to have effective exchanges of
\nideas. This can only be built in the course
\nof time, patient is needed. Secondly strong
\nleadership is indispensable for a change
\nprocess to have the chance to succeed.Man-
\nagement capacities in the organization are
\nequally important to be able to feel the im-
\npact of increased capacity of the individu-
\nals in the organization. A good monitoring
\nsystem needs to be developed both for the
\nproject as well as for the faculty. An open
\ncommunication system (internal and cross
\ncultural) is needed to ensure developments
\nare shared and understood.
\nLastly an intensive collaboration project is
\na great learning experience for all project
\nmembers involved; theories and methods
\nthat might already be implemented in one
\ninstitute need to be redesigned or adapted
\nfor the other to be useful, a copy-paste ap-
\nproach is doomed to fail.
\nOnly persons who are open minded and
\nare capable of modifying their views and
\nopinions to a changing context will suc-
\nceed in capacity building with a sustain-
\nable impact.
\nTiti Savitri P Damardjati, Vice Dean
\nof Academic Affairs Universitas Gadjah
\nMada Faculty of Medicine, Indonesia
\n& Geraldine van Kasteren, Mundo,
\nMaastricht University, The Netherlands
\nNews from the CPME
\n(Standing Committee of European Doctors)
\nCPME represents the National Medical Associations of 27 countries in Europe and works closely
\nwith the National Medical Associations of countries that have applied for EU membership as well
\nas specialized European medical associations
\nKonstanty Radziwill Birgit Beger
\nwmj 3 2011 5CS.indd 113 6\/21\/11 9:32 AM
\n114
\nCPME
\nDr. Paul Timmers from the European
\nCommission DG Information Society
\nand Media (Director of Directorate H:
\nICT addressing Societal Challenges) was
\ninvited as a guest speaker and addressed
\nthe EU eHealth Policy Developments and
\nthe Innovation Partnership on Active and
\nHealthy Ageing, a Flagship initiative from
\nthe European Commission involving three
\nDirectorate Generals (DGs): DG Health
\nand Consumers, DG Information Society
\nand DG Research. The CPME is member
\nof the Steering Group for the Innovation
\nPartnership.
\nThis article aims at highlighting a few of the
\nmany topics disussed at the fruitful CPME
\nspring meetings.
\nInnovation Partnership on
\nActive and Healthy Ageing
\nCPMEs\u2019Statement on \u2018the European Inno-
\nvation Partnership on Active and Healthy
\nAgeing\u2019 sets out main points for action for
\na successful planning and execution of the
\nnext stage within the European Innovation
\nPartnership on Active and Healthy Age-
\ning.The overall outcome set by the EU is to
\nincrease healthy lifespan in the EU by two
\nyears by 2020. According to CPME, much
\nof the \u201cinnovation\u201d required will not be a
\nnew form of telemonitoring or telemedi-
\ncine, (although these are clearly important,
\nand will drive the involvement of indus-
\ntry), but a new way of working horizontally
\nacross different clinical disciplines and sec-
\ntors. CPME suggests identifying pathways
\nfor piloting that have established clinical
\nmanagement, role identification, measur-
\nable outcomes and a degree of patient in-
\nvolvement.
\nWhile \u201chard\u201d evidence of improved out-
\ncomes is essential,\u201csoft\u201devidence is also im-
\nportant. These include more qualitative as-
\nsessments, such as independence, increased
\nconfidence in self-management, and re-
\nduced isolation. Workforce issues of health
\nprofessionals, as well as innovative tech-
\nnologies, a sustainable health policy even in
\ntimes of financial crises for the health care
\nsystems are decisive elements for any strat-
\negy of the innovative partnership from the
\ndoctors\u2019 point of view.
\nHealth Inequalities
\nIn an own initiative position paper which is
\nbased on a survey among CPME members,
\nthe CPME addresses three major reasons
\nfor caring about health inequalities. The
\nfirst is that avoidable health inequalities are
\nsimply and many would say immorally un-
\nfair. The second is that avoidable health in-
\nequalities often infringe an internationally
\nacknowledged human right to health. The
\nthird is that health inequalities are econom-
\nically costly \u2013 societies with smaller health
\ndisparities do better in economic terms than
\nsocieties with wider health inequalities.
\nAs an organisation of medical doctors,
\nCPME concentrates its lobbying activities
\non health related issues to reduce inequali-
\nties and give priority to the following mea-
\nsures: improving the data and knowledge
\nbase and mechanism for measuring, moni-
\ntoring, evaluation and reporting; improve-
\nment in infrastructure, especially water
\nand housing; improved maternal and child
\nhealth care; securing the right to health for
\ndisadvantaged people including illegal im-
\nmigrants and asylum seekers.
\nAt the National Medical Associations\u2019
\n(NMA) level, CPME recommends that
\nNMAs contribute to the reduction of social
\ngradients by drawing government attention
\nto the ratification of international conven-
\ntions or charters that secure the right to
\nhealth and lobby health authorities for bet-
\nter healthcare, particularly for the disadvan-
\ntaged people.
\nThe survey on health inequalities conduct-
\ned by CPME among its members in 2010
\nshowed that the social determinants are
\noften more important than differences in
\naccess to health care. The main reasons for
\nhealth inequalities are the social gradients.
\nEuropean Health Workforce
\nThe European Health Workforce is encoun-
\ntering the problem of shortages of workers
\nand workers\u2019 mobility. The European Com-
\nmission has established that in 2020, 1 Mil-
\nlion health care professionals will be miss-
\ning in the European Union. The CPME
\nbelieves that there is a need to offer more
\nattractiveness to the medical profession by
\ngiving good working conditions and good
\npay. To assess the current situation, a first
\nstep the CPME will undertake is to gather
\ndata among national medical associations.
\nThe CPME will closely monitor further de-
\nvelopments in the review process and will
\ntake an active stand for the interests of the
\nhealthcare workforce and their patients.
\nEuropean Working
\nTime Directive
\nIn response to the review of the Working
\nTime Directive 2003\/88\/EC, the CPME
\nrestated its previous position that the opt-
\nout clause is to be abolished.On-call time is
\nworking time as stipulated by the European
\nCourt of Justice as well as compensatory
\nrest has to be granted immediately follow-
\ning longer working periods.The CPME co-
\nsigned and submitted these comments on
\nthe review of the Working Time Directive
\ntogether with AEMH (European Associa-
\ntion of Senior Hospital Physicians), EANA
\n(European Working Group of Practitioners
\nand Specialists in Free Practice) and FEMS
\n(European Federation of Salaried Doctors).
\nTask shifting
\nThe CPME adopted a policy on the impact
\nof task shifting on doctors in training which
\nwmj 3 2011 5CS.indd 114 6\/21\/11 9:32 AM
\n115
\nCPME
\ncalls for adequate training opportunities for
\njunior doctors. CPME recommends that
\neach member state ensures that adequate
\ntraining opportunities are ring-fenced for
\ndoctors in training and that the wider im-
\npact of task shifting is investigated in order
\nto ensure that patients receive care from the
\nmost appropriate health professionals with-
\nout compromising on education and train-
\ning standards for doctors in training.
\nRecognition of Professional
\nQualifications
\nEuropean physicians welcome the three
\nchallenges set by the European Commis-
\nsion in the revision of Directive 2005\/36\/
\nEC on professional qualifications. These
\nchallenges \u2013 simplification of the existing
\nsystem of recognition of professional quali-
\nfications, facilitation of the access of profes-
\nsionals to the internal market, and enhance-
\nment of trust in the system \u2013 enjoy the full
\nsupport of European physicians.
\nThe CPME supports greater transparency
\nof training contents specified at national
\nlevel instead of a \u2018European\u2019 curriculum for
\ntraining.
\neHealth
\nThe delegations decided to consider the
\nCPME note on a professional electronic ID
\ncard for doctors as a basic document for fur-
\nther developing its policy.
\nCPME has participated in the Steering
\nGroup by the European Commission on
\nthe professional ID card, which started in
\nJanuary 2011 in the context of the revision
\nof the Professional Qualification Directive.
\nThe CPME will continue its work on assess-
\ning the scope of applications of an electronic
\nID card for professionals and is engaged in
\na debate on how to prepare European doc-
\ntors for the challenges of eHealth.
\nCurrently, CPME is involved in the
\n\u2018eHealth joint action in the eHealth Gover-
\nnance Initiative\u2019 and the EU funding proj-
\nect \u2018Chain of Trust\u2019 which aims at a better
\nunderstanding of challenges from a users\u2019
\npoint of view (including doctors, patients,
\nnurses, pharmacists), including the national
\nand regional level.
\nClimate Change
\nThe CPME delegations adopted a position
\npaper on climate change which calls for de-
\nveloping evidence of a substantial and mea-
\nsurable benefit to health arising from green-
\nhouse gas reduction, and will encourage its
\nmembers to lobby for inclusion of the eco-
\nnomic and health benefits in the Durban
\nCOP17 agreement. The Durban COP17
\nagreement is expected to be adopted at the
\nnext United Nations conference on climate
\nchange (COP17) in Durban at the end of
\nthis year.
\nThe CPME position paper underlines that
\nwhat was almost universally apparent was
\nthat little is understood about the beneficial
\neffects to health brought about by green-
\nhouse gas reduction. It is essential that doc-
\ntors within the EU give more leadership on
\nthis issue.
\nThe CPME can play a role in (a) publicis-
\ning these benefits at both EU and Member
\nState level, (b) influencing national gov-
\nernments to place these co-benefits on the
\nDurban agenda, (c) encourage further work
\nto be done on analysis at MS level, and (d)
\ninfluencing national negotiators.
\nApart from this, the CPME is involved in
\nthe Commission Working Group on Green
\nInfrastructure organised by DG Environ-
\nment. This initiative has been created out
\nof concern for the effect climate change
\nwill have on biodiversity. The uncertain ef-
\nfects on infectious disease transmission and
\nprevalence is just one example of a damag-
\ning biodiversity impact, but CPME\u2019s mem-
\nbership has been additionally welcomed
\nbecause of its interest in co-benefits, and
\ntherefore expertise in emphasising within
\nnew Commission work a \u201chealth in all\u201d ap-
\nproach to all the EU\u2019s climate change work.
\nPharmaceuticals
\nRevision of the Clinical Trials Directive
\n2001\/20\/EC
\nIn its response to the consultation, the
\nCPME in general agreed with the revision
\nof the \u2018Clinical Trials Directive\u2019 2001\/20\/
\nEC as proposed by DG Health and Con-
\nsumers, but underlined inter alias that there
\nshould be one single framework for all clini-
\ncal trials considering certain variations, e. g.
\nas to non-interventional trials taking into
\naccount the protection for patients and
\nthe respective workload involved. The non-
\ncommercial\/academic investigators should
\nreceive some financial or other support in
\norder to cope with the administrative work-
\nload. However, also in view of the recent
\npharmacovigilance legislation 2010\/84\/EU,
\nin any case, a \u201crace to the bottom\u201d needs to
\nbe prevented i. e. requirements for clinical
\ntrials must not be diminished.
\nNew CPME Members
\nAt its spring meeting, the CPME accepted
\nthe application of the Albanian Order of
\nPhysicians and welcomed them as new ob-
\nserver member to the CPME.
\nNext CPME meetings
\nThe Autumn CPME Board meeting and
\nGeneral assembly will take place in Brussels
\non 26 November 2011.
\nDr. Konstanty Radziwill, President, CPME
\nBirgit BEGER, Secretary General, CPME
\nE-mail\u00a0: birgit.beger@cpme.eu
\nwmj 3 2011 5CS.indd 115 6\/21\/11 9:32 AM
\n116
\nSocio-Medical-Affairs UNITED KINGDOM
\nCan you imagine a time when the experi-
\nence of millions of patients, families and
\ncare givers has been fundamentally trans-
\nformed?
\nFor example,there would be no-one waiting
\nunnecessarily for care; an end to the mil-
\nlions of unnecessary patient visits; hospital
\nbed days and clinician tasks eliminated; care
\nprovided is reliably \u2018right first time\u2019\u00a0 \u2013 in-
\nstead of the typical 40\u201345% defect rate; and
\nstaff have stopped \u2018firefighting\u2019 and concen-
\ntrate on quality care.
\nAll this is actually happening somewhere
\nin health systems today. Around the world
\npeople working in every aspect of health-
\ncare services have been innovating,resulting
\nin efficiency, productivity and exceptional
\ncare for patients. However, the fact that it
\nis not standard everywhere is a major chal-
\nlenge which requires innovation. I will re-
\nturn to this later.
\nInnovation
\nWhat do we mean by innovation in the
\ncontext of health services and can innova-
\ntion really lead to efficiency and productiv-
\nity? This is a question that I get asked many
\ntimes by colleagues from both within the
\nNational Health Service (NHS) and across
\nthe world. My answer is always \u201cyes, it can\u201d.
\nAnyone involved in innovation will know
\nthat the mere mention of the word will
\nevoke a debate about its meaning. If you
\nseek a definition through a search engine
\nsuch as Google, you will be rewarded by at
\nleast 61,800,000 returns [1]. I would argue
\nthat the word itself is actually not that im-
\nportant, and instead of getting hung-up on
\nsemantics, we need to focus on the people
\nwho want to be innovative and what it
\nmeans to them in their particular context.
\nWithin the NHS, we often start discussions
\nwith local teams by describing innovation as
\n\u201cDoing things differently and doing different
\nthings, to create a step change in performance\u201d
\n[2] before moving to explore exactly what
\nthis might mean for their challenges and
\naspirations in their local context.
\nIn health services we need innovation in
\ntechnology and clinical devices, informa-
\ntion systems, care processes and organisa-
\ntional systems to name a few. All of these
\nplay their part and are integral to the way
\nthat health services are delivered.
\nThe increased need
\nfor innovation
\nThe benefits of innovation have been ar-
\nticulated by many [3, 4] and innovation has
\nbeen cited as a major contributor in turn-
\ning around challenged or ailing organisa-
\ntions [5].The recent financial crisis has cre-
\nated increasing pressure on health budgets,
\nmany of which have been reduced or in the
\nleast remain static. For example, the NHS
\nin England has enjoyed a decade of unprec-
\nedented growth at an average rate of 6.6% a
\nyear [6] but is now facing the challenge of
\nreducing its financial expenditure in order
\nto achieve in an environment of rising costs,
\nexpectations and health needs. This reduc-
\ntion represents the need for health services
\nto effectively reduce expenditure by \u00a320 bil-
\nlion in the next three years.
\nFor some, the economic crisis will result
\nin actions that represent pure cost cutting,
\nwhich often leads to compromised quality
\nand rarely results in innovation. However,
\nfor others it can actually provide a fertile
\nplatform for innovation by stimulating
\norganisations to engage in conscious and
\ndeliberate thought about how to meet the
\nneed to deliver higher quality care with
\nfewer resources. It is in this type of envi-
\nronment that a crisis can stimulate innova-
\ntion which in turn can result in new ways of
\nproviding services and new ways of working
\nat reduced cost, while increasing the quality
\nof care.
\nLeadership responsibility
\nInnovations often emerge from front line
\nstaff [7] and there is a massive leadership
\nresponsibility in supporting this to enable
\nit to happen. Leaders have a disproportion-
\nately large effect on the cultures of organ-
\nisations and systems, and need to signal to
\nstaff, through communication and action,
\nthat they are seeking and supporting inno-
\nvations in order to overcome current chal-
\nlenges [8].
\nIn a recent study [10] within the NHS,
\ntwo thirds of staff respondents stated that
\nthey were not adequately supported by se-
\nnior leaders to undertake innovation and
\nInnovation, Efficiency and Productivity in
\nHealth Services…
\nKeynote speech at the Innovation in Healthcare: Improving Care, Driving Efficiency confer-
\nence. 12th
\nMay 2011, the Barbican, London
\nLynne Maher
\nwmj 3 2011 5CS.indd 116 6\/21\/11 9:32 AM
\n117
\nSocio-Medical-AffairsUNITED KINGDOM
\nimprovement activities. If staff do not feel
\nsupported, they are much less likely to be
\ninspired to have or try out new ideas.
\n\u201c\u2026Strategies and processes alone are not
\nsufficient to drive the degree of change
\nwe are seeking….the NHS should focus
\non tackling the behaviours and cultures
\nin the system that stand in the way\u201d. Sir
\nDavid Nicholson, Chief Executive of the
\nNHS. NHS Annual Report 2009 [9].
\nMany leaders believe that they do support
\nstaff and here lies a problem: a disconnect
\nbetween what is believed by leaders and
\nwhat is happening from the perspective of
\nstaff. A new diagnostic framework which
\nidentifies seven dimensions that are impor-
\ntant and influential to the culture for in-
\nnovation in organisations has proven to be
\nuseful for staff, who can share their views
\non how supported they feel, and for lead-
\ners who, when furnished with information
\nfrom the survey, can better understand how
\nto create a culture where innovation can
\nflourish.
\nSeven Dimensions of Innovation Culture
\n[8]
\n\u2022 risk taking
\n\u2022 resources
\n\u2022 knowledge
\n\u2022 goals
\n\u2022 rewards and recognition
\n\u2022 tools and methods
\n\u2022 relationships
\nRiskTaking is about establishing an organ-
\nisational climate where people feel free to
\ntry out new ideas by judging any risks ap-
\npropriately. Leaders in innovative organ-
\nisations demonstrate that they are more
\ninterested in learning from \u2018failure\u2019 than in
\npunishing it.
\nThe Resources dimension considers the
\nbroadest sense of the word. The climate for
\ninnovation is enhanced if people know that
\nthey have the \u2018resource\u2019 of authority and au-
\ntonomy to act on innovative ideas, as well as
\nsome financial resource to support the new
\nwork.
\nBroad-based Knowledge is the fuel for in-
\nnovation. We create better conditions for
\ninnovation when information, from both
\nwithin and outside the organisation or sys-
\ntem, is widely gathered, easily accessible,
\nrapidly transmitted, and honestly commu-
\nnicated.
\nContrary to what some may believe, the
\nliterature clearly shows that Goals can ac-
\ntually support innovation. Organisational
\nand system leaders should signal that inno-
\nvation is highly desirable by setting aspira-
\ntional goals in specific areas, and challeng-
\ning teams to find ways to realise the vision.
\nRewards for innovation are symbols and
\nrituals of which the main purpose is to rec-
\nognise innovative behaviour. Because it is
\nall about encouraging more of this sort of
\nbehaviour, the best rewards are those that
\nappeal to people\u2019s intrinsic and individual-
\nised motivation.
\nIn high-performing organisations, innova-
\ntion is the product of the deliberate use of
\npractical Tools. Leaders need to consider
\nhow they build capability and capacity in
\ndeliberate methods for creative thinking,
\nidea management and implementation.
\n\u201cUndervaluing and under investing in
\nthe human side of innovation is a com-
\nmon mistake\u201d.
\nRosabeth Moss Kanter 2006 [11]
\nThe Relationships dimension refers to the
\npatterns of interaction in the organisation
\nor system. Innovative ideas are rarely the
\nproduct of a lone genius, therefore environ-
\nments where staff are routinely exposed to
\na wide range of different thinking, from a
\nwide-range of people, with a wide range of
\nbackgrounds and points of view, provide
\nrich soil for the growth of innovation.
\nA mindset of abundance
\nIn times of austerity,we often focus on what
\nwe feel we do not have; for example, we feel
\nwe don\u2019t have enough financial resource,
\nwe don\u2019t have enough beds, we don\u2019t have
\nenough clinical staff, we don\u2019t have enough
\nchoice to provide the type of services that
\nwe would like to. This leads us into a spe-
\ncific mindset which can result in a down-
\nward spiral of negativity and despondence
\nand in turn, this can result in a reduction
\nof performance in staff and ultimately the
\norganisation. It is exactly at times of con-
\nstraint that we should focus on what we do
\nhave and ensure that we use those resources
\nwisely. Paul Batalden said,\u201cWe should work
\nnot from an assumption of scarcity,but from
\nan assumption of abundance\u201d [12]. Within
\nthe NHS for example, we know that we
\nhave an abundance of highly skilled nurses,
\njust over 400,000 of them. How can we as
\nleaders help those 400,000 nurses help us to
\nachieve the transformational change that is
\nneeded in our system? How can we encour-
\nage them to identify new ways to provide
\ncare that increases quality and at the same
\ntime reduces cost?
\nWould words such as \u201clet\u2019s start a new cost
\nimprovement programme\u201d or \u201cwe are stop-
\nping the employment of all temporary staff\u201d
\nor \u201cyou need to reduce consumables in-
\ncluding stationary in order to reduce costs\u201d
\ninspire those nurses who want to provide
\nthe best care that they can to patients and
\ntheir families? The answer is no, this will
\nlead them into the mindset of cost cutting.
\nHowever, there is a massive opportunity
\nto harness the will, the skills and exper-
\ntise of thousands of nurses and this can be
\nachieved by focussing on the way any par-
\nticular challenge is framed. By making it
\nclear to staff, through communication and
\naction, that innovation is needed in order
\nto overcome current challenges, leaders can
\nwmj 3 2011 5CS.indd 117 6\/21\/11 9:32 AM
\n118
\nutilise the abundance of nursing resource to
\nachieve organisational goals. When com-
\nmunicating the challenge, it needs to be
\nobvious that new ideas are desirable and
\nthat the aim is not to just tinker with the
\nstatus quo or apply a blanket cost cutting
\nformula. Staff need to understand what and
\nhow they as individuals or small teams can
\nactually contribute.
\nIf we return to the current NHS challenge
\nof maintaining high quality care while re-
\nducing costs by \u00a320 billion over the next
\nthree years and articulate that to ward staff,
\nit simply feels too overwhelming. It is a
\nleadership responsibility to help staff to be
\nable to effectively understand what all of this
\nmeans for them. One way of achieving this
\nis through effective communication which
\nframes the challenge and aspiration in a way
\nthat is more tangible and achievable within a
\nlocal context. For example, rather than only
\narticulate the high level challenge of reduc-
\ning costs across the whole NHS (the \u00a320
\nbillion) leaders need to be able to identify
\nwhat their organisation\u00a0\u2013 down to the detail
\nof each ward and department\u00a0\u2013 can contrib-
\nute (Table 1: Framing to engage staff).
\nDesigning services with
\npatients and family members
\nFollowing the theme of abundance, we also
\nneed to recognise both the sheer volume of
\npatients and family members and the valu-
\nable input they can provide. In conversa-
\ntions with colleagues at the Design Council
\nin London about designing services with
\ncustomers, the group reflected that \u2018Patients
\nand families are the biggest untapped resource
\nin the NHS\u2019.
\nBy working in partnership with patients,
\nusing methods that have been adapted from
\nthe service design industry, staff have been
\nable to demonstrate many changes that
\nhave had a fundamental impact on health
\nservice delivery. For example, when focus-
\nsing on the actual experience of being part
\nof a health care process (rather than focus-
\nsing on the process primarily from a clinical
\nperspective) one service, which was consid-
\nered to be one of the best performing within
\nan organisation, made 42 improvements,
\nincluding removing steps in the process,
\nwhich added no value to the patient, and
\nimproving safety\u00a0\u2013 both of which reduced
\noverall cost. A primary care organisation
\nconsidered transferring neurological servic-
\nes into the community in order to bring care
\ncloser to the homes of patients living with
\nmultiple sclerosis (MS). It was thought that
\nthis option would increase quality, although
\nit was actually more expensive than the cur-
\nrent provision. After working with people
\nliving with MS and their families, they dis-
\ncovered that this would not improve \u2018their\u2019
\nexperience, it would actually make things
\nmore difficult. With the current system pa-
\ntients were able to co-ordinate their various
\nhealth needs into one visit to the hospital,
\nthe change would mean they still needed to
\nmake a trip to the hospital and in addition,
\nthey would have a trip to the community
\nunit, resulting in an additional visit from
\ntheir perspective.
\nThe real problem for those living with MS
\nwas getting specialist information and other
\nhelp\u00a0\u2013 advice about benefit payments, help
\nwith movement or repairing wheelchairs
\nand other equipment. The primary care
\norganisation had good intentions, however
\ntheir proposed solution was more expensive
\nand it did not provide a better experience
\nfor patients, the actual customers of the
\nservice. The result of working closely with
\npatients and family members was in fact to
\nmaintain the existing hospital consultant
\nled service but patients and staff worked
\ntogether to explore new and more effective
\nways to access services and information that
\nthey needed and this led to the develop-
\nment of a new social network site that they
\ndesigned together [13].
\nLearning from other industries
\nWe also have to remember that patients
\nand their families bring not only their per-
\nspective of experiencing health services,
\nthey can also offer knowledge and expertise
\nfrom other aspects of their daily life\u00a0\u2013 such
\nas their work roles. Innovation often oc-
\ncurs through the adaptation of something
\ncommon to one industry, which is new to
\nTable 1. Framing to engage staff
\nFrom To
\n\u2022 The NHS needs to reduce its costs by
\n\u00a320 billion
\n\u2022 As an organisation, we need to contrib-
\nute to the overall cost reduction for the
\nNHS
\n\u2022 Everyone needs to work within the new
\nCost Improvement Programme (CIP)
\n\u2022 We are launching a \u2018call for ideas\u2019 from all
\nstaff and patients and their families
\n\u2022 With immediate effect there will be no
\nemployment of temporary staff
\n\u2022 We need new ideas that could maintain
\nquality and reduce cost on each ward by
\nat least \u00a311,000 this year; if we can save
\nmore, that would be even better
\n\u2022 All staff must reduce consumable use in-
\ncluding stationary
\n\u2022 These ideas could be about reducing
\nwaste, changing the way we work or
\nlooking at the materials we use, for ex-
\nample
\nSocio-Medical-Affairs UNITED KINGDOM
\nwmj 3 2011 5CS.indd 118 6\/21\/11 9:32 AM
\n119
\nanother. There are many illustrations of this
\nwithin the NHS, for example, when explor-
\ning how to improve safety, a checklist was
\nadapted from the aviation industry and is
\nnow being used by both airline pilots and
\nsurgeons alike. Tools and techniques for
\nunderstanding customer experience have
\nbeen adapted from the service design in-
\ndustry and lean methodology is now almost
\ncommonplace after being adapted from the
\nmanufacturing industry.
\nIt is this last example that has particularly
\nyielded improvements in efficiency and ef-
\nfectiveness. The NHS Institute for Inno-
\nvation and Improvement has utilised lean
\nmethodology within a variety of health care
\nsettings in order to increase productivity
\nand release time for professionals to focus
\non high value-adding activity. The Produc-
\ntive Series [14] incorporates seven pro-
\ngrammes designed to support different ar-
\neas within health services. All have resulted
\nin an increase of efficiency, productivity and
\nquality at lower cost.
\nWhen using the Productive methodology
\n[14], hospital ward teams report an increase
\nin direct patient care time by 40%. This
\nmeans nurses spending more time with pa-
\ntients, less time on administration increas-
\ning their ability to create more capacity for
\nvalue-added work. Unplanned staff absence
\nrates dropped by 6% in organisations using
\nthe \u2018productives\u2019, which not only represents
\na cost saving, but indicates an increased
\npositive feeling for staff.
\nIn addition to increasing quality, the pro-
\ngrammes can also lead to the reduction
\nof cost. The Productive Operating Theatre
\nprogramme can provide an average trust
\nwith an improvement opportunity of over
\n\u00a37 million through, for example, the reduc-
\ntion of waste, increase in safety and more
\nefficient scheduling. The Productive Leader
\ntools can help staff free up between 40 and
\n46 days per year in eliminating tasks that
\nwere actually \u2018wasteful\u2019. Although early in
\nits development, the Productive General
\nPractice has already identified both qualita-
\ntive and quantitative improvements.
\nThe Productive Series [14]
\nProductive Ward
\nProductive Community Hospital
\nProductive Community Service
\nProductive Leader
\nProductive Mental Health Ward
\nProductive Operating Theatre
\nProductive General Practice\u00a0\u2013 in deve-
\nlopment
\nI will now return to the beginning of this
\npaper and the issue of what is happening
\n\u2018somewhere\u2019… In healthcare we have ex-
\namples where the experience of millions of
\npatients, families and care givers have been
\ntransformed\u00a0 \u2013 for example; where no-one
\nis waiting unnecessarily for care, an end to
\nthe millions of unnecessary patient visits;
\nhospital bed days and clinician tasks elimi-
\nnated; care provided is reliably \u2018right first
\ntime\u2019\u00a0\u2013 instead of the typical 40\u201345% defect
\nrate; and staff have stopped \u2018firefighting\u2019and
\nconcentrate on quality care.
\nIf only these innovations that have the po-
\ntential to significantly impact on quality
\nand cost were implemented on a large scale,
\nin every healthcare organisation, the result
\nwould be a true and radical transformation
\nof services. Unfortunately this is not the
\ncase, but rather we see \u2018islands of improve-
\nment\u2019 when we desire a sea of transforma-
\ntion. There is a massive amount of innova-
\ntion within health services; our next big
\nchallenge is to focus our attention on new
\nideas that could break the physical and be-
\nhavioural barriers impeding the widespread
\n\u2018adoption\u2019 of these innovations into routine
\npractice.
\nCan NHS staff achieve ever increasing
\nquality and productivity and bring about
\na health service more focussed on the in-
\ndividual needs of patients? Yes, they can\u00a0\u2013
\nand we know this because some are already
\ndoing it.
\nReferences
\n1. Google\u00a0\u2013 www.google.co.uk accessed 30th
\nApril
\n2011.
\n2. Maher, L., Plsek, P., Bevan, H. (2008). Making
\na bigger difference: a guide for NHS front-line
\nstaff and leaders on assessing and stimulating
\nservice innovation. NHS Institute for Innova-
\ntion and Improvement. Coventry.
\n3. Bason, C. (2010). Leading public sector innova-
\ntion: co-creating for a better society. The Policy
\nPress. Bristol.
\n4. Christensen, C. (2009).The innovators prescrip-
\ntion. McGraw Hill. New York.
\n5. Christensen,C.(2003).The innovators dilemma.
\nHarper Business Essentials. New York.
\n6. Appleby, J., Crawford, R., Emmerson, C. (2002).
\nHow cold will it be? Prospects for NHS fund-
\ning: 2011-17. King\u2019s Fund, Institute for Fiscal
\nStudies. London.
\n7. Bessant, J. (2003). High-involvement innova-
\ntion: building and sustaining competitive ad-
\nvantage through continuous change. Wiley,
\nEngland.
\n8. Maher, L., Plsek, P., Price, J., Mugglestone, M.
\n(2010). Creating the culture for innovation: a
\npractical guide for leaders. NHS Institute for
\nInnovation and Improvement. Coventry.
\n9. Nicholson, D. (2009). Cited in the NHS Annual
\nReport. HMSO 2009. London.
\n10. NHS Institute for Innovation and Improvement
\nSurvey 2009 report. Available at www.institute.
\nnhs.uk\/innovation
\n11. Kanter, R. M. (2006). Innovation: the clas-
\nsic traps. Harvard Business Review. November.
\nUSA.
\n12. Berwick, D. (2004). Escape fire. Designs for the
\nfuture of health care. New York: John Wiley &
\nSons, Inc., 272\u2013295.
\n13. NHS Institute for Innovation and Improvement
\n(2009). Experience based design. www.institute.
\nnhs.uk\/ebd
\n14. NHS Institute for Innovation and Improve-
\nment: the productive. Available at http:\/\/www.
\ninstitute.nhs.uk
\nDr. Lynne Maher,
\nInterim Director for Design and Innovation
\nNHS Institute for Innovation
\nand Improvement
\nE-mail: lynne.maher@institute.nhs.uk
\nSocio-Medical-AffairsUNITED KINGDOM
\nwmj 3 2011 5CS.indd 119 6\/21\/11 9:32 AM
\n120
\nIT Policy AUSTRALIA
\nHealth IT or EHealth as it is called in
\nmany parts of the world is predicted to
\nradically improve the delivery of health-
\ncare. However, its implementation has
\nbeen difficult, and despite billions of dol-
\nlars being spent around the world there
\nis still much conjecture about whether it
\ncan meet its promise. Australia, the United
\nStates and almost every other Western
\ncountry has invested in it, and is looking
\nfor outcomes. However, the policy aspect
\nof it has not advanced as fast as the tech-
\nnology aspect.
\nIn recent times, under the Obama adminis-
\ntration a renewed initiative has taken place
\nin the United States, which I believe has
\nbeen a great leap forward in connecting the
\npolicy with the technology.
\nWhilst criticized for the amount of money
\ninvested, which was as much driven by a
\nneed for health reform as it was from a need
\nto stimulate the economy during the great-
\nest economic downturn since the Great
\nDepression, it has awoken interest in the
\neffective use of information technology in
\nhealthcare, and potentially set a new bench-
\nmark for the rest of the world.
\nI recently spent a week at the Harvard
\nSchool of Public Health where I attended
\na residential course on Leadership Strate-
\ngies for Healthcare IT. The course was run
\nby two gentlemen who are fairly legendary
\nin the world of ehealth.
\nDr. John Glaser, the former CIO of Part-
\nners Health, the amalgamation of Mas-
\nsachusetts General Hospital and Brigham
\nand Women\u2019s Hospital in Boston, which
\nnow includes several more facilities and
\nsome 6000 physicians in Massachusetts
\nand adjoining states.
\nDr. Glaser was called upon by the US gov-
\nernment in 2009 to draft the meaningful use
\nprovisions of the ehealth legislation. And
\nDr. John Halamka, CIO of Care Group,
\nthe amalgamation of Beth Israel Deaconess
\nhospital and several other hospitals in the
\nregion with over 2000 physicians. He is also
\nCIO of Harvard Medical School and heads
\na number of government initiatives in the
\nUS.
\nYou may ask why focus on the USA when
\nit is recognized that their healthcare system
\nis in trouble. The Commonwealth Fund re-
\nports that despite being the most expensive
\nin the world the quality of their healthcare
\nranks amongst the lowest [1].
\nThis has been recognized by the govern-
\nment and heath reform, as we are all aware,
\nis a very hot topic in the USA today. It is an
\narea that they have focused on, and quot-
\ning Sir Winston Churchill,\u201cYou can always
\ncount on Americans to do the right thing \u2013
\nafter they\u2019ve tried everything else\u201d. I believe
\nthey are now at that stage.
\nSo there are three facets of ehealth policy I
\nwant to explore.
\nThe first is the concept of Meaningful Use
\n[2]. In 2009 President Obama and the US
\nCongress passed ARRA, the American Re-
\ncovery and Reinvestment Act which pro-
\nvided almost $800 Billion to stimulate the
\nUS economy in response to the Global Fi-
\nnancial Crisis of 2008.
\nWithin that legislation was some $25 Bil-
\nlion for ehealth. However, the genius of the
\nlegislation was the need for the recipients
\nof this funding to demonstrate \u2018Meaningful
\nUse\u2019 of the technology to be eligible. At the
\ntime the legislation was enacted meaningful
\nuse had not been defined? Dr. John Glaser
\nand others were seconded to Washington to
\nthe office of the National Coordinator for
\nHealthcare Information Technology, an-
\nother Bostonian Dr. David Blumenthal to
\ndevelop the definition.
\nThe key issue is that the meaningful use
\ncriteria do not relate to technology, but
\nrather to health outcomes and the accurate
\nand timely reporting of this data. They are
\nalso staged, phase one, whilst not trivial will
\nallow most physicians to get onboard by
\n2011, but stage 2 extends into disease man-
\nagement, clinical decision support, patient
\naccess and empowerment and improved
\nbi-directional communication, while stage
\n3 focuses on aggressive quality safety and
\nefficiency improvements and population
\nhealth outcomes.
\nLinking clinical outcomes to ehealth is the
\nkey to the successful implementation in the
\nUSA, and we have seen a radical shift in the
\nthinking of ehealth companies over the last
\nyear or so with this focus on meaningful
\nuse.Tying the reimbursement to the desired
\noutcomes, basic Pavlovian psychology has
\ndriven this change.
\nWhat Australia (and the Rest of the World)
\nCan Learn from US Health IT Policy
\nGeorge Margelis
\nwmj 3 2011 5CS.indd 120 6\/21\/11 9:32 AM
\niii
\nIT PolicyAUSTRALIA
\nThe second concept is that of \u2018Bending the
\nCurve\u2019, a term used by President Obama in
\nthe 2009 State of the Union address, refer-
\nring to slowing down the rapid increase in
\nUS healthcare costs[3]. The issue is not just
\nthe gross increase in spending, but the het-
\nerogeneity of this spending.
\nHighlighted by an article in the New York-
\ner by Dr.\u00a0Atul Gawande [4], a Boston sur-
\ngeon with a knack for incisive writing on
\nhealth matters. In this article he talks about
\nMcAllen, Texas, a town with the dubious
\ndistinction of being one of the most ex-
\npensive healthcare markets in the country,
\nsecond only to Miami. Its other claim to
\nfame is being the Square Dance Capital of
\nthe World.
\nYou may argue that the New Yorker is not
\nthe best peer-reviewed journal for health
\npolicy around, and I would agree, but
\nDr.\u00a0Gawande has used it very effectively to
\ntake much of the work published in Health
\nAffairs and other learned journals and bring
\nit to the attention of the government and
\nthe lay press.
\nThe debate has now arisen on how ehealth
\ncan aid in flattening the discrepancies in
\nhealthcare spending in the US by the shar-
\ning of information,the ability to compare in
\nnear real time services, costs, outcomes and
\nuse that to influence the provision of high
\nquality care.
\nDr. Gary Gottlieb, the CEO of Partners
\nHealthcare spoke at the event about the
\nneed for a High Performance Learning
\nhealthcare system. To enable those clini-
\ncians need to be able to share information
\nand learn from each other in a non confron-
\ntational way. Ehealth provides that oppor-
\ntunity.
\nThe third issue is the \u2018Accountable Care Or-
\nganization\u2019, a new concept where healthcare
\nproviders form an ACO and provide care.
\nThey can be paid by capitation or fee for
\nservice, but they also receive reimbursement
\nfor reducing costs and meeting quality im-
\nprovement markers.
\nIn this way they are accountable to the pa-
\ntients and the third party payer for quality,
\nappropriateness and efficiency of healthcare
\nprovided.
\nIn Australia, these may equate to our Medi-
\ncare Locals or even our Super Clinics,but in
\nthe US there has been a lot of work defining
\nthem, and also working out the ehealth im-
\nplications. ACOs do not need to be physi-
\ncal entities; they can be virtual entities that
\ntake advantage of advances in ehealth tech-
\nnologies, including technologies that allow
\nhealthcare workers to reach right into the
\nhomes of patients.
\nAgain Atul Gawande has led the way in
\npublicizing in the lay press what ACOs
\ncan achieve [5]. In an article in last week\u2019s
\nNew Yorker called \u201cThe Hot Spotters\u201d he
\nlooked at how innovative care models have
\nsignificantly decreased the costs of care
\nand significantly improved the quality. It
\nbasically comes down on concentrating re-
\nsources where they make a difference and
\nfocus.
\nSo what are the three lessons we can take
\nfrom these ehealth policy perspectives from
\nthe US?
\n1. Set goals that are relevant to politicians,
\nproviders, patients and technologists so
\nthat they can all aim at the same goal.
\nDon\u2019t set different goals for different
\ngroups; you need to unite them with a
\ncommon goal. Meaningful use did that
\nin the US.
\n2. Publicize the problem so everyone can
\nunderstand. Don\u2019t lock it into articles
\nin the MJA; get it out in a way everyday
\npeople can understand. Atul Gawande
\nis a good example; his work ended up
\nin the NY Times, the LA Times, Time
\nmagazine and became an issue of discus-
\nsion in the lay press, the medical press
\nand even the IT press. Make sure every-
\none knows what the problem is.
\n3. Define a solution and work towards it.
\nIt may not be perfect, it may not even be
\nright, but a focused solution people can
\ndeliver to is better than a weighty strat-
\negy which people will debate forever.The
\nACO is the embodiment of healthcare
\nreform, and people are developing them
\nas we speak.
\nReferences
\n1. Anderson G. & Squires D. Measuring the U.S.
\nHealth Care System: A Cross-National Com-
\nparison. Commonwealth Fund Issues in Inter-
\nnational Health Policy. June 2010.
\n2. HIT Policy Committee Department of Health
\nand Human Services. Meaningful Use Work-
\ngroup Presentation. July 16, 2009.
\n3. Paterson D. Act II \u2013 Curve Bending. N Eng J
\nMed 2009: 361: e116.
\n4. Gawande A. The Cost Conundrum. The New
\nYorker, June 1, 2009.
\n5. Gawande A.The Hot Spotters.The New Yorker,
\nJanuary 17, 2011.
\nDr. George Margelis MBBS,
\nM.Optom GCEBus;
\nCare Innovations
\nAn Intel GE Company
\nE-mail: george.margelis@careinnovations.com
\nwmj 3 2011 5CS.indd Sec2:iii 6\/21\/11 9:32 AM
\niv
\n\u201cThe Speaking Book created for low literacy health education re-
\nceives the prestigious TIGA Award \u2013 (Technology in Government
\nAwards) from the UN Economic Commission for Africa.\u201d
\nThe Awards, according to the Information and Communication
\nService of the Economic Commission for Africa (ECA) are co-
\norganised by the Economic Commission for Africa (ECA) and the
\nGovernment of Finland in collaboration with the eLearning Africa
\nScholarship Trust, the organizer of the eLearning Africa annual
\nevent. The awards are given in recognition of initiatives aimed at
\nexploiting information and communication technologies (ICTs) for
\neducation and training in Africa.
\n\u201cThe second leg of the long-awaited 2011 Technology in Govern-
\nment Awards (TIGA) in the \u2018ICT in Education\u2019 category were
\ncelebrated at a high-profile event and ceremony, Friday morning.
\nOver 1,400 participants from about 80 countries are attending the
\neLearning Africa, 6th International Conference on ICT for Devel-
\nopment, Education and Training, at the Mlimani City Conference
\nCentre, Dar es Salaam,Tanzania.
\nIn remarks read by his representative at the ceremony,ECA\u2019s Execu-
\ntive Secretary and UN Under-Secretary-General,Mr Abdoulie Jan-
\nneh said, \u201ctoday we see signs that more and more ICT applications
\nare being integrated in all sectors in Africa including in government,
\neducation, health and in the economic sectors.\u201d
\nHe, however, noted that whilst the adoption of ICTs in education
\nin Africa is on the increase, \u201cit is a fact that the continent still falls
\nbehind, which is why these awards are so important.\u201d He added, \u201cIt
\nis indeed necessary for the youth in Africa to gain acquainted with
\nthe 21st century skills in order to increase the competitive advan-
\ntages of Africa.\u201d
\nThe Speaking Book project aims to make education about critical
\nissues accessible to all regardless of literacy or education level. This
\n\u2018world first\u2019 is created by South Africans for Africans and focuses
\non rural, vulnerable and excluded people living in disadvantaged re-
\ngions of Sub-Saharan Africa and communities around the world.
\nImproving health care is a top priority for Africa and through the
\nSpeaking Books ( www.booksofhope.com),access to essential medi-
\ncal information for low literacy, rural,and vulnerable Africans is im-
\nproved.
\n\u201cReceiving this TIGA Award recognizing the impact and impor-
\ntance of the Speaking Book is a great honor for us, as well as all our
\nsponsors from the Pharmaceutical Industry, Government Health
\nDepartments, and major NGO\u2019s, for their support to ensure that
\ndisadvantaged communities are able to obtain and understand criti-
\ncal health education.Their support has made it possible for Speaking
\nBooks to be distributed throughout Africa, in India, China, South
\nAmerica and the USA, and covering 45 titles in 15 languages\u201d says
\nBrian Julius, Director of Books of Hope.
\nFor further information, please contact Brian Julius
\ninfo@booksofhope.com
\nSpeaking Book Takes UN Award for Education and Training
\nContents
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
\nGlobal Forum on Human Resources for Health . . . 82
\nViolence in the Health Care Sector\u00a0\u2013 A\u00a0Global
\nIssue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
\nPhysician Suicide and Resilience: Diagnostic,
\nTherapeutic and Moral Imperatives . . . . . . . . . . . . . 90
\nWhole Genome Sequencing\u00a0\u2013 a New Paradigm
\nfor Clinical Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
\nOverview of the Vaccines in Preventing
\nInfectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 103
\nWhy Cancer Prevention isn\u2019t Working
\nWell Enough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
\nLeadership and the Medical Profession . . . . . . . . . . 108
\nCapacity Building Collaboration in the Area
\nof Undergraduate Medical Education. . . . . . . . . . . . 111
\nNews from the CPME . . . . . . . . . . . . . . . . . . . . . . . 113
\nInnovation, Efficiency and Productivity in Health
\nServices… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
\nWhat Australia Can Learn from US Health
\nIT Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
\nwmj 3 2011 5CS.indd Sec2:iv 6\/21\/11 9:32 AM<\/p>\n"},"caption":{"rendered":"

wmj33 UNITED STATES vol. 57 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 3, June 2011 \u2022 Global Forum on Human Resources for Health \u2022 Leadership and the Medical Profession \u2022 Physician Suicide and Resilience wmj 3 2011 5CS.indd I 6\/21\/11 9:32 AM Cover picture from China 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\/wmj33.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3618"}],"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=3618"}]}}