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wmj34<\/a><\/p>\n

UNITED STATES OF AMERICA
\nvol. 57
\nMedicalWorld
\nJournalJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 4, August 2011
\n\u2022 Gigantic Earthquake and Tsunami in the Japan.
\nHealthcare Support for Radiation Exposure
\n\u2022 Public Health in the Russian Federation
\n\u2022 Task Shifting in the Netherlands
\nwmj 4 2011 5CS.indd Iwmj 4 2011 5CS.indd I 09.08.2011 10:38:2709.08.2011 10:38:27
\nCover picture from France
\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:
\nAndreas Vesalius and Ambruaz Pare at the
\nbed of fatally wounded French King Henri II.
\nXylography, Germany 1559.
\nIn Paris on July 1559 during the tournament
\nwas seriously injured French King Henri II.
\nThe greatest French surgeon of 16th
\ncentury
\nAmbruaz Pare (1510\u20131590), was invited for
\nhis treatment, but the Spanish King Philip
\nII sent to Paris physician Andreas Vesalius
\n(1514\u20131564).
\nXylography from the stock of The Pauls Stradins
\nMuseum for history of medicine in Riga.
\nPublisher
\nThe World Medical Association, Inc. BP 63
\n01212 Ferney-Voltaire Cedex, France
\nPublishing House
\nPublishing House
\nDeutscher-\u00c4rzte Verlag GmbH,
\nDieselstr. 2, P.O.Box 40 02 65
\n50832 Cologne\/Germany
\nPhone (0 22 34) 70 11-0
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\nProducer
\nAlexander Krauth
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\nAdvertising rates available on request
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum
\n(incl.\u00a07%\u00a0MwSt.). For members of the World
\nMedical Association and for Associate
\nmembers the subscription fee is settled by the
\nmembership or associate payment. Details of
\nAssociate Membership may be found at the
\nWorld Medical Association website
\nwww.wma.net
\nPrinted by
\nDeutscher \u00c4rzte-Verlag
\nCologne, Germany
\nISSN: 0049-8122
\nDr. Wonchat SUBHACHATURAS
\nWMA President
\nThai Health Professional Alliance
\nAgainst Tobacco (THPAAT)
\nRoyal Golden Jubilee, 2 Soi
\nSoonvijai, New Petchburi Rd.
\nBangkok,Thailand
\nDr. Leonid EIDELMAN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nIsrael Medical Asociation
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O.Box 3566, Ramat-Gan 52136
\nIsrael
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Dana HANSON
\nWMA Immediate Past-President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nSir Michael MARMOT
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Jos\u00e9 Luiz
\nGOMES DO AMARAL
\nWMA President-Elect
\nWMA Chairperson of the Socio-
\nMedical-Affairs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP Brazil
\nDr.Torunn JANBU
\nWMA Chairperson of the Medical
\nEthics Committee
\nNorwegian Medical Association
\nP.O. Box 1152 sentrum
\n0107 Oslo
\nNorway
\nDr.Frank Ulrich MONTGOMERY
\nWMA Treasurer
\nHerbert-Lewin-Platz 1
\n(Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of Council
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\nwmj 4 2011 5CS.indd Sec1:iiwmj 4 2011 5CS.indd Sec1:ii 09.08.2011 10:38:3409.08.2011 10:38:34
\n121
\nObjective: reduction of dietary trans fatty acid consumption for all
\nearth\u2019s inhabitants!
\nThe World Medical Association faces a new challenge: Reduction
\nof trans fatty acid content in the world\u2019s foods to 2% of total fat
\nby 2017, but a complete elimination of trans fats from food pro-
\ncessing by 2020. It\u2019s an all-embracing problem \u2013 trans fatty acids
\nare cheaper than valuable fats, trans fatty acids are more compliant,
\ntherefore more suited for the production of different sweets, trans
\nfatty acids are with different melting points, therefore easily used in
\nfood processing in cases when natural fats cannot be used. However,
\nthere are also evidence-based studies that clearly show: Trans fatty
\nacids increase low-density lipoprotein (LDL) cholesterol levels, re-
\nduce high-density lipoprotein (HDL) cholesterol levels, as well as
\nthey increase TG levels in the blood. Consequently, trans fatty acids
\nactually promote the development of atherosclerosis, increase the
\nrisk of stroke and infarction, and reduce life expectancy.
\nThe struggle against dietary trans fatty acids in the world proceeds
\nwith changeable success and quite episodically. While trans fatty
\nacids are banned in separate US States and are severely restricted in
\nDenmark, Iceland, Switzerland and separate East Asian countries,
\nno practicable restrictive regulations \u2013 except maybe for the require-
\nment to indicate nutrition facts on the product label \u2013 exist in the
\nrest of the world\u2019s countries. The world food industry bravely lob-
\nbies against the opposition to the use of trans fatty acids in cookery,
\nchocolate production, and also in the production of other foods.
\nTraditions around the world differ; however, high-fat sweets are
\nloved everywhere on a holiday. These sweets usually contain more
\nor less fat, they may be served in soft creams or hard cookies, but
\nalmost everywhere the fat added with a view to economy is the
\nworst\u00a0\u2013 the artificially hydrogenated one.
\nThe World Medical Association should draw a mantra-like conclu-
\nsion that would decide what is a good fat and what is not. Good fat
\nincludes fish fat as it contains omega fatty acids, olive oil, and any
\nunrefined vegetable oil.
\nWorse fat includes refined vegetable oils, milk fat, and meat fat,
\nbut even this fat cannot be completely dispensed with, the more so
\nwhen the eating habits of a part of the world\u2019s population, whose
\nbasic diet includes beef and lamb, are considered. Saturated fatty ac-
\nids also raise total cholesterol and LDL cholesterol levels, moreover,
\nthey are most frequently found in the products which also contain
\ncholesterol.
\nNevertheless, one should completely avoid artificially produced hy-
\ndrogenated fats, namely \u2013 trans fatty acids. If any one of us \u2013 mem-
\nbers of the World Medical Association \u2013 announces in his or her
\nnative country that processed foods should not contain trans fatty
\nacids,he or she receives a furious repulse from both the industry and
\nthe politics. At such moments, politicians become defenders of the
\npoor creatures and say,\u201cIf pastries, cookies, wafers, ice-cream, cream
\nor cheese are made without trans fatty acids, the poorest people of
\nthe world will die of starvation\u201d.
\nThis is not true.The increase in the price of foods,caused by lowering
\ndietary trans fatty acids and complete elimination of them from the
\ndiet, will be minimal.The science of the world will quickly solve the
\nproblem \u2013 how to process foods from natural fat \u2013 in fact, a return
\nto long-forgotten recipes will ensue. But the struggle against trans
\nfatty acids should be simply started in the name of the health of the
\nworld\u2019s population. As we fail to do it separately, it will be neces-
\nsary to decide on a joint WMA Statement in 2012, which should
\ninclude as an objective reduction of trans fatty acid content in the
\nworld\u2019s foods to 2% of total fat by 2017, but a complete elimination
\nof trans fats from food processing by 2020. Hand in hand with the
\nWorld Health Organization (WHO), we will have to address the
\ngovernments of all states.
\nA simple algorithm should be devised, which should be repeated
\nlike a mantra: Fat should account for 25% of the calories con-
\nsumed, with one half of this fat intake consisting of monoun-
\nsaturated fatty acids and saturated fatty acids not exceeding one
\nquarter of this fat intake. Trans fatty acids have no place in this
\nproportion.
\nDr. P\u0113teris Apinis,
\nPresident of Latvian Medical Association
\nEditorial
\nwmj 4 2011 5CS.indd 121wmj 4 2011 5CS.indd 121 09.08.2011 10:38:3509.08.2011 10:38:35
\n122
\nWMA news
\nThe growing threats to health personnel
\nduring or following uprisings and mass pro-
\ntests throughout the world were subject to
\ndiscussions during this year\u2019s World Health
\nAssembly. The World Medical Association
\ntook part in the debate, reiterating its firm
\ncommitment to the international Code of
\nMedical Ethics as well as the Geneva Con-
\nventions ensuring that physicians and other
\nhealth personnel can provide care to every-
\none in need in situations of armed conflict.
\nCivil society calls for WHO
\nto take a lead in developing
\nmethodologies and plans for
\ndata collection and systematic
\nreporting of assaults on medical
\nfunctions, personnel and patients
\nOn 12 May, in a joint letter1
\nto Dr. Marga-
\nret Chan, Director General of the WHO,
\nthe WMA together with other health and
\nhuman rights non-governmental orga-
\nnizations2
\n(NGOs) urged WHO to take
\naction on the growing number of assaults
\non health personnel and facilities in areas
\nof conflict and civil unrest. The organiza-
\n1 The full text of the letter can be found at: www.
\nwma.net\/en\/20activities\/20humanrights\/20distre
\nss\/index.html
\n2 The organizations that signed the letter were
\nthe World Medical Association, the International
\nMedical Corps, Human Rights Watch, Save the
\nChildren UK, Merlin, IntraHealth International,
\nMedact, Physicians for Human Rights, Interna-
\ntional Federation of Health and Human Rights
\nOrganizations, International Rehabilitation
\nCouncil for Torture Victims, the International
\nRescue Committee, Health Poverty Action UK
\nand International Health Protection Initiative,
\nPublic Health Institute, Management Sciences for
\nHealth, Family Care International and People\u2019s
\nHealth Movement.
\ntions explained that these assaults pose a
\nthreat to health, health systems and health
\nworker retention. Furthermore they urged
\nthe WHO to convene a group of experts to
\nput in place systematic data collection from
\naround the world and to identify research
\nneeded to enhance the protection of health
\nsystems.
\nThe letter declares: \u2018In recent weeks reports
\nhave emerged of doctors being arrested and
\nassaulted for complying with their ethical
\nduty to provide care to patients in need.
\nThey provide only a snapshot of a much
\nwider problem of the lack of protection of
\nhealth functions during crises. These as-
\nsaults not only result in obstructed access to
\nhealth, but pose a formidable challenge to
\nhealth systems,limiting their effective oper-
\nation during instability while also impeding
\nthe development of health infrastructure
\nand meeting human resource needs once
\nstability returns.\u2019
\nIt says the WHO has the authority to as-
\nsist all health personnel in such hazardous
\nsituations by contributing its particular ex-
\npertise to developing methods for collect-
\ning evidence on these assaults. The NGOs
\nrequire a plan for the collection of data, for
\nassuring reporting of the data collected,
\nidentifying research needs for gaining bet-
\nter understanding of the problem, and pro-
\nviding guidance on how protection can be
\nenhanced.
\nThis would be in line with the WHO\u2019s key
\nfunctions to produce health statistics and
\n\u2018to reduce the health consequences of emer-
\ngencies, disasters, crises and conflicts, and
\nminimize their social and economic impact.\u2019
\nResponding to NGOs\u2019 concerns, Dr. Mar-
\ngaret Chan \u2013 in her opening speech to the
\n64th
\nWorld Health Assembly on the 16th
\nof
\nMay3
\n\u2013 expressed her \u2018extreme distress\u2019 at
\nreports of assaults on health personnel and
\nfacilities in some of conflict situations. The
\nWHO Director-General then urged \u2018all
\nparties to ensure the protection of health
\nworkers and health facilities in conflict situ-
\nations, to enable them to provide care for
\nthe sick and injured\u2019.
\nThe next day, the WMA, Johns Hopkins
\nBloomberg School of Public Health and
\nIntraHealth International echoed civil
\nsociety\u2019s demands in a briefing meeting4
\n,
\naimed at stimulating action by the inter-
\nnational health community to protect doc-
\ntors, nurses, other health workers and pa-
\ntients from assaults. The event, moderated
\nby Maurice Middleberg from IntraHealth,
\nprovided a means to discuss with WHO
\nthe role it can play in providing leadership
\nin this area.
\nDr. Torunn Janbu, Chairperson of the
\nWMA Medical Ethics Committee, re-
\ncalled the ongoing commitment of WMA
\nto protect health personnel worldwide and
\nexpressed its commitment to continue in
\nthis direction. Other speakers at the event
\nincluded:
\nDr. Nils Daulaire, Director of the Office
\nof Global Health Affairs from the United
\nStates Department of Health and Human
\nService. Dr. Daulaire recommended further
\nresearch and suggested an expert meeting
\non the topic.
\nDr. Robin Coupland, Medical Adviser
\nfrom the International Committee of the
\nRed Cross, explained that the protection
\nof health care in armed conflicts and other
\n3 Dr. Margaret Chan\u2019s address to the Sixty-fourth
\nWorld Health Assembly, Geneva, 16 May 2011\u00a0:
\nwww.who.int\/dg\/speeches\/2011\/wha_20110516\/
\nen\/index.html
\n4 The event was co-sponsored by the United States
\nGovernment \u2013 For further information, see\u00a0: www.
\nwma.net\/en\/20activities\/20humanrights\/20distre
\nss\/index.html
\nWorld Health Organization Urged to Act over
\nAssaults on Health Personnel and Facialities
\nwmj 4 2011 5CS.indd 122wmj 4 2011 5CS.indd 122 09.08.2011 10:38:3509.08.2011 10:38:35
\n123
\nCounterfeit medicines
\nIn a first for the Asian region, national
\nhealth professions organisations (nurses,
\npharmacists, physical therapists, dentists
\nandphysicians) have discussed and en-
\ndorsed the WHPA Taipei Call to Action on
\nCounterfeit Medical Products, to reduce
\nthe harmful impact of falsified and coun-
\nterfeit medical products on patients and
\nthe public. With the WHPA Taipei Call
\nto Action health professions leadersare
\ngearing up their response to this serious
\nthreat to patient safety and they are call-
\ning on governments in the region to do
\nthe same.
\nUnder the banner of the \u201cBe Aware, Take
\nAction\u201dcampaign against counterfeit medi-
\ncal products, theWorld Health Professions
\nAssociationworkshop, held on 30 June in
\nTaipei, tackled the grave problem of coun-
\nterfeit medical products worldwide. Co-
\nhosted with WHPA by the Taiwan Society
\nof Health Systems Pharmacists (THSP),
\nthe workshop brought together more than
\n50 participants from Indonesia, Japan, Ma-
\nlaysia, the Philippines, Singapore, South
\nKorea,Thailand and Taiwan.
\nParticipants jointly agreed on the follow-
\ning four key strategies for the basis of a
\ncomprehensive regional action plan against
\ncounterfeiting of medical products \u2013 to in-
\ncrease capacity of healthcare professionals,
\nto foster regional cooperation initiatives,
\nto strengthen collaborative practice, and to
\nsituations of violence has been identified as
\na priority theme for the ICRC for the com-
\ning years and presented briefly the related
\nactivities planned.
\nMs. Miatta Gabanya, a nurse representing
\nMerlin, talked about her personal experi-
\nence as nurse in West Africa.
\nFinally Leonard Rubenstein, Senior Schol-
\nar at Johns Hopkins Bloomberg School of
\nPublic Health, concluded by urging WHO
\nto take a lead in the protection of health
\npersonnel as a matter of priority.
\nWHO representatives participating in the
\nevent welcome the civil society initiative
\nand committed to take action in the near
\nfuture. We hope that tangible actions will
\nfollow.
\nThe US delegation suggests an
\nexpert meeting initiated by WHO
\nAlong the same lines, in its comments on
\nWHO draft resolution on Health Work-
\nforce Strengthening5
\n, the US delegation
\nrecommended research to better under-
\nstand assaults on health workers and in-
\nterference with health facilities toward the
\ngoal of strengthening health systems. Such
\n5 WHO resolution on Health Workforce
\nStrengthening (WHA64.6): http:\/\/apps.who.int\/
\ngb\/e\/e_wha64.html
\nresearch could reveal what protection strat-
\negies would be most successful and pro-
\nvide a basis for developing new ones. As
\nrecommended by Dr. Daulaire during the
\nbriefing, the delegation called for an expert
\nmeeting\u00a0\u2013 including WHO staff, interested
\nMember States, academic experts, humani-
\ntarian and development NGOs, as well as
\nhealth professionals \u2013 to tackle these issues.
\nRecent WMA press releases related to the topic:
\nWorld Health Organization urged to act over Assaults on Health Personnel and Facili-
\nties (May 2011):
\nwww.wma.net\/en\/40news\/20archives\/2011\/2011_09\/index.html
\nAlarm Expressed Over Arrest of Nurses and Physicians (May 2011):
\nwww.wma.net\/en\/40news\/20archives\/2011\/2011_08\/index.html
\nAttacks on Medical Personnel Causing Increasing Concern (March 2011):
\nwww.wma.net\/en\/40news\/20archives\/2011\/2011_02\/index.html
\nWMA policy:
\nWMA regulations in times of armed-conflicts:
\nwww.wma.net\/en\/30publications\/10policies\/a20\/index.html
\nWMA Council Resolution supporting the Preservation of International Standards of
\nMedical Neutrality\u00a0:
\nwww.wma.net\/en\/30publications\/10policies\/30council\/cr_9\/index.html
\nHealth Professionals Unite in WHPA Taipei
\nCall to Action, urging governments to ramp
\nup fight against falsified and counterfeit
\nmedicines
\nJoint Initative by the Health Professions from Asian Region and WHPA1
\n1 World Health Professions Alliance http:\/\/www.whpa.org
\nwmj 4 2011 5CS.indd 123wmj 4 2011 5CS.indd 123 09.08.2011 10:38:3609.08.2011 10:38:36
\n124
\nCounterfeit medicines
\nimprove collaboration with health and en-
\nforcement authorities and with other key
\nstakeholders.
\nTon Hoek, speaking on behalf of the
\nWorld Health Professions Alliance,
\nstressed the importance of vigilance when
\nit comes to falsified and counterfeit medi-
\ncal products.\u201cHealth professionals are
\ndeeply concerned by this serious public
\nhealth threat, which demands sustained,
\ncoordinated international action to control
\nit.Failure to act to prevent falsification of
\nessential medicines would be a fundamental
\nbreach of the trust patients place in public
\nhealth structures.\u201d
\nThe keynote address was presented by Oli-
\nver Yoa-Pu Hu, Ph.D., FAAPS, Minister
\nwithout Portofolio, Taiwan. He spoke on
\nthe collaborative combat against counterfeit
\nmedical products and summarised activities
\nagainst counterfeits around the world.
\nOther presenters included:
\n\u2022 Deng Shin Tang, President of the TSHP,
\nstated that health professionals must con-
\ntinue to work together and that in Asia,
\nthis workshop has given the impetus to
\nhealth professionals in the region to con-
\ntinue this work together.
\n\u2022 Xuanhao Chan, of the International
\nPharmaceutical Federation, also rep-
\nresenting WHPA, showed what drives
\npeople to buy counterfeit medical prod-
\nucts and where national multi-sectorial
\ninitiatives against counterfeiting have
\nbeen implemented.
\n\u2022 TeresitaBarcelo, of the PhilipinesNurses
\nAssociation, said that the WHPA Taipei
\nCall to Action will be very useful for the
\nhealth professionals from the Philipines
\nand from throughout the region, to ad-
\nvocate to their governments in order to
\nkeep counterfeiting on the public health
\nagenda.
\n\u2022 WonchatSubhachaturas, WMA Presi-
\ndent, Thailand urged all the health pro-
\nfessions to continue the combat together,
\nwith the World Health Professions Alli-
\nance,and with national alliances of health
\nprofessionals.
\n\u2022 Deputy Minister,Department of Health,
\nMei-Ling Hsiao, stated that combatting
\ncounterfeiting of drugs in every country
\nnot only belongs to Ministries of Health
\nbut also includes prosecution depart-
\nments, and wider interdepartmental
\ncooperation. She also urged health pro-
\nfessionals to show the costs of counter-
\nfeiting, and to strongly advocate to gov-
\nernments in economic terms and well
\nas in terms of patient safety and public
\nhealth.
\n\u2022 Paula de Cola and Emma Andrews of
\nPfizer Inc shared examples of advocacy in
\naction and urged healthcare professionals
\nto find ways to continue to work collab-
\noratively and to advance the Call to Ac-
\ntion in their countries.
\n\u2022 Ivan Ho, Director of Global Security
\nAsia Pacific, Pfizer Inc, highlighted some
\nof Pfizer\u2019s extensive activities to combat
\ncounterfeit medicines. He noted that
\nPfizer has uncovered examples of coun-
\nterfeit medicinal products in over one
\nhundred countries.
\nThese speakers provided a clear picture of
\nthe severity and complexity of the problem,
\nas well as the efforts being made by their
\norganisations to fight it \u2013 to define, combat
\nand penalise the production and distribu-
\ntion of counterfeit medical products.
\nThe workshop recognised that counterfeit
\nmedical products are, above all, a threat to
\npatient safety with grave consequences in
\nterms of increased disease burden, mortality
\nand costs for healthcare systems.
\nFor more information about Be Aware,
\nTake Action, see www.whpa.org\/counter-
\nfeit_campaign.htmor send an email to whpa.
\ncampaign@wma.net
\nSee WHPA Taipei Call to Action www.
\nwhpa.org\/news\/WHPA_Taipei_Call_to_Ac-
\ntion2011.pdf
\nwmj 4 2011 5CS.indd 124wmj 4 2011 5CS.indd 124 09.08.2011 10:38:3609.08.2011 10:38:36
\n125
\nCounterfeit medicines
\nWHPA Taipei Call to Action
\nWe, national member organizations1
\nof the
\nInternational Council of Nurses (ICN),
\nthe International Pharmaceutical Federa-
\ntion (FIP), the World Confederation for
\nPhysical Therapy (WCPT), the World
\nDental Federation (FDI) and the World
\nMedical Association (WMA) are meeting
\nin Taipei on the 30th
\nJune 2011, to address
\nthe alarming public health threat of falsi-
\nfied and counterfeit2
\nmedical products in
\nour region.
\nWe recognize that in some countries, the
\ninfiltration and sale of counterfeit and fal-
\nsified medicines in the legitimate supply
\nchain can cause disease, disability and death
\nto patients and healthy individuals around
\nthe world. Failure to act to prevent this
\nwould be a fundamental breach of the trust
\npatients place in public health structures.
\nWe observe that unscrupulous vendors are
\ndeliberately preying upon vulnerable groups
\nsuch as the elderly, poor and less well edu-
\ncated, thereafter misleading them into buy-
\ning counterfeit medical products.
\nWe note with grave concern that the peo-
\nple of our countries are at risk of dying from
\nmedicines that may have been accidentally
\nadulterated, produced to a poor standard
\nand\/or degraded by inappropriate storage.
\nSuch problems should not be ignored. But
\nneither should they be confused with delib-
\nerate counterfeiting.
\nWe fear that in countries with a high bur-
\nden of communicable diseases such as ma-
\n1 Indonesia, Japan, Malaysia, the Philippines, Sin-
\ngapore, South Korea,Thailand and Taiwan
\n2 A counterfeit medicine is one which is deliber-
\nately and fraudulently mislabeled with respect to
\nidentity and\/or source. Counterfeiting can apply
\nto both branded and generic products and coun-
\nterfeit products may include products with the
\ncorrect ingredients or with the wrong ingredients,
\nwithout active ingredients,with insufficient active
\ningredients or with fake packaging.
\nlaria, tuberculosis and HIV\/AIDS, coun-
\nterfeit and falsified medical products have
\nalready led to drug- resistant forms of in-
\nfective pathogens which are reversing gains
\nthat have been achieved in fighting these
\ndiseases.
\nWe strongly affirm to governments and
\nthe international community that health
\nprofessionals are uniquely positioned in
\nthis fight and will rise up to the challenge
\nto increase the awareness of this problem
\nand implement definitive strategies towards
\ncurbing it.
\nWe also acknowledge the work done by the
\nWorld Health Organization, IMPACT3
\nand the World Health Professions Alliance
\nin combating against counterfeit medical
\nproducts.
\nTherefore, Today, as leaders representing
\nnurses, pharmacists, physical therapists,
\ndentists and physicians, we jointly agree on
\nthe following 4 key strategies for the basis
\nof a comprehensive regional action plan
\nagainst counterfeiting of medical products:
\n1. Increase capacity of healthcare profes-
\nsionals
\n2. Foster regional cooperation initiatives
\n3. Strengthen collaborative practice
\n4. Improve collaboration with health and
\nenforcement authorities plus other key
\nstakeholders
\nIncrease capacity of healthcare
\nprofessionals to educate public
\nMany patients and healthy individuals seek
\nadvice on use of medical products from
\nnurses, pharmacists, physical therapists,
\ndentists or physicians. It then becomes
\nparamount that healthcare professionals
\nare adequately trained to be knowledgeable
\nabout risk of buying counterfeit and falsi-
\nfied medicines from unknown sources and
\n3 International Medical Products Anti-Counter-
\nfeiting Taskforce http:\/\/www.who.int\/impact
\nhow to better communicate those risks to
\npatients and the public.
\nThus, where appropriate, national healthcare
\nprofessional associations should collaborate
\nwith educational institutions of healthcare
\nprofessionals and the pharmaceutical sector
\nto undertake the following actions:
\nRaise awareness of the threat of counterfeit
\nmedical products amongst health profes-
\nsionals
\n\u2022 Include the subject of counterfeit medi-
\ncal products in undergraduate healthcare
\nprofessional curriculum and pre-service
\ntraining.
\n\u2022 Work with medicines manufacturers, na-
\ntional quality control laboratories, hospi-
\ntals and universities to learn about quality
\nproducts and ways of detecting counter-
\nfeits.
\n\u2022 Provide continuing education pro-
\ngrammes to healthcare professionals and
\ncommunity- based health workers on the
\ndetection and reporting of counterfeit
\nmedical products.
\n\u2022 Develop and implement tools4
\nfor patient
\ncounselling and public awareness. Con-
\nduct regular public campaigns educating
\npatients and the public about how they
\ncan protect themselves from the dangers
\nof counterfeit and falsified medical prod-
\nucts.
\nRegional cooperation initiatives
\nThere is a need to be cognizant of the cur-
\nrent situation in which counterfeit and fal-
\nsified medical products continue to move in
\ninternational commerce including through
\nthe Internet, representing a major threat to
\npublic health, especially in the poorer areas
\nof developing countries where regulatory
\nand law enforcement capacities are weak.
\nNow more so than ever, there is a need to
\n4 WHPA \u201cBE AWARE, TAKE ACTION\u201d
\nToolkit. Available from http:\/\/www.whpa.org\/
\ncounterfeit_campaign.htm
\nwmj 4 2011 5CS.indd 125wmj 4 2011 5CS.indd 125 09.08.2011 10:38:3609.08.2011 10:38:36
\n126
\nNETHERLANDSTask Shifting
\nwork together with the other organizations
\nof healthcare professionals in each country
\nand across the region in order to optimize
\nresources and maximize the effectiveness of
\nour efforts.
\nThus, where appropriate, national healthcare
\nprofessional associations should collaborate
\nwith relevant regional stakeholders to un-
\ndertake the following actions:
\n\u2022 Establish national and regional alliances
\nof healthcare professional associations
\nincluding patient\/consumer groups and
\nother relevant partners to promote in-
\nter- sectoral coordination for better in-
\nformation exchange and sharing of best
\npractices.
\n\u2022 Work together with regional entities such
\nas the WHO regional offices in Western
\nPacific and South-East Asia, the As-
\nsociation of South-East Asian Nations
\n(ASEAN) community and Asia-Pacific
\nEconomic Cooperation (APEC).
\nCollaborative practice
\nThere is a need to understand and acknowl-
\nedge the fact that escalating complexity of
\ncare demands a multidisciplinary approach.
\nHealthcare professionals must be vigilant
\nand to work together when managing un-
\nusual responses to medical treatment. They
\nneed to have heightened vigilance in geo-
\ngraphical areas where counterfeit and falsi-
\nfied medical products are prevalent.
\nThus, where appropriate, national healthcare
\nprofessional associations should undertake
\nthe following actions:
\n\u2022 Work together across various disciplines
\nto raise awareness of and actions against
\nfalsified and counterfeit medical prod-
\nucts amongst patients, the general public,
\ntheir colleagues and government leaders
\nincluding health authorities.
\n\u2022 Encourage their members to take an ac-
\ntive role in identifying, reporting and
\neliminating counterfeit and falsified
\nmedical products from the legitimate
\nsupply\/distribution chain.
\nCollaboration with relevant
\nauthorities
\nHealthcare professionals and their associa-
\ntions need to support national drug regu-
\nlatory authorities and relevant government
\nagencies to aid pharmaceutical guideline
\nenforcement.
\nThus, where appropriate, national healthcare
\nprofessional associations should collaborate
\nwith relevant authorities to undertake the
\nfollowing actions:
\n\u2022 Work towards implementation of harmo-
\nnized guidelines on the regulatory con-
\ntrol, export, import and transit conditions
\nof pharmaceutical products.
\n\u2022 Develop standards of practice for enti-
\nties involved in international, regional
\nand national trade in biopharmaceuti-
\ncals and pharmaceutical starting mate-
\nrials.
\n\u2022 Establish national reporting systems that
\nenable health professionals to report and
\nto get feedback about adverse events,
\ndrug-related problems, medication errors,
\nmisuse or drug abuse, defects in product
\nquality or detection of counterfeit and
\nfalsified medical products.
\nThe Participants of this WHPA region-
\nal workshop agree unanimously on the
\nWHPA TAIPEI \u201cCALL TO ACTION\u201d
\nand plan in cooperation to support it.
\nSummary
\nOver the past few years there has been an
\nongoing discussion in the Netherlands about
\nshifting tasks from physicians to nurses (pref-
\nerably specialized nurses). According to the
\nDutch government, such task shifting could
\nbe a way of solving the capacity problem in
\nhealthcare.Now,new legislation is on its way
\nto making this possible. The legislation will
\nenable physician assistants and nurse prac-
\ntitioners to perform certain medical health
\nchecks and procedures independently. The
\nRDMA has been positive about the propos-
\nals, but also critical of their substance.
\n1. Introduction
\nIn the coming years, finding qualified pro-
\nfessionals for the healthcare sector is set to
\nbecome a growing problem in the Neth-
\nerlands. Several studies have shown that a
\nshortage of professionals is to be expected.1
\nThere are two trends contributing to this
\ndevelopment.The first is the overall decrease
\nin the size of the workforce. Following de-
\n1 Netherlands Bureau for economic Policy Analy-
\nsis (Centraal Planbureau), Derks, W., P. Hoevens,
\nL.E.M. Klinkers: Structurele bevolkingsdaling,
\neen urgente nieuwe invalshoek voor beleidsmak-
\ners,The Hague 2006. www.cpb.nl
\nTask Shifting in the Netherlands
\nDiederik van Meersbergen
\nwmj 4 2011 5CS.indd 126wmj 4 2011 5CS.indd 126 09.08.2011 10:38:3709.08.2011 10:38:37
\n127
\nTask ShiftingNETHERLANDS
\ncades of growth, the Dutch population is
\nmoving towards a decline, which is likely
\nto result in a smaller pool of professionals.
\nThe second trend is the growing demand for
\nhealthcare as a result of demographic, tech-
\nnological and socio-cultural developments,
\nand not least because of the aging popula-
\ntion and increasing number of people with
\nchronic disorders. Faced with these devel-
\nopments, healthcare capacity will be unable
\nto meet the expanding demand. If nothing
\nchanges, we will be seeing more and longer
\nwaiting lists, a risk of declining quality of
\ncare, and upward pressure on incomes.2
\nThe
\naccessibility and affordability of healthcare
\nwill therefore come under increasing pres-
\nsure.
\nUnder the Dutch constitution, the govern-
\nment is required to promote public health.3
\nThis constitutional provision places an ob-
\nligation on the government to ensure the
\naccessibility, affordability and quality of
\nhealthcare.
\nAccordingly, the government must provide
\nsufficient resources for care providers to
\ndeliver quality care. It also implies that the
\ngovernment must adequately supervise the
\nquality of healthcare. These requirements
\nhave been elaborated in Dutch healthcare
\nlegislation, including the Quality of Health
\nCare Institutions Act4
\n(QHCI Act) and
\nthe Individual Healthcare Professions Act
\n(IHCP Act)5
\n.
\nBoth acts provide a few general standards,
\nwith broad outlines that leave room for self-
\nregulation, but nothing more. As such, they
\nplace great responsibility on healthcare pro-
\nfessionals and health institutions to ensure
\nthe delivery of appropriate and high-quality
\ncare.
\n2 Parliamentary Papers II 2009\/2010, 32 261, no.
\n3, p. 3.
\n3 Section 22 of the Dutch Constitution (Grondwet).
\n4 Kwaliteitswet zorginstellingen.
\n5 Wet op de beroepen in de individuele gezondheidszorg.
\nAiming to ensure the future accessibility
\nand affordability of care and thus honour its
\nconstitutional obligation, the Dutch gov-
\nernment introduced a bill amending current
\nDutch legislation on healthcare professions
\nby making task shifting possible.
\nAccording to the government, task shift-
\ning is one of the ways in which the capac-
\nity problem in Dutch healthcare could be
\nsolved. In 2009, the World Medical Asso-
\nciation (WMA) drew up a \u2018Resolution on
\nTask Shifting from the Medical Profession\u2019.6
\nAnd in 2010 the Standing Committee of
\nEuropean Doctors (CPME) introduced the
\nPolicy on Task Shifting.7
\nThe question now
\nis to what extent the new Dutch legislation
\non task shifting may actually go beyond the
\nWMA Resolution or the CPME Policy.
\nThis article gives an overview of the way
\nin which task shifting is being introduced
\ninto the Dutch legal system. To this end,
\nI first provide a detailed definition of task
\nshifting and describe the positions that
\nthe WMA and CPME have taken on task
\nshifting. Next, I describe the current Dutch
\nlaws governing healthcare professions and
\nthe new legislation being introduced to fa-
\ncilitate task shifting.The article ends with a
\ndiscussion and conclusion.
\n2. Definitions and positions
\non task shifting
\nDefinitions
\nIn the WMA\u2019s 2009 \u2018Resolution on Task
\nShifting from the Medical Profession\u2019 the
\nterm task shifting is used to describe a situ-
\nation where a task normally performed by a
\nphysician is transferred to a health profes-
\nsional with a different or lower level of edu-
\n6 WMA \u2018Resolution on Task Shifting from the
\nMedical Profession\u2019, Delhi, October 2009.
\n7 Comit\u00e9 Permanent Des M\u00e9dicins Europ\u00e9ens
\n(CPME), CPME Policy on Task Shifting,
\n2010\/128.
\ncation and training, or to a person specifi-
\ncally trained to perform a limited task only,
\nwithout having a formal health education.
\nThis definition is also used by the CPME\u2019s
\nPolicy on Task Shifting. The definition of-
\nten used in the Netherlands is: \u2018The struc-
\ntural redistribution of tasks between dif-
\nferent professions to ensure effective use of
\nskills and capacity\u2019.8
\nUnlike in job differentiation, task shifting
\ndoes not entail the redistribution of tasks
\nbetween jobs. Rather, tasks are distributed
\nover entire professions or occupational
\ngroups, which gain direct authorization to
\nperform a given task. In the present context
\nit entails assessing the need for the task,
\nfollowed by its actual performance, both of
\nwhich are carried out independently. A case
\nin point is shifting tasks from a doctor to a
\nnurse.
\nAnother term commonly used in this
\ncontext is task delegation. The difference
\nbetween task shifting and task delegation is
\nthat the former refers to the predetermined
\nstructural allocation of tasks to a new pro-
\nfession. That task can subsequently be in-
\ndependently performed by the profession
\nto which it has newly been assigned. In
\nthe case of task delegation, by contrast, the
\ntask is formally allocated to a professional
\npractitioner who can decide in any given
\nsituation to delegate that task to another
\npractitioner. Under the current Dutch sys-
\ntem so called reserved procedures, as de-
\nscribed in section 3, qualify for task delega-
\ntion but not for task shifting.
\nWMA and CPME positions on task shifting
\nIn its Resolution, the WMA expresses that
\nalthough task shifting may be useful in cer-
\ntain situations, and may sometimes improve
\nthe level of patient care, it can also be risky.
\nFirst and foremost the WMA signals the
\nrisk of decreased quality of patient care,
\n8 Parliamentary Papers II 2009\/2010, 32 261, no.
\n3, p. 2.
\nwmj 4 2011 5CS.indd 127wmj 4 2011 5CS.indd 127 09.08.2011 10:38:3709.08.2011 10:38:37
\n128
\nNETHERLANDSTask Shifting
\nparticularly if medical judgment and deci-
\nsion-making is transferred. According to
\nthe WMA, beyond the fact that the patient
\nmay be cared for by a healthcare worker
\nwith less training, there are other specific
\nquality issues involved, including reduced
\npatient-physician contact, fragmented and
\ninefficient service, lack of proper follow up,
\nincorrect diagnosis and treatment, and in-
\nability of the less-qualified practitioner to
\ndeal with complications.
\nIn addition, the WMA signals that task
\nshifting that deploys assistive personnel
\nmay actually increase demand on physicians.
\nPhysicians will have increased responsibility
\nas trainers and supervisors, diverting scarce
\ntime away from their many other tasks,
\nsuch as direct patient care. They may also
\nhave increased professional and\/or legal re-
\nsponsibility for the care given by healthcare
\nworkers under their supervision.The WMA
\nexpresses particular concern about the fact
\nthat task shifting is often initiated by health
\nauthorities, without consultation with phy-
\nsicians and their professional representative
\nassociations.9
\nAs part of its efforts to ad-
\ndress these issues, the WMA has drawn up
\nfifteen recommendations on task shifting,
\nthe first of which states that the quality and
\ncontinuity of care and patient safety must
\nnever be compromised and should be the
\nbasis for all reforms and legislation dealing
\nwith task shifting.
\nThe CPME endorses the WMA resolu-
\ntion.10
\nIt points out that the shifting of
\nsome tasks may facilitate better use of man-
\npower and resources, free up valuable time
\nfor physicians and therefore contribute to
\nbetter care for patients, provided it is done
\nwith due care. However, it goes on to stipu-
\nlate that, in the interests of patient safety,
\nresponsibility for diagnoses and therapeutic
\n9 WMA \u2018Resolution on Task Shifting from the
\nMedical Profession\u2019, Delhi, October 2009.
\n10 Comit\u00e9 Permanent Des M\u00e9dicins Europ\u00e9ens
\n(CPME), CPME Policy on Task Shifting,
\n2010\/128.
\ndecisions cannot be divided and always re-
\nmains with the doctor.
\n3. Current Dutch legal situation
\nThe Dutch Individual Healthcare Profes-
\nsions Act (IHCP Act)seeks to monitor and
\npromote the quality of professional care by
\nproviding regulations for a number of oc-
\ncupations devoted to individual healthcare.
\nIndividual healthcare comprises in particu-
\nlar the performance of any procedure that
\ndirectly affects an individual person and
\nserves to promote or maintain that person\u2019s
\nhealth. The law further seeks to protect
\npatients from incompetent and negligent
\ntreatment care.
\nOne of the provisions laid down to achieve
\nthis aim is the rule defining what are known
\nas \u2018reserved procedures\u2019 (voorbehouden
\nhandelingen). Effectively, these are certain
\nmedical procedures that only legally desig-
\nnated professionals are allowed to perform
\nindependently. Prior to the IHCP Act, the
\nNetherlands had a blanket prohibition on
\nthe performance of medical procedures by
\nanyone other than a physician.
\nThat prohibition was revoked when the
\nIHCP Act took effect in 1997. Since then,
\nanyone may perform medical procedures.
\nThe general consensus was that patients
\nshould be given the freedom to seek out aid
\nand assistance for their own health situation
\nwhere and as they saw fit.11
\nHowever, the prohibition was not revoked
\nentirely, the exception being the rule in
\nrespect of reserved procedures. The Act
\nspecifies a number of procedures that may
\nonly be carried out by designated profes-
\nsionals. These procedures are deemed to
\npose a considerable risk to the health of
\nthe patient if performed by anyone who is
\nnot qualified.
\n11 Parliamentary Papers II 1985\/1986, 19 522, no.
\n3, p. 1.
\nThe reserved procedures specified in the Act
\nare:12
\n\u2022 surgical procedures;
\n\u2022 obstetric procedures;
\n\u2022 catheterizations and endoscopies;
\n\u2022 punctures and injections;
\n\u2022 general anaesthesia;
\n\u2022 procedures involving the use of radioac-
\ntive substances and ionizing radiation;
\n\u2022 cardioversion;
\n\u2022 defibrillation;
\n\u2022 electroconvulsive therapy;
\n\u2022 lithotripsy;
\n\u2022 artificial insemination;
\n\u2022 prescribing medication.
\nReserved procedures may be carried out by
\ntwo groups of professionals: those with di-
\nrect authorization (zelfstandig bevoegd) and
\nthose who perform the procedure on the
\norder of someone else with direct autho-
\nrization (task delegation). Physicians have
\nthe authority to perform all categories of
\nreserved procedures.
\nDentists and midwives do for some pro-
\ncedures. This authority entitles them to
\nperform reserved procedures in their own
\nname, implying responsibility for the di-
\nagnosis and decision to perform a specific
\nprocedure. They are only authorized to act
\nto the extent that they deem themselves
\ncompetent to perform the procedure.
\nReserved procedures can also be carried out
\nby others on the order of a professional with
\ndirect authorization. Issuing such an order
\nis subject to certain conditions. Most im-
\nportant is that both the person giving the
\norder and the person receiving it are confi-
\ndent that the latter is in fact competent to
\nperform the procedure. Where necessary,
\nthe practitioner in question must give in-
\nstructions, supervise the performance of the
\nprocedure and be on hand to intervene. In
\n2001, the Dutch Ministry of Health, Wel-
\nfare and Sport issued a brochure on the
\nIHCP Act in English. For further informa-
\n12 Section 36 of the IHCP Act.
\nwmj 4 2011 5CS.indd 128wmj 4 2011 5CS.indd 128 09.08.2011 10:38:3809.08.2011 10:38:38
\n129
\nNETHERLANDS Task Shifting
\ntion about the IHCP Act, please refer to
\nthis brochure.13
\nUnder the current laws, nurses, nurse prac-
\ntitioners14
\nand physician assistants are not
\npermitted to perform reserved procedures
\nunder their own authority; they may only
\ndo so on the orders of a physician.
\n4. New legislation on
\ntask shifting
\nThe shifting of tasks between practitio-
\nners is a dynamic and continuous pro-
\ncess. Tasks that were once the exclusive
\npreserve of physicians can now be carried
\nout by other professions. Often, this redis-
\ntribution of tasks is a natural and gradual
\nprocess, acquiring structural permanence
\nin due time.
\nMany routine medical procedures that are
\nnow performed by doctors could equally be
\nperformed by specially trained profession-
\nals such as nurse practitioners and physician
\nassistants. This re-division of tasks would
\nenable doctors to spend more time on more
\ncomplex medical matters directly related to
\ntheir specializations.
\nVarious studies have been conducted in the
\nNetherlands over the past few years to in-
\nvestigate the effects, and possible effects, of
\ntask shifting.15
\nThese studies have shown
\nthat task shifting in general can contribute
\nto improving the quality, continuity and
\nefficiency of care. A report published by
\nthe Dutch Council for Public Health and
\n13 Ministry of Health, Welfare and Sport, The In-
\ndividual Health Care Professions Act,The inter-
\nnational publication series on Health, Welfare
\nand Sport, no. 10, http:\/\/english.minvws.nl\/en\/.
\n14 In Dutch: Verpleegkundig Specialist.
\n15 For instance: \u2018Task Shifting proven to be
\nbeneficial for quality of healthcare\u2019, Inspectorate
\nfor Health Care, Staat van de gezondheidszorg,
\n2007, december 2007, and \u2018Taskshifting in
\nhealthcare\u2019, Health Counsel, December 2008.
\nHealth Care16
\nreveals that task shifting is
\nbeing driven by a wide range of interests.
\nIn most cases it is a combination of fac-
\ntors,such as the desire to establish a rational
\nbreakdown of jobs and operational pro-
\ncesses, knowledge-building within and the
\nemancipation of professional fields, capac-
\nity shortages in one or more occupational
\ngroups, and technological developments.17
\nSeeking to ensure the accessibility and af-
\nfordability of care, the Dutch government
\nintroduced a bill in December 2009 to le-
\ngalize task shifting. The bill is necessary
\nbecause the current statutory regulations,
\nas described in section 3, offer no scope for
\ntask shifting.
\nSpecifically, it provides that, by way of a tri-
\nal, subordinate legislation may grant direct
\nauthority to assess and perform reserved
\nprocedures to professions that do not cur-
\nrently have such authority.The trial can run
\nfor a maximum of five years. If the amend-
\nment is ultimately approved and task shift-
\ning enacted, the minister will therefore have
\nto draw up subordinate legislation specify-
\ning the professions \u2013 new or existing \u2013 in
\nquestion, along with the requisite training
\nfor those professions and which reserved
\nprocedures may be performed directly.
\nThe new provision will therefore also serve
\nto grant authorities to the professions of
\nphysician assistant and nurse practitioner. It
\nis in this context that two orders in council
\nwere recently (May 2011) submitted to the
\nUpper and Lower Chambers of the Dutch
\nparliament, granting direct authority to
\nthe aforementioned professions to perform
\ncertain reserved procedures \u2013 as specified
\nin the decisions. The new element in these
\ndecisions is that they allocate direct author-
\n16 Raad voor de Volksgezondheid & Zorg.The Dutch
\nHealth Counsel and the Dutch Council for
\nPublic Health and Healthcare are (independent)
\nadvisory bodies to the Dutch Government.
\n17 Council for Public Health and Health Care,
\nTask shifting in healthcare,2002.www.RVZ.net.
\nity to perform both the medical health check
\nand the procedure.
\nThe direct authority granted by the bill is
\nlimited in scope, with restrictions regarding
\ntraining, personal competence and the spe-
\ncialization in which the practitioner is per-
\nmitted to work. Under the IHCP Act, each
\noccupational group in the medical sector is
\nlinked with a distinct area of expertise, and
\nit is only within their own general area that
\npractitioners can operate.
\nIn addition, the provision is restricted to
\ninclude only procedures that are of limited
\ncomplexity, routine in nature and subject to
\nmanageable risks, and will further be subject
\nto national guidelines, standards and proto-
\ncols derived from these. According to the
\nexplanatory notes to the decision, these pro-
\ntocols will be reflecting the cooperative re-
\nlationships between nurse practitioners and
\nthe other disciplines with whom they work.
\nAs is the case under the current statutory
\nregime, a nurse practitioner or physician as-
\nsistant will only be authorized to perform
\nthe designated reserved procedure within
\nthe designated parameters if he or she is,
\nin fact, qualified to do so. Once these prac-
\ntitioners have direct authority to perform
\nreserved procedures, they will also, in turn,
\nhave the inherent authority to instruct
\nother care workers to carry out those same
\nreserved procedures.
\nIf the trial period shows this form of task
\nshifting to be effective, the next step would
\nbe definitive recognition of the designated
\noccupational groups. The proposed regula-
\ntions recommend that the trial be subject
\nto an evaluation focusing on, among other
\nthings, the consequences of task shifting on
\nthe quality of actual care.
\n5. Discussion
\nThe bill paving the way to task shifting has
\nmet with mixed responses in the Neth-
\nwmj 4 2011 5CS.indd 129wmj 4 2011 5CS.indd 129 09.08.2011 10:38:3809.08.2011 10:38:38
\n130
\nTask Shifting NETHERLANDS
\nerlands. The associations for nursing pro-
\nfessions and for physician assistants have
\nwelcomed the bill, echoing the minister of
\nHealth, Welfare and Sport\u2019s position that
\ntask shifting will be the key to resolving im-
\npending healthcare capacity problems.18
\nThe Royal Dutch Medical Association
\n(RDMA) has been positive about the spirit
\nof the proposals, but also critical of their
\nsubstance. Recognizing that task shifting
\ncould offer advantages for the quality of
\ncare, provided certain conditions are met,
\nthe association had previously already advo-
\ncated the allocation of new authorizations
\nto practitioners by means of experimental
\ntrials.
\nHowever, like the international physicians\u2019
\nassociations,the RDMA is concerned about
\nthe risks involved. Task shifting will lead to
\na rise in the number of people caring for
\neach individual patient, for example. If it is
\nto be effective, there need to be clear, defini-
\ntive and transparent agreements between all
\ninvolved care workers regarding the tasks
\nand the associated responsibilities and au-
\nthorizations. The RDMA considers it vital
\nthat the proposed statutory regulations and
\nresulting subordinate legislation eliminate
\nthese risks as much as possible.That has yet
\nto happen.19
\nIn fact, it is debatable whether the new leg-
\nislation would even comply with the first
\nrecommendation of the WMA Resolu-
\ntion, which states, as mentioned above, that
\n\u2018Quality and continuity of care and patient
\nsafety must never be compromised and
\nshould be the basis for all reforms and legis-
\nlation dealing with task shifting\u2019.
\n18 The Verpleegkundigen & Verzorgenden
\nNederland (V&VN) and the Nederlandse
\nAssociatie Physician Assistant (NAPA).
\n19 A.C. Hendriks, D.Y.A. van Meersbergen, \u2018Af-
\nspraken nodig over taakherschikking\u2019, Medisch
\nContact, 4 March 2011, nr . 9, p. 555-557.
\nwww.medischcontact.nl or www.KNMG.nl
\nIn a letter addressed to the Upper and
\nLower Chambers of Dutch parliament, the
\nRDMA emphasized the need for greater
\nclarity on the scope of the authorization.
\nIn addition, the RDMA stated that it sees
\nthe delegation of reserved procedures to
\nnew categories of practitioners as going a
\nstep too far, resulting in a confused view
\nof who is supposed to do what and thereby
\nputting the quality of care at an increased
\nrisk.Moreover,many of the existing medical
\nguidelines contain no provisions that would
\nallow for task shifting, prompting questions
\nas to their validity in the new situation.
\nA coordinated effort to prepare the neces-
\nsary treatment protocol\u2014involving the new
\nprofessions and guided by physicians\u2014is
\ntherefore one of the first steps that would
\nneed to be taken.
\nThe minister in charge has indicated that
\nthe bill should enter into effect as soon as
\npossible after its acceptance by the Upper
\nChamber. It is essential that occupational
\ngroups affected by task shifting are jointly
\ninvolved in the subsequent defining of the
\nbasic statutory framework in order to ensure
\nthat task shifting does, in fact, make a real
\ncontribution to the quality of care.
\nEqually vital, according to the RDMA, are
\nthe quality of cooperation between the oc-
\ncupational groups involved in the actual
\nimplementation of task shifting and their
\nsharing of responsibility for the provision of
\ngood care.
\nIt further recommends conducting a thor-
\nough evaluation after the first five years of
\nthe trial in order to come to a well-founded
\ndecision regarding the definitive statutory
\nenactment of task shifting.
\nThe RDMA notes that the new legislation
\ndoes not comply with the strict CPME
\nPolicy on Task Shifting, which states that
\nresponsibility for diagnoses and therapeutic
\ndecisions cannot be divided and always re-
\nmains with the physician.
\n6. Conclusion
\nOver the coming years the Netherlands
\nwill be facing a growing shortage of care
\nworkers, even as demand continues to rise.
\nIf nothing changes, the resulting problems
\ncould be huge. Task shifting is being held
\nup as a possible solution. The introduction
\nof an amendment to the existing legisla-
\ntion would make it possible to grant di-
\nrect authorization to certain professions to
\nperform specific medical health checks and
\nprocedures on a limited trial basis.
\nThe RDMA has been positive about the
\nproposals, but has serious, enduring con-
\ncerns related to their substance. It feels that
\nthe conditions under which task shifting is
\nto be introduced fail to provide the neces-
\nsary degree of clarity about its scope and
\nlimits. And without that foundation of clar-
\nity, there is no firm guarantee of the quality
\nof care. Guaranteeing quality will require
\nthat new treatment protocols be drawn up
\nunder the supervision of physicians. Finally,
\nall of the occupational groups involved in
\nthe implementation of task shifting must
\nbe able to work together effectively. A sub-
\nsequent evaluation of that implementation
\nwithin the Dutch system should demon-
\nstrate whether task shifting can in fact lead
\nto measurable improvement. Then \u2013 and
\nonly then \u2013 can the trial make way for de-
\nfinitive legislation. It is debatable whether
\nthe new legislation would comply with the
\nWMA\u2019s resolution and the CPME Policy
\non Task Shifting.
\nMr. Diederik van Meersbergen,
\nLegal Advisor Health Care Law,
\nRoyal Dutch Medical Association
\nE- mail: D.van.Meersbergen@fed.knmg.nl
\nwmj 4 2011 5CS.indd 130wmj 4 2011 5CS.indd 130 09.08.2011 10:38:3809.08.2011 10:38:38
\n131
\nDisastersJAPAN
\n1. Introduction
\nI experienced the magnitude 9.0 under-
\nwater earthquake the moment it struck
\nat 14:46 JST on Friday, March 11, 2011,
\nrocking an area stretching 500 km from
\nthe Tohoku region to the Kanto region
\nof Japan. I was in my house adjoining a
\nhospital in the city of Iwaki, Fukushima,
\na place with the most moderate climate in
\nthe Tohoku region and also very few natu-
\nral disasters.
\nBy right, that day I should have celebrated
\nthe 26th
\nanniversary of my hospital\u2019s open-
\ning. Instead, a series of tremors suddenly
\nstruck as if the ground were being violently
\nthrust up from below. Books and dishes
\nfell with a clatter and the pendant lighting
\nswung wildly, damaging the ceiling. In Iwa-
\nki the shaking, which registered as a lower 6
\nintensity quake on the seven-point Japanese
\nintensity scale, was said to have gone on for
\nmore than three minutes.
\nNearly all my bookcases fell over, scat-
\ntering almost 4,000 records and count-
\nless CDs across the floor. The SP records,
\nwhich I had placed on the bottom shelves
\nbecause they are the most easily damaged,
\nwere unharmed. The LPs were also in one
\npiece, although some jackets had been torn.
\nThe biggest trouble was picking up the little
\npieces of broken CD cases and CDs, many
\nof which had been smashed. It was also a
\nshock to find that my British Garrard 301
\nturntable, which had been made about 60
\nyears ago, had been damaged when it fell
\nupside down during an aftershock.
\nTwo days later I was supposed to leave from
\nNarita International Airport for Peru early
\nin the morning to attend a symposium and
\nthe 30th
\nanniversary commemoration of the
\nJapan-Peru Clinic.I canceled the trip,which
\nwas troublesome since even the mobile
\nphone that I had registered for emergencies
\nhad difficulty connecting at this time.
\nThe scale of the disaster, stretching from the
\nTohoku to the Kanto region, and the extent
\nof the damage caused by the earthquake and
\ntsunami along the Pacific coast was massive
\n(Picture 1). Moreover, in the midst of on-
\ngoing aftershocks the accidents at the To-
\nkyo Electric Power Company\u2019s (TEPCO)
\nFukushima Daiichi and Fukushima Daini
\nNuclear Power Plants caused huge second-
\nary damage to the area.
\nMedical institutions throughout Iwaki,
\nincluding hospitals, nursing homes, and
\nclinics, as well as my own corporation\u2019s fa-
\ncilities\u2014some 50\u00a0km away from the Dai-
\nichi plant\u2014were all affected tremendously
\nby burst water and sewer lines and power
\noutages.
\nJapan Medical Association Teams\u2019 (JMATs)
\nFirst Operation: Responding to the Great
\nEastern Japan Earthquake
\nMasami Ishii
\nPicture 1. Tsunami damage in Toyoma, Iwaki City, Fukushima. This picture was taken
\non March 30 near the coast about a ten-minute drive from the author\u2019s house. The tsunami had
\nknocked utility poles down and left mountains of wreckage behind
\nwmj 4 2011 5CS.indd 131wmj 4 2011 5CS.indd 131 09.08.2011 10:38:3809.08.2011 10:38:38
\n132
\nDisasters JAPAN
\n2. Japan Medical Association
\nTeams (JMATs) Activation
\nThe situation was such that the Japan Med-
\nical Association\u2019s (JMA) Committee on
\nEmergency and Disaster Medicine judged
\nthat the Japan Medical Association Teams
\n(JMATs), which it had been discussing,
\nneeded to be activated. The JMA Disaster
\nHeadquarters immediately held an emer-
\ngency meeting and sent a request out to
\nprefectural medical associations nationwide
\nto dispatch JMATs to the four prefectures
\nof Iwate, Miyagi, Fukushima, and Ibaraki.
\nAn emergency press conference was then
\nheld on March 15th
\n.
\n3. Process leading to the
\nJMAT concept
\nThe Civic Protection Act and the Ba-
\nsic Act on Disaster Control Measures,
\nwhich were enacted in 2004, designated
\nprefectural medical associations as speci-
\nfied local public entities. This means that
\nthey are incorporated into the disaster
\ncountermeasures headquarters set up by
\nprefectural governments when a disaster
\noccurs and, as a general rule, the president
\nof the prefectural medical association is
\npositioned as a deputy head of the disas-
\nter headquarters. For this reason, disaster
\nagreements were signed between prefec-
\ntural governments and medical associa-
\ntions in conjunction with the provision of
\nthese laws.
\nThe Agreement regarding Medical Assis-
\ntance during a Disaster [1] was entered into
\nbetween Fukushima Prefecture and Fuku-
\nshima Medical Association in January 2004.
\nIn my capacity as vice-president of the Fu-
\nkushima Medical Association, I made sure
\nthat the agreement included a \u201cdeemed
\nclause\u201d that the deployment of medi-
\ncal teams sent out on the judgment of the
\nmedical association immediately after the
\noccurrence of a disaster when communica-
\ntion may be in disarray would be deemed
\nas a requested action by giving notice after
\nthe fact.
\nI also ensured that the agreement guaran-
\ntees that team members are compensated
\nas public servants during mobilization and
\nthat actual expenses to perform their work
\nare reimbursed. After becoming responsible
\nfor the area of emergencies and disasters in
\nthe JMA, I encouraged prefectural medical
\nassociations nationwide to adopt these con-
\ncepts in order to give the highest priority to
\nthe saving of human life based on human-
\nism.
\nIn 2006 I was appointed an executive
\nboard member of the JMA and that year
\nthe World Medical Association\u2019s (WMA)
\nAsian-Pacific Regional Conference was
\nheld in Tokyo. We discussed the issue of
\ndisaster preparedness, specifically to natural
\ndisasters such as earthquakes and tsunami
\nand to infectious disease pandemics as the
\nmain themes of the conference. The entire
\ncontents of the conference were published
\nin a special edition of the Japan Medical
\nAssociation Journal (JMAJ), the JMA\u2019s
\nEnglish language journal [2].
\nAt the same time,we built up the discussion
\nin the JMA\u2019s Committee on Emergency
\nand Disaster Medicine, which I was presid-
\ning over. The committee membership in-
\ncluded regional block representatives from
\ndifferent prefectural medical associations
\nand Japan\u2019s leading emergency aid special-
\nists. In addition, members of the Ministry
\nof Health,Labour and Welfare,the Fire and
\nDisaster Management Agency, the Japan
\nCoast Guard, the National Institute of Ra-
\ndiological Sciences, and the Self-Defense
\nForces Central Hospital participated as ob-
\nservers.
\nAfter examining past major disasters,
\nJMATs were conceived based on the con-
\ncept of providing support until community
\nhealth in an afflicted area could function
\nagain, starting from the time Disaster Med-
\nical Assistance Teams (DMATs), which
\nwere established to be responsible for
\nhealthcare in the hyperacute phase of a di-
\nsaster and have the capability to function for
\nthe initial 48 hours,begin withdrawing after
\nfinishing wide area medical transportation
\nand their other duties. On March 11, 2010,
\nexactly one year before the Great Eastern
\nJapan Earthquake, the basic JMAT concept
\nwas officially proposed in the JMA\u2019s email
\nnewsletter, after giving a press conference
\nthe day before, based on a newly finished
\nreport [3].
\n4. Framework of JMAT
\nDispatches
\nWhen activating JMATs it was presumed
\nthat there were more than 400,000 evacu-
\nees spread over an area of 500 km long. We
\ndecided to send teams to the four afflicted
\nprefectures of Iwate, Miyagi, Fukushima,
\nand Ibaraki (Picture 2). Our basic im-
\nage was teams consisting of one physician,
\ntwo nurses, and one coordination staff that
\nwould be deployed for a period of three days
\nto one week [4].
\nWe divided supporting regions into prefec-
\ntural blocks and made it a general principle
\nthat each block would continually support
\nthe afflicted prefecture that they had been
\nassigned to help. We also provided teams
\nwith accident insurance under an umbrella
\npolicy taken out by the JMA for 5,000 peo-
\nple, regardless of whether team members
\nwere members of the JMA or not. We pre-
\npared JMAT triage cards for use in medi-
\ncal activities in evacuation shelters and also
\nprepared a sample checklist for each evacu-
\nation shelter to make it easy for the presi-
\ndents of municipal medical associations,
\nwho head on-the-ground joint conferences,
\nto link information.
\nSpecific matching between afflicted areas
\nand support providers was left to direct
\ncontact between both sides, with the JMA
\nproviding information and acting as a co-
\nordinator.
\nwmj 4 2011 5CS.indd 132wmj 4 2011 5CS.indd 132 09.08.2011 10:38:4009.08.2011 10:38:40
\n133
\nDisastersJAPAN
\n5. Second Stage
\nA strong inland aftershock struck Miyagi on
\nApril 7 and another hit Fukushima on April
\n11.There is still disaster risk in the area.Nev-
\nertheless, one month after the earthquake
\nthe Ibaraki Medical Association requested
\nthe discontinuation of JMAT dispatches,
\nindicating that it would continue operations
\nwith its own support system. Similarly, the
\nremaining three prefectures requested the
\nvwdispatch of JMATs be limited to areas
\nthat were severely damaged and concluded
\nfor areas where the community and com-
\nmunity health had recovered. We therefore
\ncommunicated to medical associations na-
\ntionwide a policy of ongoing support with
\nnecessary teams on standby. Thus JMAT
\nsupport entered its second stage. Since
\nthen, the support system has been gradu-
\nally reduced as community and surrounding
\nhealthcare systems recover and with the ap-
\nplication of the universal healthcare system,
\nwhich had just marked its 50th
\nanniversary.
\nIn response to the crisis situation of the
\nnuclear power plant accident, the JMA un-
\ndertook medical support activities based on
\ngathering and disclosing information and
\ndisseminating a better understanding of
\nmedical treatment for radiation exposure, as
\ndescribed in my another article to be pub-
\nlished in the WMJ [5].
\nLooking back at the situation up to now and
\nseeing that more than 1,114 JMATs have
\nbeen on the ground up to May 24 and that
\n71 teams are on standby, the JMAT concept
\nhas demonstrated the truly immense pow-
\ner of Japan\u2019s medical professionals and of
\nmedical association activities in responding
\nto this huge disaster of unprecedented scale.
\n6. Conclusion
\nNumerous DMATs that operate in the
\nhyperacute phase of a disaster took part in
\nresponding to Great Eastern Japan Earth-
\nquake in addition to local medical resources
\nin the affected areas. However, there were
\nvery few instances of lifesaving rescues in the
\nmidst of the enormous damage caused by
\nthe tsunami on top of the earthquake.More-
\nover, lifesaving operations were restricted by
\nthe significant damage to infrastructure, in-
\ncluding roads through the coastal zone. In
\na case like this, had there been awareness
\nof the emergency situation and had it been
\npossible to save victims drifting on the near-
\nly 0\u00b0 C Pacific Ocean by carrying out land,
\nair, and marine rescue operations right from
\nthe first day with support from the Japan
\nSelf-Defense Forces, Japan Coast Guard,
\nand Japan-based US military, I think that
\nthe operations in the few hours until sunset
\ncould have produced better results.I also feel
\nthat JMAT activities that were carried out
\nthereafter fulfilled healthcare for evacuees,
\nwhich accounted for the main part of opera-
\ntions in each afflicted area this time.
\nWe need to prepare for the future by tak-
\ning time to do an ex-post verification of the
\nJMAT concept in the JMA\u2019s Committee on
\nEmergency and Disaster Medicine and by
\nestablishing a training system for Japan and
\nholding various other discussions while col-
\nlaborating with the WMA.
\nAppendix1
\n1. Proposal for JMATs
\n(Japan Medical Association Teams)
\n(1) JMATs
\nThe Committee on Emergency and Disas-
\nter Medicine proposes JMATs (Japan Med-
\nical Association Teams) as the name for di-
\nsaster medical assistance teams formed by
\nprefectural medical associations at the level
\nof municipal medical associations and serv-
\ning in disaster areas under the name of the
\nJapan Medical Association (JMA).
\nThe proposal for the name JMAT is intend-
\ned to clarify the difference from\u2019 DMATs
\n1 Appendix consists of excerpts from the Report by
\nthe JMA\u2019s Committee on Emergency and Disas-
\nter Medicine released in March 2010.
\nAppendix
\n(Attached)
\nReferences
\nIwate: 324 teams
\nMiyagi: 546 teams
\nFukushima: 229 teams
\nIbaraki: 12 teams
\nEpicenter
\nPicture 2. Map of JMAT dispatch locations. The map gives a general view of the areas to
\nwhich JMATs were dispatched in the Great Eastern Japan Earthquake and the number of teams
\nsent to each area. As of May 24, 2011, 1,114 JMATs have been dispatched including three teams
\nthat were dispatched to several prefectures (not shown in the map), and 71 JMATs are on standby
\nwmj 4 2011 5CS.indd 133wmj 4 2011 5CS.indd 133 09.08.2011 10:38:4109.08.2011 10:38:41
\n134
\nDisasters JAPAN
\n(Disaster Medical Assistance Teams) and
\nalso includes the following meanings: these
\nare the JMA\u2019s disaster medical assistance
\nteams; they cover all of Japan through all
\nthe prefectural and municipal medical asso-
\nciations; and they take over from Japan and
\nlocal DMATs.
\nJMATs go on standby and then into action
\nbased on requests from the JMA to prefec-
\ntural medical associations (including retro-
\nspective approval). JMATs mainly provide
\nhealthcare during the acute phase of a disas-
\nter, cooperation with medical associations in
\nthe disaster areas, and activity support while
\nsharing roles with and collaborating organi-
\ncally with DMATs (Japan\/local) and medi-
\ncal associations in the disaster areas during
\nan uninterrupted period of time starting im-
\nmediately after the occurrence of a disaster.
\nHowever, arrangements need to be made to
\navoid competition between requests from
\nthe JMA and requests from prefectural gov-
\nernments based on agreements for health-
\ncare during a disaster.
\n(2) Regarding Basic policy for JMATs
\nA. JMATs should be organized based on
\na Basic Policy for JMATs. JMATs\u2019 rela-
\ntionship with the JMA, prefectural medi-
\ncal associations, and municipal medical
\nassociations is as depicted in Table 1, Figs
\n1 and 2
\nClarification of the roles of the JMA, pre-
\nfectural medical associations, and munici-
\npal medical associations, the composition
\nof JMATs, training structure, contents of
\nactivities, and the division of roles and col-
\nlaboration with DMATs (Japan\/local) will
\nall be important.
\nB. Many prefectural and municipal medi-
\ncal associations have already entered into
\ndisaster medical assistance agreements with
\ngovernment administrations prescribing
\nthe dispatch of disaster medical assistance
\nteams by the medical association.2
\nThe JMA and prefectural medical associa-
\ntions need to work out a balance between
\nJMATs and these already existing teams
\nthrough exchange of opinions and dis-
\ncussion during the processes of creating
\nJMATs.
\nMoreover, in order to implement medical
\nassociation-based medical assistance ac-
\ntivities nationwide, existing teams that meet
\nthe requirements for JMATs shall be recog-
\nnized as JMATs, and for those that do not
\nmeet the requirements, measures need to be
\ntaken so that they fall in line with the Basic
\nPolicy for JMATs.
\nC. It is also important for each medical
\nassociation to have the view that it could
\n2 According to a survey conducted in June 2001
\nby the JMA on medical associations\u2019 disaster
\nhealthcare systems, the dispatch of disaster medi-
\ncal assistance teams was prescribed in agreements
\nbetween 35 prefectural medical associations and
\nprefectural governments (Fiscal 2000-2001 re-
\nport by the JMA\u2019s Committee on Emergency and
\nDisaster Medicine).
\nTable 1. Relationship between Municipal Medical Associations in a Disaster Area, JMATs, and
\nDMATs
\nMunicipal
\nmedical as-
\nsociations in a
\ndisaster area
\nJMATs DMATs (Japan\/
\nlocal)
\nPre-disaster
\n(usual condi-
\ntions)
\n\u2022 Organize teams, register team members
\n\u2022 Conduct training
\n\u2022 Coordinate
\nwith the JMA
\nand prefectural
\nmedical associa-
\ntions
\nImmedi-
\nately after
\ndisaster (before
\nDMATs arrive)
\n\u2022 Voluntary
\nactivities by
\nthe medical
\nassociation in
\nthe disaster
\narea
\n\u2022 Standby, prepare for mobiliza-
\ntion
\n\u2022 Prefectural medical associations
\nin disaster areas \uf0ae JMA \uf0ae
\nRequest for mobilization from
\nprefectural medical associations
\n(mobilization at own discre-
\ntion\u00a0\uf0ae retrospective approval
\nby the JMA and prefectural
\nmedical associations)
\n\u2022 Standby, prepare
\nfor mobilization
\nVery early pe-
\nriod of disaster
\n\u2022 Mobilization
\n\u2022 Take action
\nunder direction
\nof supervising
\nDMAT person-
\nnel
\nAfter arrival of
\nDMATs
\n\u2022 Cooperate
\nwith JMATs
\n\u2022 Triage patients, take other
\naction at evacuation shelters
\nand temporary medical care
\nfacilities in collaboration with
\nDMATs
\n\u2022 Cooperate with and support
\nmunicipal medical associations
\nin a disaster area
\n\u2022 Take action
\nunder direction
\nof supervising
\nDMAT person-
\nnel
\nAfter with-
\ndrawal of
\nDMATs
\n\u2022 Rebuild
\nhealthcare
\nsystem in
\ndisaster area
\n\u2022 Resume usual
\nhealthcare
\n\u2022 Place DMAT members who
\ncontinue to engage in disaster
\nhealthcare after DMAT with-
\ndrawal in JMATs
\n\u2022 Evaluate withdrawal phase.
\nwmj 4 2011 5CS.indd 134wmj 4 2011 5CS.indd 134 09.08.2011 10:38:4109.08.2011 10:38:41
\n135
\nDisastersJAPAN
\nbecome the victim of a disaster. Especially
\nin the case of a large-scale disaster, situa-
\ntions are envisioned in which a municipal
\nmedical association in a disaster area ceas-
\nes to function and cannot take action as a
\nJMAT. Accordingly, in parallel with the es-
\ntablishment of the JMAT system, munici-
\npal medical associations need to cooperate
\nwith municipal governments and establish
\na system that, even in such an event, will
\nenable nearby members in private practice
\nto voluntarily and systematically gather at
\nevacuation shelters and temporary medical
\nfacilities and engage in disaster medical as-
\nsitance activities.
\n2. Basic Policy for JMATs
\n(1) Roles of the JMA, Prefectural Medical
\nAssociations, and Municipal Medical As-
\nsociations
\nA. Role of the JMA (Table 2)
\n1) Promoting the signing of disaster medi-
\ncal assistance agreements between prefec-
\ntural medical associations and prefectural
\ngovernments
\n\u2022 With a prefecture-by-prefecture structure
\nin which the government administration
\nrequests the medical association to dis-
\npatch teams, the system becomes ineffi-
\ncient in a disaster outside the prefecture
\nJapan
\nMedical
\nAssociation
\nFigure. 1 Depiction of JMATs, Japan Medical Association, Prefectural Medical Associations, and Municipal Medical Associations during a Disaster
\nwmj 4 2011 5CS.indd 135wmj 4 2011 5CS.indd 135 09.08.2011 11:12:3309.08.2011 11:12:33
\n136
\nDisasters JAPAN
\nFigure. 2 Depiction of JMATs, the Japan Medical Association, Prefectural Medical Associations, and Municipal Medical Associations during Usual
\nConditions
\nwmj 4 2011 5CS.indd 136wmj 4 2011 5CS.indd 136 09.08.2011 11:12:3609.08.2011 11:12:36
\n137
\nDisastersJAPAN
\nor in a wide area disaster affecting more
\nthan one prefecture. Accordingly, the
\nJMA will promote the signing of bundled
\nagreements between prefectural medical
\nassociations and prefectural administra-
\ntions either in blocks or at the nationwide
\nlevel through an occasion arranged by the
\nJMA.
\n\u2022 The JMA will seek inclusion in the agree-
\nments of provisions for cases in which
\nthe prefectural medical associations con-
\ncerned act as JMATs.
\n\u2022 The JMA will seek inclusion in the agree-
\nments of provisions for cases in which
\nJMATs are sent to a disaster site outside
\nthe prefecture.
\n\u2022 The JMA will seek to have DMAT per-
\nsonnel who wish to remain on-site after
\nDMAT activities are concluded and en-
\ngage in the medical association\u2019s disaster
\nmedical assistance activities recognized as
\nJMATs.
\n\u2022 The JMA will periodically collect infor-
\nmation and provide feedback about mat-
\nters such as the status of the conclusion
\nof agreements by each prefectural medical
\nassociation, the contents of agreements,
\nactual examples of disaster responses, and
\nthe status of revisions, in an attempt to
\nenhance agreement contents and prevent
\nagreements from becoming a mere shell
\n(including in addition to agreements be-
\ntween prefectural medical associations
\nand government administrations, agree-
\nments among medical associations within
\nblocks and agreements between prefec-
\ntural medical associations and municipal
\nmedical associations in their jurisdiction).
\n2) Logistical support for local medical as-
\nsociations and JMATs
\n\u2022 It will be necessary during a disaster to
\nwork with relevant national agencies to
\ngather needed information and provide it
\nto local medical associations and JMATs.
\nParticularly in regards to special disasters
\n(CBRN: chemical, biological, radiologi-
\ncal, and nuclear), important information
\nwill include an overview of the disaster,
\nconceivable diseases and their diagnostic
\nmethods, main symptoms, coping strate-
\ngies,measures to prevent secondary disas-
\nters such as radiation exposure and con-
\ntamination, and the system for reporting
\nto government administrations.
\n\u2022 It is also necessary, in order to make
\nJMATs\u2019 activities effective, to secure in
\nJMATs the participation of specialists
\nwith experience determining the need for
\nDMATs and other disaster medical as-
\nsistance teams and deciding the areas to
\nwhich they should be dispatched.
\n3) Taking part in revising disaster health-
\ncare measures
\nNational disaster healthcare measures may
\nbe revised based on lessons learned from a
\ndisaster. The JMA will take part, from the
\nstandpoint of community healthcare, in the
\nwork of revising the basic disaster manage-
\nment plans and the Guidelines on the Es-
\ntablishment of Healthcare System in Times
\nof Disaster.3
\nB. Role of Prefectural Medical Associa-
\ntions (Table 3)
\n1) Signing of disaster medical assistance
\nagreements with prefectural governments
\nIn order to dispatch JMATs to a disaster
\narea, prefectural medical associations have
\nto have signed an agreement with the gov-
\nernment administration in advance and in-
\nclude provisions such as the following re-
\ngarding JMATs:
\n3 One of what are called the Four Diseases and
\nFive Programs.
\nTable 2. Role of the Japan Medical Association
\nUsual conditions (pre-disaster) During a disaster
\n\u2022 Request prefectural medical associations
\nto organize JMATs
\n\u2022 Coordinate with relevant national agen-
\ncies
\n\u2022 Coordinate with hospital organizations
\n\u2022 Promote the signing of disaster medical
\nassistance agreements between prefec-
\ntural medical associations and prefectural
\ngovernments
\n– Ascertain the status of disaster medical
\nassistance agreements in each area
\n– Provide useful information, such as
\nsample agreements for reference
\n\u2022 Coordinate with Japan DMAT; request
\ncooperation in JMAT training
\n\u2022 Request prefectural medical associations to put JMATs on standby and to dispatch
\nJMATs
\n\u2022 Decide the order and length of dispatch for JMATs from each prefecture
\n\u2022 JMAT activities
\n– Gather information on the ground; request materials needed
\n– Provide medical care
\n\u2022 JMAT logistical support
\n– Gather information from the national government
\n– Provide information to prefectural medical associations
\n\u2022 Negotiate with the national government
\n– Infections disease, community health measures
\n– Health services covered by health insurance
\n– Support for rebuilding of medical institutions (e.g., government subsidies, preferential
\ntax treatment, public financing)
\n– Taking part in revising national disaster healthcare measures
\nwmj 4 2011 5CS.indd 137wmj 4 2011 5CS.indd 137 09.08.2011 10:38:4409.08.2011 10:38:44
\n138
\nDisasters JAPAN
\n\u2022 Position within the prefectural disaster
\nmanagement plan and disaster healthcare
\nplan
\n\u2022 Content of operations
\n\u2022 The administration\u2019s (prefectural govern-
\nment) burden of status-based compensa-
\ntion, expense reimbursement.
\n\u2022 A provision to the effect that in a disas-
\nter the medical association will mobi-
\nlize teams at its own discretion and the
\ngovernment administration will grant
\nretrospective approval and provide status-
\nbased compensation and expense reim-
\nbursement.
\n– The criteria for mobilization has to be
\nclarified for application of a retrospec-
\ntive approval provision
\n– This is to establish a rapid response sys-
\ntem, although the dispatch of disaster
\nmedical assistance teams is on a \u201cre-
\nquest basis.\u201d
\n\u2022 A provision for applying the above two
\npoints even if the deployment destination
\nis outside the prefecture.
\n– A provision included in case the disas-
\nter area is in another prefecture.
\n\u2022 A provision with a one-year review clause.
\n– This is to avoid the agreement becom-
\ning a mere shell or dead letter in addi-
\ntion to dealing with such things as the
\nemergence of a new disaster, adminis-
\ntrative organizational reform, and sys-
\ntem reforms.
\nNotes
\n\u2022 The Niigata Medical Association has,
\nthrough the Basic Plan on Disaster
\nHealthcare and Relief Activities by the
\nPrefectural Medical Association, pro-
\nvided for status-based compensation and
\nreimbursement of expenses in the event
\nthat members of the association or a mu-
\nnicipal medical association work as relief
\nactivity personnel during a disaster (this
\ndoes not apply, however, in cases where a
\nwork allowance for the relief squads, re-
\nimbursement of expenses, and compensa-
\ntion are provided in accordance with the
\nprovisions of the Disaster Relief Act, nor
\nin cases where, regardless of the applica-
\ntion of the Disaster Relief Act, Niigata
\nPrefecture provides reimbursement of
\nexpenses associated with the turnout of
\nrelief squads provided for in the Niigata
\nPrefecture Disaster Healthcare and Relief
\nActivity Manual).
\n– Actual costs are to be reimbursed for
\ndrugs and medical supplies used in
\nthe event a member turns out for work
\nduring a disaster.
\n– Allowances for turning out to work are
\n17,400 yen per day and reimbursement
\nof travel expenses is as stipulated in the
\nmedical association\u2019s regulations con-
\ncerning travel expenses.
\n– Coverage by ordinary accident insur-
\nance: Coverage provided for up to 10
\nphysicians and 20 nurses with a benefit
\nof 50 million yen on the death or physi-
\ncal impairment of a physician.
\n\u2022 The Aichi Medical Association has made
\na contract with an insurance company for
\nTable 3. Role of Prefectural Medical Associations
\nUsual conditions (pre-disaster) During a disaster
\n\u2022 Request municipal medical associations
\nto organize JMATs
\n\u2022 Coordinate with prefectural government
\nagencies (medical, public health, welfare,
\nand fire and disaster management
\nauthorities), the police, the Japan Self
\nDefense Forces, and the Japan Coast
\nGuard
\n\u2022 Coordinate with nuclear power facilities
\n\u2022 Participate in disaster drills conducted
\nby the prefectural administration
\n\u2022 Coordinate with hospital organizations
\n\u2022 Take part in establishing prefectural
\ndisaster management plans and disaster
\nhealthcare plans
\n\u2022 Sign disaster medical assitance agree-
\nments with the prefectural government
\n\u2022 Coordinate with Japan DMAT-des-
\nignated medical institutions and local
\nDMATs
\n\u2022 Conduct JMAT training
\n\u2022 Request municipal medical associations to put JMATs on standby and to dispatch JMATs
\n\u2022 Decide the order and length of dispatch for each JMAT
\n\u2022 Provide information to municipal medical associations
\n\u2022 Negotiate with the prefectural government
\n– (In the event of a disaster outside the prefecture) Obtain approval of the governor
\nwhen sending JMATs outside the prefecture
\n– Burden of expense for JMATs
\n
\n\u2022 Ascertain the situation in the disaster area
\n\u2022 Request the JMA to dispatch JMATs
\n\u2022 Request cooperation from block and nearby medical associations
\n\u2022 Gather information from the prefectural government, and provide information to mu-
\nnicipal medical associations
\n\u2022 Negotiate with the prefectural government
\n– Secure means of transport for JMATs
\n– Infections disease, community health measures, health services covered by health
\ninsurance
\n– Support for rebuilding of medical institutions (e.g., government subsidies, preferential
\ntax treatment, public financing)
\n\u2022 Take part in revising prefectural disaster healthcare measures
\nwmj 4 2011 5CS.indd 138wmj 4 2011 5CS.indd 138 09.08.2011 10:38:4409.08.2011 10:38:44
\n139
\nDisastersJAPAN
\nthe Aichi Medical Association Informa-
\ntion Center Disaster Compensation Plan,
\nwhich will provide status-based compen-
\nsation for physicians and nurses requested
\nby the Center to provide medical care.
\n– Physicians and nurses (insurance cov-
\nerage for 50 people)
\n– Death or physical impairment benefit:
\n70.14 million yen.
\n2) Role of prefectural medical associations
\nin municipal medical associations
\nPrefectural medical associations will create
\na manual and standardize the activities that
\nshould be taken by municipal medical asso-
\nciations during a disaster in order to enable
\nuniform activities.
\nPrefectural medical associations will pro-
\nmote collaboration between municipal
\nmedical associations and DMATs (Japan\/
\nlocal) through disaster drills. They will also
\narrange for DMAT physicians and others to
\ngive lectures for municipal medical associa-
\ntions.
\nC. Role of Municipal Medical Associa-
\ntions
\nThe role of municipal medical associations
\nis as shown in Table 4.
\n(2) Composition of JMATs
\nIn Japan, private hospitals (including those
\nrun by medical corporations and individu-
\nals), which are relatively small and medi-
\num sized hospitals, account for 70.6% of
\nall hospitals and accept the vast majority
\nof emergency patients. In regional areas,
\nprivate-practice physicians who went in-
\ndependent with their respective specialties
\nlook after patients with a wide range of
\nconditions.
\nJMATs will be underpinned by these kinds
\nof medical resources.In other words,JMATs
\nwill mainly be composed of physicians and
\nnursing personnel working in small and
\nmedium sized hospitals and association
\nmembers who run their own clinic.
\nHowever, small and medium sized hospitals
\nare faced with a serious shortage of physi-
\ncians and nursing personnel, and so partici-
\npation in JMATs could be difficult. Also, it
\nis not always the case that emergency physi-
\ncians can participate.
\nConversely, association members who run
\ntheir own clinic will have to close their clin-
\nic while mobilized and so cannot participate
\nin long-term activities.
\nTaking as a reference the Oita DMAT,
\nwhich reflects the medical context in a pre-
\nfecture where hospitals are mostly small and
\nmedium sized and in some cases there is
\nonly one hospital in a large area,the smallest
\npossible unit is a team of two people (one
\nphysician and one nurse), and it is conceiv-
\nable that other co-medical personnel and a
\nlogistics expert could be added at the discre-
\ntion of the prefectural medical association.
\nAlso,teams need to be organized on the pre-
\nsumption of short-term rotation.
\n(3) Training of JMATs
\nThe JMA should provide support for the
\nimplementation of JMAT training in each
\nregion. For example, it should set out a
\nStandard JMAT Training Curriculum, tak-
\ning as a reference the Japan DMAT\u2019s four-
\nday training program, minus parts such as
\nstaging care units (SCU). At the same time,
\nit should request cooperation from Japan
\nDMAT and seek the dispatch of instructors
\nto JMAT training sessions.
\nJMAT training should be open to per-
\nsons who have completed a training ses-
\nsion based on the existing JMA Advanced
\nTable 4. Role of Municipal Medical Associations
\nUsual conditions (pre-disaster) During a disaster
\n\u2022 Organize JMATs and register
\nteam members
\n\u2022 Coordinate with municipal
\nagencies (medical, public
\nhealth, and welfare), fire de-
\npartments, and the police
\n\u2022 Take part in establishing mu-
\nnicipal disaster management
\nplans and disaster medical
\ncare plans
\n\u2022 Sign disaster medical as-
\nsistance agreements with the
\nadministrators of airports.
\n\u2022 Coordinate with nuclear
\npower facilities, chemicals
\nfactories.
\n\u2022 Conduct JMAT training
\n\u2022 Create a system for healthcare
\nactivities in case of a disaster
\nin one\u2019s own municipality and
\nconduct drills
\n\u2022 Organize and mobilize JMATs
\n
\n\u2022 Ascertain disaster situation
\n– Medical institutions within jurisdiction
\n– Patients receiving medical treatment at home,
\npeople needing nursing care
\n– Stationing of evacuation shelters and temporary
\nmedical care facilities
\n– Healthcare needs
\n\u2022 Request the prefectural medical association to dis-
\npatch JMATs
\n\u2022 Request cooperation from nearby municipal medical
\nassociations
\n\u2022 Provide information to members
\n\u2022 Negotiate with municipal agencies
\n– Infections disease, community health measures,
\nhealth services covered by health insurance
\n– Support for rebuilding of medical institutions
\n(government subsidies, preferential tax treatment,
\npublic financing)
\n– Securing means of transport for JMATs
\n\u2022 Take part in revising city disaster healthcare mea-
\nsures
\nwmj 4 2011 5CS.indd 139wmj 4 2011 5CS.indd 139 09.08.2011 10:38:4409.08.2011 10:38:44
\n140
\nDisasters JAPAN
\nCardiovascular Life Support (ACLS) Train-
\ning program and should be eligible under
\nthe JMA\u2019s continuing education system.
\nThe content of training should include
\ntraining on determining when to withdraw
\nand leave the situation in the hands of phy-
\nsicians and medical institutions in the di-
\nsaster area.
\nAlso, currently DMATs are designated on a
\nhospital basis, but a policy needs to be con-
\nsidered that will enable individual member
\nphysicians to receive DMAT training.
\nFor instance, a conceivable method for hav-
\ning members participate together with the
\nphysicians and staff of a DMAT-designated
\nmedical institution would be to have the
\nprefectural medical association gather to-
\ngether member physicians within the pre-
\nfecture who wish to take DMAT training
\nand have, for example, a hospital physician
\nand nurse from hospital A and a private-
\npractice physician from clinic B participate
\nas one group.
\n(4) Contents of JMAT activities
\nActivities that JMATs will be required to
\nperform are not the extremely early disas-
\nter medicine like that provided by DMATs;
\nrather,they are healthcare in the acute phase
\nof a disaster, cooperation with medical as-
\nsociations and other organization in the di-
\nsaster area, and activity support.
\nMembers of a disaster-affected medical as-
\nsociation are engaged in healthcare for sur-
\nvivors even though their own clinics have
\nbeen afflicted.It is medical association in the
\ndisaster area that can handle the provision
\nof healthcare based on information about
\ndialysis or perinatal care that medical insti-
\ntutions in the disaster area have performed
\nor about the whereabouts of patients receiv-
\ning house calls, patients undergoing oxygen
\ntherapy at home, elderly people living alone,
\nand persons needing nursing care. JMATs\u2019
\nrole played in cooperation with the medical
\nassociation of the disaster area is therefore
\nimportant.
\nActivities such as the following are conceiv-
\nable as the main activities of JMATs:
\n\u2022 On-site triage
\n\u2022 Ascertaining needed medical supplies
\nand requesting their delivery
\n\u2022 Healthcare at evacuation shelters and
\ntemporary healthcare facilities
\n– Providing healthcare in the early phase
\nof the disaster
\n– Implementing measures such as infec-
\ntion control measures and countermea-
\nsures against disuse syndrome
\n– Continuity of healthcare from before
\nthe accident: dialysis, perinatal, geriat-
\nric, and home care.
\n\u2022 Supporting continuation of medical and
\nnursing care by association members in
\nthe disaster area
\n\u2022 Giving advice to the on-site countermea-
\nsures headquarters centered on the af-
\nflicted medical association (arrangement
\nof disaster medical assistance teams, de-
\ntermination of withdrawal period, baton
\npassing to successor teams)
\n(5) JMATs and local DMATs
\nSeparately from Japan DMAT, local
\nDMATs are organized in various locations
\naround the country.Their main scope of ac-
\ntivity is natural disasters within a prefecture
\nand urban disasters such as traffic accidents.
\nLocal DMATs\u2019 degree of conformity to
\nJapan DMAT operating procedures, re-
\nquirements for DMAT-designated medical
\ninstitutions, team composition (physicians,
\nnursing personnel, clerical staff, and logis-
\ntics experts), completion of Japan DMAT
\ntraining, mobilization criteria (scale of di-
\nsaster,number of patients affected by the di-
\nsaster), and other attributes differ according
\nto local characteristics such as the medical
\ncontext in the prefecture.4
\n4 Based on data for Oita DMAT and Kochi
\nDMAT.
\nThe Oita DMAT established at the sug-
\ngestion of the Oita Medical Association,
\nfor example, has characteristics including a
\nteam composition of one physician plus one
\nnurse as a the smallest unit size, a scope that
\nincludes small-scale disasters and accidents
\nin the prefecture (at least one injured per-
\nson), the ability to mobilize on independent
\ndiscretion in an emergency, and no limiting
\nof DMAT-designated hospitals to core di-
\nsaster hospitals and critical care centers.
\nPrefectural medical associations should be
\ninvolved in the establishment and operation
\n(system establishment, DMAT member
\nregistration, training, after-the-fact inspec-
\ntion) of local DMATs aimed mainly at di-
\nsasters within the prefecture and should also
\nclarify the sharing of roles and coordination
\nwith JMATs.
\nMoreover, by having local DMAT physi-
\ncians conduct JMAT training, DMAT and
\nmedical association members can commu-
\nnicate with each other.
\nReferences
\n1. Agreement regarding Medical Assistance during
\na Disaster (Saigai ji no Iryo Kyugu ni kansuru
\nKyotei), entered into between Fukushima Pre-
\nfecture and Fukushima Medical Association on
\nJanuary 5, 2004. (in Japanese).
\n2. JMAJ 50(1), 2007. http:\/\/www.med.or.jp\/eng-
\nlish\/journal\/pdf\/jmaj\/v50no01.pdf. (accessed
\nMay 24, 2011).
\n3. 2010 Report by the JMA\u2019s Committee on Emer-
\ngency and Disaster Medicine. http:\/\/dl.med.
\nor.jp\/dl-med\/teireikaiken\/20100310_3.pdf (in
\nJapanese. accessed May 24, 2011).
\n4. JMAT. http:\/\/www.med.or.jp\/english\/report\/
\nJMAT.pdf. (accessed May 30, 2011).
\n5. Ishii M. WMJ (forthcoming). Fukushima Nu-
\nclear Power Plant Accidents Caused by Gigantic
\nEarthquake and Tsunami\u2013Healthcare Support
\nfor radiation exposure.
\nMasami Ishii, MD
\nExecutive Board Member
\n(responsible \u00a0or\u00a0emergencies and \u00a0isasters),
\nJapan Medical Association,
\nVice-Chair of Council,
\nWorld\u00a0Medical Association
\nE-mail: ishiihom@ishiihp.or.jp
\nwmj 4 2011 5CS.indd 140wmj 4 2011 5CS.indd 140 09.08.2011 10:38:4409.08.2011 10:38:44
\n141
\nDisastersJAPAN
\n1. Introduction
\nIn the magnitude 9.0 Great Eastern Ja-
\npan Earthquake that occurred at 14:46 on
\nMarch 11, 2011, nuclear reactors in opera-
\ntion went into emergency shutdown. The
\nsix reactors at the Tokyo Electric Power
\nCompany\u2019s (TEPCO) Fukushima Daiichi
\nNuclear Power Plant, including reactors
\nthat were shut down beforehand for peri-
\nodic inspection, and the four reactors at
\nTEPCO\u2019s Fukushima Daini Nuclear Power
\nPlant were all shut down (Picture 1).
\nOf these, reactors 5 and 6 at the Daiichi
\nPlant, which had already been shut down,
\nand reactor 4 at the Daini Plant seemed to
\nhave reached the condition of a cold shut-
\ndown. Later, however, reactors 1\u20134 at the
\nDaiichi Plant lost backup power [1]. At
\n16:36 the emergency core cooling system
\nfor reactors 1 and 2 at the Daiichi Plant
\nstopped working,starting the nuclear power
\nplant crisis. At 19:03, Prime Minister Kan
\nissued Japan\u2019s first Declaration of a Nuclear
\nEmergency Situation. At 21:23, people
\nwithin 3\u00a0km of the Daiichi Plant were in-
\nstructed to evacuate and those within the
\nzone between 3 km and 10 km from the
\nfacility were told to stay indoors.
\n2. Progression of the nuclear
\npower plant accident
\nAt 15:36 the following day a hydrogen ex-
\nplosion occurred at reactor 1, which was
\nfeared to have gone into meltdown. At
\n18:25 the evacuation order around the Dai-
\nichi Plant was expanded to a 20 km radius
\nand an earnest evacuation of residents was
\nimplemented using buses and other means.
\nAt 11:01 on March 14 there was a hydrogen
\nexplosion at reactor 3, where cooling was
\nfeared since the day before to have stopped.
\nIt was said that the reactor had been run-
\nning on MOX fuel, which is a mix of pluto-
\nnium and uranium for a plutonium-thermal
\nproject.
\nOn March 15, an explosion and fire were
\nreported at reactors 2 and 4, respectively.
\nIn addition to an evacuation order within
\n10 km around the Daini Plant, which is
\nabout 10 km south of the Daiichi Plant, at
\n11:00\u00a0a.m. the government instructed near-
\nly 140,000 people living within the zone
\n20\u201330 km around the Fukushima Daiichi
\nPlant to stay indoors.
\nFrom the 17th
\nthe Ground Self-Defense
\nForces and Tokyo Fire Department started
\nspraying water from the outside to cool the
\nreactors. In the meantime, contamination
\nwith radioactive iodine and cesium from
\nnear the plant to the far-away Tokyo metro-
\npolitan area was reported in the news. Later,
\non March 31 the contamination of ocean
\nwater was reported, and then on April 4
\nthe marine contamination progressed with
\nthe release of over 10,000 tons of contami-
\nnated water into the ocean from the Daiichi
\nNuclear Power Plant. It became impossible
\nto ship dairy and agricultural produce from
\nthe contaminated region, and the interrup-
\ntion of fishing was prolonged. Additionally,
\non March 17 the United States indepen-
\ndently issued a recommendation for evacu-
\nation outside an 80 km zone around the
\nplant. Harmful rumors and misinformation
\ncaused a reluctance to buy foods and other
\nproducts from Fukushima, resulting in dis-
\ntribution paralysis and shortages.
\n3.The Japan Medical
\nAssociation\u2019s response
\nI experienced the earthquake in my house
\nadjoining a hospital in the city of Iwaki,
\nFukushima, more than 50 km away from
\nTEPCO\u2019s Fukushima Daiichi Nuclear
\nPower Plant. Immediately after the earth-
\nquake struck I contacted the Japan Medi-
\ncal Association (JMA). A countermeasures
\nheadquarters was set up and I started activi-
\nties to respond to the devastated areas as the
\nofficer responsible for emergency and disas-
\nter operations.
\nIn addition to seismic damage, the Great
\nEastern Japan Earthquake caused a gi-
\nFukushima Nuclear Power Plant Accidents
\nCaused by Gigantic Earthquake
\nand Tsunami\u2013Healthcare Support for
\nRadiation Exposure
\nFukushima Daiichi Nuclear Power Plant Fukushima Daini Nuclear Power Plant
\nPicture 1. Fukushima Daiichi and Fukushima Daini Nuclear Power Plants
\n(Source: TEPCO. http:\/\/www.tepco.co.jp\/index-j.html)
\nwmj 4 2011 5CS.indd 141wmj 4 2011 5CS.indd 141 09.08.2011 10:38:4509.08.2011 10:38:45
\n142
\nDisasters JAPAN
\ngantic tsunami that dramatically devas-
\ntated over 500 km of Eastern Japan\u2019s Pa-
\ncific coastline, resulting in nearly 25,000
\ndead or missing. On top of this, Fukushi-
\nma prefecture suffered damage from the
\ncoastal nuclear power plant accidents and
\nassociated harmful rumors and misinfor-
\nmation.
\nI also started coordinating with the local
\nIwaki Medical Association. In Iwaki alone
\n14,000 evacuees were confirmed in about
\n140 shelters. The government\u2019s orders to
\nevacuate the zone 20 km from the Daiichi
\nNuclear Power Plant and to stay indoors
\nin the 20\u201330 km zone meant in effect that
\nnearly the entire central part of Fukushima\u2019s
\nPacific coastal region, which was hardest hit
\nby the earthquake and tsunami, were shut
\noff from social activities.
\nThey also required adequate medical care
\nsetup at first-aid stations including health-
\ncare for radiation exposure. This consider-
\nably weighed down the initial movements
\nin Fukushima, especially along the coast,
\ndespite healthcare support provided in the
\nafflicted areas by more than 1,000 Japan
\nMedical Association Teams (JMATs) from
\noutside the region.
\nTo be sure, even at my own hospital the
\nsituation during the first week was of work-
\ning in the midst of an unfathomable chill
\nbrought on by the lack of real-time infor-
\nmation from the ground or even from TEP-
\nCO and the government.
\nTo deal with the seriousness of this prob-
\nlem, the JMA, with the cooperation of Yo-
\nshinari Kimura, a lecturer in the Graduate
\nSchool of Literature and Human Sciences
\nat Osaka City University, created a map of
\npublished air contamination levels in Fu-
\nkushima\u2019s coastal areas and made daily up-
\ndates to the data, which it released for JMA
\nmembers on its website (Picture 2). The
\nJMA also requested Nagasaki University to
\ndispatch experts in healthcare for radiation
\nexposure. Professors Shunichi Yamashita
\nand Noboru Takamura responded imme-
\ndiately and became advisors to Fukushima
\nprefecture\u2019s disaster countermeasures head-
\nquarters.
\nThe effort to share and get reliable infor-
\nmation out in this way resulted in obtain-
\ning sufficient healthcare support from the
\neighth day for Iwaki and Soma, which are
\nthe principal coastal cities, as well as for the
\ncity of Mina-misoma, which is partially in-
\nside the 20\u201330 km stay-indoors-zone, and
\nenabled excellent first-aid station health-
\ncare (Fig 1) [2]. Additionally, Professors
\nYamashita and Takamura gave lectures
\nthroughout the prefecture for evacuees and
\nresidents. This communication of evidence-
\nFukushim
\nIitate
\nIwaki
\nFukushima Daiichi Nuclear Power Plant
\nFukushima Daini Nuclear Power Plant
\nPicture 2. Onion diagrams of radioactivity readings in Fukushima prefecture. These dia-
\ngrams were prepared with the help of Yoshinari Kimura, a lecturer in the Graduate
\nSchool of Literature and Human Sciences at Osaka City University, based on pre-
\nliminary environmental radioactivity readings in Fukushima prefecture. The diagram
\nincluded here is based on readings taken at 14:00 on March 29. A reading of 2.23 was
\nrecorded in Iwaki on March 22 and a high reading of 13.1 was recorded in Iitate on
\nMarch 23, but these gradually declined afterward. On April 26, when publication of
\nthese maps was concluded, the reading in Iwaki was 0.27 and that in Iitate was 4.07.
\nwmj 4 2011 5CS.indd 142wmj 4 2011 5CS.indd 142 09.08.2011 10:38:4609.08.2011 10:38:46
\n143
\nDisastersJAPAN
\nbased information to the mass media and
\nlocal residents play an important role.
\n4. Healthcare for
\nradiation exposure
\nThe Japanese government had been con-
\nducting annual evacuation drills with ad-
\nministrative agencies, residents, and medi-
\ncal personnel in the prefectures where the
\nnation\u2019s nuclear power plants and their 54
\nreactors are located. These drills were con-
\nducted under the policy of the Nuclear
\nSafety Commission as a measure for im-
\nproving medical responses, including per-
\nsons associated with the local medical as-
\nsociation, through lectures on healthcare
\nfor radiation exposure and other activities.
\nThis policy was implemented after the To-
\nkai Village JCO Criticality Accident that
\noccurred in Tokai, Ibaraki, which borders
\nFukushima\u2019s southern coastal area, in 1999.
\nIn addition, the government established
\nguidelines for taking iodine tablets in the
\nevent of an accident at a nuclear power
\nplant, distributed iodine tablets to residents
\nliving within 20\u00a0km of nuclear power plants,
\nand put survey meters in place to monitor
\nradioactive contamination.
\nI myself had gone through training sessions
\nin airport disaster prevention and health-
\ncare for radiation exposure in addition to
\nmy specialty of neurosurgery due to the
\nfact that I had been in charge of emergency
\nand disaster medicine as vice-president of
\nthe Fukushima Medical Association and
\npresident of the local medical associa-
\ntion in Iwaki, Fukushima, to the north of
\nwhich are TEPCO\u2019s Fukushima nuclear
\npower plants and to the south of which is
\nthe Tokai Nuclear Power Plant in Ibaraki.
\nI also attended an unforgettable intensive
\nsymposium on disaster medicine focusing
\non bioterrorism among the issues of NBC
\n(nuclear, biological, and chemical weapons)
\nat the World Medical Association (WMA)
\nGeneral Assembly held in Washington DC
\nin 2002. From the beginning when I was
\nnominated an executive board member of
\nthe JMA five years ago in 2006, I was in
\ncharge of emergency and disaster medi-
\ncine. In that capacity I participated in rel-
\nevant committees in the Japanese govern-
\nment as well as continuing discussion in
\nthe JMA\u2019s Committee on Emergency and
\nDisaster Medicine. I was also appointed to
\nbe a member of the Radiation Emergency
\nMedicine Network in the National Insti-
\ntute of Radiological Sciences, which is in
\ncharge of healthcare for radiation exposure
\nin Eastern Japan.
\nThe Iwaki City, where the facilities in my
\nmedical corporation are located, is a little
\nless than 30 km away from TEPCO\u2019s Fu-
\nkushima nuclear power plants at the north-
\nernmost point, and more than 50 km away
\nfrom the Tokai Nuclear Power Plant. Since
\nit is outside the 20 km zone around both
\nplants Iwaki is not located in a special ad-
\nministrative zone like the one mentioned
\nabove.
\nNevertheless, with a population of 350,000
\nit is the second largest city in the Tohoku
\nregion, which encompasses the northern
\npart of the island of Honshu,and is home to
\nthe region\u2019s only critical care center. It also
\nhas a local network of about 30 hospitals
\nand so as a medical district it covers both
\nareas where the nuclear power plants are
\nlocated and has relevance on various other
\nlevels such as industrial medicine activi-
\nties. For this reason, it is an area that must
\nfunction as a support center on the medical
\nfront once a special disaster occurs, such as
\nan accident at a nuclear power plant. It used
\nto be customary to send a number of teams
\nbesides those that were in charge to par-
\nticipate in the Fukushima Nuclear Power
\nPlant\u2019s annual evacuation drill.
\nHowever, at the government level no mea-
\nsures were implemented for Iwaki, since it
\nis outside the 20 km zone. For that reason,
\nwhen a disaster prevention agreement was
\nsigned between the city and the municipal
\nmedical association, on the advice of the
\nmedical association a stockpile of iodine
\ntablets for 300,000 people was put in the
\nIwaki Health and Welfare Center under the
\ncontrol of the center\u2019s director.
\nOn top of this it seems undeniable that in-
\nformation released by the government and
\nTEPCO was in each case, in terms of both
\nthe amount and the speed with which it was
\nreleased, fragmentary and too little, too late.
\nThis did nothing to dispel the past image
\nof information relating to nuclear power
\nplants being, for example, falsified or con-
\ncealed and then apologies given later with
\ndeclarations of intent to make improve-
\nments. Evacuation drills with the admin-
\nNumber of
\nTeams
\nJMA&Okayama MA 1
\nAichi MA 20
\nToyama MA 12
\nKyoto MA 5
\nTokyo MA 7
\nFukuoka MA 15
\nSaitama MA 2
\nChiba MA 1
\nNagasaki MA 2
\nTotal 65
\n* MA: Medical Association
\nMarch 11-31 April 1-15 April 16-May 4
\nFigure 1. Calendar of JMAT dispatches to Iwaki. The period of dispatch is from the time a
\nteam leaves home until it returns. So, this may differ from the time actually spent in
\naction in the afflicted areas. There are also instances of multiple teams being dispatched
\non the same day.
\nwmj 4 2011 5CS.indd 143wmj 4 2011 5CS.indd 143 09.08.2011 10:38:4609.08.2011 10:38:46
\n144
\nDisasters JAPAN
\nistration, residents, and medical personnel
\nhad been conducted for more than 10 years
\nand people had been educated every year
\nabout outside contamination checking and
\nthe taking of iodine tablets. Through this
\nkind of process,the local residents chose the
\nposition of a place where a nuclear power
\nplant is located for nuclear power genera-
\ntion by TEPCO, which does not make the
\npower used by these residents.1
\nThat is all the more reason why there is
\nstill doubt over whether there was a need
\nfor people to all suddenly follow along and
\ngather together like abductees without even
\nbeing able to lock their houses or get cash
\nor their iodine tablets to carry in a situation
\nlike this where detailed information was
\nnot made known. During the usual drills,
\nforecasts and contamination levels based on
\nthe Ministry of Education, Culture, Sports,
\nScience and Technology\u2019s System for Pre-
\ndiction of Environmental Emergency Dose
\nInformation (SPEEDI) had been reliably
\ndisclosed, but unfortunately it does not
\nseem that such thorough procedures were
\ntaken to gain the understanding of residents
\nthis time.
\nDuring this disaster the Ministry of Health,
\nLabour and Welfare raised the limit for
\nworkers\u2019 radiation exposure at the site of
\na nuclear power accident from 100 mSv\/y
\nto 250 mSv\/y. So far two cases of hospital-
\nization due to beta radiation exposure and
\nseveral cases of internal exposure have been
\nreported, but none entailed serious conse-
\nquences.
\nOn the other hand, the exposure limit for
\nthe general public has been at 1\u201320\u00a0mSv\/y.
\nThus far no serious cases of radiation expo-
\nsure have been reported, including among
\nevacuees. The shipping of vegetables and
\nmarine products from the 20 km zone and
\ndesignated areas was banned. In other ar-
\neas beside these the drinking of water from
\n1 This region uses power from the Tohoku Electric
\nPower Company.
\nsources that had exceeded threshold values
\nwas banned, and the shipping of vegetables,
\nfish, and other products was temporarily
\nbanned. These bans were lifted one by one
\nafter the measurements were detected to fall
\nbelow the threshold values.
\nAdditionally, the JMA made an urgent rec-
\nommendation regarding residual contami-
\nnation on school grounds in Fukushima
\nprefecture, namely that even if contamina-
\ntion is below 20mSv\/y in the case of chil-
\ndren steps should be taken to reduce the
\ncontamination as much as possible, such as
\nremoving top soil and plowing to replace
\nsurface soil with subsoil [3].
\n5. Conclusion
\nThe nuclear power accidents triggered by
\nthe Great Eastern Japan Earthquake caused
\nair, soil, and marine pollution in the vicin-
\nity as a result of the meltdown of three fuel
\nrods, hydrogen explosions in the reactor
\nbuildings, and other factors.
\nResidents living within a zone with a radius
\nof 20 km around the Fukushima Daiichi
\nNuclear Plant and even some residents out-
\nside that zone are still in a state of evacu-
\nation, having been compelled to take shel-
\nter or been part of scheduled evacuations.
\nAlthough the power plant itself has not
\nyet reached a cold shutdown, it has been
\nbrought into a stable situation through
\ncooling with continuous injection of water
\nfrom the outside.
\nIn this situation the JMA, in cooperation
\nwith the Fukushima Medical Association
\nand local medical associations, provided
\nhealth and medical assistance to evacuees
\nmainly in evacuation shelters and supported
\ndamaged local healthcare. This resulted in
\nthe dispatch of JMATs to Fukushima pre-
\nfecture being nearly over in mid-June.
\nDuring this incident I felt keenly once
\nagain that basically it is extremely impor-
\ntant to get sufficient information to medical
\nprofessionals in order to provide healthcare
\nfor radiation exposure, which entails deal-
\ning with damage caused by radiation that
\ncannot be seen. Additionally, the continual
\ncommunication of robust information from
\nmedical professionals to residents contrib-
\nuted to people\u2019s peace of mind.
\nPostscript
\nOn June 6, the Japanese government an-
\nnounced that radioactive emissions from the
\nstricken Fukushima Daiichi Nuclear Power
\nPlant in the first week after the March 11
\nearthquake and tsunami disaster might have
\nbeen 770,000 terabecquerels, which is more
\nthan double the 370,000 terabecquerels ini-
\ntially estimated by TEPCO.
\nThe next day the government admitted the
\npossibility that fuel could have suffered a
\n\u201cmelt-through,\u201d a more serious situation
\nthan a core meltdown. Perhaps this could
\nbe said to be the characteristic attitude of
\nTEPCO and the Japanese government dur-
\ning this accident.
\nReferences
\n1. Tokyo Electric Power Company.Status of Fuku-
\nshima Daiichi and Fukushima Daini Nuclear
\nPower Stations after Great East Japan Earth-
\nquake. http:\/\/www.tepco.co.jp\/index-j.html (ac-
\ncessed May 31).
\n2. JMA Disaster Headquarters Status Reports,
\nMarch 19, 2011. http:\/\/www.med.or.jp\/english\/
\n(accessed May 25).
\n3. Japan Medical Association\u2019s position regard-
\ning the Ministry of Education, Culture, Sports,
\nScience and Technology\u2019s \u201cTentative Thinking
\nin Determining whether to use Schools and
\nSchoolyards in Fukushima Prefecture\u201d (May
\n12, 2011) http:\/\/dl.med.or.jp\/dl-med\/teirei-
\nkaiken\/20110512_31.pdf (accessed June 7. In
\nJapanese).
\nMasami Ishii, MD
\nExecutive Board Member
\n(responsible \u00a0or\u00a0emergencies and \u00a0isasters),
\nJapan Medical Association,
\nVice-Chair of Council,
\nWorld\u00a0Medical Association
\nE-mail: ishiihom@ishiihp.or.jp
\nwmj 4 2011 5CS.indd 144wmj 4 2011 5CS.indd 144 09.08.2011 10:38:4709.08.2011 10:38:47
\n145
\nKOREA Disasters
\nSeveral months have passed since the dev-
\nastating earthquake and tsunami near To-
\nhoku, Japan. The exact number of deaths is
\nstill unknown.The recovery effort is expect-
\ned to cost an astronomical 25 trillion yen.
\nOn behalf of KMA, I once again offer my
\nsincere condolences to all people of Japan
\nas a neighboring country and greatly respect
\nJapanese people and colleagues for their
\nstrong will to stand up and recover from the
\nunseen disaster. I am sure Japan will be able
\nto recover from this difficult situation with
\nunity and recognize the great leadership
\nand dedicated services in the field by fellow
\nphysicians under JMA.
\nKorea\u2019s response to the recent disaster has
\nbeen remarkably prompt and sensitive. As
\nJapan\u2019s closest neighbor, Korea was quickly
\naware of the seriousness of the earthquake,
\nwhich was accompanied by a tsunami and
\nnuclear accident. Furthermore, the ex-
\ntended nature of the damage necessitates
\ninternational coordination and the entire
\nKorean public is aware that Korea\u2019s role as
\nfriendly neighbor in this coordination is
\ncritical.
\nDue to the complex nature of the disas-
\nter, urgent medical tasks include care for
\nchronic conditions such as diabetes and
\nhypertension as well as prevention of con-
\ntagious diseases such as respiratory con-
\nditions and norovirus infection among
\npeople living in high density environments
\nincluding shelters. My impression is that
\nsuch urgent issues are being well addressed
\nby Japan\u2019s own medical capabilities. In
\nthe mid to long-term, mental issues re-
\nlated with post-traumatic stress disorder
\n(PTSD) and social problems from sud-
\nden family disruptions still pose a grave
\nchallenge. The international medical com-
\nmunity could play a valuable role here by
\ncontinuing interest and research support.
\nExchange of experience learned from pre-
\nvious disasters will help devise the most ef-
\nfective solutions.
\nThe most formidable challenge would be
\nthe response to the nuclear reactor accident
\nand following exposure to radioactive ma-
\nterial. Ionizing radiation is defined as ra-
\ndiation that has sufficient energy to displace
\nelectrons from molecules. Free electrons can
\ndamage macromolecules in human cells.
\nIonizing radiation arises from both natural
\nand man-made sources. At low-dose ex-
\nposures, late effects such as cancer are pro-
\nduced many years after the initial exposure.
\nAbout 3% of total cancers in the US are at-
\ntributed to ionizing radiation.
\nOur greatest concern is the possible conse-
\nquences of a very or extremely low dose of
\nexposure. Epidemiological data is available
\nfrom several sources such as atomic bomb
\nsurvivors, nuclear facility workers and ura-
\nnium miners. However, such data tells us
\nonly of results from relatively higher level
\nexposure. Since the annual amount of ex-
\nposure to all natural radioactivity is around
\n2.5mSv, the criteria for annual exposure to
\nartificial radioactivity is set at a lower level
\nof 1mSv, which is in turn broken down into
\nradioactivity standards for air, water and
\nfood, etc. Considering the potential con-
\ntroversy over such standards, multifaceted
\nanalysis of scientific data on a case by case
\nbasis is necessary for effective risk commu-
\nnication.
\nDuring the Great Depression, the then US
\nPresident Franklin D. Roosevelt said, \u201cThe
\nonly thing we have to fear is fear itself.\u201dThis
\napplies to radioactive contamination.Fueled
\nby the disaster of a public faced with a never
\nbefore experienced situation, information
\nwhich is not based on science could spread
\nand then further be spun by the social me-
\ndia, creating a malicious cycle of magnify-
\ning public concerns.The medical profession
\nis the most accurate and trusted authority
\nwhen it comes to the impact of radioac-
\ntive contamination on the human body.The
\nmedical communities of Japan and Korea
\nneed to play their roles as health commu-
\nnicators by providing accurate and reliable
\ninformation and behavioral guidelines on
\nradioactive contamination.To fulfill its role,
\nKMA announced its humble recommenda-
\ntions on nuclear contamination immediate-
\nly following the Japanese disaster.
\nThe radioactive leakage caused by the
\nJapanese earthquake has heightened pub-
\nlic interest on environmental protection
\nand energy management. It will be wise
\nfor medical professionals to set the right
\nexample by practicing proper energy man-
\nagement.The WMA must reiterate the im-
\nportance of its \u201cHealth and Environment\u201d
\npolicies such as the New Delhi Declaration
\non Climate Change and Health and mo-
\ntivate each NMA to implement them in
\ntheir respective countries. In particular, the
\ncampaigns and policy making for creating
\na greener health care sector need to be ad-
\nopted by more NMAs, which can in turn
\nmotivate patients and the general public to
\nbecome more active in environmental pro-
\ntection and energy management.
\nThe Japanese disaster is calling upon the
\nhealth and medical community to step
\nup its social leadership in addition to tak-
\ning care of humanity and public health. By
\nwillingly accepting this leadership role and
\nthoroughly fulfilling our public obligations,
\nthe NMAs and the WMA can progress to
\nthe next level as organizations that maintain
\ncontinuous interaction with society.
\nTai Joon Moon, MD, PhD
\nPresident Emeritus, KMA
\nFormer President, WMA
\nE-mail: intl@kma.org
\nThe Japanese Earthquake and the Role
\nof Medical Society
\nwmj 4 2011 5CS.indd 145wmj 4 2011 5CS.indd 145 09.08.2011 10:38:4709.08.2011 10:38:47
\n146
\nUNITED STATES OF AMERICARegional and NMA news
\nFor 40 years Americans have been breathing
\neasier thanks to common-sense limits on toxic
\nair pollution. But an emerging threat has the
\nmedical community concerned \u2013 just as the
\nUnited States Congress begins a new assault
\non public health protections
\nIn the past two decades, extreme heat events
\nhave killed tens of thousands around the globe,
\nincluding populations here in the United
\nStates.Heat waves are more frequent,of longer
\nduration and more intense\u00a0\u2013 and the lack of
\nnighttime relief make them all the more lethal,
\ncausing illness and death from heart disease,
\ndiabetes, stroke, respiratory disease and even
\naccidents,homicide and suicide.
\nIncreases in winter weather anomalies are
\nemerging.Though winters have become short-
\ner (two-to- three weeks shorter in the North-
\nern Hemisphere, depending on latitude), they
\nhave grown more perilous.For several decades
\nmore winter precipitation has been falling as
\nrain rather than snow,increasing the chance of
\nice storms when temperatures do drop. Glob-
\nally, westerly winds are also changing with
\nclimate change, affecting the shifts in weather
\nfronts. Now, warming seas and melting Arctic
\nice are generating harsher winters in the US
\nand Europe. And heavier, wetter snowstorms
\ncan be treacherous for travel and ambulation.
\nMeanwhile, warming favors insect migration.
\nIn the past decade, case reports of tick-borne
\nLyme disease rose ten-fold in Maine and
\nnorthern counties are experiencing Lyme for
\nthe first time. In Alaska, especially warm win-
\nters have ushered in swarms of allergy-induc-
\ning, stinging insects, along with mosquitoes
\nand devastating pine bark beetle infestations.
\nThe spread of forest and crop pests \u2013 requir-
\ning chemicals for control \u2013 pose additional
\nlong term health and environmental risks.
\nElevated carbon dioxide levels from burn-
\ning fossil fuels boosts pollen production from
\nragweed, and the pollen grains hitch rides on
\nparticulates from diesel and coal combustion,
\nhelping to deliver the allergens deep inside our
\nlungs.Meanwhile,the allergy and asthma sea-
\nson has lengthened some two-to-three weeks,
\nwhile,since 1980,asthma rates have more than
\ndoubled in the U.S.In short,climate change is
\nhazardous to our health. We are deeply con-
\ncerned that climate instability and changing
\nweather patterns threaten our health and the
\nvitality of our life-support systems.The Amer-
\nican Medical Association is working actively
\nto educate health care professionals about the
\nprojected rise in climate-related illness. Medi-
\ncal and public health groups are also taking
\nleading roles in advocating for climate and
\nenergy policies, and measures \u2013 like electric
\nvehicles,\u201csmart\u201dgrids and healthy cities initia-
\ntives \u2013 that will improve public health, create
\njobs and combat climate change. And physi-
\ncians and other health care professionals have
\nbegun serving as role models for patients by
\nadopting environmentally responsible,energy-
\nand waste-reducing practices in the health sec-
\ntor. As medical professionals, our focus is first
\nand foremost on preventing health threats,but
\na new report from the U.S. Environmental
\nProtection Agency (EPA)makes a clear eco-
\nnomic case for more action. In one year alone,
\nthe Clean Air Act, prevented an estimated
\n18 million child respiratory illnesses, 850,000
\nasthma attacks,674,000 cases of chronic bron-
\nchitis, and 205,000 premature deaths. Ac-
\ncording to EPA,\u201cThe mere monetary value of
\nsaving Americans from those harms through
\nimplementing the Clean Air Act is projected
\nto reach $2\u00a0trillion in 2020 alone \u2026 Over the
\nperiod from 1990 through 2020,the monetary
\nvalue to Americans of the Act\u2019s protection is
\nprojected to exceed the cost of that protection
\nby a factor of more than 30 to 1.\u201d
\nLawmakers may be unaware of the stunning
\nreturns on our investments in clean air, the
\nrange of benefits from EPA\u2019s efforts to protect
\nus from greenhouse gas pollution, and of the
\nwork that still needs to be done. The protec-
\ntions some in Congress are now seeking to
\nundercut call on big power plants and facto-
\nries to adopt cost-effective efficiency measures.
\nGreater efficiency means lower combustion
\nof fossil fuels, which translates directly into a
\nreduction of mercury, particulate matter, and
\nother health-threatening pollutants.
\nNow is the time to use our 40 years of experi-
\nence in reducing air pollution to reduce green-
\nhouse gases and the co-pollutants. The harm
\nto our health and our well-being, and the as-
\nsociated health and social costs, will continue
\nto mount unless we take action.
\nCecil B. Wilson, M.D.,
\nPresident of the American Medical Association
\nPaul R. Epstein, M.D., M.P.H.,
\nAssociate Director, Center for Health and the
\nGlobal Environment, Harvard Medical School
\nProtecting Our Nation\u2019s Health
\nCecil B. WilsonPaul R. Epstein
\nwmj 4 2011 5CS.indd 146wmj 4 2011 5CS.indd 146 09.08.2011 10:38:4709.08.2011 10:38:47
\n147
\nPublic HealthRUSSIAN FEDERATION
\nHealth of a nation determines the quality of
\nworkforce, the latter being the base of any
\nstate economic model. While developing
\ninnovative economy, Russia has faced vari-
\nous challenges connected with progressing
\ninsufficiency of workforce, which is tackled
\neverywhere as one of the main long-term
\nstrategic risks and threats to national safety
\nin the field of economic growth. (Russian
\nFederation National Safety Strategy Until
\n2020 adopted by the RF President\u2019s Decree
\nNo. 537 of 12.05.09) (Figure 1, 2, 3).
\nInsufficiency of workforce is explained
\nabove all by age and sex structures. Small
\npopulation groups born in the 1990s have
\nstarted their active working life while nu-
\nmerous after-war working cohorts (born
\nafter World War II) are dropping out of the
\nworking-age population (Figure 4).
\nIn accordance with Rosstat (Official Rus-
\nsian Statistics Agency), the reduction of
\nworking-age population will reached the
\nfigure of 13 million people by the year 2030.
\n80% of losses are expected to occur dur-
\ning the period until 2020 on the average by
\n1\u00a0million of people annually.
\nNicolay Izmerov
\nStrengthening and Promotion of Working Population as the Base of
\nSocioeconomic and Demographic Policies in the Russian Federation
\n14.4%
\n17.5%
\n57.4%
\n69.9%
\n28.20%
\n12.60%
\n0.0%
\n10.0%
\n20.0%
\n30.0%
\n40.0%
\n50.0%
\n60.0%
\n70.0%
\n80.0%
\nFemales Males
\nYounger than acive Active workers
\nOlder than active workers
\nFigure 1. Working-age population in the RF matched by age and sex, in %
\nMales and females ageing 0\u201315 Males ageing 60 and more, females ageing 55 and more
\n28.6%
\n23.3%
\n24.5%
\n18.1%
\n15.9%15.4%
\n16.3%
\n18.5%
\n20.5% 21.2%
\n0.0%
\n5.0%
\n10.0%
\n15.0%
\n20.0%
\n25.0%
\n30.0%
\n35.0%
\n1970 1979 1989 2002 2009
\nFigure 2. Age-related changes: share of people younger and older than active working age com-
\npared to general population, in %
\nwmj 4 2011 5CS.indd 147wmj 4 2011 5CS.indd 147 09.08.2011 10:38:4809.08.2011 10:38:48
\n148
\nPublic Health RUSSIAN FEDERATION
\nThe reduction of active workforce and its
\nshare in the general population is going to
\ntake place on the background of growth
\nboth of number and proportion of pension-
\ners.
\nIn 2009, 38 million was the number of re-
\ntired population in the country including
\naround 30 million old age pensioners.
\nIn accordance with the official data, em-
\nployment of pensioners has been growing
\nsince 2002. At present, working pension-
\ners make up about one fourth of the total
\nnumber of pensioners. It is of great impor-
\ntance nowadays to involve and effectively
\nemploy aging workers in the economy of
\nRussia.
\nThe growth of the employment of retired
\npensioners will contribute to both reduction
\nof workforce shortage and greater resort of
\nwork experience accumulated during work-
\ning years.The main obstacle for the involve-
\nment of pensioners in active work is the
\nstate of their health.
\nThe results of sociological research among
\npensioners show that the number of work-
\ning pensioners who assess their health as
\n\u201csatisfactory\u201d is three times larger than the
\nnumber of those pensioners who do not
\nwork and thus assess their health as \u201cunsat-
\nisfactory\u201d.
\nIn 2009, life expectancy in the Russian
\nFederation was 62.8 years for men, which
\nis 15\u201317 years less than globally in the de-
\nveloped countries, while for women it was
\n74.7\u00a0 years, which is 7\u201311 years less than
\nglobally in the developed countries.
\nGreat success in the reduction of mortal-
\nity rates among the adult population was
\nachieved in the majority of the world\u2019s
\ncountries in the second half of the 20th
\ncen-
\ntury and at the beginning of the 21st
\ncentury.
\nRussia stands aside from these achieve-
\nments.While in the 1960s and at the begin-
\nPopulation ageing 15-72
\nFemales. In thousands
\n(100%)
\nMales. In thousands
\n(100%)
\nActive workers
\nFemales: 62,5%
\nMales: 72,2%
\nGroups not
\nengages in
\neconomy
\nFemales: 37,5%
\nMales: 27,8%
\nStudents
\nFemales: 10,7%
\nMales: 12,0%
\nEmployed
\nFemales: 59,2%
\nMales: 67,9%
\nUnemployed
\nFemales: 3,3%
\nMales: 4,3%
\nPensioners
\nFemales: 19,6%
\nMales: 12,1%
\nHousewives
\nFemales: 4,6%
\nMales: 0,3%
\nOthers
\nFemales: 2,6%
\nMales: 3,4%
\nFigure 3. Distribution of the population aged 15\u201372 by economic activities in 2008 and its
\nshare compared to the general population of respective sex, in %
\n36.3%
\n19.9%
\n50.2%
\n57.1%
\n0.70% 0.50%
\n9.30%
\n6.20%
\n3.50% 4.70%
\n0.0%
\n10.0%
\n20.0%
\n30.0%
\n40.0%
\n50.0%
\n60.0%
\n2003 2008
\nState and municipal Private
\nPublic and religious organizations Mixed Russian
\nJoint Russian and foreiign ventures
\nFigure 4. Structure of the mean annual number of population employed in economy with regard
\nto patterns of ownership
\nwmj 4 2011 5CS.indd 148wmj 4 2011 5CS.indd 148 09.08.2011 10:38:4809.08.2011 10:38:48
\n149
\nPublic HealthRUSSIAN FEDERATION
\nning of the 1970s Russian life expectancy
\nwas almost the same as in the greater part
\nof the world, at present it shows multiple
\nincrease discrepancy, especially in males.
\n(Figure 5)
\nImpact analysis of mortality rates for
\n1987\u20132008 testifies to the fact that infan-
\ntile and child mortality shows a 1.5\u20132-fold
\nreduction. In senior age groups, mortality
\nrates were either stable or insufficiently (by
\n10\u201320%) increased whereas at active work-
\ning ages 16\u201359 they showed a 1.5\u20132.5-fold
\nincrease.
\nTable 1. Rates of industrial injuries are pres-
\nently decreasing at a very quick pace
\nin Russia
\nIndustrial
\nInjuries
\n2008 2009
\nChange,
\nin %
\nIndex of
\noccupational
\ninjuries per
\n1000 workers
\n2.5 2.1 \u201316.0
\nLethality index
\nof occupational
\ninjuries per
\n1000 workers
\n0.109 0.09 \u201317.4
\nIndustrial traumatism decreased from 3.4 to
\n2.1 during 2004\u20132009 (per 1000 workers),
\nwhich made up 38%,and lethal outcomes of
\noccupational injuries decreased from 0.129
\nto 0.090, or by 30.2%, respectively.
\nIn Europe, the share of one lethal injury is
\n500 to 2000 cases of injuries.
\nAt present, this ratio is 1 to 22\u201323 in Rus-
\nsia, though in the 1970s and the 1980s it
\nwas 50 to 60 cases of occupational injuries
\nper one lethal injury. (Figure 6)
\nAt present, mean indices of the number of
\ncases and disability days compared with the
\nbeginning of the 1990s have reduced by one
\nthird. They correspond to the analogous
\ndata in the EU countries. (Figure 7)
\n12.4
\n11.5
\n10.7 10.7
\n10.1 10.1
\n8.8
\n7.5 7.2 6.9 6.7 6.4
\n6 6 5.8 5.6 5.4
\n4.9 4.7 4.7
\n4
\n3.6
\n0
\n2
\n4
\n6
\n8
\n10
\n12
\n14
\nRussia
\nBieloRussiaLatviaEstoniaLithuaniaU
\nkrainePolandFranceFinland
\nSpainRum
\naniaBulgariaG
\nerm
\nany
\nItalyA
\nustria
\nSwitzerlandN
\norwayG
\nreeceSweden
\nG
\nreatBritainTurkey
\nIsland
\nFigure 5. Difference of life expectancy in men and women, in years in 2008
\nOne lethal injury versus the number of non-lethal injuries
\nWork-related accidents
\nLethal outcomes
\n2.7
\n16.8
\n26.5
\n28 28.5
\n35.8
\n39.4
\n0
\n5
\n10
\n15
\n20
\n25
\n30
\n35
\n40
\n45
\nRussia Czech
\nRepublic
\nItaly Germany Finland Austria France
\n0.124
\n0.041 0.04
\n0.022
\n0.017
\n0.039 0.04
\n0
\n0.02
\n0.04
\n0.06
\n0.08
\n0.1
\n0.12
\n0.14
\nRussia Czech
\nRepublic
\nItaly Germany Finland Austria France
\nFigure 6. Level of occupational traumas in Russia compared with developed countries of the
\nworld in 2008 (per 1000 workers)
\nwmj 4 2011 5CS.indd 149wmj 4 2011 5CS.indd 149 09.08.2011 10:38:4809.08.2011 10:38:48
\n150
\nPublic Health RUSSIAN FEDERATION
\nAlong with this, the mean duration of one
\ndisability case increased by 16%. Increase of
\nthe mean duration of one case indicates a
\nlate visit to the doctor as well as the fact that
\nthe worker\u2019s health condition needs more
\ntime to be restored.
\nThe reduction of registered morbidity rates
\nof working population on the background
\nof extremely high levels of disability and
\nmortality of working ages speaks of:
\n\u2022 Social ill-being in the society, continu-
\ning gap in the real income of population,
\ngrowth of poor layers for whom medical
\naid is less accessible;
\n\u2022 High prevalence rates of alcoholism and
\nunhealthy life style, low standard of cul-
\nture, including hygiene at home and in
\nworking surroundings;
\n\u2022 Low appraisal of health and life in pop-
\nulation striving for maintaining higher
\nlife standards at the expense of their own
\nhealth
\nTable 2. Share of workers engaged in hazard-
\nous and dangerous working condi-
\ntions, in %
\nIndicators 2008 2009
\nShift,
\n%
\nMining
\noperations
\n39.1 40.3 +3.1
\nManufacturing
\nactivity
\n26.8 28.2 +5.2
\nDistribution of
\nenergy, gas and
\nwater
\n30.6 31.0 +1.3
\nConstruction 14.6 28.2 +93.2
\nTransport 31.4 33.1 +5.4
\nCommuni-
\ncations
\n2.9 3.7 +27.6
\nWorkers with
\nheavy physical
\nloads
\n9.0 9.8 +8.9
\nIncluding
\nfemales
\n3.5 3.8 +8.6
\n0.0
\n0.2
\n0.4
\n0.6
\n0.8
\n1.0
\n1.2
\nCases Disability days Mean duration
\n1990 2006
\nFigure 7. Morbidity with temporary disability
\n1.5%
\n23.8% 24.4%
\n26.6%
\n20.4%
\n3.4%
\n2.1%
\n17.5%
\n25.3%
\n28.1%
\n19.6%
\n7.3%
\n0.0%
\n5.0%
\n10.0%
\n15.0%
\n20.0%
\n25.0%
\n30.0%
\nunder 20 20\u201329 30\u201339 40\u201349 50\u201359 60\u201372
\nEmpoyes workers Unemployes workers
\nFigure 8. Structure of employed population matched by age and type of employment
\nin 2008, in %
\nwmj 4 2011 5CS.indd 150wmj 4 2011 5CS.indd 150 09.08.2011 10:38:4909.08.2011 10:38:49
\n151
\nPublic HealthRUSSIAN FEDERATION
\nTable 3. Actual number of working hours per
\nweek averagely per one worker (in-
\ncluding the time for additional place
\nof employment)
\nIndices
\nTotalnumberofworkers
\nWorkershavingoneplaceof
\nemployment
\nWorkershavingtwoormore
\nplacesofemployment
\n2007 39.1 38.6 51.8
\n2008 39.3 38.9 52.5
\n\u2022 In accordance with the official data, more
\nthan 2\u00a0million 600 thousand workers had
\ntwo or more places of employment.
\n\u2022 Excessive employment is characteristic of
\nworkers engaged in the non-formal in-
\ndustrial sector at small and medium-scale
\nenterprises. (Figure 8)
\nIn accordance with the Rosstat data, rates
\nof occupational morbidity in Russia grew by
\n17.8% in 2009, which was equal to 1.79 per
\n10,000 workers (1.52 in 2008, respectively).
\n(Table 4; Figure 9)
\nThe State Concept of the Demographic
\nPolicy for the Period until 2020, among
\nother tasks to be fulfilled by public health,
\nhas a special task which includes reduction
\nof mortality rates and injuries from occupa-
\ntional accidents and occupational diseases by:
\n\u2022 shift in the field of safety at work to the
\nsystem of management and control of
\noccupational risks including informing
\nworkers of relevant risks, development of
\nsystem for revealing such risks, evaluating
\nand controlling them;
\n\u2022 economic motivation for the improve-
\nment of working conditions by employ-
\ners.
\nTable 4. Share of workers to be compensated for their work in dangerous and hazardous conditions
\n(in accordance with types of economic activity) in 2008, in %
\n\u00a0Indicators
\nTypes of economic activity
\nMining
\nopera-
\ntions
\nManu-
\nfacturing
\nindustries
\nProduction
\nand consump-
\ntion of energy,
\ngas and water
\nCon-
\nstruc-
\ntion
\nTrans-
\nport
\nCom-
\nmuni-
\ncation
\nWorkers engaged
\nin hazardous and
\ndangerous working
\nconditions
\n68.4 41.9 43.3 33.7 44.6 6.7
\nAmong them work-
\ners had the right to:
\n\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0
\nAdditional breaks 60.2 29.8 32.7 22.9 33.6 4.1
\nReduced working
\nhours
\n8.8 3.8 2.0 1.8 1.6 2.0
\nFree medical treat-
\nment and nutrition
\n1.9 3.0 2.0 0.8 0.1 0.0
\nFree delivery of
\nmilk and other food
\nproducts
\n3.0 27.7 24.5 14.3 11.7 2.0
\nIncreased remu-
\nneration for work
\n28.1 27.5 29.0 9.6 19.7 3.4
\nThe right to early
\nretirement and old
\nage pension reward,
\nList 1 and List 2
\n42.1 17.9 12.2 13.6 5.4 1.7
\nFigure 9. Distribution of occupational diseases and poisonings by number of cases in 2009
\nwmj 4 2011 5CS.indd 151wmj 4 2011 5CS.indd 151 09.08.2011 10:38:4909.08.2011 10:38:49
\n152
\nPublic Health RUSSIAN FEDERATION
\nOne of the most important factors which
\ninfluence this situation is the market of
\nworkforce where migrant workers, above all
\nthose arriving from the NIS, change align-
\nment of force.
\nIn accordance with the assessment by the
\nRAS (Russian Academy of Science) Re-
\nsearch Economy Prognosis Institute, the
\nnumber of migrants at the beginning of
\n2009 was 6\u20137 mln people, or more than
\n10% of the full list of Russian workers in the
\nRF. The number of illegal migrants makes
\nup approximately 4\u20135 mln people and about
\n30% among them have neither registration,
\nnor work ticket.
\nMore than half of legal migrants with work
\ntickets are employed in the shadow econo-
\nmy sector, their employers do not send rel-
\nevant notifications to the Migration Service
\nand Rostrud (Table 5).
\nThe Russian Federation National Safety
\nStrategy Until 2020 sets the following aims
\nfor national safety in the field of public
\nhealth:
\n\u2022 Increase of life expectancy, reduction of
\ndisability and mortality rates;
\n\u2022 Development of preventive measures and
\ntimely qualified primary medical aid to
\nworkers;
\n\u2022 Prevention of socially dangerous diseases;
\n\u2022 Quality and accessibility of medical ser-
\nvice.
\nIn October 2010, ILO Convention No. 187
\non Occupational Safety and Health was
\nratified by federal authorities. The aim of
\nthe convention is to prevent industrial ac-
\ncidents, occupational diseases and deaths of
\nworkers in industry by means of working out
\nthe relevant national policies, systems and
\nprograms on the subject. This fully agrees
\nto the WHO Global Plan of Actions on
\nWorkers\u2019 Health for 2008\u20132017, which has
\na recommendation directed to the WHO
\nmember states to encourage developing na-
\ntional health programs and national systems
\nof occupational health.
\nTable 5. Number of migrant workers in Russia
\n\u00a0 In %
\n2000 2003 2004 2005 2006 2007 2008
\nTotally 100 100 100 100 100 100 100
\nAbroad workers 50.1 52.2 51.8 51.1 47.0 32.8 26.6
\nVietnam 6.2 9.3 9.1 7.9 6.8 4.6 3.9
\nChina 12.3 19.3 20.4 22.9 20.8 13.3 11.6
\nNorthern Korea 4.1 3.5 3.2 2.9 2.7 1.9 1.4
\nUSA 0.9 0.5 0.4 0.4 0.4 0.3 0.2
\nTurkey 8.4 10.0 10.4 10.5 10.0 7.6 5.4
\nNIS workers: 49.9 47.8 48.2 48.9 53.0 67.1 73.4
\nAzerbaijan 1.5 1.6 2.1 2.5 2.8 3.4 3.1
\nArmenia 2.6 2.7 3.7 3.7 3.9 4.3 4.1
\nGeorgia 2.4 0.8 0.8 0.6 0.5 0.3 0.2
\nKazakhstan 1.4 1.0 0.9 0.6 0.5 0.4 0.4
\nKyrgyzstan 0.4 1.3 1.7 2.3 3.3 6.4 7.6
\nRepublic of Moldova 5.6 5.7 4.9 4.4 5.0 5.5 5.0
\nTajikistan 2.9 3.6 5.1 7.5 9.7 14.6 16.1
\nTurkmenistan 0.1 0.1 0.1 0.2 0.1 0.1 0.1
\nUzbekistan 2.9 3.9 5.2 7.0 10.4 20.1 26.5
\nUkraine 30.1 27.1 23.6 20.2 16.9 12.2 10.1
\n39.1%
\n24.4%
\n49.8% 49.6%
\n38.0%
\n14.8%
\n60.2%
\n30.1%
\n62.1%
\n68.3%
\n62.4%
\n40.7%
\n21.7%
\n17.8%
\n37.9%
\n31.3%
\n18.2%
\n2.9%
\n0.0%
\n10.0%
\n20.0%
\n30.0%
\n40.0%
\n50.0%
\n60.0%
\n70.0%
\n80.0%
\nAll adults groups 15\u201318 19\u201324 25\u201344 45\u201364 65+
\nTotally Males Females
\nFigure 10. Prevalence of tobacco smoking among adults (aged 15 years or older) matched by sex
\nand age in the Russian Federation in 2009
\nwmj 4 2011 5CS.indd 152wmj 4 2011 5CS.indd 152 09.08.2011 10:38:5009.08.2011 10:38:50
\n153
\nPublic HealthRUSSIAN FEDERATION
\nThe Russian Program entitled Health in
\nIndustry is underway in the Ministry of
\nHealth and Social Development. The pro-
\ngram is based on the WHO Global Plan of
\nActions on Workers\u2019Health for 2008\u20132017.
\nThe aims of it are:
\n\u2022 Development of medical and preventive
\nservices for the working population of
\nRussia;
\n\u2022 Timely identification of occupational dis-
\neases;
\n\u2022 Reduction of health risks due to unfavor-
\nable occupational factors;
\n\u2022 Bringing up of ideas of a healthy life style
\nto the working population.
\nThe experience of many countries shows
\nthat a new social key-point for preventing
\nand quitting bad habits can be the idea of
\ngeneral health promotion in the society
\nalong with the work at individual develop-
\nment of a healthy life style. In 2009, a pro-
\ngram to form a healthy life style until 2012
\nwas introduced in Russia. The Ministry of
\nHealth and Social Development initiated
\nthe program and called it \u2018Healthy Russia\u2019
\nattracting mass media and other social in-
\nstruments to implement it. Health control
\nand prevention centers are being developed
\nin the country.
\nMedical specialists of the local outpatient
\nservice fulfill the functions of hygienic edu-
\ncation. The system of medical prevention,
\nforgotten in the recent years, is now being
\nrestored to life.
\nIn accordance with the WHO data, the
\nleading mortality and morbidity factors in
\nthe Russian Federation are as follows:
\n\u2022 high arterial blood pressure;
\n\u2022 high level of cholesterol;
\n\u2022 tobacco smoking and alcohol abuse.
\nThe following correlation has been detected
\nbetween risk factors and mortality rates:
\n\u2022 17.1% for tobacco smoking;
\n\u2022 12.9% for unbalanced nutrition;
\n\u2022 12.5% for extra weight;
\n\u2022 11.9% for alcohol intake.
\nAbout 50% of Russian population are to-
\nbacco smokers. The rates of tobacco smok-
\ning growth are the highest compared with
\nthe rest of the world: the number of smoked
\ncigarettes during the recent three years has
\nannually increased by 2% to 5%. The num-
\nber of tobacco smokers, including women
\nand teenagers, annually increases by 1.5% to
\n2% (Figure 10).
\nIn accordance with the WHO researches,
\nthe prevalence of tobacco smoking among
\n13\u201315-year-old teenagers is 33.4% (40.8%
\namong boys and 29.8% among girls, respec-
\ntively).
\nAccording to expert assessment,Russia occu-
\npies the fourth place in the world by the prev-
\nalence of tobacco smoking among teenagers.
\nRussia joined the WHO Convention
\nagainst tobacco smoking where it was for
\nthe first time proclaimed as global challenge
\nand threat. In accordance with this docu-
\nment, Russia has to introduce measures to
\nrestrict tobacco consumption.
\nAlcohol abuse shows high repeatability dy-
\nnamics. In accordance with the data of Ros-
\nstat, the consumption of registered alcohol
\nper person increased from 5.83 liters of ab-
\nsolute alcohol in 1990 to 10.1 liters in 2007,
\nwhich otherwise makes up an increase of
\n1.8 times. In accordance with the data of
\nexperts, the real per capita consumption of
\nalcohol is around 18 liters with regard to il-
\nlegal turnover of alcohol-containing prod-
\nucts in Russia.
\nAccording to the opinion of the WHO
\nexperts, if pure alcohol consumption per
\ncapita increases 8 liters a year, it is already
\ndangerous for the health of population
\n(Table 6).
\nGreat harm to the health of population is
\ninflicted by malnutrition.
\nDiscrepancy between caloric content and
\npower inputs, extra consumption of fats, in-
\nsufficient intake of vitamins, minerals and
\nbiologically active food components have
\nbeen found in the nutrition of Russians.
\nTable 6. Number of diseases due to alcoholism and alcoholic psychosis, drug addiction and drug
\nabuse in 2008 (newly diagnosed diseases)
\nIndicators Totally
\nAges, years
\n0\u201314 15\u201317 18\u201319 20\u201339 40\u201359
\nTotally
\nAlcoholism and alcoholic
\npsychosis
\n173,430 39 660 1705 77,886 84,569
\nDrug addiction 26,516 28 649 1451 22,628 1754
\nDrug abuse 1161 288 502 135 214 19
\nFemales\u00a0
\nAlcoholism and alcoholic
\npsychosis
\n38,278 6 177 286 17,577 18,503
\nDrug addiction 5238 4 129 284 4629 191
\nDrug abuse 142 25 60 17 30 7
\nMales
\nAlcoholism and alcoholic
\npsychosis
\n135,152 33 483 1419 60,309 66,066
\nDrug addiction 21,278 24 520 1167 17,999 1563
\nDrug abuse 1019 263 442 118 184 12
\nwmj 4 2011 5CS.indd 153wmj 4 2011 5CS.indd 153 09.08.2011 10:38:5009.08.2011 10:38:50
\n154
\nRegional and NMA news AUSTRIA
\nHospital reform, migration of doctors,
\nworking conditions in hospitals, increasing
\nmedical underservice in outlying areas, the
\nrisk of quality losses due to budget cuts \u2013
\nthese are the considerable challenges the
\nAustrian health care system has to face in
\n2011. In addition, the reform of the funding
\nsystem, the development of medical docu-
\nmentation, and of electronic data exchange
\nis imminent. All players will be required to
\nmake considerable efforts in order to solve
\nthese problems. However, enduring solu-
\ntions can only be achieved in cooperation
\nwith the medical profession, represented
\nby the Austrian Medical Chamber. Imple-
\nmenting reforms without referring to the
\nexpertise of the medical profession would
\nbe comparable to a blind speaking of colour.
\nNo doubt, the most urgent concern is the
\nhospital reform. First of all, the legal provi-
\nHealth in Russia has not been a public or
\npersonal treasure so far. Russians are not
\ninclined to think over their health as a per-
\nsonal capital, they are not accustomed to
\ntaking care of it.
\nThe Ministry of Health and Social Devel-
\nopment of the Russian Federation is pres-
\nently working at a new national system of
\noccupational risk management and control
\nto prevent occupational injuries and main-
\ntain the health of workers at Russian enter-
\nprises.
\nOccupational risk control in the sphere of
\nwork protection allows for establishing of
\na direct link between working conditions
\nat workplaces and health state of the em-
\nployed personnel with the necessity to work
\nout managerial decisions which increase the
\nefficiency of safety at work and work pro-
\ntection measures.
\nThe analysis of foreign law enforcement
\npractices in the field of safety at work shows
\nthe efficiency of occupational risk man-
\nagement and control at workplaces in the
\nEU countries. Thanks to it, the efficiency
\nof preventive measures in safety at work is
\nincreased, working conditions are improved
\nand occupational injuries and morbidity are
\nreduced.
\nIn Russia, the system of occupational risk
\ncontrol and management has already been
\nintroduced by the \u201cR 2.2.1766-03\u201d Guid-
\nance on the Assessment of Occupational
\nRisks for Workers\u2019 Health. The guidance
\nwas approved by the Chief State Health
\nPhysician of Russia on June 24, 2003. Also
\ntwo other legal documents were published
\nin 2010, namely, Prognosis of Exposure to
\nHarmful Factors of Working Conditions
\nand Assessment of Occupational Risks
\nfor Workers\u2019 Health; Methods Applied
\nto Reveal and Prevent Work-related Dis-
\neases Developed by the Researchers of the
\nRAMS Institute of Occupational Health
\nwith Their Co-workers.
\nIt is necessary to develop legislative acts for
\nthe introduction of methods aimed at the
\nmanagement and control of occupational
\nrisks and health assessment of the employed
\nworkers as well as of the funds necessary for
\ntheir treatment and occupational rehabilita-
\ntion.
\nIt is proposed to be fulfilled by introduc-
\ning amendments to the Labor Code of the
\nRussian Federation by applying as the main
\nnotion in the field of safety at work such a
\nterm as \u201coccupational risk\u201d and establishing
\nrights and responsibilities of employment
\nparties related to occupational risk manage-
\nment and control as well as to procedures
\naimed at the prevention of occupational
\ndiseases and occupational rehabilitation of
\nworkers.
\nMethodological legislative acts on the pre-
\nvention of occupational diseases and occu-
\npational rehabilitation of workers are to be
\ndeveloped based on a three-staged system of
\nsocial protection and medical aid to workers
\nif dangerous and\/or harmful industrial fac-
\ntors are present at a particular enterprise.
\nFirst stage is to determine the level of occu-
\npational risk due to the working conditions
\nat workplaces and the workers\u2019 health.
\nSecond stage is to render medical aid in-
\ncluding early diagnosis based on medical
\nsigns revealed by regular medical examina-
\ntions for groups with increased risk factors.
\nThird stage is to establish compensatory
\nmechanisms and other social benefits for
\nthose who have suffered due to accidents or
\noccupational diseases.
\nIt is advisable to introduce a system of social
\nprotection into the National Plan of Action
\nto maintain workers\u2019health in Russia,which
\nwill help to solve demographic problems,
\ngive an increase to the number and quality
\nof workforce of the state, work efficiency,
\neconomy and GDP.
\nProf. Nicolay Izmerov,
\nRussian Academy of Medical Sciences
\nE-mail: niimt@niimt.ru
\nAustrian Health Care System Faces
\nConsiderable Challenges
\nwmj 4 2011 5CS.indd 154wmj 4 2011 5CS.indd 154 09.08.2011 10:38:5009.08.2011 10:38:50
\n155
\nRegional and NMA newsAUSTRIA
\nsions for hospitals have to be harmonized.
\nAt present, the country has one federal
\nand nine provincial regulatory systems. All
\nthe more it is positive that the Minister of
\nHealth has responded to this long-standing
\nclaim of harmonization made by the Aus-
\ntrian Medical Chamber, which shall be
\nimplemented in the course of the hospital
\nreform.
\nIn addition, the hospital reform will tackle
\nthe exasperating funding problem, as a con-
\nsiderable share of costs is attributable to
\nhospitals. This is explained mainly by high
\nfrequencies in hospital outpatient depart-
\nments, which in turn is due to medical un-
\nderservice of self-employed doctors in the
\nearly morning, late evening or on weekends.
\nThe solution is obvious: group practices are
\nable to disburden outpatient departments
\nin taking over many tasks conditional that
\nthese services are remunerated adequately.
\nAt the same time, the Austrian Medical
\nChamber advocates two pots of funding in
\norder to increase transparency \u2013 this would
\nallow hospitals to be funded by taxes, and
\nextramural services including hospital out-
\npatient departments to be funded by health
\ninsurance funds.
\nThe reform should not take place exclu-
\nsively on political grounds, but should be
\nexpert-based and take into consideration
\nboth medical and social needs. In contrast
\nto this, the Austrian social insurances have
\npresented a \u201cmaster plan\u201c for the reform-
\ning of the entire health care system, which
\naims to concentrate the entire power in the
\nhands of the social insurances. In this plan,
\nmedical expertise and the needs of patients
\nare sacrificed ruthlessly to economic targets.
\nIt appears that the social insurances, which
\nat present are influenced significantly by
\nthe economy, see the health care system as
\na production process under economic laws.
\nThe medical profession has protested vehe-
\nmently against this trend outlining that the
\ndevelopment of new reforms in the health
\ncare area should fall within the political
\ncompetence of the Minister of Health,rath-
\ner than being developed by representatives
\nof the economy.
\nThe reforms at issue and scheduled for
\n2011 also concern the training of young
\ndoctors. After graduation from Medi-
\ncal University, it is common to undergo
\na three year hospital training in order to
\nbecome a general medical practitioner; at
\nthis level, doctors enter specialist training.
\nThe Austrian Medical Chamber advocates
\nthat medical university education shall be
\nmore practice-oriented to allow students to
\ndirectly enter specialist training at the end
\nof the medical curriculum.
\nAt the same time it favours the intensifi-
\ncation of the training in general medical
\npractice in depth and in length, including
\none compulsory year of training in a teach-
\ning practice. Such a system would advance
\nintensive vocational training and prevent
\ndoctors in training from being reduced to
\nsustaining and upholding the system. A re-
\nstructuring of the present system shall also
\navoid that young doctors leave the coun-
\ntry, undergo training in another European
\ncountry, and never come back.
\nSeveral improvements like the radical im-
\nprovement of training conditions are im-
\nperative in order to keep young doctors
\nfrom migrating abroad. Also, the working
\nconditions in hospitals and practices have
\nto be rendered more attractive. Despite of
\nseveral successes, hospital doctors in Aus-
\ntria work too much and too long.Therefore,
\nthe working conditions have to be rendered
\nmore quality-, patient- and doctor-centred.
\nThis includes the creation of new working
\ntime models which allow for compatibility
\nof professional activity and family life. Run-
\nning a practice means facing excessive bu-
\nreaucratic overload while offering not a lot
\nof perspectives from an economical point of
\nview. These facts will contribute to creating
\na serious shortage of doctors in the future,
\nas the readiness to work under these condi-
\ntions will decline.
\nIn the near future one major issue will
\nalso be the trend towards electronification.
\nE-medication and the introduction of an
\nelectronic health record are imminent, how-
\never, not always well-received. Concerns
\nregarding data protection and data secu-
\nrity are increasing just as financing and cost
\nconsiderations. However, it shall be noted
\nthat international companies are highly in-
\nterested in the introduction of such systems,
\nand economic considerations are given pri-
\nority. Creating the possibility for patients to
\nopt out both generally and partially from an
\nelectronic health record system in order to
\nprevent for instance mental illnesses from
\nbeing recorded, finally reduces the idea of
\ndoctors having a consistent overview of
\ntheir patients\u2019medical situation to the point
\nof absurdity.
\nDr. Walter Dorner,
\nPresident,
\nAustrian Medical Chamber
\nWalter Dorner
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\n156
\nRegional and NMA news UZBEKISTAN
\nImprovement of the quality of medical
\nservices is very important worldwide, in-
\ncluding Uzbekistan. The government and
\nMinistry of Health take various measures
\ndirected at the improvement of the quality
\nof medical services. It is not a secret that
\nthe improvement of the quality of medical
\naid is a difficult problem which demands
\ncarrying out of complex measures, such as
\nimprovement of material conditions, in-
\ncrease of medical personnel\u2019s knowledge,
\nimprovement of working conditions and
\nintroduction of the modern methods of
\npayment and motivation of medical work-
\ners\u2019 work.
\nThe European forum of medical associa-
\ntions and the World Health Organization
\nhave made an address on December 29th,
\n1993 with a statement on the development
\nof the quality of medical aid that will allow
\neach patient to receive quality help. With
\nthat end in view, national medical associa-
\ntions should develop perspective indicators
\nfor the estimation of quality, independent
\nexternal estimation of the quality of medi-
\ncal services (accreditation), and increase the
\nknowledge of physicians by means of semi-
\nnars and training.
\nThe Medical Association of Uzbekistan,
\nbeing one of the large non-governmental
\nnon-commercial organizations, has author-
\nity in wide circles of the medical society and
\nactively works at introducing the modern
\nmethods of medical aid regulation, directed
\nat the improvement of the quality of the
\nmedical aid rendered by medical institu-
\ntions to the population of the Republic of
\nUzbekistan.
\nThe first initiative: increase of physicians\u2019
\nknowledge by introducing remote training
\nin the post-degree period on the basis of in-
\nternational experience.
\nIn the USA and some European countries,
\nphysicians, for employment in clinical
\npractice, should obtain a license (primary
\nand repeated). An indispensable licensing
\ncondition is the improvement passage. For
\nexample, in the USA, each physician with-
\nin three years should pass the 150-hour
\ncurriculum of improvement. A widespread
\nmode of physicians\u2019 study is using cur-
\nriculums published in medical journals, for
\nexample, in the Journal of the American
\nAcademy of Dermatology. In Uzbekistan,
\neach physician within five years should pass
\nimprovement in the course of 288 hours.
\nImprovement includes internal and corre-
\nspondence training. There is the Tashkent
\nInstitute of Postgraduate Education of
\nPhysicians to which the functions of car-
\nrying out internal post-degree training are
\nassigned. The Medical Association of Uz-
\nbekistan, together with the leading experts
\nof the Tashkent Institute of Postgraduate
\nEducation of Physicians, prepares curricu-
\nlums (seven have already been published in
\nthe Bulletin of the Medical Association of
\nUzbekistan). Having answered tests, phy-
\nsicians at an affirmative reply and a set of
\ncertain percent receive the certificate by
\nway of remote training with instruction of
\n18 hours. Since 2010, more than 200 phy-
\nsicians have received certificates by way of
\nremote training.
\nThe second initiative: introduction of
\nthe accreditation of medical institutions.
\nWe have adjusted relations with one of
\nthe most influential organizations dealing
\nwith the introduction of medical institu-
\ntion accreditation, namely the Joint Com-
\nmission International (JCI), which is part
\nof the Joint Commission on Accreditation
\nof Healthcare Organizations (JCAHO)
\nof the USA. JCI has been working on the
\naccreditation of medical institutions in
\nmore than 70 countries. It renders consult-
\ning services in more than 90 countries of
\nthe world and cooperates with the World
\nHealth Organization, ministries of health
\nof various countries, and also with medical
\nassociations. The results of accreditation are
\npublished and are accessible on the Internet
\nto all population.All rules and the standards
\ndeveloped by the accreditation commission
\nare available on a site of the incorporated
\ncommission and are accessible to all medical
\nclinics. According to rules, medical clinics
\nshould pass accreditation each three years.
\nIn Uzbekistan, the grant from the Ger-
\nman Agency for International Cooperation
\n(GIZ) for the \u00abDevelopment of the system
\nof public health services in Central Asia
\nwith pilot actions in Kyrgyzstan, Tajikistan
\nand Uzbekistan\u00bb is realized. At this point,
\nnegotiations for signing the Memorandum
\nof Understanding between JCI and the
\nMedical Association of Uzbekistan are be-
\ning conducted.
\nThe third initiative: diagnosis-related
\ngroup (DRG) system introduction for the
\nperfection of the mechanism for financing
\nRealization of the Perspective Initiatives for
\nImproving the Quality of Medical Services in
\nUzbekistan
\nZokhid Abdurakhimov
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\n157
\nMedical Education
\nmedical aid in hospitals. Used methods of
\nfinancing through the global budget and by
\na design procedure on duration of stay on
\na cot, and also by quantity of rendered ser-
\nvices do not promote an intensification of
\nmedical workers\u2019 work, improvement of the
\nquality of treatment and reduction of the
\nhospitalization terms for patients. Design
\nprocedure use on duration of stay on a cot,
\nand also by quantity of rendered services in
\nUzbekistan has revealed that even in one
\nclinic the cost of treatment of the patient
\nwith the same diagnosis differs \u22651,5-fold.
\nAt the same time, the cost of the medical
\nservices with the same name, for example,
\nan electrocardiography, in medical institu-
\ntions located in one territory (city of Tash-
\nkent) differs \u22652-fold. It all has demanded
\nstudying of this problem, and also of the
\ninternational experience in this area. We
\nstudy the methods of payment for medical
\nservices worldwide.
\nThe Association suggests introduction of
\nthe system of patient classification devel-
\noped by R. Fetter (USA), the so-called di-
\nagnosis-related group system. This system
\nhas been introduced in the USA, Canada,
\nJapan, Great Britain, and also in more than
\n20 other European countries (Germany,
\nFrance, etc.) and is an important mecha-
\nnism for estimating and stimulating the
\nactivity of medical institutions and a uni-
\nform method for calculating the treatment
\ncost for each patient who has left a hos-
\npital.
\nIntroduction of this method will allow of
\npassing from the physician payment on
\na uniform scale to the contract system of
\npayment allowing of stimulating the im-
\nprovement of the quality and intensity of
\nphysicians\u2019 work. We understand that it is a
\ndifficult and long process.
\nWe know that the European countries have
\ngained a wide experience in the realization
\nof these initiatives and the Medical As-
\nsociations of Uzbekistan is searching for
\npartners that could impart experience and
\nwould help to put these working outs into
\npractice.
\nZokhid Abdurakhimov,
\nThe Chief Executive,
\nMedical Association of Uzbekistan
\nEMSA is a students\u2019 initiative under Bel-
\ngian law, volunteer-based organisation ad-
\nvocating and representing the voice of the
\nmedical students of geographical Europe. It
\nwas founded in 1991 to provide a common
\nnetwork for these students, to share proj-
\nects, culture and experience, and to repre-
\nsent their opinion in medical organisations
\nsuch as the EU body CPME \u2013 the Standing
\nCommittee of European Doctors.
\nEMSA aims to form a network among Eu-
\nropean medical students, facilitate Europe-
\nan integration, develop a sense of European
\nidentity,and promote training,activities and
\nprojects related to health in Europe for the
\nbenefit of medical students and society.
\nThrough a wide variety of projects, we aim
\nto raise the quality of medical education and
\nto empower students in the field of medical
\nscience. Furthermore, we focus on medical
\nethics and address the need to raise public
\nawareness of the social and cultural issues
\nthat occur in the process of improving the
\nEuropean healthcare system.
\nEMSA seeks to improve the health and
\nquality of care of the citizens of Europe by
\nacting as a conduit for increased interaction
\nand sharing of knowledge among European
\nmedical students in the areas of medical
\neducation ethics and science.
\nFinally, we are a platform of European in-
\ntegration and foster student exchange, free
\nflow of information, and the transfer of best
\npractices. While facing the oncoming chal-
\nlenges of the 21st
\ncentury, we recognise the
\nimportance of standing together and ad-
\ndressing these challenges with a clear vision,
\nboldness and creative way of finding solu-
\ntions. After all, activation, innovation, and
\ndetermination of our mind are what truly
\nfurther positive change and constant im-
\nprovement.
\nWe collaborate with European medical or-
\nganisations. This connection allows us to be
\nalways updated on the ongoing topics and
\nthe new topics to be followed. We have an
\naccess to a platform of information, con-
\ntacts, and existing organisations.
\nWe have many initiatives and projects. One
\nof EMSA\u2019s initiatives is the European Med-
\nical Students\u2019 Council. The EMS Coun-
\ncil gives the medical students in Europe a
\nvoice that is heard by the European health-
\ncare stakeholders. The EMS Council works
\nMedical Student Impact on the Future of European Healthcare
\nElif Kele\u015f
\nwmj 4 2011 5CS.indd 157wmj 4 2011 5CS.indd 157 09.08.2011 10:38:5209.08.2011 10:38:52
\n158
\nWMA news
\ntowards the common goals of medical stu-
\ndents throughout the European Union and
\ngeographical Europe. We have produced
\nseveral valuable policy papers in the past
\nyears, some of which have been published
\nin international papers and accepted by our
\npartner organisations.
\nEMSA is interested in policy making to
\nsupport students in Europe to involve in
\nglobal health and health policy. We repre-
\nsent the medical students and the voices of
\nyoung people in Europe that stay unheard
\nregarding health policy and healthcare.
\nAs a result of our European collaboration
\nwith medical students, we are aware that
\nmedical students themselves want to be
\nmore involved in health policy as future
\nphysicians. EMSA and the EMS Council
\nendeavour to make policy by informing,
\nraising awareness, and, most importantly,
\nencouraging students to engage in the fu-
\nture of healthcare in Europe.
\nThe latest paper, which was adopted by the
\n7th
\nEMS Council, is the Vienna Resolution,
\na policy statement about the future of Euro-
\npean healthcare. In this paper, we deal with
\nthe development of high common health-
\ncare standards in Europe, the shortage of
\nhealthcare professionals, especially in rural
\nareas, and the intra-European mobility of
\nhealthcare professionals.
\nElif Kele\u015f
\nEuropean Medical Organizations
\nLiasion Officer,
\nEuropean Medical
\nStudents\u2019 Association(EMSA)
\nE-mail: Elifkeles.dr@gmail.com;
\nemo-lo@emsa-europe.eu
\nPreamble
\nThe European Medical Students\u2019 Council 2010 in Vienna:
\n\u2022 Intending to contribute to a better European Healthcare,
\n\u2022 Wishing to participate as a stakeholder in the discussion about
\nthe future of European health and healthcare,
\n\u2022 Strongly supporting the common values as defined by the Euro-
\npean Ministers of Health [1] (universality, access to good quality
\ncare, equity and solidarity) and adding integrity, transparency and
\nconfidentiality,
\n\u2022 Emphasising the importance of healthcare workers within the
\nEuropean society,
\n\u2022 Acknowledging current public priority to increase internation-
\nal collaboration and sharing of knowledge on improvement of
\nhealthcare [2]
\n\u2022 Observing the increasing complexity of healthcare and the chang-
\ning roles of healthcare professionals,
\n\u2022 Taking into account the changing European demographics, the
\nincreasingly mobile workforce, the changing demands of society,
\ntechnological development and the increasing costs of health-
\ncare\u00a0[3],
\n\u2022 Taking into account workforce migration which affects the acces-
\nsibility of healthcare in rural areas,
\n\u2022 Building upon current European statements with regards to
\nhealthcare as well as related policy papers [4] and scientific lit-
\nerature,
\n\u2022 Appreciating the efforts of all stakeholders in this field, from pol-
\nicy makers, through healthcare workers to patients,
\n\u2022 Expressing our belief that leadership skills are essential when
\ndealing with patients as well as other stakeholders,
\n\u2022 Affirming the importance of the continuous development of
\nLifelong Learning strategies [5],
\n\u2022 Convinced that organizations providing healthcare must evolve
\ninto learning organizations1
\nin order to increase the quality of
\ncare,
\n\u2022 Keeping in mind that all our endeavours should be patient-cen-
\ntred, while taking into account their impact on society2
\n,
\n\u2022 Contributing to a vision of the future of European healthcare, the
\nEuropean Medical Students\u2019 Council,
\n\u2022 Calls for attention to the topics of access to healthcare and mobil-
\nity of students and healthcare workers.
\nStandards of healthcare
\nRecommends development of high standards of healthcare with
\nspecial attention to the following:
\n\u2022 Increasing the importance of preventive medicine,
\n1 Learning Organization: an organization which has developed an infrastruc-
\nture to utilize every educational opportunity for improvement of patient care,
\nas well as for the benefit of all individuals working within the organization, to
\ncontinuously adapt to and respond to a changing environment.
\n2 Impact on society: the public health and financial meanings of medical in-
\nterventions.
\nVienna Resolution of the Future of European Healthcare
\n7th
\nEuropean Medical Students\u2019 Council in Vienna, Austria, 22nd
\nto 25th
\nApril 2010
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\nWMA news
\n\u2022 Ensuring that sufficient time is devoted to meet all the patients\u2019
\nhealth3
\nneeds,
\n\u2022 Implementing measures to improve inter- and multidisciplinary
\ncooperation,
\n\u2022 Encouraging development of leadership skills of all healthcare
\nprofessionals involved in shaping the future of healthcare,
\n\u2022 Promoting conflict resolution and teamwork skills to become an
\nintegral part of the medical profession,
\n\u2022 Demanding communication trainings in the medical curriculum
\nwith the aim to improve the doctor-patient relationship as well as
\nhealthcare team dynamics.
\nAnnotations
\nPermanent access to high quality healthcare has become an integral
\npart of European societies.Thanks to advances in modern medicine,
\nmost illnesses can be cured or treated, or at least life is extended
\nsignificantly; we feel however, that due to the technological nature
\nof these improvements, certain basic aspects of the care that is pro-
\nvided should receive more attention than is given to it now.
\nPreventive medicine should take a more prominent role in health-
\ncare, both in education and in medical practice. We would like to
\nremind policy makers that prevention is much more cost-efficient
\nthan treating an illness,and therefore significant attention should be
\ngiven to it. At an early stage medical professionals should encounter
\nhealthcare in practice, both in a clinical and a political and organi-
\nzational manner by ways of introducing these topics in educational
\nprogrammes.
\nWe advise to implement communication trainings in the medical
\ncurriculum. Work overload, lack of personnel and limited resources
\nlead to decreasing patient-doctor-interaction.This leads to decreas-
\ning quality of healthcare as doctors lack the time to recognize the
\npatients\u2019 needs and initiate adequate treatment. Training in ad-
\nequate communication skills of medical professionals should facili-
\ntate higher quality of patient-doctor-interaction.
\nMeeting all the patients\u2019 needs includes tackling all their somatic,
\npsychological and social problems without neglecting any of these.
\nDoctors tend to regard their patients problem only from the doctors\u2019
\nperspective. To ensure a high quality treatment, multidisciplinary
\nteams are the preferred working structure to view and judge all pos-
\n3 Health is a state of complete physical, mental and social well-being and not
\nmerely the absence of disease or infirmity. [Preamble to the Constitution of
\nthe World Health Organization as adopted by the International Health Con-
\nference, Ney York, 19.22 June, 1946, signed on 22 July 1946 by the representa-
\ntives of 61 States (Official Records of the World Health Organisation, no. 2,
\np. 100) and enters into force on 7 April 1948.]
\nsible views of a case. Teamwork and leadership skills are therefore
\nessential for every doctor to ensure.
\nThe best possible outcome for the patient. Integrating trainings in
\ncommunication and conflict solving into the curriculum as well as
\nthe life long learning process enables future doctors to work as ef-
\nficiently as possible in this integral part of the medical profession.
\nAccess to healthcare
\nExpresses its concern about the shortage of healthcare professionals,
\nespecially in rural areas [6].
\nCalls for structural support to healthcare professionals in this context.
\nProposes a common European fund to implement the following
\nstructural and financial support measures:
\n\u2022 Facilities and adapted rewards4
\nfor healthcare workers in under-
\nserved areas,
\n\u2022 Systems supporting access to academic networks and programmes
\nfor doctors,
\n\u2022 Flexible working conditions in underserved areas5
\n,
\n\u2022 Distance-learning opportunities,
\n\u2022 Implementation of e-health, telemedicine and e-consultations,
\nAffirms the Heidelberg Resolution on Information to patients [7],
\nCalls for appropriate use of new technologies,emphasizing that sig-
\nnificant attention must be paid to privacy concerns, distribution and
\nregulations,
\nRecommends the establishment of a freely accessible online database
\nlisting all health care providers in order to provide information about
\navailable resources, treatment and diagnostics as well as waiting lists,
\nStrongly suggests that adequate measures are taken to ensure that
\npeople in need of care may remain living in their own homes with
\nsufficient support, whenever feasible in terms of patient safety and
\navailable resources,
\nUrges the following actions with regard to demographic develop-
\nments:
\n\u2022 Integration of geriatrics and palliative care [8] into the medical
\ncurriculum,
\n4 Additional benefits such as housing or transportation.
\n5 E.g. shortened working times, only for a limited amount of time, travelling
\nbetween areas, having shared working times (e.g. two days in a popular, three
\ndays in an underserved area).
\nwmj 4 2011 5CS.indd 159wmj 4 2011 5CS.indd 159 09.08.2011 10:38:5309.08.2011 10:38:53
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\nWMA news
\n\u2022 Offering clerkship opportunities in geriatric and palliative care
\nrelated fields6
\n,
\n\u2022 Provide incentives to ensure medical coverage in retirement
\nhomes.
\nDraws attention to the specific needs of vulnerable minority groups
\nby means of:
\n\u2022 Approaching all patients with equality regardless of their back-
\nground [9] ensuring social inclusion,
\n\u2022 Effective communication with the patients regardless of their
\nbackground [10],
\n\u2022 Providing required assistance, such as the removal of administra-
\ntive obstacles to healthcare access,
\n\u2022 Guidelines securing access to healthcare for unregistered mi-
\ngrants and asylums,
\nAnnotations
\nMany countries all over the world and also in Europe have actual
\nand projected shortages of physicians. Smaller EU countries are es-
\npecially vulnerable to sudden changes in migratory patterns. Espe-
\ncially in rural areas measures need to be taken to ensure continuous
\navailability of necessary health care resources. Further loss of physi-
\ncians mainly through migration is very likely to result in reduced
\navailability of health services [11].
\nThus, a transnational approach is needed to the emerging problems.
\nFollowing examples from the farming industry, we propose a com-
\nmon European fund to lower imbalanced access to healthcare in
\nrural and city areas by giving incentives to health care professionals
\nto serve in rural areas.
\nEven though the personal contact to a health care professional is
\nan integral part of treating a patient we see the potential in the
\nuse of new technologies in the means of e-health, telemedicine or
\ne-consultations to maintain the constant availability of health care
\nin underserved areas. Privacy concerns as well as distribution and
\nregulations need to be taken into consideration, before such a sys-
\ntem can be implemented.
\nUsing new technologies communication skills will be an even more
\nimportant part of patient-doctor interaction and we continuously
\nsupport the results of the 4th
\nEMS council concerning Information
\nto patients.
\nCitizens are living longer and in better health. Life expectancy has
\nincreased consistently since the 1950s by around 2.5 years per de-
\n6 e.g. social medicine, geriatrics or palliative care.
\ncade and is expected to continue to increase. Nevertheless, as people
\nlive longer, it is expected that there will be increasing numbers of
\nolder people with a severe disability and in need of long-term care.
\nA growing number of geriatric patients will be in need of treatment
\nin the future and a prolonged lifespan will lead to rising numbers
\nof patients receiving palliative care. We therefore demand a better
\ntraining in the aforementioned fields and the necessary support to
\nenable people to stay as long as possible in their familiar environ-
\nment at home.
\nFor migrants, barriers to accessing healthcare represent a complex
\npicture. It has long been recognised that newly arriving migrants
\nmay face special health risks and frequently do not receive the
\ncare they need. The barriers to accessing healthcare include: lack
\nof knowledge about available services; language differences, varying
\ncultural attitudes to health and healthcare and administrative and
\nbureaucratic factors.
\nMobility
\nDemands a free choice of and equal conditions for acceptance into
\nmedical programs and postgraduate medical education throughout
\nEurope,
\nStrongly opposes any form of discrimination regarding medical
\neducation7
\n,
\nAims for the implementation of the European Core Curriculum [12],
\nCalls for high European-wide standards in regard to basic and post-
\ngraduate medical education as well as continuous professional de-
\nvelopment,
\nReaffirms the statements on the Bologna Process created by inter-
\nnational medical student organisations [13],
\nDemands all countries of Europe to provide sufficient high quality
\nmedical school placements to meet their country\u2019s need for doctors
\n[14],
\nDemands the freedom of movement for doctors, provided the nec-
\nessary language proficiency8
\n,
\n7 Referring for example to different tuition fees or selection criteria based on
\ncountry of origin, ethnicity, religion, gender, sexual orientation or social back-
\nground.
\n8 Proficiency in this context referring to language abilities sufficient to take a
\nproper clinical history and communicate the diagnosis and treatment within
\nthe framework of the appropriate socio-cultural context.
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\nWMA news
\nStresses the importance of comparable high standards of working
\nand living conditions as well as equal opportunities for academic
\nand professional development across Europe.
\nAnnotations
\nThe freedom of movement for workers is one of the major principles
\nof the European Community. Applying this principle to students
\nand healthcare professionals all throughout Europe is an integral
\npart of our vision for the future of European healthcare. We ac-
\nknowledge that treating every European applicant equally might
\nbe challenging especially for small countries facing an overwhelm-
\ning number of foreign candidates outnumbering local high school
\ngraduates. We envision though that in the near future the notion
\nof being European will be more important than the national back-
\nground and therefore strongly oppose any form of discrimination
\nbased on the country of origin.
\nMigration often moves in certain directions, partly due to some
\ncountries not educating enough doctors to meet their own needs
\nbut instead attracting medical school graduates from poorer coun-
\ntries. To prevent shortages in underserved areas we therefore ask
\nall countries to provide enough medical school places to meet their
\nown country\u2019s needs. Areas facing a shortage of doctors despite the
\nmeasures taken may benefit from the European fund mentioned
\nabove to ensure medical coverage.
\nTo ensure that the same high standards are met by all medical
\nschool graduates, common goals like the European Core Curricu-
\nlum or guidelines such as the WFME Global Standard for Qual-
\nity Improvement in Medical Education need to be implemented
\nthroughout Europe.
\nMaking health policy is very essential itself and much more effort
\nshould be put by us, the future healthcare professionals. Therefore,
\nwe will be able to encourage ourselves with enthusiasm, to get more
\nprogress as a European Policy making platform for medical students
\nand to be heard by European Stakeholders.
\nLet us join our forces in 2012 to reach high common standards
\nand qualified healthcare in the whole Europe to meet the needs of
\nEuropean Citizens.
\nReferences
\n1. Council Conclusions on Common values and principles in European Union
\nHealth Systems (2006\/C 146\/ 01)
\n2. Together for Health: A Strategic Approach for the EU 2008-2013,WHITE
\nPAPER \u2013 COM(2007) 630 Final
\n3. Green Paper on the European Workforce for Health 2008\/725\/EC final
\n4. Together for Health: A Strategic Approach for the EU 2008-2013,WHITE
\nPAPER \u2013 COM(2007) 630 Final
\n5. Recommandation of the European Parliament and of the Council on key
\ncompetences for lifelong learning (2006\/962\/EC)
\n6. The global and European shortage of physicians: Proposals for European
\nstrategy\u00a0\u2013 La p\u00e9nurie mondiale et europ\u00e9enne de medicines : propositions
\npour une strat\u00e9gie europ\u00e9enne (CPME 2008\/097 FINAL EN\/FR)
\n7. EMSA (2007), HeidelbergResolution on Information to Patients. Heidel-
\nberg (Germany)
\n8. 5th
\nEMS Council resolutions, Athens
\n9. IFMSA\/EMSA (2006),European Core Curriculum – the Students\u2019Perspec-
\ntive. Bristol (UK)
\n10. IFMSA\/EMSA (2006),European Core Curriculum – the Students\u2019Perspec-
\ntive. Bristol (UK)
\n11. The global and European shortage of physicians: Proposals for European
\nstrategy \u2013 La p\u00e9nurie mondiale et europ\u00e9enne de medicines : propositions
\npour une strat\u00e9gie europ\u00e9enne (CPME 2008\/097 FINAL EN\/FR)
\n12. IFMSA\/EMSA (2006),European Core Curriculum – the Students\u2019Perspec-
\ntive. Bristol (UK)
\n13. IFMSA \/ EMSA (2004), The Bologna Declaration and Medical Education.
\nMeg\u00e8ve (France)
\n14. WFME Global Standard for Quality Improvement in Medical Education,
\nEuropean Specifications
\nwmj 4 2011 5CS.indd iiiwmj 4 2011 5CS.indd iii 09.08.2011 10:38:5309.08.2011 10:38:53
\niv
\nContents
\nThe Rep\u00fablica Oriental del Uruguay is located in the Southern Cone of South America. \u00a0Borders to the north and northeast, Brazil.\u00a0To the
\nwest, Argentina and to the south and southeast the Rio de la Plata and the Atlantic Ocean. \u00a0Uruguay has an area of 176.215 km2
\n(square
\nkilometres) and a population of 3.300.000 inhabitants with a high literacy level that reaches near 97% of the population. \u00a0The climate is
\ntemperate and generally stable.\u00a0 Its main production is based on agriculture and livestock and is surrounded by large farm neighbours such
\nas Brazil, Argentina, Paraguay and Chile. \u00a0Uruguay is a cosmopolitan society as a result of several successive European migrations. \u00a0It is
\nan open society with a democratic government elected by free elections every five years and promotes tolerance of all religions or political
\nideologies and non-discrimination.
\nWednesday, 12 October 2011 Preliminary Meeting of the Council Session
\nMedical Ethics Committee
\nFinance and Planning Committee
\nSocio-Medical Affairs Committee
\nCredentials Committee
\nThursday, 13 October 2011 Scientific Session \u201cTobacco Cessation\u201d
\nFriday, 14 October 2011 Council \u00a0Plenary Session
\nAssembly Ceremonial Session
\nSaturday, 15 October 2011 Council \u00a0Plenary Session
\nwww.congresos-rohr.com\/wma2011\/webs\/eng\/contact.html
\nWMA General Assembly \u2013 Montevideo 2011
\n189th
\n& 190th
\nWMA Council Sessions
\n12\u201315 October 2011, Hotel Radisson
\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
\nWorld Health Organization Urged to Act over
\nAssaults on Health Personnel and Facialities . . . . . . 122
\nHealth Professionals Unite
\nin WHPA Taipei Call to Action . . . . . . . . . . . . . . . 123
\nTask Shifting in the Netherlands . . . . . . . . . . . . . . . 126
\nJapan Medical Association Teams\u2019 (JMATs)
\nFirst Operation: Responding to the Great Eastern
\nJapan Earthquake . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
\nFukushima Nuclear Power Plant Accidents Caused
\nby Gigantic Earthquake and Tsunami\u2013Healthcare
\nSupport for Radiation Exposure . . . . . . . . . . . . . . . . 141
\nThe Japanese Earthquake and the Role of Medical
\nSociety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
\nProtecting Our Nation\u2019s Health . . . . . . . . . . . . . . . . 146
\nStrengthening and Promotion of Working Population
\nas the Base of Socioeconomic and Demographic
\nPolicies in the Russian Federation . . . . . . . . . . . . . . 147
\nAustrian Health Care System Faces Considerable
\nChallenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
\nRealization of the Perspective Initiatives for
\nImproving the Quality of Medical Services
\nin Uzbekistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
\nMedical Student Impact on the Future
\nof European Healthcare . . . . . . . . . . . . . . . . . . . . . . 157
\nVienna Resolution of the Future of European
\nHealthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
\nwmj 4 2011 5CS.indd ivwmj 4 2011 5CS.indd iv 09.08.2011 12:59:5809.08.2011 12:59:58<\/p>\n"},"caption":{"rendered":"

wmj34 UNITED STATES OF AMERICA vol. 57 MedicalWorld JournalJournal Official Journal of the World Medical Association, INC G20438 Nr. 4, August 2011 \u2022 Gigantic Earthquake and Tsunami in the Japan. Healthcare Support for Radiation Exposure \u2022 Public Health in the Russian Federation \u2022 Task Shifting in the Netherlands wmj 4 2011 5CS.indd Iwmj 4 2011 […]<\/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\/wmj34.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3621"}],"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=3621"}]}}