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wmj201301<\/a><\/p>\n

COUNTRY
\n\u2022 President Elect of WMA, Margaret Mungherera,
\nHealth Care in Uganda
\n\u2022 Prison Health
\nvol. 59
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 1, February 2013
\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
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\nDeutscher \u00c4rzte-Verlag
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\n\u201cMedic\u012bnas apg\u0101ds\u201d,
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\nBela Vista, CEP 01333-903
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\nEthics Committee
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\nWMA Treasurer
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\nWMA Secretary General
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\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
\n1
\nEditorial
\nA draft Regulation of the European Union on Clinical Trials falls back
\nin the time before the Declaration of Helsinki
\nAll new medical drugs need testing in humans. Experimentation
\nwith human beings has become a matter of international atten-
\ntion after World War II, when in the Nuremberg Doctors\u2019Trial an
\nAmerican Military Tribunal set up ten rules for such experiments.
\nInterestingly enough the so-called Nuremberg Code did not find
\nwide reception until nearly half a century later, when historians
\nrediscovered it. However, in the late 50s and early 60s the World
\nMedical Association began working on rules for experimentation
\non humans resulting in the Declaration of Helsinki in 1964.
\nThe Declaration of Helsinki since then is being regarded as the gold
\nstandard for experiments on humans and it has directly or indi-
\nrectly made its way into many national and international regula-
\ntions and laws.In 1964 the mayor step forward was the requirement
\nof informed consent. Not only should nobody be subjected to an
\nexperiment, but he or she should know what it is means for them
\npersonally to be subjected to an experimental situation.This concept
\nwas not new \u2013 at least in a few countries \u2013 but for the first time it
\nwas demanded by an international policy. In 1975 the World Medi-
\ncal Association went a step forward to include the concept of ethics
\nreviews by independent ethics committees.
\nTo bring new medicines to the market is a highly expensive process.
\nExtreme scrutiny is being applied not only to make the drugs safe
\n(and hopefully effective) but also to make the process of testing safe
\nand ethically acceptable. The protection of the subjects in a clinical
\ntrial preceding the marketing authorization as well as the patients
\nreceiving the medicines later should be paramount. On the other
\nhand there are at least three reasons to make this process as fast as
\npossible: First, if new medicines are better than old ones, patients
\neverywhere should benefit from them as soon as possible. Let\u2019s not
\nforget, until today many, if not most diseases wait for a final cure.
\nSecond, the high development cost and a limited patent lifetime
\nfavour an early market access to produce a return on investment.
\nThird, having innovations first secures an economic advantage over
\nyour international competitors.
\nCompetition in this global market requires clear structures in the
\nprocess of bringing new drugs to the market. In the late 90s the Eu-
\nropean Union (EU) started to develop a common set of rules for the
\ntesting of new drugs now including 27 European States resulting in
\nthe Clinical trials Directive (CTD) from 2001.
\nHowever, the legislative approach fell short of the expectations.The
\nprocess of getting a new drug to the market appears being still too
\nlong.The European Commission has now presented a draft regula-
\ntion that is meant to replace the 2001 CTD.
\nThis draft however has (or reveals) three major problems:
\n\u2022 Ethics reviews by independent ethics committees are no longer
\nexpressively mentioned as an obligatory requirement,
\n\u2022 the timelines to authorize a clinical trial by the ethics committees
\nare very short and appear non-workable in practice, and
\n\u2022 one member state will be in charge taking the final decision on the
\nacceptability of a trial, which may happen even, if other member
\nstates find them scientifically or ethically unacceptable.Although,
\nmember states can opt out from a specific trial under certain cir-
\ncumstances, they have to accept a marketing authorization finally
\nresulting from this process.
\nIn a common effort with the Standing Committee of European
\nDoctors (CPME) the President of the World Medical Association,
\nDr. Cecil Wilson and the Chairperson of the WMA Council, Dr.
\nMukesh Haikerwal, raised their concerns to the Members of the
\nEuropean Parliament currently dealing with the draft regulation.
\nThe WMA leadership also stressed the potential effect of the EU
\nRegulation for non-EU countries. It would be a fatal signal, if the
\nEuropean authorities no longer require an ethics review in all coun-
\ntries where trials are being performed.
\nMrs. Glenis Willmott MEP, lead rapporteur on the draft regulation
\nfor the European Parliament proposed to reintroduce the manda-
\ntory ethics review by ethics committees and referred to the WMA
\nDeclaration of Helsinki. Many of the national governments have
\nraised their concerns against the short timelines dictated by the draft
\nregulation. There is hope that the draft regulation as incomplete as
\nit is will not pass the Parliament and Council (the representation of
\nthe national governments) without major changes.
\nHowever the third problem of forcing member states to accept what
\nthey believe are marketing authorizations based on insufficient sci-
\nentific or ethical standards remains. It may lead to an \u201cethics shop-
\nping\u201d, which means that producers of new drugs could try to find
\nthe \u201cleast critical\u201dcountry for their trial. Fixing those problems may
\nrequire additional amendments in the laws on marketing authoriza-
\ntion, but starting now to deal with that problem would be a good
\nsign. Not only for Europe.
\nOtmar Kloiber
\nBack to the 50s?
\n2
\nWMA news
\nDistinguished ethicists, educators and gov-
\nernment officials from around the world
\nmet in Cape Town, South Africa, Decem-
\nber 5, 2012 for a three-day conference to
\nevaluate potential revisions of the Declara-
\ntion of Helsinki (DOH).
\nThe DOH was first adopted by the World
\nMedical Association (WMA) in1964 and is
\na statement of ethical principles for medical
\nresearch involving human subjects, includ-
\ning research on identifiable human material
\nand data. It is widely recognized as a core
\nstandard for ethical research.
\nThe DOH is the loadstone; the North Star
\nif you will that guides physicians, govern-
\nments and industry in the area of advice on
\ndoing medical research on human subjects.
\nThe DOH has undergone multiple revisions
\nover the years, not to change core principles
\nbut to determine whether more guidance in
\nthe importance area of medical research in
\nthis area is needed to deal with the com-
\nplexities of today\u2019s world.
\nThe process by which the WMA is con-
\nducting work on potential changes in the
\nDOH is to draw on the expert opinion of
\na wide spectrum of leaders in ethics around
\nthe world and to work in a public, transpar-
\nent way to reach agreement.
\nWhat gives added significance to this work
\nis that 2014 will mark the fifty-year anni-
\nversary of this important document.
\n87 delegates from 26 countries were in at-
\ntendance at the conference and provided
\nrich discussions that were for me reassuring
\nconfirmation that physicians as a profession
\ncare deeply about ethics. The diversity of
\nattendees and the quality of presentations
\nvalidated the worldwide importance of the
\nDOH to those in the field.
\nThe South African Medical Association
\nunder the leadership of Dr. Zephne M. van
\nder Spuy,president who along with Precious
\nMatasoso, Director General, South African
\nMinistry of Health,provided welcoming re-
\nmarks, ably hosted the conference.
\nThose participating in the conference in-
\ncluded among others representatives from the
\nWorld Health Organization,US Department
\nof Health and Human Services (HHS), Eu-
\nropean Medicines Agency (EMA), The So-
\nciety of Swiss Physicians (FMH), Medicines
\nControl Council South America,Internation-
\nal Federation of Pharmaceutical Manufactur-
\ners and Associations,(IFPMA),the European
\nClinical Research Infrastructures Network
\n(ECRIN), academic medical centres from
\naround the world and representatives from
\nmember associations of the WMA.
\nTopics discussed related to the DOH includ-
\ned vulnerable groups, bio banks, post-study
\narrangements, and ethics committees. There
\nwas also consideration about whether the
\nDOH should provide additional guidance
\nin insurance\/compensation\/protection, use
\nof proven interventions,placebos,broad con-
\nsent and medical research involving children.
\nUrban Wiesing,Director Institute for Ethics
\nand History of Medicine University of Tub-
\ningen described the process for revising the
\nDOH and the history of previous similar ef-
\nforts.The questions, debate and engagement
\nof attendees responding to the speakers were
\nprobing, passionate and persuasive.
\nAs part of this process I think it is impor-
\ntant to remember some of the core prin-
\nciples specified in the introduction to the
\nDeclaration of Helsinki as follows:
\n\u2022 Although the declaration is addressed
\nprimarily to physicians, the WMA en-
\ncourages other participants in medical re-
\nsearch involving human subjects to adopt
\nthese principles.
\n\u2022 It is the duty of the physician to promote
\nand safeguard the health of patients, in-
\ncluding those who are involved in medi-
\ncal research.
\n\u2022 The Declaration of Geneva binds the
\nphysician with the words. \u201cThe health of
\nmy patient will be my first consideration\u201d.
\n\u2022 The International Code of medical Eth-
\nics declares, \u201cA physician shall act in the
\npatient\u2019s best interest when providing
\nmedical care.\u201d
\n\u2022 In medical research involving human
\nsubjects, the well being of the individual
\nresearch subject must take precedence
\nover all other interests.
\n\u2022 Medical research is subject to ethical stan-
\ndards that promote respect for all human
\nsubjects and protect their health and rights.
\n\u2022 Physicians should consider the ethical,
\nlegal and regulatory norms and standards
\nfor research, involving human subjects in
\ntheir own countries as well as applicable
\ninternational norms and standards.
\nIn remarks at the opening session I shared
\nwith the participants my enthusiasm about
\nthe process being undertaken with the fol-
\nlowing remarks:
\n\u2022 On behalf of the member associations of
\nthe World Medical Association and the
\npatients and physicians we represent let
\nme express my appreciation for your will-
\ningness to take time out of very busy lives
\nto be a part of this effort.
\n\u2022 I am awed by the experience, expertise
\nand the international reputations you
\nbring to this conference.
\n\u2022 I thank you for your interest in this im-
\nportant subject and for your participation
\nin this endeavour. I look forward over the
\nnext three days to being educated and im-
\npressed.
\nThe WMA Council last year established a
\nWorking Group to lead the effort of evalu-
\nating the DOH for possible changes. The
\nWorking Group has scheduled an additional
\nexpert conference to be held inTokyo in Feb-
\nruary (2013) to receive input and perspec-
\ntives from experts in the Far East geographic
\nregion. It is anticipated that draft document
\nwill be submitted to the WMA Council in
\nthe spring, followed by solicitation of public
\ncomment. Plans are for presentation of a re-
\nvised DOH in conjunction with celebration
\nof its fiftieth anniversary in 2014.
\nThanks again to the South African Medical
\nAssociation for hosting the DOH Expert
\nConference. I was educated and impressed.
\nCecil Wilson, MD, MACP, President, WMA
\nDeclaration of Helsinki. Expert Conference
\n3
\nCAM in OncologyGERMANY
\nCancer patients often turn to complemen-
\ntary (CAM) therapies because they believe
\nthese will improve their body\u2019s ability to fight
\ncancer and therefore their chances of survival
\nor at least will ameliorate quality of life.This
\narticle suggests recommendations which
\nrepresent a framework for advice on and safe
\napplication of CAM methods in oncology.
\nIn oncology safety with regard to CAM is
\neven more important than in other areas of
\nmedicine because data on effectiveness are
\nmostly missing and any intervention that is
\nable to enhance cancer cell survival either
\ndirectly or indirectly by interactions could
\nalso reduce patient\u2019s chance of cure or longer
\nsurvival. In contrast to other disciplines in
\noncology any delay in effective therapy may
\nenhance the possibility of resistance of the
\ndisease, incurability and progress. Wrong
\ndecisions taken during primary (or later)
\ntreatment of most types of cancer can not be
\ncompensated for later on. This very reason
\nmakes it important to monitor cancer treat-
\nments continuously and carefully so that pa-
\ntients receive the best chances of a therapy.
\nIntroduction
\nTreatment of cancer disease remains one of
\nthe greatest health challenges, and although
\ngreat strides have been made in some treat-
\nments, the prognosis for many patients re-
\nmains poor. Cancer patients often turn to
\ncomplementary (CAM) therapies because
\nthey believe these will improve their body\u2019s
\nstrength to fight cancer and therefore their
\nchances of survival. Many consider that
\nCAM therapies will improve their emo-
\ntional or physical well-being, help to avoid
\naggressive treatment, or at least make it
\nmore easily tolerated.
\nThe poor prognosis of many cancer patients
\nand their desire to participate actively in
\nany therapy which might ameliorate their
\ncondition have motivated CAM therapists
\nto search for new therapeutic approaches.
\nMany CAM practitioners are integer and
\ntheir intentions are entirely honourable.
\nHowever, others appear to be less prin-
\ncipled. They seem to view CAM practice
\nas a way of making easy money and exploit
\nthe fact that some patients with a poor out-
\nlook may try anything, often ignoring the
\nexpense, if they think it might help them.
\nThese practitioners of dubious motivation
\noften justify their activities with claims that
\nthey are pursuing \u201ctherapeutic freedom\u201dand
\nthat conventional medicine is often unable
\nto cure the disease.
\nConventional medicine has always had diffi-
\nculty in knowing how to judge and evaluate
\nCAM methods,and how to deal with CAM
\ntherapies and therapists. Mainly it has cho-
\nsen to ignore it. Meanwhile the US- Ameri-
\ncan National Academy of Sciences regards
\nbeing informed on CAM methods with fre-
\nquent usage as an \u201dobligation\u201c for physicians
\n(http:\/\/www.nap.edu\/catalog\/11182.html;
\nEthical Framework for CAM). This means
\nthat experts on CAM in oncology recom-
\nmend physicians to inform patients on data
\nconcerning safety and efficacy. Physicians
\nshould point at the missing proof of efficacy
\nof CAM as well as the relation of chances
\nand risks of conventional therapy [6].
\nAdams [1] denotes aspects of ethical de-
\ncisions: Severity and acuteness of disease,
\nchance of cure by conventional therapy, side
\neffects of conventional therapy, existence,
\nquality and evidence for efficacy and safety
\nof CAM, patient\u2019s understanding of risks
\nand usefulness of CAM and the voluntary
\nconsent of patients to accept the risks. \u201cIf
\nevidence (concerning the CAM therapy)
\nsupports both safety and efficacy, the phy-
\nsician should recommend the therapy but
\ncontinue to monitor the patient conven-
\ntionally. If evidence supports safety but is
\ninconclusive about efficacy, the treatment
\nshould be cautiously tolerated and moni-
\ntored for effectiveness. If evidence supports
\nefficacy but is inconclusive about safety, the
\ntherapy could still be tolerated and moni-
\nA Guideline for Treatment Decisions
\non CAM in Oncology: Prerequisites
\nfor Evidence Based Integration
\nKarsten M\u00fcnstedt Jutta H\u00fcbner
\n4
\nCAM in Oncology GERMANY
\ntored for safety. Finally, therapies for which
\nevidence indicates either serious risk or
\ninefficacy obviously should be avoided and
\npatients actively discouraged from pursuing
\nsuch a course of treatment\u201d [1].
\nFigure 1 shows 4 possible ways how to man-
\nage CAM use based on its safety and evi-
\ndence [4].If patient and physician consent to
\nan alternative therapy, omitting or delaying a
\nconventional therapy a close follow up has to
\nbe done (Ernst 2001, Cohen 2002). In order
\nto do this he has to have profound knowledge
\non remission, progression and time intervals
\nand the diagnostic measures to take in order
\nto provide maximum security for the patient.
\nOnly experienced oncologists with thorough
\nknowledge on oncology as well as CAM will
\nbe able to follow this rule.
\nThere is another obstacle to this rule: pa-
\ntients who adhere to complementary and
\nalternative medicine are likely to omit
\nfollow-up visits at their oncologists. One
\nreason for this is inherent with their seek-
\ning for alternatives: the oncological setting
\ndoes not provide the holistic approach they
\nare looking for. Another reason might be
\nthat they want to avoid any testimony of
\nfailure of alternative therapy and therefore
\nprefer diagnostics done by healers or other
\npersons. Finally, patients are told by their
\ndubious protagonists that they should avoid
\ncontact with conventional oncologists. This
\nis one reason why patients should be active-
\nly informed about CAM in the first place.
\nRegarding communication on CAM in on-
\ncology [5] developed a guideline for such
\ndiscussions with patients. This guideline is
\nbased on a systematic review of the litera-
\nture concerning patient-doctor communi-
\ncation in general and on CAM. 10 steps are
\nrecommended in this guideline (table 1).
\nWhy a guideline for
\nCAM use is needed
\nAll above mentioned recommendations and
\nguidelines focus on the discussion with the
\npatient and not on the treatment itself. In-
\ndeed, many CAM methods can be applied
\nby the patient himself.So the discussion may
\nlead to the decision on what the patient will
\ndo. But there are methods which the patient
\ncannot apply without the aid of his physi-
\ncian. These are likely to be based on techni-
\ncal devices (f. e. bioresonance, hyperthermia)
\nor are medical therapies with substances
\nwith side effects.Here the patient has to rely
\non the physician and in such a situation the
\nphysician has to accept a higher medical as
\nwell as ethical responsiveness than in a mere
\ndiscussion on CAM. Thus it is important to
\nestablish ways which assure that treatments
\nare given which are both well founded on
\nmedical knowledge and also in accordance
\nwith ethical values.The problem is that spe-
\ncific guidelines which have been issued for
\nsome tumour entities do not meet the indi-
\nvidual situation of the patients. Since most
\npatients also want that their etiologic con-
\ncept behind the development of cancer is
\nconsidered, it is important to suggest ways
\nfor such individualized treatments without
\nthe risk of composing something totally irra-
\ntional. Such a guideline is missing. It would,
\nonce established, not only improve individ-
\nual counselling but also regulate treatment
\ndecisions and allow addressing the problem
\nof \u201ccharlatans and quacks\u201d.
\nAdvancing to a guideline on CAM use by
\nphysicians:
\nWe have to consider three constellations:
\n1. Administration of CAM in conjunction
\nwith conventional treatments in a cura-
\ntive or palliative situation
\n2. Administration of CAM after comple-
\ntion of adjuvant therapy in a curative
\nsituation
\n3. A highly palliative setting with a patient
\nfacing death asking for an alternative
\nFor all three situations we have to ask for the
\nbenefit and risks for the patient. In order to
\ndefine benefit we should look at the scientific
\nTable1. 10 steps as a guideline for discussing Complementary and alternative medicine with patients [5]
\n1. Elicit the person\u2019s understanding of their situation
\n2. Respect cultural and linguistic diversity and different epistemological frameworks
\n3. Ask questions about CAM use at critical points in the illness trajectory
\n4. Explore details and actively listen
\n5. Respond to the person\u2019s emotional state
\n6. Discuss relevant concerns while respecting the person\u2019s beliefs
\n7. Provide balanced, evidence-based advice
\n8. Summarize discussions
\n9. Document the discussion
\n10. Monitor and follow-up
\nLow or missing evidence Reliable clinical evidence
\nHigh
\nsafety
\nOPTION B
\n\u2022 Tolerate
\n\u2022 Provide caution and
\n\u2022 Closely monitor effectiveness
\nOPTION A
\n\u2022 Recommend and
\n\u2022 Continue to monitor
\nLow
\nsafety
\nOPTION D
\n\u2022 Avoid and
\n\u2022 Actively discourage
\nOPTION C
\n\u2022 Consider tolerating
\n\u2022 Provide caution and
\n\u2022 Closely monitor safety
\nFigure 1. Possible options how to cope with CAM based on its safety and evidence et al. [3,5]
\n5
\nCAM in OncologyGERMANY
\ndata concerning influence on disease, quality
\nof life and side effects. Strength of evidence
\nregarding CAM, aspects of safety and the
\ncomparison of chances and risks between
\nconventional medicine and CAM has to be
\nscrutinized thoroughly. In the past, several
\nproblems have been encountered in studying
\nCAM. These are summarized in table 2. But
\nthe inherent problem of CAM is missing evi-
\ndence \u2013 if we had evidence, it would be easy
\nto define a method as conventional or alterna-
\ntive.Thuswehavetosetupruleshowtoconfer
\nrecommendations on an insecure fundament.
\nIn this context it seems appropriate to define
\na set of principles which will enable the devel-
\nopment of the guideline.These principles are
\nbased on logical and ethical considerations.
\nEthical fundament for a
\nguideline: Principles for
\nCAM in oncology
\nDefinition: There is a clear distinction be-
\ntween complementary and alternative medi-
\ncine, the former being part of scientifically
\nbased treatment strategies the latter sug-
\ngesting an \u201calternative\u201d way to cure. Only
\nthe complementary approach is scientifically
\nevaluable and can thus be discussed.
\nPrinciple 1: Any method in complemen-
\ntary medicine has to be tailored to the in-
\ndividual. This means that benefit only can
\nbe defined if it has been proven in a setting
\nsimilar to the situation of the patient.
\nPrinciple 2: In cases of unknown benefits,as
\nis typical for most methods of complemen-
\ntary medicine, safety is the most important
\nissue.
\nPrinciple 3: Cancer is a deadly disease with
\npoints of no return; therefore use of any ex-
\nperimental treatment is unethical as long as
\na proven treatment option exists. In cases of
\nadvanced palliative settings, palliative medi-
\ncine is the standard with which any other
\ntreatment has to be compared.It is unethical
\nto deny or delay palliative care in this setting.
\nPrinciple 4: Conventional medicine and
\nCAM must be assessed equally. This means
\nthat both must prove their efficacy and ef-
\nfectiveness following the rules of evidence
\nbased medicine.
\nPrinciple 5: In case of missing evidence
\nboth in conventional as well as complemen-
\ntary therapy in a given setting the physician
\nshould make his recommendations accord-
\ning to principle 1 and 2. Shared decision
\nmaking is the recommended way of com-
\nmunication in this situation.
\nPrinciple 6: Physicians giving advice on
\nCAM must adhere to honesty and sincerity.
\nNo undue hope should be evoked by false
\npromises.
\nPrinciple 7:Patients\u2019autonomy has to be con-
\nsidered.Complementary medicine should be
\na means to strengthen autonomy and should
\nnot be abused to enhance dependency.
\nThese seven principles follow the ethical
\nrules of Beauchamp and Childress:
\n\u2022 Autonomy \u2013 patients have the right to
\nchoose, but not obligation to choose
\n\u2022 Nonmaleficiency
\n\u2022 Beneficence
\n\u2022 Honesty
\nDeveloping a guideline by syn-
\nthesis from the principles and the
\nevidence based recommendations
\nconcerning discussion on CAM
\nA synthesis of the ethical principles pre-
\nsented above and the recommendations
\nfrom Shoffield and others which sum up the
\nevidence on counselling patients on CAM
\nin oncology is the fundament for a guide-
\nline on CAM use.
\nA comparison of both shows, that they are
\ncomplementary to each other as they focus on
\ncommunication on the one side and action on
\nthe other.There is only a small overlap in the
\nfield of patient\u2019s autonomy.Table\u00a03 provides a
\ncomparison of the recommendations [5] and
\nthe principles suggested in this article. In or-
\nder to achieve maximum safety and efficacy
\nin CAM, ten steps can be identified. They
\ndescribe the whole process of counselling,de-
\ncision making and administration of CAM.
\nEach step is accompanied by requirements
\nwhich are mandatory for its realization.These
\nsteps are explained as follows:
\n1. Counselling
\nAll patients with cancer should be counselled
\nabout CAM, especially about the methods
\nmost frequently used, so that they are able
\nTable 2. Problems in studying CAM. Up to the present, studies on CAM in oncology have limited
\nthemselves to a very general exploration
\n1. CAM literature is not always published in mainstream journals and listed in f.e.Medline.
\n2. Articles often are written in native language and only accessible as abstract in English.
\n3. Mostly it is not clear whether a CAM method is applicable to every type of tumour
\nand medical condition or is only suitable for certain settings.
\n4. Most studies on supportive treatment issues do not look for long term safety as follow-
\nup of the studies is too short.
\n5. Reviews are often out of date soon after they have been published.
\n6. Published reports are not revisited and updated regularly and frequently enough.
\n7. Not all CAM methods are covered and in the meantime, new ones are invented or old
\nones modified.
\n8. Furthermore most reviews rely on only few studies if any and therefore tend to be nar-
\nrative reviews instead of systematic.
\n6
\nCAM in Oncology GERMANY
\nto judge critically any promises and offerings
\nof dubious therapists and can thus avoid any
\npotentially harmful influences of the meth-
\nod itself or when it is given in combination
\nwith other treatments. If desired, patients
\nshould be advised about methods which are
\nlikely to have beneficial effects. Counsel-
\nling should be done according to the rec-
\nommendations of Shoffield and colleagues.
\nUnderlying requirements: Oncologists need
\ngreater knowledge of CAM therapies.There
\nmust be ongoing education in CAM,begin-
\nning with undergraduate medical training
\nand continuing during specialisation.
\n2. Evidence in CAM
\nSelection of a treatment method must take
\ninto the account the levels of evidence and
\nthe credibility of the data and its authors.
\nBoth have to be evaluated critically. The
\nlevels of evidence and grades of recom-
\nmendations apply as much to CAM as they
\ndo to conventional medicine. Generally,
\nthe method which has yielded best results
\nshould be the one be selected.
\nUnderlying requirement: There must be con-
\ntinuing reviews in the field of CAM,aiming
\nto identify new and perhaps rational treat-
\nment approaches and also potentially risky
\nor ineffective methods.
\n3. Selection of CAM treatment
\nSelection of CAM methods must be done
\nrationally and objectively. Only methods
\nwhich have been investigated in clinical tri-
\nals and have shown positive effects should
\nbe chosen. Methods based on philosophical
\nor pseudo-religious beliefs can not be ac-
\ncepted unless their efficacy has been proven
\nin such trials.
\nIf this clinical proof is missing, preclinical
\ndata should not be the bases for an active
\nrecommendation, yet they can be used as a
\nrefererence to inform patients who are ac-
\ntively asking about a certain method.
\nCAM is used in two intentions: as support-
\nive agent or as antitumor agent. Since there
\nis no universal cancer \u201cdrug\u201din conventional
\nmedicine, the selection of antitumor treat-
\nment should focus on methods which have
\nbeen tested in the type of tumour being
\ntreated.
\nCAM should only be used if it has been
\nstudied in a setting similar to the one dis-
\ncussed with the patient.
\nUnderlying requirement: Therapeutic con-
\ncepts for treating different tumours in vari-
\nous treatment situations or supportive situ-
\nations should be developed.
\n4. Applying CAM methods
\nIn a curative setting and during active
\ntreatment, the use of any CAM therapies
\nshould be restricted to those methods
\nwhich have high clinical evidence. In a
\npalliative situation and after all reasonable
\nconventional treatments have been tried
\nmore poorly investigated, other methods
\nmay be used if patients actively demand
\nfor them. However, there always must
\nbe some rational to support the use of a
\nmethod. If this is only based on preclini-
\ncal data the same rules of counselling as
\nin informing patients on a phase I study
\nmust be applied.
\nUnderlying requirements: Physicians in-
\nforming patients on CAM use in advanced
\npalliative care without clinical data or with
\nthe intention of using a method\u2019s antican-
\ncer effects must have excellent knowledge
\nTable 3. Comparison of the principles suggested in this article to the recommendations of Shoffield
\net al. [5]
\nPrinciple Recommendation of Shoffield et al.
\n1: Therapy has to be individualized No equivalent
\n2: Safety is of highest importance No equivalent
\n3: Do not deny therapies with known
\nbenefit
\nNo equivalent
\n4: Evidence on CAM follows the rules of
\nEvidence based medicine
\n7. Provide balanced, evidence-based advice
\n5: In case of missing evidence in conven-
\ntional as well as complementary therapy
\nfollow principles 1 and 2
\nNo equivalent
\n6: Ethical principles to follow are honesty
\nand sincerity
\nNo equivalent
\n7: Respect patient\u2019s autonomy
\n1. Elicit the person\u2019s understanding of their
\nsituation
\n2. Respect cultural and linguistic diversity
\nand different epistemological frameworks
\n6. Discuss relevant concerns while respect-
\ning the person\u2019s beliefs
\nNo equivalent
\n3. Ask questions about CAM use at critical
\npoints in the illness trajectory
\nNo equivalent 4. Explore details and actively listen
\nNo equivalent 5. Respond to the person\u2019s emotional state
\nNo equivalent 8. Summarize discussions
\nNo equivalent 9. Document the discussion
\nNo equivalent 10. Monitor and follow-up
\n7
\nCAM in OncologyGERMANY
\nof all preclinical data of the method. Inclu-
\nsion of patients in ongoing clinical studies
\ncould also be discussed as a true alternative
\nfor the patient.
\n5. Safety
\nCAM methods must have proven benefits
\nand must be safe in relation to drug interac-
\ntions. If drug interactions are suspected, the
\nCAM treatment must be discussed criti-
\ncally and patients must be advised not to
\nuse it.These considerations refer to all kinds
\nof conventional treatments (chemotherapy,
\nradiotherapy, hormonal and immunological
\ntherapies).
\nUnderlying requirement: Checklists should
\nbe developed which can help to exclude the
\nmost common causes of drug interactions
\nin oncology.
\n6. Costs
\nThere must be a reasonable relationship be-
\ntween expected benefits and costs. Poorly
\nstudied methods should only be considered
\nwhen costs are low. Patients should be ad-
\nvised to avoid expensive CAM treatments
\nunless they have proven efficacy.
\nUnderlying requirement: A list of CAM
\nmethods with evidence which fulfils the
\nrules for reimbursement should be set up
\nand funding by a defined process discussed
\nwith stakeholders.It must be made sure that
\nthis discussion will not open the process to
\nthe reimbursement of methods with low
\nevidence.
\n8. Shared decision making, informed con-
\nsent and documentation
\nThe whole process of counselling and
\ntherapy has to be discussed thoroughly
\nwith the patient. The principles of shared
\ndecision making should be obeyed. Any
\ncommunication which increases patients\u2019
\ndependence on the physician must be
\navoided.
\nPatients should provide written informed
\nconsent to their records being used for re-
\nsearch purposes. Monitoring of patients
\nduring CAM use assessing the course of the
\ndisease and adverse effects as well as quality
\nof life is mandatory.
\nUnderlying requirement: The physician must
\nhave sound knowledge about the course of
\nthe disease and the use of adequate diag-
\nnostic means. He must also know the side
\neffects of ongoing conventional therapy as
\nwell as the CAM method selected and he
\nmust be highly sensitive to any sign of in-
\nteraction.
\n10. Generating Evidence: Studies and Pub-
\nlication
\nCase reports and case series on CAM
\nmethods should be published once a con-
\nclusive situation was reached. Practitioners
\nwith experience of certain CAM methods
\nshould be encouraged to analyse their data.
\nFurthermore, CAM therapists should col-
\nlect data on certain methods for subsequent
\nanalysis.
\nUnderlying requirements: As most practitio-
\nners do not have experience with publica-
\ntion cooperation with scientists could be
\nhelpful. A consented reporting system with
\ndefined data sets would enable scientists to
\nfind all necessary information in order to
\ndecide whether the case report gives hints at
\nthe effects of the CAM method used. Case
\nreports and case series can be important
\nwhen they refer to new medical situations
\nor report new side effects. Clinical studies
\non CAM must be encouraged. Also trials
\nin conventional medicine should assess the
\nprevalence of CAM methods in order to
\ndetect possible positive or negative effects.
\nThere also must be greater awareness of
\nCAM, including the willingness to grant
\nmoney to support studies in the field and to
\ncooperate with the scientific study groups.
\nStudies should be published in peer-re-
\nviewed journals.
\nConclusion
\nThese recommendations represent a frame-
\nwork which should enable the safe applica-
\ntion of CAM methods in oncology. Adopt-
\ning recommendations such as these seems
\nparticularly important for cancer patients
\nsince they, unlike patients in other areas of
\nmedicine, will not perhaps have a second
\nchance. Wrong decisions taken during pri-
\nmary treatment of most types of cancer can
\nnot be compensated for later on. This very
\nreason makes it important to monitor can-
\ncer treatments continuously and carefully
\nso that patients receive the best chances of
\na cure. Furthermore, only a rational and evi-
\ndence based approach to CAM in oncology
\ncan make this field more generally respected.
\nReferences
\n1. Adams KE, Cohen MH, Eisenberg D, Jonsen
\nAR. Ethical considerations of complementary
\nand alternative medical therapies in convention-
\nal medical settings. Ann Intern Med. 2002 Oct
\n15;137(8):660-4.
\n2. Beauchamp TL, Childress JF. Principles of
\nBiomedical Ethics. 6. Aufl., Oxford University
\nPress, 2008, ISBN 0-19-533570-8.
\n3. Cohen MH, Eisenberg DM. Potential physician
\nmalpractice liability associated with comple-
\nmentary and integrative medical therapies. Ann
\nIntern Med. 2002 Apr 16;136(8):596-603.
\n4. Ernst E, Cohen MH. Informed consent in com-
\nplementary and alternative medicine. Arch In-
\ntern Med. 2001 Oct 22;161(19):2288-92.
\n5. Schofield P, Diggens J, Charleson C, Marigliani
\nR,Jefford M.Effectively discussing complemen-
\ntary and alternative medicine in a conventional
\noncology setting: communication recommenda-
\ntions for clinicians. Patient Educ Couns. 2010
\nMay;79(2):143-51.
\n6. Sugarman J, Burk L. Physicians\u2019 ethical obliga-
\ntions regarding alternative medicine. JAMA.
\n1998 Nov 11;280(18):1623-5.
\nProf. Dr. Karsten M\u00fcnstedt
\nUniversit\u00e4tsfrauenklinik
\nGiessen Klinikstrasse 33
\nE-mail: karsten.muenstedt@
\ngyn.med.uni-giessen.de
\nDr. Jutta H\u00fcbner
\nKlinikum der J.W. Goethe Universit\u00e4t
\n8
\nRegional and NMA news CHINA
\nMissions set in the three-year plan for Chi-
\nna\u2019s healthcare reform from 2009 to 2011
\nhave been completed on schedule. Now,
\nplease, allow me to introduce you to the ba-
\nsic facts of the current healthcare reform in
\nChina.
\nI. By achieving periodical
\ngoals as scheduled, the
\nthree-year healthcare reform
\nachieved remarkable effect
\nIn April 2009, the central government initi-
\nated the new round of healthcare reform. In
\nthe past three years, we have been sticking
\nto the philosophy of providing basic health-
\ncare system to our people as public goods.
\nGuided by the principle of ensuring the
\nbasic, strengthening the grass-roots and es-
\ntablishing the mechanism, providing meth-
\nodology for coordinating arrangements,
\nemphasizing the priorities, and advancing
\nin a stepwise manner, we intensified leader-
\nship,increased input,innovated the working
\nmechanism and improved policy support.
\nThe key priorities of the health care reform
\nhave been pushed forward and obvious
\nprogress has been achieved.
\nFirstly,residentsinurbanandruralareashave
\nbenefited as seen fron the National Health
\nIndicators. Maternal mortality rate dropped
\nfrom 34.2\/100,000 to 26.1\/100,000, infant
\nmortality rate went down from 14.9\u2030 to
\n12.1\u2030, and average life expectancy has also
\nincreased. Urban and rural residents have
\naccess to 41 basic public health care services
\nin 10 categories.The out-of-pocket medical
\npayment for rural residents who have joined
\nthe New Rural Co-operative Medical
\nScheme (NRCMS) decreased from 73.4%
\nthree years ago to 49.5% in 2011. The ac-
\ncessibility and affordability of medical care
\nservice has been improved. Secondly, health
\ncare resource allocation and utilization have
\nbeen optimized.With preferential public fi-
\nnance policy towards the grass-roots, rural
\nareas, and public health, the gap of medical
\ncare and health development between urban
\nand rural areas has been narrowed gradually.
\nThere emerges the tendency of increased
\nutilization of primary healthcare services,
\nand research and science are developed in
\nthe health sector. Thirdly, the framework
\nof basic healthcare system has been pre-
\nliminarily established. Medical insurance
\nfor urban employees, urban residents and
\nthe NRCMS have covered over 95% of the
\npopulation, which forms the largest basic
\nmedicare security and safety net. The na-
\ntional essential drug system has been im-
\nplemented in all government-run medical
\nand health institutions at grass-roots level,
\nthus meeting the people\u2019s basic needs for
\nessential medicine. Primary health delivery
\nsystem has been enhanced with improved
\nservice quality. Public hospital pilot reform
\nhas been pushed forward actively in good
\norder. Access to basic public health services
\nhas been enhanced by institutional arrange-
\nments with emphasis on prevention. Tra-
\nditional Chinese Medicine (TCM) plays a
\nmore important role in health care and pre-
\nvention. Fourthly, major structural changes
\nhave taken place in total health expenses.
\nProportion of individual health expendi-
\nture dropped from 40.4% in 2008 to 35.5%
\nin 2010 due to more reasonable health fi-
\nnancing and led to enhanced health care
\nequity. Excessive growth in public hospital
\nexpenses has been effectively controlled, as
\ncalculated in comparable price, the annual
\nrise of in-patient and out-patient expenses
\nin public hospitals have been brought down
\nby 3\u20134% average.
\nIn the past three years, five reform priori-
\nties have been promoted and great improve-
\nments have been achieved in the healthcare
\nfield.
\n1. Basic medical insurance system
\nhas been established and
\nconsolidated, being a critical step
\nforward to the goal of universal
\naccess to health care service
\nUniversal access to medical insurance is
\nthe top priority in the healthcare reform.
\nIt plays an important role in safeguard-
\ning people\u2019s health and providing healthy
\nworkforce for sustainable development. At
\npresent, medical insurance for urban em-
\nployees, urban residents and the NRCMS
\nhave covered 1.3 billion people (over 95%),
\nand the coverage of the NRCMS reached
\n97.5%. The NRCMS fund pooled has
\nreached 243 RMB Yuan per capita, out
\nof which 208 RMB Yuan is subsidized by
\ngovernments of various levels.This year, the
\nper capita fund will reach 290 RMB Yuan
\nand the subsidy will be 240 RMB Yuan. In
\nrural areas out-patient expenses have been
\ncovered by the NRCMS, and maximum in-
\npatient compensation has been set 6 times
\nhigher than rural per capita net income and
\nno lower than 50,000 RMB Yuan. In 86%
\nof the rural areas covered by the NRCMS,
\nthe reimbursement rate within the scheme
\nhas reached over 70%. Medical insurance
\npilot on catastrophic diseases also advances.
\nSince the initiation of including leukemia
\nand child congenital heart disease in 2010,
\ntill the end of 2011, 93% of the NRCMS
\nareas have started pilot work. In some areas,
\n6 more major diseases including holergasia,
\ntuberculosis, cervical cancer, breast cancer,
\nend-stage renal disease and HIV\/AIDS are
\nalso covered, having benefited more than
\n200,000 patients.
\n2. National essential drug system
\nhas been preliminarily established,
\ngrass-roots level health care service
\noperated under new mechanism
\nIn accordance with the reform plan, by
\nimplementing essential drug system, com-
\nprehensive reform of the grass-root level
\nmedical and healthcare institution has been
\nHealthcare System Reform in China
\n9
\nRegional and NMA newsCHINA
\ncarried out. It aims to build a public man-
\nagement system, to set competitive employ-
\nment and incentive distribution mecha-
\nnism, to adopt regulated drug purchasing
\nand long-acting multi-channels compensa-
\ntion mechanism.
\nUnder joint efforts, essential drug system
\nhas been implemented in government-run
\ngrass-roots medical and healthcare institu-
\ntions, where essential drugs are distributed
\nand sold with zero markup. The practice of
\nsubsidizing medicine services with drugs
\nsales profits has been eliminated. Essential
\ndrug system also extends to county level
\nhealth care institutions and non-govern-
\nmental grass-roots healthcare institutions.
\nA total of 307 kinds of drugs have been
\nincluded in the national essential drug list,
\nwhile additional drugs are added by prov-
\ninces (autonomous regions, municipal cit-
\nies). Average 210 kinds of drugs have been
\nadded and 29 provinces (autonomous re-
\ngions, municipal cities) have adopted new
\nmeasures for the purchase of essential drugs.
\nMeanwhile, we promote the comprehensive
\nreform of the grass-roots level medical and
\nhealthcare institutions. Government-run
\ngrass-roots level medical and healthcare
\ninstitutions are defined as public institu-
\ntions, provided with special fiscal subsidy
\nand regular balance of payment subsidy.
\nStaffing system of total amount control
\nand dynamic management is adopted while
\nstaffing checking and posts adjustment has
\nbeen carried out. Hence a new employment
\nmechanism is founded offering employees
\nentry and exit, promotion and demotion. In
\ngovernment-run grass-roots level medical
\nand healthcare institutions, comprehen-
\nsive quantified performance evaluation and
\nperformance-based salary system have been
\nimplemented, linking the evaluation results
\nwith the government subsidy and the in-
\ncome of the healthcare staff. Preliminarily,
\nthe compensation channel mainly support-
\ned by fiscal investment and health care in-
\nsurance payment has been formed in grass-
\nroots medical and health care institutions.
\nThe subsidy to village doctors for providing
\npublic health services has been realized and
\nessential drug system is promoted in village
\nclinics.
\n3. Healthcare delivery system at
\ngrass-roots level has been effectively
\nconsolidated and the goal of
\n\u201cstrengthening the grass-roots\u201d
\nhas been preliminarily realized
\nDuring the past three years of the reform,
\nthe central government had invested 47 bil-
\nlion RMB Yuan to support 35, 000 hous-
\ning construction programs of the grass-root
\nmedical and health care institutions. Grass-
\nroots healthcare service delivery system has
\nbeen strengthened; poor medical facilities
\nand weak service capability in rural and
\nremote areas has been greatly improved;
\nqualification, knowledge and the number of
\npersonnel recruited are all improved.By ini-
\ntiating the general practitioner cultivation
\nplan, 36,000 health workers in grass-roots
\nmedical and health institutions received on
\nthe job training to become general practi-
\ntioners. Through the central\/western rural
\narea-oriented cultivation plan, more than
\n10,000 medical students were trained free of
\ntuition for grass-roots health institutions in
\ncentral and western rural areas. In the three
\nyears, visits to township hospitals, commu-
\nnity health centers or stations, village clin-
\nics amounted to 10.81 billion person times,
\n61.4% of the total number of visits to medi-
\ncal institutions at all levels.
\n4. Equal access to basic public
\nhealth services has been enhanced
\nIn the past three years, the coverage of the
\nbasic public health services has been ex-
\npanded and planned mega public health
\nprograms have been accomplished ahead
\nof schedule. Major communicable disease
\nprevention has been improved with the
\nprinciple of prioritizing prevention put into
\ngood practice. The basic public health ser-
\nvice fund reaches unified standard in both
\nurban and rural areas and is increasing year
\nby year, from 15 RMB Yuan in 2009 to 25
\nRMB Yuan in 2011 per capita. A total of
\n982,000,000 residents now have health
\nrecords and 62.9% of them have standard-
\nized electronic health records. Mega public
\nhealth service programs in total have cov-
\nered nearly 0.2 billion people.
\n5. Public hospital pilot reform
\nis advancing systematically,
\nexperience in institutional
\nreform has been accumulated
\nThe reform exploration has been carried out
\nin 17 national pilot cities,37 provincial pilot
\ncities and 2000 public hospitals, and posi-
\ntive progress has been achieved in service
\ndelivery, institutional innovation, internal
\nmanagement and diversified pattern of hos-
\npital running. Through reducing the elimi-
\nnating drug markup, payment mode reform
\nand separation of revenue and expenses,
\nwe are exploring ways to separate medical
\nservices from drug sales. By improving the
\nsupervision system and emphasizing the
\ngovernment\u2019s function in supervision, we
\nare actively searching for an effective model
\nof administration reform in public hospitals.
\nComprehensive pilot reform of county-level
\nhospitals has started, featuring eliminating
\nthe practice of subsidizing medical services
\nwith profits from drug sales, and advancing
\ncomprehensive reform in management sys-
\ntem, compensation system, human resource
\nsystem, purchasing mechanism and pric-
\ning mechanism. All these measures aim to
\ngradually set up a new public hospital oper-
\nation mechanism that maintains the public
\nwelfare nature, motivates health profession-
\nals and ensures sustainable development.
\nII. Reflection of the three-
\nyear healthcare reform
\nThe three-year health care reform practice
\nproves that the guiding ideology, principle
\n10
\nRegional and NMA news CHINA
\nmethodology and basic pathway set out by
\nthe central government are fully in line with
\nour national circumstances, health care de-
\nvelopment rule, and the wish and needs of
\nour people. We summarize our experience
\nand reflection as follows:
\n1. Strengthen the policy
\nimplementation and promote
\nthe establishment of basic
\nhealthcare system
\nThe guiding documents on healthcare re-
\nform of the central government explicitly
\nstipulated that basic medical and healthcare
\nservices be provided to the people as pub-
\nlic goods. This demonstrates the significant
\nchange of our health development from
\nideology to mechanism. It shows the deter-
\nmination of the Party and the government
\nto improve people\u2019s well-being by taking
\nmeasures in the health sector. The health
\nsystem carries out the deployment from
\nthe party central committee and the State
\nCouncil unswervingly, follows the principle
\nof the central government document with
\nperseverance. These are the fundamental
\nguarantees to achieving the expected results
\nof the healthcare reform.
\n2. Increase input and promote
\ninstitutional reform
\nInstitutional reform has a comprehensive,
\nfundamental and long-term influence on
\nthe development of the health sector. In or-
\nder to obtain success, we must not only in-
\ncrease input, but also pay attention to insti-
\ntutional transformation in order to reform
\nthe old improper interest pattern.
\n3. Insist on the leading role of the
\ngovernment and promote inter-
\ndepartment coordination
\nAs the healthcare reform is a critical trans-
\nformation in society, powerful leadership
\nand working system secure its smooth
\nprogression. Leading groups and inter-de-
\npartment coordination mechanism set up
\nby the central and local government have
\nplayed an important role in overall plan-
\nning, consensus building and the reform
\npromotion.
\n4. Highlight top-level policy
\ndesign and advance each reform
\ntask in a coordinated manner
\nAdhering to the masterstroke of the health-
\ncare reform document from the central
\ngovernment, insisting on the five key re-
\nform priorities, we promulgated series of
\nguiding policy measures. Every slight move
\nmay affect the work as a whole. Hence we
\nmust make an overall plan and take all fac-
\ntors into consideration. We must gradually
\ncarry forward the work with the supporting
\npolicy, through close coordination, by high-
\nlighting the key points.
\n5. Enhance policy implementation
\nand motivate medical professionals
\nWhether we can accomplish the reform
\nand make breakthrough in the key tasks or
\nnot depends on arousing the enthusiasm,
\ncreativity and activeness of medical profes-
\nsional to let them devote to the reform with
\nheart and soul. Therefore, we must improve
\nthe relevant policies and set up salary sys-
\ntem, performance evaluation system and
\nincentive distribution system compatible
\nwith the features of this profession. Related
\nissues as welfare and benefits, career devel-
\nopment and practicing environment should
\nalso be addressed appropriately.
\n6. Strengthen the joint actions of
\ncentral and local governments and
\nrespect the local pioneering spirit
\nAlong with the implementation of health-
\ncare reform policies of the central govern-
\nment, local experiences have been drawn
\nand transformed into national policy. This
\nleads to the interaction between the guid-
\nance of central government and the practice
\nof local health departments. This three-year
\nreform journey reveals that the driving force
\nand sources of practice are at the grass-roots
\nlevel. Thus, we shall emphasize that local
\ngovernments should explore to make break-
\nthroughs, and experiences in this regard can
\nlead to central-local interaction and make
\nnational breakthroughs.
\nIII. Continuously promote
\nthe healthcare reform
\nThe twelfth five-year period serves as a
\nlinkage between the past and the future
\nin the healthcare reform. Guided by the
\nhealthcare reform spirit and principles en-
\nshrined in the address of Vice Premier LI
\nKeqiang at the National Working Meet-
\ning on Deepening the Healthcare Reform,
\nwe shall intensify our efforts in the three
\npriorities stipulated in the twelfth five-year
\nplan of the healthcare reform, namely, ac-
\ncelerating the construction of the basic
\nmedical insurance system, improving es-
\nsential drug system and enhancing new op-
\neration mechanism in grass-roots medical
\nand health institutions. We shall focus on
\nmedical insurance, medicine and medi-
\ncal services and take well-coordinated ac-
\ntion jointly in these three aspects so as to
\nachieve greater progress in the healthcare
\nreform.
\n1. Accelerate the construction of the
\nbasic medical insurance system
\nFirstly, consolidate the coverage and en-
\nhance the basic medical insurance level.
\nOn the one hand, a stable fund increase
\nmechanism should be set up. With the ris-
\ning income of urban and rural residents,
\nsubsidy from the government shall rise
\naccordingly. By 2015, yearly subsidy for
\nurban residents\u2019 medical insurance and the
\n11
\nRegional and NMA newsCHINA
\nNRCMS shall have reached above 360
\nRMB Yuan per capita. On the other hand,
\nwith the increased funding, insurance
\npackage shall be expanded and the com-
\npensation proportion shall be raised, fea-
\nturing about 75% of the in-patient expens-
\nes paid within the urban employee medical
\ninsurance, residents\u2019 medical insurance and
\nthe NRCMS and the out-of-pocket medi-
\ncal payments for residents shall continue to
\nbe reduced.
\nSecondly, promote reform in medical in-
\nsurance payment. The payment system
\nreform is an important way to control ex-
\npenses. In order to replace the current
\npay-by-item, such payment methods as
\ntotal prepaid, diagnosis-related grouping,
\nfee-for-service and\/or capitation shall be
\nadopted. New ways of payment will further
\nregulate the medicare service, control the
\nexpenses and promote the comprehensive
\nreform of the medical institutions.
\nThirdly, improve basic medicare manage-
\nment and service. Information manage-
\nment should be forwarded to avail resident
\nhealth card, realize immediate accounting
\nin overall planned regions and speed up
\ntrans-regional immediate accounting. We
\nare also to level up the overall planning of
\nthe NRCMS and increase fund risk resis-
\ntance. The NRCMS funding is encouraged
\nto be used for purchasing commercial medi-
\ncare insurance as complementing the medi-
\ncare insurance system.
\nFourthly, explore to build medical insur-
\nance for catastrophic diseases. By linking
\nthe NRCMS fund and medical aid, the
\ncompensation rate for catastrophic diseases
\nshall reach 90%. By the end of this year,
\nthe insurance scheme of 8 major diseases
\nincluding child congenital heart disease
\nand leukemia will be implemented entirely
\nand in 1\/3 of the overall planned regions,
\n12 kinds of diseases including lung cancer,
\nacute myocardium infarction, hemophilia
\nand hyperthyroidism will also be included
\nto maximally prevent disease-led poverty
\nand disease-led back to poverty for the
\nNRCMS peasants.
\n2. Consolidate and improve
\nessential drug system and new
\ngrass-roots operation mechanism
\nFirstly, consolidate national essential
\ndrug system. Based on the previous 3-year
\nwork, the system shall be expanded to all
\nvillage clinics this year. In the meantime,
\nessential drugs shall be given priority in
\nterms of distribution and use in other
\nmedical institutions. The national essential
\ndrug list shall be improved, local essential
\ndrug list amendment, drug use by medi-
\ncal institutions and purchase mechanism
\nshall be further regulated in order to ensure
\nsafety, efficacy and timely supply of essen-
\ntial drugs.
\nSecondly, keep promoting comprehensive
\nreform in grass-root medical and health-
\ncare institutions. Improve the long-term
\nstability of the multi-channel compensa-
\ntion mechanism and implement the fiscal
\ninput policy to the letter. Carry out the gen-
\neral consultation fee and medical insurance
\npayment policy and ensure a long-term
\nstabilized operation of grass-root medical
\nand health care institutions. By means of
\nimproving the performance evaluation sys-
\ntem, salary and distribution system in line
\nwith medicare character, there should be a
\nreasonable gap in salary in order to motive
\nhealth professionals.
\nThirdly, improve grass-root medical and
\nhealthcare service. Standardized construc-
\ntion of grass-root medical and health care
\ninstitutions will be supported continually,
\naiming to cover more than 95% of them
\nby the end of the twelfth five-year period.
\nGeneral practitioner (GP) team building
\nwill be promoted to cultivate over 150 000
\nGP by 2015, featuring more than 2GPs for
\neach 10 000 urban residents and a GP in
\nevery health clinics in towns. Free medical
\nstudents orientation training and GP spe-
\ncial duty plan will also be continued to en-
\ncourage talents serve in grass-root areas.The
\nissues of rural doctors in terms of function
\npositioning, working environment, com-
\npensation and pension should be properly
\naddressed to build a solid foundation for
\nrural healthcare system.
\n3. Advance comprehensive
\npublic hospital reform
\nPublic health reform shall focus on the
\ncounty level. Efforts should be made to
\npromote institutional reform and to pro-
\nvide convenient and accessible health
\nservices to the people. According to the
\nrecently issued opinion on comprehensive
\npilot reform in county level public hospital by
\nthe General Office of the State Council,
\nthe reform should follow the principle of
\njoint action of the central and local gov-
\nernments with inner vitalization and outer
\nthrust. According to the requirements of
\nthe reform to separate administration from
\nservice, management from running, medi-
\ncare from medicine, the for-profit from the
\nnon-for-profit, we shall eliminate the prac-
\ntice of subsidizing medical services with
\nprofit from drug sales as the key link, the
\ncompensation system reform and indepen-
\ndent management of hospitals as the break-
\nthrough points. We shall promote reforms
\nin the administration, compensation, per-
\nsonnel distribution, pricing, medical insur-
\nance payment, purchasing and supervision
\nsystems.
\nFirstly, eliminate the practice of subsidiz-
\ning medical services with profit from drug
\nsales, a compensation mechanism formed
\nunder special historical conditions. At
\npresent, this mechanism has cast negative
\ninfluence, hurt the public nature of public
\nhospitals and become a malady need to be
\neliminated in the healthcare field. Public
\nhospital is the main body to provide medi-
\ncare services in China while issues of ac-
\ncessibility and affordability mainly occur
\nhere. Unless we eliminate the malady, it is
\n12
\nRegional and NMA news CHINA
\nhard for us to eradicate the prescription of
\nexcessive and costly drugs, and to suppress
\nthe improper increase of medicare expenses
\nfrom the root. This mechanism hurts not
\nonly the interests of the people but also the
\ndoctor-patient relationship. With its exis-
\ntence, it is hard to form the mechanism of
\ngrass-root gatekeeper, dual referral, preven-
\ntion-treatment combination, acute-chronic
\nseparation and inter-institution coordina-
\ntion.
\nSecondly, improve comprehensive com-
\npensation mechanism. Income reduced
\nby eliminating the practice of subsidiz-
\ning medical services with profit from drug
\nsales should be compensated by setting up
\nmulti-channel compensation mechanism
\nof medicare insurance-finance joint action.
\nWe need to properly adjust the medicare
\nservice pricing system, to improve cost ac-
\ncounting of public hospitals, to increase
\ngeneral service fee, nursing fee and opera-
\ntion fee that give expression of the medi-
\ncal professionalism and to fully respect
\nthe professional dedication and values of
\nmedicare service. At the same time, we
\nshould control the total amount and adjust
\nthe structure, and reduce large equipment
\nexamination fee to achieve total balance.
\nSince medical insurance has become the
\nmain funding for public hospitals, we must
\ngive full play of its compensating function,
\nto promote payment reform, to include
\nthe increasing expenses into insurance re-
\nimbursement and to avoid adding burden
\nto the people. Meanwhile, governmental
\ninvestment shall be increased, including
\nsubsidies for public hospital infrastruc-
\nture construction, large medical equipment
\npurchase, personnel training, key discipline
\ndevelopment, pension and policy-related
\nloss.
\nThirdly, motivate the medical profession-
\nals. As medical professionals are the major
\ndriving force of the healthcare reform, a
\nsalary system in which special features of
\nthis profession are taken into consideration
\nshould be set up. To ensure an income in-
\ncrease after the reform, we should explore
\nto reform the current total wage limit in
\npublic institutions and raise the expendi-
\nture ratio on personnel over operation. In
\nthe meantime, to provide medicare staff a
\npromising career development, we should
\ncreate a good environment, improve pro-
\nfessional qualification system and develop
\nkey clinical disciplines. Furthermore, to
\nbuild a harmonious doctor-patient rela-
\ntionship, we should adopt more training
\non humane care, enhance mutual trust and
\nbuild the third-party negotiation mecha-
\nnism.
\nFourthly, improve medical care services
\nin public hospitals. We will strive to re-
\ncruit talented personnel, and formulate
\nfavorable policies on staffing administra-
\ntion, professional qualification appraisal,
\nsalary and welfare, so as to attract the
\ntalents to practice in public hospitals. By
\nenhancing performance evaluation and
\nincentive mechanism, implementing stan-
\ndardized resident-training and on the job
\ntraining for medical professionals, we shall
\nimprove the overall medicare services in
\npublic hospitals. A special post will be set
\nup in county level hospitals and badly-in-
\nneed high level talents will be recruited. In
\nthe meantime, central-local government\u2019s
\njoint action will continue to target support
\nat designated areas, and first diagnosis at
\nprimary health facilities, graded diagnos-
\ntic and treatment, and dual referral system
\nwill be developed.
\n4. Promote other healthcare reform
\nwork in a coordinated manner
\nFirstly, improve equal access to public
\nhealth service. We shall proactively re-
\nspond to population aging and disease
\nmodel transformation, strengthen chronic
\nnon-communicable disease management,
\ninnovate working methods and enrich the
\nservices we provide, gradually expand the
\npackage of basic and mega public health
\nservices and benefit more people.The role of
\nTraditional Chinese Medicine (TCM) shall
\nbe given full play in preventive medicine
\nwhile proper TCM preventive technique
\nshall be promoted. By 2015, expenditure
\non basic public health service shall reach 40
\nRMB Yuan per capita.
\nSecondly, accelerate the process of en-
\ncouraging multi-sectors to run medical
\ninstitutions. We are to further improve
\nmedical practicing environment and im-
\nplement the policy encouraging private
\nsectors to run medical institutions. Priority
\nsupport will be given to private nonprofit
\nmedical institutions which are encour-
\naged to develop towards higher level and
\nlarger scale. Qualified medical profession-
\nals are encouraged to open private clinics.
\nBy 2015, non-public medicare institutions
\nbeds and service shall take up 20% of the
\ntotal.
\nThirdly, innovate personnel cultivating
\nand utilization system. Standardized resi-
\ndent training system shall be built and con-
\ntinuing medical education system shall be
\nimproved. Meanwhile special talents in ur-
\ngent need and high level personnel shall be
\ncultivated. Improvement is also expected to
\nbe made in doctor multi-site practicing and
\nin medical insurance perfection as well as in
\nthe third-party negotiation mechanism set-
\nting medical disputes.
\nFourthly, promote health informatiza-
\ntion. We shall further promote the creation
\nof electronic resident health record and
\nelectronic medical record, based on which
\nto promote examination results recognition
\namong different medicare institutions, re-
\nmote consultation and in-time supervision
\nover medical practice. Meanwhile, resident
\nhealth cards will be spread to facilitate
\nseeking medical service and health man-
\nagement.
\nChen Zhu, Health Minister of China
\nReport at the China Bio-industry
\nConvention, June 28, 2012
\n13
\nRegional and NMA newsUGANDA
\nThis is a story with pictures of my visit to
\nKampala, the capital city of Uganda, to find
\nout more about how and where the President
\nElect of WMA, Margaret Mungherera, lives
\nand works.\u00a0
\nOn 27th
\nDecember, 2012, I flew into En-
\ntebbe airport from Kenya, and in just a
\ncouple of days I was able to visit Margaret\u2019s
\nhome, her parent\u2019s home, Butabika Hos-
\npital, a mental hospital where she worked
\nfor 19 years and Mulago National Referral
\nHospital where she currently works as Se-
\nnior Consultant Psychiatrist. I also visited
\nthe Ministry of Health headquarters, her
\nprimary school, her medical school, Mak-
\nerere University main campus and Kampala
\nInternational University, a private institu-
\ntion where she serves as Council member.
\nI also had an opportunity to meet her hus-
\nband, Richard, her parents and some of her
\nsiblings, co-workers, students and Rotary
\nclub members. I was driven around in a
\ncar which though provided for her by the
\nMinistry of Health, she has to pay for the
\ndriver\u2019s salary and the fuel.
\nWhen European or American doctors
\nthink of Uganda, usually two stereotypes
\ncross their mind. The first\u00a0 \u2013 medicine in
\nAfrica is very charlatan, they use frog\u2019s skin
\nto treat burns, and soil \u00a0\u2013 to get rid of diar-
\nrhoea, but a very ill person gets visited by
\na shaman who dances around the patient
\nsix times first. The other stereotype\u00a0\u2013 well,
\nif you are a doctor and, god forbid, went to
\nCambridge, then you are just like all of us,
\nso go ahead and pay the same conference
\nfees as we do,\u00a0start giving your patients all
\nthe necessary drugs and stop those excuses!
\nSomething like this can be heard from col-
\nleagues who read in the business news that
\neach year the economic growth of Uganda
\nis 3.5%. But what they can\u2019t read among the
\nlines is that just a couple of years ago, the
\neconomy of Uganda which was about a hun-
\ndred times behind the leading economies,
\nand even now is still far behind, is rapidly
\ngrowing due to coffee and fish as the ma-
\njor exports and that Southern Sudan relies
\non Uganda for its food and basic essentials.
\nThere are only 4700 physicians for a popula-
\ntion of approximately 32\u00a0million people! In
\nrural areas of the country, the health centres
\nare mainly headed by nurses and in some
\nplaces by clinical officers who are known
\nelsewhere as medical assistants or physician
\nassistants. A large part of the population
\ncan only have access to a nursing assistant
\nwho is someone who has had a few weeks of
\nbasic medical training.The number of phar-
\nmacists is very low and so drugs are often
\ndispensed by lay people.
\nEvery year, about 250 young doctors gradu-
\nate from the four medical schools in the
\ncountry with most of them shunning em-
\nployment in the public hospitals opting to
\njoin the private sector or leave the country
\nwith the hope of finding better working con-
\nditions.In the past,the majority of Ugandan
\ndoctors migrated to the Republic of South
\nAfrica, but more recently many are migrat-
\ning to neighbouring Rwanda and Southern
\nSudan.Some of those who manage to obtain
\nemployment in South Africa have moved on
\nto the USA, Canada and Australia.
\nMargaret\u2019s brother, Andrew works as an or-
\nthopaedic surgeon in South Africa and her
\nyoungest sister is doing her PHD in Pub-
\nlic Health in Australia while she does her
\nFamily Medicine residency in Auckland,
\nNew Zealand. Another sister, Lydia, also a
\nphysician, is a well known HIV\/AIDS ac-
\ntivist. She returned to Uganda from South
\nAfrica where she worked as a Medical Of-
\nficer for about 20 years. Margaret herself
\nchose to stay in Uganda where she has made
\nher name in the field of mental health.
\nMargaret Mungherera was born in Jinja, a
\ntown located on the shores of the largest
\nlake in Africa, Lake Victoria, and the source
\nof the River Nile which is the longest river in
\nAfrica. Uganda or Kenya is the place where
\n2 million years ago our ancestors got off a
\ntree and sharpened a stick to chase leopards
\naway. Now that is what actually started our
\nway to space travels in the 20th
\ncentury and
\na rapid spreading of the Internet in the 21st
\n.
\nNever Say Never, Uganda!
\n14
\nRegional and NMA news UGANDA
\nAbout a million years ago, here in Kenya (or
\nUganda) our ancestor learned how to start
\na fire and had the first \u201cbarbeque\u201d, and in
\nanother half million years packed his back-
\npack and went ahead to explore the rest of
\nthe globe\u00a0\u2013 Europe and Asia at the begin-
\nning, then Australia, Americas and Antarc-
\ntica. Being at Lake Victoria in the city of
\nJinja makes it easy to imagine how it actu-
\nally happened when our ancestor got up,
\nstretched, took his axe and said he was go-
\ning away to see and explore other countries.
\nUganda should be the Holy Land to come
\nto feel your roots.
\nUganda is full of contrasts. Just next to a
\nfancy colonial building with lots of marble
\nis a simple and tiny shack where the owner
\nsells live chicken to be able to make a living.
\nThe side roads in Kampala are like arteries\u00a0\u2013
\nfull of life. They sell everything\u00a0\u2013 drinking
\nwater, meat, fish, bananas, vegetables, fruits,
\nbeds, reclining chairs that are being made
\nright there in front of your eyes. They sell
\nfire wood, construction materials, gasoline,
\npaints, but considerably more than any-
\nwhere else in the world\u00a0 \u2013 fashion goods.
\nNearly every store is proudly showing off
\ngorgeous and fancy dresses. I have to admit
\nthat never ever on Europe\u2019s streets will you
\nsee as many women dressed in long evening
\ngowns as I saw here in Uganda. Ugandan
\nwomen go to church dressed up like Euro-
\npean women would do for,say,a presidential
\nreception. And I have to admit those dress-
\nes are absolutely wonderful, designed with
\nsuch taste! Local designers are lost to the
\nrest of the world, Armani and any other top
\nfashion designer would just die of jealousy
\nseeing what Africa\u2019s colours have to offer.
\nMargaret Mungherera is a true patriot, and
\ncarries her WMA brooch attached to a
\nblouse of all shades of yellow,orange and red.
\nWe all come from different families. I\u00a0am
\nvery lucky to have met Margaret\u203as parents,
\nSeth and Joyce Mungherera. They live ap-
\nproximately 6 kilometres outside the city.
\nTwo sons and a daughter still live with
\nthem, a son, Dan\u00a0 is a graphics artist, the
\nother, Peter a journalist trained in Zambia
\nand with many years of working experience
\nin Germany, speaks fluent German. The
\nfamily itself is very conservative and car-
\nries strong traditions\u00a0\u2013 the father plays the
\npiano, while the daughters sing.
\nMargaret\u2019s mother keeps all Margaret\u2019s lo-
\ncal and international awards which include
\na certificate of her Honorary Doctor of Sci-
\nence degree and another from the Ministry
\nof Health in recognition of her advocacy
\nefforts. Since the Ministry of Health does
\nnot have enough funds to adequately pay
\nMargaret for the work she does as Senior
\nConsultant she has been assigned an official
\nvehicle which she fuels herself.
\n15
\nRegional and NMA newsUGANDA
\nMargaret\u2019s father is a retired public ser-
\nvant and her mother worked for more than
\n40 years as General Secretary for Uganda
\nYWCA and for several years was executive
\nmember of the World YWCA represent-
\ning Eastern, Central and Southern Africa.
\nShe is therefore widely travelled.The family
\nbelongs to the Anglican Church, so Mar-
\ngaret and I visited St. Paul\u2019s Cathedral, very
\nbeautiful, simple, spacious and mighty, and
\nlocated on top of a hill.
\nWe found the choir singing in a manner that
\nwill make any organist plain jealous. Men-
\ndelssohn would have been quite surprised to
\nknow how vocally rich, polyphonic, beauti-
\nful and rhythmic his Wedding March can
\nbe. However, the choir sang it faster than
\nwe are used to hear it in Europe (a wedding
\nceremony was being held in the cathedral
\nduring our visit).
\nMost Ugandans are either Anglican or
\nCatholic with a small number belonging to
\nthe Moslem faith. Each of the three reli-
\ngious groups has its main house of worship
\nsituated on a hill.
\nWe visited the primary school which Mar-
\ngaret had attended and it had formerly
\nbeen known as Kampala European Primary
\nSchool.
\nDuring the whole time she was there, there
\nwas only one black teacher. We found ex-
\ntensive renovation work being done, but the
\nold school bell is still in its place though no
\nlonger used. More than 50 year old tradition
\nof holding an assembly for the whole school
\nis being continued. It was introduced during
\nthe time of an English headmaster who was
\nstrict and insisted on punctuality.The current
\nheadmaster believes punctuality should not
\nbe instilled by using a school bell. Children
\nshould simply use their own watches to learn
\nto keep time. The lawn around the school is
\nneatly mowed, bushes carefully trimmed.
\nMargaret had her secondary school educa-
\ntion at a famous girls school, Gayaza High
\nSchool,approximately 10 km from Kampala
\ncity centre.Then she was admitted to Mak-
\nerere University Medical School, the oldest
\nmedical school in Eastern and Central Af-
\nrica known for its research and training. At
\none time it was the only medical school for
\nKenya and Tanzania.
\nNaturally, a lot has changed since the time
\nMargaret graduated. There are now four
\nmedical schools in Uganda. Margaret was
\nvery instrumental in founding one of them,
\nKampala International University (KIU).
\nWe visited the main campus of KIU which
\nhas several large buildings and the grounds
\nare green and clean.
\nBurglar proof windows and doors and se-
\ncurity guards are common in public build-
\nings and homes,a reminder of the insecurity
\noften experienced by the population during
\nthe times of Idi Amin.
\nMargaret started her working life in But-
\nabika Hospital, the only mental hospital
\nfor a population of more than 30 million
\npeople.
\n16
\nRegional and NMA news UGANDA
\nShe worked there for 19 years before she
\nrequested to be transferred to Mulago Hos-
\npital where she is currently based. Butabika
\nHospital is a 700 bed hospital located about
\n9 kilometres from Kampala city centre and
\nhas a beautiful view of Lake Victoria. The
\nHospital is incredibly clean, has beautifully
\nkept green lawns, decorative bushes, flower
\ngardens and gravel walkways. The male and
\nfemale wards are separated by the office
\nbuildings. The environment reminds one of
\na European resort. Margaret\u2019s former co-
\nworker, David, now acting as Executive Di-
\nrector, gave us a brief tour of the Hospital.
\nMargaret and David are 2 of the small
\nnumber of psychiatrists, 34 to be exact,
\nfor a population of 35 million people. Yet,
\nmental health problems such as depression
\nare common in Uganda with approximately
\n40% of the population affected.This may be
\nthe reason why Margaret is in high demand,
\nconstantly receiving referrals and consulta-
\ntion from colleagues all over the country.
\nWhen she responds to the calls in Lugan-
\nda, the most commonly spoken vernacular,
\nI\u00a0am only able to pick up names and doses
\nof common antidepressants and antipsy-
\nchotics. In addition to the severe shortage
\nof mental health specialists, there are often
\ninadequate supplies of drugs and hospital
\nbeds in the rural parts of the country where
\nthe majority of people live.
\nOn the other hand, Uganda has made im-
\npressive progress in fighting HIV\/AIDS
\nwith the prevalence dramatically going
\ndown from 30% in the 1990s to the cur-
\nrent 7.3%. Maternal mortality is still a huge
\nproblem and so is malaria and TB. Yet, ac-
\ncording to the UN, Ugandans are amongst
\nthe most optimistic people in the world.
\nThey see a lot more light and hope in the
\nworld than people in rich European coun-
\ntries and North America.
\nMargaret got married to her husband Rich-
\nard who is a retired banker. On our way
\nto the Hospital she pointed out to me the
\nhouse they lived in for 9 years.
\nAlthough she left the Hospital 9 years ago,
\nmanypeopleinthenearbytradingcentrestill
\nrecognize her and wave to her. Store own-
\ners are eager to welcome us in their stores.
\nMargaret Mungherera now works at Mu-
\nlago National Referral Hospital as Senior
\nConsultant Psychiatrist in the Department
\nof Psychiatry.
\nShe also has additional administrative re-
\nsponsibilities of the Clinical Head in charge
\nof the Departments of Internal Medicine,
\nPsychiatry and Community Health. She
\nstill maintains an office in the Department
\nof Psychiatry, but the emptiness of the of-
\nfice shows that she hardly spends time
\nthere. All the doctors we met seemed free
\nto consult her which is a sign that they
\nconsider Margaret more as a friend than an
\nadministrator.
\n17
\nRegional and NMA newsUGANDA
\nHer main administration office is located
\nin the offices of the Department of Inter-
\nnal Medicine because it is the largest of
\nher three departments. It is not too big and
\nhas a maroon sofa set, four chairs and one
\ntable.
\nThere are several files on the shelves, some
\nfor the Hospital, others for the Uganda
\nMedical Association of which she is Presi-
\ndent and others are for the Commonwealth
\nMedical Association where she was once
\nVice-president and is now Treasurer.
\nOther documents are from the Medical
\nAssociations of Uganda, Kenya, Zambia,
\nRwanda and Burundi.These countries form
\nthe East African Community and the na-
\ntional medical associations (NMA) have
\nbeen working together to ensure quality
\nstandards in training and health care. The
\nNMAs have accomplished much as regards
\nbringing their regulatory bodies together
\nto harmonise the training of doctors in-
\ncluding the curriculum. As a result there is
\njoint inspection of medical schools in the
\nfive countries with reciprocal recognition of
\nqualifications so doctors graduating from a
\nmedical school in any country in the region
\ncan work in any of the other four countries
\nwithout doing pre-registration exams. Mar-
\ngaret has been at the forefront of this de-
\nvelopment.
\nOne of many problems that Margaret had
\nto solve during our tour round the city is
\nevidence of the state of affairs as regards
\nthe political governance of the country. The
\ngovernment is investigating the death of an
\noutspoken member of the Parliament and
\na member of the ruling party. A patholo-
\ngist acting on behalf of the family and the
\nParliament was arrested by the police as he
\ntried to leave the country to take the speci-
\nmens to South Africa. As President of the
\nNMA, Margaret has had to make state-
\nments in the media about the opinion of the
\nmedical profession.
\nI am not saying Parliament members die
\nevery day in Uganda, but when they do,
\nquestions like this do come up.
\nIt is obvious from her conversations with
\ndoctors, nurses and other medical staff that
\nMargaret Mungherera is a strict boss, there
\nis none of that sparkling humour we are
\nused to at the WMA meetings. Although
\nI\u00a0 do not understand the local vernacular,
\nI can sense from her tone dissatisfaction
\nabout the care of patients, the wet floor and
\nthe conditions of the wards. The wards are
\ncongested with some patients sleeping in
\nthe hallways. Visiting relatives, many with
\nyoung children, of patients sit patiently out-
\nside on the grass, waiting to see their be-
\nloved ones. The hospital grounds are beau-
\ntiful\u00a0\u2013 plenty of trees, bushes, long legged
\nmarabou storks walking around. My seem-
\ningly innocent question about correlation
\nbetween the Pathology Anatomy unit and
\nthose marabou storks on the roof went by
\nunanswered.
\nMeanwhile,the marabou storks at the Mak-
\nerere University main campus have decided
\nto build their nests in the trees of the alley
\nright in front of the main building, making
\nthe trees dry due to the many nests in the
\ntree.
\nThe exodus of physicians from Uganda to
\nelsewhere is determined by two impor-
\ntant aspects\u00a0\u2013 first of all, an\u00a0experienced
\nsenior doctor working for government is
\npaid approximately USD 1000 per month,
\nwhile their colleagues in Kenya make
\nabout 4-5 times more, and the situation is
\neven better in Rwanda where the salaries
\nare 5-6 times better. This means doctors
\n18
\nRegional and NMA news UGANDA
\nhave to supplement their meagre pay by
\ndoing private practice. Margaret is not an
\nexception. She supplements her income
\nby seeing private patients in the evenings
\nat a clinic owned by a friend who is a pae-
\ndiatrician.
\nThe second aspect is the incredible workload
\ndue to the lack of physicians. More than
\n60% of the population receives health care
\nfrom the government hospitals and health
\ncentres. This covers tuberculosis, cancer and
\nHIV\/AIDS.This is a huge workload for the
\nfew doctors available.
\nThough free, still the services often lack
\ndrugs and investigative facilities.This means
\npatients often have to be prescribed drugs
\nso they procure them at their own expense
\nfrom local drug shops. This makes doctors
\nfeel uncomfortable because the majority of
\npatients are poor.
\nAs I watched her friend examining a small
\nchild, I was reminded of the infant mortal-
\nity rate which is still alarmingly high and is
\nlargely due to diarrhoeal diseases, malaria,
\nmalnutrition and HIV\/AIDS. Being a large
\ncity, Kampala is very different from the
\nother parts of the country. This is because
\nthe health care services are more accessible.
\nUganda has very few medical specialists if
\ncompared to the United Kingdom for in-
\nstance that is approximately the same size.
\nThat being said, the average life expectancy
\nis approximately 45 years mainly because of
\nHIV\/AIDS and the high maternal mortal-
\nity rate which is around 490 women dying
\nfor every 100,000 live births and the high
\ninfant mortality rate. Indeed, healthcare has
\nto come first, then statistics.There are many
\nprivate clinics in Kampala and outskirts,but
\nprimary care is still in high demand.
\nAll these issues seem to be important
\nenough for us to go visit the Ministry of
\nHealth of Uganda. I do have to tell, it was
\nan early afternoon of December 27, when
\nthe rest of the world is stuck between cel-
\nebrating Christmas and New Year\u2019s.
\nUnfortunately, the security measures at
\nthe Ministry of Health headquarters seem
\nmore relaxed than elsewhere where anyone
\ncoming in has to be searched or scrutinised
\nby the security guards. Here, the doors are
\nopen and anyone is free to go in and out.
\nThe doors of the Minister of Health and
\nher deputies are locked which as Marga-
\nret points out is because of the Christmas
\nseason. We run into a a Commissioner who
\npolitely advises us to come back the follow-
\ning week when the holiday season is over.
\nBut here is the good news\u00a0 \u2013 it is nice to
\nwatch Margaret Mungherera walk freely
\ninto the Ministry, a sign that the President
\nof the National Medical Association means
\na lot to the country.Of course,it would have
\nbeen nice to see the\u00a0 Minister of Health
\njump out of her chair to welcome Margaret
\nbut she just was not there…And I do under-
\nstand that she does not always have to just
\nsit in her office signing documents. There
\nis so much work to be done away from the
\nMinistry head offices.
\nMeanwhile, an Irish doctor who came to
\nwork in Uganda as a missionary several
\nyears ago, has built a state-of-the-art hos-
\npital near the city centre. Even though he
\nhas been elected as one of the four mayors
\nof the city, he still has time to spend some
\ntime at his hospital even during the holiday
\nseason.
\n19
\nRegional and NMA newsUGANDA
\nRotary is a very important part of Marga-
\nret\u2019s life. During her time as Country Chair,
\nshe was able to have a total of nine new
\nRotary clubs formed. Rotary has supported
\nthe equipping of hospitals and Rotarians
\nare even constructing a new Cancer Ward
\nat one of the Catholic church-run hospitals.
\nMy personal impression was that Ugandan
\nRotarians are generally not wealthy people
\ncompared to the average European but they
\nare keen to be involved in charity work and
\nto donate generously.
\nEverywhere we go, we are greeted by many
\npeople who know Margaret and are eager
\nto talk to her. These include members of
\nher Rotary Club, lawyers, bankers and gov-
\nernment officers. A few people introduce
\nthemselves as her former patients or fam-
\nily members of her former patients and re-
\nspectfully greet her from a distance.
\nI enquired of Margaret as to her priorities
\nduring her term as President of the WMA.
\nHer interest is increasing access to health
\ncare. A patient should be able to see a doc-
\ntor regardless of his\/ her status,age or where
\nin the country they live. She is concerned
\nthat Africa suffers from human resources
\nfor health crisis. She is however quick to
\nadd that the crisis is also affecting other
\nparts of the world, including Europe.
\nAs a doctor working in Africa, Margaret is
\nconcerned about the high maternal mortal-
\nity and infant mortality rates in many of
\nthe African countries. Infectious diseases
\ncontinue to be the major cause of morbidity
\nand mortality. However, non-communica-
\nble diseases (NCDs) including hyperten-
\nsion, cardiac diseases, cancer are on the rise
\nin Africa. This is largely due to the chang-
\ning life style including increased consump-
\ntion of alcohol and tobacco products. Many
\nUgandans are not able to access a doctor
\nand in the best scenario may be able to see
\na nurse.
\nMargaret is participating in the process to
\nrevise the Declaration of Helsinki (DoH).
\nThese important ethical guidelines for re-
\nsearch involving human subjects will be
\nclocking 50\u00a0years during her term as Presi-
\ndent of the WMA.
\nShe recently attended an experts meet-
\ning in Cape Town, South Africa, and will
\nbe attending review meetings to be held in
\nTokyo and New York. Her brief discussion
\nabout the DoH shows that she is concerned
\nabout the adverse effects the DoH is likely
\nto have on poor countries.
\nThere is a large resort hotel on the suburbs
\nof Kampala city and on the shores of Lake
\nVictoria where the Commonwealth Head
\nof Government Meeting (CHOGM) was
\nrecently held. It is a popular venue for in-
\nternational meetings with ample conference
\nfacilities and a scenic view that according to
\nMargaret can easily host a General Assem-
\nbly of the WMA.
\nTo my mind the costs would be too high
\nbut Margaret believes the government
\nand international organisations would be
\nwilling to support a meeting that attracts
\nmedical professionals from all over the
\nworld.
\nTo date, South Africa is the only country
\nin Africa that has hosted a WMA event,
\nmoreover, only two WMA presidents have
\never visited Uganda.
\nI put it to Margaret that the Uganda Medi-
\ncal Association might not be able to afford
\nsuch an event and asked her about the As-
\nsociation\u2019s financial situation. For the last
\nfew years the government has not supported
\nthe Association financially as it used to do
\nin the past. Occasionally some departments
\nsponsored doctors in rural areas to attend
\nthe annual meetings of the UMA.
\nGovernment regional hospitals have some-
\ntimes provided the UMA with space for
\nCPD seminars. A few District Health Of-
\nficers have sponsored their doctors to be
\nable to travel to Kampala and occasion-
\nally paid the conference registration fees.
\nSome of the costs are covered by the fees
\npharmaceutical companies pay to exhibit at
\nthe conference venue. Every so often a cor-
\nporation will offer to sponsor such events,
\nfor instance, the electricity distribution
\ncompany has recently offered the UMA
\nsupport for CPD seminars for doctors in
\nremote areas.
\nThe members of the Association recently
\nregistered a savings and credit society for its
\nmembers and have already received a small
\ncontribution from the President of Uganda.
\nThe Association is a shareholder in the soci-
\nety and will use funds obtained from savings
\nto put up the UMA House.
\nThe office block which was given to the
\nUMA by President Idi Amin in the 1970s
\nwas repossessed by the previous owners in
\nthe early 2000s. Since then the Association
\nhas been renting offices.
\n20
\nRegional and NMA news UGANDA
\nThe biggest more recent accomplishment of
\nthe Association has been the almost 300%
\nraise in salaries of junior doctors working in
\nremote areas. The salary of those doctors is
\nnow higher than that of a specialist working
\nin the national referral hospital in Kampala.
\nMargaret believes that the number of doctors
\nworking in the rural areas where the majority
\nof people live needs to be increased. Increas-
\ning access to doctors in rural areas will have
\na significant impact on the morbidity and
\nmortality of people living there and lead to
\neconomic growth and development.
\nMargaret witnessed the signing of the
\nmemorandum of understanding by the
\nWMA and the World Veterinary Associa-
\ntion. As a result the UMA and the Uganda
\nVeterinary Association will be holding a
\nOne Health Conference in Kampala. The
\ntheme of the conference is \u201cDisease Eradi-
\ncation: What will it take?\u201dand the areas
\nto be covered include disease surveillance,
\npolicy, advocacy, communication, disease
\nprevention and control. The conference
\nhas received tremendous support from the
\nWHO, UNICEF, USAID and the Uni-
\nversity of Minnesota, USA. Margaret plans
\nto spend her year as President encouraging
\nthe NMAs in low income countries in Af-
\nrica and the Middle East to participate in
\nthe WMA activities. She would like to see
\nstronger NMAs twinning with and men-
\ntoring the smaller NMAs. Her specific ar-
\neas of emphasis will be the human resources
\nfor health crisis, maternal health, mental
\nhealth,HIV\/AIDS and non-communicable
\ndiseases (NCDs).
\nOn the 28th
\nDecember, I briefly visited the
\napartment complex where Margaret lives
\nwith her husband Richard.
\nThe apartment complex is located in the
\neastern part of the capital city, Kampala,
\nand is near the shores of Lake Victoria.
\nRight across from where Margaret lives is
\nan elementary school for Moslem girls. Is-
\nlam is commonly practised in Uganda espe-
\ncially with the large influx of refugees from
\nEritrea and Somalia. The large mosque on
\none of the hills of Kampala was donated
\nto Uganda by Muammar Gaddafi and was
\nnamed after him.
\nShe collects wooden mementoes from all
\nthe African countries she visits. I\u00a0 laugh
\nbecause I believe they are made in China
\nwhich she says is not true.
\nMargaret\u2019s husband Richard has a firm
\nhandshake, a low voice, a friendly smile and
\na keen interest in Margaret\u2019s activities.
\nHe knows the names of all the leaders of
\nthe WMA, what they look like and what
\nthey do. He sits in the passenger seat by the
\ndriver in the car, Margaret sits behind him.
\nOur destination is the source of the River
\nNile, where it comes out from Lake Victo-
\nria. I have \u201cgoogled\u201dJinja and so I am aware
\nthe distance is approximately 80-90 kilo-
\nmetres. They rush me saying that the term
\n\u201chighway\u201d has a whole different meaning in
\nAfrica….
\nThe traffic made of passenger minibuses,
\nlarge trailers on their way to Kenya, oc-
\ncasionally pedestrians and large herds of
\ncattle, sheep and goats and even chicken
\ncrossing the main road make our travel
\nmuch slower than it should be on a highway.
\nToyota minivans rule the road\u00a0\u2013 they are the
\nmost popular mode of public transportation
\nin Uganda.
\n21
\nRegional and NMA newsUGANDA
\nWhere in Europe oncoming cars would
\nslowly pass by each other, here it\u2019s com-
\nmon to see two cars in one lane pass
\neach other with the side mirrors collid-
\ning. Wherever there is a speed limit of
\n20\u00a0km\/h, there is a hawker trying to sell
\nsome food through the window. The sides
\nof the road are also popular meeting plac-
\nes for motorcyclists.
\nMargaret\u2019s driver Ibrahim is also Moslem
\nand is very polite and calm. One can learn
\na lot from him on the highway of Uganda.
\nDriving here is not as difficult as it is for
\ninstance in India where there seems to be
\nno traffic rules.
\nMany of the roads are of bad quality and
\nthere are traders on the sidewalks often
\non both sides narrowing the roads even
\nmore.
\nIt is not unusual to find a truck parked by
\nthe roadside with the driver selling pine-
\napples from it.
\nNormally, there are three people on a mo-
\ntorcycle but sometimes the kids are seated
\non top of it. And their riding makes me
\nworry about Uganda as an organ donor
\ncountry…
\nWe drive through woods (even there are a
\nlot of pedestrians).
\nIt is a broadleaf forest\u00a0\u2013 Uganda is more
\nthan 1 km above the sea level and the air
\ntemperature is not burning hot. Informa-
\ntion available for public states that Ugan-
\nda is constantly planting new forests, but
\nMargaret disagrees\u00a0\u2013 she thinks\u00a0that even
\nthe existing ones are very poorly main-
\ntained.
\nAlso, she is not happy about Uganda\u203as re-
\nsults in preserving gorillas and chimpan-
\nzees, let alone\u00a0savanna animals. Especially
\nhard is her take on military\u2019s destructive
\nactions against preserving forests and ani-
\nmals. Being green is just another Marga-
\nret\u2019s interest amongst many, she is ready
\nto fight the global warming because in
\nher opinion, rain forests play an essential
\nrole in the climate change and producing
\noxygen. In general, Uganda is a very green
\ncountry\u00a0\u2013 there are big trees in the cities, a
\nbeautiful lawn and bushes surround every
\nhouse.
\nAfter a two hour ride, we arrive in Jinja,
\nwhere Margaret was born in the local hos-
\npital. Jinja was once the most industrious
\ntown in the country but all this changed
\nwith the coming of Idi Amin. Some of the
\nareas still look clean while others are run
\ndown and there is evidence of rehabilitation.
\nThere is evidence that there are ongoing ef-
\nforts to improve the sanitation standards of
\nthe town. The reconstruction is a common
\nsight in many of the towns in Uganda in
\nbetween large residential houses with beau-
\ntiful gardens.
\nWe get out of the car, pay the parking fees,
\nthen go down to the River Nile where we
\neat delicious fried tilapia fresh from Lake
\nVictoria accompanied by a cold Nile Gold
\nbeer.
\nAs we take in the cool breeze from the
\nsource of the longest river in Africa, the
\nPresident Elect continues to share her as-
\npirations for the WMA. I wish her the best
\nknowing that with her energy and charisma,
\nthe Annual General Assembly will come to
\nUganda sooner than later.
\nDr. Peteris Apinis
\nEditor in Chief, WMJ,
\nPresident of Latvian Medical Association
\n22
\nHealthcare
\nThe vaccination rates among healthcare pro-
\nfessionals are shockingly low. Yet, these are
\nindividuals who are most frequently exposed
\nto communicable diseases.Our member orga-
\nnizations should be informed about these in-
\nconsistencies among healthcare professionals.
\nEven in the developed world there are sig-
\nnificant inconsistencies in vaccination rates
\nof healthcare professionals (HCPs) [1, 3,
\n4, 5]. For example, according to a survey
\nconducted at a major teaching hospital in
\nFrance, the rate of fully immunized HCPs
\nand other healthcare workers (HCWs) was
\naround 30 percent [4]. In some developed
\nnations, statistics regarding the vaccination
\nrates of HCPs were unavailable despite the
\npolicy encouraging specific vaccinations for
\nHCPs [1, 5]. These disparities are mostly
\ndue to a considerable lack of understanding
\nof specificity of vaccines,fear of the vaccina-
\ntion itself, and inconvenience in obtaining
\nvaccinations [2, 4, 6, 9].
\nEven the policy recommendations for
\nHCPs and HCWs vary greatly between
\ncountries. Thus, in the European Union the
\nvaccination recommendations for HCPs
\nand HCWs were nearly universal for sea-
\nsonal influenza, as well as hepatitis B, but
\nonly 9 of the 27 member states recom-
\nmended pertussis vaccination [5].It would
\nbe reasonable to assume that the policies
\nregarding HCPs protection are relatively
\ncomprehensive in comparison to recom-
\nmendations for the general population of
\nthese states. It would also be expected that
\nHCPs as well as their employers would
\nmonitor such policies closely. As it has been
\ndemonstrated, neither is the case with many
\ndeveloped nations.
\nThe reasons for HCPs to be fully vaccinated
\nare not just the obvious ethical reasons per-
\ntaining to the concept of \u201cdo no harm,\u201d but
\nalso for the economic reasoning of avoid-
\ning aggregate productivity losses associated
\nwith illness. This is true in both developed
\nand underdeveloped nations. For instance,
\nproductivity loss of USD 1.2 billion could
\nbe avoided in the decade preceding 2020 in
\nLMEs if caretakers alone were updated on
\nvaccinations [10].
\nThe fluctuation in vaccination rates in
\nthe underdeveloped world due to lack of
\nknowledge, convenience, or understanding
\nis secondary. These variables do still affect
\nthe vaccination rates of HCPs and HCWs
\nin the underdeveloped world, and should
\nbe addressed. However, the deficits in im-
\nmunization rates are primarily due to low
\npolitical commitment by respective gov-
\nernments, civil unrest, weak health delivery
\ninfrastructure, underfunding, poor develop-
\nment, and low levels of further research and
\ndevelopment of vaccines needed for these
\nnations [11]. In addition to these problems,
\nthere are matters of standardizing the injec-
\nSusceptible Healthcare Professionals
\nAlley Ronaldi
\n0
\n5
\n10
\n15
\n20
\n25
\n30
\nHepatitis B
\nTuberculosis
\n(BCG vaccine)
\nHepatitis A
\nPoliomyelitis
\nPertussis
\nDiptheria\/Tetanus
\nVaricella
\nMeasles\/RuellaMumps
\nInfluenza Meningococcus
\n(tetravalent vaccine)
\nFigure 1. Number of Countries with Vaccine Recommendations for Healthcare Workers (by disease). Source: \u201cVaccination policies for health-
\ncare workers in acute health-care facilities in Europe.\u201d (Vaccine): 27 EU member countries as well as Norway, Russia, and
\nSwitzerland surveyed
\n23
\nHealthcare
\ntion safety itself. Nearly half of the vaccines
\nadministered in Sub-Saharan Africa are be-
\nlieved to be unsafe [11].
\nThe administration problems, as well as the
\ndata inconsistency have resulted in reported
\noutbreaks of specific preventable diseases in
\nthe least developed nations of the world. Ac-
\ncording to WHO\u2019s 2010 monitoring system
\nreport, between the years 2008\u20132009, the
\nnumber of reported cases of measles, mumps,
\nand rubella actually increased significantly
\namong the general population of the least de-
\nveloped nations. Since this is the case for the
\ngeneral population, and because data regard-
\ning the vaccination rates of HCPs are nearly
\nnon-existent in such countries, it can be as-
\nsumed that the HCP vaccination rates are
\ncorrespondingly lower in developing nations.
\nThe dangers of HCPs not maintaining vac-
\ncinations while spending most of daily life
\nexposed to communicable diseases are ob-
\nvious. There are not only personal risks in-
\nvolved for the HCPs, but also risks to their
\npatients. Physicians should do everything
\nin their power to make healthcare settings
\nsafe for their patients. It is their ethical duty
\nas professionals. Hospitals and other stake-
\nholders could work to ensure that high lev-
\nels of vaccination rates among their employ-
\nees are maintained to ensure a safe setting
\nfor the provision of healthcare. Such actions
\ncould also serve to protect their organiza-
\ntions from large productivity losses from
\nincapacitation of HCPs due to vaccine-pre-
\nventable illnesses. As is the case with many
\npublic health dilemmas, physicians should
\nbe made aware and use their leadership po-
\nsitions to help augment discussions regard-
\ning HCP vaccination policy.
\nReferences
\n1. Gargalianosb, Panagiotis, Pavlos Nikolaidisc,
\nPanos Katerelosa, Natasa Tedomaa, Efstratios
\nMaltezosd, and Marios Lazanase. \u201cAttitudes to-
\nwards Mandatory Vaccination and Vaccination
\nCoverage against Vaccine-preventable Diseases
\namong Health-care Workers in Tertiary-care
\nHospitals.\u201d Journal of Infection 64.3 (2012): 319-
\n24. Print.
\n2. Hollmeyer, Helge G., Frederick Hayden,
\nGregory Poland, and Udo Buchholz. \u201cInfluenza
\nVaccination of Health Care Workers in Hospi-
\ntals\u00a0\u2013 A\u00a0Review of Studies on Attitudes and Pre-
\ndictors.\u201d Vaccine 27.30 (2009): 3935-944. Print.
\n3. Lindley, M., G. Horlick, A. Shefer, F. Shaw,
\nand M. Gorji. \u201cAssessing State Immunization
\nRequirements for Healthcare Workers and Pa-
\ntients.\u201d American Journal of Preventive Medicine
\n32.6 (2007): 459-65. Print.
\n4. Loulergue, P., F. Moulin, G. Vidal-Trecan,
\nZ.\u00a0Absi, C. Demontpion, C. Menager, M. Goro-
\ndetsky, D. Gendrel, L. Guillevin, and O. Launay.
\n\u201cKnowledge, Attitudes and Vaccination Cover-
\nage of Healthcare Workers regarding Occupa-
\ntional Vaccinations.\u201dVaccine 27.31 (2009): 4240-
\n243. Print.
\n5. Maltezou, Helena C., Sabine Wicker, Michael
\nBorg, Ulrich Heininger, Vincenzo Puro, Maria
\nTheodoridou, and Gregory A. Poland. \u201cVaccina-
\ntion Policies for Health-care Workers in Acute
\nHealth-care Facilities in Europe.\u201d Vaccine 29.51
\n(2011): 9557-562. Print.
\n6. Murray, S. B., and S.A. Skull. \u201cInfectious Dis-
\nease: Poor Health Care Worker Vaccination
\nCoverage and Knowledge of Vaccination Rec-
\nommendations in a Tertiary Australia Hospital.\u201d
\nAustralian and New Zealand Journal of Public
\nHealth 26.1 (2002): 65-68. Print.
\n7. Ozawa, Sachiko, Meghan L. Stack, David
\nM.\u00a0Bishai, Andrew Mirelman, Ingrid K. Friberg,
\nLouis Niessen, Damian G. Walker, and Orin
\nS.Levine. \u201cDuring The \u2018Decade Of Vaccines,\u2019 The
\nLives Of 6.4 Million ChildrenValued At $231 Bil-
\nlion Could Be Saved.\u201d Health Affairs 30.6 (2011):
\n1010-020. Health Affairs. Web. .
\n8. Prato, Rosa, Silvio Tafuri, Francesca Fortu-
\nnato, and Domenico Martinelli. \u201cVaccination in
\nHealthcare Workers: An Italian Perspective.\u201dEx-
\npert Review of Vaccines 9.3 (2010): 277-83. Print.
\n9. Seale, H., J. Leask, and CR Macintyre.\u201cDo They
\nAccept Compulsory Vaccination? Awareness,
\nAttitudes and Behaviour of Hospital Health
\nCare Workers following a New Vaccination
\nDirective.\u201dVaccine 27.23 (2009):3022-025.Print.
\n10. Stack, Meghan L., Sachiko Ozawa, David
\nM.\u00a0 Bishai, Andrew Mirelman, Yvonne Tam,
\nLouis Niessen, Damian G. Walker, and Orin
\nS.\u00a0Levine. \u201cEstimated Economic Benefits Dur-
\ning The \u2018Decade Of Vaccines\u2019Include Treatment
\nSavings,Gains In Labor Productivity.\u201dEstimated
\nEconomic Benefits During The \u2018Decade Of Vaccines\u2019
\nInclude Treatment Savings, Gains In Labor Pro-
\nductivity 30.6 (2011): 1021-028. Print.
\n11. Jamison, Dean Tecumseh., and John T. Sentz.
\n\u201cChapter 12: Vaccine-Preventable Diseases.\u201d
\nDisease and Mortality in Sub-Saharan Africa. 2nd
\ned.Washington, DC: World Bank, 2006. N. pag.
\nPrint.
\nAlley Ronaldi
\nE-mail: aronaldi@me.com
\nFigure 2. Self-Reported Susceptibility Rates (Tertiary-Care Hospital Employees).
\nSource: \u201cAttitudes towards mandatory vaccination and vaccination coverage
\nagainst vaccine-preventable diseases among health-care workers in tertiary-care
\nhospitals\u201d (Journal of Infection): Survey taken in Greece
\n24
\nHealthcare
\nUnder the umbrella of the WHO Emer-
\ngency and Essential Surgical Care program
\naimed at strengthening surgical care sys-
\ntems, WMA participated in a global forum
\ncalled the Global Initiative for Emergency
\nand Essential Surgical Care. This Forum
\nwas established with multidisciplinary
\nstakeholders \u2013 professionals, academic in-
\nstitutions, societies, NGOs \u2013 interested in
\ncollaborative activities to reduce death and
\ndisability from injuries, pregnancy-related
\ncomplications, congenital anomalies and
\nother surgical conditions.
\nIntroduction
\nThe WHO Integrated Management for Emer-
\ngency & Essential Surgical Care (IMEESC)
\ne-learning toolkit (CD) has been developed
\nby the WHO Emergency & Essential Sur-
\ngical Care program with input from mem-
\nbers of the Global Initiative for Emergency
\nand Essential Surgical Care. The target
\naudience is policy-makers, managers, and
\nhealth-care providers (especially surgeons,
\nanaesthetists, non-specialist doctors, health
\nofficers,nurses,and technicians).This toolkit
\ncontains WHO recommendations for mini-
\nmum standards and best practice protocols
\nin emergency,surgery,trauma,obstetrics and
\nanaesthesia at first-referral level healthcare
\nfacilities. Also contained are WHO best
\npractice protocols for minimum standards
\nin disaster management and equipment at
\nfirst-referral health facilities. Training tools,
\na trainer\u2019s guide, teaching slides, self-evalu-
\nations, needs assessments, quality and safety
\ntools, and a planning tool for district-level
\nmanagers complete the toolkit.
\nThe WHO Integrated Management for Emer-
\ngency & Essential Surgical Care toolkit has
\nbeen introduced in 38 low- and middle-
\nincome countries (LMICs) through WHO
\nand Ministry of Health partnerships, to
\nidentify and address development needs in
\nnational and district-level surgical capacity.
\nThe tool has also been used to teach safety
\nduring clinical procedures, infection control
\nand HIV prevention as well as management
\nof disaster situations.
\nTraining and educational tools
\nThe WHO IMEESC toolkit aims to address
\nthe healthcare workforce shortage in much
\nof the developing world through its train-
\ning materials. The most comprehensive tool
\nprovided in the toolkit is the WHO Surgi-
\ncal Care at the District Hospital, which cov-
\ners the full compendium of first-referral
\nlevel surgical practice and procedures. This
\nmanual is a practical resource for frontline
\nproviders and also a potential teaching in-
\nstrument at the undergraduate and post-
\ngraduate levels.
\nIn addition,the toolkit offers training work-
\nshops which are geared towards equipping
\nfrontline health care providers with the
\nappropriate skills to address surgical emer-
\ngencies and routine procedures. Teaching
\nand reference materials are available for
\nthe workshop leader, including a Trainer\u2019s
\nGuide, a workshop agenda, and teaching
\nslides. Following the training, participants
\ncan evaluate the workshop through a formal
\nassessment and can assess their own knowl-
\nedge through a self-learning module. The
\ntoolkit also contains seven practical videos
\non general principles of wound manage-
\nment, head and back injuries, and fracture
\nmanagement along with special topics such
\nas fractures in children.
\nImplementation of best
\npractices at the point of care
\nAn integral component of the IMEESC
\ntoolkit are the Best Practices Protocols.These
\nprotocols are in the form of posters to be
\ndisplayed throughout hospitals and health
\nfacilities. Messages for the best practices
\nis informed by WHO standards and rep-
\nresent the basic skills and trainings for
\npracticing emergency, obstetrics, trauma,
\nanaesthesia and other surgical proce-
\ndures. There are eleven protocols which
\ncover diverse topics including safety and
\nsanitation, wound and burn management,
\npost-operative care, female genital injury
\nmanagement, intensive care settings, and
\nemergency resuscitation.
\nDisaster management
\nguidelines
\nIn relation to Clinical Procedures Safety for
\ndisaster planning, guidance is offered to de-
\ntermine trauma team responsibilities, per-
\nform a disaster-centered needs assessment,
\nmanage anaesthesia, and treat gunshot and
\nlandmine injuries.
\nEquipment lists & quality\/
\nsafety management
\nEqually important to training surgical care
\nprofessionals is the availability of high qual-
\nity, safe resources. The Essential Emergency
\nEquipment list offers a guideline for the
\nminimum equipment needs at the first re-
\nferral health facility in LMICs.This generic
\nlist outlines both capital outlays as well as
\nrenewable items. A similar list is provided
\nfor anaesthesia materials, including access
\nto general supplies, medicines, and infra-
\nstructure-based resources such as oxygen.
\nBoth these equipment lists can serve as in-
\nventory tools at higher level facilities to im-
\nprove quality and safety, through a careful
\nassessment of the quantity and functioning
\nof available equipment.
\nImplementing Surgical Care at the National
\nLevel:TheWHO Integrated Management for
\nEmergency and Essential Surgical CareToolkit
\n25
\nRegional and NMA newsTURKEY
\nResearch tool
\nHealth facilities can easily assess their surgi-
\ncal capacity through two components of the
\nIntegrated Management for Emergency & Es-
\nsential Surgical Care toolkit \u2013 the Situational
\nAnalysisTool to Assess Emergency and Essential
\nSurgical Care and the Needs Assessment for
\nEssential Emergency Room Equipment. Both
\ntools enable health care providers and hospi-
\ntal managers to conduct research on poten-
\ntial gaps in surgical care provision.The Needs
\nAssessment evaluates human and physical
\nresources, quality and safety of available re-
\nsources and also policy measures in place at
\nthe facility. The Situational Analysis Tool
\ntakes a comprehensive approach to identify-
\ningpersonnelcapabilities,proceduralbreadth,
\nand material resources at the health facility.
\nPolicy management
\nAide-Memoire: Well-organised surgical,
\nobstetric, trauma care and anaesthetic ser-
\nvices are essential within the framework
\nof a country\u2019s and a district\u2019s health care
\ninfrastructure as they substantially reduce
\nthe death and disability from trauma and
\npregnancy-related complications.The over-
\nall responsibility of establishing and main-
\ntaining effective district surgical services
\nrequires government support and national
\npolicies.
\nPlanning Tool: The WHO Planning Tool for
\nEmergency and Essential Surgical Services
\nprovides advice for first referral level facili-
\nties on how to develop a national plan for
\ndistrict-level surgical services.
\nQuality and Safety
\nEstablishing quality and safety of emergen-
\ncy and essential surgical care is tantamount
\nto its appropriate delivery. The WHO In-
\ntegrated Management for Emergency & Es-
\nsential Surgical Care toolkit provides docu-
\nments on safety protocols for anaesthesia
\nand obstetrics \u2013 a step-by-step guide for
\ncomponents of safe practice.
\nA Monitoring and Evaluation tool is also
\navailable to measure the progress and the
\nimpact of various trainings in health facili-
\nties. It relates to those that address person-
\nnel, infrastructure, equipment functionality
\nand availability, continuing education op-
\nportunities, and Best Practice Protocols for
\nClinical Procedures safety.
\nMore information about the IMEESC
\ntoolkit and its resources is available at http:\/\/
\nwho.int\/surgery.
\nBonnie Chien
\nStanford University School of Medicine,
\nStanford, California, USA
\nUnwanaobong Nseyo
\nDuke University School of Medicine,
\nDurham, North Carolina, USA
\nHealth is considered a basic human right.
\nEach country in the world is trying to
\nprovide health care \u201cfor all\u201d its citizens. In
\n2006 the European Council outlined the
\naims for its member states: universal cover-
\nage, solidarity in financing, equity of access
\nand provision of high quality health care.
\nOn the other hand health care is getting
\nmore expensive every year in connection
\nwith developing technology and increas-
\ning life span. These huge health spending
\ncosts must be somehow funded. Realisti-
\ncally, there are only a few recognized ways
\nto cover the health care costs. They can be
\nfunded by the state from general tax rev-
\nenues or by a mandatory health insurance
\nprogram backed by a payroll tax. Health
\ncare funding can also be based on private
\nsector health insurance plans as in the
\nUSA, and in many countries there are sys-
\ntems where these are combined. Personal
\nout of pocket spending far exceeds private
\npooled and government health spending in
\nlow income countries [1].
\nAs beginning with the 1970s the \u201cwelfare
\nstate\u201d developed problems with funding,
\na new wave of privatization began. It was
\nclaimed that the state provided services, in-
\ncluding health and education, should be run
\nby the private sector because the state run
\nservices were inadequate, ineffective, prone
\nto corruption, and resistant to new technol-
\nogies and developments. Moreover, money
\nspent for health and social security was re-
\ngarded as going into a \u201cbig black hole\u201d and
\nthus creating a great burden for the govern-
\nment budgets.
\nThe United Nation\u2019s Millennium Devel-
\nopment Goals are focused on improving
\noverall health outcomes, securing financial
\nprotection against impoverishment and
\nHealth Care Reform: Does One Size Fit All
\nA.Ozdemir Aktan
\n26
\nRegional and NMA news TURKEY
\nensuring long-term sustainable financing.
\nIn the developing countries steps to be
\ntaken to accomplish these are framed and
\nfunded by the World Bank and the Interna-
\ntional Monetary Fund (IMF).
\nThe biggest problem in financing is obvi-
\nously its long term sustainability. Continu-
\nous economic growth is necessary to main-
\ntain the percentage of health spending at
\nan acceptable percentage of the gross na-
\ntional income (GNI). On the other hand,
\nfor fiscal sustainability public revenues
\nshould be gradually increased. The model
\nimplemented by the World Bank to ac-
\ncomplish this for East European members
\nof the European Union (EU) (some of
\nthem being former Soviet States) and Tur-
\nkey (which is not a member of the EU) and
\nmany other countries is to establish a man-
\ndatory health insurance system financed
\nby payroll tax, as well as encourage private
\ninsurance and increase cost sharing (user
\ncharges). At the same time, privatization of
\nthe government health care system is en-
\ncouraged including the state run medical
\nfacilities [2].
\nIn Turkey, the first step in this process was
\ntaken when the legislation on establishing
\na payroll tax financed mandatory health in-
\nsurance fund was passed in 2006.This fund,
\nrun by the Social Security Institution (SSI)
\nis the only state financer of health. Turkey
\nspends 6.0% of its GNI for health while the
\naverage for 31 OECD countries is 9.0%.
\nPer capita health expenditure in Turkey is
\nUSD 767 which is the lowest among the
\nOECD countries.This breaks down as 69%
\nfor the state and 31% for the private sector.
\nIn comparison,in the USA government and
\nprivate expenditures are 45.5% and 54.5%
\nrespectively as reported in 2010 OECD re-
\nport and the WHO database.
\nAs of June 2010, the unemployment rate in
\nTurkey was 13.6% and it is estimated that
\nroughly 50% of the working population is
\nunregistered and pays no tax.This obviously
\nis a very big problem to finance the health
\ncare system through the SSI. At present,
\nthe premiums collected can only support
\nless than half of the total SSI spending
\n(see\u00a0Fig)\u00a0[3]. The rest comes from the state
\nbudget. The current Social Security Law
\ndefines as \u201cpoor\u201d anyone with an income
\nless then 1\/3 of the minimum wage which
\nis around USD 400. With these figures, the
\nbest estimate is that less than 50% of the
\npopulation can receive the SSI provided
\nhealth care. Private health insurance covers
\nonly one million in a population of 72 mil-
\nlion. In Turkey, the uninsured and poor are
\ncovered by a \u201cgreen card\u201d which enables the
\nholder to access health care through the SSI
\nand run by the government. However, in
\nthis ill defined and politically manipulated
\nsystem, the number of green cards increases
\nto 11\u00a0million just before elections,and drops
\nto 5\u00a0million thereafter.
\nA new law which is expected to go into
\neffect soon will open the way to privatiza-
\ntion of all state hospitals that are now run
\nby the Ministry of Health. These activities
\nare being pursued in nearly all developing
\ncountries in a standard fashion. General
\nAgreements on Tariffs and Trade (GATT)
\naimed at increasing and regulating interna-
\ntional trade prohibit the states to form mo-
\nnopolies on any service given and encourage
\nprivatization.
\nPrivatization of the health care system
\nhas certain advantages such as effective
\nand timely implementation of new tech-
\nnologies and a better quality health care in
\naddition to decreasing the burden on the
\ngeneral budget. On the other hand, over-
\nall health spending and population un-
\nable to receive health care increase while
\npremiums required for health care rise. In
\nTurkey and similar countries spending on
\nhealth care has been steeply rising. When
\nthe governments can no longer compen-
\nsate the health deficit, someone must pay.
\nThis means more out of the pocket spend-
\ning and charging more, accompanied by
\nreduced health care coverage. In private
\nhealth care systems, spending must be
\nlowered to increase profits that lead to re-
\nduced fees for physicians and other health
\nprofessionals.
\nPresident Obama\u2019s health care reform in the
\nUSA was aimed at providing health care to
\naround 50 million who could not afford
\nhealth insurance.Through a state owned in-
\nsurance fund financed by taxes, health care
\nwill be provided to those who cannot af-
\nford it, which essentially is a great turn back
\nfrom a completely private system. Another
\naim of the health care reform is to decrease
\nthe prohibitively high health care costs in
\nthe USA. Among other steps taken, the
\nmost prominent is to reduce the physician
\nfees.The USA is the biggest economy in the
\nworld, while the GDP is about five times
\nthat of Turkey.If a completely private health
\nsystem cannot work effectively in a country
\nlike the USA, how can anyone expect it to
\nbe successful in developing countries?
\nIn Turkey overall infant mortality rate has
\nbeen constantly decreasing, down from 52.6
\nin 1993 to 20.7 in 2007 per 1000 live births.
\n40
\n47
\n51 50 48
\n44 42
\n46 47
\n43
\n0
\n40
\n50
\n60
\n2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
\nFigure. Collected Premiums\/Social Security Health Payment (%)
\n27
\nPrison Health
\nHowever, in 1978, 1.2 infants died in rural
\nareas for every one infant from urban areas.
\nThis ratio rose to 1.7 in 2007 [4]. The same
\ntrend is observed when the richer western
\npart of Turkey is compared with the poorer
\neastern part, being a clear indicator of the
\npoor not receiving proper health care. The
\nbig problem is that the rich are getting rich-
\ner every year and the gap between the rich
\nand the poor is increasing.
\nHealth care should not be completely priva-
\ntized, especially in developing countries,
\nand one single model of health care reform
\nwill not solve health care problems. Primary
\nhealth care is essential in these countries
\nand must be provided by the state. In addi-
\ntion to the poor, the combination of unreg-
\nistered labor force and high unemployment
\nrates form a large group of population that
\ncannot afford private health care. This fact
\nalone makes a payroll tax financed system
\nunrealistic. Health care in these countries
\nshould be provided mainly by the state at
\nleast until these countries join the \u201cdevel-
\noped\u201d countries.
\nReferences
\n1. Thomson S, Foubister T, Mossialos E. Financing
\nhealth care in the European Union: challenges
\nand policy responses.World Health Organization,
\nCopenhagen,Denmark.Observatory Studies No:
\n17. (2009) ISBN 9789289041652
\n2. Fleisher L, Gottret P, Leive A Schieber GJ,
\nTandon A,Waters HR. Assessing good practice
\nin health care reform. In: Gottret P, Shieber GC,
\nand Waters HR, eds Good practices in health
\ncare financing; lessons from low and middle
\nincome countries. 2008 World Bank Report.
\nwww.sitesourcesworldbank.org
\n3. Financial Statistics of Social Security Institu-
\ntion. (accessed at http:\/\/sgk.gov.tr\/wpr\/portal\/
\nanasayfa\/istatistikler)
\n4. Turkey Health Statistics of the Ministry of
\nHealth. (accessed at http:\/\/saglik.gov.tr\/TR\/
\nGenel\/BelgeGoster.aspx)
\nA.Ozdemir Aktan MD
\nProfessor of Surgery
\nPresident, Turkish Medical Association
\nIntroduction
\nThe act of fasting for a prolonged period
\nof time as a form of protest goes back more
\nthan a century. It has been used since the
\nsuffragette movements in the UK and the
\nUS in the early 20th
\ncentury. Hunger strikes
\noccurred sporadically in Ireland during the
\nlong protracted struggle between the Irish
\nNationalists and the British authorities. In
\nthe first half of the last century, Mahatma
\nGandhi, in Britain\u2019s Imperial India, went
\non and off hunger strikes many times, both
\nwhen in and out of prison. It was Gandhi
\nwho perhaps actually gave hunger strikes
\ntheir lettre de noblesse as a means of mak-
\ning the protest known to the general pub-
\nlic. Hunger strikes attracted world-wide
\nattention in the late 20th
\ncentury in Belfast
\nand Turkey. Ten much politicized deaths in
\nNorthern Ireland and several dozens deaths
\nin Turkey put hunger strikes back in the
\nnews. In this century, the vast media atten-
\ntion given to hunger strikes by the inmates
\nat Guant\u00e1namo Bay did not center on the
\nphenomenon of the protest, but of the very
\ncontroversial \u201csolution\u201d applied\u00a0 \u2013 force-
\nfeeding the hunger strikers. There have also
\nbeen other, less highly publicized, hunger
\nstrikes in Europe, the Middle East and
\nelsewhere, which have attracted particular
\nmedia attention, and have raised different
\ncontroversies.
\nThe 21st
\ncentury hunger strikes put the spot-
\nlight onto the high-level,often heated argu-
\nments between two antagonistic authorities.
\nOn the one hand, there are the Prison au-
\nthorities, responsible for keeping prisoners
\nconfined, and also legally responsible for
\ntheir welfare.Then there are the judicial au-
\nthorities, judges and lawyers that apply and
\nprocess the rule of law in the wide sense of
\nthe term, including appeals and demarches,
\nfor sentenced and remand prisoners. Both
\nprison and \u201cjudicial\u201d authorities are non-
\nmedical entities. To simplify the text, both
\nshall hereafter come under the generic
\nterm of \u201ccustodial authorities\u201d, unless one
\nof the two needs to be specified. On the
\nother hand, there are the \u201cmedical authori-
\nties\u201d, the physician(s) in charge of caring for
\nprisoners who go on hunger strike, and by
\nextension the national medical association,
\nand further up the World Medical Associa-
\nPhysicians and Hunger Strikes in Prison: Confrontation,
\nManipulation, Medicalization and Medical Ethics (part 1)
\nHern\u00e1n Reyes George J. AnnasScott A. Allen
\n28
\nPrison Health
\ntion (WMA). The recent confrontations on
\nhunger strikes have been between these two
\ngroups of authorities,\u201ccustodial\u201dand \u201cmedi-
\ncal\u201d. In some cases, it has almost been as if
\nthe actual hunger striker, as an individual
\nperson, has become an afterthought. The
\nconflict has been mainly around the \u201ccus-
\ntodial\u201d authorities who have decreed and
\nimposed force-feeding, and those who are
\nthe only ones who can perform it, the actual
\nphysician(s), who often object, with the im-
\nplicit support of the WMA.The controversy
\nhas in fact not been so clear cut, as there
\nhave been physicians willing to perform
\nforce-feeding of hunger strikers, taking
\nsides with the \u201ccustodial\u201dauthorities, and, as
\nshall be seen,against their ethical principles.
\nThe controversy around this force-feeding,
\nwhich has essentially been a major issue in
\njust one context\u00a0\u2013 Guant\u00e1namo Bay\u00a0\u2013 but
\nhas been the Damocles sword in many oth-
\ners, is a major issue, but it is just the tip of
\nthe iceberg. As shall be shown, the force-
\nfeeding controversy is indeed a serious bone
\nof contention for the medical profession.
\nHowever, the true role of the physician has
\nbeen corrupted and co-opted. By \u201cmedical-
\nizing\u201d the situation with the contentious
\nsolution of force-feeding, the \u201ccustodial\u201d
\nauthorities have shifted the onus onto the
\ndoctors to \u201csolve the issue\u201d, i.e. to make the
\nprotest fasting cease. Physicians have been
\nordered to intervene, artificially feeding fully
\nconscious and mentally competent prisoners
\nagainst their will. This is what constitutes the
\nforce-feeding which shall be one of the focal
\npoints of this paper. The real role the doc-
\ntors should be playing in the vast majority
\nof cases will also be defined and illustrated.
\nFrom and ethical, practical and clinical per-
\nspective, in many if not most cases, there are
\nbetter options than force-feeding available
\nin the competent management of a hunger
\nstrike. We will describe them in this paper.
\nThe reason the \u201ccustodial\u201d authorities have
\nshifted the responsibility for making the
\nhunger strike stop is obviously because pro-
\nlonged fasting is undoubtedly not good for
\nhealth. The physician\u2019s role, however, is not
\njust about monitoring calorie intake (or the
\nlack thereof), controlling blood pressure
\nand weight-loss\u00a0\u2013 and ultimately inserting
\na tube down a hunger striker\u2019s throat to de-
\nliver nutrients by force. As shall be demon-
\nstrated, the physician can and should play
\nmuch more important role, which in most
\ncases will facilitate to avoid getting close to
\nthe need for any feeding.This role, however,
\nrequires having a relationship of trust, as
\nthere should be in any doctor-patient re-
\nlationship. Imposing any solution perverts
\nthis relationship, perhaps irretrievably, and
\nprevents physicians from carrying out their
\ntask of intermediary, towards a compromise,
\nand a solution acceptable to all. This is the
\npractical basis for the ethical prohibition of
\nforce-feeding. Forced treatment against the
\ncompetent informed consent of the patient
\ndestroys trusting and functioning doctor-
\npatient relationship. The practical conse-
\nquence of that destruction is the elimina-
\ntion of almost all non-coercive solutions to
\nthe hunger strike. Furthermore, the practice
\nof force-feeding corrupts the already fragile
\nfoundation of trust between all correctional
\nphysicians and their patients, and may have
\nthe effect of undermining the efficacy of the
\nprofession in the prison at large.
\nEthical framework: the \u201cWMA
\n2006 Malta declaration\u201d
\nThe World Medical Association (WMA),
\nis the \u201cinternational organization created in
\n1947 to ensure the independence of physi-
\ncians, and to work for the highest possible
\nstandards of ethical behaviour and care by
\nphysicians,at all times\u201d1
\n.At the time of writ-
\ning this, it comprised about one hundred
\nnational medical associations, including the
\nAmerican Medical Association (AMA),one
\nof its founding members. The WMA issued
\nspecific medical ethical principles relating to
\nhunger strikes in its Declaration of Malta
\nof 1991 (\u201cMalta 1991\u201d), updating them in
\n1 www.wma.net What we do
\n20062
\n(\u201cMalta 2006\u201d), together with an ac-
\ncompanying Background paper and Glos-
\nsary3
\n. The WMA guidelines recognize that
\nhunger strike situations are complex and
\nrequire the physician to make individualized
\nclinical judgements. Discussions around the
\nWMA guidelines for dealing ethically with
\nhunger strikes have led to heated confron-
\ntations between custodial and judiciary au-
\nthorities, on the one hand, and physicians
\non the other. In some cases local medical
\nauthorities, not familiar with the WMA
\nguidance, of choosing not to follow it, have
\nadded to the confrontation. Heated argu-
\nments, sometimes in the full spotlight of
\nthe media and general public, have even dis-
\ntracted from the plight of the actual hunger
\nstriker(s). As shall be seen, these confronta-
\ntions may in some cases have pushed fasting
\nprisoners into adopting positions more radi-
\ncal than they initially intended to take. It is
\nthis phenomenon, and how to avoid it, that
\nthis paper ultimately intends to document
\nand so to provide practical recommenda-
\ntions for constructive action.
\nHow and why \u201cMalta 2006\u201d evolved from
\nthe original \u201cMalta 1991\u201d relates directly to
\nthe complexitiy of hunger strike manage-
\nment, and is discussed in the second section
\nof this paper.
\nDefinitions: what are hunger
\nstrikes\u00a0\u2013 and what they aren\u2019t
\nThere is a vast literature on hunger strikes,
\nmaking it almost futile to ask, \u201cwhat a hun-
\nger strike is.\u201d Nonetheless our experience
\naround the globe has shown time and again
\nthat many fundamental misunderstandings
\nand misconceptions about hunger strikes
\n2 https:\/\/www.wma.net\/en\/30publications\/
\n10policies\/h31\/index.html
\n3 WMA Declaration of Malta\u00a0\u2013 A Background Paper
\non the Ethical management of Hunger Strikes., In:
\nWorld Medical Journal, Vol 52, N\u00b0 2, June 2006,
\nhereafter WMJ. One of the authors of this paper
\nwas co-author of the background paper, together
\nwith the British Medical Association (AS).
\n29
\nPrison Health
\npersist. It is first necessary to recall what
\nis meant by a \u201chunger strike\u201d, what is not
\nmeant\u2026 what benchmarks need to be de-
\nfined, and finally how such fasting is in-
\ntended to \u201cwork.\u201d
\nHunger strikes fundamentally are a form
\nof protest against the custodial authority
\nwhere the hunger striker is attempting to
\ndraw attention to a grievance by creating an
\nurgent situation that may bring unwanted
\nattention or shame upon the authority as a
\nmeans of moral leverage.
\nPerhaps the earliest recorded hunger strike,
\nin the sense of a political protest against the
\ncustodial authority, was that of the revo-
\nlutionary Vera Figner in Czarist Russia in
\n1889. At the beginning of the 20th
\ncentury,
\nin the UK, countless suffragettes suffered
\nignoble force-feedings ordered by the Brit-
\nish judiciary authorities, widely reported and
\nvehemently criticized at the time. Eloquent
\nposters showed how these brave women were
\nsubmitted to force-feeding, a tube being in-
\nserted by a doctor into their stomachs while
\nthey were held down,struggling.It was how-
\never Mahatma Gandhi, protesting against
\nthe government of his Majesty \u201cEmperor of
\nIndia\u201d who gave hunger strikes their titre de
\nnoblesse, in the first half of the 20th
\ncentury.
\nThere have been many hunger strikes in
\nthe past thirty or so years. However, not
\nall prisoners \u201cwho-refuse-to-eat\u201d should
\nbe considered hunger strikers. The generic
\nterm \u201chunger strike\u201d is used to cover a va-
\nriety of very different situations in which a
\nprisoner refuses to take nourishment as a
\nform of protest. Two main types of fasting
\nprotesting prisoners can be distinguished,
\ndiffering essentially by their modus operandi,
\nthe \u201cfood refusers\u201don the one hand, and the
\n(true) \u201chunger strikers\u201d on the other. The
\nvast majority of what prison directors, law-
\nyers,judges,the media and even most physi-
\ncians call \u201chunger strikers\u201d, are in fact food
\nrefusers. The difference, as shall be seen, is
\na major one, as in the case of the \u201crefusers\u201d,
\nthose prisoners do not have the slightest in-
\ntention of hurting themselves by fasting \u201cto
\nthe brink\u201d so to say. Therefore, there will be
\nno question of forcing them to take food,
\nforce-feeding them, and hence little or no
\nethical dilemma involved at all.
\nFood refusers are what a senior medical col-
\nleague working in the prisons of Northern
\nIreland used to call \u201cthe blokes who give hun-
\nger strikes a bad name!\u201d\u2026 These are prisoners
\nwho for any motive, great or small, justified
\nor not, important or petty, declare themselves
\nto be on \u201chunger strike\u201d; make a big fuss
\nover it; ensure that the prison director, the
\nprison staff, the doctor, if possible their fam-
\nilies, and above all the media, know they are
\n\u201con strike\u201d. The key concerns here are that
\nthis type of the so-called \u201chunger strike\u201d is
\nalways short-lived. Food refusal as defined is
\nquite common amongst common-law pris-
\noners, generating a \u201clot of noise\u201d, but most
\noften not much else.Such prisoners trumpet
\nwhatever their complaints are, but in fact
\nthey have not the slightest intention of hurt-
\ning themselves by their fasting.Medical staff
\nwho are used to this category of prisoners
\ncall them the \u201cprofessional hunger strikers\u201d\u00a0\u2013
\n\u201cwho go on strike at the drop of a hat\u201d\u2026
\nOthers less kindly call their action \u201cnuisance
\nfasting\u201d, as it generates extra work for the
\nmedical staff,but essentially for no purpose.1
\nWho, then, is a \u201ctrue\u201d hunger striker? Are
\nthere different \u201ccategories\u201d of hunger strik-
\ners? Are there \u201creal\u201d hunger strikers and
\n\u201cphoney\u201d hunger strikers, as some authori-
\nties have asked2
\n. Before the Turkish protests
\nat the end of last century, hunger strikers
\nwere often classified as \u201cserious\u201d, when like
\nBobby Sands, they were effectively ingest-
\ning only water, and thus posed a risk to
\n1 Owing to the fact that most of these actions
\nare short and self limited, optimal management
\noften involves little to no response by either
\ncustodial or medical authorities for the first 72
\nhours assuming the patient is healthy at baseline.
\nThe clinical rationale for this approach will be
\nexplained later in this paper.
\n2 The author\u2019s own personal experience of twenty-
\neight years working as a doctor with the ICRC\u2026
\ntheir lives by their action.Any other form of
\nfasting was deemed \u201cnot-so-serious\u201d. These
\nother forms were by far the most common
\namong prisoners who were fasting, but who
\nalso took nourishment \u201con the side\u201d and
\nwere thus deemed to be \u201ccheating\u201d on their
\nstrike. This vast majority had their strikes
\ncatalogued as \u201cnot-so-serious\u201d. One of the
\nauthors of this paper fell into that trap at
\nthe time. While the Irish hunger strikers
\nfasted totally and died after eight to ten
\nweeks from acute malnutrition, the Turk-
\nish hunger strikers obviously did take some
\nnourishment on the side, as they survived
\nmuch longer than the Irishmen. The Turks
\ndid this to make their protest last as long as
\npossible, to extend the moral pressure put
\non the authorities, and on public opinion.
\nA\u00a0 great many of them died anyway, from
\nprolonged and not acute malnutrition, af-
\nter up to several months. Thus, simplistic
\ndistinctions cannot be made when dealing
\nwith this complex issue.
\nA \u201chunger striker\u201d, as we use the term here,
\nis thus a prisoner who uses fasting as a way
\nof protesting, and is willing to place his
\nhealth\u00a0\u2013 and perhaps his life\u00a0\u2013 \u201con the line\u201d,
\nso as to be heard by an authority that does
\nnot allow any other meaningful way for him
\nto make his grievances known. The mascu-
\nline form is used here to ease the reading
\nof this text, as the great majority of hunger
\nstrikers in the world are indeed males, with
\nall due apologies and respect to the suf-
\nfragettes, and even more so to the Irish and
\nTurkish women hunger strikers who died.
\nThe determination of a hunger striker to
\ncarry through with his actions is subject to
\nmany factors and pressure from many sides.
\nIt is therefore unfair to judge the \u201cserious-
\nness\u201dof a hunger strike on any one criterion
\nalone. Each context, and each individual,
\nmust be judged on its, or his, own merits.
\nIt is paramount to realize that the hunger
\nstriker, in the vast majority of cases, does
\nnot fast with the intention of dying! Thus,
\nto compare hunger strikes to \u201csuicidal
\nbehaviour\u201d is a major error, made by many,
\n30
\nincluding judges and senior physicians who
\nshould know it better. Going on a hunger
\nstrike is not an attempt to commit suicide.
\nA hunger striker wants to make his case
\nknown, to protest, and to change his situa-
\ntion or perhaps change the world. He wants
\nto live better in that world, not to die in
\nit. Bobby Sands was as determined as any
\nhunger striker could be, yet if he had ob-
\ntained from Margaret Thatcher a concession
\nto his demands the day before he died, he
\nwould have taken nourishment.The Green-
\npeace activists who used to sail their boats
\ninto the atoll where French nuclear tests
\nwere being carried out in the Pacific Ocean,
\nin the early and mid-1990s, were not seek-
\ning to get themselves blown up. They were
\nmost certainly not suicidal.They were, how-
\never,willing to risk their lives as a last resort,
\nin order to publicize their protest against
\nnuclear weaponry. Indeed, soldiers often
\nenter the battle with full knowledge that
\ntheir mission carries with it the high risk of
\ndeath. But they are not suicidal. Death is a
\nrisk of the form of protest called \u201chunger
\nstrike.\u201d It is not the goal, and therefore, a
\ndeath by hunger strike is not suicide.
\nAs will be developed further on, this
\ncomparing determined hunger strikes to
\n\u201csuicide\u201d is a common misunderstanding
\nthrough lack of knowledge in many cases,
\nbut also through \u201cbad faith\u201d. In the case
\nof the hunger strikes at Guant\u00e1namo Bay,
\nDepartment of Defence (DoD) directive
\n2310.08e specifically classifies any hunger
\nstrike as an \u201cattempted suicide\u201d or an at-
\ntempt to \u201cself-harm.\u201d This is an improper
\nand inaccurate classification that has per-
\nsisted in the face of efforts by a number of
\noutside health professionals to correct the
\nDepartment\u2019s policy.
\nIn most cases when the term \u201chunger strik-
\ner\u201dis used, there is a political connotation to
\nthe protest fasting.The common denomina-
\ntor between Emily Pankhurst, suffragette;
\nBobby Sands, IRA leader and member of
\nParliament; Holger Meins, member of the
\nGerman \u201cBaader-Meinhof \u201d group in Ger-
\nmany in the 1970s; and the already men-
\ntioned Turkish hunger strikers, is that all of
\nthem evoked political motives for ceasing to
\ntake nourishment, and steadfastly \u201cstuck to
\ntheir guns\u201d.Less well-known prisoners have
\nto consider the probability of their protest
\nbeing heard, and how far they really want to
\ngo to get attention.
\nTo conclude, a prisoner who goes on a hun-
\nger striker, determined to pursue the fasting
\nfor a certain length of time, does so because
\ns\/he feels, rightly or wrongly, that such an
\naction is a \u201clast resort\u201d to be heard. The de-
\nmands will vary considerably according to
\nthe time and context, but the protest fast-
\ning most often seen as the \u201conly way\u201d to be
\ntaken seriously. As shall be seen, it is up to
\nthe physician to determine \u201chow seriously a
\nhunger striker wants to be taken seriously\u201d\u2026
\nClinical Framework:
\nDiet and Time
\nThe benchmarks that need to be clearly de-
\nfined concern diet and time frame. It may
\nseem a bit ludicrous to define any \u201cdiet\u201d,
\nsince it would seem that hunger strikes
\nimply a lack of any intake of nutrition.
\nHowever, as shall be seen, a majority of the
\nso-called \u201chunger strikes\u201dinvolve less-than-
\ntotal fasting. Therefore some definitions are
\ncalled for. The time frame will define when
\na hunger strike should attract attention, and
\nhow long a span of time one can actually
\nlast.
\nDiet
\nThere are different kinds of fasting and dif-
\nferent concepts of \u201ceating\u201d, but for our pur-
\nposes only three are important.1
\n\u2022 The dry hunger striker takes no food or
\nwater of any kind. This is often put for-
\n1 See WMA Internet Course for Prison Doctors.
\nHunger Strike, Chapter 5; accessible at http:\/\/
\nwww.wma.net\/en\/70education\/10onlinecourses\/
\n20prison\/index.html
\nward, by the hunger striker wanting at-
\ntention, or by the authority to justify
\nintervention, as a \u201cvery dangerous\u201d form
\nof hunger strike, as a body cannot survive
\nvery long without any water.No \u201cdry hun-
\nger striker\u201d will survive more than a few
\ndays at most, depending on climate and
\ntemperature. Hunger strikes need time
\nif they want to exert any effect, thus this
\nkind of strike is by definition counterpro-
\nductive. It may be either a \u201cgimmick\u201d to
\nattract publicity, or the manifestation of
\na possible psychological problem.There is
\nno known record of a hunger striker dy-
\ning on a \u201cdry\u201d strike.
\n\u2022 Total fasting means no solid food, and
\nonly ingestion of water. This differs from
\nthe US definition, which uses the term
\n\u201ctotal fasting\u201d for what has been defined
\nabove as \u201cdry hunger strike\u201d.This is unfor-
\ntunate because the concept of \u201cVoluntary
\nTotal Fasting\u201d is in fact what a hunger
\nstrike is all about. Two litres of drinking
\nwater a day is the suggested quantity,with
\nor without salt, preferably mineral water…
\nIn a \u201crigorous\u201d,i.e.strict hunger strike,\u00e0 la
\nBobby Sands,there would be no other ad-
\ndition to the water, no sugar, no vitamins
\nand certainly no nutritive concoction.
\nNon-total fasting simply means a \u201cless
\nrigorous\u201dhunger strike,and includes prac-
\ntically any other type of fasting, e.g. with
\nvitamin and mineral intake; sometimes
\nliquid nutrients taken in addition to plain
\nwater; or other supplements. The term is
\nnot strictly defined, as it also includes a
\nsupposedly strict, \u201ctotal\u201d, hunger strike\u00a0\u2013
\nwith unofficial (\u201con the sly\u201d\u2026) intake of
\nfood.The physician must know what type
\nof a hunger strike the prisoner is on as
\nthis will change the approach he may
\nhave in dialogues with the prisoner(s).
\nThe determination and hence \u201cseriousness\u201d
\nof a hunger strike depends on its duration
\nand not alone on its being total or not.
\nA\u00a0non-total hunger strike may be just as de-
\ntermined as a total one\u00a0\u2013 and lead to deaths
\nas well,only at a much later stage,as was the
\ncase in Turkey in the nineties.
\nPrison Health
\n31
\nThe fact that a non-total hunger strike allows
\nmore time for negotiations is a positive\u00a0\u2013 not
\nan inconsistent\u00a0\u2013 position. Physicians need
\nto keep this in mind, as prison authorities
\ntend to malign non-total fasting as \u201ccheat-
\ning\u201d. Some even may deny a declared hun-
\nger striker any access to food as if they were
\n\u201ccalling his bluff\u201d.Although this may \u201cbreak\u201d
\nsome hunger strikes, it may radicalize others
\nand may uselessly lead to loss of life.Denying
\naccess to nutrition is of course unacceptable
\nas a medical intervention.
\nThese distinctions are emphasized here as a
\nquestion of credibility for medical staff, as
\nterms of reference. Anyone, claiming that
\nhunger strikers have been on total fasting
\nfor six or nine months, de facto proves that
\nthe fasting was not total.This in itself is not
\na problem, and the physician should abstain
\nfrom the arguments some prison authori-
\nties, or the media, would like to get him
\ninto\u00a0\u2013 whether the fasting is \u201cgenuine\u201d or
\nnot\u2026A physician needs to clearly state that
\nany form of fasting can indeed be prejudi-
\ncial for health, and that the doctor\u2019s role is
\nto see what the best solution is in each case.
\nHe should not fall into the trap of \u201cconfirm-
\ning\u201da hunger striker is indeed \u201ceating on the
\nsly\u201das this will destroy his credibility for ne-
\ngotiating both with the hunger strikers and
\nthose around him. Any partial fasting for a
\nlengthy period of time will provide much
\nmore time to perhaps finding a face-saving
\nsolution for all involved\u00a0\u2013 and thus be in-
\nstrumental in avoiding fatal outcomes.
\nTimeframe
\n\u201cWhen does a hunger strike begin\u201d? Skip-
\nping several meals may well be a form of
\nfood refusal\u00a0\u2013 and therefore a form of pro-
\ntest\u00a0\u2013 but such short-lived, often episodic,
\nfasting certainly does not qualify for the
\nterm hunger strike. There are no set criteria
\nfor the minimum duration for protest fast-
\ning, so reference can be made to physiol-
\nogy. A healthy, normally nourished adult,
\nwithout any medical contra-indication to
\nprolonged fasting, should have no problem
\nwhatsoever fasting totally (i.e. taking only
\nwater) for around 72 hours.This is when the
\nonset of ketosis, the presence of metabolites
\nknown as \u201cketone bodies\u201d, usually occurs,
\nfor physiological reasons1
\n.
\nKetosis is discernible clinically on the
\nbreath by what has been described a \u201cpear-
\nlike smell\u201d. Ketosis subdues the voracious
\nsensation of hunger,\u201chunger pangs\u201d,experi-
\nenced during the first 2\u20133 days of total fast-
\ning. It could thus be argued that, as a simple
\n\u201crule of thumb\u201d, total fasting (i.e. taking
\nwater only) for longer than 72 hours quali-
\nfies on metabolic grounds for the term hun-
\nger strike. The appearance of ketone bodies
\nin the breath will depend on many factors,
\nincluding body mass and fat, but this rule of
\nthumb has been found to work in the ma-
\njority of cases. Strictly fasting for 72 hours
\ndoes absolutely no harm to anyone in good
\nhealth, but does need some determination,
\nand thus allows separating so to say \u201cthe
\nwheat from the chaff \u201d.
\nThe purpose of this \u201ctest\u201dis to eliminate any
\nconfusion with short-lived fasting, which
\nshould not even qualify as \u201cfood refusal\u201d\u00a0\u2013
\nmost cases petering out by themselves be-
\nfore 72 hours. It will not be relevant\u00a0\u2013 and
\nmay even be counter-productive\u00a0\u2013 to insist
\non distinguishing between somewhat more
\ndetermined food refusers (but food refusers
\nnonetheless) and hunger strikers immedi-
\nately after the 72 hours. Such food refusers
\nwill not want to lose face by appearing to
\nbe less determined than real hunger strikers.
\nAt the other end of the spectrum, there can
\nbe another rule of thumb. The fatal out-
\ncomes of terminal total fasting were medi-
\ncally documented during the 1981 hunger
\nstrikes in Northern Ireland. Death occurred
\nduring these total hunger strikes anytime
\nbetween 55 and 75 days. During the 1981
\nIrish hunger strikes one of the \u201cTen Men\u201d
\ndied at 46 days, according to one account
\n1 WMJ; op. cit. p.32
\nbecause he could no longer ingest water2
\nonly one exception at 46. Similar experienc-
\nes have confirmed this time bracket\u00a0\u2013 the
\nthree-week span being due to differences in
\ninitial physical constitution, and individual
\nadaptation. It is not possible to precisely
\npredict when, within this time span, death
\nmay or is \u201cmost likely\u201d to occur.
\nDeath caused by ingesting only water does
\nnot occur before six weeks, and usually later
\nif the person was in good health at the start
\nof the fasting, and after a specific phase of
\nthe total hunger strike, called the \u201cocular
\nmotility\u201d phase3
\n.The clinical manifestations
\nduring this phase last about a week, roughly
\nbetween 35 and 42 days according to the
\nvery few contexts where it has been medi-
\ncally observed, and are troubles of ocular
\nmotility due to progressive paralysis of the
\noculo-motor muscles:
\n\u2022 uncontrollable nystagmus
\n\u2022 diplopia
\n\u2022 extremely unpleasant sensations of ver-
\ntigo
\n\u2022 uncontrollable vomiting
\n\u2022 extremely difficult to swallow water
\n\u2022 converging strabismus
\nThe onset of this phase has been described
\nas the most unpleasant stage by those who
\nhave survived prolonged fasting, and is the
\none most dreaded by prisoners who envis-
\nage beginning a hunger strike.
\nWhat is essential for the clinician to know
\nhere is that the beginning of the final stages
\nof fasting occur after the \u201cocular\u201d phase\u201d,
\nhence roughly from six\u2013seven weeks on-
\nwards. It is during the weeks following the
\nocular phase that the hunger striker may
\nprogressively become no longer capable of
\nclear discernment. Survival any time after
\nten weeks of total fasting is practically im-
\npossible.
\n2 Walker R.K. (2006) The Hunger Strikes. Belfast:
\nLagan Books; p. 126
\n3 See WMA Internet Course for Prison Doctors,
\nChapter 5, www.wma.net
\nPrison Health
\n32
\nIn short,the \u201c72\u201372\u201drule holds: seventy two
\nhours should be the minimum for any fast-
\ning to be taken seriously; and 72 days are
\nthe maximum a hunger striker taking only
\nwater can hope to last. This knowledge is
\nindispensable for the physician so he can
\nrealistically modulate his interventions as
\nneeded. Total fasting is the form of hunger
\nstrike that can pose a vital threat as early as
\nsix weeks into the hunger strike; and death
\noccurs between the 8th
\nand 10th
\nweek.
\nPhysicians should not be overly obsessed
\nby these benchmarks. On the one hand,
\nthey should be alert to the global clinical
\nsituation, as it has been mentioned. On the
\nother hand, and they should remember that
\nthe vast majority of hunger strikers do not
\ncome anywhere close to the \u201cocular phase\u201d.
\nThe main point is that there is time before
\nthings theoretically can become alarming,
\nand the physician will need to use this time
\nconstructively for the benefit of all.
\nUnderstanding how
\nhunger strikes \u201cwork\u201d
\nHunger strikes in prisons can become effec-
\ntive forms of protest only in countries where
\nthere is some respect for basic human rights
\nvalues1
\nor at the very least a desire to appear
\nto have such respect. If such values do not
\nexist, or are flouted, hunger strikes will ei-
\nther be repressed, or all and any knowledge
\nabout them be stifled.If a hunger strike is to
\nhave any effect, by \u201cshaming\u201dthe authorities
\ninto action, it is necessary for it to become
\npublic knowledge. If it does not, \u201cprotest
\nfasting\u201d is unlikely to have any impact at all
\nand custodial authorities may well choose to
\nignore it\u00a0\u2013 rendering any such fasting moot.
\n1 Reyes, H. Medical and Ethical Aspects of Hunger
\nStrikes in Custody and the Issue of Torture (1998)
\nIn: Maltreatment and Torture, Oehmichen M.
\n(ed.) L\u00fcbeck: Schmidt-R\u00f6mhild; J. P. Restellini
\n(1989) Les gr\u2192ves de la faim en milieu p\u00e9nitentaire
\n.Staempfli (ed) In:Revue P\u00e9nale Suisse (Bern),
\nGeneva, Vol. 106
\nConfrontations between the custodial\/ju-
\ndicial authorities and the medical staff thus
\nimply a hunger strike that is in the public
\neye. Such a clash does not always occur.The
\nhunger strikes in Northern Ireland in the
\n1980s and in Turkey in the 1990s created
\nvociferous confrontations\u00a0\u2013 but not with the
\nphysicians. Force-feeding was not an issue
\neither in Northern Ireland, as the authori-
\nties and physicians decided to acknowledge
\npatient Autonomy. If a prisoner refused to
\ntake food,it was his or her right,and as long
\nas that person was capable of discernment
\nin taking the decision, it was to be respect-
\ned. In Turkey, the situation was very much
\nmore complex, but force-feeding was not an
\noption either. Hunger strikes in other con-
\ntexts have been a mixture of different mod-
\nels, the vast majority of them \u201cbenign\u201d, with
\nshort-lived confrontations.
\nA hunger strike is a way to protest against
\nthe detaining authority. A prisoner may
\nfeel, rightly or sometimes wrongly, that
\nall means of making his or her grievances
\nknown have been thwarted. By refusing to
\neat, such a prisoner tries to retain, or regain,
\nsome \u201ccontrol\u201d over what is left to him or
\nher\u00a0\u2013 the body and its nourishment. A hun-
\nger striker thus uses control over bodily in-
\ntegrity as a \u201clast resort\u201d for protesting. Any
\ncustodial authority, with the support and all
\nthe weight of the judicial (or in the case of
\nGuant\u00e1namo Bay, \u201cmilitary\u201d) authority, will
\nattempt to control all aspects of prisoners\u2019
\nlives. In a (real) hunger strike, the authori-
\nties consider this protest fasting tantamount
\nto a \u201chostage situation\u201d, where hostage taker
\nand hostage is one and the same person.
\nThey consider it as a form of \u201cblackmail\u201d.
\nThis is what they find intolerable and can-
\nnot accept. It has to be stated here clearly
\nthat a competent prisoner, that is to say, ca-
\npable of discernment, and not submitted to
\nany pressure or coercion, direct or indirect,
\nhas the right to autonomy. This includes
\naccepting or refusing any treatment, once
\ninformed of the pros and cons. This also
\nincludes fasting as a way of protest, as this
\ncan be considered as a last resort the pris-
\noner has to make a message known or to
\nmake a demand. As has been mentioned,
\nthe maximum authority on medical ethics
\nhas decided that patient autonomy trumps
\nbeneficence in such a case, and that a phy-
\nsician should respect not to force a hunger
\nstriker to eat. Some voices have tried to cir-
\ncumvent the right to autonomy by stating
\nthat prisoners are never in a position to take
\nany decisions freely.This is not tolerable. As
\nis generally accepted2
\n, \u201cprisoners are sent to
\nprison as punishment, not for punishment\u201d,
\nand this includes prisoners still having the
\nright to make decisions about their welfare.
\nAs prolonged fasting can arguably become a
\nmedical problem, the \u201ccustodial\u201d authorities
\noften medicalize the issue by order force-
\nfeeding. Their argument is that the reason
\nphysicians should intervene is to \u201csave lives\u201d.
\nThey thus \u201cthrow the hot potato\u201d, so to say,
\ninto the medical camp, and ordering the
\nphysician to solve their problem and thus
\nquell the protest. The counter argument to
\nthis is relatively simple, as the weight of the
\nethics is in favour of the physicians. The
\nphysician\u2019s role is not to \u201cresolve the prob-
\nlem\u201d with an unethical invasive procedure
\nagainst the patients informed refusal. The
\npower to \u201cresolve the problem\u201d lies with the
\nauthorities; only they have the power to en-
\ngage in negotiations regarding the grievanc-
\nes of the hunger striker. The physician\u2019s role
\nis to counsel the patient about the health ef-
\nfects of the various options and even make
\nrecommendations for what would be best
\nfor the health of the patient.In addition,the
\nphysician must communicate the general
\nhealth status of the patient to the authori-
\nties as needed. While not the mediator for
\nthe grievances per se, the physician, as a pro-
\nfessional, has the ability to calm the situa-
\ntion by injection of reason and rationality as
\nan intermediary regarding the health status
\nof the patient as well as the various permis-
\nsible clinical options. However, there needs
\n2 Reyes H. (1996) Doctors at Risk. In: Healthy
\nprisons: A vision for the future. Report at the 1st
\nInternational Conference on Healthy Prisons.
\nLiverpool
\nPrison Health
\n33
\nto be a full and careful assessment in every
\ncase, as shall be seen.
\nSecond, and more important still, the vast
\nmajority of hunger strikers,as has been stated,
\ndo not want to \u201cdie\u201d. Hence, there should be
\nno need to use force to feed them.During the
\nfirst weeks of the hunger strike there is time.
\nThe physician needs to obtain their trust, by
\ntalking to them and having them accept the
\nphysician in an additional role of confident,
\nmediator, neutral intermediary or something
\nsimilar as the case may be. The physician
\nshould never appear as the one who is there to
\nimplement the will of the custodial authority.
\nSome, very few hunger strikers, may have
\nsufficient motivation to pursue their fasting,
\nand will not allow the physician to intervene.
\nThey constitute a very small minority. The
\nphysician responsible for the patient, and not
\nan \u201coutsider\u201d who only arrives once a critical
\nstage has been reached, should then act ac-
\ncording to the guidance provided by \u201cMalta
\n2006\u201d.This shall be discussed in detail further
\non with reference to examples from the field.
\nThe majority of controversial cases are pre-
\ncisely in between these extremes\u00a0\u2013 and the
\ncontroversy is most often due to custodial
\nauthorities clashing with the physicians.
\nRole of the Physician spelled out
\nThe physician has a role to play when a pris-
\noner decides to fast for longer than 72 hours.
\nWhether the prisoner is a \u201cfood refuser\u201d as
\ndefined above, or a real hunger striker, the
\nphysician has to determine whether any ini-
\ntial medical factors need assessment or in-
\ntervention. An insulin-dependent diabetic,
\nor a prisoner with a history of gastric ulcer
\nshould not be fasting, whether seriously or
\n\u201cfood refusing.\u201dIf the physician has the trust
\nof the prisoner, in most cases the prisoner
\nwill understand, and relent from fasting.
\nThe physician has a more crucial role to play
\nwhen caring for a prisoner who decides to go
\non a serious hunger strike. In this case, the
\nphysician has certain ethical principles to
\nrespect, as set down in the guidelines estab-
\nlished by the World Medical Association1
\n.
\nEven more important however\u00a0\u2013 the physi-
\ncian has a different role to play, if s\/he has
\nthe trust of the hunger striker, as stated pre-
\nviously. The physician is in an ideal position,
\nand has the time,to try to find a compromise
\nsolution, calm everyone down and ultimately
\ndefuse the conflictual situation. In the very
\nfew hunger strikes involving die-hard or
\ndesperate hunger strikers\u00a0 \u2013 respecting the
\nethics of the situation will be paramount. In
\nthe majority of cases,the situation gets out of
\nhand by the blundering and often bad faith of
\ncustodial or judicial authorities\u00a0\u2013 and some-
\ntimes of those physicians who do not follow
\nthe ethical guidance. An ethical physician is
\nable to act constructively\u00a0\u2013 but only if she or
\nhe knows how to avoid the many pitfalls in-
\nvolved, and defends the ethical high ground
\nagainst the non-medical authorities who
\nmay try to force unethical conduct. Finally,
\nthe physician needs also to know that prison-
\ners, the hunger strikers, can also attempt to
\nmanipulate him.Here the physician needs to
\nstand firm, and defend \u201cphysician autonomy\u201d
\nas well as \u201cpatient autonomy\u201d2
\n.
\nThus, the physician\u2019s role is twofold. First,
\nthere is the clinical and \u201ctechnical\u201d evalua-
\ntion of the situation, initially after 72 hours,
\nand on an on-going basis. Second, there is
\nthe ethical framework within the doctor-
\npatient relationship, the essential element
\nhere being that of trust between the hunger
\nstriker and the physician. It is this second
\naspect that has been skewed in recent well-
\npublicized hunger strikes, for reasons that
\nshall be illustrated with examples.
\nThe doctor-patient relationship
\nAny hunger strike fasting should be a vol-
\nuntary action undertaken by a prisoner as
\n1 Malta, op. cit.
\n2 Allen S. dixit.
\nan individual without coercion from any-
\none. This is not always easy to determine in
\na prison setting. Pressures on hunger strik-
\ners come from many directions3
\n. The prison
\nauthorities; the prison officers; family mem-
\nbers; often the media; other prisoners; and
\neven sometimes medical staff, all have some
\nsort of influence, and can exert pressure
\non the hunger striker(s). The physician re-
\nsponsible for caring for the fasting prisoner
\nshould appreciate this fact, and be prepared
\nto deal each entity as the case requires. The
\nvoluntary nature of the hunger strike is thus
\nan imperative factor to determine.Whatever
\ndecision a hunger striker makes has to be his
\nor her own.The prisoner\u2019s bodily integrity is
\ninvolved, and the physician has to be certain
\nthat no outside coercion is exerted on the
\nprisoner. It is not uncommon for prisoners
\nto be \u201cvolunteered\u201d to go on a hunger strike,
\nby their peers or by an unofficial prisoner
\nhierarchy. In extreme cases, such hierarchy
\nmay even \u201cforce\u201d a prisoner to keep fasting
\nway beyond whatever moment he or she
\nwould have stopped. The physician has a
\nduty to detect such a case, so as to help him
\nor her break loose from such coercion.
\nThus during on-going discussions between
\ndoctor and patient, it will be necessary to
\nfind out how serious the prisoner is about
\nnot taking any nourishment for how long a
\nperiod of time.The physician and the medi-
\ncal team need this information to act effi-
\nciently in the best interests of all4
\n.
\nPhysicians should not let their overall view
\nof the situation be obscured by the obsession
\nof the hunger striker dying in the early stag-
\nes of a hunger strike. Even considering the
\nshortest time frame,there is at least a month,
\nthirty full days, before the afore-mentioned
\n\u201cocular\u201dphase which flags the passage to the
\n3 WMA Internet course for prison doctors; op. cit.;
\nChapter 5.
\n4 Gravier B., Wolff H. et al. Une gr\u2192ve de la faim
\nest un acte de protestation\u00a0\u2013 Quelle est la place des
\nsoignants?, In: Bulletin des M\u00e9decins Suisses
\n2010 N\u00b0 39 , pp 1521-25.
\nPrison Health
\n34
\nmore dangerous second stage of a prolonged
\ntotal hunger strike. During these 30 or more
\ndays there is plenty of time for the physi-
\ncian to play a constructive role.All too often,
\nand because of the hubbub around \u201cV.I.P.\u201d
\n(very important prisoner) hunger strikes, it
\nis the authorities who become nervous and
\nmake decisions or issue feeding orders that
\nare unwarranted and premature. The physi-
\ncian thus has a duty to inform the custodial,
\nand if need be the judicial, that there is no
\nmedical emergency looming.
\nThe doctor-patient relationship in any con-
\ntext implies that the patient, in this case the
\nprisoner hunger striker, trusts the physi-
\ncian. This is not a moot point. Relations be-
\ntween prisoners and medical staff are always
\nfraught with uncertainties, and a degree of
\nmistrust. If the physician is seen as part of
\nthe coercive system any prison of necessity is,
\nthen any relationship of trust will be in jeop-
\nardy. In prisons, inmates cannot choose their
\nphysician; nor can the doctors choose their
\npatients. Conscientious prison doctors know
\nthis and do their best to demonstrate they are
\nthere to care for prisoners,and not to enforce
\ndiscipline. In many countries, unfortunately,
\nthis principle has yet to be accepted, and is
\nseen still as foreign to local culture.
\nIt should further be anticipated here that
\nany bond of empathy between the doctor as
\nhealer and his patient is obviously skewed,
\nif not eliminated altogether, if physicians
\nhave participated in abusing prisoners or
\nin military cases (e.g. Guant\u00e1namo) par-
\nticipated in interrogations. Whether the
\nmethods used for interrogation \u201cqualify\u201d as
\nill-treatment or torture is beyond the scope
\nof this paper\u00a0\u2013 what matters is their being
\nperceived as such by the prisoners. In such
\ncases, developing a relationship of trust may
\njust not be realistic. In such cases, prisoner
\naccess to outside physicians may be the only
\nsolution.This type of case will be considered
\nin the final recommendations.
\nThe main point to make here, in discussing
\nthe doctor-patient relationship is upstream
\nfrom such intervention. It is to draw the
\nprison doctors\u2019 attention to the fact that
\nthey are the ones who can make a differ-
\nence, and can in most cases avoid getting
\ninto the force-feeding controversy. The vast
\nmajority of prisoners neither want to die
\nnor \u201churt themselves\u201d, as it has been stated.
\nThe custodial authorities resent the protest,
\nand want it ended. Furthermore, they do no
\nwant any prisoner to die \u201con their watch\u201d
\nbecause they are on hunger strike.The phy-
\nsician obviously wants also to avoid any fatal
\noutcome of the hunger strike. One wonders,
\nthen, how it is that heated confrontations
\ndo ensue, though everyone agrees to the es-
\nsential fact that deaths must be avoided.
\nThe answer is a complex one, and has many
\nfacets that are not acknowledged by one or
\nthe other of the participants.The custodial au-
\nthorities cannot accept that a prisoner holds
\nhim\/herself\u00a0 \u2013 and therefore the whole sys-
\ntem\u00a0\u2013 hostage,by threatening to fast to death.
\nIn addition,judges and prison governors most
\nusually have no knowledge about the medical
\nevolution of total fasting, and fear \u201closing\u201d a
\nprisoner on their watch. Finally, the custodial
\nauthorities have no ethical obligation to re-
\nspect the principle of patient autonomy,not to
\nmention physician autonomy and usually do
\nnot understand this medical position.
\nPhysicians, hold the key to solving the im-
\npasse in most cases. Before entering into
\nconsiderations about exceptional cases of
\n\u201cdiehard\u201d hunger strikers, one should con-
\nsider the much more frequent case that has
\nbeen mentioned. A physician, if s\/he can
\nhave a meaningful discussion in private
\nwith the fasting prisoner, should be able to
\ndetermine what exactly the hunger striker
\nis prepared\u00a0\u2013 and is not prepared\u00a0\u2013 to do.
\nOnce it becomes clear that the prisoner
\ndoes not intend to go \u201call the way\u201d, the issue
\nbecomes that of serving as useful interme-
\ndiary between the hunger striker(s) and the
\ncustodial authorities.
\nThis is not necessarily an easy matter.
\nA\u00a0physician may be able to convince a hun-
\nger striker to accept an intravenous drip, for
\nexample, with or without nutrients, but at
\nleast with minerals and vitamins. Or even a
\nnaso-gastric tube in some cases. The point
\nis, if the hunger striker has declared (not
\nnecessarily publicly) that s\/he does not want
\nto die, the whole issue of \u201cforce-anything\u201d
\nbecomes moot. An agreement, even only
\ntacit and unspoken, between the hunger
\nstriker and the doctor takes the latter off the
\nhook, and allows for any and all measures to
\nbe taken. The physician then has the \u201cdip-
\nlomatic\u201d task of weighing the sensitivities
\nof both sides, and trying to avoid any side
\nlosing face as much as possible. This may
\nentail, for example, inserting an intravenous
\nline, while \u201callowing\u201d the hunger striker to
\ndeclare vociferously that the \u201chunger strike
\ncontinues\u2026\u201d The physician may have to
\ncalm down a cantankerous prison governor,
\nassuring him that all is for the better, and
\nthat the measures taken will eventually de-
\nflate the conflict and end the fasting.
\nThe key element here is time. Hunger
\nstrikes only \u201cwork\u201d if there is enough time
\nfor negotiation and for communication.
\n(This is the main reason why a \u201cdry\u201d hunger
\nstrike is an aberration, leaving no time at all
\nfor any appeasement to be found.)
\nWhat the physician then has to do is main-
\ntain this relationship of trust\u00a0\u2013 both with
\nthe hunger striker and with the nervous
\ncustodial authorities who are itching to \u201cdo
\nsomething\u201d to make the protest stop.
\nHunger strikes \u00e0 la Bobby Sands, i.e. going
\nall the way with strict total fasting are an
\nextremely rare occurrence. The reason the
\nwhole argumentation about hunger striking
\nand force-feeding has inflated to what it has
\nis mainly because of the custodial authorities
\nincreasing tendency to enforce force-feeding,
\nleaving the physicians no leeway at all to act
\nas intermediaries.In the case of military phy-
\nsicians, they may be less than knowledgeable
\nabout the ethical guidelines that were being
\nflouted, or they agree on principle to fol-
\nlow superior orders whatever they entailed.
\nPrison Health
\n35
\nIf indeed a hunger striker is adamant about
\nnot giving in at any cost, then the physician
\nmust theoretically weigh the principle of
\npatient autonomy (informed consent and
\nthe right to refuse treatment) against that of
\nbeneficence before deciding what to do. In
\nfact, this discussion has already taken place
\nwithin the World Medical Association, and
\nthe guidance given for doctors in \u201cMalta
\n2006\u201d is quite clear.
\nWhen such a conflict exists, it is the autono-
\nmy of the informed, competent patient that
\nis the governing principle. Beneficence, in
\nthe words of the WMA, \u201cincludes respect-
\ning individuals\u2019 wishes as well as promoting
\ntheir welfare\u2026\u201d Avoiding harm \u201cmeans not
\nonly minimising damage to health but also
\nnot forcing treatment upon competent peo-
\nple nor coercing them to stop fasting. Be-
\nneficence does not involve prolonging life at
\nall costs, irrespective of other values.\u201d1
\nThus,
\na competent individual who is informed
\nand able to understand the implications of
\nhis\/her choice cannot be treated against h\/h
\nwill. They can refuse contemporaneously or
\nin advance of losing mental capacity2
\n.
\nExamples shall be given in the second part
\nof this paper that fully illustrate the correct
\nethical conduct of a hunger strike, in the
\nevent that it does go to its final resolution.
\nWhat is perhaps infinitely more important
\nis that the physician most often has the
\npower to avoid the conflictual situation get-
\nting anywhere near death by starving. This
\nwill be developed in the \u201cWay Forward\u201d
\nsection below.
\nThe clinical role of the physician
\nwhen caring for hunger strikers
\nThe medical evaluation of the prisoner on
\nhunger strike requires an accurate assess-
\nment of both his\/her physical and mental
\n1 Malta, op. cit., Article 19
\n2 Medical EthicsToday,2nd
\ned.(2004) British Medical
\nAssociation, London; pp. 602-607, 623-625
\nhealth, and first of all a precise and candid
\nhistory. Any ailments or diseases should be
\ndiagnosed and if necessary documented.
\nThe prisoner should be given accurate clini-
\ncal information about the foreseeable ef-
\nfects of fasting in his or her particular case.
\nThe fasting prisoner needs to be aware that
\nheretofore-unknown underlying health
\nproblems may come to the foreground be-
\ncause of the total fasting,and should indicate
\nwhether they accept treatment or pain relief
\nfor these. Some diseases, such as gastritis,
\nany kind of ulcer,duodenal or gastric,diabe-
\ntes,other metabolic diseases,to mention but
\nthe most obvious ones, should be contra-in-
\ndications to going on hunger strike. As pre-
\nviously stated, if the physician can explain
\nthis to the prisoner convincingly and so s\/
\nhe does not get the (false) impression that it
\nis all merely a ploy to get the hunger strike
\nto stop, in most cases the hunger strike will
\nquickly desist.
\nThis first evaluation should also determine
\nthe mental state and competency. If refusal
\nof food is a manifestation of some mental
\ndisorder, such as severe depression, psycho-
\nsis, or anorexia, then the situation is not that
\nof a hunger strike.The authors of this paper
\nhave argued that most mental disorders dis-
\nqualify a prisoner from the \u201cstatus\u201dof hunger
\nstriker, and make him a full-fledged patient
\nrequiring medical attention. A prisoner, re-
\nfusing to eat because of a mental affliction,
\nmay be reasonably declared incompetent to
\nrefuse treatment. A psychiatrist may even
\nprescribe medically prescribed feeding, if
\nand when such feeding is necessary to sus-
\ntain such a patient\u2019s life. To the extent that
\nindividual competency assessment has been
\nproperly conducted, this may be medically
\nindicated. The physician should direct care
\nat treating the underlying mental disor-
\nder or illness. For this reason, when in any
\ndoubt, a full psychiatric assessment of the
\nfasting person is an essential feature of the
\nevaluation.
\nAn examination of the hunger striker\u2019s
\npsychiatric and medical history may reveal
\nfactors affecting decision-making abilities
\nand cognitive processes3
\n. It has already been
\nmentioned above that a hunger striker, al-
\nmost by definition, does not want to die, s\/
\nhe is not trying to commit suicide by fast-
\ning to death.There is often confusion in the
\nminds of prison authorities and judges, who
\nare steadfastly determined against any pris-
\noner \u201ckilling himself \u201dor \u201cescaping justice by
\ncommitting suicide\u201d.
\nThe psychiatrists M. Wei and J.W. Bren-
\ndel have stated, \u201cMost commonly, hunger
\nstrikers do not have mental disorders\u2026\u201d. The
\ndistinction is paramount between behav-
\niours intended to kill oneself and behav-
\niors undertaken to protest as a last resort.
\nA politically motivated hunger striker may
\npursue a total fast with a very positive goal
\nin mind, for himself, or his community\u00a0\u2013
\nso as to \u201clive better\u201d, even risking death if
\nhis plea not be heard4
\n. The Turkish prison-
\ners who went on repeated and prolonged
\nhunger strikes in the late nineties did not
\nwant to die\u00a0\u2013 even if though they were vo-
\nciferous in declaring they were on \u201cdeath
\nfasts\u201d. The suicide excuse does not apply
\nto prisoners at Guant\u00e1namo, even though
\nsome could arguably have multiple reasons
\nto feel desperate and hopeless. As Major
\nGeneral Jay W. Hood, the camp\u2019s com-
\nmander, told a group of visiting physicians
\nin the fall of 2005, \u201cthe prisoners at Guan-
\nt\u00e1namo are protesting their confinement;
\nthey are not suicidal\u201d5
\n.
\nThe already mentioned more difficult role
\nfor the physician is the all-important task
\nof acting as medical intermediary if consis-
\ntent with the patient\u2019s wishes.This does not
\nmean negotiating the terms of the hunger
\n3 Wei M., Brendel J.W..Psychiatry and Hunger
\nStrikes. In: Harvard Human Rights Journal, Vol.
\n23, 2010.
\n4 WMJ Case example 1; op. cit.; Wei M. Brendel
\nJ.W., op. cit., Footnote 16
\n5 Okie, S Glimpses of Guant\u00e1namo\u00a0\u2013 Medical Ethics
\nand the War on Terror. In: N Engl J Med 2005;
\n353:2529-34.
\nPrison Health
\n36
\nIn Memoriam
\nstrike, nor interceding on behalf of either
\nparty.It may imply determining what possi-
\nble alternatives to harm-causing, prolonged
\ntotal fasting can be acceptable. In this way
\nthe physician acts in the hunger striker\u2019s
\nbest interests, while respecting freely taken
\ndecisions.This will,again,require a relation-
\nship of trust.
\nThe custodial authority sometimes sees the
\nphysician as being the \u201cfinal umpire\u00a0\u2013 the
\none charged with informing the hunger
\nstriker that fasting \u201cto the end\u201d can result
\nin irreversible harm and death. This limited
\nrole of the doctor misses the main point.
\nToo much is focused on what should be
\ndone late in the fasting, and not enough on
\nwhat should be done during the less pres-
\nsured time earlier on in the fasting\u00a0\u2013 where
\nbetter solutions exist. In fact, in the col-
\nlective experience, the best opportunities
\nto de-escalate and resolve a hunger strike
\noccur long before there is any real risk of
\nserious harm or death. The more technical
\nand monitoring roles for medical staff in
\nthe supervision of hunger strikes, concern-
\ning laboratory exams, weight monitoring,
\nelectrolyte intake are fairly straight-forward
\nhave been largely documented elsewhere1
\nand shall not be repeated here.
\nTo be continued…
\n1 Assistance in Hunger Strikes: a Manual for
\nPhysicians and Other Health Personnel Dealing
\nwith Hunger Strikers. (1995 ) Johannes Wier
\nFoundation for Health and Human Rights;
\nAmersfoort, Netherlands, ISBN 90-733550-
\n122
\nDr. Hern\u00e1n Reyes,
\nMD, Medical coordinator for the
\nInternational Committee of the Red Cross,
\nspecializing in medical and ethical aspects
\nof Human Rights, Prison Health, and in
\nthe field of MDR TB in prisons. Observer
\nfor the ICRC on issues of medical ethics.
\nProf. George J. Annas,
\nChair of the Department of Health
\nLaw, Bioethics & Human Rights of
\nBoston University School of Public
\nHealth; Prof. Boston University School
\nof Medicine, and School of Law.
\nScott A. Allen, MD, FACP, School of
\nMedicine,University of California, Riverside
\nE-mail: manzikert@gmail.com
\nIan Field, a past Secretary General of the World Medical Association
\ndied on 23 December 2012 after a long illness.
\nIan was born in Rawalpindi, then in British India (now in Paki-
\nstan) in 1933. His father was a Regular Army Officer, not medi-
\ncally qualified, serving there during the dying days of the British
\nRaj. Ian childhood and early education were in India. During the
\nsecond World War he remained in India, while his father was
\nreported killed in action but was in fact captured by the Japanese
\nand held in Changi for 3 years. During this time Ian was admit-
\nted to a military school in Poona alongside the younger sons of
\nmaharajas. He had been given the aristocratic Hindu caste of a
\nwarrior to fit with the princely hierarchy.
\nWhen his father was eventually freed the family returned to the
\nUK and settled in Bournemouth where Ian completed his school
\neducation.After school he undertook national service in the Roy-
\nal Engineers, starting an interest which remained all his life.
\nHaving decided to study medicine Ian applied to medical school.
\nHis choice of Guys Hospital, University of London was cement-
\ned when they presented him with tea in a china cup when he
\nattended his interview in military uniform.
\nGuys was the ideal choice; not least as he met there Christine
\nwho was to become his wife for 52 years.
\nAfter qualifying and the usual round of house posts Ian entered
\nGeneral Practice, becoming a GP principal. He joined the BMA
\nstaff as an assistant secretary in 1964, rising to Undersecretary
\nbefore leaving in 1974\/5 to work in International Health first
\nwith the Department of Health (then DHSS) and later with the
\nOverseas Development Agency (ODA) where he rose to Chief
\nMedical Adviser. Ian rejoined the BMA in 1985 as Deputy Sec-
\nretary for National Medical Services, the trade union \u201carm\u201dof the
\nBMA, and because BMA Secretary in 1989.
\nAmongst many other significant achievements while working at
\nDHss and the ODA Ian was responsible for relationships with
\nthe WHO and with the Council of Europe. At that time the lat-
\nter in particular was emerging as an important voice that would
\ninfluence health policy within the UK,and Ians deep understand-
\ning of the processes and politics as well as of the policies was
\ninvaluable.
\nIn the ODA Ian was advising ministers on how the UK could use
\nits influence, and money, to improve the health lot of the poor in
\ndeveloping countries. This included work on some of the great
\nkillers of those, and indeed of these, times. He chaired the WHO
\nGlobal Advisory Committee on Malaria; he was the only mem-
\nber who had personally had malaria and he remembered the toll
\nit took from his childhood in India.
\nAlong with those roles came exotic travel. I was exciting o visit
\nChina officially, to be taken to Bokhara and Samarqand by the
\nRussians and to be wined and dined with the Japanese.But along-
\nside the fun of meeting new people and exploring new places he
\nIan Trevor Field
\n37
\nIn Memoriam
\nnever lost his commitment to health in developing countries. In
\nZanzibar he zoomed in on a maternity ward that had been given
\nmodern incubators for premature babies but had no electricity or
\noxygen to put them to use.The survival of the babies still depend-
\ned on loving care and their isolation. On the mainland of Africa
\nhe noted how bedsores were treated with honey and exposure to
\nsunlight.
\nIn this work Ian was using his childhood experiences, which were
\nfar more diverse than the average senior civil servant or British
\ndoctor, to see further and to connect better with the people his
\ndepartment were seeking to help.
\nReturning to the BMA Ian inherited an organisation expand-
\ning rapidly and consolidating its member-facing services, helping
\ndoctors in employment difficulties. At the same time relation-
\nships with the UK government were going through a difficult
\nphase with changes to the National Health Service that were
\ndeeply unpopular with most and to which the BMA was vocally
\nopposed. The Association needed a steady hand at the top, keep-
\ning diverse interests together, and that is what Ian delivered.
\nThe BMA had always had strong international links; many of the
\nmedical associations in the former British Empire were now in-
\ndependent bodies in their own independent countries. But many
\nremained then (and now) attached to memories of working with
\nthe BMA and Ian was always delighted to meet and host col-
\nleagues from around the world. His genuine respect and affection
\nfor people from all over the world shone through.
\nIans knowledge of the way international organisations worked,
\nincluding WHO, was especially helpful as the BMA increased its
\npublic health lobbying internationally on matters such as tobacco
\ncontrol. Help in identifying the right routes to influence were in-
\nvaluable and always available.
\nBy the time he retired the BMA had raised its membership to
\nover 100,000 for the first time and was continuing to expand both
\nits political and professional activities. In recognition of his ser-
\nvice the BMA appointed Ian a Vice President, one of its most
\nsenior honours.
\nAs a broader recognition of his service to health, including his
\nenormously important work while at the Department of Health
\nand the ODA Ian was homoured by her Majesty the Queen who
\nmade him a Commander of the Order of the British Empire.
\n(CBE).
\nAs soon as Ian left the BMA he was snapped up by the World
\nMedical Association. He and Christine moved to Ferney Voltaire
\nand Ian set about persuading lapsed members to rejoin, and to
\ntake an active part in developing WMA policy and direction.
\nA number of member associations had left the Wma in the early
\n1980\u2019s in protest at a number of matters, including voting sys-
\ntems. Ian cajoled them back into active membership promising
\nthat, as always, he would listen to their concerns and ensure real
\nproblems were fair-
\nly addressed. This
\nwas a significant
\nperiod of growth
\nfor the WMA.
\nIan also encour-
\naged engagement,
\nand many more
\nmembers began to
\ndevelop hew poli-
\ncies for the WMA.
\nAs always Ian was
\na strong source of
\nadvice as well as en-
\ncouragement; new
\nmembers knew he
\nwas always there to
\nhelp with drafting,or with help in understanding how to get poli-
\ncies through the byzantine and confusing processes of the WMA.
\nIan loved the opportunity to travel with the WMA, and was a
\npopular visitor at national medical association meetings where he
\nnever failed to promote membership of and engagement with the
\nWMA.
\nAfter Ian retired his many friends hoped he would have a long
\nperiod in which to enjoy life, including his family. His involve-
\nment in the Worshipful Society of Apothecaries, a livery com-
\npany in the City of London that had long had the right to grant
\nmedical licences, culminated in its highest honour when Ian be-
\ncame master.
\nSadly Ian suffered a stroke in the late 1990s which severely cur-
\ntailed his ability o travel,but he remained active in his community.
\nAmong other things Ian enjoyed helping Primary School chil-
\ndren with their reading.
\nIan was, throughout his life, a committed Christian. Raised in the
\nJesuit tradition he later embraced the Benedictine traditions. As
\na community activist Ian played an important part in both local
\nchurch management and in Ecumenism. His faith was a part of
\neverything he did.
\nIan was also a family man. He was devoted to his partner, wife
\nChristine, their three sons and daughters in law and 8 grandchil-
\ndren. All took part in his funeral showing their deep love for heir
\ndevoted grandfather.
\n(With grateful thanks to Sir Colin Imray whose Eulogy
\noffered great help in compiling this obituary.)
\nVivienne Nathanson
\n29 January 2013
\n38
\nOrder of Physicians of Albania
\nRr. Dibres. Poliklinika Nr.10, Kati 3,
\nTirana
\nALBANIA
\nDr. Din ABAZAJ, President
\nTel\/Fax: (355) 4 2340 458
\nE-mail: albmedorder@albmail.com
\nWebsite: www.umsh.org
\nCol\u2019legi de Metges
\nC\/Verge del Pilar 5, Edifici Plaza 4t.
\nDespatx 11, 500 Andorra La Vella
\nANDORRA
\nDr. Manuel Gonz\u00e1lez BELMONTE,
\nPresident
\nTel: (376) 823 525
\nFax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nOrdem dos M\u00e9dicos de Angola
\nRua Amilcar Cabral 151-153, Luanda
\nANGOLA
\nDr. Carlos Alberto Pinto DE SOUSA,
\nPresident
\nTel. (244) 222 39 23 57
\nFax (244) 222 39 16 31
\nE-mail: secretariatdormed@gmail.com
\nWebsite: www.ordemmedicosangola.
\ncom
\nConfederaci\u00f3n M\u00e9dica de la Rep\u00fablica
\nArgentina
\nAv. Belgrano 1235, Buenos Aires 1093
\nARGENTINA
\nDr. Jorge C. JA\u00d1EZ, President
\nTel\/Fax: (54-11) 4381-1548\/4384-
\n5036
\nE-mail: comra@confederacionmedica.
\ncom.ar
\nWebsite: www.comra.health.org.ar
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nARMENIA
\nDr. Parounak ZELVIAN, President
\nTel: (3741) 53 58 68
\nFax: (3741) 53 48 79
\nE-mail: info@armeda.am
\nWebsite: www.armeda.amt
\nAustralian Medical Association
\nP.O. Box 6090, Kingston, ACT 2604
\nAUSTRALIA
\nDr. Steve HAMBLETON, President
\nTel: (61-2) 6270 5460
\nFax: (61-2) 6270 5499
\nE-mail: ama@ama.com.au
\nWebsite: www.ama.com.au
\nOsterreichische Arztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213,
\n1010 Wien
\nAUSTRIA
\nDr. Artur WECHSELBERGER,
\nPresident
\nTel: (43 1) 514 063000
\nFax: (43 1) 514063042
\nE-mail: post@aerztekammer.at
\nWebsite: www.aerztekammer.at
\nAzerbaijan Medical Association
\nP.O. Box 16, AZE 1000, Baku
\nREPUBLIC OF AZERBAIJAN
\nDr. Nariman SAFARLI, President
\nTel: (99 450) 328 18 88
\nFax: (99 412) 510 76 01
\nE-mail. info@azmed.az
\nWebsite: www.azmed.az
\nMedical Association of the Bahamas
\nP.O. Box N-3125, MAB House\u00a0– 6th
\nTerrace Centreville, Nassau
\nBAHAMAS
\nDr.Timothy BARRETT, President
\nTel. (242) 328-1858
\nFax. (242) 328-1857
\nE-mail: medassocbah@gmail.com
\nBangladesh Medical Association
\nBMA Bhaban 15\/2 Topkhana Road,
\nDhaka 1000
\nBANGLADESH
\nProf. Mahmud HASAN, President
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2 9566060\/9562527
\nE-mail: info@bma.org.bd
\nWebsite: www.bma.org.bd
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4,
\n1050 Bruxelles
\nBELGIUM
\nDr. Roland LEMYE, Pr\u00e9sident
\nTel: (32-2) 644 12 88
\nFax: (32-2) 644 15 27
\nE-mail: info@absym-bvas.be
\nWebsite: www.absym-bvas.be
\nColegio M\u00e9dico de Bolivia
\nCalle Ayacucho 630,Tarija
\nBOLIVIA
\nDr. Alfonso Barrios VILLA,
\nTel: (591) 6 227 256
\nFax: (591) 6 122 750
\nE-mail: secretario@
\ncolegiomedicodebolivia.org.bo
\nWebsite: colegiomedicodebolivia.org.bo
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 – Bairro,
\nBela Vista,
\nSao Paulo SP – CEP 01333-903
\nBRAZIL
\nDr. Florentino de Ara\u00fajo CARDOSO
\nFILHO, President
\nTel. (55-11) 3178 6810
\nFax. (55-11) 3178 6830
\nE-mail: rinternacional@amb.org.br
\nWebsite: www.amb.org.br
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.,
\n1431 Sofia
\nBULGARIA
\nDr. Cvetan RAYCHINOV, President
\nTel: (359-2) 954 11 81
\nFax: (359-2) 954 11 86
\nE-mail: blsus@mail.bg
\nWebsite: www.blsbg.com
\nCanadian Medical Association
\nP.O. Box 8650, 1867 Alta Vista Drive,
\nOttawa, Ontario K1G 3Y6
\nCANADA
\nDr. Jeffrey TURNBULL, President
\nTel: (1-613) 731 8610 ext. 2236
\nFax: (1-613) 731 1779
\nE-mail: karen.clark@cma.ca
\nWebsite: www.cma.ca
\nOrdem Dos Medicos du Cabo Verde
\nAvenue OUA N\u00b0 6 – B.P. 421
\nAchada Santo Ant\u00f3nio
\nCiadade de Praia-Cabo Verde
\nCAPE VERDE
\nDr. Luis de Sousa NOBRE LEITE,
\nPresident
\nTel. (238) 262 2503
\nFax (238) 262 3099
\nE-mail: omecab@cvtelecom.cv
\nWebsite: www.ordemdosmedicos.cv
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639, Santiago
\nCHILE
\nDr. Enrique PARIS, Presidente
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940\/6336732
\nE-mail: rdelcastillo@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nChinese Medical Association
\n42 Dongsi Xidajie, Beijing 100710
\nCHINA
\nDr. Zhu CHEN, President
\nE-mail: siwen@cma.org.cn
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nCOLOMBIA
\nDr. Sergio Isaza VILLA, President
\nTel.\/Fax: (57-1) 8050073
\nE-mail: federacionmedicacolombiana@
\nencolombia.com
\nWebsite: www.encolombia.com
\nConseil National de l\u2019Ordre des
\nM\u00e9decins du\u00a0RDC, B.P. 4922,
\nKinshasa, Gombe
\nCONGO, DEMOCRATIC
\nREPUBLIC
\nDr. Antoine MBUTUKU
\nMBAMBILI, President
\nTel: (243-12) 24589
\nFax: (243) 8846574
\nE-mail: cnomrdcongo@gmail.com
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000, San Jos\u00e9
\nCOSTA RICA
\nDr. Jos\u00e9 Federico ROJAS
\nMONTERO, President
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: junta@unionmedica.com
\nOrdre National des M\u00e9decins
\nde la C\u00f4te d\u2019Ivoire
\nCocody Cite des Arts,
\nB\u00e2timent U1, Escalier D, RDC,
\nPorte n\u00b01, BP 1584, 01 Abidjan
\nC\u00d4TE D\u2019IVOIRE
\nDr. Florent Pierre AKA KROO,
\nPresident
\nTel: (225) 22486153\/22443078\/
\n02024401\/08145580
\nFax: (225) 22 44 30 78
\nE-mail: onmci@yahoo.fr
\nWebsite: www.onmci.org
\nCroatian Medical Association
\nSubiceva 9, 10000 Zagreb
\nCROATIA
\nDr. Zeljko METELKO, President
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: tajnistvo@hlz.hr
\nWebsite: www.hlz.hr
\nColegio M\u00e9dico Cubano Libre
\n717 Ponce de Leon Boulevard,
\nP.O. Box 141016,
\nCoral Gables, FL 33114-1016
\nCUBA
\nDr. Enrique HUERTAS, President
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nE-mail: info@sirspeedy5551.com
\nWMA Directory of Constituent Members
\n39
\nCyprus Medical Association
\n14 Thasou Street, 1087 Nicosia
\nCYPRUS
\nDr. Andreas DEMETRIOU, President
\nTel. (357) 22 33 16 87
\nFax: (357) 22 31 69 37
\nE-mail: cyma@cytanet.com.cy
\nCzech Medical Association
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nCZECH REPUBLIC
\nProf. Jaroslav BLAHOS, President
\nTel: (420) 224 266 201-4
\nFax: (420) 224 266 212
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nDanish Medical Association
\n9 Trondhjemsgade, 2100 Copenhagen
\nDENMARK
\nDr.Mads Koch HANSEN, President
\nTel: (45) 35 44 82 29
\nFax: (45) 35 44 85 05
\nE-mail: er@dadl.dk
\nWebsite: www.laeger.dk
\nEgyptian Medical Association
\nDar El Hekmah
\n42 Kasr El-Eini Street, Cairo
\nEGYPT, ARAB REPUBLIC
\nProf. Ibrahim BADRAN
\nTel: (20-2) 27 94 09 91
\nFax: (20-2) 27 95 78 17
\nE-mail: ganzory@tedata.net.eg
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10, Colonia Miramonte
\nSan Salvador
\nEL SALVADOR
\nDr. Rodolfo Alfredo Caniz\u00e1lez
\nCH\u00c1VEZ, President
\nE-mail: marnuca@hotmail.com
\njuntadirectiva@colegiomedico.org.sv
\nWebsite: colegiomedico.org.sv
\nEstonian Medical Association
\nPepleri 32, 51010 Tartu
\nESTONIA
\nDr. Andres KORK, President
\nTel: (372) 7 420 429
\nFax: (372) 7 420 429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nEthiopian Medical Association
\nP.O. Box 2179, Addis Ababa
\nETHIOPIA
\nDr. Fuad TEMAM, President
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@ethionet.et
\nema@eth.healthnet.org
\nFiji Medical Association
\n304 Wainamu Road, G.P.O. Box 1116,
\nSuva
\nFIJI
\nDr. Ifereimi WAQAINABETE,
\nPresident
\nTel: (679) 3315388
\nFax: (679) 3315388
\nE-mail: fma@unwired.com.fj
\nFinnish Medical Association
\nP.O. Box 49, 00501 Helsinki
\nFINLAND
\nDr. Raija NIEMEL\u00c4, President
\nTel: (358-9) 393 091
\nFax: (358-9) 393 0794
\nE-mail: riikka.rahkonen@fimnet.fi
\nfma@laakariliitto.fi
\nWebsite: www.medassoc.fi
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann,
\n75389 Paris Cedex 08
\nFRANCE
\nMichel LEGMANN, President
\nTel: (33) 2 99 38 55 88
\nFax. (33) 2 99 38 15 57
\nE-mail: international@cn.medecin.fr
\nWebsite: www.assmed.fr
\nGeorgian Medical Association
\n7 Asatiani Street, 0177 Tbilisi
\nGEORGIA
\nProf. Gia LOBZHANIDZE,
\nPresident
\nTel. (995 32) 398686
\nFax. (995 32) 396751\/398083
\nE-mail. georgianmedicalassociation
\n@gmail.com
\nWebsite: www.gma.ge
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1, 10623 Berlin
\nGERMANY
\nDr. Frank Ulrich MONTGOMERY,
\nPresident
\nTel: (49-30) 4004 56 360
\nFax: (49-30) 4004 56 384
\nE-mail: international@baek.de
\nWebsite: www.baek.de
\nGhana Medical Association
\nP.O. Box 1596, Accra
\nGHANA
\nDr. Kwabena OPOKU-ADUSEI,
\nPresident
\nTel. (233-21) 670510\/665458
\nFax. (233-21) 670511
\nE-mail: gma@dslghana.com
\nWebsite: www.ghanamedassn.org
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re Av. du Travail #33 – Bois Verna
\nPort-au-Prince
\nHAITI
\nDr. Marie Ginette RIVIERE LUBIN,
\nPresident
\nE-mail: secretariatamh@gmail.com
\nHong Kong Medical Association, China
\nDuke of Windsor Social Service Building
\n5th
\nFloor, 15 Hennessy Road
\nHONG KONG
\nDr. Gabriel K. CHOI, President
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.orgoui
\nWebsite: www.hkma.org
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ), P.O. Box 200,
\nH-1364 Budapest
\nHUNGARY
\nDr.Tibor ERTL, President
\nTel: (36-1) 312 2389 – 311 6687
\nFax: (36-1) 383-7918
\nE-mail: nagy.dora@motesz.hu
\nWebsite: www.motesz.hu
\nIcelandic Medical Association
\nHlidasmari 8, 201 K\u00f3pavogur
\nICELAND
\nDr.Thorbj\u00f6rn J\u00d3NSSON, President
\nTel: (354) 864 0478
\nFax: (354) 5 644106
\nE-mail: icemed@icemed.is
\nWebsite: www.icemed.is
\nIndian Medical Association
\nIndraprastha Marg, 110 002 New Delhi
\nINDIA
\nDr.K.VIJAYAKUMAR,National President
\nTel:(91-11) 23370009\/23378819\/23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: nationalpresident.imahq@gmail.com
\nWebsite: www.ima-india.org
\nIndonesian Medical Association
\nJl. Samratulangi No. 29, 10350 Jakarta
\nINDONESIA
\nDr. Zaenal ABIDIN, President
\nTel: (62-21) 3150679\/3900277
\nFax: (62-21) 390 0473
\nE-mail: pbidi@idionline.org
\nWebsite: www.idionline.org
\nIrish Medical Organisation
\n10 Fitzwilliam Place, 2 Dublin
\nIRELAND
\nDr. Ronan BOLAND, President
\nTel: (353-1) 6767273
\nFax: (353-1) 662758
\nE-mail: imo@imo.ie
\nWebsite: www.imo.ie
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, 52136 Ramat-Gan
\nISRAEL
\nDr. Leonid EIDELMAN, President
\nTel: (972-3) 610 0444
\nFax: (972-3) 575 0704
\nE-mail: michelle@ima.org
\nWebsite: www.ima.org.il
\nJapan Medical Association
\n2-28-16 Honkomagome,
\n113-8621 Bunkyo-ku,Tokyo
\nJAPAN
\nDr. Yoshitake YOKOKURA, President
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nWebsite: www.med.or.jp\/english
\nNational Medical Association
\nof the Republic of Kazakhstan
\n117\/1 Kazybek bi St., Almaty
\nKAZAKHSTAN
\nDr. Aizhan SADYKOVA, President
\nTel. (7-327 2) 624301\/2629292
\nFax. (7-327 2) 623606
\nE-mail: doktor_sadykova@mail.ru
\nKorean Medical Association
\n302-75 Ichon 1-dong
\n140-721 Yongsan-gu, Seoul
\nKOREA, REPUBLIC
\nDr. Hwan Kyu ROH, President
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190\/795 1345
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKuwait Medical Association
\nP.O. Box 1202, 13013 Safat
\nKUWAIT
\nDr. Abdul-Aziz Al-ENEZI, President
\nTel. (965) 5333278, 5317971
\nFax. (965) 5333276
\nE-mail. kma@kma.org.kw
\nalzeabi@hotmail.com
\nLatvian Medical Association
\nSkolas Str. 3, Riga 1010
\nLATVIA
\nDr. Peteris APINIS, President
\nTel: (371) 67287321\/67220661
\nFax: (371) 67220657
\nE-mail: lma@arstubiedriba.lv
\nWebsite: www.arstubiedriba.lv
\nLiechtensteinische \u00c4rztekammer
\nPostfach 52, 9490 Vaduz
\nLIECHTENSTEIN
\nDr.Remo SCHNEIDER,Secretary LAV
\nTel: (423) 231 1690
\nFax. (423) 231 1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\n40
\nLithuanian Medical Association
\nLiubarto Str. 2, 2004 Vilnius
\nLITHUANIA
\nDr. Liutauras LABANAUSKAS,
\nPresident
\nTel.\/Fax. (370-5) 2731400
\nE-mail: lgs@takas.lt
\nWebsite: www.lgs.lt
\nAssociation des M\u00e9decins et M\u00e9decins
\nDentistes
\ndu Grand-Duch\u00e9 de Luxembourg
\n(AMMD)
\n29, rue de Vianden, 2680 Luxembourg
\nLUXEMBOURG
\nDr. Jean UHRIG, President
\nTel: (352) 44 40 33 1
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMacedonian Medical Association
\nDame Gruev St. 3, P.O. Box 174,
\n91000 Skopje
\nMACEDONIA, FYR
\nProf. Dr. Jovan TOFOSKI, President
\nTel: (389-2) 3162 577\/7027 9630
\nFax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nWebsite: www.mld.org.mk
\nSociety of Medical Doctors of Malawi
\nPost Dot Net, PO Box x387,
\nCrossroads
\n30330 Lilongwe
\nMALAWI
\nDr. Douglas Komani LUNGU,
\nPresident
\nE-mail: dlungu@sdnp.org.mw
\nWebsite: www.smdmalawi.org
\nMalaysian Medical Association
\n4th
\nFloor, MMA House,
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nMALAYSIA
\nDr. Mary Suma CARDOSA, President
\nTel: (60-3) 4041 1375
\nFax: (60-3) 4041 8187
\nE-mail: info@mma.org.my
\nWebsite: www.mma.org.my
\nOrdre National des M\u00e9decins du Mali
\nHopital Gabriel Toure
\nCour du Service d\u2019Hygi\u00e8ne
\nBP .E 674, Bamako
\nMALI
\nProf. Alhousse\u00efni AG MOHAMED,
\nPresident
\nTel. (223) 223 03 20\/222 20 58\/
\nE-mail: cnommali@gmail.com
\nWebsite: www.keneya.net\/cnommali.com
\nMedical Association of Malta
\nThe Professional Centre,
\nSliema Road, Gzira GZR 06
\nMALTA
\nDr. Steven Fava, President
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: martix@maltanet.net
\nWebsite: www.mam.org.mt
\nColegio Medico de Mexico
\nAdolfo Prieto #812, Col. Del Valle,
\nD. Benito Ju\u00e1rez, Mexico 03100
\nMEXICO
\nDr. Ramon MURIETTA, President
\nE-mail: colegiomedicomexico.
\nfederacion@gmail.com
\nWebsite:www.colegiomedicodemexico.org.mx
\nAssociacao Medica de Mocambique
\nAvenida Salvador Allende, n. 560,
\n1 andar, Maputo
\nMOZAMBIQUE
\nDr. M. Rosel SALOMAO, President
\nTel: (258) 843 050 610
\nFax: (258) 213 248 34
\nE-mail: rsalomao@teledata.mz
\nMyanmar Medical Association No. 249,
\nTheinbyu Road Mingalartaungnyunt,
\nTownship, Yangon Region
\nMYANMAR
\nDr. Khine Soe WIN, Secretary General
\nE-mail: mmacorg@googlemail.com
\nWebsite: www.mmacentral.org
\nMedical Association of Namibia
\n403 Maerua Park, POB 3369,
\nWindhoek
\nNAMIBIA
\nDr.Reinhardt SIEBERHAGEN,President
\nTel. (264) 61 22 4455
\nFax. (264) 61 22 4826
\nE-mail: man.office@iway.na
\nWebsite: www.man.com.na
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189,
\nExhibition Road, Katmandu
\nNEPAL
\nDr. Kiran Prasad SHRESTHA,
\nPresident
\nTel. (977 1) 4225860, 4231825
\nFax. (977 1) 4225300
\nE-mail: mail@nma.org.np
\nWebsite: www.nma.org.np
\nRoyal Dutch Medical Association
\nP.O. Box 2005, 3502 LB, Utrecht
\nNETHERLANDS
\nDr. R.J. VAN DER GAAG, President
\nTel: (31-30) 282 32 67
\nFax: (31-30) 282 33 18
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: www.knmg.nl
\nNew Zealand Medical Association
\nP.O. Box 156,\u00a0Level 13 Greenock
\nHouse, 39,The Terrace,
\nWellington 1
\nNEW ZEALAND
\nDr. Paul OCKELFORD, Chairman
\nTel: (64-4) 472 4741
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNigerian Medical Association
\n8 Benghazi Street, Off Addis Ababa,
\nCrescent, Wuse Zone 4,
\nFCT, PO Box 8829, Wuse Abuja
\nNIGERIA
\nDr. Akpufuoma L. PEMU, Secretary
\nGeneral
\nTel: (234-1) 480 1569, 876 4238
\nFax: (234-1) 493 6854
\nE-mail: nationalnma@yahoo.com
\nWebsite: www.nigeriannma.org
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum, 0107 Oslo
\nNORWAY
\nDr. Geir RIISE, Secretary General
\nTel: (47) 23 10 90 00
\nFax: (47) 23 10 90 10
\nE-mail: Bjorn.Hoftvedt
\n@legeforeningen.no
\nWebsite: www.legeforeningen.no
\nAsociaci\u00f3n M\u00e9dica Nacionalde la
\nRep\u00fablica de Panam\u00e1
\nApartado Postal 2020, Panam\u00e1 1
\nPANAMA
\nDr. Alfredo MACHARAVIAYA,
\nPresident
\nTel: (507) 263 7622\/263-7758
\nFax: (507) 223 1462
\nE-mail: amenalpa@cwpanama.net
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791,
\nMiraflores, Lima
\nPERU
\nDr. Julio Castro GOMEZ, President
\nTel: (51-1) 213 1400
\nFax: (51-1) 213 1412
\nE-mail: prensanacional@cmp.org.pe
\nWebsite: www.cmp.org.pe
\nPhilippine Medical Association
\n2\/F Administration Bldg.,
\nPMA Compound, North Avenue,
\n1105 Quezon City
\nPHILIPPINES
\nDr. Oscar TINIO, President
\nTel: (63-2) 929 63 66
\nFax: (63-2) 929 69 51
\nE-mail: philmedas@yahoo.com
\nWebsite: philippinemedicalassociation.org
\nPolish Chamber of Physicians and
\nDentists
\n(Naczelna Izba Lekarska)
\n110 Jana Sobieskiego, 00-764 Warsaw
\nPOLAND
\nDr. Konstanty RADZIWILL,
\nPresident
\nTel. (48) 22 55 91 300\/324
\nFax: (48) 22 55 91 323
\nE-mail: sekretariat@hipokrates.org
\nWebsite: www.nil.org.pl
\nOrdem dos M\u00e9dicos (Portugal)
\nAv. Almirante Gago Coutinho 151,
\n1749-084 Lisbon
\nPORTUGAL
\nDr. Jos\u00e9 Manuel SILVA, President
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: intl@omcn.pt
\nWebsite: www.ordemdosmedicos.pt
\nRomanian College of Physicians
\nBulevardul Timisoara nr. 15,
\n061303 Sector 6, Bucarest
\nROMANIA
\nProf. Dr. Vasile ASTARASTOAE,
\nPresident
\nTel: (40-21) 413 88 00
\nFax: (40-21) 413 77 50
\nE-mail: office@cmr.ro
\nWebsite: www.cmr.ro
\nRussian Medical Society
\nUdaltsova Street 85, 119607 Moscow
\nRUSSIAN FEDERATION
\nDr. Sergey BAGNENKO, President
\nTel: (7-495) 734 12 12
\nFax: (7-495) 734 11 00
\nE-mail. info@russmed.ru
\nWebsite: www.russmed.ru\/eng\/
\nwho.htm
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag\u00a0– National Health Services,
\nApia
\nSAMOA
\nDr. Viali LAMEKO, President
\nTel. (685) 778 5858
\nE-mail: viali1_lameko@yahoo.com
\nOrdre National des M\u00e9decins du
\nS\u00e9n\u00e9gal
\nInstitut d\u2019Hygi\u00e8ne Sociale
\n(Polyclinique)
\nBP 27115 Dakar
\nSENEGAL
\nProf. Lamine SOW, President
\nTel. (221) 33 822 29 89
\nFax: (221) 33 821 11 61
\nE-mail: lamsow@orange.sn
\nWebsite: www.ordremedecins.sn
\nLekarska Komora Srbije
\n(Serbian Medical Chamber)
\nKraljice Natalije 1-3, Belgrade
\nSERBIA
\nDr.Tatjana RADOSAVLJEVIC,
\nGeneral Manager
\nE-mail: lekarskakomorasrbije@gmail.com
\nSingapore Medical Association
\nAlumni Medical Centre, Level 2
\n2 College Road 169850
\nSINGAPORE
\nDr. Jing Jih CHIN, President
\nTel. (65) 6223 1264
\nFax. (65) 6224 7827
\nE-mail. sma@sma.org.sg
\nWebsite: www.sma.org.sg
\nSlovak Medical Association
\nCukrova 3, 813 22 Bratislava 1
\nSLOVAK REPUBLIC
\nProf. Peter KRIST\u00daFEK, President
\nTel. (421) 5292 2020
\nFax. (421) 5263 5611
\nE-mail: secretarysma@ba.telecom.sk
\nWebsite: www.sls.sk
\nSlovenian Medical Association
\nKomenskega 4, 61001 Ljubljana
\nSLOVENIA
\nProf. Dr. Pavel POREDOS, President
\nTel. (386-61) 323 469
\nFax: (386-61) 301 955
\nE-mail: matija.cevc@trnovo.kclj.si
\nSomali Medical Association
\n7 Corfe Close, Hayes,
\nUB4 0XE Middlesex, United Kingdom
\nSOMALIA
\nDr. Abdirisak DALMAR, Chairman
\nE-mail: drdalmar@yahoo.co.uk
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nSOUTH AFRICA
\nProf. Zephne VAN DER SPUY,
\nPresident
\nTel: (27-12) 481 2037
\nFax: (27-12) 481 2100
\nE-mail: VusiM@samedical.org
\nWebsite: www.samedical.org
\nConsejo General de Colegios M\u00e9dicos
\nde Espa\u00f1a
\nPlaza de las Cortes 11 4a,
\n28014 Madrid
\nSPAIN
\nDr. Juan Jos\u00e9 RODRIGUEZ-
\nSENDIN, President
\nTel: (34-91) 431 77 80
\nFax: (34-91) 431 96 20
\nE-mail: internacional@cgcom.es
\nWebsite: www.cgcom.es
\nSri Lanka Medical Association
\nWijerama House, 6 Wijerama
\nMawatha 00700 Colombo
\nSRI LANKA
\nDr. B.J.C. PERERA, President
\nTel: +94-112-693 324
\nFax: +94-112-698 802
\ne-mail:\u00a0office@slma.lk
\nWebsite: www.slma.lk
\nSwedish Medical Association
\n(Villagatan 5) P.O. Box 5610,
\nSE – 114 86 Stockholm
\nSWEDEN
\nDr. Marie WEDIN, President
\nTel: (46-8) 790 35 01
\nFax: (46-8) 10 31 44
\nE-mail: info@slf.se
\nWebsite: www.slf.se
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18, C.P. 170, 3000 Berne 15
\nSWITZERLAND
\nDr. Juerg SCHLUP, President
\nTel. (41-31) 359 11 11
\nFax. (41-31) 359 11 12
\nE-mail: saqm@fmh.ch
\nWebsite: www.fmh.ch
\nTaiwan Medical Association
\n9F,No 29 Sec.1,An-Ho Road,10688Taipei
\nTAIWAN
\nDr. Ming-Been LEE, President
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@tma.tw
\nWebsite: www.tma.tw\/EN_tma
\nMedical Association of Tanzania
\nP.O. Box 701, 255 Dar es Salam
\nTANZANIA
\nDr. Rodrick KABANGILA, President
\nE-mail: kajuna2010@gmail.com
\nWebsite: www.mat-tz.org
\nMedical Association of Thailand
\n2 Soi Soonvijai, New Petchburi Road,
\nHuaykwang Dist., 10320 Bangkok
\nTHAILAND
\nDr. Wonchat SUBHACHATURAS,
\nPresident
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: www.mat.or.th
\nTrinidad andTobago Medical Association
\nThe Medical House, #1 Sixth Avenue,
\nOrchard Gardens, Chaguanas
\nTRINIDAD AND TOBAGO
\nDr. Rohit DASS, President
\nTel: (868) 671-5160
\nFax: (868) 671-7378
\ne-mail: medassocS@tntmedical.com
\nWebsite: www.tntmedical.com
\nConseil National de l\u2019Ordre des
\nM\u00e9decins de Tunisie, 16,
\nrue de Touraine, 1002 Tunis
\nTUNISIA
\nDr. Mohamed N\u00e9jib CHAABOUNI,
\nPresident
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: cnom@planet.tn
\nWebsite: www.ordre-medecins.org.tn
\nTurkish Medical Association
\nGMK Bulvari, Sehit Danis Tunaligil
\nSok. N\u00b0 2 Kat 4, 06570 Maltepe,
\nAnkara
\nTURKEY
\nDr. Eris BILALOGLU, President
\nTel: (90-312) 231 31 79
\nFax: (90-312) 231 19 52
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.ttb.org.tr
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874, Kampala
\nUGANDA
\nDr. Margaret MUNGHERERA,
\nPresident
\nTel. +256 772 434 652
\nFax. (256) 41 345 597
\nE-mail. mmungherera@yahoo.co.uk
\nUkrainian Medical Association
\n7 Eva Totstoho Street, PO Box 13,
\n01601 Kyiv
\nUKRAINE
\nDr. Oleg MUSII, President
\nTel: (380) 50 355 24 25
\nFax: (380) 44 501 23 66
\nE-mail: sfult@ukr.net
\nBritish Medical Association
\nBMA House,Tavistock Square,
\nWC1H 9JP London
\nUNITED KINGDOM
\nMr.Tony BOURNE, Secretary
\nGeneral
\nTel: (44-207) 387-4499
\nFax: (44-207) 383-6400
\nE-mail: vnathanson@bma.org.uk
\nWebsite: www.bma.org.uk
\nAmerican Medical Association
\n515 North State Street,
\n60654 Chicago, Illinois
\nUNITED STATES
\nDr. Jeremy A. LAZARUS,
\nPresident-Elect
\nTel: (1-312) 464 5291\/464 5040
\nFax: (1-312) 464 2450
\nE-mail: ellen.waterman@ama-assn.org
\nWebsite: www.ama-assn.org
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515,
\nCP 11200 Montevideo
\nURUGUAY
\nDr. Martin REBELLA, President
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nWebsite: www.smu.org.uy
\nMedical Association of Uzbekistan
\nStr. Parkenentskay 51,
\nTashkent City 100007
\nUZBEKISTAN
\nProf. Abdulla KHUDAYBERGENOV,
\nPresident
\nE-mail: info@avuz.uz
\nWebsite: www.avuz.uz
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano,
\n00120 Citt\u00e0 del Vaticano
\nVATICAN STATE
\nProf. Renato BUZZONETTI,
\nPresident
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\nE-mail: servizi.sanitari@scv.va
\nFederacion MedicaVenezolana
\nAv. Orinoco con Avenida Perija,
\nUrbanizacion Las Mercedes,
\n1060 CP Caracas
\nVENEZUELA, RB
\nDr. Douglas Leon NATERA, President
\nE-mail: sgeneral@saludfmv.org
\nWebsite:www.federacionmedicavenezolana.
\norg
\nVietnam Medical Association
\n68A Ba Trieu-Street, Hoau Kiem
\nDistrict, Hanoi
\nVIETNAM
\nDr.Tran Huu THANG, Secretary
\nGeneral
\nTel: (84) 4 943 9323\/943 1866
\nFax: (84) 4 943 9323
\nE-mail: vgamp@hn.vnn.vn
\nZimbabwe Medical Association
\nP.O. Box 3671, Harare
\nZIMBABWE
\nDr. Billy RIGAWA, President
\nTel. (263-4) 791553
\nFax. (263-4) 791561
\nE-mail: zima@zol.co.zw
\nwww.zima.org.zw
\nIV
\nContents
\nEFMA (European Forum of Medical As-
\nsociations) meeting will take place in the
\ncapital city of Latvia \u2013 Riga on March 21\u2013
\n22, 2013. Already for 30 years EFMA has
\norganized this meeting together with Re-
\ngional Office for Europe.The 2010 EFMA
\nmeeting took place in St. Petersburg, 2011
\nin Brussels and 2012 in Yerevan.
\nMeeting is organized by the EFMA Pres-
\nident Lea Wapner form Israel and Latvian
\nMedical association.
\nThe EFMA meeting 2013 is supported by
\nthe World Health Organization, Ministry
\nof Health of the Republic of Latvia and
\nWorld Medical Association
\nThe Medical Associations, Unions and
\nChambers of the European Union, the
\nMedical Associations of the Economical
\nZone of Europe are going to participate
\nin EFMA.
\nEFMA is the only forum where not only
\nEuropean Union members and medical
\norganizations which belong to countries
\nbased on classical European values comes
\ntogether, but also medical associations
\nfrom former Soviet Union countries like
\nBelarus, Tajikistan, Turkmenistan, Mol-
\ndova, Armenia and Albania, Kosovo, Is-
\nrael are represented.This is an opportunity
\nto discuss among different systems, tradi-
\ntions and possibilities.
\nThe goal of Latvian Medical association
\nfor the meeting in Riga is to create a dia-
\nlogue or a kind of bridge between different
\nmedical organizations in Europe and put-
\nting emphasis on exchange of experience
\namong medical associations of Western
\nEurope, Central Europe, new participants
\nof European Union, CIS countries, Israel
\nand perspective members.
\nThere is quite different experiences among
\nEuropean countries regarding issues con-
\ncerning possibilities of medical NGO\u2019s to
\nsolve problems connected to public health
\nin their respective countries.
\nMore information: liene@arstubiedriba.lv
\nEFMA meeting March 21\u201322, 2013 Riga, Latvia
\nBack to the 50s?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
\nDeclaration of Helsinki. Expert Conference . . . . . . . . . . . 2
\nA Guideline for Treatment Decisions on CAM
\nin Oncology: Prerequisites for Evidence Based
\nIntegration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
\nHealthcare System Reform in China . . . . . . . . . . . . . . . . . 8
\nNever Say Never, Uganda! . . . . . . . . . . . . . . . . . . . . . . . . . 13
\nSusceptible Healthcare Professionals . . . . . . . . . . . . . . . . . 22
\nImplementing Surgical Care at the National
\nLevel: The WHO Integrated Management for
\nEmergency and Essential Surgical Care Toolkit . . . . . . . . . 24
\nHealth Care Reform: Does One Size Fit All . . . . . . . . . . . 25
\nPhysicians and Hunger Strikes in Prison: Confrontation,
\nManipulation, Medicalization and Medical Ethics . . . . . . 27
\nIan Trevor Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
\nWMA Directory of Constituent Members . . . . . . . . . . . . 38<\/p>\n"},"caption":{"rendered":"

wmj201301 COUNTRY \u2022 President Elect of WMA, Margaret Mungherera, Health Care in Uganda \u2022 Prison Health vol. 59 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 1, February 2013 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@arstubiedriba.lv editorin-chief@wma.net Co-Editor […]<\/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\/wmj201301.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3645"}],"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=3645"}]}}