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wmj201304<\/a><\/p>\n

COUNTRY
\n\u2022 Declaration of Helsinki
\n\u2022 Strong Tobacco Policy
\n\u2022 Model of Colombian Social Security in Health
\nvol. 59
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 4, September 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
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nVintage Letter (18 Century) Grunge Medicine
\nBackground.
\nPublisher
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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
\n121
\nThe globalization in more narrow sense is
\npresenceof international contacts as well as
\ndependance of people and groups of people
\non international activities. International
\ncontacts have been taking place through-
\nout the history of the world. Since ancient
\ntimes trade, migration and wars have been
\nbringing together people from different
\norigins. The notion \u201ccitizen of the world\u201d
\nbelongs to Diogenes of Sinope, an ancient
\nGreek philosopher who lived in 4th
\ncentury
\nBC.
\nThe term \u201cglobalization\u201d and the concept
\nof global development emerged in the 80-
\nties and was first broadly used in 1981 by
\nJ.\u00a0Mcleen and later expanded by R.\u00a0Rob-
\nertson in 1983. More detailed research of
\nglobalization as a process or phenomenon
\nstarted in 90-ties. R.\u00a0 Robertson\u2019s \u201cGlo-
\nbalization\u201d, was published in 1992, while
\nM.\u00a0Waters\u2019s fundamental work \u201cGlobaliza-
\ntion\u201d came out in 1995.
\nThe main achievements of XX century\u00a0\u2013
\ncomputers and space exploration,
\nglobalization and communication,
\nantibiotics and hormone replacement
\ntherapy in medicine
\nThe XX century brought to humankind
\nhuge changes and astonishing events, wars,
\nepidemies, discoveries, development, and
\nboth human reasoning and insanity. There
\nwas more news in the human world than in
\nthe whole millennium before. New matters,
\nthat were crucial for the formation of new
\nculture and new world, emerged.
\nGlobalization is essential here. A human
\nlife became completely different, particu-
\nlarly the volume of received information
\nincreased dramatically. One of the main
\ncornerstones of globalization was the devel-
\nopment of new means of On the other hand
\nthis brought along dependence on informa-
\ntion and its carriers and changed the way
\npeople communicated.
\nGlobalization in XXI century means
\ndifferent economic situations
\nToday the world is divided into two parts: the
\neconomically developed one and the other
\nthat suffers from stagnation. In addition, the
\ndeveloped countries declare that they are try-
\ning to eliminate the gap while in reality they
\noften do everything to deepen the gap. In the
\ncontext of globalization processes the world
\neconomy is concentrated in three re\u0123ions
\n(Eastern Asia, North America, Western Eu-
\nrope). Meanwhile the interests of the devel-
\noped countries determine the way science and
\ntechnologies move towards absolute privati-
\nzation, decentralization and liberalization.
\nGlobalization is also charaterized by un-
\nbalanced demographics\u00a0\u2013 Asian numerous
\ndominance and African powerty. At the
\nsame time there is economic growth in Chi-
\nna, India, Nigeria etc. That sooner or later
\nwill lead to shift of economic centres.
\nThe social strategy in the most of the world
\nis wavering between free market economy
\nand restricted social market economy that
\nis supplemented by moderate protection-
\nism. Big companies more and more actively
\nbecome participants of co-operating net-
\nworks while middle-sized and small ones
\nare subjected to huge management changes
\nand market demands. At the same time the
\ngap between socially integrated groups of
\npopulation and those socially outcast is con-
\ntinuously increasing, unemployment rates
\ngrow and they move towards developed
\ncountries. In the sphere of health care and
\nmedicine prevention, diagnostics, treatment
\nand rehabilitatition both concerning quan-
\ntity and quality are determined by financial
\ncapacities. Inhabitants of poor countries
\nsuffer from diseases hardly imaginable for
\nan European doctor as they are caused by
\ninsufficient nutrition or even hunger.
\nGlobalization means speed.
\nInformation is spreading fast, so are
\ndiseases, however, particularly fast
\ntravel people who spread the diseases
\nNot so long ago in the XIX century an epid-
\nemy of flu was travelling at speed of a horse
\ncarriage while today it is taken around by
\nairlines. Any flight to a distant destination
\nis shorter than any period of incubation of
\nany infectuous disease.
\nDistribution of diseases in the age of glo-
\nbalization is determined by changes in peo-
\nple\u2019s lifestyles, growth of population and the
\nprocess of urbanization, as well as migration
\nof peoples caused by wars or natural or hu-
\nman-inspired catastrophes and particularly
\nmigration as a result of economic problems.
\nTravelling is also an important factor when
\nspread of diseases is concerned, as travellers
\ncontact rain forests or other wild habitats
\nP\u0113teris Apinis
\nThe Globalization and the Role
\nof Medical Professional Associations
\n122
\nGlobalisation LATVIA
\nthat serve as reserve for insects and other
\nanimals that carry infections.
\nThe third influence of globalization is the
\none of medicine that happens through in-
\nternational drug companies that develop
\nand produce medications and provide in-
\nternational schemes and guidelines. The
\nconsequence of this is increased antibacte-
\nrial resistance that is also based on uncon-
\ntrolled use of pesticides in agriculture and
\nuncontrolled use of antibacterial substances
\nin animal and fish farming.
\nAs the fourth aspect that essentially influ-
\nences human health and medicine I would
\nname uncontrolled use of chemicals in
\nhouseholds, washing the linen and dishes,
\ncar wash, machine oils, biotechnologies,
\nwhich results in chemicals being washed
\naway into oceans where after being absorbed
\nby plancton they return to dining tables of
\npeople through prawns, fish and crayfish.
\nHuman health is essentially influnced by
\nthe harm done to nature by people. De-
\nforestation, irrigation, genetical crops have
\ncaused changes both in human bodies and
\nrecarriers of illnesses. Moreover, serious
\nchanges have taken place in human behav-
\niour, overexcessive amounts of medicine,
\nnarcotics, alcohol; traditional family pat-
\nterns and sexual culture have changed a lot.
\nGlobalization as loss of geographical
\nsegmentation concerning food
\nSimilarly to people goods and food travel
\nlong distances. Today all food supplies have
\nbecome global\u00a0\u2013 people consume more and
\nmore international food and the role of lo-
\ncally grown and processed food has lost its
\nsignificance.This means that seafood is con-
\nsumed worldwide, tropical fruit is mostly
\nconsumed in Northern countries in Scan-
\ndinavia, South-eastern Asian poultry can be
\nfound anywhere in the world as well as lamb
\nfrom New Zealand and South American
\nbeef. Globalization has brought along un-
\njustified schemes of nutrition,meals that are
\neasy to cook, but that do not contain neces-
\nsary ingredients and is referred to as junk
\nfood\u00a0\u2013 different kinds of macburgers, chips,
\nFrench fries, hotdogs.
\nThe world tends to repeat mistakes once
\nmade in the USA. If we observe the ten-
\ndency to obesity of the whole nation in the
\nUSA in the end of XX century, we can pre-
\ndict that illness number one worldwide in
\nXXI century will be obesity carrying along
\ndiabetes and cardio-vascular diseases. Ger-
\nmans (along with other Central Europe-
\nans) have bread and sausage with beer for
\nlunch while Americans help themselves on
\nbig burger and cola. In the evening football
\nmatch on TV is supplemented by chips in
\nGermany but Americans enjoy their French
\nfries with American football.
\nGlobalization as changes in ideology
\nand lifestyle.Tobacco as an example
\nA classical example of globalization is
\nsmoking. Bradford Hill in 1951 discovered
\nthat smoking causes lung cancer. It was a
\nstunning discovery at that time as almost
\nevery male adult in Europe was smoking.
\nDuring the war tobacco served as conso-
\nlation in all entrenchments; even if it did
\nnot help to relax, it could serve as a pass-
\ntime. In those times it was difficult to prove
\nthat smoking caused lung cancer because
\nit was common among both the ill and
\nthe healthy. In 1947. the Council of Brit-
\nish Medical Research asked Bradford Hill,
\nRichard Doll, Edward Kenneway and Percy
\nStock to find out whether smoking could
\nbe the reason for the shocking increase of
\ndeath rate 15 times during the last 25 years.
\nSince 1951 it has been proven that smok-
\ning is a threat to human life. Already in
\n70-ties doctors started to fight the calam-
\nity of smoking while in 80-ties and 90-ties
\nboth in USA and Western Europe merci-
\nless fight against smoking started. Major
\nTobacco companies lost millions in courts,
\nlost their advertising facilities, started pay-
\ning huge taxes. It seemed that smoking
\nwas going to lose the battle. However, the
\nresult was opposite.Tobacco companies felt
\nthreatened and started fighting desperately
\nto win new markets.They best succeeded in
\nEastern Europe, South Asia, North Africa
\nand Latin America.Tobacco companies en-
\ntered developing countries using excellent
\nmarketing strategies, attractive advertising,
\nexact political approach and friendly atti-
\ntude to mass media. As a result number of
\nsmokers in the world increased three times.
\nGlobalization today is an economic
\nstrategy that proposes unrestricted
\nfree trade and free market economy
\nIn the end of XX century globalization
\ncame on the stage with a patented econom-
\nic prescription for any situation\u00a0 \u2013 privati-
\nzation above all. The state lost its position
\nof menufacturer and employer becoming a
\njudge, surveyor and dictator of the rules of
\nthe game.
\nThe process of globalization along with ex-
\npansion of market economy caused not only
\npolitical changes in the map of the world
\nbut also economic fluctuations. The market
\nof raw materials was redivided, this process
\nbrought along the collapse of the Soviet
\nUnion and Yugoslavia, a number of new
\nindependent countries emerged. Any eco-
\nnomics has faced serious problems during
\nthe last twenty years yet the most significant
\ncrisis touched Mexico (1995), Taiwan, Ko-
\nrea (1997), Thailand (1998), Brazil (2000),
\nArgentina (2002), Baltic states (2008),
\nGreece (2009). In all mentioned countries
\nthe economic difficultiess brought along so-
\ncial and health problems, besides in Mexico
\nand Thailand children\u2019s health was severely
\naffected (they had to work and missed
\nschool and medical examination), while in
\nArgentina\u00a0\u2013 the elderly (the collapse of pen-
\nsion system, bankruptcy of social homes).
\nEconomic crises in individual and national
\nlevel show as depression, alcoholism, family
\n123
\nGlobalisationLATVIA
\nunstableness, diseases determined by stress,
\nincreased death rate from cardio-vascular
\ndiseases, more suicides and lethal accidents.
\nThere is even a new term in the world litera-
\nture\u00a0\u2013 the losses of transitional period.
\nMarket took over everywhere including
\nmedicine, however, the state should have
\ntaken the best possible control of this mar-
\nket. The role of the patient had changed\u00a0\u2013
\nthe patient was not anymore a grateful
\nsubject of help but a customer, who buys
\nservices offered by a doctor, nurse, rehabili-
\ntation speci\u0101list, laboratory assistant. Con-
\nsumer philosophy became a part of health
\ncare. There are two axiomes in consumer
\nphilosophy: \u201cmore medicine is better health\u201d
\nand \u201cexpensive medicine is better than
\ncheap medicine\u201d. This leads to get served as
\nroyal customers not ill people. So the result
\nis that a person who suffers from an illness
\nis treated as a broken car.the situation when
\nthose who are able to pay.
\nMedicine, if it has enough
\nfunds is able to extend any
\nindividual\u2019s life essentially
\nThis means that any individual is entitled
\nto significant amount of common funds to
\nprolong their individual life which causes
\ncatastrophic lack of money in medical sec-
\ntor not depending on how rich the coun-
\ntry is. Any resource (professional medical
\nknowledge, intuition, experience, working
\nhours, premises, equipment, medications,
\nmoney) that is invested in health care, spe-
\ncific prevention issues, diagnostics, treat-
\nment and rehabilitation, prolongs an indi-
\nvidual\u2019s lifespan and improves the quality
\nof life. This is where the main paradox of
\nmedicine appears\u00a0\u2013 the more money is in-
\nvested in health care, the longer people live
\n(and as it was mentioned before agree with
\ntheir chronical illness), the more resources
\nwill be required for health care.
\nAll the countries that have reached this
\nstage of economic development face rapidly
\ngrowing discontentment with the health
\ncare system and financial regulation of
\nhealth care.
\nThe proportion of medical expenses in the
\nbig money purse of the world or global
\neconomy has been increasing during last
\nthirty years. In the world as whole the
\ngrowth of funding medicine is 3\u20135% per
\nyear, which is significantly more than total
\nglobal gross product. Consequently, rules
\nof globalization are dictated by economic
\ninterest and market. Where big money is
\npresent, business interests emerge.
\nCommerce has entered the medical world
\nthrough spirit of market competition,priva-
\ntization, rivalry, information technologies,
\ncirculation of information, mass media and
\nother routines of globalization, which can
\nbe seen in different ways in major capitalist
\ncountries, Eastern Europe, as well as South
\nAmerica and even Africa.
\nThe biggest player in the arena
\nof global medicine \u2013 the BIG
\nPHARMA. Medication companies
\nhave set their new goals to reach
\nevery person on the plan\u0113t and make
\nthem take medications every day
\nPharmacy business is ranked as the third or
\nsixth by significance in the world depending
\non methodology of accounting.
\nMoreover, pharmacy business is the sig-
\nnificant player in advertising market, direct
\nand indirect advertising expenses are higher
\nthan those on cars, travelling and fashion
\ngoods in total. There are 5 billion USD
\n(30\u201335% of all expenses) spent on farmacy
\nmarketing .
\nThe global pharmacy market is explic-
\nitly heterogeneous. 89% of funds spent on
\nmedicine go to 11% people. More than
\n80% of the world population only use folk-
\nmedicine and do not receive contemporary
\nmedications.
\nIn Europe 2\/3 of total medications are pre-
\nscribed to people who are older than 66.
\nPolypragmasia dominates in treatment of
\nthe elderly\u00a0\u2013 on average 6 (2.7\u20139.3) medi-
\ncations. All the side effects elderly patients
\nface stand out against the background of a
\nnumber of medications. More than 50% of
\nelderly patients suffer from side effects as a
\nresult of combination of polypragmasia and
\ndisturbances of kidney function. The big-
\ngest problem is the situation that there is no
\nmonitoring of medication for elderly people.
\nIn the XXI century massive use of medica-
\ntions has reduced the role of other ways of
\ntreatment (including rehabilitation). In the
\nXIX century as well as the most of XX cen-
\ntury in Europe there was equal proportion
\nregarding surgery, treatment using medica-
\ntions, physical therapy and psychotherapy.
\nIn the end of XX century the role of surgery
\nbecame less important because of the phar-
\nmacy business (e.\u00a0g. stomach resection dis-
\nappeared, number of appendectomies de-
\ncreased), physical therapy significantly lost
\nits weight,and psychotherapy lost a lot of its
\nposition, while Eastern and non-traditional
\nmethods of treatment came in. Consump-
\ntion of medications rose exponentially.
\nThere is an opinion that pharmacy com-
\npanies invest their assets and profit in the
\nworld\u2019s biggest news agencies. As a result
\nthe big pharmacy business on the earth has
\nmerged with the big media.The industry of
\nfarmacy supports the journalism of sickness.
\nIn 2001 we had type C hepatitis,
\n– in 2003 there was Bovine spongiform
\nencephalopathy or Creutzfeldt\u2013Jakob
\ndisease,
\n– in 2005\u00a0\u2013 SARS,
\n– in 2007\u00a0\u2013 Bird flu,
\n– in 2009\u00a0\u2013 Swine flu.
\nLooking back, we can see that every two
\nyears a new reason to spend money is in-
\nvented. It is easy to compare: every year
\nhalf a million peoplr die of common flu.
\n124
\nBird flu took 250 lives in the period of 10
\nyears, but what fantastic profit it gave to
\nBIG PHARMA! Half a million against 25
\na year. Newspaper headlines inform about
\nbird migration that spreads bird flu. Birds
\nusually travel from North to South while flu
\nspreads from East to West!
\nPharmacy companies try to supply every-
\nbody wth everyday pills. One of the most
\nobvious examples is the presumption that
\ncontraception pills is a must for every
\nwoman every day while those in menopause
\nhave to take hormones regularly at least to
\nprevent osteoporosis. This guarantees two
\nmilliard pills a day and this where the big
\nbusiness starts. Pharmacy companies do not
\nstrive to create new medications that could
\ntreat malaria or infectious diseases; they ac-
\ntively develop antidepressants, new ways to
\nreduce blood lipids, blood pressure, try to
\nfind Viagra for women in order to gain their
\ninterest from market.
\nAn analogous situation: in the sphere of
\ntransportation most funds go to develop avi-
\nation while most of the world\u2019s population
\ninhabiting India, China, countries of Indo-
\nchine mostly travels by rickshaw or bicycle.
\nSo pharmacy as a part of medical treatment
\nbecomes similar to aviation as a part of trans-
\nportation. The market structure changes,
\nmedications leave chemist\u2019s stores and go
\nto supermarkets or internet stores.
\nThe traditional model of medical treatment
\n(a medical professional\u00a0 \u2013 a patient who
\nneeds help) is threatened; self treatment is
\non the rise.
\nMedications leave for drugstores and to es-
\ncape the Swine flu every second british citi-
\nzen buys a thermometer and Tamiflu.
\nIn the age of globalization the roles of doc-
\ntor and farmacist are taken over by internet.
\nInternet drugstores advertise their bene-
\nfits\u00a0\u2013 no visit to a doctor is required, no pre-
\nscription, time and money are saved as they
\nsay that the prices are lower.Today there are
\ndrugstore systems that function as cartel all
\naround the world.
\nSerios changes concerning morbidity
\nThe doctor of the XXI century is much more
\nthan ever involved in the treatment process
\nof incurable patients suffering from chronic
\nillnesses. Most of those who would be con-
\nsidered sentenced to death today have be-
\ncome survivors, however, chronically ill.They
\nare people who will have to agree with their
\nillness that is incurable in theurapetic or
\nsurgical way until the end of their lives. Ac-
\ncordingly the frequency of different types of
\nillnesses has changed: today\u2019s patient as a rule
\nis a chronic one while acuities are exceptional.
\nA typical patient, for example, is a 65-year-
\nold lady. Her diagnosis is the third stage of
\nadiposity accompanied by 2nd
\ntype diabetes
\nmellitus, hypertension, cardiovascular in-
\nability, as well as breathing inability. Exces-
\nsive weight has caused pain in knee and
\nhip joints. She has been prescribed eight to
\ntwelve different medications to treat every
\nseparate illness.
\nPolypragmasia is a problem of XXI century.
\nIf there are more than three types of pills,
\none can be almost 100% sure that there will
\nbe confusion about which are to be taken
\nthree times a day by one pill and which four
\ntimes a day by two pills. It is even worse if
\nseveral doctors have been visited; and every
\nof them did their duty giving a prescription.
\nTask shiffting and global migration
\nof medical workers in XXI
\ncentury are consequences of the
\nglobalisation of medicine
\nEven in the beginning of XX century no-
\nbody could imagine a Riva Rocci device
\nor a fonendoscope in the hands of a non-
\nmedical person. Not longer than ten years
\nago nobody could imagine ultrasound diag-
\nnostic device operated by someone whose
\nqualifications are not adequate. However,
\nthe costs of educating a doctor are becom-
\ning higher and higher, doctor\u2019s work costs
\nmore and more, while as a result of the ag-
\ning of population has caused lack of doctors.
\nIt is cheaper to produce \u201csubstitute doc-
\ntors\u201d\u00a0 \u2013 functional specialists, optometrists,
\nlogopedes, ergotherapists, technical ortho-
\npaedists. In many countries a nurse has a
\nright to give prescriptions.
\nAt the same time emmigration waves of
\nmedical workers travel the world. At lest
\n70% of Philipinian nurses work abroad.The
\nmost typical bramin exporters are India,
\nPakhistan, Malaysia, Philipines as welll as
\nEastern European countries. Doctors and
\nnurses from Eastern Europe are enticed by
\nmassive advertising campaigns carried out
\nby Professional recruiting companies. An
\nopposie tendency is medical tourism. The
\nexpansion of hospitals, that is becoming
\nmore and more fashionable, ensures that
\nnew medical centres emerge in developing
\ncountries. For instance, in Thailand and In-
\ndia the most Professional doctors get con-
\ncentrated in medical institutions belonging
\nto foreigners, working with foreign patients.
\nAs a result of globalisation doctors can find
\nany education materi\u0101ls on the Internet in a
\nfew minits; materi\u0101ls of almost all medical
\ncongresses are available on the world wide
\nweb. Exactly the same way possibilities to
\ncontact and consult anyone are widely avail-
\nable as well as telemedicine.
\nGlobalisation in medicine in
\nXXI century is often referred to
\nas a global crisis in health care.
\nPsychological pressure is applied
\nto medical workers widely exposing
\nnegations in mass media
\nHealth care expenses have been increasing
\nboth absolutely and relatively related to na-
\ntional gross product in civilized countries. At
\nthe same time it means longer lifespan.Every-
\nbody wants to live longer not depending on
\nGlobalisation LATVIA
\n125
\nbeing a labourer, doctor, journalist or politi-
\ncian.The last two wish to get it free of charge.
\nIt is quite typical that politicans when they
\ntalk about medicine not being competent
\nenough try to promote e-health, expensive
\nTechnologies and premises but trying avoid
\nto pay the medical professionals.
\nThe World Wide Web also anwers the
\nquestion about the people who are loudly
\ncampaigning against doctors\u00a0 \u2013 they are
\nmiddle-aged people wno are practically
\nhealthy, however, in this economically com-
\nplex situation suffer from stress, emotional
\ndisturbances and as a result from vegetative
\ndisorders. They complain about palpita-
\ntion, frequent colds, dizziness etc. and they
\nwish to be cured by a doctor immediately.
\nThis group of people are frequent visitors
\nat quack doctors and healers, and they con-
\nsume a lot of food supplements.
\nThey feel they have paid their taxes, however
\nthey do not get in return attention or finan-
\ncial value for that as most of the money goes
\nto elderly chronic patients.They have no idea
\nthat after some time they will belong to the
\ncategory themselves. This unfair situation in
\nfinancing the health care is the key factor that
\nruins reputation of doctors\u00a0\u2013 someone who is
\nstill young and pays taxes does not know that
\nat some point life starts turning down. So ev-
\nerybody declaring now that they do not need
\nthis kind of doctors and health care sooner or
\nlater will face the situation when they do.
\nOn the other hand\u00a0\u2013 those who form opin-
\nions of humankind, country or just locality
\nas a rule are not chronic patients or elderly
\npeople who are receiving more health care
\nthan they are actually paying for.
\nThe Professional prestige of
\ndoctors (hospitals, whole medicine)
\nis falling in XXI century
\nThe significance of doctor\u2019s profession has
\ndecreased, the role of bureaucracy has swol-
\nlen, the profession has lost its autonomy.
\nWorld wide research results show that a
\ndoctor (variously in different countries and
\nspecialities) has to spend 50\u201375% of their
\nworking time making written or digital re-
\nports.
\nIs the decrease of medical professions pres-
\ntige reasonable? Doctors work better and
\nmore professionally, which is proved by
\nlengthening the lifespan in the entire civi-
\nlized world. New technologies are applied
\nin doctors\u2019work, which means fast and pre-
\ncise diagnostics, atraumatic operations and
\nsafe application of narcosis. Every year new
\nmedications\u00a0\u2013 safer and more effective \u2013 are
\ndeveloped while there is a new qualitative
\nimprovement in pharmacy every decade.
\nCancer is not any more one hundred per-
\ncent lethal not to mention infectious dis-
\neases that have been threatening people for
\ncenturies.
\nFirstly, the problem is caused by qualitative
\nchanges in lifestyle, economic formation,
\nattitude to health issues simultaneously
\nchanging opinions regarding fundamental
\nprinciples. For instance, in the beginning of
\nXX century the notion diet meant enough
\nof \u201cproper food\u201d as patients lacked food or
\nhad food that was not nutritional enough.
\nIn the beginning of XXI century diet means
\nnecessity of \u201cless food\u201d.
\nIn the beginning of XX century prescription
\nof sustaining regime meant warmed room
\nand lying in bed. In the beginning of XXI
\ncentury active movements, swimming in a
\npool, running, and ways of toughening the
\nbody are considered sustaining. There are
\nalso changes in procedure of diagnostics\u00a0\u2013
\na conversation between doctor and patient,
\ninspection and auscultation have been re-
\nplaced by megacomputers that carry out vi-
\nsual diagnostics and complicated machines
\nthat make analyses.
\nToday doctor\u2019s opinion is substituted by re-
\nsults of proved research that are part of evi-
\ndence based medicine.
\nThe patient today is much more educated,
\nwhich is ensured by extensive flow of infor-
\nmation coming from pharmacy companies.
\nAs a resut quite often patients know more
\nabout newest medications than overloaded
\ndoctors who do not have enough time to
\nsurf the internet.
\nDoctors who work to hard but do not get
\nrewarded neither financially nor morally
\ncome to frustration regarding the medical
\nsystem and their job. TV and press abuse
\nand slander doctors that results in decreas-
\ning self-confidence, patients do not trust
\ndoctors and mutual co-operation rearding
\nthe process of treatment becomes inef-
\nfective. The doctors\u2019 frustration influences
\nheavily the quality of health care.
\nThe only protection comes
\nthrough Professional medical
\nassociations or chambers
\nDoctors elect their representatives who are
\nentitled to protect their interests. At the
\nsame time electors are not always satisfied
\nwith the potection they receive. Associa-
\ntions cannot cope with their duties because
\ngovernment, the ministry, patients, journal-
\nists and ordinary doctors oppose them.
\nThe tasks of National medical associations
\nare:
\n\u2022 protection of doctors\u2019 professional, eco-
\nnomic and legal interests;
\n\u2022 promotion of prestige and respect of doc-
\ntor\u2019s profession as a free profession;
\n\u2022 perfection of doctors\u2019ethical code and ca-
\ntering for professional ethics;
\n\u2022 facilitation of postgraduate education;
\n\u2022 improvement of professional skills and
\nperfection of professional knowledge;
\n\u2022 assessment of professional qualifications
\nof foreign doctors and dentists;
\n\u2022 improvement of health care organization;
\n\u2022 facilitation of improvement of the health
\nof society;
\n\u2022 certification and licensing;
\n\u2022 co-operation regarding legislation etc.
\nGlobalisationLATVIA
\n126
\nProfessional medidal associations in differ-
\nent countries function differently and they
\nreach their objectives by different means.
\nThe new issues imposed by globalization
\nrequire serious financial way of dealing with
\nthem instead of just public activities.
\nContemporary medical non-governmental
\norganizations are non-profit organizations
\nin reality are non-profit organizations that
\nhave thousands of shareholders thus being
\ntransparent business structures. Mostly they
\ndo not depend on the budget of the state,
\nfunctioning on finance obtained in other
\nways.
\nNacional medical associations are financed
\nby membership fees, income from certi-
\nfication and licensing, publishing books
\nand magazines, creating other mass me-
\ndia, income from post-graduate education,
\norganizing of conferences and congresses,
\nincomes from international funds of envi-
\nronmental and public health, income from
\ninternational projects of health care over
\nthe borders, donations and gifts, and differ-
\nent kind of co-operation between pharmacy
\nand food companies etc.
\nThe role of non-governmental
\nmedical associations in the area of
\npublic and environmental health
\nis continuously increasing
\nOnly 7% of world\u2019s population are con-
\ncerned about environmental health while
\nonly 1% are ready to act in benefit of it.
\nAmazingly, the most interested people in
\nenvironmental issues are clinical doctors.
\nNational medical associations can be con-
\nsidered as the most influential power re-
\ngarding public and environmental health,
\nin some countries it is the only power. For
\nexample, in some Eastern European coun-
\ntries National medical associations in reality
\nfunction as Green parties.
\nPublic health is a science that is continu-
\nously developing. Public health is based on
\nscience, that is why only science performed
\nby doctors promotes health and quality life.
\nThe main function of a medical association
\nis to serve as medium between doctors and
\nthe government trying to explain doctors\u2019
\nideas to politicians.
\nIt is true that politicians love saying that
\ndoctors are interested in people being ill
\nand that is why doctors are not promoting
\npublic health issues. The real truth is quite
\nopposite\u00a0\u2013 all around the world doctors are
\nthose who promote public health because
\nour profession due to its humanity is con-
\nstantly searching not only for solutions in
\nindividual\u2019s health but also in health of en-
\ntire humankind.This driving force has been
\nand still is obliged to work in the frames of
\nthe system determinated by legislation and
\nstate structure.
\nThe crucial health issues that are to be
\nsolved by National medical associations in
\nXXI century are:
\n\u2022 controlling tobacco consumption, active
\nfighting against children and young peo-
\nple smoking. Prevention of children and
\npregnant women from active and passive
\nsmoking. Banning tobacco advertising in
\nmass media available to children.
\n\u2022 reducing of alcohol consumption in soci-
\nety. World wide fighting against alcohol
\nconsumption by young people until age of
\n21. Banning alcohol advertising in mass
\nmedia available to children.
\n\u2022 fighting against spreading of narcotics.
\n\u2022 elimination of trans fatty acids from
\npeople\u2019s food. Initially reach legislative
\nrestrictions of not more than 2% trans
\nfatty acids from the whole amount of fat
\nin any product.
\n\u2022 eliminating sugary drinks from schools or
\nany places where children gather togeth-
\ner. Banning sugary drinks advertising in
\nmass media available to children.
\n\u2022 reducing the salt (NaCl) consumption in
\nfood, reaching in average 5g daily;
\n\u2022 active fighting of sedentary lifestyle, pop-
\nularizing the principle\u00a0\u2013 sports at lest half
\nan hour at least 5 times daily.The balance
\nof calories organized in a way that people
\ncan reduce the weight while the world
\ncan fight the epidemy of obesity. Sports
\nas means of prevention and treatment of
\nillnesses.
\n\u2022 more fruit and vegetables in everyday
\nfood (5 times a day), popularization of
\nfiber-rich food.
\n\u2022 popularization of breast-feeding, edu-
\ncation of young mothers and pregnant
\nwomen (The best progress in reducing
\ninfant mortality is reachable by educating
\nwomen).
\n\u2022 fighting for clean air and water world-
\nwide, fighting against global warming.
\n\u2022 fighting against charlatanism and quack
\ndoctors;
\n\u2022 popularization of healthy workplaces;
\n\u2022 promotion of prevention diabetes,cardio-
\nvascular diseases, obesity and other non-
\ncontagious illnesses;
\n\u2022 promotion of prevention HIV\/AIDS and
\ncarrying out interpretive activities;
\n\u2022 cancer prevention, especially breast and
\ncervical cancer prevention;
\n\u2022 reducing of antibacterial resistance and
\npolypragmasia etc.
\nWorking to improve public health, national
\nmedical associations can obtain publicity
\nand recognition, which empowers them to
\nsolve their main tasks\u00a0\u2013 protection of doc-
\ntors\u2019 rights, forwarding ethical issues.
\nThe most significant goal
\non the earth is clean air and
\nclean water as well as reducing
\ntoxic and not tested chemicals
\nin everyday life
\nThe most important issue for every per-
\nson is clean air and clean water, unpol-
\nluted environment. Air pollution is most-
\nly caused by fossil fuels, road traffic and
\nvolcanoes.
\nUsually when we talk about clean water we
\nmean clear and clean drinking water. Every
\nGlobalisation LATVIA
\n127
\nEurope pays a hefty price for its slow ac-
\ntion on tobacco, both in economic costs
\nand harm to its citizens\u2019 health and well-
\nbeing (1). Today, EU Health Ministers
\nwill meet to agree a common position on
\nthe revised,smarterTobacco Products Di-
\nrective (TPD) (2)
\n\u201cA majority of Europeans support to-
\nbacco control policies (3). They deserve
\na strong commitment both from the EU
\nHealth Ministers and the outgoing and
\nupcoming rotating presidencies of the
\nEU\u00a0 \u2013 Ireland and Lithuania respectively.
\nThey should make sure that tobacco
\nproducts are not presented in a way that
\nmanipulates people, in particular chil-
\ndren and youth, to pick up a smoking
\nhabit,\u201d said Monika Kosi\u0144ska, Secretary
\nGeneral of the European Public health
\nAlliance (EPHA).
\nThis week five committees of the Euro-
\npean Parliament (4) are giving their non-
\nbinding opinions on the revision of the
\nTPD in a disappointing affair that widely
\nprioritises the interests of the tobacco in-
\ndustry(5)attheexpenseofpeople\u2019shealth.
\nIf European policy-makers keep on basing
\ntheir decisions on arguments by the tobacco
\nlobby, the final Directive will resemble a to-
\nbacco industry report. Additionally, if the
\napproval of the tobacco legislation does not
\noccur by the end of the year, it would put
\nits adoption dangerously close to the next
\nEuropean Parliament\u2019s elections, putting
\nthe hard-fought political process back to
\nsquare one.
\nIn a letter (6) co-signed this week, nine
\npublic health organisations stress that
\nthe current political procedure around an
\nyear 1.5 million children die of diarrhea that
\nis mostly caused by polluted water.
\nRegarding chemical pollution today\u2019s
\nworld could be characterized being in
\nthe state of chemical war. The largest ca-
\ntastrophe of the world last year was toxic
\nred sludge spill in a Hungarian aluminum
\nplant. Nobody ever expected chemical ca-
\ntastrophes. Nobody ever expected radio-
\nlogical catastrophes\u00a0 \u2013 neither Chernobyl
\nnor Fukushima.
\nEvery rich country tries to get rid of their
\nchemical or nuclear waste preferably bury-
\ning them in another country or sinking in
\nthe sea.
\nDuring the last 60 years 70,000 new chemi-
\ncals have been introduced.15,000 chemicals
\nthat are used in everyday life have not been
\nteted and there is no information about
\ntheir toxicity. In more than 90% cases there
\nis no information, what their impact on
\nchildren\u2019s health is.
\nAn average woman during their lifetime
\nfeeds into her body about 80 kilograms
\nof different chemicals using cosmetics to
\nnourish their face and body skin. . At least
\n200 different compounds used in cosmet-
\nics have harmful or as minimum negative
\neffect on one\u2019s health. Human tissues and
\nparts of body have become a target for toxic
\nsubstances. Pollution heavily influences
\nhuman health and functioning\u00a0\u2013 liver, kid-
\nneys, intestines, nervous system, skin and
\nimmune system.The most sensitive parts of
\nhuman body are reproductive system and
\nimmune system; they suffer from pollution
\nthe most
\nToday\u2019s reality is the fact that most of the
\nfood we consume comes from supermar-
\nket chains; it is no more grown in our farm
\nfields, gardens or cattle-sheds.
\nToday every animal that is grown by meth-
\nods of intensive breeding gets antibiotics,
\nhormones and other stuff added to their
\nfood aiming to speed up the process of
\ngrowth and prevent any disease.
\nThe shop counter exposes genetically modi-
\nfied food (grain, root vegetables, soy). Even
\nif we do not buy them directly, we consume
\nit through animal food or as ingredients of
\ncomplex foodstuff.
\nIn XXI century there is a rapid
\nupsurge of science for health and life
\nPrognosticating progress of science is a
\ncomplicated issue. In the 70-ties of XX cen-
\ntury scientists predicted that human genome
\ncould be read at the end of XXI century, but
\nit was done almost a whole century earlier.
\nThe most significant achievements and dis-
\ncoveries of XXI century will be connected
\nwith sciences about life. The competition in
\nthe sphere of biomedical and genome tech-
\nnologies is going to be tough and expensive,
\ncomparable to space investigation race in
\nXX century. Last century was the one of the
\nspaceship, nuclear power station, Internet
\nand mobile phone. At the same time people
\ndiscovered that environment has changed
\nnot bringing along longer lifespan and bet-
\nter health. In XXI century medicine will be
\nsignificantly driven by science.
\nWe are living in a perspective era.There is
\na lot to do for us.
\nDr. P\u0113teris Apinis,
\nEditor-in-Chief of World Medical Journal,
\nPresident of Latvian Medical Association
\nEU Health Ministers Need to Agree on Strong Tobacco Policy
\nand Stop 650,000 Europeans from Dying Each Year
\nTobacco
\n128
\nTobacco
\nupdated TPD represents a window of op-
\nportunity to better control the marketing
\nof an addictive product that kills half of
\nits users when used as intended. Some of
\nthe letter\u2019s signatories spell out why Health
\nMinisters, Members of the European Par-
\nliament and national authorities should take
\nthis piece of legislation seriously:
\n\u201cTobacco kills over 650,000 Europeans
\neach year. It is 1,800 people each day, the
\nequivalent of three jumbo jets crashing
\neach day in the EU. This is unacceptable.
\nWe need a bold new TPD so that our chil-
\ndren are not taken hostage by the tobacco
\nindustry,\u201d said Francis Grogna Secretary
\nGeneral of the European Network for
\nSmoking and Tobacco Prevention (ENSP).
\n\u201cThe revision of the TPD is aimed at pre-
\nventing new generations from lighting up
\nby reducing the attractiveness of tobacco,
\nespecially to children and young women. It
\nis very disquieting that even if all EU Mem-
\nber States are committed to the WHO
\nFramework Convention onTobacco Con-
\ntrol (FCTC), some of them still protect
\nthe tobacco industry, in what amounts, to
\nput it mildly, to an unethical practice,\u201d said
\nby Professor Aurelijus Veryga, President of
\nthe Lithuanian National Tobacco and Alco-
\nhol Control Coalition.
\n\u201cA strong European legislation prevent-
\ning the uptake of smoking and making
\ntobacco less accessible and glamorous
\nis essential to protect EU citizens from
\nthe hazards of smoking. Smoking causes
\nChronic Obstructive Pulmonary Disease
\n(COPD), an irreversible chronic disease
\nthat is not curable and reduces one\u2019s life
\nexpectancy of more than 10 years and one\u2019s
\nability to contribute to EU economy. EU
\nleaders must show they care by adopting the
\nproposed tobacco products directive,\u201d said
\nCatherine Hartmann, Secretary General of
\nthe European COPD Coalition.
\n\u201cThe Standing Committee of European
\nDoctors (CPME) warmly welcomes the
\npresidencies\u2019 commitment to ensuring that
\nthe TPD revision results in a meaningful
\nlegal framework to reduce tobacco-related
\nharm. European doctors call on decision-
\nmakers to keep health at the heart of the
\nnegotiations,\u201d Dr. Katr\u00edn Fjeldsted, Presi-
\ndent of the CPME.
\n\u201cThe EU faces a tobacco epidemic.Tobacco
\nis a lifestyle factor that causes huge number
\nof premature and preventable deaths every
\nyear. Therefore, the EU\u2019s transposition of
\nthe FCTC is a crucial element to preserve
\nthe health of people living in Europe,\u201d said
\nProfessor V.\u00a0 Grabauskas, President of the
\nHealth Forum.
\n(1) The estimated annual cost of tobacco
\nto the European economy is of more than
\nhalf a trillion euros, or about 4.6% of the
\nEU\u2019s GDP. Furthermore, close to 13 mil-
\nlion people in the 27 countries of the EU
\nsuffer from smoking-related diseases, with
\ndevastating effects on economies, societies,
\nand healthcare systems\u00a0\u2013 Study on liability
\nand health costs of smokingproduced for
\nthe European Commission (DG SANCO,
\n2012).
\n(2) The revision addresses the following
\nmain issues: (a) how to regulate products
\nwhich do not contain tobacco, for example
\nelectronic cigarettes; (b) labelling and pack-
\naging of tobacco products; (c) additives,
\nsuch as flavourings; (d) internet sales of to-
\nbacco products; (e) and racking and tracing
\nof these products.
\n(3) Attitudes of Europeans Towards To-
\nbacco, Report: Special Eurobarometer 385
\n(May 2012)
\n(4) The TPD is subject to co-decision pro-
\ncedure and therefore needs to be approved
\nby both co-legislators: the Council of the
\nEU representing the Member States (in
\nthis case the Employment, Social Policy,
\nHealth and Consumer Affairs Coun-
\ncil \u2013EPSCO-) and the European Parlia-
\nment (EP). As regards the EP procedure,
\nfive Committees (IMCO, INTA, AGRI,
\nJURI, ITRE) are giving this week their
\nnon-binding opinion to the leading Envi-
\nronment, Public Health and Food Safety
\n(ENVI) Committee. After the final ENVI
\nvote in July, the EP Plenary will discuss the
\nproposal in September and vote it in Oc-
\ntober. Following the Plenary vote, the EP
\nwill have the mandate to reach an agree-
\nment with EPSCO in the few months be-
\nfore the end of this year.
\n(5) Tobacco companies claim that large
\npictorial warnings and standardised pack-
\naging of tobacco products will increase
\nsmuggling, that tobacco product regulation
\nendangers European jobs, or that labelling
\nand packaging measures are ineffective.
\nThere is strong evidence that these state-
\nments are not just false but intentionally
\naimed at preventing or delaying imple-
\nmentation of effective measures to reduce
\nsmoking prevalence.Tobacco Products Di-
\nrective: fact not fiction (by the Smoke Free
\nPartnership).
\n(6) Public Health NGOs call for an updat-
\ned EU Tobacco Products Directive
\nFor more information, please contact:
\nBirgit Beger
\nCPME Secretary General
\nE-mail:\u00a0secretariat@cpme.eu
\nwww.cpme.eu
\n129
\nTobacco
\nThe European Union and tobacco legisla-
\ntion: revision of the Tobacco Products Di-
\nrective\u00a0\u2013 opportunity to be seized
\nThere are some products on the market that
\nalways cause controversy when discussed
\nand even more\u00a0\u2013 when regulated. However,
\nthere is only one\u00a0\u2013 tobacco\u00a0\u2013 \u2018legally avail-
\nable consumer product which kills people
\nwhen it is used entirely as intended.\u2019\u00a0 [1]
\nThis is the same product\u00a0\u2013 regarded in regu-
\nlatory circles\u00a0\u2013 that would probably not be
\nplaced on the market if introduced today
\ndue to the proven health risks. Govern-
\nments across the world have tried to tighten
\ntobacco control policies to improve public
\nhealth, and the European Union (EU), an
\neconomic and political partnership between
\n28 European countries, is no exception.
\nAlthough the proposal from the European
\nCommission regarding the revision of the
\nTobacco Products Directive has the inter-
\nests of public health at heart, the discus-
\nsions in two co-legislator institutions\u00a0\u2013 the
\nCouncil of the EU (the EU Council) and
\nthe European Parliament\u00a0\u2013 show inconsis-
\ntent willingness to legislate in favour of the
\nhealth of European citizens for fear of eco-
\nnomic effects. Nevertheless, there is still a
\nchance for health community in the EU to
\npush further in support of common sense
\nand public health.
\nThe situation in the EU is considered un-
\nsatisfactory by the public health community.
\nMany EU Member States are \u2018significant
\noffenders as key exporters of the tobacco
\nproblem to the rest of the world,\u2019and \u2018many
\nEU countries are now falling behind best
\npractice in the WHO Framework Conven-
\ntion on Tobacco Control (FCTC) imple-
\nmentation.\u2019 [2] It is the only international
\ntreaty devoted solely to tobacco control
\nunder the auspices of the WHO.\u00a0[3] Mea-
\nsures taken to reduce smoking have made
\na difference; however, tobacco use remains
\nthe leading preventable cause of death in
\nthe EU, and around 700\u00a0 000 people die
\nfrom tobacco-related diseases each year.The
\nnumber of smokers has dropped but is still
\nhigh\u00a0 \u2013 around 28% population-wide, and
\neven higher for young people aged 15\u201324 at
\n29% in 2012. [4]
\nEleven years after an agreement on the first
\nTobacco Products Directive in 2001, the
\nEuropean Commission tabled a proposal
\nto revise the Directive (COM(2012)788)
\nin December 2012. \u2018From a broader per-
\nspective, the revision will contribute to the
\noverall aim of the EU to promote the well-
\nbeing of its people [..], as keeping people
\nhealthy and active longer, and helping peo-
\nple to prevent avoidable diseases and pre-
\nmature death, will have a positive impact
\non productivity and competitiveness.\u00a0 [5]
\nHowever, taking into account that 70% of
\nsmokers start before the age of 18 and 94%
\nbefore the age of 25 years in Europe [6] the
\nfocus of the revised Directive is on children
\nand youth. In essence\u00a0\u2013 its aim is to pre-
\nvent young people from starting to smoke.
\nTo achieve this, the Commission proposes
\nto make pictorial warnings mandatory,
\nto increase the size of combined text and
\npictorial warnings on both sides of a pack
\nto 75%, to ban slim cigarettes and to pro-
\nhibit characterising flavours such as vanilla
\nor menthol. The proposal suggests tobacco
\nshould smell and taste like tobacco, and
\nmost importantly\u00a0 \u2013 should be packaged
\nin a way that accurately informs consum-
\ners of its risks, while making the product
\nless attractive to children and young people.
\nMoreover, the Commission proposal estab-
\nlishes measures such as security features on
\npacks, which are designed to reduce coun-
\nterfeiting of tobacco, along with tracking
\nand tracing features to better control the
\nsupply chain. Furthermore, the proposal
\nregulates those products which do not
\nnecessarily contain tobacco, but are closely
\nlinked to smoking, for instance, nicotine
\ncontaining products. In brief, the proposal
\nof the Commission favours public health
\ninterests by trying to deter young people
\nfrom starting to smoke.
\nAccording to the EU legislative procedure
\nthere are several steps before the proposal
\nfrom the European Commission can come
\ninto force.There are two co-legislators\u00a0\u2013 the
\nEU Council and the European Parliament.
\nAgreement first has to be reached separately
\nin the EU Council among Member State
\ngovernments and in the European Parlia-
\nment among parliamentarians elected by
\nEuropeans every 5 years. Afterwards both
\ninstitutions as co-legislators have to reach
\nan agreement between themselves by com-
\npromising. Both have made an effort and it
\nseems they would like to get an agreement
\nby the end of 2013 before the elections of
\nthe Parliament next year.
\nThe EU Council, where governments of
\nall EU Member States are represented, has
\nPeteris Ancans
\nThe European Union andTobacco Legislation:
\nRevision of the Tobacco Products Directive\u00a0\u2013
\nOpportunity to be Seized
\n130
\nmanaged to reach \u2018a general approach\u2019 on
\nthe Directive under the Irish Presidency
\nafter heavy and intense discussions during
\nthe first half of 2013. The Council\u2019s posi-
\ntion, described by the Minister for Health
\nof Ireland, Dr. James Reilly, as \u2018a remarkable
\nachievement for the Irish Presidency,\u2019\u00a0 [7]
\nwas forged in a number of meetings among
\nrepresentatives mostly from the Ministries
\nof Health (Health Attach\u00e9s) in Brussels and
\nwas officially finalised during the Council
\nof Health Ministers in Luxembourg on
\n21\u00a0June.
\nThe agreement, however, was a compro-
\nmise between Member States as not all 27
\n(Croatia joined later on 1 July) could sup-
\nport the proposal as put forward by the Eu-
\nropean Commission. Therefore, substan-
\ntial changes were introduced to the initial
\nCommission\u2019s proposal. Although the EU
\nCouncil accepted a ban on characterising
\nflavours, it could not reach agreement on
\nthe ban on slim cigarettes, and that provi-
\nsion was removed. The size of combined
\npicture and text health warnings was also
\nreduced from 75% to 65%. Regarding nico-
\ntine containing products, such as electronic
\ncigarettes, Member States maintained the
\nCommission\u2019s principle. These products
\nshould be regulated depending on their
\nnicotine content\u00a0 \u2013 as consumer products
\nbut with health warnings if nicotine levels
\nfall below a certain threshold; and only as
\nmedicinal products if they contain nicotine
\nabove this threshold. Nevertheless, Mem-
\nber States maintained the option of allow-
\ning individual Member States to go further
\nthan EU legislation. For example, individ-
\nual Member States could introduce plain
\nstandardised packaging like in Australia on
\na national level under the approach adopted
\nby the EU Council. It should be stressed,
\nhowever, that the agreement between
\nthe Health Ministers on 21 June was not
\nunanimous. It was a result of intense dis-
\ncussion process led by the pro-health Irish
\nPresidency that had to reach a compromise
\nwhich took into account the differing posi-
\ntions of all Member States.
\nThe position of the EU Council regarding
\nthis Directive is prepared in discussions
\namong Member States\u2019 representatives,
\nwhereas the position of the European Par-
\nliament, the other co-legislator, is adopted
\nin debates among Members of the Euro-
\npean Parliament (MEPs) that take place in
\nCommittees, and a final vote\u00a0\u2013 in a plenary
\nsession. The plenary vote by 766 elected
\nmembers from all 28 Member States for
\nthe Directive is scheduled for early Sep-
\ntember. The Directive is steered through
\nthe European Parliament [8] and discussed
\nin several Committees. After votes in five
\nopinion Committees, the sixth\u00a0 \u2013 lead
\nCommittee\u00a0\u2013 Environment, Public Health
\nand Food Safety (ENVI), voted on its po-
\nsition on 10\u00a0 July. The ENVI Committee
\nnot only accepted a ban on characterising
\nflavours but also voted for the prohibition
\nof slim cigarettes, a different position than
\nthat of the EU Council. Although plain
\nstandardised packaging, initially suggested
\nby MEP Linda McAvan,was not approved,
\nthe size of health warnings was kept at the
\nlevel of 75% as proposed by the Commis-
\nsion. Regarding electronic cigarettes, the
\nENVI Committee voted in favour of their
\nregulation as medicinal products regardless
\nof nicotine content, thus eliminating the
\nthresholds limits proposed by the Com-
\nmission. The position of the ENVI Com-
\nmittee will be a basis for the vote in the
\nplenary session in September during which
\nthe position of the Parliament shall be ap-
\nproved.
\nAt times the process both in the EU Coun-
\ncil and the European Parliament was any-
\nthing but smooth.There are several Member
\nStates who do not support the new measures
\nproposed by the Commission and continue
\nto object to some aspects of the Directive
\nor delay the legislative process. The Irish
\nPresidency diligently managed to carve out
\na compromise that at the same time unfor-
\ntunately involved weakening some aspects
\nof the Commission\u2019s proposal. However, it
\nwas not enough to sway Poland, Czech Re-
\npublic, Bulgaria and Romania which voted
\nagainst the particular compromise proposal
\nduring the Ministerial meeting on 21 June.
\nFor example, Poland wished to have the
\npossibility to keep menthol cigarettes, and
\nthe Czech Republic objected generally to
\nthe proposal.
\nAlthough there were four Member States
\nthat voted openly against the compromise,
\nsome presume that there are more which are
\nworking in silent opposition and making it
\nharder for the EU Presidencies to reach
\nagreement on the Directive. Media reports
\nhave documented reluctance to support
\nthe Directive also in several other Member
\nStates.
\nIt seems unclear and controversial espe-
\ncially as Europeans of all Member States
\nask for more decisive action and a major-
\nity of them support strong tobacco control
\npolicies. A Eurobarometer published in
\n2012\u00a0[9] shows, for instance, that 76% of
\nthe EU population supports putting pic-
\ntorial warnings on all packages of tobacco
\nproducts and 57% support a ban on lo-
\ngos, colours and promotional elements on
\npacks\u00a0\u2013 which means there might be a sup-
\nport for plain standardised packaging like
\nin Australia.
\nHowever, it seems that the public adminis-
\ntrations of these countries are keeping their
\n\u2018eyes shut\u2019 to public opinion and scientific
\nmedical evidence. Moreover, their attention
\nto the voice of the tobacco industry along
\nwith their disproportionate focus on alleged
\ndisastrous economic effects of the tobacco
\nregulation, sheds doubts on their compli-
\nance with Article 5.3 of the WHO FCTC.
\nThis Article requires all Parties, \u2018when set-
\nting and implementing their public health
\npolicies with respect to tobacco control\u2019, to
\n\u2018[..] act to protect these policies from com-
\nmercial and other vested interests of the to-
\nbacco industry in accordance with national
\nlaw.\u2019 [10]. As surprising it could be it ap-
\npears that there might be Member States
\nwho only partly care about the health of
\ntheir citizens and especially the health of a
\nTobacco
\n131
\nnew generation putting other, for instance,
\neconomic interests as first priority. By doing
\nso they prevent other EU Member States
\nfrom reaching the agreement that would
\nbring maximum benefit to the health of all
\nEuropeans.
\nUnfortunately, the same can be said about
\na number of Members of the European
\nParliament (MEPs) who voted to weaken
\nthe legislative proposal and ignored public
\nhealth aspects. In June four opinion Com-
\nmittees\u00a0\u2013 on legal affairs, agriculture, inter-
\nnational trade, and industry\u00a0\u2013 voted to wa-
\nter down the Directive significantly. A fifth
\nCommittee, dealing with consumer affairs,
\nhad a more balanced approach. Despite the
\nfierce opposition,the ENVI Committee ad-
\nopted a health focused report,strengthening
\nseveral measures in the proposal. The Rap-
\nporteur Linda McAvan will now have to
\nface the plenary session in early September
\nwhere it is assumed that the strong health
\nposition of the ENVI Committee might be
\nwatered down as lobbying is expected to in-
\ntensify from the side of the tobacco industry
\nand their allies.
\nThe EU Council is waiting for the posi-
\ntion of the European Parliament to start
\nnegotiations towards a final agreement
\namong both institutions. There are a num-
\nber of European countries who support
\nthe strongest possible tobacco legislation
\nto help safeguard their citizens\u2019 health. As
\nthe decision has to be made together with
\nother Member States and in negotiations
\nwith the European Parliament afterwards,
\nthe outcome is unclear. The new Lithu-
\nanian Presidency of the EU Council that
\ntook over from Ireland on 1 July seems to
\nbe aware of the tense situation. Minister
\nfor Health of Lithuania, Dr. Vytenis Povi-
\nlas Andriukaitis, in a passionate speech in
\nthe ENVI Committee on 11 July, thanked
\nENVI for their vote the day before and
\nadded: \u2018I know that the negotiations on
\nTobacco Products [Directive] are diffi-
\ncult because of influential tobacco indus-
\ntry lobbying but many non-governmental
\norganizations at the EU and a big part of
\nthe voters support those measures on to-
\nbacco control or even stricter regulation.
\nThe WHO FCTC also obliges us to im-
\nplement more active tobacco control mea-
\nsures.\u2019 [11].
\nAs outcome is still unclear, health care pro-
\nfessionals in Europe play a crucial role in re-
\nminding their politicians of the importance
\nof health both at national and EU level.
\nTheir engagement in promoting a sound
\nTobacco Products Directive by contacting
\ntheir national public administration or their
\nMEPs could help to achieve healthier Eu-
\nrope.
\nHippocrates said\u00a0 \u2013 \u2018wherever the art of
\nmedicine is loved, there is also a love of
\nhumanity.\u2019This is why physicians enjoy the
\ntrust of people\u00a0\u2013 they possess knowledge
\nand they also care to use it when needed.
\nHippocrates also noted that time is of
\nimportance, but sometimes an opportu-
\nnity matters the most. This might be one
\nof those opportunities to make an impact
\nand reach the agreement that supports
\nstrong public health interests in the EU
\nthat might have an effect outside Europe
\nas well.
\nReferences
\n1. The Oxford medical companion, 1994.
\n2. Arnott D., Berteletti Kemp F., Godfrey F.,
\nJoossens L.,King J.,Ratte S.,Turnbull A; Out of
\nStep: Shadow Report from EU tobacco control
\nNGOs on the European Commission\u2019s report
\n\u2018Dancing the Tango\u2019, 2012., p.3.
\n3. WHO FCTC; http:\/\/www.who.int\/fctc\/about\/
\nen (2013.07.01.)
\n4. Special Eurobarometer 385, May 2012; http:\/\/
\nec.europa.eu\/health\/tobacco\/docs\/eurobaro_
\nattitudes_towards_tobacco_2012_en.pdf
\n(2013.06.28.).
\n5. (COM(2012) 788 final; 19.12.2012) The Pro-
\nposal for a Directive of the European Parliament
\nand the Council on the approximation of the
\nlaws, regulations and administrative provisions
\nof the Member States concerning the manufac-
\nture, presentation and sale of tobacco and related
\nproducts, p.4.
\n6. (SWD(2012) 452 final; 19.12.2012) EC
\nIMPACT ASSESSMENT of the Proposal for
\na Directive of the European Parliament and
\nthe Council on the approximation of the laws,
\nregulations and administrative provisions of the
\nMember States concerning the manufacture,
\npresentation and sale of tobacco and related
\nproducts.
\n7. Further eu2013ie success in Health field with
\nagreementonTobaccoProductsDirective;http:\/\/
\nwww.eu2013.ie\/news\/news-items\/20130621
\npostepscohealth (2013.06.22.).
\n8. MEP Linda McAvan is from the United
\nKingdom in Group of the Progressive Alliance
\nof Socialists and Democrats in the European
\nParliament.
\n9. Special Eurobarometer 385, May 2012; http:\/\/
\nec.europa.eu\/health\/tobacco\/docs\/eurobaro_
\nattitudes_towards_tobacco_2012_en.pdf
\n(2013.06.28.)
\n10. Guidelines for implementation of Article 5.3 of
\nthe WHO Framework Convention on Tobacco
\nControl; http:\/\/www.who.int\/fctc\/guidelines\/
\narticle_5_3.pdf (2013.06.05.)
\n11. Speech by Vytenis Povilas Andriukaitis,
\nMinister of Health, at the European Parliament,
\nEnvironment, Public Health and Food Safety
\nCommittee; http:\/\/www.sam.lt\/go.php\/eng\/Full
\n_Article_\/4001 (2013.07.14.)
\nPeteris Ancans
\nAdvisor to the Smoke Free Partnership
\nFormer Health Attach\u00e9 of Latvia
\nto the European Union
\nSFP is a partnership between the European
\nRespiratory Society, Cancer Research UK, the
\nEuropean Heart Network, Action on Smok-
\ning and Health UK, and the Irish Cancer
\nSociety. SFP aims to promote tobacco control
\nadvocacy and policy research at EU and na-
\ntional levels in collaboration with other EU
\nhealth organisations and EU tobacco control
\nnetworks.
\nTobacco
\n132
\nWMA news
\nImportant progress in revising the Dec-
\nlaration of Helsinki was achieved at the
\nfinal WMA stakeholders meeting held in
\nWashington DC on August 26. As a re-
\nsult, a final draft document was developed
\nto be sent to the WMA\u2019s Medical Ethics
\nCommittee and then the Council in For-
\ntaleza, Brazil, for forwarding to the WMA
\nGeneral Assembly for adoption. The one-
\nday Washington meeting, hosted by the
\nAmerican Medical Association at the Hay-
\nAdams Hotel opposite the White House,
\nwas originally intended to be a routine
\nmeeting of the WMA workgroup set up in
\n2011 to progress the revision of the Dec-
\nlaration of Helsinki. However, following a
\ndecision taken at the Council meeting in
\nBali in April, the meeting was extended
\nto include interested national medical as-
\nsociations and stakeholders and as a result
\nmore than 70 people attended the gather-
\ning in the US capital.
\nAn impressive line-up of outside experts
\nand leading figures from 13 NMAs spent
\nthe day discussing the draft revised Decla-
\nration paragraph by paragraph, line by line
\nsuggesting further changes and alternative
\nwording.
\nThe meeting was opened by Dr. Ardis D.
\nHoven, President of the American Medi-
\ncal Association. She welcomed people to
\nWashington, reminding them that their
\ndrive towards reaching the goal of a revised
\nDeclaration of Helsinki was coinciding
\nwith the 50th
\nanniversary celebrations in
\nWashington that week of the Poor People\u2019s
\nMarch in the city and the \u2018I Have a Dream\u2019
\nspeech by Martin Luther King.
\nDr. Mukesh Haikerwal, Chair of the
\nWMA, said that the Declaration of Hel-
\nsinki was a seminal document that guided
\nthe way physicians worked and the way that
\nethics were protected. He said that Dr. Ce-
\ncil Wilson, President of the WMA, was to
\nhave addressed the meeting, but because of
\nillness could not attend. So Dr. Haikerwal
\nread the words he would have spoken.
\nDr. Wilson declared: \u201cPhysicians are most
\ncredible when we speak from a platform
\nbased on ethics and principle. As physicians
\nwe must have moral authority and speak
\nand act with moral authority. That means
\nwe must speak out on broad public health
\nissues. Doing that makes our message more
\ncredible and more effective when we advo-
\ncate on matters of public policy.\u201d
\nHe said that those physicians from around
\nthe world who came together to form the
\nWorld Medical Association in 1947 un-
\nderstood that an organization was needed
\nto become the authoritative voice on global
\nstandards for medical ethics and profes-
\nsional conduct, rather than focusing solely
\non protecting the interests of the profession.
\nThey recognized the importance of endeav-
\noring to achieve the highest possible stan-
\ndards of medical care, ethics and health-
\nrelated human rights for all people.
\n\u201cThere is perhaps no clearer example of ad-
\ndressing ethics in medicine than the Decla-
\nration of Helsinki that advises physicians on
\ndoing medical research on human subjects.
\nToday we benefit from truly astounding ad-
\nvances in development of medications and
\ndevices that save lives and relieve suffering.
\nThis would not be possible without research
\ninvolving human subjects. Fortunately the
\npublic in general accepts the importance of
\nresearch, and in fact many volunteer to par-
\nticipate out of a desire to help others. That
\nparticipation is dependent on having trust
\nin those who conduct research.
\nIt is important to have an international
\nstandard for research in a world where stud-
\nies on human subjects increasingly involve
\nmultiple countries.The Declaration of Hel-
\nsinki is that key international standard, the
\nloadstone, the North Star if you will, that
\nguides physicians, governments and indus-
\ntry in this area of advice on doing medical
\nresearch on human subjects. And adher-
\nence to its principles is critical to preserv-
\ning the trust of those who are subjects, our
\npatients \u2013 and those who conduct research.\u201d
\nDr. Wilson\u2019s speech reminded the meeting
\nthat the Declaration, adopted in 1964, had
\nhad multiple revisions and the current pro-
\ncess begun in 2011 was based on being thor-
\nough, transparent and reflecting of diverse
\nviewpoints.To that end the WMA had held
\nexpert conferences to receive insights and
\nrecommendations from ethics scholars, aca-
\ndemicians, practicing physicians, govern-
\nment officials and those engaged in spon-
\nsoring clinical research.These had been held
\nin different parts of the world, including the
\nNetherlands, South Africa, Japan and now
\nWashington, D.C.
\nThe speech concluded: \u201cTo reiterate points
\nmade earlier, medical progress is dependent
\non research that ultimately includes studies
\nDeclaration of Helsinki
\nStakeholders Meeting in Washington, DC
\nNigel Duncan
\n133
\nWMA news
\ninvolving human subjects. The Declaration
\nof Helsinki provides the roadmap for trust
\nand duty,essential to the success of research.
\nThe revisions being considered are impor-
\ntant and will preserve and strengthen that
\nroadmap.\u201d
\nDr. Raman Parsa-Parsi, Chair of the WMA
\nWorkgroup, reminded the meeting about
\nhow the workgroup was set up with a man-
\ndate to develop a draft revised version of the
\nDeclaration to be sent to the WMA\u2019s Medi-
\ncal Ethics Committee for approval and then
\nto the General Assembly for adoption. He
\nsaid that during the public consultation that
\ntook place in the summer 129 submissions
\nhad been received from 36 different coun-
\ntries or regions.
\nHe added: \u201cWe were extremely delighted
\nwith this response to the public consultation
\nboth for the broad range of respondents as
\nwell as the carefully thought out comments.
\nAll of the submissions were carefully re-
\nviewed and considered in the development
\nof a new draft version.\u201d
\nProfessor Urban Wiesing, one of the two
\nethical experts on the workgroup, said that
\nthe group had received suggestions from 150
\npublic comments,50 expert presentations and
\nnumerous articles. He detailed the changes
\nthat had been proposed before the public
\nconsultation, saying that they were based on
\nthe document being more readable, provid-
\ning more protection for participants and with
\nmore precise post study arrangements.
\nHe outlined why some of the suggested
\nchanges that had been proposed would not
\nbe appropriate.
\nHe said the placebo issue was still contro-
\nversial, adding: \u201cI am afraid that no guide-
\nlines will ever be able to end this contro-
\nversy.\u201dThe workgroup proposal in the draft
\ndid not change the ethical principles from
\nthe 2008 version, but set up a new paradigm
\nthat was more comprehensive and more
\nsystematic because it addressed not only
\nthe controls but any control of less than the
\nbest intervention. The workgroup did not
\nchange the section from the draft for public
\ncomment.
\nAlso receiving much comment was the sec-
\ntion on research ethics committees. Prof.
\nWiesing said that many commenters re-
\nquested more details for the committees.
\nThe same was true for the section on in-
\nformed consent, but he said: \u201cWe received
\nso many suggestions to mention this and
\nthis and this. We decided not to adopt fur-
\nther changes to maintain the character and
\nlength of the Declaration.\u201d
\nThe same problem was confronted with vul-
\nnerable groups. \u201cWe received many sugges-
\ntions by commentators to mention this or
\nanother vulnerable group, at least a dozen.
\nThe question was always which one shall
\nwe take? Lists are never comprehensive. We
\ndecided not to mention specific vulnerable
\ngroups but rather to provide a general defi-
\nnition and general regulation.\u201d
\nMany commentators had also suggested
\nthat the Declaration should address all pro-
\nfessions involved in bio-medical research
\nand not only physicians. However, he said
\nthat the mandate of the WMA was to rep-
\nresent national medical associations.
\nDr. Jeff Blackmer, the second ethical expert
\non the workgroup, explained the reasoning
\nbehind the revisions that had been incor-
\nporated in the revised draft Declaration.
\nMuch of the new wording had been intro-
\nduced for the purposes of clarification and
\nconsistency, such as using the word \u2018groups\u2019
\nrather than \u2018populations\u2019 or \u2018communities\u2019.
\nThe section on informed consent had been
\namended in several areas to use the word
\n\u2019must\u2019 rather than \u2018should\u2019 to increase the
\nlevel of obligation on physicians.In addition
\nthe document had been amended to clarify
\nthe meaning of the word \u2018competence\u2019.
\nHe referred to the issue of the well-being
\nof the individual research subject having
\nto take precedence over all other interests.
\nThe new draft changed that to read: \u201cWhile
\nthe primary purpose of medical research is
\nto generate new knowledge, this goal can
\nnever take precedence over the health, well-
\nbeing, safety, rights and best interests of the
\nindividual research subjects.\u201d This was one
\nof the more substantive changes made to
\nthe document as a result of the consultation.
\nOther parts of the Declaration that had
\nprompted considerable comment included
\nphysicians combining medical research with
\nclinical care, compensation for injury, privacy
\nand confidentiality,post-study provisions,tri-
\nal registration and publication of results and
\nunproven interventions in clinical practice.
\nThe workgroup also changed \u201cappropriate
\ncaution must be exercised in the conduct
\nof medical research that may harm the en-
\nvironment\u201d to \u201cmedical research should be
\nconducted in a manner that minimizes pos-
\nsible harm to the environment.\u201d This pro-
\nvided increased specificity around minimi-
\nzation of harm.
\nUnder measures to minimize risks, the
\nwork group added that \u201cthe risks must be
\ncontinuously monitored,assessed and docu-
\nmented by the researcher.\u201d
\nAmbassador Jimmy Kolker, Acting Head
\nof the Office of Global Affairs in the Of-
\nfice of the Secretary of the US Department
\nof Health and Human Services, said the
\nDeclaration had been an important source
\nof ethical guidance in the conduct of clini-
\ncal research throughout the world for nearly
\nhalf a century. It was highly respected as a
\nsource of fundamental principles and wide-
\nly-held values.
\n\u201cWe support your efforts to maintain the
\ncurrency and relevance of the DoH through
\nperiodic updates to address new ethical
\nchallenges and make adjustments to reflect
\nnew research practices and directions. We
\ncommend the WMA for the integrity and
\ntransparency of its consultative and delib-
\n134
\nWMA news
\nerative processes to revise the Declaration
\nand for giving due consideration to the per-
\nspectives of a wide variety of stakeholders
\nand interest parties.\u201d
\nHowever, the HHS did have concerns
\nabout several paragraphs. One of its gen-
\neral concerns related to the prescribing of
\nspecific procedural steps in a statement of
\nethical principles.
\n\u201cThis presents a tension between the Dec-
\nlaration and the mandatory procedures that
\ncountries have in place to protect human
\nresearch participants. Such conflicts can di-
\nminish the impact of the Declaration as a
\nsource of fundamental guidance. Procedural
\ndetails should not be mandated; the Declara-
\ntion should allow for more flexibility in how
\nthe principle or safeguard is implemented.
\nThe use of the word \u201cmust\u201dcan also establish
\nan ethical standard that may be impossible to
\nachieve. Establishing an unachievable stan-
\ndard as a global norm may inhibit ethical and
\nscientifically sound research.\u201d
\nHe said that the word \u201cmust\u201d should be
\nused only in the articulation of an ethical
\nprinciple. However, there were a number of
\ninstances in the revised draft in which the
\nword \u201cmust\u201d was used regarding a process
\nor procedure.
\nAmbassador Kolker specifically raised con-
\ncerns about paragraph 10 which, as current-
\nly written, stated that researches need only
\n\u201cconsider\u201d the laws of their countries and
\nappeared to assert the Declaration\u2019s primacy
\nover national laws.
\n\u201cEthical norms and standards and national
\nlaws and regulations are both important,
\nbut they are not equivalent. Researchers are
\nrequired to follow national laws and regula-
\ntions, but their duty to follow ethical prin-
\nciples is a matter of medical ethics.\u201d
\nHe suggested a new wording to address this
\nconcern \u2013 that \u201cphysicians must follow the
\nethical, legal and regulatory requirements for
\nresearch involving human subjects in their
\nown countries as well as the ethical principles
\nunderlying this Declaration and other appli-
\ncable international norms and standards. No
\nnational or international legal or regulatory
\nrequirement should reduce or eliminate any
\nof the fundamental protections for research
\nsubjects set forth in this Declaration\u201d.
\nWith regard to paragraph 15 on compensa-
\ntion he agreed with its intent that at a mini-
\nmum researchers had an ethical obligation
\nto ensure that individuals received treat-
\nment if they were harmed as a result of par-
\nticipation in research. However, compensa-
\ntion for harms or costs of long term care was
\na more complex issue and guaranteeing that
\ninjured participants received compensation
\nwas a standard that might not be achievable
\nin many countries.
\nHe said that the responsibility for determin-
\ning compensation for research injuries varied
\namong countries. For example, in the US
\ninjured parties could seek remedy in a court
\nof law through the country\u2019s tort system, but
\nthere was no guarantee that they would re-
\nceive compensation. There was recognition
\nthat this current approach might not be suf-
\nficient and there had been calls for further
\nstudy to determine whether a research-spe-
\ncific national system of compensation was
\nneeded. For these reasons he recommended
\nthat \u201cmust\u201dbe changed to \u201cshould\u201d.
\nDuring the discussion that followed, the
\nmeeting heard interventions from speak-
\ners from many organisations, including the
\nCouncil for International Organisations of
\nMedical Sciences, the National Institutes of
\nHealth and the World Health Organisa-
\ntion, proposing different wording for vari-
\nous parts of the document.
\nRepresentatives from several National
\nMedical Associations also spoke, includ-
\ning Dr. Antoine Mbutuku, President of the
\nCongolese NMA. He said that for the Af-
\nrican continent facing a lot of problems in
\nrelation to human research, the Declaration
\nwas a very important document. It was seen
\nin many African countries as the fundamen-
\ntal document on which the countries based
\ntheir own regulations to protect people.
\nHe emphasised that there should not be
\ndouble standards and that the same stan-
\ndards should be applied in the north as in
\nthe south for placebo control trials. It was
\nnecessary in less developed countries to al-
\nlow placebo controlled trials and not to have
\ntoo many barriers.
\nDr.Mbutuku also referred to the idea of fair
\nbenefit, suggesting that this was question-
\nable. It might be that participants in a trial
\nwere seen from the north as a vulnerable
\ngroup when they were not regarded as such
\nin the south.
\nRoopa Dhatt,President of the International
\nFederation of Medical Students Associa-
\ntion, spoke about the special attention that
\nmust be given to the storage of personal
\ninformation on digital platforms. This in-
\nformation must be encrypted to ensure the
\nprivacy of the research subjects and only
\navailable to the responsible of the study.
\nShe said that consideration of social media
\nwas applicable to digital platform use.\u00a0Ev-
\nery day, more patients\u2019data was being stored
\non digital platforms.These digital platforms
\nexisted in hospitals, schools, research insti-
\ntutions and many others. Any access to the
\nplatforms was a breach of privacy and viola-
\ntion of the rights of research subjects. The
\nsystem must be encrypted to ensure that
\nonly those responsible for the research were
\naccessing that data.\u00a0
\nShe added that while the argument for in-
\ncluding details was valid for many aspects of
\nthe document,in the opinion of the IFSMA,
\ndigital platforms were a reality of medical
\nresearch and care. Yet often the principles
\nof confidentiality, privacy and consent were
\nnot implemented in the case of digital data,
\nespecially when looking beyond clinical tri-
\nals and health systems research.
\n135
\nHealth in all Policies
\nAs for social media, she said that while it
\nmight not be necessary to explicitly include
\nit in the Declaration, it was still an area that
\nrequired consideration in the areas of medi-
\ncal research. \u00a0
\nDr. Blackmer, summing up the day\u2019s dis-
\ncussion, said that many of the points raised
\nhad already been made during the previous
\nexpert conferences. Other points raised had
\nreceived conflicting views. They had not
\nheard complete consensus on any single
\ntopic. Not surprisingly the paragraphs of
\nthe Declaration that had engendered the
\nmost focus and discussion during the day
\nwere those on which the workgroup had
\nspent the most time and those upon which
\nthey had received the most input from
\nstakeholders.
\nDr. Otmar Kloiber, Secretary General of
\nthe WMA, thanked the participants at
\nthe meeting for a useful discussion: \u201cWe
\nhope that this gives another emphasis to
\nthe question of research and research eth-
\nics.We still think this is very necessary even
\nafter 50 years.There are always some things
\nthat we have to repeat and express more
\nprecisely and more openly or to say more
\nprovocatively.\u201d
\nHe said the WMA had always tried with
\nthe Declaration of Helsinki to \u2018set new
\nstandards,to reach out to a new age,to drive
\nthe environment, to be better, to be more
\nethical and to be more responsible\u2019.
\nFollowing the open discussion, the WMA
\nworkgroup convened to consider the points
\nraised. Some further amendments were
\nmade to the revised Declaration and it was
\ndecided that the draft document should be
\nsent to the Medical Ethics Committee for
\nfurther debate and approval in Fortaleza,
\nBrazil, in October. The document would
\nthen go to the WMA Council for forward-
\ning to the General Assembly for adoption
\non October 19.
\nMr. Nigel Duncan,
\nPublic Relations Consultant, WMA
\nBuilding on our heritage, looking to our future
\nThe 8th
\nGlobal Conference on Health Promotion was held in Hel-
\nsinki, Finland from 10\u201314 June 2013. The meeting builds upon
\na rich heritage of ideas, actions and evidence originally inspired
\nby the Alma Ata Declaration on Primary Health Care (1978) and
\nthe Ottawa Charter for Health Promotion (1986). These identified
\nintersectoral action and healthy public policy as central elements
\nfor the promotion of health, the achievement of health equity,
\nand the realization of health as a human right.Subsequent WHO
\nglobal health promotion conferences1
\ncemented key principles for
\nhealth promotion action.These principles have been reinforced in
\nthe 2011 Rio Political Declaration on Social Determinants of Health,
\nthe 2011 Political Declaration of the UN High-level Meeting of the
\nGeneral Assembly on the Prevention and Control of Non-commu-
\n1 Subsequent conferences were held in Adelaide (1988); Sundsvall (1991);
\nJakarta (1997); Mexico City (2000); Bangkok (2005); Nairobi (2009).
\nnicable Diseases, and the 2012 Rio+20 Outcome Document (the
\nFuture We Want). They are also reflected in many other WHO
\nframeworks, strategies and resolutions, and contribute to the for-
\nmulation of the post-2015 development goals.
\nThe 8th
\nGlobal Conference on Health Promotion (8GCHP) was
\nheld in Helsinki, Finland, from 10 to 14 June 2013. The con-
\nference was co-organized by the World Health Organization
\n(WHO) and the Ministry of Social Affairs and Health of Fin-
\nland (MSAH).
\nThe plenary sessions and the press briefings were broadcasted
\nlive on the Internet and may be viewed as recordings here: www.
\nhealthpromotion2013.org\/media-healthpromotion2013\/videos
\nThe presentations may be viewed here: www.slideshare.net\/
\nstmslide
\nFurther information: healthpromotion@who.int
\nThe Helsinki Statement on Health in all Policies
\nThe 8th
\nGlobal Conference on Health Promotion, Helsinki, Finland, 10\u201314 June 2013
\nHealth for All is a major societal goal
\nof governments,and the cornerstone
\nof sustainable development
\nWe, the participants of this conference
\nAffirm our commitment to equity in health
\nand recognize that the enjoyment of the
\nhighest attainable standard of health is one
\nof the fundamental rights of every human
\nbeing without distinction of race, religion,
\npolitical belief, economic or social condi-
\ntion.We recognize that governments have a
\nresponsibility for the health of their people
\nand that equity in health is an expression of
\nsocial justice.We know that good health en-
\nhances quality of life, increases capacity for
\nlearning, strengthens families and commu-
\n136
\nHealth in all Policies
\nnities and improves workforce productivity.
\nLikewise, action aimed at promoting equity
\nsignificantly contributes to health, poverty
\nreduction, social inclusion and security.
\nHealth inequities between and within coun-
\ntries are politically, socially and economical-
\nly unacceptable, as well as unfair and avoid-
\nable. Policies made in all sectors can have
\na profound effect on population health and
\nhealth equity. In our interconnected world,
\nhealth is shaped by many powerful forces,
\nespecially demographic change, rapid ur-
\nbanization, climate change and globaliza-
\ntion. While some diseases are disappearing
\nas living conditions improve, many diseases
\nof poverty still persist in developing coun-
\ntries. In many countries lifestyles and living
\nand working environments are influenced
\nby unrestrained marketing and subject to
\nunsustainable production and consumption
\npatterns. The health of the people is not
\nonly a health sector responsibility, it also
\nembraces wider political issues such as trade
\nand foreign policy. Tackling this requires
\npolitical will to engage the whole of gov-
\nernment in health.
\nHealth in All Policies is an approach to
\npublic policies across sectors that system-
\natically takes into account the health im-
\nplications of decisions, seeks synergies, and
\navoids harmful health impacts in order to
\nimprove population health and health eq-
\nuity. It improves accountability of policy-
\nmakers for health impacts at all levels of
\npolicy-making. It includes an emphasis
\non the consequences of public policies on
\nhealth systems, determinants of health and
\nwell-being.
\nWe recognize that governments have a
\nrange of priorities in which health and eq-
\nuity do not automatically gain precedence
\nover other policy objectives. We call on
\nthem to ensure that health considerations
\nare transparently taken into account in pol-
\nicy-making, and to open up opportunities
\nfor co-benefits across sectors and society at
\nlarge.
\nPolicies designed to enable people to lead
\nhealthy lives face opposition from many
\nsides. Often they are challenged by the
\ninterests of powerful economic forces that
\nresist regulation. Business interests and
\nmarket power can affect the ability of gov-
\nernments and health systems to promote
\nand protect health and respond to health
\nneeds. Health in All Policies is a practical re-
\nsponse to these challenges. It can provide a
\nframework for regulation and practical tools
\nthat combine health, social and equity goals
\nwith economic development, and manage
\nconflicts of interest transparently. These
\ncan support relationships with all sectors,
\nincluding the private sector, to contribute
\npositively to public health outcomes.
\nWe see Health in All Policies as a constituent
\npart of countries\u2019 contribution to achieving
\nthe United Nations Millennium Develop-
\nment Goals and it must remain a key con-
\nsideration in the drafting of the post-2015
\nDevelopment Agenda.
\nWe, the participants of this conference
\n\u2022 Prioritize health and equity as a core re-
\nsponsibility of governments to its peo-
\nples.
\n\u2022 Affirm the compelling and urgent need
\nfor effective policy coherence for health
\nand well-being.
\n\u2022 Recognize that this will require political
\nwill, courage and strategic foresight.
\nWe call on governments to fulfil their ob-
\nligations to their peoples\u2019 health and well-
\nbeing by taking the following actions:
\n\u2022 Commit to health and health equity as
\na political priority by adopting the prin-
\nciples of Health in All Policies and tak-
\ning action on the social determinants of
\nhealth.
\n\u2022 Ensure effective structures, processes and
\nresources that enable implementation of
\nthe Health in All Policies approach across
\ngovernments at all levels and between
\ngovernments.
\n\u2022 Strengthen the capacity of Ministries of
\nHealth to engage other sectors of gov-
\nernment through leadership, partnership,
\nadvocacy and mediation to achieve im-
\nproved health outcomes.
\n\u2022 Build institutional capacity and skills that
\nenable the implementation of Health in
\nAll Policies and provide evidence on the
\ndeterminants of health and inequity and
\non effective responses.
\n\u2022 Adopt transparent audit and account-
\nability mechanisms for health and equity
\nimpacts that build trust across govern-
\nment and between governments and their
\npeople.
\n\u2022 Establish conflict of interest measures
\nthat include effective safeguards to pro-
\ntect policies from distortion by commer-
\ncial and vested interests and influence.
\n\u2022 Include communities, social movements
\nand civil society in the development, im-
\nplementation and monitoring of Health in
\nAll Policies, building health literacy in the
\npopulation.
\nWe call on WHO to
\n\u2022 Support Member States to put Health in
\nAll Policies into practice.
\n\u2022 Strengthen its own capacity in Health in
\nAll Policies.
\n\u2022 Use the Health in All Policies approach
\nin working with United Nations agen-
\ncies and other partners on the unfinished
\nMillennium Development Goals agenda
\nand the post-2015 Development Agen-
\nda.
\n\u2022 Urge the United Nations family, other
\ninternational organizations, multilateral
\ndevelopment banks and development
\nagencies to achieve coherence and syn-
\nergy in their work with Member States
\nto enable implementation of Health in
\nAll Policies.
\nWe, the participants of this conference
\n\u2022 Commit ourselves to communicate the
\nkey messages of this Helsinki Statement
\nto our governments, institutions and com-
\nmunities.
\n137
\nWMA news
\nThe world has made tremendous strides in
\nimproving health and there are many suc-
\ncess stories all over the world. Global ma-
\nternal deaths have dropped nearly 50% since
\n1990. And in October 2012 we celebrated
\nthe first ever International Day of the Girl
\nChild. Yet economic, social and political
\nbarriers still exist for women and girls. For
\ninstance, 287,000 expectant mothers die ev-
\nery year, that is 800 women every day. In ad-
\ndition, more than 200 million women want
\nbut do not have the tools they need to plan
\ntheir families.
\nMany countries will not be meeting the tar-
\ngets set and there are several discussions on-
\ngoing at various levels There are for instance
\ngrowing consensus that Non Communicable
\nDiseases (NCDs) and Universal Health Care
\nshould be additional goals. There is also talk
\nabout introducing Sustainable Development
\nGoals.
\nThe stumbling goals to attainment of goals
\ndiffer in the different countries. Generally
\nthe most important challenges are:
\n\u2022 Political will and commitment
\n\u2022 Ineffective leadership \u2013 within and out-
\nside Health Sector
\n\u2022 Poor prioritization \u2013 resource allocation
\n\u2022 Weak health systems \u2013 especially Human
\nResource for Health
\n\u2022 Limited high impact solutions
\n\u2022 Sustainable interventions \u2013 impact
\n\u2022 Social mobilization \u2013 prevention, rights
\n\u2022 Inter-sectoral and intra-sectoral collabo-
\nration
\n\u2022 Low literacy levels
\nMedical women can play an important role in
\naddressing the above issues in their countries.
\nHowever, as individuals, the impact is likely
\nto be minimal.However,as organized groups,
\nmedical women can make a difference.
\nIndeed it will take a critical mass of strong
\nprofessional and influential medical women
\nwho are strategically positioned and actively
\nengaged in in setting national and global
\npolicy agenda.It will require women who are
\nfocused and committed to improving access
\nto, and quality of health care, in line with
\nnational and global goals and standards for
\nhealth and development. This requires more
\nsupport from Medical Women International
\nAssociation (MWIA) as regards:
\n\u2022 Encouraging mentoring programs aimed
\nat enabling medical students and young
\nwomen doctors become leaders.
\n\u2022 Training materials on advocacy, negotia-
\ntion, communication, etc
\n\u2022 Advocacyforgendertrainingofallhealthpro-
\nfessionals \u2013 pre-service and in-service (CPD)
\n\u2022 More active participation and visibility in
\non-going global level discussions eg. Post
\nMDG
\n\u2022 Capacity assessment of medical women
\nassociations vis a vis the MDGs.
\n\u2022 Capacity building opportunities. Eg. \u2013
\nsharing information and training manu-
\nals, promoting joint projects, and even
\ntwinning between the stronger and the
\nweaker associations.
\n\u2022 Identification of medical women who
\nhave had extensive experience and en-
\ncourage them to take up leadership roles
\nat national, regional and global levels.
\n\u2022 Emphasis should also be placed on groom-
\ning the next generation of women lead-
\ners\u00a0\u2013 medical students and young women
\ndoctors should receive mentorship.
\nAll the above strategies will require MWIA
\nto form new alliances and partnerships at
\nglobal level with likeminded organizations.
\nThe World Medical Association\u2019s efforts are
\naimed at that all the people in the world
\nhave access to health care and therefore
\nsubscribed to the MDGs. Therefore both
\nWMA and MWIA have a common interest,
\none that needs alliances and partnerships.
\nDuring my own term as WMA President
\nwhich begins in October this year, I plan
\nto focus on the following key areas which
\nI strongly feel many countries especially the
\nlow and middle income ones urgently need
\nto address in order to achieve the MDGs.
\nThese are:
\n1. Engendering the Health Sector
\n2. The Human Resource for Health crisis
\n3. Integrating Mental Health into general
\nhealth services
\n4. NCDs
\n5. Preventive Medicine
\n6. The One Health approach.
\nThe areas identified are also key areas for
\nMWIA. In conclusion, I look forward to
\nstrengthened collaboration between the 2
\norganizations.Thank you for listening.
\nDr. Margaret Mungherera,
\nPresident Elect,
\nWorld Medical Association
\nAdvancing The Global Health Agenda: the Role for Medical Women
\nKeynote speech at 29th
\nMedical Women International Association Congress, Seoul, Korea \u2013 1\u20133 August, 2013
\nMargaret Mungherera
\n138
\nUNITED STATES OF AMERICAPublic Health
\nThe Chicago Department of Public Health and Healthy Chicago
\nJanis Sayer Raed Mansour Erica Salem Bechara Choucair
\nBackground
\nThe Chicago Department of Public Health
\n(CDPH), like many of the more than 2000
\nlocal public health agencies (LPHAs) in the
\nUnited States, has faced numerous chal-
\nlenges in ensuring the public health of its
\nresidents [1]. Public health is responsible
\nfor three core functions \u2013 assessment, policy
\ndevelopment and assurance \u2013 and a LPHA\u2019s
\nstrength lies in its capacity to provide essen-
\ntial public health services within these areas
\n[2]. Confronted by funding cuts, limited
\nresources and workforce shortages, LPHAs
\nmust re-think the way they conduct busi-
\nness.
\nIn 2011, 57% of LPHAs (serving 65% of
\nthe U.S. population) surveyed by the Na-
\ntional Association of County and City
\nHealth Officials (NACCHO) reported
\nhaving reduced or eliminated service [3].
\nSince the most recent recession began in
\n2008, NACCHO reports that 39,600 local
\npublic health positions have been lost due to
\nlay-offs and attrition [4].
\nLike other health departments, CDPH has
\nbeen forced to change its service array. Es-
\ntablished in 1835, the CDPH has a long
\nhistory of service delivery. Many services
\nand programs were initiated in response to
\nthe emergence of new public health threats
\n(such as HIV and West Nile Virus). Un-
\ntil recently, a large portion of CDPH re-
\nsources was directed towards clinical ser-
\nvices. While not core to public health, these
\nprimary health care services were initially
\nneeded to fill gaps in care in the 1970\u2019s. In
\n2011, and in response to significant growth
\nin community based primary care capac-
\nity, the Department transitioned its several
\nprimary care centers to Federally Qualified
\nHealth Centers that were better positioned
\nto deliver this care.
\nBudget cuts have necessitated that pub-
\nlic health concentrate efforts to those
\nat the core of the public health mission.
\nLPHAs have also sought out opportuni-
\nties to increase their impact in the midst
\nof declining resources. In Chicago, these
\nchallenges presented an opportunity to
\nenvision public health in a new way. With
\na commitment to strategically prioritizing
\nefforts and capitalizing on opportunities to
\nachieve the greatest public health impact,
\nChicago\u2019s public health system remains
\nvital.
\nHealthy Chicago
\nThe challenges facing LPHAs in general
\nand CDPH specifically require that public
\nhealth efforts be both strategic and focused.
\nIn Chicago, the Healthy Chicago public
\nhealth agenda provides that focus.
\nThe Healthy Chicago agenda, released in
\nAugust 2011, serves as a blueprint for city-
\nwide public health action.The Agenda con-
\ntains 16 health outcome targets, 12 priority
\nareas, and 193 related policy, program and
\npublic awareness strategies.The Agenda not
\nonly presents concrete actions for commu-
\nnity health improvement, it also provides a
\nroadmap for partners and other stakehold-
\ners to contribute to a healthier Chicago [5].
\nKey Elements of
\nHealthy Chicago
\nOf Healthy Chicago\u2019s many features, three
\nhave proven essential to the successes
\nachieved to date.The first has been the shift
\nfrom programmatic interventions to policy
\nsolutions, which hold greater promise for
\nsustainable change. Policy changes make
\nhealthy choices practical and available for
\n139
\nPublic HealthUNITED STATES OF AMERICA
\neveryone, and can create a large and lasting
\nimpact with little time and few resources.
\nThe second critical element has been the
\nmove to maximize and leverage partner-
\nships.The third element is the utilization of
\ninnovative technology, which has provided
\nnew avenues for carrying out our essential
\nservices, maximized resources and facilitat-
\ned improved communication and informa-
\ntion sharing.
\nFocus on Policy Solutions
\nOne of the best examples of this shift con-
\ncerns efforts to reduce tobacco use. Prior
\nto the development of Healthy Chicago,
\nCDPH\u2019s tobacco prevention resources were
\ndirected almost exclusively towards smok-
\ning prevention and cessation efforts. Pre-
\nvention programming was directed towards
\nabout 500 of the City\u2019s 400,000 public
\nschool students annually, while counsel-
\ning and nicotine replacement therapy was
\nprovided to a few hundred adults each year.
\nWhile these services undoubtedly affected
\nsome proportion of the limited number
\nof persons reached, it was clear that more
\ncould be done.Thus,efforts were re-directed
\ntowards policy solutions. Within the first
\n18 months following the release of Healthy
\nChicago, smoke-free policies were enacted
\nat five hospitals, four institutions of higher
\nlearning, six behavioral health agencies, four
\npublic housing developments (currently
\nnearly 1000 individual units of public hous-
\ning), and more than 3,200 units of multi-
\nunit private housing. Legislatively, tobacco
\nenforcement laws were strengthened, fines
\nfor illegal sales doubled, and tobacco vend-
\ning machines were prohibited.
\nOpportunities for policy change also
\nabound in the area of obesity prevention.
\nFor example, in collaboration with CDPH,
\nin late 2011, the Chicago Park District con-
\nverted all of their snack vending machines
\nto 100% healthy options. In April 2013,
\nin a multi-departmental effort, all snack
\nand beverage vending machines on City of
\nChicago owned or operated property be-
\ngan offering healthier options. Under this
\nnew policy, at least 75% of offerings must
\nmeet specified nutritional standards. Pub-
\nlic schools have also implemented healthy
\nvending policies. Policy changes within the
\nCity\u2019s Department of Transportation have
\ndramatically increased opportunities for
\nactive transportation, with over 200 miles
\nof on-street bikeways, including almost 35
\nmiles of new barrier and buffer protected
\nbike lanes; a bike-sharing program and the
\ndevelopment of a Pedestrian Plan.
\nPolicy solutions have also been imple-
\nmented in the area of maternal and child
\nhealth. One way to help improve outcomes
\nfor infants is by breastfeeding. Rather than
\npromoting breastfeeding solely through
\neducation, Chicago\u2019s efforts have focused
\non influencing the breastfeeding support
\npolicies of its 19 labor and delivery hospi-
\ntals, thus increasing the likelihood that new
\nmothers will choose to breastfeed. With
\nfederal support and in partnership with the
\nnot-for-profit the Consortium to Lower
\nObesity in Chicago Children, 15 Chicago
\nhospitals with Labor and Delivery services
\nhave committed to support breastfeed-
\ning and are currently working towards the
\nWorld Health Organization\u2019s Baby-Friend-
\nly designation which requires hospitals to
\nimplement a breast-feeding policy. The ini-
\ntiative has been shown to dramatically in-
\ncrease breastfeeding among its patients.
\nLeveraging Partnerships
\nA second contributor to the success of
\nHealthy Chicago is the priority placed on
\npartnerships. The complexity of the chal-
\nlenges facing public health necessitates col-
\nlaborative responses that draw upon and le-
\nverage the expertise and resources of public,
\nprivate, and community-based partners.
\nThe City\u2019s work to eliminate food deserts
\nhas been strengthened through such part-
\nnerships. Last year, CDPH and the Chi-
\ncago Department of Business Affairs and
\nConsumer Protection worked together to
\npass a mobile produce cart ordinance, in
\nessence creating a new class of vending.
\nSubsequently, CDPH and the City\u2019s De-
\npartment of Housing and Economic Devel-
\nopment partnered with Neighbor Capital,
\nLCC, to establish the \u201cNeighborhood Cart\u201d
\nsystem to increase access to fresh produce
\nand to create jobs for the unemployed and
\nunderemployed. By providing training and
\nthen leasing their carts, the partnership
\nprovides an opportunity for meaningful
\nemployment while promoting healthy foods
\nin underserved communities. A partnership
\nwith Streetwise, a community organization
\nserving homeless persons, ensures these op-
\nportunities are presented first to those at
\nrisk of homelessness. Over 60 people have
\nenrolled in classes to enter the program, 41
\nhave completed job training, and 33 indi-
\nviduals have been placed in employment.By
\nthe end of the year, a total of 30 carts will
\nbe operating in Chicago\u2019s low food access
\nneighborhoods.
\nOther partnerships have focused on in-
\ncreasing physical activity. One example is
\nthe Healthy Chicago PlayStreets initiative.
\nWith support from Blue Cross Blue Shield
\nof Illinois, and in partnership with three
\ncitywide and several community-based or-
\nganizations,CDPH launched Healthy Chi-
\ncago PlayStreets to provide children and
\nadults with safe, supervised outdoor spaces
\nfor structured and unstructured play and
\nphysical activity. Sixty community-based
\nevents were held in 2012 where either a
\nlack of park space or concerns about com-
\nmunity violence were limiting the ability of
\nresidents to be physically active, and close
\nto 50 will be conducted by the end of 2013.
\nPartnerships have also proven critical in
\nre-focusing CDPH\u2019s efforts on core public
\nhealth services. In 2012, CDPH partnered
\nwith the Cook County Health & Hospital
\nSystem (CCHHS) to better align Tuber-
\nculosis (TB) services. CDPH transitioned
\nresponsibility for the clinical care of TB
\n140
\ncases to the CCHHS, which has a core fo-
\ncus on health care service delivery. CDPH
\nretained the core services of TB surveillance
\nand prevention. And as previously noted,
\nCDPH partnered with seven FQHCs to
\nprovide primary care. In making this tran-
\nsition, CDPH retained its public health
\npresence in these centers and continues to
\nprovide services such as HIV and Sexually
\nTransmitted Disease (STD) screening and
\ntreatment, and women and children\u2019s health
\nservices such as the Women, Infant and
\nChildren\u2019s (WIC) supplemental food and
\nnutrition program.
\nThe Role of Technology
\nin Healthy Chicago
\nThe policy and partnerships that have to
\ndate been the hallmarks of Healthy Chi-
\ncago efforts are strongly complemented by a
\nchanging role in technology.There are many
\nways LPHAs can use technology to support
\npublic health\u2019s mission. In Chicago, leader-
\nship has facilitated communication with the
\npublic through increased transparency and
\nliberating data through the Internet. This
\nliberated data, commonly known as online
\nopen data portals, provides an opportunity
\nfor CDPH to collaborate with nonprofits
\nand civic volunteers to not only make sense
\nof the data, but also to make it useful. And
\nas Internet usage moves more towards mo-
\nbile and smartphone use,opportunities arise
\nto reach a wider audience. With increased
\nmobile usage,a demand for useful health re-
\nlated applications usually follows. Support-
\ning all of these technological innovations is
\nCDPH\u2019s social media strategy. All of these
\nadvancements in information technology
\nand social networking are used to drive our
\nHealthy Chicago agenda.
\nSocial Media
\nIn public health, offline strategies are used
\nto support online strategies and vice versa.
\nChoosing the channel on which a LPHA
\nshould operate depends on where resi-
\ndents are having their conversations. For
\nCDPH, Twitter (https:\/\/twitter.com\/Chi-
\nPublicHealth) and Facebook (https:\/\/www.
\nfacebook.com\/ChicagoPublicHealth) are the
\ntwo most frequently used social media
\nchannels. CDPH\u2019s social media strategy
\ndoes not exist to replace other communica-
\ntion channels. Rather, CDPH\u2019s social me-
\ndia channels complement and support all
\nof the communication channels. CDPH\u2019s
\nsocial media channels are supportive of the
\nDepartment\u2019s website, which serves as the
\ninformation hub. Social media employs
\ntwo-way symmetric conversations as well
\nas one-way symmetric conversations[6]. To
\nobtain resident feedback on initiatives is a
\ngreat opportunity to either confirm strate-
\ngies are on target or possibly modify an
\napproach. Sometimes, CDPH will engage
\nwith residents that may never have inter-
\nacted with the department before on social
\nmedia, thus increasing trust and comfort
\nlevel to interact with CDPH, which is es-
\npecially important with vulnerable popula-
\ntions. Social media channels also serve to
\nframe messages so that all residents easily
\ncomprehend them.
\nSocial media performance metrics are
\ncalculated to guide goals and objectives
\nto ensure that they are in line with the
\nHealthy Chicago agenda. They also help
\ngive CDPH a glimpse into who the influ-
\nencers, key opinion and knowledge leaders
\nare, as well as ongoing health conversations
\nin general, through hashtag analysis. Tap-
\nping into these social media resources aids
\nin building and solidifying necessary part-
\nnerships within CDPH\u2019s Healthy Chicago
\nagenda.
\nData Portal
\nThe City of Chicago has established an
\nopen data portal for many reasons, includ-
\ning for increased government transparency.
\nThe data portal has provided an abundance
\nof information to the public, such as the
\nlocations of condom distribution centers,
\nclinics and immunization sites; food in-
\nspection results; and birth, death, and dis-
\nease data (https:\/\/data.cityofchicago.org). Not
\nonly does making this data readily available
\nto the public help to facilitate positive rela-
\ntionships with residents, it has also freed up
\nlimited resources by reducing the number of
\ndata requests.
\nApplications
\nA unique opportunity also arises by mak-
\ning data readily available \u2013 application de-
\nvelopment thrives. Civic programmers lend
\ntheir unique talents by taking open data and
\nvisualizing complex data sets into applica-
\ntions they develop, usually through web
\napplications. The concentration of applica-
\ntion development lies in using HTML5 ap-
\nplications that removes barriers of needing
\nunique iOS or Android coding skills and
\nisolating groups of people that may or may
\nnot be on either of these platforms. The ef-
\nfect is to reach a wider population, which
\nachieves almost universal access when no
\noperating system is favored over another.
\nThe Chicago Flu Shot App (http:\/\/www.
\ncityofchicago.org\/city\/en\/depts\/cdph\/iframe\/
\nscc_app.html) and Back to School Immuni-
\nzation App (http:\/\/backtoschool.cdphapps.org)
\nare examples. Vaccination locations, which
\nare listed in the data portal, were format-
\nted onto a map with an address finder that
\nfinds nearby vaccination clinics or mobile
\nimmunization vehicles based on a resident\u2019s
\nlocation.These maps can be used on smart-
\nphones or on computers making vaccination
\nlocations easier to find. Ultimately, applica-
\ntions like these make information relevant
\nto the user. Removing barriers to adoption
\nof technology is also accomplished since
\nthese types of web applications do not need
\nto be downloaded. The only requirement to
\nuse the application is the entry of the URL
\ninto any web browser.
\nWhen LPHA utilize apps such as these,
\npublic health work can be performed with
\nUNITED STATES OF AMERICAPublic Health
\n141
\ngreater efficiency despite diminished re-
\nsources. By working with civic program-
\nmers,relationships are forged with residents
\nthat volunteer their own skills for the great-
\ner good of their communities, thus, building
\nstronger relationships with the communi-
\nties overall.
\nThe CDPH found that many residents are
\ntweeting about their food poisoning symp-
\ntoms and restaurant experiences on Twitter.
\nHowever, most food poisoning cases go un-
\nreported, and most times, it is because resi-
\ndents do not know that they can report this
\nto the city. The Smart Chicago Collabora-
\ntive, in partnership with local civic develop-
\ners and the Chicago Department of Public
\nHealth, launched Foodborne Chicago, an
\ninnovative application that scans Twitter
\nfor mentions of food poisoning in Chicago
\n(http:\/\/foodbornechicago.org).
\nThis web app enabled CDPH to connect
\nwith Chicago residents on Twitter through
\n@foodbornechi and encourage them to re-
\nport details of their food poisoning to the
\nCDPH Food Protection Division. Resi-
\ndents also get to see the inspection results
\nof their report through an online service
\ncalled 311 Service Tracker Chicago. In or-
\nder to determine if a tweet is relevant to
\n\u201cfood poisoning,\u201d the web app has to clas-
\nsify tweets by sifting through Chicago\u2019s
\n50,000 tweets\/day as relevant or noise.
\nThis classification is done via machine
\nlearning. In this process, a mathematical,
\nnatural language model was built using
\nexisting tweets and human classifiers to
\nlearn which tweets may be food poisoning
\nincidents.
\nFoodBorneChi has the capability of serv-
\ning as a sentinel for outbreaks. As the app
\ngets smarter, it presents Tweets that are
\nmore likely to be food poisoning cases,
\nincreasing the chance of reporting by af-
\nfected residents. If the app shows one loca-
\ntion generating several complaints, a faster
\ninvestigation response can prevent more
\npeople from being affected.This \u201creal-time\u201d
\ndigital syndromic surveillance comple-
\nments traditional methods of public health
\nsurveillance and in the future, may be ap-
\nplied to increase response times to natural
\ndisasters and flu outbreaks.
\nBig Data
\nBig data is a large and complex collec-
\ntion of data, that when presented without
\nany visualization or within a stand-alone
\nspreadsheet, makes little sense. CDPH,
\nalong with several informatics research-
\ners, collaborated to make sense out of de-
\nidentified electronic health record data of
\none million Chicagoan inpatient and out-
\npatient visits from 2006 through 2011.This
\nserves to provide information regarding
\nresident health and illness events, behaviors
\nand disparities.
\nA website was created, Chicago Health At-
\nlas, that brings together many data sets to
\nmake sense of diseases and healthcare de-
\nlivery within the city as well as within the
\n77 neighborhoods in Chicago. Included
\nin the data are demographics, vital signs,
\nencounter types, diagnoses, medications
\nand lab tests (http:\/\/www.chicagohealthat-
\nlas.org). The result is a website that can be
\nused to see prevalence of specific diseases,
\nhealth trends and outcomes within differ-
\nent neighborhoods and can provide focus in
\nimproving the public\u2019s health.
\nConclusion
\nBy providing a focus for local public health
\nefforts,theHealthyChicagoagendahaspro-
\nvided CDPH the opportunity to maximize
\nthe use of limited resources, strengthen its
\nuse of policy development as a public health
\ntool, and establish a significant network of
\npartners who share the Department\u2019s public
\nhealth mission. CDPH\u2019s adoption of new
\ntechnology has not only served to promote
\nthe work of Chicago\u2019s public health com-
\nmunity and Healthy Chicago, it has in it-
\nself, provided a new means to efficiently
\naddress a wide-ranging number of public
\nhealth goals. Further, the adoption of new
\ntechnology created new partnerships and
\nstrengthened existing partnerships within
\nthe technology community.
\nThe changing political and economic cli-
\nmate requires all LPHAs to focus on core
\npublic health issues and to do so in ways
\nthat have significant results. LPHAs cannot
\nsinglehandedly create healthy communi-
\nties, nor can they rely solely on traditional
\ninterventions. Innovative efforts through
\npartnerships, policy, and technology can
\nprovide significant and sustainable impact
\nwith fewer resources. LPHAs must develop,
\npilot,and share new interventions with oth-
\ners as we work to keep our communities
\nhealthy.
\nReferences
\n1. NACCHO. (2011). 2010 National Profile of
\nLocal Health Departments. Accessed at http:\/\/
\nwww.naccho.org\/topics\/infrastructure\/profile\/
\nresources\/2010report\/upload\/2010_Profile_
\nmain_report-web.pdf
\n2. Institute of Medicine. (1988). The Future of
\nPublic Health. Washington, DC: National
\nAcademies Press.
\n3. National Association of County and City Health
\nOfficials. (2012). Research Brief: Local Health
\nDepartment Job Losses and Program Cuts:
\nFindings from the January 2012 Survey.Accessed
\nat http:\/\/www.naccho.org\/topics\/infrastructure
\n\/lhdbudget\/index.cfm
\n4. Ibid.
\n5. Chicago Department of Public Health. (2011).
\nHealthy Chicago: Transforming the Health of
\nOur City. Accessed at http:\/\/www.cityofchicago.
\norg\/content\/dam\/city\/depts\/cdph\/ CDPH\/ Public
\nHlthAgenda2011.pdf
\n6. Grunig, L. A., Grunig, J. E., & Dozier, D. M.
\n(2002). Excellent Public Relations and Effective
\nOrganizations. New York: Routlage Taylor and
\nFrancis Group.
\nJanis Sayer, MSW;
\nRaed Mansour, MS;
\nErica Salem, MPH;
\nBechara Choucair, MD
\nChicago Department of Public Health,
\nE-mail: Bechara.Choucair@cityofchicago.org
\nPublic HealthUNITED STATES OF AMERICA
\n142
\nWMA news UNITED STATES OF AMERICA
\nArdis Dee Hoven, M.D., an internal medi-
\ncine and infectious disease specialist from
\nLexington, Ky., became the 168th
\npresi-
\ndent of the American Medical Association
\n(AMA) on June 18, 2013. In her inaugural
\naddress, Dr. Hoven emphasized the tre-
\nmendous power physicians have to change
\nthe course of history. (Watch or read the
\nentire address (http:\/\/www.ama-assn.org\/
\nama\/pub\/news\/speeches\/2013-06-18-hoven-
\ninaugural-address.page)
\n\u201cThe collective voice\u2013the voice of America\u2019s
\nphysicians,\u201d Dr. Hoven said, \u201chas the power
\nto make a difference.\u201d
\nReflecting upon her decades of inspirational
\nefforts to improve access to care for the un-
\ninsured and advance care for patients with
\nHIV\/AIDS, Dr. Hoven pointed to the op-
\nportunity presented to physicians as they live
\nthrough a time of unprecedented change.
\n\u201cI say we are lucky,\u201d she told the assem-
\nbly. \u201cBecause the great thing about living
\nthrough history is we don\u2019t have to just wit-
\nness it. We can shape it.\u201d
\nShe called on physicians to face today\u2019s
\nchallenges head on. By working together,
\nshe said,physicians can make strides in such
\nareas as combating the nation\u2019s epidemic of
\nchronic diseases, fostering innovation in
\nmedical education and creating a practice
\nenvironment in which physicians can thrive.
\nReminding physicians of the century and a
\nhalf of history in which organized medicine
\nhas won resounding victories for the health
\nof the nation, Dr. Hoven encouraged phy-
\nsicians to stand together and leverage the
\npower of organized medicine. \u201cToday we
\nstand at a crossroads in the history of health
\ncare in this great nation,\u201d she said. \u201cLet\u2019s
\nnever forget the future of American health
\ncare is in our hands.\u201d
\nDr. Hoven has been a member of the
\nAMA Board of Trustees since 2005, serv-
\ning as its secretary for 2008\u20132009, chair for
\n2010\u20132011 and immediate past chair for
\n2011\u20132012. Dr. Hoven is the third female
\npresident in the organization\u2019s history.
\nPrior to her election to the board, Dr.
\nHoven served as a member and chair of the
\nAMA Council on Medical Service. She was
\na member of the Utilization Review and
\nAccreditation Commission for six years
\nand served on its executive committee. Ad-
\nditional activities have included service on
\nthe AMA Foundation board of directors,
\nthe Group Practice Advisory Council of the
\nAMA and an appointment to the Practic-
\ning Physicians Advisory Commission. Cur-
\nrently Dr. Hoven serves as the AMA repre-
\nsentative on the Board of Directors of the
\nNational Quality Forum and the Quality
\nAlliance Steering Committee.
\nDr. Hoven\u2019s involvement at the state level in
\nKentucky has been extensive.She was presi-
\ndent of the Kentucky Medical Association
\nfrom 1993 to 1994 and served as a delegate
\nto the AMA from Kentucky prior to her
\nelection to the AMA Board of Trustees.She
\nhas also been actively involved in medical
\nstaff issues at her local hospital where she
\nhas held a variety of positions including
\npresident of the medical staff, member of
\nthe board of directors and president of the
\nhospital foundation board.
\nBorn in Cincinnati, Ohio, Dr. Hoven re-
\nceived her undergraduate degree in micro-
\nbiology and then her medical degree from
\nthe University of Kentucky, Lexington. She
\ncompleted her internal medicine and infec-
\ntious disease training at the University of
\nNorth Carolina, Chapel Hill.
\nBoard-certified in internal medicine and
\ninfectious disease, Dr. Hoven is a fellow of
\nthe American College of Physicians and
\nthe Infectious Disease Society of America.
\nShe has been the recipient of many awards,
\nincluding the University of Kentucky Col-
\nlege of Medicine Distinguished Alumnus
\nAward and the Kentucky Medical Asso-
\nciation Distinguished Service Award. In
\n2013 Dr. Hoven was named one of Modern
\nHealthcare Magazine\u2019s Top 25 Women in
\nHealthcare.
\nAmerican Medical Association Inaugurates New President
\nCecil Wilson, MD, WMA President; Ardis D. Hoven, MD, AMA\u00a0President;
\nOtmar Kloiber, MD, WMA Secretary General
\n143
\nRegional and NMA newsCOLOMBIA
\nAs a result of the campaign in the year
\n1938 the Colombian Medical Federation
\n(FMC) managed to establish the Min-
\nistry of Hygiene, actually the Ministry
\nof Health. In the same year it also par-
\nticipated in setting up the Committee for
\nPharmaceutical Specialities and Medical
\nBoard which resulted in the emergence
\nof medical specialities and the Colom-
\nbian Association of Scientific Societies
\n(ACSC).
\nAct 90 of 1946 stipulated the establish-
\nment of compulsory social insurance and
\nin 1948 the Colombian Institute of Social
\nInsurance (ICSS) was founded. The Insti-
\ntute started as a private facility to insure
\nworkers in the private sector receiving
\ncontributions to the following amount
\n\u2013 50% from employers, 25% from work-
\ners and 25% from the State. Workers in
\nthe public sector covered by the social
\nwelfare were excluded, so that all social
\nbenefits to the employees and workers of
\nthe private sector equalled the compul-
\nsory social insurance through the ICSS
\nand the public benefits of the sector were
\nin charge of the National Fund of Social
\nWelfare \u2013 CAJANAL \u2013 and the depart-
\nmental and municipal funds. To embrace
\nall health services, there were included
\nhospitals receiving contributions from the
\nnational Government for the operations
\nperformed and caring for the unemployed
\nor low income people by means that was
\nknown as subsidy to clinics, private or
\nreligious or civil organizations, receiving
\nparticular patients or offering services to
\npeople of high income not covered by
\nother systems.
\nIn 1973 by Decree No 1935 the Govern-
\nment unilaterally changed the economic
\nframework of the ICSS and forgave the
\ndebt that had since then started, but it re-
\ntained all its power of management and
\nadministrative control. In 1977 Decree No
\n1650 was passed stipulating reorganization
\nof the ICSS and the establishment of the
\nISS \u2013 Instituto de Seguros.
\nUntil 1990 health care in Colombia was
\nunder a completely vertical framework of
\nthe National Health System, supervised
\nby the Ministry of Health that developed
\npolicies and concentrated most of the re-
\nsources. The four-tier system consisted of
\nthe national level represented by the Min-
\nistry of Health and the supervised estab-
\nlishments and decentralized institutions;
\nthe sectional level, embracing 33 sectional
\nhealth services working under the direc-
\ntion of Head of Health Services and a
\nsectional meeting that operated in each
\ncapital of the Departments and techni-
\ncally depended on the Ministry of Health;
\nthe regional level comprised 107 regional
\nunits and generally followed the directions
\nof the level II regional hospital; and the
\nfourth level consisting of local units and
\nfunctioning under the jurisdiction of the
\nmunicipalities and level I care, without in-
\nvolvement in the decision making of the
\nrespective municipality on health care is-
\nsues.
\nHealth care was based on a model of
\nprogressive complexity according to the
\ntechnical and scientific capacity of level I
\nor the primary level, offering basic health
\nservices of first aid, emergency, general
\ndental medical care and sanitation; institu-
\ntions offering this care level were the local
\nhospitals and and health posts and cen-
\ntres; level II or the secondary level, having
\ngreater technical and scientific possibilities
\nat its disposal and including level I, offered
\noutpatient and hospital care in the basic
\nmedical fields: Internal Medicine, Gen-
\neral Surgery, Paediatrics, Gynaecology and
\nObstetrics, Surgery and Anaesthesiology
\ndivision as well; level III or the tertiary
\nlevel included the activities of the two
\nlower levels, as well as hospitalization and
\ndifferent specialities and medical subspe-
\ncialties with high complexity diagnostic
\nand therapeutic procedures in a clinical
\nlaboratory, diagnostic imaging, endoscopy,
\nmedical and pathological anatomy; much
\nof it served as a basis for higher medical
\neducation.
\nSocial security establishments, such as
\nthe ISS, funds of compensation, etc., and
\nthe private sector functioned within the
\nframework of the national system, even
\nthough they had autonomy in their in-
\nternal organization. This system, known
\nas subsidy to the offer, implied that all
\nthe entities from the public sector as well
\nas foundations and private institutions
\nthat provided health care and who had
\ncontracts or agreements with the State
\nto serve low income people, received re-
\nsources, requested by these entities at the
\nend of the year, from the annual budget.
\nThe Central Government assessed the
\ncosts and coverage for the following pe-
\nriod and the execution depended on the
\nincome of the nation and was included
\nin its annual budget. In many cases this
\nsystem resulted in hospitals receiving
\nresources not for their performance, but
\nModel of Colombian Social Security in Health
\nCesar Prieto Avila
\n144
\nCOLOMBIARegional and NMA news
\ndue to their political orientation or the
\ndirectors\u2019 capacity of reaching the deci-
\nsion-making level at the head of the De-
\npartment of Health Care or the Ministry
\nof Health.
\nThere were three sectors in health care.The
\nfirst was Social Security represented on the
\none hand by a monopoly for the private
\nsector: ICSS that covered only workers
\nbut, at the end of the 1970\u2019s, included the
\nfamily medicine program and the Com-
\npensation Family Funds, representing the
\nfamilies of workers in the private sector
\nand on the other hand there was a system
\nof public welfare for the workers and em-
\nployees in the public sector, with the Na-
\ntional Fund (CAJANAL) for the sector
\nand the majority of entities created its own
\nwelfare system, e.g. such institutions as the
\nCongress, Ecopetrol, workers of ports, rail-
\nways, public universities, etc., as well as the
\narmed forces and at the departmental and
\nlocal levels established funds for medical
\nemployees. Each entity had its governing
\nbodies and their boards of Directors had
\nrepresentation in the national Govern-
\nment.
\nThe second sector was that of welfare re-
\nsponsible of care for the population without
\naffiliation to social security or welfare funds.
\nThe service network was formed by 906
\nhospitals, 3705 centres and health posts and
\nsome foundations receiving official contri-
\nbutions. It was supervised by the Ministry
\nof Health and addressed issues at national
\nlevel, while the sectional level was in charge
\nof the Departments and the local level \u2013 of
\nmunicipalities.
\nThe third sector was private embracing pre-
\npaid medical entities, insurance companies
\nand institutions and professional groups
\noffering health services under the prepay-
\nment of fees or by direct payment as pri-
\nvate entities, but under the surveillance and
\ncontrol of the Ministry of Health through
\nthe National Superintendence of Health, a
\nsemi-centralized entity.
\nAt that time according to the data released
\nby the Ministry of Health 34% of the popu-
\nlation were not covered by any health sys-
\ntem, i.e. the system-wide coverage was 66%
\nof the Colombians.
\nAct 10 of 1990 reorganized the national
\nhealth system, establishing that \u201c…the pro-
\nvision of the health services, at all levels, is
\na public service in charge of the nation, free
\nbasic services for all inhabitants managed in
\npartnership with local authorities and local-
\nly decentralized…\u201d. Moreover, it provided
\nthat \u201c…the National Health System con-
\nsists both of the entity set public and pri-
\nvate health sector, as well as, in the relevant
\ninstitutions of other sectors that influence
\nhealth risk factors…\u201d
\nThis law reassigned the responsibility for
\nthe provision of health services, it fractured
\nthe vertical frame, made it more horizontal
\nby totally decentralizing it, thus:
\n\u2022 the municipalities were to provide the di-
\nrection and provisions of health services
\nat the primary care level that included lo-
\ncal hospitals, centres and health posts;
\n\u2022 the Departments were to provide the di-
\nrection and delivery of health services at
\nthe second and third levels of care that
\nincluded regional, specialized and univer-
\nsity hospitals.
\nThe responsibility of the managing bod-
\nies was transferred to the regional and lo-
\ncal levels \u2013 the respective Governor, each
\nDepartment or Mayor of each municipal-
\nity, through their respective Secretaries of
\nHealth, as the search for resources at the
\nlocal level, reordered the offer of services to
\ndecentralize the competences to the munic-
\nipalities and Departments.The only institu-
\ntion remaining at the Central level was the
\nNational Cancer Institute.
\nSocial State Enterprises (ESE)
\nThe enactment of Act 10 of 1990 intro-
\nduced structural, more radical transforma-
\ntion in the Law of Public Health, concern-
\ning both the Health Promoting Companies
\n(EPS), lnstituto de Seguros Sociales (ISS),
\nCaja Nacional de Prevision Social (Cajanal),
\nthe Fund of Social Welfare of the Ministry
\nof Communications \u2013 Caprecom \u2013 etc., the
\ninstitutions, health providers \u2013 IPS, and all
\nthe network hospitals. The Law provided
\nprovisions for receiving resources drawn
\nfrom the State: located Prosecutor, ceded
\nincome, transfers, etc., to all territorial en-
\ntities to carry out the institutional trans-
\nformations necessary for the provision of
\nhealth services as stipulated in Article 6 of
\nthis Law and, in particular, providing legal
\nstatus and an administrative structure of
\nhealth units.
\nAct 60 of 1993 already carried out the
\nconstitutional reform of 1991, Social State
\nEnterprises (ESE) were established which
\nwas a \u201cspecial category of public entity, de-
\ncentralized, with legal personality, its own
\npatrimony and administrative autonomy,
\ncreated and organized by law or by the de-
\npartmental assemblies and municipal coun-
\ncils\u201d.The objective of that \u201cwill be the provi-
\nsion of health services, understood as public
\nservice by the State and as an integral part
\nof the General Social security health sys-
\ntem\u201d.
\nThis situation, caused by the major system
\nchange as it was suspension of the subsidy
\noffer to transform it into a demand subsidy,
\ncreated not only problems for the Colom-
\nbian population to create the provision of
\nsubsidized health but the financial difficulty
\nand the collapse in the provision of the
\nhealth services in public hospitals.
\nSummary of the effect of this legislation:
\nAct 10\/ 1990 and Act 60\/ 1993 and its
\nregulatory decrees requiring administra-
\ntive processes and billing services to public
\nentities without training, without technol-
\nogy, without accompaniment that very few
\ncould meet, producing the greatest crisis of
\nthe system of institutions providing health
\nservices,providing system-wide entities pri-
\n145
\nCOLOMBIA Regional and NMA news
\nvate technology on silver tray-staff trained,
\nwithout labour or performance loads the
\nnew methods of recruitment of human tal-
\nent, etc. that public institutions could not
\nprovide.
\nThe most dire consequence of the reform of
\nthe system for involvement in the econo-
\nmies of scale of the neoliberal thought,
\n\u201ctuning of the central power\u201d, was the
\nloss of financial support from the State\u2019s
\nhospitals and the obligation to all public
\nentities to have health care programs, re-
\ntain a high percentage of their income for
\nself-management without information and
\nregistration systems, no studies of costs,
\nwithout training administrative personnel,
\ninvoicing, marketing etc., but with high la-
\nbour costs and pension loads, low budgets
\nfor the maintenance of buildings for many
\nyears,all circumstances that made the public
\nentities to remain with a minimum option
\nto compete with the private Institutions
\nProviders of Services (IPS) for the sale of
\nhealth services, led to complete financial
\ncrisis in hospitals, to have a minimum per-
\ncentage of the total of the hiring by private
\nEPS, which implemented the construction
\nand adaptation of its own clinics IPS and
\nwith legalistic manoeuvres achieved vertical
\nintegration by means of which hire private
\nEPS with their own IPS insurers and round
\noff the business.
\nAs coup de grace there was the rancid neo-
\nliberal strain of the 1991 Constitutional Re-
\nform that by approving two articles allowed
\nthe health system, called the General Sys-
\ntem of Social Security in Health (SGSSS),
\nlead the country to the brink of collapse in
\nthe social area: Article 480 deprived the
\nColombians the right to health as a FUN-
\nDAMENTAL right and an INDIVIDU-
\nAL right and transformed it into the right
\nto buy health care according to the capacity
\nof payment and Article 49 suppressed the
\nState of its obligation to be responsible for
\nthe public health, words that do not appear
\nin the constitutional text as there is only the
\nterm \u201csanitation\u201d.
\nLAW 100 of 1993
\nOn the basis of the Constitutional reform,
\nin 1993 Law 100 was passed establishing
\nthe General Social Security System, con-
\nsisting of three branches: health, pensions
\nand occupational hazards but, in a deci-
\nsion completely harmful to the majority of
\nColombians and transcendental, delivered
\nthe management of these branches to indi-
\nviduals, national and multinational private
\ncapital.
\nHealth developed the mandatory Plan
\nof Health (POS) according to which all
\nColombians had to be affiliated to the
\nhealth system. But what we have seen is
\nthat it is taking the country to a crisis in
\nhealth care, into bankruptcy and closure
\nof many hospitals in the network, to the
\ndisappearance of all public Social Security
\nhealth care entities, income earned from
\nthe provision of the health service to the
\neconomy of scale, the law of supply and
\ndemand but, the most disastrous, to cir-
\ncumvent the surveillance and control of
\nthe system and accountability by the State
\nfor public health.
\nThere were established the National Coun-
\ncil of Social Security in Health (CNSSS)
\nwith the power of advisory entity, unless
\nits decisions were enforced by the Govern-
\nment, which was under the \u201cdictates\u201d of
\nthe compulsory National Health Plan and
\nsome Territorial Councils of Social Security
\nin Health (CTSSS) for Departments with
\nmuch less decision-making role; on the oth-
\ner hand the National Superintendence of
\nHealth in a single office in Bogota, without
\nregional delegations and without legal or
\nlogistical tools to exercise their theoretical
\nrole of surveillance and control, especially
\nfor the EPS, and private IPS was central-
\nized.
\nAll the public EPS ceased to exist and final-
\nly there was the liquidation of the ISS, the
\nonly insurance company that regulated the
\nentire system to introduce, now yes, \u201cwild
\ncapitalism\u201din terms of Social Security in our
\ncountry.
\nIt developed the process in three different
\nregimens:
\n\u2022 contributory \u2013 for persons with the ability
\nto pay the entities to join public and pri-
\nvate insurance companies that are called
\nProviders of Health (EPS);
\n\u2022 subsidized \u2013 for the population of strata
\n0 and I without the ability to pay that
\ntheoretically would receive a subsidy
\nfrom the State; surrendered the adminis-
\ntration and management institutions to
\npublic and private managers subsidized
\nregime ARS. By Law 1122 of 2007 the
\nname was changed to the regime subsi-
\ndized EPS-S, but with the same vices of
\nthe ARS;
\n\u2022 customs-related or UBN (unsatisfied ba-
\nsic needs) \u2013 for the population in poverty
\nand misery that even do not have access
\nto the subsidy, until then it could access
\na subsidy, a term absurd as it is an impor-
\ntant part of the population not affiliated
\nto anything.
\nWhat is even worse that the process en-
\nvisaged three types of patients and three
\nmedicines: the contributory regime had
\nfree choice of doctors and clinics, no more
\nproblem of access to specialized medicine
\nand technology and the best hotel service
\nin private clinics. Those of the subsidized
\nregime had all kinds of geographic barri-
\ners to access the same benefits, less lim-
\nited by the attention on the part of auxil-
\niary staff or basic drugs that could only be
\nthose listed in an arbitrary manner in the
\n\u201cVademecum of the POS\u201d and concern-
\ning those whom no one wanted to attend
\nas there was no answer who should do it,
\nturning attention to hospitals in the net-
\nwork that had hired the care for patients
\nof the subsidized regime, but to attend the
\nrelated tort-produced \u201cbilling surplus\u201d that
\nthe State did not recognize, and paying less
\nleading to deepening of the financial crisis
\nand putting at risk the survival of public
\nhospitals.
\n146
\nCOLOMBIA
\nAnother fundamental aspect that must be
\nanalyzed concerns drugs in general, but
\nespecially generic drugs in Colombia, and
\nthere is a very serious problem of market-
\ning and the POS drug supply and the situ-
\nation posed by the recovery by the EPS and
\nthe risk of the shot cost for patients after
\nsigning of the terrible FTA with the Unit-
\ned States and with the European Union
\nthat is even more harmful than that of the
\nUSA.
\nFigures for the recovery of drugs not in
\nPOS of the EPS to the Fosyga spent $58
\nbillion pesos in 2003 rose to 628 billion in
\n2007, according to these, 507 billion corre-
\nspond to the contributory scheme; for the
\nclosing of the year 2008 the forecast was
\nthat recovery via guardianship and the tech-
\nnical-scientific committees of the EPS, the
\nfigure would reach $ 1 billion 139 million
\npesos, these data mean that in two years,
\nby the year 2010, all the Fosyga and health
\nsystem resources would not be enough to
\npay for medicines not POS regains. One
\nof the causes of morbidity and mortality in
\nthe country, more than the epidemiological
\ntransition,a profile of structural heterogene-
\nity predominate while the diseases of pover-
\nty are unequally combined with the diseases
\nof development, and in which the expres-
\nsion of the inequities of social and health
\ncare that have characterized the Colombian
\nHealth System for long is very strong. The
\ntopical problems of today are high and early
\ndeaths homicides and violence, though pre-
\ndominantly affecting young males,begins to
\nappear more strongly in other age groups;
\nthe persistence of inequalities between re-
\ngions, between urban and rural areas and
\ngenders; the deterioration in the living con-
\nditions has deepened in recent years and the
\nhigh vulnerability of young people, women
\nand rural inhabitants.
\nThis latest health reform in Colombia in
\nthe 1990s failed to overcome the chronic
\ninequalities and exclusions from the Co-
\nlombian Health System. Executed in the
\nperiod of transition, the universality in the
\nassurance and approval of benefits plans
\nare promises unfulfilled and impossible
\nto realize in the midst of policy adjust-
\nment, co-modification of health services,
\nand deepening of the neo-liberal social
\npolicies. A big question is posed which has
\nproven to be the main achievement of Law
\n100\/93, what was the assurance of the poor
\npeople as the official figures show that for
\nthe year 2006, 56% and 63% of the popula-
\ntion of deciles 1 and 2 respectively, was not
\ninsured, the total coverage of the health
\nsystem in that same year was 64%; but as
\nregards the alleged coverage of the sub-
\nsidized regime another fallacy was used,
\ncalled \u201cpartial subsidies\u201d which were those
\nvertical subsidies given to a person who did
\nnot have coverage in case of disease, as they
\ncalled them traders of \u201chigh-cost\u201d health
\n(cancer, AIDS, heart problems that re-
\nquire procedures of high complexity, etc.)
\nonly for that person and for the respective
\nmedical problem, implying support at any
\ntime to the same person for other health
\nproblems that appear and less for the other
\nmembers of the family. These subsidies
\nadded, they inflate the number of patients
\nallegedly \u201ccovered by the system\u201d.
\nToday the population, especially the poor-
\nest, spends more on health and the subsi-
\ndized regime affiliates receive from the plan
\nof benefits 30% fewer services than the con-
\ntributory scheme. For the population not
\ninsured, \u201clinked\u201d, inequities are larger, and
\nthe poor becoming poorer have decreased
\nthe use of services and those who have most
\nincreased spending in health care have fewer
\nopportunities and the levels of poverty and
\nmisery have expanded dramatically and the
\nsocial gap between them and the rich in-
\ncreases; increase in absolute numbers reveals
\nthat more than 50% of the Colombians are
\nout of the health system in the 15 years of
\nimplementation of Law 100 of 1993 and its
\nregulatory decrees.
\nComprehensive addressing of the transfor-
\nmation of the health situation of the coun-
\ntry requires acting in double perspective,
\nthe construction of a model of alternative
\ndevelopment and, in this context, a new
\nsystem of health, both aimed at resizing
\nthe social policy and equity, placing them,
\ninstead of economic growth, as the axes of
\nthe development agenda. Equity and social
\npolicy understood as equality of opportu-
\nnity for all and the guarantee of universal
\nrights, to deploy capabilities and individual
\nfreedoms that materialize the plural proj-
\nects of good life of human groups, and not
\nas welfare, residual and subsidiary actions,
\neconomic growth and financial sustainabil-
\nity criterion.
\nThe results of the current health system,
\nbased on the cumulative evidence of the
\npoor health situation of the population with
\na high percentage of Colombians that never
\nout of it, the inequalities between regions
\nof the country, the collapse of the hospital
\nnetwork, the decrease in the coverage of the
\nsystem, the resurgence of priority of health
\nproblems increased and all this in the midst
\nof increase of progressive resources both
\npublic and private. The system caused cri-
\nsis due to structural reasons and not imple-
\nmentation because it was built based on
\ninequalities and therefore is self-destructive.
\nNumerous studies revealing the crisis of the
\ngeneral system in all aspects, including the
\nmost critical, its inability to respond de-
\ncently and humanely to the needs of citi-
\nzens in health or, perhaps better, its great
\ncapacity for nugatory rights, even to the
\nservices specified in the compulsory Health
\nPlan have been published in the \u2018private\u2019
\ncontract that supposedly governs the rela-
\ntionship between the citizens and the insur-
\nance companies in the contributory scheme,
\nor between the State and the corresponding
\nEPS in the subsidized regime.
\nThe same studies that confirm the growth
\nof spending on health as a result of the Ref-
\normation (National Health Accounts) show
\nthat spending grew only between 1993 and
\n1997 and then declined steadily until the
\nyear 2003. Health expenditure increased
\nRegional and NMA news
\n147
\nfrom 6.2% to 9.6% of the GDP between
\n1993 and 1997 and fell from the 9.6% to
\n7.8 % between 1997 and 2003. It also shows
\nan increase of the expenditure per capita of
\n257 thousand pesos in 1993 to 403 thou-
\nsand in 1997 and a fall to 320 thousand pe-
\nsos in 2003.In addition,the expenditure per
\ncapita grew significantly in the population
\ncovered by the contributory scheme and did
\nnot grow for the poor population.
\nIt also shows increase of specific care spend-
\ning of 10.6% between 1993 and 2003 (less
\nthan the population growth in the same
\nperiod), and reveals a fall of per capita ex-
\npenditure in the resources actually allocated
\nto health care. This is the worst outcome to
\ndemonstrate a reform. Moreover, the per
\ncapita annual expenditure spent on outpa-
\ntient services fell unceasingly since 1995
\nwhen it reached 178, 000 pesos to 130,000
\nin 2003, and made the situation very seri-
\nous and demonstrated the greatest failure
\nregarding the real access to early diagnosis
\nand treatment needs.
\nIt should be noted at this point that \u201clinked\u201d
\nare not simply \u201cnot insured\u201d as it is claimed
\nin the studies, at least not as it was implied
\nby the National Health System before the
\nyear 1993. Linked are a construction of the
\nsystem, most of which have been excluded
\nintentionally from the benefits of the system
\nby the focus mechanism (Benefits System or
\nSISBEN) At the time when systematically
\nthe hospitals cut their care resources it is
\nlogical to find advantages of affiliates to the
\nsubsidized regime with respect to those who
\nhad been left intentionally at the gates of
\nhealth services. Therefore, we cannot prove
\nthat members of the subsidized regime are
\nwell or much better provided, what happens
\nis that the linked are really excluded, except
\na few exceptions as in the district capital,
\nBogota, and the Valle del Cauca that are
\ninvesting in this group significant resources
\npursuing policies of their own.
\nSummarizing, we can point out that one
\nof the many goals Law 100\/ 1993 was not
\nable to meet and could not meet because
\nthe very structure of the Law was based on
\ninequality and made it self-destructive was
\nthe idealistic \u201cuniversal coverage\u201d according
\nto which there would be health care for all
\nby the year 2000 and then as an electoral
\nstrategy of the current Government which
\nset its deadline in 2005 there was passed the
\nfamous Law 1122\/07 or \u201cAmendments to
\nAct 100\u201dwhich lowered the \u201cuniversal\u201dcov-
\nerage at levels I, II and III of the SISBEN
\nand so spent the highest percentage of the
\nmoney of the health sector to increase that
\ncoverage at the level of municipalities at the
\nexpense of the subsidy to the offer and the
\npossibility of maintaining of level II care
\nhospitals functioning and financially stable
\nto meet their objectives of providing health
\ncare of specialized medicine and advanced
\ntechnology to the most vulnerable part of
\nthe departments for the uninsured poor
\nwhereupon health care moved towards total
\ncollapse.
\nThe official sector has a network of public
\nhospitals monitored by the departments, by
\nthe Ministry of Social Protection, the Na-
\ntional Superintendence of Health; each pri-
\nvate EPS has its own vertically integrated
\nnetwork, adverse selection, the constraint
\nof professional practice, the labour abuse,
\nde-professionalization of medicine and the
\ndelabourization of unregulated by the de-
\npartments health workers not integrated
\nin the surveillance systems, morbidity and
\nmortality committees that are only moni-
\ntored by the National Superintendence of
\nHealth entity that is located in the capital
\nwith a single office and only 100 employees
\nto cover the entire country.
\nFinally, it is necessary to point out that
\nSocial Security is the best way to ensure
\nthe health of Colombians and when ask-
\ning about the current occurrences, it is
\nnot questioning social security, or even
\nthe delegation of public service to private
\nactors, what is in question is the absolute
\nlack of capacity of the system to address
\nand regulate the system, the deviation
\nfrom the objectives of a universal system
\nwith equal benefits plan for all Colombi-
\nans, the vulnerability of the majority of
\nworkers in the country without formal
\nemployment contract, the road taken from
\nthe assistance and the political patronage
\nin the subsidized regime which disclaims
\nemployers and leaves without rights work-
\ners managing many EPS under the two
\nregimes (especially the ownerless), where
\nadministrators steal or simply dispose with
\ntotal irresponsibility of money earmarked
\nfor the health of Colombians and there is
\ndevelopment towards de-professionaliza-
\ntion of medicine and delaborization of the
\nmedical profession.
\nThe everyday positive account of the system
\nis contrary to what happens to the citizens,
\nthe majority of whom do not find a decent
\nand humane response to their health needs
\nin the current operation of the SGSSS.
\nAll this leads us to conclude that if noth-
\ning is done, Colombia will become the only
\ncountry with no public Social Security in
\nwhich all health assurance will remain in
\nprivate hands and where there is private
\nmonopoly in assuring the health of Colom-
\nbians in less than 15 years if implementing
\nthe \u201cColombian model\u201d which is nothing
\nto be proud of because instead of being an
\nadvanced model it is totally regressive from
\nthe social point of view, excellent in finan-
\ncial returns but without meeting any social
\nfunction of equity and universality.
\nCesar Prieto Avila M.D.
\nPresident Colegio Medico del Valle del Cauca
\nVicepresident Federacion Medica Colombiana
\nE-mail: colmedvalle@gmail.com
\nCOLOMBIA Regional and NMA news
\n148
\nMYANMARRegional and NMA news
\nFounded in 1949, MMA is the only pro-
\nfessional organization of qualified medi-
\ncal doctors in the Republic of the Union
\n(ROU) of Myanmar. It is a registered, non-
\npolitical, non-governmental, non-profitable
\norganization and operates with its own
\nbudget, generated from its activities and
\nmembership fees. MMA has its own policy,
\nconstitution, bylaws and regulations.
\nMember Strength of MMA
\nOver 18,000 of 33,000 registered doctors
\nare MMA members, out of which over
\n8,000 doctors are not involved in Public
\nService (non-service personnel); they are
\nmedical practitioners (General Practitio-
\nners) in the community.
\nMMA Offices
\nUnder MMA, 83 medical association offices
\nare located all over the country in major cities
\n(townships and districts) of the states and re-
\ngions, covering nearly the whole population,
\nexcept in a few areas where communications
\nis encumbered, the population density is low
\nand the doctor community is small.
\nThere are 33 clinical and non-clinical spe-
\ncialist societies, and the General Practitio-
\nners (GP) society is the biggest, strongest
\nand most active among the other societies.
\nLeadership
\nOrganization leaders are elected (at all
\nlevels every two years) by democratic vot-
\ning, a system based on meritocracy and all
\nmembers enjoying equal rights. MMA has
\nbeen sharing responsibilities and working
\ntogether for the global aims of philanthropy
\nand altruism with true professionalism.
\nVision
\nMMA vision is to be instrumental in
\npromoting the health of the people by
\nenhancing the professionalism of the
\nmembers and striving to work together,
\nsharing responsibilities and experiences,
\nwith strong commitment towards quality
\nhealth care.
\nMission
\nMMA mission is volunteer spirit on non-
\nprofit basis, democratic leadership, shar-
\ning responsibilities with equity and unity
\namong the members, private-public part-
\nnership approach to other health alliances,
\nworking together for quality healthcare
\nfor all.
\nMain Functions
\n1. Education and Training towards the
\nCME accreditation.
\n2. Clinical and Public Health Research with
\nethical and professional needs and standard.
\n3. Community healthcare including pub-
\nlic health projects, health promotion in-
\ncluding reproductive health.
\n4. Maintain high professional and ethical
\nstandard among the members.
\n5. Collaboration and coordination with
\nmedical societies in the region as well as
\noutside the region.
\n6. Partnership approach to allied medical so-
\ncieties,INGOs,NGOs within the country.
\n7. Encourage and support total capacity
\nbuilding of the association at all levels
\nwith professional aspiration.
\nMyanmar Medical Association (MMA)
\nOn the left, Professor Pe Thet Khin, Minister for Health, receiving the souvenir
\nfrom Professor Kyaw Myint Naing, President of Myanmar Medical Association,
\non the right, at the Inaugural Ceremony of the 59th
\nMyanmar Medical Conference
\n(22\u00a0January\u00a02013) held in Mawlamyaing, the fourth largest city of Myanmar.
\n149
\nGERMANY Medical Research
\nActivities in 2012\u20132013
\n1. Annual Meeting together with Annual
\nAcademic Conference every January. In
\n2013 the 59th
\nConference was held in
\nMawlamyaing, the fourth largest city of
\nthe ROU of Myanmar.
\n2. The 19th
\nSurgeons Conference was held
\nin November 2013 at Mandalay,the third
\nlargest city of the ROU of Myanmar.
\n3. The 10th
\nO&G Conference was held in
\nFebruary 2013 at Yangon, the second
\nlargest city of the ROU of Myanmar.
\n4. The 21st
\nENT Conference was held in
\nJanuary 2013 at Yangon.
\n5. The 21st
\nEye Conference was held in
\nNovember 2012 at Yangon.
\n6. The 14th
\nGeneral Practitioners Scientific
\nConference was held in November 2012
\nat Lashio, Northern Shan State.
\n7. The 9th
\nRehabilitation Medicine Confer-
\nence was held in October 2012 at Yangon.
\n8. The 2nd
\nInternational Pain Seminar was
\norganized by the ROU of Myanmar and
\nwas held in January 2013 at Yangon.
\n9. There are 3 academic projects, and 18
\npublic health related projects funded
\nby various International donor agencies
\nincluding Myanmar Medical Associa-
\ntion itself, covering 80 townships in the
\nROU of Myanmar.
\n10. Support Group for Elderly Doctors
\n(SGED), care about doctors over the
\nage of 70 with sickness support, social
\nvisits, regular medical check-ups, social
\ngatherings, support in cataract opera-
\ntions, and at funeral.
\n11. Lady Doctors Section organized to pay
\nhomage to the elderly doctors residing in
\nYangon every December of the year (the re-
\ncent data: 340 doctors over 75 years of age).
\n12. Emergency Ambulance Service has
\nbeen established and initiated and has
\nan appreciable performance in Yangon
\nby Myanmar Medical Association with
\ncharity support.
\nDr. Khine Soe Win, Executive Director,
\nMyanmar Medical Association
\nIncidental findings and chance findings en-
\ncounter in many areas of medical investiga-
\ntions in diagnosis and research. But due to
\nthe refinement of new technologies in the
\ncontext of medical research they appear
\nmore frequently in modern clinical stud-
\nies and biomedical research projects. In
\ngeneral, the term \u201cincidental finding\u201d can
\nbe considered to refer to an unexpected
\nmedical (clinically uncertain or possibly
\nrelevant) finding, whose presence was not
\npreviously suspected, and which was not
\nspecifically sought for during the research
\nprocedure. Whereas \u201cchance findings\u201c are
\nin fact, fairly probable due to the large scale
\nnature of a specific research process like in
\nmedical genetics. Those findings are not re-
\nally \u201cincidental\u201d [cf. Lanzerath et al 2013].
\nIn particular the introduction of imaging
\ntechniques (e.g. PET, MRT) to investigate
\nfunction and dysfunction of the human
\nbrain produces incidental findings and has
\ninitiated a vital ethical and legal debate on
\nthe question to which extent investigators\u00a0\u2013
\nincluding doctors engaged in research\u00a0 \u2013
\nneed to inform about these kinds of find-
\nings and how they should deal in general
\nwith pathological, or potentially pathologi-
\ncal, findings arising within the context
\nof a research project that are of no direct
\nrelevance to the research question in hand.
\nAlthough data on this subject remain lim-
\nited, empirical studies have shown that in-
\ncidental findings are widespread (up to 8%)
\nwithin brain imaging studies [Morris et al.
\n2009]. At the time of writing, no common
\nguidelines or laws are available to research-
\ners in Europe that regulate this very specific
\nissue of the management of incidental find-
\nings. Only general provision concerning the
\nresearcher-participant-relationships and in
\nparticular those on data protection are ap-
\nplicable here and create a pattern \u201cthat gives
\nrights to data subjects (those to whom the
\npersonal data in question relates) and im-
\nposes duties upon data controllers (those
\nwho control the processing of those data)\u201d
\n[Townend 2013]. Only some professional
\nmedical associations [e.g. GFHEV 2013]
\nor groups of researchers [e.g. Wolf et al.
\n2008 or Heinemann et al. 2013] published
\nspecific proposals and statements concern-
\ning the management of incidental or chance
\nfindings in research.
\nAgainst this background the question arises
\nas to how ethical principles and rules estab-
\nlished over past decades should be speci-
\nfied and supplemented in order to create
\nethically acceptable conditions for medi-
\ncal research. Some even suggest that the
\nnormative obligations between researchers
\nand research subjects on the one hand, and
\ndoctors and patients on the other, must be
\nfundamentally re-evaluated. This view indi-
\ncates that medical ethics and research ethics
\nEthical Principles of the Management
\nof Incidental Findings in Research
\nDirk Lanzerath
\n150
\nMedical Research GERMANY
\ndiffer more widely in the normative sense
\nthan hitherto assumed. Others consider
\nthis appraisal too far-reaching, and assume
\nthat the updating of established medical
\nand research ethics will lead to an adequate
\nsolution [Heinrichs 2013]. Most of those
\ninvolved are, however, in agreement that
\nbinding ethical and legal standards \u2013 e.g.
\nincluded in professional law \u2013 should be es-
\ntablished in order to ensure equal clarity for
\nresearchers and research subjects in terms
\nof the normative auspices under which the
\nrelevant techniques within medical research
\nare applied.
\nInformation, Autonomy,
\nand Knowledge
\nThe management of incidental findings
\ntouches upon certain fundamental ethical
\nprinciples that exert a reciprocal influence
\non each other in both other areas of medical
\ncare and medical research.The most promi-
\nnent of these are the right to informational
\nself-determination, and the associated right
\nof a research subject to receive comprehen-
\nsive information prior to the performance
\nof the study. This latter right includes en-
\ntitlement to an adequate explanation con-
\ncerning the aim of the research, the data to
\nbe gathered, and the techniques to be used
\nin order to ensure that research subjects
\nare in a position to provide informed con-
\nsent. In the sense intended here, however,
\nthis right also includes the entitlement to
\nreceive information regarding the possible
\nconsequences of research participation.
\nThese possible consequences include any in-
\ncidental findings, or indeed chance findings,
\nthat may be detected during analysis of the
\ndata. Thus first and foremost, we may speak
\nof a basic obligation to provide information
\nthat data with this potential are to be gen-
\nerated. However, the question of how com-
\nprehensive this information may and needs
\nto be clarified. For example in the field of
\nwhole genome sequencing many data will
\nbe available even those which cannot be in-
\nterpreted for the moment. But the investi-
\ngator has the duty to explain and to specify
\nwhich kind of data will be analyzed and can
\nor cannot be disclosed to the state of the art.
\nRights pertaining to the principle of the au-
\ntonomy of the research subject include not
\nonly the right to know, but also the right
\nnot to know. No individual may be forced
\nto (want to) know all that can be detected
\nin someone\u2019s brain or discovered about
\nsomeone\u2019s genetic constitution [Oviedo
\nConvention, Council of Europe, Article
\n10]. Although knowledge of this kind may
\nbe of benefit to the individual in terms of
\nlife planning, it may also prove very bur-
\ndensome. For instance, awareness of a par-
\nticular genetic predisposition may be asso-
\nciated with serious disadvantages, and may
\nresult in discrimination or stigmatisation
\nin day-to-day life (e.g. insurance cover, oc-
\ncupational status). Therefore this right not
\nto know has become an established ethical
\nprinciple, which is also reflected by several
\nlegal regulations. However, this should not
\nto be confused with simple ignorance of
\ncertain possibilities; what is meant here is
\nan enlightened desire not to know. If I am
\nthe person who will be affected, then I must
\nknow in advance what I am letting myself
\nin for if I do not wish to gain a particular
\nkind of knowledge. In other words, not
\nwanting to know does not obviate the need
\nfor elucidation; rather the consequences of
\nnot wanting to know must be elucidated in
\nadvance.The decisive point is that this right
\nnecessitates a limitation of elucidation, i.e.
\nit respects the wishes of individuals not to
\nbe so informed.
\nNon-maleficence
\nversus Solidarity
\nTwo further principles are of importance in
\nthe ethical appraisal of strategies for deal-
\ning with incidental findings and of the cri-
\nteriology that is to be elaborated for this
\npurpose. Medical intervention should not
\ncause harm (primum nil nocere). This has
\nbeen developed as a basic ethical principle
\nin medicine initiated already in the Hip-
\npocratic tradition, as even though thera-
\npeutic interventions often result in damage
\nto health, they are necessary to prevent or
\nremedy even greater harm.Clearly the prin-
\nciple of non-maleficence must be applied
\nmore stringently in medical research than
\nin day-to-day medical practice, since heal-
\ning a research subject is not the main pur-
\npose of research,and even healing in general
\nis only one of its aims. Therefore, there is
\nno justification for causing detriment, not
\neven temporarily, such as can and must per-
\ntain to direct curative treatment. Scientific
\nenquiry may only expose research subjects
\nto risks that are not disproportionate to the
\npotential benefits of the research [Oviedo
\nConvention, Council of Europe, Article
\n16]. A common tendency exists among
\nmedical professionals to consider the prin-
\nciple of non-maleficence as being restricted
\nto instances of physical harm. However, the
\nspoken word can also cause considerable
\ndistress, for instance in the course of a con-
\nsultation to explain findings or test results.
\nEvaluation of specific and problematic in-
\ncidental findings arising within a research
\nsetting cannot be evaluated according to
\ncriteria applied within a clearly defined
\ndiagnostic and therapeutic context. The re-
\nlationship that exists between a physician
\nand a patient is typically of a diagnostic\/
\ntherapeutic nature which includes specific
\nlegal implications. In the research context,
\nhowever, the ethical principles of solidar-
\nity and common good must be taken into
\naccount to justify that human subjects will
\nbe involved as research subjects in research
\nprojects. In Anglo-Saxon bioethics, such
\nprinciples are frequently subsumed under
\nthe principle of justice. The performance
\nand success of medical research are by no
\nmeans guaranteed under all circumstances.
\nFirstly, they require enormous amounts of
\nmoney, and secondly they are contingent
\nupon the research being attractive to indi-
\nvidual researchers and scientific institutions,
\nas well as the preparedness of people to act
\nas research subjects. In many cases, these
\n151
\nMedical ResearchGERMANY
\nlatter individuals are healthy volunteers in
\nno need of medical treatment.Although the
\nimprovement of treatments and medicines
\nthrough scientific endeavour may be regard-
\ned as conferring a high degree of social ben-
\nefit, this consideration does not override the
\nethically justified rights of research subjects.
\nIt must also be borne in mind that social
\nbenefits including the increase of knowl-
\nedge do not accrue on the basis of any single
\nstudy \u2013 which may in any case fail to gen-
\nerate significant data \u2013 but rather from the
\nfact that this study is part of a general and
\ninternational body of biomedical research.
\nOn this basis, it may be legitimate \u2013 under
\nappropriate circumstances and with appro-
\npriate deference to the principles of research
\nethics \u2013 to engage healthy volunteers for
\ntesting purposes and expose them to some
\nrisks, if the anticipated benefit cannot oth-
\nerwise be achieved.It is then the task of Re-
\nsearch Ethics Committees to determine, on
\na case to case basis, whether the design and
\nimplementation of a given medical study
\ninfringes upon the rights of research sub-
\njects.The risks to research subjects posed by
\nparticipation in research should be justified
\nby the anticipated benefits to the subjects
\nor society.This process also involves scrutiny
\nof whether the proposed procedures with
\nrespect to incidental findings are in accor-
\ndance with existing laws and guidelines for
\nresearch ethics.
\nCriteriological Considerations
\nSuch general ethical principles do not,how-
\never,suffice as a criteriology for dealing with
\nincidental findings within the research set-
\nting; they only provide a set of boundary
\nconditions.To establish the degree to which
\nresearchers are obliged to provide informa-
\ntion concerning incidental findings, these
\nfindings should first be categorised accord-
\ning to their information content, since this
\nrepresents a means of assessing possible
\nbenefits or detriment for research subjects.
\nQuestions of relevance in relation to infor-
\nmation content are:
\n\u2022 Reliability of knowledge: What can be-
\ncome known on the basis of the informa-
\ntion that has been obtained?
\n\u2022 Transferring medical knowledge into
\npersonal knowledge: How might the
\nknowledge of a finding affect a person\u2019s
\nlife planning?
\n\u2022 Concernment of person involved, off-
\nspring or relatives: Who is affected by the
\ncommunication of findings?
\n\u2022 Therapeutic value of the knowledge: Can
\nthe prognosticated disorder be treated
\nby preventative, therapeutic, or palliative
\nmeans?
\n\u2022 Pathogenic significance of the knowl-
\nedge: How serious is the prognosticated
\ndisease?
\n\u2022 Prognostic value of the knowledge: What
\nis the likelihood that a condition will
\nmanifest itself?
\nThese questions categorize the different in-
\ncidental findings to constitute a framework
\nfor recommendations for a criteriology for
\nuse in communications with research sub-
\njects in medical studies. [Lanzerath et al.
\n2013] Incidental findings are categorised
\naccording to the respective degree of obli-
\ngation to provide information, and with re-
\nspect to the physician\u2019s duty of care, and the
\nrights of the research subject to self-deter-
\nmination and to know or not to know. The
\nphysician\u2019s duty of care includes the offer of
\ninformation of relevance to the current or
\nfuture state of health. But the investigator
\nhas to take account that the research sub-
\nject might exercise his or her right not to
\nknow, i.e. that a research subject does not
\nwant to receive such information about a
\nfinding.
\nNevertheless, two potential conflict scenar-
\nios remain. In the first case, the researcher
\nis of the opinion that the incidental genetic
\nfinding is of major significance to the re-
\nsearch subject that its disclosure would be
\nof considerable benefit to them, but the re-
\nsearch subject has declared in advance that
\nhe or she does not wish to be told (conflict
\nbetween the right not to know and duty of
\ncare).In the second case,the researcher con-
\nsiders the benefits of imparting information
\nto be questionable, or that the information
\nis based on unreliable data, but the research
\nsubject wants to know more (\u201ctell me every-
\nthing you did find\u201d); however, the knowl-
\nedge may cause him or her unnecessary
\ndisquiet. These conflicts cannot be resolved
\nthrough the presently proposed categorisa-
\ntion process, and must instead be clarified
\nahead of study participation. Whether the
\nright to self-determination or the duty of
\ncare should take precedence in such cases,
\nand whether research subjects who insist
\nupon not being informed about incidental
\nfindings (even if these are of great potential
\nbenefit) should be excluded from studies,
\nare matters of heated debate [cf. Lanzerath
\net al. 2013].
\nConclusion
\nEven if researchers \u2013 including doctors en-
\ngaged in research \u2013 implement the proposed
\nnormative categorisation of incidental find-
\nings in order to determine their degree of
\nobligation in terms of disclosure, they may
\nnevertheless find it difficult in individual
\ncases to make a reliable assignment. A di-
\nlemma emerges from the experience that
\nmany incidental findings are of \u201cunclear
\nsignificance\u201d. The research subject faces an
\nunclear risk-benefit ratio when it is unclear
\nhow this certain kind of knowledge can
\nbe applied, in particular in the field of hu-
\nman genetics. The involved subject decides
\non what kind of risk he or she is ready to
\ntake. But this can be done only on a basis
\nof categorized types of data and informa-
\ntion. Raw data do not automatically cor-
\nrelate with \u201cinformation\u201d; generating and
\ncompiling reliable information emerges
\nfrom a prior interpretive and hermeneutic
\napproach. Therefore it must devolve upon
\nthe specialist associations to formulate the
\nproposed categorisation in more detail, so
\nthat even in the case of multi-centre stud-
\nies, clearer criteria for the protection of the
\nresearch subject, which are oriented on the
\n152
\nHealth Care REPUBLIC OF BELARUS
\nethics of research practice, are generally
\navailable. At the same time, there is a strong
\nneed to specify the \u201ccounselling capacities\u201d
\n(i.e. their skill in imparting information in
\nan appropriately empathic manner) of those
\nentrusted with the task of provide and dis-
\nclose information to research subjects. Un-
\nfortunately, competency for this task cannot
\nbe assured in all cases.
\nReferences
\n1. Council of Europe (1997) Convention on hu-
\nman rights and biomedicine. European Treaty
\nSeries No. 164. Oviedo
\n2. GFHEV (2013): http:\/\/www.gfhev.de\/de\/
\nleitlinien\/LL_und_Stellungnahmen\/2013_
\n05_28_Stellungnahme_zu_genetischen_
\nZufallsbefunden.pdf
\n3. Heinrichs B (2013) Incidental findings and the
\nright not to know. In: Lanzerath (2013), 83-92
\n4. Heinemann T et al (2013) Incidental Findings
\nin Neuroimaging Research: Ethical Considera-
\ntions and a Framework for Ethical Guidelines.
\nIn: Lanzerath (2013), 59-73
\n5. Lanzerath D et al. (eds) (2013) Incidental
\nFindings. Scientific, Legal and Ethical Issues.
\nDeutscher \u00c4rzte Verlag, K\u00f6ln
\n6. Morris Z et al. (2009) Incidental findings on
\nbrain magnetic resonance imaging: system-
\natic review and meta-analysis. BMJ (2009), 17,
\n339:b3016
\n7. Townend. D (2013) Incidental Findings, Data
\nProtection, Privacy, and Politeness. In: Lanzer-
\nath (2013), 27-43
\n8. Wolf SM et al. (2008) Managing incidental
\nfindings in human subjects research. Analysis
\nand recommendations. In: J Law Med Ethics,
\n36, 219\u2013211
\nPriv.-Doz. Dr. Dirk Lanzerath
\nGesch\u00e4ftsf\u00fchrer \/ Executive Officer
\nDeutsches Referenzzentrum f\u00fcr Ethik
\nin den Biowissenschaften (DRZE)
\nGerman Reference Centre for
\nEthics in the Life Sciences
\nUniversit\u00e4t Bonn \/ University of Bonn
\nE-mail: lanzerath@drze.de
\nThe Belarusian Medical Academy of Post-
\ngraduate Education in Minsk, Belarus, has
\ndeveloped speleotherapy as one of the per-
\nspective drug-free methods in the treatment
\nof bronchial asthma (BA), chronic obstruc-
\ntive pulmonary disease (COPD), allergic
\nprocesses (rhinitis, pollinosis, dermatitises)
\nwhich allows to prevent the development
\nof those diseases at the early stages of their
\ndevelopment, and it does not have any sig-
\nnificant side effects.
\nThe Republican Clinic of Speleotherapy
\n(RCS) in Soligorsk has opened a unique
\nsubsurface speleo complex, constructed in
\nthe rock salt (halite) massif and the potas-
\nsium (sylvinite) layer.
\n34 thousand patients have been treated
\nthere during the 23 years of its functioning.
\nThe treatment efficiency is high. Positive
\nresults have been achieved in 97.6% of the
\ncases.
\nThe world practice has accumulated experi-
\nence in the application of the speleotherapy
\nmethod for treating diseases of respiratory
\norgans, which testifies to the high effective-
\nness without the risk of developing side
\nreactions due to the microclimate of salt
\nmines.
\nThe RCS in Soligorsk carries out the spe-
\ncialized treatment with the speleotherapy
\nmethod by using the subsurface space, ex-
\nisting in different mining and geological
\nlayers.
\nThe uniqueness of the RCS subsurface spe-
\nleo complex manifests in the following:
\n1. It is in the rock salt (halite) massif and
\nthe potassium (sylvinite) layer, pro-
\nviding the possibility of placing the
\npatients in different therapeutic envi-
\nronment depending on the form of the
\ndisease and individual reaction of the
\norganism to the speleo environment
\n[Figure 1].
\n2. The subsurface departments are built
\naccording to the scientifically-based
\nproject [Figure 2].
\n3. Special air intake labyrinths ensure the
\nair flow to the therapeutic area and also
\nindividually to each ward.
\n4. The physico-chemical properties of the
\nmicroclimate in Soligorsk salt mines
\nsignificantly differ from those in other
\nspeleo complexes. The sylvinite layer
\nnear the halite layer of the salt exceeds
\nthe potassium chloride content in the
\nair 20 times in comparison with other
\nsimilar mines.
\nThe specific therapeutic effect of the speleo
\nenvironment is achieved due to the stable
\nmicroclimate, the optimal ionic composi-
\ntion, the presence of fine salt aerosol in it,
\nthe absence of allergens and pathogenic mi-
\ncroflora.
\nCharacteristics of the
\nspeleo environment:
\n\u2022 The optimal gas composition of the air
\naccording to the content of oxygen (20,
\n80\u201320, 90 by volume) and according to
\nthe content of CO2
\n(0.031\u20130.047 by vol-
\nume); 0.35 mg\/m3
\n\u2022 The total microbial contamination of the
\nair is 42\u2013102 colonies in m3
\n.
\nExperience inTreating Patients in Sylvinite-Halite Mines
\nof Soligorsk in the Republic of Belarus
\n153
\nHealth CareREPUBLIC OF BELARUS
\n\u2022 The following factors also apply to the
\nsubsurface environment.
\n\u2022 The shielding effect of the rock mass from
\nthe effects of radio frequency electromag-
\nnetic fields; the psycho-emotional read-
\naptation due to the strange conditions in
\nthe underground.
\nMaterials and methods
\nThe RCS treats about 2000 people a year
\naverage.The twice increased hospital capac-
\nity in 2012 has increased the number of pa-
\ntients to 4000 respectively.
\n78 treatment courses of speleotherapy
\nhave been performed during the period
\n2009\u20132013, lasting for not less than 12\u2013
\n18 beds\/days. 11407 patients have been
\ntreated during this period. 6896(61%) of
\nthem were women, 4421 (39%) were men
\n[Figure 3a]. The number of grown-ups was
\n9424(82.6%),children and teenagers \u2013 1983
\n(17.4%) [Figure 3b].
\nOf all the patients treated in the RCS 58%
\nwere 18\u201350 years old, it means the most ac-
\ntive working age. The average length of the
\ntreatment is 17.4 days,the average amount of
\nspeleo manipulations for one patient\u00a0\u2013 15.7.
\nThe speleo manipulations are performed in
\nthe day time and in the evening and at night
\nfor 5 and 12 hours, during the above period
\n8924 (77.4%) patients with BA, 1540 (12%)
\npatients with COPD and chronic bronchi-
\ntis, 1095 (4.8%) patients with allergic rhini-
\ntis have been treated [Figure 4].The positive
\neffect is observed after speleotherapy among
\nthe patients with allergic skin disease etiol-
\nogy. The method of research: computer spi-
\nrometer was used in this work.
\nResults and Discussion
\nSpeleo environment reduces allergic dis-
\nposition of the body, reduces inflammatory
\nchanges in the bronchi, helps to improve
\nthe rheological properties of sputum and
\n1. Cloakroom
\n2. Wards in the halite layer
\n3. Remedial gymnastics rooms
\n4. Wards in the sylvinite layer
\n5. Doctors post
\n6. Treatment room
\n7. Nursespoint
\nEmergency exit
\nIeeja
\n8. Junior medical sta\ufb00
\n9. Technician
\n10. Recreation room
\n11. Garbage collection
\nblock
\n12. Air feeding system
\nFigure 1. The structure of salt Figure 2. The subsurface speleocomplex
\nMedical indications to treatment Medical contraindications
\n\u2022 Bronchial asthma, all forms of light and
\naverage course;
\n\u2022 RI(respiratory insufficiency) of 1st
\ndegree;
\n\u2022 COPD, light and average course of RI;
\n\u2022 Chronic bronchitis;
\n\u2022 Pollinoses (before and during the pollen
\nseason);
\n\u2022 Allergic rhinitis;
\n\u2022 Allergic urticaria.
\n\u2022 Acute diseases;
\n\u2022 Chronic diseases in the acute stage or in
\nthe case of heavy clinical course;
\n\u2022 Asthma;
\n\u2022 Respiratory diseases with respiratory in-
\nsufficiency of 2nd
\n\u20133rd
\ndegree;
\n\u2022 Malignant neoplasms of all localizations;
\n\u2022 Blood circulation system diseases with
\ncases of cardiac insufficiency;
\n\u2022 Mental insanity;
\n\u2022 Tuberculosis of various localization.
\nWomen
\n61%
\nMen
\n39%
\n10\u201317 years
\n20% 18\u201330 years
\n10%
\n30\u201350 years
\n48%
\n50\u201360 years
\n20%
\n60\u201370 years
\n2% children
\nFigure 3a. The structure of the patients
\nby gender (2009\u20132013)
\nFigure 3b. The structure of the patients
\nby age
\n154
\nbronchial drainage function, has antibacte-
\nrial action, mild immunomodulatory effect,
\nwhich explains the wide list of indications
\nfor speleotherapy [Figure 5].
\nConsidering the information above, at the
\nRCS research has been performed focusing
\non the influence of speleo treatment in the
\ncourse of allergic rhinitis, BA and COPD.
\nIt was aimed at the development of various
\nmethods of treatment, defining the modes
\nof speleo influence, duration and multiplic-
\nity of speleotherapy courses depending on
\nthe nosology and the severity of the disease.
\nThe effectiveness of the method for patients
\nwith different clinical forms of the disease
\nand severity was assessed by the severity of
\nthe dynamics of the main functional pa-
\nrameters and immunological criteria. The
\nstudy revealed significant differences in the
\ndynamics of the functional parameters in
\npatients with different forms and levels of
\nBA. During the speleotherapy a statistically
\nsignificant increase in the basic forced ex-
\npiratory volume in the first second (FEV1
\n)
\nwas observed in patients with controlled
\nBA allergic form by the end of the 2nd
\nweek
\nof the treatment and it was 19.3 \u00b1 8.4%. In
\nthe following days, significant increase of
\nthe indicator was not observed [Figure 5].
\nA slower dynamics of the Function of In-
\nternal Respiration was observed in patients
\nwith partly controlled allergic BA. The dy-
\nBronchial asthma
\n77%
\nCOPD
\n7%
\nChronic bronchitis
\n5%
\nPollinosis
\n6%
\nOther allergic
\ndisturbances
\n2%
\nOther bronchial
\nobstructive
\ndiseases
\n1% Accompanying
\ndiseases
\n2%
\nFigure 4. The structure of the patients according to nosology
\n100
\n90
\n80
\n70
\n60
\n50
\n40
\n30
\n20
\n10
\n0
\n0 I II III IV
\nFEV1
\nTi\ufb00noindex
\nPEF50
\nPEF75
\nFigure 5. The dynamics of the Function of
\nInternal Respiration parameters
\nin patients with controlled BA
\nof allergic form
\n100
\n90
\n80
\n70
\n60
\n50
\n40
\n30
\n20
\n10
\n0
\n0 I II III IV
\nFEV1
\nTi\ufb00noindex
\nPEF50
\nPEF75
\nFigure 6. The dynamics of the Function of
\nInternal Respiration parameters
\nin patients with partly controlled
\nBA of allergic form
\n100
\n90
\n80
\n70
\n60
\n50
\n40
\n30
\n20
\n10
\n0
\n0 I II III IV
\nFEV1
\nTi\ufb00noindex
\nPEF50
\nPEF75
\nFigure 7. The dynamics of the Function of
\nInternal Respiration parameters
\nin patients with controlled BA
\nof mixed form
\n100
\n90
\n80
\n70
\n60
\n50
\n40
\n30
\n20
\n10
\n0
\n0 I II III IV
\nFEV1
\nTi\ufb00noindex
\nPEF50
\nPEF75
\nFigure 8. The dynamics of the Function of
\nInternal Respiration parameters
\nin patients with partly controlled
\nBA of the mixed form
\n100
\n90
\n80
\n70
\n60
\n50
\n40
\n30
\n20
\n10
\n0
\n0 I II III IV
\nFEV1
\nTi\ufb00noindex
\nPEF50
\nPEF75
\nFigure 9. The dynamics of the Function of
\nInternal Respiration parameters
\nin patients with COPD
\nHealth Care REPUBLIC OF BELARUS
\n(PEF\u2013peakexpiratory\ufb02ow)
\n155
\nnamics of the main indicators of respira-
\ntory function was observed throughout
\nthe treatment, but statistically significant it
\nwas in the second week of speleo influence,
\nreaching the level of FEV1
\n12.8 \u00b1 4.2%.Sig-
\nnificant differences in the dynamics of the
\nFunction of Internal Respiration in patients
\nwith the mixed form of BA, depending on
\nthe level of control, have not been identified
\n[Figure\u00a06].
\nA statistically significant increase in FEV1
\nin patients with controlled BA of the mixed
\nform was observed during the third week of
\nthe treatment and amounted to 11.9 \u00b1 4.4%
\n[Figure 7].
\nPartly controlled BA of the mixed form was
\ncharacterized by a gradual increase in the
\nvalues of the basic functional parameters,
\nreaching a statistically significant level dur-
\ning the third week of speleotherapy \u2013 12.5 \u00b1
\n3.8% in terms of FEV1
\n[Figure 8].
\nThe revealed changes in the level of the
\ninvestigated Ig were treated as the stabi-
\nlization of defense mechanisms at a lower
\nfunctional level by minimizing immune
\nstimulation. The identified functional and
\nimmunological changes in patients with
\nlight and moderate course of COPD had no
\nrelationship to the severity of the disease and
\ntherefore were joined into one observation
\ngroup. During speleotherapy a statistically
\nsignificant dynamics of the main indicators
\nof the Function of Internal Respiration was
\nobserved in these patients during the third
\nweek of the treatment [Figure\u00a09].
\nDuring speleotherapy a statistically signifi-
\ncant increase in the basic of FEV1
\nat the end
\nof the third week of the treatment was 16.7
\n\u00b1 4.7%, which continued during the fourth
\nweek, but had no statistical significance in
\ncomparison with the levels achieved during
\nthe third week.
\nConclusions
\n1. The subsurface departments of speleo-
\ntherapy based in Soligorsk sylvinites-
\nhalite mines are unique in the structure
\nof salt and they are constructed accord-
\ning a specially designed project.
\n2. Speleotherapy in Soligorsk sylvinites-
\nhalite salt mines has a positive effect on
\nthe course of allergic rhinitis, BA, COPD,
\nresulting in the possibility of its use in the
\nprevention of progression of these diseases.
\n3. It is appropriate to use differential treat-
\nments of speleotherapy from 12 to 18
\nbeds\/days; it depends on the level of
\ncontrol and forms of BA, severity of the
\ncourse of COPD.
\n4. A more rapid and significant therapeu-
\ntic effect of speleotherapy is achieved
\namong patients with the controlled
\ncourse of the disease.
\n5. According to our observations, the
\neffectiveness of the treatment is 97%
\nand it manifests as improving the qual-
\nity of life of patients, long-term stable
\nremission of the disease, reducing the
\nfrequency of asthma attacks, improving
\nthe performance of the respiratory func-
\ntion, reducing pill burden.
\nReferences
\n1. \u0411\u043e\u0433\u0434\u0430\u043d\u043e\u0432\u0438\u0447 \u0410.\u00a0 \u0421. \u0421\u043f\u0435\u0446\u0438\u0444\u0438\u0447\u0435\u0441\u043a\u0438\u0435 \u0444\u0430\u043a\u0442\u043e\u0440\u044b
\n\u0441\u0440\u0435\u0434\u044b \u043a\u0430\u043b\u0438\u0439\u043d\u044b\u0445 \u0440\u0443\u0434\u043d\u0438\u043a\u043e\u0432 \u0421\u043e\u043b\u0438\u0433\u043e\u0440\u0441\u043a\u043e\u0433\u043e
\n\u0431\u0430\u0441\u0441\u0435\u0439\u043d\u0430 \u0438 \u0432\u043e\u0437\u043c\u043e\u0436\u043d\u043e\u0441\u0442\u044c \u0438\u0445 \u0438\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u043d\u0438\u044f
\n\u0434\u043b\u044f \u0441\u043f\u0435\u043b\u0435\u043e\u0442\u0435\u0440\u0430\u043f\u0438\u0438. \/\/ \u0417\u0434\u0440\u0430\u0432\u043e\u043e\u0445\u0440\u0430\u043d\u0435\u043d\u0438\u0435 \u0411\u0435-
\n\u043b\u043e\u0440\u0443\u0441\u0441\u0438\u0438. \u2013 1985. \u21161. c. 39\u201340
\n2. \u0411\u043e\u0433\u0434\u0430\u043d\u043e\u0432\u0438\u0447 \u0410.\u00a0\u0421. \u0418\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u043d\u0438\u0435 \u043f\u043e\u0434\u0437\u0435\u043c\u043d\u044b\u0445
\n\u043f\u0440\u043e\u0441\u0442\u0440\u0430\u043d\u0441\u0442\u0432 \u0434\u043b\u044f \u043e\u0437\u0434\u043e\u0440\u043e\u0432\u043b\u0435\u043d\u0438\u044f \u043c\u0435\u0442\u043e\u0434\u043e\u043c \u0441\u043f\u0435-
\n\u043b\u0435\u043e\u0442\u0435\u0440\u0430\u043f\u0438\u0438. \/\/ \u0413\u043e\u0440\u043d\u044b\u0439 \u0436\u0443\u0440\u043d\u0430\u043b, 2003. \u21167. c.
\n62\u201364
\n3. \u0411\u043e\u0433\u0434\u0430\u043d\u043e\u0432\u0438\u0447 \u0410.\u00a0\u0421., \u041f\u043e\u043b\u0435\u0449\u0443\u043a \u0412.\u00a0\u0424., \u041a\u0430\u0447\u0443\u0440 \u0422.\u00a0\u0417.,
\n\u041c\u0438\u043d\u044e\u043a\u043e\u0432\u0438\u0447 \u041d.\u00a0\u0424. \u041f\u0435\u0440\u0432\u044b\u0439 \u043e\u043f\u044b\u0442 \u0441\u043f\u0435\u043b\u0435\u043e\u0442\u0435\u0440\u0430-
\n\u043f\u0438\u0438 \u0431\u043e\u043b\u044c\u043d\u044b\u0445 \u043d\u0430 \u0431\u0430\u0437\u0435 \u0421\u043e\u043b\u0438\u0433\u043e\u0440\u0441\u043a\u043e\u0433\u043e \u0440\u0443\u0434\u043d\u0438\u043a\u0430
\n\/\/ \u0417\u0434\u0440\u0430\u0432\u043e\u043e\u0445\u0440\u0430\u043d\u0435\u043d\u0438\u0435 \u0411\u0435\u043b\u043e\u0440\u0443\u0441\u0441\u0438\u0438. 1991. \u211611,
\n\u0441. 48\u201350
\n4. \u041b\u0435\u0432\u0447\u0435\u043d\u043a\u043e \u041f.\u00a0\u0410., \u041b\u0430\u043f\u0442\u0435\u0432\u0430 \u0415.\u00a0\u0410., \u0414\u0443\u0431\u043e\u0432\u0438\u043a \u041d.\u00a0\u041d.
\nBronhi\u0101l\u0101s astmas un HOPS \u0101rst\u0113\u0161anas pieredze
\nsilvinita un halita \u0161ahtu apst\u0101k\u013cos Soligorsk\u0101
\nBaltkrievijas Republik\u0101 \/\/ Latvijas \u0101rsts, \u0441. 60\u201364
\n5. \u0421\u043a\u0435\u043f\u044c\u044f\u043d \u041d.\u00a0\u0410., \u0411\u043e\u0433\u0434\u0430\u043d\u043e\u0432\u0438\u0447 \u0410.\u00a0\u0421. \u0417\u0434\u043e\u0440\u043e\u0432\u044c\u0435 \u0438
\n\u0431\u0440\u043e\u043d\u0445\u0438\u0430\u043b\u044c\u043d\u0430\u044f \u0430\u0441\u0442\u043c\u0430. \/\/ \u041f\u0443\u043b\u044c\u043c\u043e\u043d\u043e\u043b\u043e\u0433\u0438\u044f, 2001.
\n\u21167, \u0441,30\u201332
\nP.\u00a0A. Levchenko, Y.\u00a0A. Lapteva
\nState-owned enterprise The Republican
\nClinic of Speleotherapy
\nSoligorsk, Belarus
\nThe current global financial crisis inevitably
\nalters the quality of life of many individuals,
\nmainly (but not exclusively) its fourth\u00a0\u2013 after
\nGuelfi \u2013 dimension: the economic one (a deeply
\nintricate component). Under these conditions,
\nwe can only hope that the holistic and ideal-
\nistic definition of health, adopted by the World
\nHealth Organization (WHO) more than 65
\nyears ago, will maintain its contemporaneity
\nand applicability \u2013 from before the recession \u2013
\nat least in the more developed countries\/econo-
\nmies.This work presents a synthetic overview
\nof the main issues related to the notion of qual-
\nity of life: the presence\/absence of risk factors,
\n(especially) the ones associated to the \u201cciviliza-
\ntion pathology\u201d, wellness, current thinking\/
\nparadigm (integrating the medical and social
\nmodels) of the WHO regarding human func-
\ntioning, (di)stress\u00a0\u2013 including its relationship
\nto premature\/pathologic ageing \u2013 respectively,
\nactive prophylactic (relaxing, fitness\/\u201cmise en
\nforme\u201d anti-stress, maintenance, rejuvenation\/
\nanti-ageing\/gero-prophylaxis) balnear therapy
\ncourses.
\nPublic HealthROMANIA
\nBasic Wellness Features and Some Rlated Actions Propensive
\nfor Active and Healthy Ageing
\n156
\nROMANIAPublic Health
\nBackground.The WHO
\ndefinition of health.
\nConnected concepts
\n\u201cHealth is a state of complete physical,
\nmental and social well-being and not mere-
\nly the absence of disease or infirmity\u201d (1).
\nThis definition was formulated almost sev-
\nen decades ago and it included a \u201cwishful
\nthinking\u201d dimension, representing, con-
\nceptually, the option for the main strategic
\ntarget of general human progress and of
\nsustainable (peaceful) development: to en-
\nsure the quality of life (QoL). Nowadays,
\nthis forward-looking strategic option is not
\nobsolete, but on the contrary, it proves to be
\nmodern and desirable.
\nEffective physical well-being entails:
\n\u2022 the absence of medical disorders or\/and
\nof physical overwork\/strain
\n\u2022 the absence\/alleviation of disease risk
\nfactors (e.g., those for vascular pathology,
\nthat may lead to strokes\/lesional attacks
\nto virtually any organ \u2013 brain, heart, etc.\u00a0\u2013
\nrelatively easy to avoid, modify or elimi-
\nnate: sedentary life,obesity,smoking,dys-
\nlipidemia, diabetes, hypertension, cardiac
\ndysrhythmia, hyperfibrinogenemia) (2)
\nMoreover, an optimal\/complete state of
\nphysical well-being requires not only the
\nmere absence of illness risk factors and\/or
\nphysical distress, but also a state of moder-
\nate physical performance \u2013 fitness.
\nFitness is defined as \u201cgood health or physi-
\ncal condition, especially as the result of ex-
\nercise and proper nutrition or the extent to
\nwhich an organism is adapted to or able to
\nproduce offspring, in a particular environ-
\nment\u201d) (3).
\nThe definition of physical fitness also in-
\ndicates to the indissoluble relationship of
\nhealth with physical exercise and nutri-
\ntion\u00a0 \u2013 major \u201cpoles\u201d of the \u201clifestyle\u201d no-
\ntion, a comprehensive concept that includes
\nmany positive and negative factors (e.g.,
\nsedentary life \u2013 a negative factor, of course,
\nand a central pathogenic item of the \u201ccivili-
\nzation pathology\u201d (4).
\nEffective mental well-being entails:
\n\u2022 the absence of psychological and\/or cog-
\nnitive disorders and\/or absence of psychic
\ndistress
\n\u2022 the absence\/alleviation of specific risk
\nfactors (dissatisfaction, suppression, de-
\nnial, low self-esteem)
\nA simple, quick, orientative modality to as-
\nsess the cognitive function, frequently used
\nin clinical settings, is the Mini-Mental
\nState Evaluation (MMSE) (5).
\nEffective social well-being entails not
\nmerely the lack of poverty, but also (con-
\nstant) decent living from an economic
\npoint of view. Furthermore, certain social
\nconditions should be met: leading one\u2019s
\nlife in a democratic\/constitutional state
\nwith a valid system of laws and regula-
\ntions that are effectively enforced in a
\ncivilized society, engaged in \u201csustainable
\ndevelopment\u201d, characterized by tolerance
\nand cohesion, adhering to the principles
\nof non-discrimination and inclusion, with
\nincreased consideration for the individuals
\nwith special needs (including morbid obe-
\nsity or frail elderly, for example) and at the
\nsame time, based on fair competition and
\nprofessional performance\u00a0 \u2013\u201cknowledge-
\nbased society\u201d.
\nThe current understanding of health as
\nphysical, mental and social well-being is
\nbased on two fundamental, strategic, com-
\nplementary concepts, which were brought
\nforth and intensively promoted by the de-
\nveloped contemporary societies:
\n\u2022 Quality of Life (QoL)
\n\u2022 Wellness (\u201cwell tempered hedonism\u201d.)
\nThe major determinants of the QoL are
\nphysical and functional performance, psy-
\nchological well-being, social interactions
\nand the economic status (6).
\nThe Flanagan Quality of Life Scale is a com-
\nmonly used instrument for QoL assesment.
\nThe concept of \u201cwellness\u201d \u2013 antonym to
\nthe word \u201cillness\u201d, according to the Oxford
\nEnglish Dictionary (cited by 7), generally
\ndesignates an adequate balance of \u201cbody,
\nmind, and spirit\u201d, leading to a harmonious
\ninteraction with the \u201cconstantly changing
\ntotal environment\u201d (8).
\nAn adequate physical, cognitive and spiri-
\ntual interaction with one\u2019s environment (in
\nall its dimensions: physical, familial, pro-
\nfessional, social, economic, political, cul-
\ntural, etc.) leads, in turn, to a state\/feeling
\nof general well-being, which represents far
\nmore than the mere absence of illness. Con-
\nsequently, wellness may be defined as \u201can
\nintegrated method of functioning, which is
\noriented toward maximizing the potential
\nof which the individual is capable\u201d (7).
\n\u201cWhen we learn how to diagnose high-level
\nwellness through objective measures, we shall
\nprobably find that a substantial amount of cre-
\native expression, altruism, and love in daily
\nlife is essential for the approach to a high state
\nof well-being. Through the development and
\napplication of these values in daily life, we will
\nachieve self-confidence and faith in ourselves.
\nThis in turn will bring growth of self, develop-
\nment toward fuller maturity, and a balanced
\nwellness of body, mind, and spirit.\u201d (8)
\n(Di)stress is a concept of paramount impor-
\ntance, related to the QoL and wellness. In a
\nvery general sense, at least for the biomedi-
\ncal field, the term stress, introduced since
\nthe first half of the last century by the endo-
\ncrinologist Hans Selye who has \u201cfathered\u201d
\nthe stress research, is translated as pressure\/
\nstrain\/tension. It must be underlined from
\nthe beginning that both, the lack of stress
\n(such as a sedentary life or social margin-
\nalization) as well as the excess\/overload are
\nequal sources of pathogenic stress (distress).
\nHistorically, the first clinical preliminary\/
\ncollateral observations in connection to this
\n157
\nROMANIA Public Health
\nsubject were noted at the end of the 19th
\ncentury by one of the most celebrated and
\ncontributive nurses Florence Nightingale
\n(\u201dNotes on nursing: What it is and what it is
\nnot\u201d\u2013 cited by 9),but the Austrian-Hungar-
\nian endocrinologist Hans Selye was the first
\nto develop the theory of \u201cgeneral adaptation
\nsyndrome\u201d\/\u201cdiseases of adaptation\u201d (10) as
\na bio-physio-psychological paradigm to un-
\nderstand the concept of stress (initially, dur-
\ning the interwar period, he had formulated
\nit as \u201cthe alarm reaction\u201d) (11).
\nAccording to this paradigm, the general
\nadaptation syndrome is triggered by any
\nevent that affects (to a lesser or more often
\nlarger extent) the equilibrium state of an
\norganism\u00a0\u2013 called stressor (10). The initial
\nresponse to distress is coordinated by the
\nhypothalamic-pituitary axis,a system which
\nwill \u201cgear the body for defence\u201d (10). With-
\nin the reactivity to stress, the link between
\nthe brain \u2013 as an initiator \u2013 and the immune
\nsystem [immune-neuro-endocrine interac-
\ntions (12)] involves the neuro-endocrine
\nsystem as a whole (12, 13).
\nStress is one of the six major representative
\nsituations\/biological phenomena character-
\nized by duality, where the physiological\/the
\nfunctional is intertwined with the patho-
\nlogical, listed here in the alphabetical order:
\n\u2022 ageing (through genetic program\/a major
\nrisk factor for old age polipathology)
\n\u2022 hyperthermia (reactional or therapeuti-
\ncal \u2013 fever versus pathological \u2013 burns,
\ninsolation)
\n\u2022 inflammation (reactional versus patho-
\nlogical)
\n\u2022 neuroplasticity (learning versus patho-
\nlogical reorganization)
\n\u2022 pain (reactional \u2013 a physiological, biopro-
\ntective alarm response to nociceptive stim-
\nuli versus pathological, neuropathic pain)
\n\u2022 stress (eustress \u2013 a vital stimulus for the
\nantientropic behaviour of the organism
\nversus distress \u2013 pathogenic stress) (4)
\nFrom a medical and biological point of view,
\nthe psychological distress influences the hy-
\npothalamic\u2013pituitary\u2013adrenal axis (which is
\nconnected and modulated by suprathalamic,
\nincluding centers), leading to the release (as
\na neuro-endocrine mechanism of the \u201cad-
\naptation syndrome\u201d) of a large number of
\nhormones: CRH (corticotropin-releasing
\nhormone \u2013 from the paraventricular nucle-
\nus of the hypothalamus), somatotrophins
\n(from the anterior pituitary): ACTH (ad-
\nrenocorticotropic hormone), GH (growth
\nhormone), PRL (prolactin), hormones from
\nthe posterior pitutary: ADH (antidiuretic
\nhormone), respectively catecholamines
\n(epinephrine and norepinephrine, from the
\nadrenal medulla), cortisol (from the adrenal
\ncortex), insuline (from pancreas), as well as
\nneurotransmitters (serotonine, GABA \u2013
\ngamma-aminobutyric acid) and neuromod-
\nulators (endorphins, enkephalins), resulting
\nin a series of alterations of humoral param-
\neters and\/or organ functions (14).
\nAll these changes induced by distress make
\none prone to \u201corganic body damage\u201d (15),
\ngenerate major risk factors for phychoso-
\nmatic syndromes and diseases.
\nHence, gastroduodenal ulcer disease, ir-
\nritable bowel syndrome, arterial hyperten-
\nsion, some forms of cardiac ischemia and\/or
\nischemic strokes, diabetes mellitus, amenor-
\nrhea, etc. can be considered as such condi-
\ntions. These add to a long list of disorders
\nalso related to distress\/overload that alter
\nthe QoL and\/or the work capacity\/profes-
\nsional performance: neurovegetative dysto-
\nnias (including spasmophilic phenomena,
\nthermoregulation disorders, nycthemeral
\nrhythm alterations with, in a vicious circle,
\ndisturbances of the circadian hormonal se-
\ncretion biorhythms), neurastenic\/neurotic
\nsyndromes, deconditioning syndromes, etc.
\nOn the basis of the extremely tight and in-
\ntricate morph-functional immune-neuro-
\nendocrine connections\/feedbacks most of
\nthe substances released by stress alter the
\nfunctionality of the immune system. A
\nspecific example is serotonine that seems
\nto act, in this context, directly on the lym-
\nphocytes with repressive effects on some
\nmorph-functional changes which normally
\ntake place before their blastic transforma-
\ntion (Rozman, cited by 14). In addition, it
\nis currently recognized that mental distress,
\nrepeatedly present in everyday life, produces
\nin time, in both, experimental and clini-
\ncal situations, an activity decrease of NK
\n(natural killer) lymphocites, a decline in
\ninterferon production, a lowering of IgA
\n(immunoglobulin A) serum titers and con-
\nsequently leads to the alteration of endog-
\nenous antineoplastic surveillance, as well as
\nto reduction of the organism\u2019s resistance to
\ninfections (14). In this respect, an example
\nof a disease that may also be considered psy-
\nchosomatic disorder is the chronic fatigue
\nsyndrome.
\nPsychic (di)stress \u2013 including the one in-
\nduced by chronic\/neuropathic pain \u2013 results
\nin lowering of the mass of cortical-thalamic
\ngray matter (and\/or medullary neuron apop-
\ntosis \u2013 observed in rats with such suffer-
\nance) by an excitotoxic mechanism leading
\nto functional overload atrophy \u2013 \u201coveruse
\natrophy\u201d, associated with destructive, in-
\nflammatory phenomena (16). The (di)stress
\nof intense lumbar chronic pain can diminish
\nthe brain volume by 11% in one year, more
\nprecisely by 1.3 cm3
\nof gray matter \u2013 equiva-
\nlent to 10-20 years of normal ageing. This
\nfact highlights the psychosomatic link\u00a0 \u2013
\n\u201cthe mind-body connection\u201d \u2013 manifested
\nin both, eustress and distress. The latter, es-
\npecially when prolonged\/chronic,affects the
\nhigh complexity levels of the organization
\nof living structures, the molecular geno-
\ntype including. Chronic distress appears to
\nbe an accelerator of telomere shortening;
\ntelomeres are intimate markers of ageing,
\nbut they are closely related with longevity,
\nas well as with various pathological condi-
\ntions. At an intimate level, chronic stress in-
\nduces cumulative lesional phenomena, with
\nrepercussions extending to the DNA level.
\nThese have micro- and macro- metabolic
\nconsequences \u2013 including an increased risk
\nof developing obesity in the second half of
\nlife \u2013 and on the processes of replication\/
\n158
\nageing\/longevity, as well as the oncogenic
\nskidding (17), all primarily by:
\n\u2022 oxidative stress (including unbalanced
\ndiet, quantitatively\u00a0and\/or qualitatively)
\n\u2022 increased telomeric activity\/metabolism\u00a0\u2013
\nwith accelerated shortening
\n\u2022 reduction of telomerase activity
\nA clinical study showed that healthy, pre-
\nmenopausal women who reported the high-
\nest levels of perceived stress had shorter
\ntelomeres by the equivalent of at least one
\ndecade of additional ageing, in comparison
\nto those who reported low levels of stress
\n(18).
\nTo date,there are arround 200 genes,among
\nwhich over 150 recently identified, consid-
\nered to interfere (whose mutations affect
\ntelomere length) with the telomere metabo-
\nlism\/length: 2\/3 shorten and 1\/3 lengthen
\nthem; they are generically called \u201cclock\u201d
\ngenes, as they control \u2013 in an complex and
\nsometimes, apparently controversial\/dialec-
\ntical way \u2013 ageing and, respectively, longev-
\nity.
\nThere is a definite connection between
\nstress and ageing: by accelerated telomere
\nshortening \u2013 linked with longevity but also
\nwith illness, especially cancer, through telo-
\nmere length\/metabolism.
\nIt has been documented that mental distress
\nis associated with premature mortality and
\nincreased risk of coronary heart disease, el-
\nevated blood pressure, type 2 diabetes (19),
\nand disability, while positive affective states
\nare protective (20, 21), though the pathways
\nleading to these effects remain still poorly
\nunderstood. Low levels of stress are associ-
\nated with lower heart rates, lower cortisol,
\nlower plasma fibrinogen levels and smaller
\nfibrinogen stress responses; inversely, high
\nlevels of psychological stress are associated
\nwith accelerated heart rates, higher cortisol
\nlevels (increasing the risk for arterial hyper-
\ntension and type 2 diabetes), higher plasma
\nfibrinogen (leading to an elevated risk of
\natherosclerosis and ischemic heart disease)
\nand intense acute phase response (APR)
\n(20, 21).
\nThe QoL of the elderly in
\nthe contemporary society
\nStarting, especially with the last quarter of
\nthe past century, there is an international
\ntrend towards connecting and integrating
\nhealthcare\/medical assistance with social
\ncare\/social solidarity endeavors. As a result,
\nthere emerged the modern idea of provid-
\ning and maintaining an adequate QoL for
\nall society members, including the elderly.
\nThe first decade of this millennium was
\ndedicated by the WHO, among other sub-
\njects, to the QoL.
\nAs a corollary to these contemporary con-
\ncepts and realities, in 2001, after more than
\n20 years from its precedent model (The In-
\nternational Classification of Impairments,
\nDisabilities and Handicaps \u2013 ICIDH) (22),
\nand following almost a decade of prepara-
\ntion, the WHO published The Internation-
\nal Classification of Functioning, Disability
\nand Health (ICF-DH) (23).
\nICF-DH is an universal, trans-cultural sys-
\ntem, taking into account not only the medi-
\ncal\/health aspects, but also the social ones
\nand, thus, it holds a large applicability from
\nhealthcare-related activities (prophylaxis,
\nmedical therapy, rehabilitation, biostatistics,
\nresearch,medical management\/health strat-
\negies) to the ones related to social care and
\nsocial policy, environment adjustment and
\nprotection, advocacy \u2013 to increase the QoL
\nand\/or legislative measures (including those
\nrelated to protection of the individuals with
\nspecial needs, social reinsertion, profession-
\nal\/vocational reorientation, etc.).
\nIn conclusion,ICF-DH is designed to allow
\nthrough its implementation the syncretic
\nand integrative analysis and monitoring of
\nhealth and well-being states at an individual
\nlevel through the use of core sets, as well as
\nat a population (\u201cmacro\u201d) level, by compar-
\ning the results of various disability pattern
\nanalysis, between (groups of) statuses from
\ndifferent pathologic entities.
\nStatistical reports show that the average
\nlife expectancy of Europeans has increased
\nover the last few decades (approximately by
\n0.25 years annually) while their number of
\nhealthy life years (HLY \u2013 the lifespan spent
\nin good health) has remained unchanged
\n(24, 25). Thus, it can be inferred that the
\naverage lifespan spent in poor health has
\nbeen increasing.The European Union (EU)
\ntakes on a significant challenge \u2013 to increase
\nthe number of HLY by two years by 2020.
\nMaintaining a good QoL in elderly, from
\nthe point of view of physical well-being,
\nentails effective prevention, early detection
\n(using appropriate assessment tools) and
\ntimely medical treatment of all disorders
\nthat may lead to functional and\/or cognitive
\ndecline.
\nTo optimize the social and psychological
\nwell-being of the ageing individual, active
\nand independent living should be promoted
\nand extended for as long as possible, so-
\ncial inclusion should be maximized (e.g.,
\nby including the elderly in adequate group
\nactivities at the community level) and assis-
\ntance with daily living should be provided
\nfor those with functional and\/or cognitive
\nimpairments.To achieve these goals, educa-
\ntion\/counseling of the patients, community
\nand healthcare workers may prove helpful;
\nfor example:
\n\u2022 patient and caretaker education\/counsel-
\ning (information leaflets; e-learning)
\n\u2022 qualification courses on the management
\nof the elderly, for general practitioners
\nand specialist doctors
\n\u2022 courses on the psychology of elderly care
\n\u2022 teaching courses for community care vol-
\nunteers
\n\u2022 qualification courses for nurses\/creating
\nof management teams for elderly home
\nand\/or community care, etc.
\nHowever, the current global financial crisis
\ninevitably alters the quality of life of many
\nROMANIAPublic Health
\n159
\nindividuals, especially of the elderly, mainly
\n(but not exclusively) its fourth dimension:
\nthe economic one. Under these conditions,
\nwe can only hope that the holistic and ide-
\nalistic definition of health, adopted by the
\nWHO more than 65 years ago, will main-
\ntain its contemporaneity and applicability\u00a0\u2013
\nfrom before the recession \u2013 at least in the
\nmore developed countries\/economies.
\nThe number of employment opportunities
\nfor people with disabilities tends to decrease
\nduring the economic crisis, leading to un-
\nwanted increase in the number of individu-
\nals receiving disability benefits. Moreover,
\nthe ageing phenomenon in the European
\npopulation brings about a need for elderly
\npeople to remain professionally active up to
\nan older age in order to avoid a decline of
\nproductivity coupled with the accumulation
\nof the financial burden of pensions (24).
\nThe contribution of Physical
\nand Rehabilitation Medicine
\n(PRM) to QoL\/wellness,
\nactive and healthy ageing
\nIt is clear that the medical field contributes
\nonly partly to the QoL\/wellness through its
\nthree types of chrono-interventional mea-
\nsures:
\n\u2022 primary prophylaxis (elimination or miti-
\ngation of risk factors)
\n\u2022 secondary prophylaxis \u2013 medical therapy
\n(aimed at preventing complications, re-
\nlapses and\/or chronicization)
\n\u2022 tertiary prophylaxis \u2013 medical rehabilita-
\ntion (aimed at diminishing dysfunction\/
\nchronic disability\/invalidity)
\n\u2022 PRM is particularly concerned with the
\nenhancement of the QoL and a large
\narray of tools is available, applicable in
\norder to improve the functional capacity
\nand related to QoL:
\n\u2022 balneotherapy, climatotherapy, health
\ntourism
\n\u2022 physical medicine\/physiatry, including
\nkinesiology
\n\u2022 assistive technologies and devices
\n\u2022 rehabilitative care\/nursing (RC\/N)
\nThe great importance of anti-stress\/relax-
\nation, active prophylactic, \u201cmise en forme\u201d\/
\nmaintenance, rejuvenation\/anti-ageing bal-
\nneotherapy courses in modern society has
\nalready been revealed by the above discus-
\nsion. Regardless of how healthy individuals
\nwill be after \u201cthe new revolution in regen-
\nerative medicine\u201d, there will remain some
\nfundamental human behavioral traits whose
\noptimization will continue to be essentially
\nnecessary.
\nThe main types of methodological sequenc-
\nes used in anti-stress\/wellness balneothera-
\npy courses are the following:
\n\u2022 techniques, possibly combined of extrin-
\nsic and especially intrinsic relaxation
\n\u2022 kinetic prophylaxis, mainly targeting:
\ngeneral optimization of the muscle and
\njoint function \u2013 possibly with some ana-
\nlytical loco-regional accents (e.g., muscle
\nand posture rebalance of the cervical
\nregion, associated with contracture re-
\nlaxation in the middle trapezius muscles
\nfor office workers, requiring for several
\nhours a day monotonous position of the
\nhead \u2013 working at the computer with the
\neyes focused on the screen or excessive
\nTV watching), increasing the physical
\nendurance, and possibly \u2013 if required and
\nno contraindications present \u2013 programs
\nto improve the somatic image, \u201cbody for-
\nmer\u201d\/aesthetics of the body
\n\u2022 for the overall objectives of relaxation
\nand maintenance\/\u201cmise en forme\u201d, stated
\nabove, the following are recommended:
\nland therapy, recreational occupational
\ntherapy and various types and forms of
\nmassage \u2013 appropriately, individually pre-
\nscribed
\n\u2022 various procedures of physiotherapy, in-
\ncluding water-based, and climatotherapy,
\nexploiting in a professional manner the
\nnatural physical\/chemical therapeutic
\nagents
\n\u2022 nutritional education and assistance
\n\u2022 individual and group psychotherapy
\n\u2022 health education
\n\u2022 biotrophic treatment (rejuvenation\/\u201canti-
\nageing\u201d) general and\/or cosmetic (for the
\npresenescent and elderly)
\n\u2022 alternative procedural sequences, such
\nas: chromotherapy, aromatherapy, and\/or
\nmelotherapy may be used in a comple-
\nmentary way
\nIt is possible and advisable to combine these
\nsequences with recreational activities, like
\ncultural events, tourism and\/or sports.
\nIt should also be underlined in this context,
\nthe particular value of sanogenous natural
\nfactors such as: the sedative climate of the
\nhills, the lack of pollution, including the
\nphonic one and the aesthetic valences of the
\nlandscape.
\nAll the above recommend balnear resorts \u2013
\ntrue \u201cecologic niches\u201d \u2013 as optimal areas for
\ncarrying out anti-(di)stress, active prophy-
\nlactic\/rest, fitness\/\u201cmise en forme\u201d\/wellness,
\nmaintenance\/, rejuvenation (anti-ageing)
\ntherapy courses.
\nThe main Romanian climatic health re-
\nsorts appropriate for this purpose are:
\nC\u0103lim\u0103ne\u015fti-C\u0103ciulata-Cozia, Ol\u0103ne\u015fti,
\nGovora, Felix, Herculane, Eforie Nord,
\nMangalia, Techirghiol, Covasna, Sovata,
\nSl\u0103nic-Moldova, Sinaia, and respectively
\nOtopeni \u2013 the clinical premises of the Na-
\ntional Institute of Gerontology and Geriat-
\nrics \u201cAna Aslan\u201d, Bucharest.
\nIn recent years a modern concept is emerg-
\ning, based inclusively on the experience and
\nmany contributions in the field of the Ro-
\nmanian medical school: complex \u201cgeronto-
\nprophylaxis\u201dby physiatric,balnear,hygienic-
\nbehavioral and pharmacological means.The
\nsubject is quite vast, exceeding the current
\napproach framework. This concept is ex-
\ntended, incorporating the sustained efforts
\nto fight on daily basis the distress. Specifi-
\ncally, it involves daily, dynamic exercises\u00a0\u2013
\ntailored based on regular, individual clinical
\nand functional assessment of the exercise
\nROMANIA Public Health
\n160
\ncapacity, such as running (jogging) and\/or
\ncycling, coupled with a balanced diet (with-
\nout excesses and avoiding highly processed
\naliments) and taking once or twice a year, a
\ncourse of anti-(di)stress balneotherapy, last-
\ning for 10\u201314 days.
\nCorollary of this current synthesis on such
\nan important subject matter \u2013 the strategic
\nattention of the European Commission
\n(EC) is to be underlined when considering
\n\u201cFrailty in old age, a public health concern
\nat EU level\u201d and, accordingly, supporting
\nthe \u201cEuropean Innovation Partnership on
\nActive and Healthy Ageing\u201d (EIP-AHA)\u00a0\u2013
\nwith the involvement of members of the
\nAction Group on Frailty and Functional
\nDecline and respectively of the I2
\nFRESCO
\nproject on integrated interventions for frail-
\nty prevention in older people\/patients (the
\nComit\u00e9 Permanent\/Standing Committee
\nof the European Doctors (CPME), includ-
\ning in this field, very contributive, specifi-
\ncally by the sustained activity of its Working
\nGroup on Active and Healthy Ageing).
\nReferences
\n1. Preamble to the Constitution of the World
\nHealth Organization as adopted by the Inter-
\nnational Health Conference, New York, 19-22
\nJune, 1946; signed on 22 July 1946 by the rep-
\nresentatives of 61 States (Official Records of the
\nWorld Health Organization, no. 2, p. 100) and
\nentered into force on 7 April 1948
\n2. Whiteson HJ, Cardiac Rehabilitation \u2013 in
\nBraddom R, Buschbacher RM, Chan L, et al.
\nPhysical Medicine & Rehabilitation. 3rd
\nedition.
\nSaunders Co,Philadelphia,Elsevier.712-4,2007
\n3. http:\/\/www.thefreedictionary.com\/fitness
\n4. Onose G. Recuperare, Medicin\u0103 Fizic\u0103 \u015fi bal-
\nneoclimatologie \u2013 no\u0163iuni de baz\u0103 \u015fi actualit\u0103\u0163i.
\nVol. I. Editura Medical\u0103, Bucure\u015fti, 2007
\n5. Folstein MF, Folstein SE, McHugh PR. \u00abMini-
\nmental state\u00bb. A practical method for grading
\nthe cognitive state of patients for the clinician.
\nJ Psychiatr Res. 12(3):189-98, 1975
\n6. Guelfi JD. Measuring quality of life. Ann Med
\nPsychol (Paris). (9):671-6; discussion 676-7,
\n1992
\n7. Zimmer B. On Language Wellness (Wellness
\nJessica Walsh) \u2013 The New York Times, April 16,
\n2010
\n8. Dunn HL. High-level wellness for man and so-
\nciety.Am J Public Health Nations Health.49(6):
\n786-92, 1959
\n9. Rice VH. Theories of Stress and Its Relation-
\nship to Health \u2013 in: (Part II, Chap. 2) Rice VH
\n(ed.). Handbook of Stress, Coping, and Health:
\nImplications for Nursing Research, Theory, and
\nPractice. SAGE Publications, Inc., USA, 2012
\n10. Selye H. Stress and the general adaptation syn-
\ndrome. Br Med J. 1(4667): 1383-92, 1950
\n11. Selye H. The Evolution of the Stress Concept:
\nThe originator of the concept traces its develop-
\nment from the discovery in 1936 of the alarm
\nreaction to modern therapeutic applications of
\nsyntoxic and catatoxic hormones \u2013 American
\nScientist, 61(6): 692-9, 1973
\n12. Besedovsky HO, del Rey A. Immune-neuro-
\nendocrine interactions: facts and hypotheses.
\nEndocr Rev. 17(1): 64-102, 1996
\n13. Morm\u00e8de P. Psychobiology of stress and im-
\nmune functions \u2013 in: Puglisi-Allegra S, Oliverio
\nA. (Eds.) Psychobiology of stress. Kluwer Aca-
\ndemic Publishers, Dordrecht, The Nederlands,
\n1990
\n14. Pere\u0163ianu D, Grigorie D, Onose G \u2013 Edit. Co-
\nord. Imunoendocrinologie \u00een boli de colagen \u015fi
\nosteoporoz\u0103, Ed. Academiei Rom\u00e2ne, 2002
\n15. Rotenberg VS, Schattenstein A.A. Neurotic and
\npsychosomatic disorders interdependence in
\nterms of the search activity concept. The Pavlo-
\nvian Journal of Biological Science. 25(2): 43-4,
\n1990
\n16. Apkarian AV, Sosa Y, Sonty S, Levy RM, Hard-
\nen RN, Parrish TB, Gitelman DR. Chronic back
\npain is associated with decreased prefrontal and
\nthalamic gray matter density. J Neurosci. 24(46):
\n10410-5, 2004
\n17. Herbert TB, Cohen S. Stress and immunity in
\nhumans: a meta-analytic review. Psychosom
\nMed. 55(4):364-7, 1993
\n18. Epel ES, Blackburn EH, Lin J, Dhabhar FS,
\nAdler NE, Morrow JD, Cawthon RM. Accel-
\nerated telomere shortening in response to life
\nstress \u2013 Proc Natl Acad Sci U S A, 101(49):
\n17312-5, 2004
\n19. Golden SH, Williams JE, Ford DE, et al. De-
\npressive symptoms and the risk of type 2 dia-
\nbetes: the Atherosclerosis Risk in Communities
\nstudy. Diabetes Care. 27(2): 429-3, 2004
\n20. Black PH. The inflammatory consequences of
\npsychologic stress: relationship to insulin resist-
\nance, obesity, atherosclerosis and diabetes mel-
\nlitus, type II. Med Hypotheses. 67(4): 879-91,
\n2006
\n21. Steptoe A, Wardle J, Marmot M. Positive af-
\nfect and health-related neuroendocrine, cardio-
\nvascular, and inflammatory processes. Proc Natl
\nAcad Sci USA. 102(18): 6508-12, 2005
\n22. World Health Organization. The International
\nClassification of Impairments, Disabilities and
\nHandicaps \u2013 A manual of classification relat-
\ning to the consequences of disease. Published in
\naccordance with resolution WHA29. 35 of the
\nTwenty-ninth World Health Assembly, May
\n1976. Geneva, 1980. (http:\/\/whqlibdoc.who.int\/
\npublications\/1980\/9241541261_eng.pdf)
\n23. World Health Organization. ICF International
\nClassification of Functioning Disability and
\nHealth. Geneva. 2001. (http:\/\/www.handicapin-
\ncifre.it\/documenti\/icf_18.pdf)
\n24. Harbers MM, Achterberg PW (eds.). Europe-
\nans of retirement age: chronic diseases and eco-
\nnomic activity. Specific contract \u2013 No SC 2011
\n62 51, implementing Framework Contract No
\nEAHC\/2010\/Health\/01 (Lot 1). RIVM, De-
\ncember 2012 (http:\/\/ec.europa.eu\/health\/ma-
\njor_chronic_diseases\/docs\/rivm_report_retire-
\nment_en.pdf)
\n25. Eurostat Statistics Database [database on the
\nInternet] 2012. (http:\/\/epp.eurostat.ec.europa.
\neu\/portal\/page\/portal\/statistics\/search_data-
\nbase).
\nProf. Onose G, MD, PhD, MSc1, 2
\n,
\nUniv. Assist. Haras MA, MD, PhD1, 2
\n,
\nProf. Sinescu CJ, MD, PhD1, 2
\n,
\nUniv. Assist. Daia CO, MD, PhD1, 2
\n,
\nAndone I, MD, Postgrad2
\n,
\nOnose\u00a0VL,\u00a0MD3
\n,
\nAssist. Prof. Capisizu A, MD, PhD1, 4
\n,
\nAssoc.\u00a0Prof. Grigorean VT, MD, PhD1,2
\n,
\nAssist. Prof. Ciobotaru C, MD, PhD5,6
\n,
\nSandu\u00a0AM, MD, PhD2
\n,
\nAssist. Prof. Blendea\u00a0CD, MD, PhD7,8
\n1 (State) University of Medicine
\nand Pharmacy \u201cCarol Davila\u201d, Bucharest.
\n2 Teaching Emergency Hospital
\n\u201cBagdasar-Arseni\u201d, Bucharest.
\n3 Metrorex, the Medical Service, Bucharest.
\n4 St. Luke Hospital for Chronic\u00a0Diseases,
\nBucharest.
\n5 Ovidius University, Constanta.
\n6 County Teaching Hospital, Constanta.
\n7 Titu Maiorescu University, Bucharest.
\n8 County Teaching Hospital, Ilfov.
\nE-mail: geluonose@clicknet.ro
\nROMANIAPublic Health
\niii
\nKOREA Environmental Health
\nThe WMA together with other health and medical organizations are
\nworking on the preparation of a second Climate and Heath Summit
\nin parallel to the official conference.This will provide an opportunity
\nto share progress on the development and implementation of strate-
\ngies to build resilience to the impact of climate change on health.
\nGlobal Climate & Health Summit that will take place on the 16th
\nof November, in parallel to the official Conference Climate Change
\nConference.
\nThe Summit is co-organised by a range of organizations work-
\ning on health and environmental matters, under the auspices of
\nWHO. The WMA is one of the organizers of the event. Prof. V.
\nNathanson (BMA), who is co-chairing the Environment Caucus
\ntogether with Dr. DC Shin, will represent WMA at the meeting.
\nMore information: http:\/\/www.climateandhealthalliance.org\/summit\/
\nsummit-programme
\nUN Climate Change Summit
\n(http:\/\/www.cop19.gov.pl) will take place 11\u201322 November 2013,in Warsaw
\nThe Environment Caucus was organized
\nwith the purpose of exchanging opinions
\namong WMA members and related bod-
\nies regarding WMA\u2019s future activities re-
\nlated with \u201chealth and the Environment\u201d,
\nwhen the working group devoted to the
\ntopic completed its term as of the Council
\nMeeting in April 2011. Since its first gath-
\nering at the 191st
\nCouncil meeting in April
\n2012 (Prague, Czech Republic), about 15
\nconstituent members have participated in
\nthe caucus held in conjunction with WMA
\nCouncil Session and General Assembly.
\nProf. Vivienne Nathanson of the BMA
\nand Prof. Peter Orris of the University of
\nIllinois have been contributing as advisors
\nand myself is the coordinator. Ms Clarisse
\nDelorme from WMA secretariat provides
\nus support.
\nThe main activity of the Environment Cau-
\ncus is to share global trends and conferences
\ninformation regarding environment, to
\nidentify common topics of interest and to
\ndiscuss follow-up measures. It aims to share
\nthe various wisdom and experience of each
\nmember and observer and to encourage free
\nexchange of opinions by adopting such an
\ninformal setting.
\nMajor themes discussed at the Environmental
\nCaucus with regards to the direction of future
\nWMA activities include the role of physicians
\nand of constituent members in greenhouse gas
\nreduction, promoting research on the health
\nco-benefits of countering climate change and
\nexpansion of green hospitals and clinics.
\nThe Environment Caucus also monitors
\nhow each member is utilizing the environ-
\nment-related policies adopted by WMA and
\nstudies ways of encouraging their utilization.
\nAs a part of such efforts, a survey of mem-
\nber NMAs was conducted in 2012. Accord-
\ning to the survey results, members agreed
\nthat WMA must continue to take an active
\nstance in tackling environmental problems.
\nA wide majority stated that they use WMA\u2019s
\nenvironment-related policies in developing
\ntheir own policies or in raising awareness
\namong their members. Constituent mem-
\nbers expressed the opinion that WMA must
\ncontinue to place top priority on climate
\nchange issues and provide guidance on en-
\nvironmental issues to medical professionals.
\nThe WMA is also expected to set the ex-
\nample by making WMA meetings greener.
\nBased on such feedback, the Environment
\nCaucus plans to diversify the direction of
\nWMA\u2019s activities on Environment and as a
\nfirst step, to focus on promoting and encour-
\naging the increase of green hospitals in each
\ncountry. Furthermore, the Caucus would like
\nto work on a WMA policy on pollution or en-
\nvironmental degradation from energy sources
\nby collecting data and conducting discussions.
\nKorea, an active participant in the Environ-
\nment Caucus, established the Korea Society
\nfor Green Hospital last June as the focal point
\nof information exchange and cooperation for
\ngrowth of green hospitals. This Society also
\nplans to collaborate with international or-
\nganizations such as the WMA in the future.
\nTo strengthen the network for Environ-
\nment Caucus\u2019 activity, a green page is es-
\ntablished on the WMA website devoted to
\nenvironmental issues, so that environment-
\nrelated activities of WMA and each con-
\nstituent members can be posted and various
\ninformation can be shared. We encourage
\nall members to actively use this section on
\nWMA website and also eagerly seek your
\nparticipation and advice in the future activi-
\nties of the Environment Caucus.
\nDong Chun Shin, MD, PhD
\nProf. Dept. of Preventive Medicine
\nYonsei Univ. College of Medicine
\nChair, Executive Committee
\nof International Relations
\nKorean Medical Association
\nActivities of Environment Caucus in the WMA
\nIV
\nWMA news COUNTRY
\nContents
\nThe Globalization and the Role of Medical Professional
\nAssociations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
\nEU Health Ministers Need to Agree on Strong Tobacco
\nPolicy and Stop 650,000 Europeans from Dying
\nEach Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
\nThe European Union and Tobacco Legislation . . . . . . . . . 129
\nDeclaration of Helsinki . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
\nThe Helsinki Statement on Health in all Policies . . . . . . . . 135
\nAdvancing The Global Health Agenda . . . . . . . . . . . . . . . 137
\nThe Chicago Department of Public Health and Healthy
\nChicago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
\nAmerican Medical Association Inaugurates
\nNew President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
\nModel of Colombian Social Security in Health . . . . . . . . . 143
\nMyanmar Medical Association (MMA) . . . . . . . . . . . . . . 148
\nEthical Principles of the Management of Incidental
\nFindings in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
\nExperience in Treating Patients in Sylvinite-Halite Mines
\nof Soligorsk in the Republic of Belarus . . . . . . . . . . . . . . . 152
\nBasic Wellness Features and Some Rlated Actions
\nPropensive for Active and Healthy Ageing . . . . . . . . . . . . 155
\nActivities of Environment Caucus in the WMA . . . . . . . . iii
\nIn the West African Region regulated by
\nthe Economic Community of West African
\nStates (ECOWAS), medical integration is
\nevolving favourably. (15 countries, 03 lan-
\nguages \u2013 population # 300 million) Recently,
\nApril 3,2015,the Assembly of Health Minis-
\nters adopted in Praia (Cape Verde) more doc-
\numents to improve the effective integration;
\n\u2022 The Harmonised Codes of Conduct and
\nExercise doctors and dentists (applicable
\nin 2015).
\n\u2022 The Training Curricula General Medicine
\n\u2022 The Curricula harmonized degrees (med-
\nical specialties)
\nIn C\u00f4te d\u2019Ivoire, after a dozen years of
\ncivil-military crisis marked by an episode of
\narmed conflict in 2011, the National Order
\nof Physicians of C\u00f4te d\u2019Ivoire (ONMCI)
\ndecided to write a \u201cwhite paper\u201d on the
\nRights and Duties of Physicians face to vio-
\nlence, in period crisis and armed conflicts in
\nthe exercise of profession.
\nThis book recalls the summary:
\n1. \u201dRespecting and protecting health care in
\narmed conflicts and in areas not covered
\nby international humanitarian law situa-
\ntions\u201d \u2013 technical specifications ICRC\u00a0\u2013
\nInternational Humanitarian Law in rela-
\ntion to The Geneva Conventions of 12
\nAugust 1949 and their Additional Pro-
\ntocols developed June 8, 1977, with the
\nduties and expectations of physicians.
\n2. The general guidelines of the World
\nMedical Association (WMA) in crisis
\nand armed conflicts.
\n3. The Code of Conduct (WMA): Duties
\nof physicians in crisis and armed conflicts.
\n4. The position of the World Medical As-
\nsociation Statement on Violence in the
\nHealth Sector on the part of patients
\nand people close.
\nThe characteristic of this book (A5) which
\nwill be freely available to the Physicians
\nis that it contains several testimonials
\nfrom doctors and family doctors victims
\nof these sad events in the life of the Na-
\ntion. Particular emphasis was placed on
\nthe prevention of violence by reactivating
\nSecurity Observatory of Physicians in the
\ncourse of their professional practice; struc-
\nture that will be responsible for identifying
\nall the verbal and physical abuse, by mak-
\ning available medical Corps as a whole
\ninspired questionnaire of our colleagues
\nfrom the College of Physicians of France
\nfighting this unfortunate phenomenon in
\ntheir country.
\nThe West African region is unfortunately
\nnot preserved by other episodes of crises
\nand armed conflicts which is why the Na-
\ntional Order of Physicians of C\u00f4te d\u2019Ivoire
\n(ONMCI) will make this book available
\nto the West African Health Organization
\n(WAHO) for translation in English and
\nPortuguese for the 15 countries of the re-
\ngion.
\nDr. AKA Kroo Florent
\nPresident of National Council of the Order
\nPhysicians in C\u00f4te d\u2019Ivoire
\nMedical West African
\nRegion
\nHarmonisedCodes
\nECOWASRegion\u00abWhitepaper\u00bbRightsandDuties
\nofphysicians<\/p>\n"},"caption":{"rendered":"

wmj201304 COUNTRY \u2022 Declaration of Helsinki \u2022 Strong Tobacco Policy \u2022 Model of Colombian Social Security in Health vol. 59 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 4, September 2013 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@arstubiedriba.lv […]<\/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\/wmj201304.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3654"}],"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=3654"}]}}