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wmj201306<\/a><\/p>\n

COUNTRY
\n\u2022 Communication of Results and Incidental Findings in
\nMedical Research
\n\u2022 Working for Health Equity: The Role of Health
\nProfessionals
\nvol. 59
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 6, December 2013
\nCover picture from Latvia
\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:
\nNikolai Pirogov in the hospital of Sevostopol.
\nPainter Irene Stradi\u0146a. Oil painting, 1949.
\nNikolai Pirogov (1810\u20131881).
\nAn outstanding Russian surgeon and scientist.
\nProfessor and academician of the St. Petersburg
\nImperial Medical Academy of Surgery. Beginner
\nof the development of topographic anatomy, one
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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
\n201
\nMedical Research
\nElmar Doppelfeld1
\nThe principle of free and informed consent\u00a0\u2013
\ncodified, perhaps for the first time ever, as
\nearly as December 29, 1900 [Minister der
\ngeistlichen Unterrichts- und Medizinal-
\nAngelegenheiten 1900] by a decree of the
\nPrussian Minister of Education\u00a0\u2013 is con-
\nsidered an essential prerequisite for the
\ninvolvement of human subjects in medi-
\ncal research. Since World War II, numer-
\nous sets of rules\u00a0\u2013 including both legally
\nbinding and so-called \u201csoft law\u201d instru-
\nments intended to serve as recommenda-
\ntions\u00a0\u2013 have established legal and ethical
\nprinciples that need to be observed to
\nensure that \u201cfree and informed consent\u201d is
\nobtained. One of them is to provide full
\nand frank information to the potential re-
\nsearch participant, or \u201ca proper instruction
\nregarding potential adverse effects that
\nmight result from the intervention\u201d, to put
\nit in the words of the aforementioned de-
\n1 Based on a lecture given at the IMAGEN Meet-
\ning of the Ethics Council and Workshop \u201cInciden-
\ntal Findings and Disclosure of Information in the
\nContext of Research\u201d, September 20, 2010\u00a0\u2013 Berlin.
\ncree. Thus, the principle of informing par-
\nticipants before the commencement of a
\nresearch project is well-established and no
\nlonger contested.
\nLess clear, however, is the extent to which
\na person who participated in a research
\nproject is to be informed about the results.
\nShould, or may, the participant be informed
\nat all? Should the information be restrict-
\ned to \u201chealth-related\u201d findings obtained
\nin the course of the project? Who defines
\nwhat \u201chealth-related\u201d means? These ques-
\ntions are all the more important as research
\nprojects in all disciplines produce findings
\nthat are difficult to interpret\u00a0\u2013 if they can be
\ninterpreted at all. But does this entitle the
\nresearcher or the physician-researcher to
\nwithhold such findings (even if they cannot
\nbe interpreted) from the person concerned?
\nAfter all,an increasing number of incidental
\nfindings2
\ncan be related to the choice of the
\nresearch methodology. They, too, raise the
\nquestion of the research participant\u2019s right to
\nknow and not to know. Can, or may, the de-
\ncision regarding disclosure of information
\nabout such findings be left to the good will
\nor the discretion of the physician-researcher
\nor other researchers?
\nThe right to know and not to know can
\nbe associated with the right to informa-
\ntional selfdetermination. Hence, it needs
\nto be established whether the respect for
\nthe dignity of the research participant calls
\nfor this right to be respected. To this end,
\nthe present Chapter will examine the legal
\nstandards for the protection of that dignity,
\nparticularly the instruments of the Council
\nof Europe.
\n2 \u201cThe term \u2018incidental finding\u2019 refers to the unex-
\npected discovery of an abnormality for which there
\nwas no recognizable prior evidence and that was not
\nspecifically looked for.\u201d [Heinemann et al. 2007].
\nInterest in the results
\nof medical research
\nThe vast majority of people who agree to
\nparticipate in a medical research project do
\nnot do so to serve as a mere \u201csource of data\u201d.
\nThe decision to be part of a research study
\nmay be motivated by various interests\u00a0\u2013 in-
\nterests, which may also give rise to the de-
\nsire to know the results.
\nFor instance, participants who are patients
\nmay hope to learn more about the current
\nstatus of diagnostics and therapy for their
\ndisease, or they may desire to contribute to
\nimprovements in these areas. This motiva-
\ntion may be coupled with the need to gain
\nknowledge about the overall results of this
\ndisease-specific research and, as the case
\nmay be, also about the status of their own
\ndisease. It must be borne in mind, however,
\nthat a patient may also refuse to be informed
\nabout the possibly advanced stage of their
\ndisease. Furthermore, unexpected findings
\nmay occur during the diagnostic process,
\nwhich the patient may or may not want
\nto know about. Healthy volunteers may be
\nguided by the idea of making a contribu-
\ntion to research in general, without expect-
\ning any personal benefit; there might still be
\nsome advantage for them. Furthermore, it
\nshould be recognised that patients and test
\npersons (healthy volunteers) alike may also
\nhave a legitimate interest when it comes to
\nthe future use of findings that have been ob-
\ntained with their participation. It may not
\nbe acceptable to everybody that \u201ctheir find-
\nings\u201d might be used in follow-up studies in
\nareas they do not approve of.
\nIn the context of research projects, we can
\nsystematically distinguish between expected
\nor preferred findings and unexpected find-
\nings with respect to the applied method,
\ndisease status or evidence of a previously
\nCommunication of Results and Incidental Findings in Medical
\nResearch\u00a0\u2013 A European Perspective1
\n202
\nGERMANYMedical Research
\nundiagnosed disease, as well as limitations
\nor new possibilities for therapy.To complete
\nthis attempt at classification,we need to add
\nfindings discovered in the course of a re-
\nsearch project involving healthy volunteers
\nthat are not related to the aims of the study.
\nCommunication of results
\nto research participants
\nWhen considering how to deal with the
\nfindings obtained, respect for the dignity of
\nthe persons concerned and for their right
\nto informational self-determination should
\nbe given priority. The idea that\u00a0\u2013 from an
\n\u201cethical\u201d or \u201cmedical\u201d perspective\u00a0\u2013 it is un-
\nacceptable to inform people about negative
\nfindings (especially when they cannot be in-
\nterpreted) is quite common and understand-
\nable. Others argue that unexpected findings
\npointing to a potential disease should be
\ncommunicated to a person even against his
\nor her will, so that appropriate measures can
\nbe taken to preserve that person\u2019s health if
\nnecessary. Such considerations, reasonable
\nthough they may seem, find their limits in
\nprovisions that, in respect for human dig-
\nnity, have been established to protect the
\n\u201cright to know\u201dand the \u201cright not to know\u201d.
\nThese provisions, which have only been in-
\ntroduced in the past few years, do not dif-
\nferentiate between different categories of
\nfindings, as mentioned in the classification
\nproposal above. A systematic distinction is
\nmade between rules with a general scope
\nthat also extend to medicine and medical
\nresearch and provisions that, in the form of
\nlegal or quasi-legal instruments (\u201csoft law\u201d),
\npertain specifically to these areas.
\nGeneral provisions
\nOne example of a legal instrument with a
\ngeneral scope is the German Federal Data
\nProtection Act (Bundesdatenschutzgesetz).
\nThis Act stipulates the obligation to inform
\nindividuals about recorded data relating to
\nthem (Section 34). This obligation is ex-
\npressly linked to the person concerned in
\nmaking a request to be informed about the
\ndata. If no such request is put forward, there
\nis no obligation to inform.At the same time,
\nthis right granted by Section 34 may not be
\nexcluded or restricted by a legal transaction
\n(Section 6), such as an agreement between
\nthe researcher and the research participant.
\nThe cited provisions\u00a0\u2013 which also apply to
\nmedical research without restriction\u00a0\u2013 bind
\nthe owner of the data, whether they are a
\nmedical researcher or a member of any oth-
\ner scientific discipline, to provide informa-
\ntion on request. The waiver of this right to
\ninformation, which can be found in many
\ncontracts with research participants, con-
\nflicts with the cited Section 6, and should
\ntherefore be considered invalid.
\nSpecific provisions
\nThe current version of the Declaration
\nof Helsinki [World Medical Association
\n2008] clearly states that \u201cpatients\u201d entered
\ninto a study are entitled to be informed
\nabout the outcome of the study (Paragraph
\nNo. 33). The guidelines issued by CIOMS
\n[Council for International Organizations of
\nMedical Sciences 2002] stipulate that the
\nresearch protocol (Appendix 1, Item\u00a0 34)
\nmust include \u201cplans to inform subjects
\nabout the results of the study\u201d. Hence, it
\ncan be acknowledged that two prominent
\nand widely accepted instruments of \u201csoft
\nlaw\u201d postulate an obligation to inform re-
\nsearch participants about research findings.
\nIn particular, the definition established
\nin the Declaration of Helsinki, which has
\nbeen developed by the medical profession as
\na statement of ethical principles for medical
\nresearch, could help to point the way ahead
\nwhen conflicts arise between the legal obli-
\ngation to inform and \u201cethical\/medical con-
\ncerns\u201dagainst the disclosure of information.
\nBesides,it remains unclear why the Helsinki
\nDeclaration only affirms the patient\u2019s right
\nto information, without explicitly including
\nother test persons (healthy volunteers) as
\nwell. The CIOMS guidelines use the neu-
\ntral term \u201csubjects\u201d, without differentiating
\nbetween the two groups.
\nOn the European level, the primary rule
\ngoverning the handling of data from medi-
\ncine and research in the context discussed
\nhere is Article 101
\n3 of the Oviedo Con-
\nvention [Council of Europe 1997], which
\n30\u00a0members of the Council of Europe have
\nratified to date.
\nAccording to Article 10, \u201ceveryone is en-
\ntitled to know any information collected
\nabout his or her health. However the wishes
\nof individuals not to be so informed shall be
\nobserved.\u201d Article 10 further provides that
\n\u201cin exceptional cases, restrictions may be
\nplaced by law\u201d on the exercise of the afore-
\nmentioned rights \u201cin the interests of the
\npatients\u201d. It should be noted that this provi-
\nsion, besides establishing the right to obtain
\nexhaustive information on all recorded data,
\nexplicitly codifies the right not to know.
\nNo such explicit stipulation is contained in
\neither of the other aforementioned docu-
\nments. In general, the right not to know is
\nconsidered as an element of informational
\nself-determination, requiring no specific
\nwording. Article 10 of the Oviedo Conven-
\ntion provides that in exceptional cases, both
\nrights may be restricted for the benefit of
\nthe patient, namely on a legal basis. Article
\n10 grants rights to the persons concerned,
\nwithout naming those who must comply
\nwith them. This suggests that anyone who
\ndisposes of the collected information\u00a0 \u2013
\nwhether a medical researcher or a member
\nof any other scientific discipline\u00a0\u2013 must ful-
\n1 \u201cPrivate life and right to information:
\na. Everyone has the right to respect for private
\nlife in relation to information about his or her
\nhealth.
\nb. Everyone is entitled to know any information
\ncollected about his or her health. However,
\nthe wishes of individuals not to be so in-
\nformed shall be observed.
\nc. In exceptional cases, restrictions may be
\nplaced by law on the exercise of the rights
\ncontained in paragraph 2 in the interests of
\nthe patient.\u201d (Convention on Human Rights
\nand Biomedicine, Article 10).
\n203
\nGERMANY Medical Research
\nfil the obligation to provide information on
\nthe one hand,and to respect the right not to
\nknow on the other.Thus,anyone who deems
\nit necessary to deviate from this principle
\nshould (even if there may be good reasons in
\nindividual cases) first make sure that there is
\na legal basis for doing so. It should also be
\nborne in mind that the Oviedo Convention
\nonly allows for such deviations if they are in
\nthe interests of the patient.
\nThe Additional Protocol to the Oviedo
\nConvention on \u201cBiomedical Research\u201d
\n[Council of Europe 2005], is\u00a0 \u2013 like the
\nConvention itself\u00a0\u2013 an instrument of Inter-
\nnational Law, and hence legally binding in
\ncountries that have ratified it. With regard
\nto the right to information, the Protocol
\nspecifies the framework conditions laid
\ndown in Article 10 by adding more detailed
\nprovisions. The Chapter on information
\nfor research participants\u00a0 \u2013 which makes
\nno distinction between patients and other
\ntest persons (healthy volunteers)\u00a0\u2013 explicitly
\nstates that it must be made comprehensible
\nto participants how they can get access to
\ninformation that is relevant to them, as well
\nas to the overall research project results (Ar-
\nticle 13.2).The ethics committee must veri-
\nfy that this requirement has been met when
\nevaluating the research project in question.
\nThe Appendix to the Research Protocol
\n(\u201cInformation to be given to the ethics
\ncommittee\u201d) specifies the details of this re-
\nquirement by referring to the relevance of
\nthe generated information to the present
\nor future health of the research participants
\nand their family members.
\nThe Additional Protocol on Biomedical Re-
\nsearch emphasises the research participant\u2019s
\nright to be informed in three articles cov-
\nering different areas. To begin with, Article
\n26 of the Protocol reaffirms the right of re-
\nsearch participants \u201cto know any informa-
\ntion collected on their health in conformity
\nwith Article 10 of the Convention.\u201dThe text
\nrefers to \u201cresearch participants\u201d, i.e. no dis-
\ntinction is made between patients and test
\npersons (healthy volunteers). Since refer-
\nence is made to Article 10, the right not to
\nknow is secured, too. Data collected in the
\ncourse of the project that are not health-
\nrelated shall be made accessible to the per-
\nson concerned, in accordance with national
\nlaw.The main objective here is to guarantee
\nthe rights of Third Parties to the results ob-
\ntained. Article 27 regulates the handling of
\ninformation on research results that are of
\nrelevance to the present or future health or
\nquality of life of research participants. Such
\ninformation is to be offered to the person
\nconcerned within a framework of health
\ncare or counselling; confidentiality and the
\nright not to know are to be respected.
\nThe obligation to offer the information
\nto research participants is not limited to a
\nparticular profession. Physician-researchers
\nand researchers from other disciplines are
\nequally bound to make this offer; only the
\ndisclosure itself shall take place within a
\nframework of health counselling. Since ref-
\nerence is made to Article 10 of the Con-
\nvention, it is made clear that in the context
\nof information disclosure also, the right to
\nknow and the right not to know may only
\nbe restricted under the provisions contained
\ntherein.
\nFinally, the conclusions of the research
\nproject must be made available to the par-
\nticipants\u00a0 \u2013 again, no distinction is made
\nbetween patients and test persons (healthy
\nvolunteers)\u00a0\u2013 on request (Article 28 of the
\nProtocol). Further, Article 28 refers to the
\nobligations to submit a report to the ethics
\ncommittee on completion of the research,
\nand to take measures to make the results
\npublic.
\nConclusions
\nThe provisions which have been addressed\u00a0\u2013
\nwhether they are legally binding or \u201csoft
\nlaw\u201d instruments, and whether they are
\nbased on data protection law or have been
\nspecifically established for the areas of
\nmedicine and medical research\u00a0\u2013 allow for
\nthe statement that everybody has the right
\nto be informed about any data collected on
\nhis or her health. To this end, the legal in-
\nstruments of the Council of Europe provide
\ndetailed guidelines pertaining to medical
\nresearch. The authors deemed it necessary
\nto adopt detailed regulations in order to
\nguarantee right to informational self-deter-
\nmination and to avoid the possibility that
\nresearchers circumvent this right by making
\ndecisions that may well be morally justifi-
\nable in certain cases, but which may also be
\nsomewhat arbitrary in nature. Information
\non collected data relating to health and to
\nthe conclusions of a research project is to
\nbe provided to the persons concerned on
\nrequest.
\nThe obligation to offer information to the
\nresearch participant only applies in the case
\nof findings of relevance to the health of the
\nperson concerned. The research protocols,
\nwhich are submitted to the ethics commit-
\ntee for evaluation, must specify how the
\nprocess of disclosure will be managed.
\nWhen a research participant requests to be
\ninformed, he or she exercises his\/her right
\nto know.The exercise of this right cannot be
\nrestricted or invalidated by means of a waiv-
\ner signed by the participant\u00a0\u2013 at least not
\nunder German data protection law. Here,
\nthe right not to know comes into play: It
\nmust be respected, even in the case of find-
\nings and research outcomes that are of rele-
\nvance to the health of the person concerned.
\nFrom the author\u2019s point of view, the cre-
\nators of these different provisions have set
\nclear standards to substantiate the right to
\ninformational self-determination, which is
\nassociated with the autonomy of the person.
\nA responsible person must be able to decide
\nfor himself\/herself what he or she does or
\ndoes not want to know, since it is this per-
\nson who has to live with the consequences
\nof, for instance, a disease in an advanced
\nstage that might have been successfully
\ntreated if information\u00a0\u2013 which the person
\nrefused to obtain\u00a0\u2013 had been given. A re-
\n204
\nsponsible person must also decide whether
\nhe or she wants to let the matter rest when
\na research project produces findings that are
\ndifficult or nearly impossible to interpret, or
\nwhether he or she desires further clarifica-
\ntion. It is the responsible person who bears
\nthe risk of a potentially adverse progression
\nof the condition,not the researcher by with-
\nholding this information and of acting con-
\ntrary to law.
\nOf course, these clear provisions\u00a0 \u2013 which
\ndo not yet provide for any exceptions in
\nthe case of incidental findings or inex-
\nplicable findings\u00a0 \u2013 give rise to the ques-
\ntion of morally acceptable conduct in the
\nphysician-researcher. Some rules could be
\nfound in \u201cCodes of Deontology\u201d of physi-
\ncians (in Germany: \u201cBerufsordnungen der
\nLandes\u00e4rztekammern\u201d). It must be noted,
\nhowever, that the right to know and the
\nright not to know are regulated by law and
\ncannot be modified or invalidated by any
\ncode of deontology. With the exception of
\nthe German \u201cBerufsordnung\u201d, such codes of
\ndeontology are not legally binding in any
\nEuropean State. Hence, they do not really
\nprovide a solution to the moral dilemma
\nof either burdening a person by informing
\nthem about findings which may be irrel-
\nevant after all, or\u00a0\u2013 if the right not to know
\nis invoked\u00a0\u2013 of leaving this person with the
\nrisk of a looming disease. But again: This
\nrisk is borne by the responsible person alone.
\nTo conclude, a few remarks are warranted
\nconcerning incidental findings, which occur
\nmore and more frequently in research proj-
\nects in many areas. Such findings are not
\ngiven any special status in the provisions
\ndiscussed above\u00a0\u2013 they are to be treated in
\nthe same way as any other \u201chealth-related
\ninformation\u201d, and the right to know or not
\nto know is to be respected. Sometimes it
\nis argued that incidental findings only oc-
\ncur when certain parameters apply to the
\nresearch project, e.g. the use of imaging
\ntechniques, and that it is impossible to draw
\nconclusions about their medical relevance.
\nIn the author\u2019s opinion, which is substan-
\ntiated by the cited provisions, the person
\nconcerned must be informed in such cases,
\nat least on request. He or she may then
\ndecide whether they want to let the mat-
\nter rest, or whether they prefer to watch
\nfor further developments related to these
\nfindings\u00a0\u2013 for instance in the context of a
\nlong-term observation, which is sometimes
\ndesired by researchers. However, the re-
\nsearcher may not make this decision tacitly
\nor on the participant\u2019s behalf. As regards
\nthe requirement that findings which can-
\nnot be interpreted with the methods used
\nin the research project should be clarified
\nby means of appropriate medical diagnos-
\ntics, this is often objected to on the grounds
\nthat it would involve excessive costs and
\nadministrative effort. However, cost and
\neffort should be considered and budgeted
\nfor when such projects are being planned\u00a0\u2013
\nafter all, we are talking about the weal and
\nwoe of the research participants. The mea-
\nsures envisaged for a medical clarification
\nof incidental findings must be documented
\nin the research protocol, which is submit-
\nted to the ethics committee. It is sometimes
\nargued that, in the context of the research
\nsituation discussed here, the doctor and the
\nresearch participant are not engaged in a
\ntypical physician\/patient relationship, and
\nthat hence there is no obligation to perform
\nfurther medical diagnostics. Whether this
\nsplitting of roles between physicians and
\nphysician-researchers is consistent with
\nthe requirement contained in Item No. 4 of
\nthe Declaration of Helsinki, \u201cThe health of
\nmy patient will be my first consideration\u201d,
\nis something that everybody must judge
\nfor themselves. However, the instruments
\nof the Council of Europe do not allow for
\nsuch splitting. They refer exclusively to the
\n\u201cresearcher\u201d, who has both rights and du-
\nties, or, in more neutral terms, to actions,
\nmeasures etc. to be taken.
\nReferences
\n1. Minister der geistlichen Unterrichts- und
\nMedizinal-Angelegenheiten, Anweisung an die
\nVorsteher der Kliniken, Polikliniken und sonsti-
\ngen Krankenanstalten. Zentralblatt f\u00fcr die gesa-
\nmte Unterrichts-Verwaltung in Preu\u00dfen (1900),
\n188\u2013189
\n2. Heinemann T, Hoppe C, Listl S, Spickhoff A,
\nElger CE, Incidental findings in neuroimaging:
\nEthical problems and solutions. Dtsch Arztebl
\n(2007), 104, A1982\u20137
\n3. Bundesdatenschutzgesetz in der Fassung der
\nBekanntmachung vom 14. Januar 2003 (BGBl. I
\n4. S. 66), das zuletzt durch Artikel 1 des Gesetzes
\nvom 14.August 2009 (BGBl.I S.2814) ge\u00e4ndert
\nworden ist
\n5. World Medical Association (2008) Dec-
\nlaration of Helsinki: Ethical Principles for
\nMedical Research Involving Human Sub-
\njects. Adopted by the 18th
\nWMA General
\nAssembly, Helsinki, Finland, June 1964, and
\namended by the 59th
\nWMA General Assem-
\nbly, Seoul, October 2008. https:\/\/www.wma.net\/
\nen\/30publications\/10policies\/b3\/index.html
\n(26.03.13)
\n6. Council for International Organizations of
\nMedical Sciences (2002) International Ethical
\nGuidelines for Biomedical Research Involving
\nHuman Subjects, Geneva
\n7. Council of Europe (1997) Convention for the
\nprotection of human rights and dignity of the
\nhuman being with regard to the application of
\nbiology and medicine: Convention on human
\nrights and biomedicine. European Treaty Series
\nNo. 164. Oviedo
\n8. Council of Europe (2005) Additional protocol
\nto the convention on human rights and biomed-
\nicine, concerning biomedical research. European
\nTreaty Series No. 195. Strasbourg
\nProf. Elmar Doppelfeld, MD
\nChair of the Working Group
\n\u201cBiomedical Research\u201d, Committee on
\nBioethics (DH-BIO),Chair (2005\u20132007)
\nof the \u201cSteering Committee
\non Bioethics (CDBI)\u201d
\nCouncil of Europe
\nChair (1994\u20132012) of the Permanent
\nWorking Party of Research Ethics
\nCommittees in Germany
\nE-mail: elmar-doppelfeld@t-online.de
\nIn: Lanzerath D et al. (eds) Incidental Findings. Scien-
\ntific, Legal and Ethical Issues. K\u00f6ln: Deutscher \u00c4rzte-
\nVerlag, 2014: 53\u201358.
\nGERMANYMedical Research
\n205
\nForeword
\nThe Merseyside Fire and Rescue Service
\nmade a lasting impression. When conduct-
\ning the Marmot Review of Health Inequal-
\nities, published as Fair Society Healthy Lives,
\nwe partnered with the North West Region
\nof England. On one of our visits to Liver-
\npool, we were hosted by the fire fighters.
\nTheir compelling story was of going outside
\ntheir core professional practice of fighting
\nfires to preventing them, which entailed
\nengaging with the local community. They
\nthen became involved in looking at quality
\nof housing, and at smoking, which are fire
\nrisks, to more general issues that benefit the
\ncommunity, including activities for young-
\nsters and older people.
\n\u201cIf the fire fighters can do it, why not the
\ndoctors?\u201dwas a question I posed to the Brit-
\nish Medical Association, during my time as
\nPresident. Doctors are involved in treating
\nillness but most accept they have an im-
\nportant role in prevention. If illness arises
\nfrom the conditions in which people are
\nborn, grow, live, work, and age \u2013 the social
\ndeterminants of health \u2013 should the doctors
\nnot get involved in the causes of illness and,
\nindeed, the causes of the causes. The BMA
\npicked up the challenge and produced a
\nreport on what doctors could do about the
\nsocial determinants of health. But why stop
\nat doctors? Other health professionals have
\nkey roles to play on improving the condi-
\ntions of people\u2019s lives and hence could have
\nprofound effects on health inequalities.This
\nreport builds on the BMA\u2019s report and the
\ninspiring work of health professionals.
\nFair Society Healthy Lives laid out the evi-
\ndence and made recommendations of what
\nshould be done on the social determinants
\nof health in order to reduce health inequali-
\nties. Many of the recommendations were
\naimed at sectors other than health. But the
\nmedical and health professions are well
\nplaced to take action on the social deter-
\nminants of health\u00a0\u2013 they are trusted, expert,
\ncommitted, and great powerful advocates.
\nOne response to the evidence on social de-
\nterminants of health is weary reluctance\u00a0\u2013
\nit is simply all too difficult. The response
\nwe have had from colleagues who helped
\nus with this report has been far from that.
\nNineteen organisations have contributed,
\nincluding medical Royal Colleges, nurses,
\nmidwives, medical students, and several al-
\nlied health professions. We appear to have
\nstruck a chord. And it is hugely encourag-
\ning.
\nThe response can be summarised as: not
\nonly should we be taking action but there
\nHealth Equity
\nSir Michael Marmot
\nMatilda Allen, Jessica Allen,
\nSue Hogarth with Michael Marmot
\nStatements for action were written by the
\nfollowing:
\n– Nurses by the Royal College of Nursing;
\n– Social workers and social care by the Social
\nWork & Health Inequalities Network;
\n– Clinical Commissioning Groups by the
\nRoyal College of GPs;
\n– General practitioners by the Royal Col-
\nlege of GPs;
\n– Paediatricians by the Royal College of
\nPaediatrics & Child Health;
\n– Midwives by the Royal College of Mid-
\nwives;
\n– Obstetricians and gynaecologists by the
\nRoyal College of Obstetricians and Gyn-
\naecologists;
\n– Hospital doctors by the Royal College of
\nPhysicians;
\n– Psychiatrists by the Royal College of Psy-
\nchiatrists;
\n– Dentists and the oral health team by
\nthe Faculty of Dental Surgery, Royal
\nCollege of Surgeons of England; Den-
\ntal Faculty, Royal College of Surgeons
\nof Edinburgh; Dental Faculty, Royal
\nCollege of Physicians and Surgeons of
\nGlasgow; Faculty of General Dental
\nPractice, Royal College of Surgeons of
\nEngland; Dental Schools Council; Brit-
\nish Association for the Study of Com-
\nmunity Dentistry;
\n– Medical students by Medsin
\n– Allied health professionals by the Allied
\nHealth Professions Federation with sec-
\ntions on: Music therapists by the British
\nAssociation of Music Therapy, Dieticians
\nby the British Dietetic Association, Oc-
\ncupational therapists by the College of
\nOccupational Therapists, Physiothera-
\npists by the Chartered Society of Phys-
\niotherapy, Paramedics by the College of
\nParamedics, Radiographers by the Soci-
\nety and College of Radiographers,Speech
\nand language therapists by the Royal Col-
\nlege of Speech and Language,Therapists.
\nWorking for Health Equity:The Role of Health Professionals
\n206
\nHealth Equity
\nis ample evidence that we can. This report
\nshows the evidence base for actions,the case
\nstudies present examples of organisations
\nwith effective strategies, and the statements
\nfor action put forward practical actions.
\nThe report and statements make clear that
\naction on the social determinants of health
\nshould be a core part of health profession-
\nals\u2019 business, as it improves clinical out-
\ncomes, and saves money and time in the
\nlonger term. But, most persuasively, tak-
\ning action to reduce health inequalities is
\na matter of social justice. The enthusiastic
\nresponse from medical and health profes-
\nsionals to the challenges of a fairer distri-
\nbution of health contributes to what I have
\ndescribed as my evidence-based optimism:
\nwe are making progress in a good cause.
\nJoin us.
\nProfessor Sir Michael Marmot
\nDirector of the UCL Institute
\nof Health Equity
\nExecutive Summary
\nThose in the health sector regularly bear
\nwitness to, and must deal with, the effects of
\nthe social determinants of health on people.
\nThis report will demonstrate that the health
\ncare system and those working within it
\nhave an important and often under-utilised
\nrole in reducing health inequalities through
\naction on the social determinants of health.
\nThe health workforce are, after all, well
\nplaced to initiate and develop services that
\ntake into account, and attempt to improve,
\nthe wider social context for patients and
\nstaff.
\nThis report launches a new programme
\nof activities to tackle health inequalities
\nthrough action by health professionals on
\nthe social determinants of health. It draws
\non many examples of inspiring and excel-
\nlent practice which demonstrate what can
\nbe done. The report describes areas where
\ngreater action is necessary and possible and
\nmakes some practical suggestions about
\nhow to take forward action on the social
\ndeterminants of health.
\nThe report contains recommendations and
\nanalysis in six core areas, described below. It
\nalso contains nineteen Statements for Ac-
\ntion about actions health professionals can
\ntake to tackle the social determinants of
\nhealth through their practitioner role.These
\nhave been written by Royal Colleges and
\nother representative organisations, and set
\nout, for each profession, a rationale for ac-
\ntion, practical guidance on what activities to
\nengage in, and relevant case studies and fur-
\nther reading. Working with the authors of
\nthese statements, and other organisations,
\nthe Institute of Health Equity (IHE) will
\nsupport and encourage health profession-
\nals to take greater action to tackle health
\ninequalities.
\nThe report also sets out a series of com-
\nmitments made specifically for this report
\nand future work programme, from twenty
\nrelevant organisations. These cover each
\nof the six priority areas in this report, and
\ndisplay an impressive ambition to take
\nforward action on the social determinants
\nof health. Organisations have committed
\nto work in partnership to implement the
\nrecommendations of this report by pro-
\nducing educational materials, developing
\nnew research and publications, setting up
\nnetworks, embedding the social determi-
\nnants of health in current work and dis-
\nseminating information to health profes-
\nsionals. These commitments are described
\nthroughout the document at the ends of
\nchapters, and a full list can be found on
\nthe IHE website (1). They will form the
\nbasis for an on-going programme of work
\nled by IHE in partnership with Royal Col-
\nleges, the Academy of Medical Royal Col-
\nleges (AoMRC), the British Medical As-
\nsociation (BMA), the Canadian Medical
\nAssociation (CMA), the World Medical
\nAssociation (WMA), and other organisa-
\ntions and institutions. These commitments
\nwill extend and develop over time, but are
\nincluded in the full report in their current
\nform in order to give an indication of fu-
\nture steps. As we continue the programme
\nof work over the next few years, these will
\nbe developed, tested and implemented fur-
\nther.
\nBackground
\nEvidence presented in the Marmot Review
\n2010 (2), and many other evidence-based
\nanalyses of health inequalities (3\u20136) show
\na clear social gradient in health outcomes,
\nwhich closely relates to social and economic
\nfactors: the conditions of daily life. Most of
\nthe factors influencing health lie outside the
\nimmediate reach and traditional remit of
\nthe health system \u2013 early-years experiences,
\neducation, working life, income and living
\nand environmental conditions. The recom-
\nmendations of the Marmot Review were
\ntherefore mainly focussed on actions which
\ncould be taken outside the health care sys-
\ntem to reduce health inequalities. This re-
\nport now focuses on actions and strategies
\nthat can be developed within the health care
\nsystem, and particularly the health work-
\nforce, where there is great scope. It builds
\non and learns from other recent initiatives
\n(7\u20139).
\nWhile inequities in access and care within
\nthe NHS do exist, they do not account for
\na large proportion of health inequality, par-
\nticularly when compared to the powerful
\ninfluence of social and economic factors on
\nhealth (10\u201312). This report demonstrates
\nthat there is much that the health system
\ncan do to influence these wider social and
\neconomic factors,beyond ensuring equity of
\naccess and treatment.Those working within
\nthe health system have an important, albeit
\noften under-utilised, role in reducing health
\n207
\nHealth Equity
\ninequalities through action on the social
\nand economic factors: the social determi-
\nnants of health. Tackling health inequity is
\na matter of social justice; it is also essential
\nin order to provide the best care possible.
\nPreventive measures that improve the con-
\nditions in which people live can lengthen
\npeople\u2019s lives and years spent in good health,
\nimprove services and save money (2).
\nThe report is based on literature, case stud-
\nies, and other evidence about how health
\nprofessionals and organisations can influ-
\nence social determinants and tackle health
\ninequalities in a systematic and effective
\nway. Many relevant organisations have had
\ndirect input into the report, and this input
\nforms much of the basis for the analysis and
\nrecommendations. We organise this analy-
\nsis into six areas in which actions will be
\nparticularly effective: education and train-
\ning, working with individuals, action by
\nNHS organisations, working in partnership,
\nworkforce as advocates, and opportunities
\nand challenges within the health system.
\nThese are described briefly below and in
\ngreater detail in the main report, where they
\nare also accompanied by case studies, rec-
\nommendations and commitments.
\nPart A. Ways for health professionals
\nto take action on health inequalities
\n1 Workforce education and training
\nIn order for the health workforce to suc-
\ncessfully tackle health inequalities and take
\naction on the social determinants of health,
\nthe right education and training are essen-
\ntial. Good education on the social determi-
\nnants of health will not only inform but also
\nempower the health workforce to take ac-
\ntion. Changes should take place within un-
\ndergraduate education, postgraduate educa-
\ntion, Continued Professional Development,
\nand other forms of training.
\nThere are two important actions in this
\narea. Firstly, professionals should be taught
\nabout the nature of the social determi-
\nnants of health, and what actions by those
\nwithin, and outside, the health system have
\nbeen successful in tackling them. Educa-
\ntion should include information about the
\ngraded distribution of health outcomes,
\nhow social and economic conditions can
\nhelp to explain these unequal outcomes,
\nand what practical actions can be undertak-
\nen by health professionals to decrease these
\ninequalities. This teaching should take the
\nform of dedicated compulsory and assessed
\nmodules, and should be included in other
\nspecialised courses, for instance a course on
\ncardiovascular disease should include infor-
\nmation on the social determinants of that
\ndisease (13).
\nThis first area can then be supplemented
\nby a second action, the teaching of skills:
\nthat is, how to reduce inequalities within
\nprofessional practice areas. Some necessary
\nskills are more general and have broad ap-
\nplication \u2013 for example, skills of commu-
\nnication, partnership and advocacy are all
\nessential for tackling health inequalities.
\nThere are also specific strategies which
\nhave been shown to be effective, for exam-
\nple, taking a social history and making pa-
\ntient referrals to external support services.
\nTeaching skills in these specific practice-
\nbased areas should be a core element of all
\nhealth courses.
\nSeeing the effects of social and economic
\ninequalities will ground and \u2018realise\u2019 the
\nknowledge described above. For this reason,
\nstudent placements are central to learning.
\nThey should take place in a range of non-
\nclinical settings, for example with social
\nservices or with a debt advice service, and
\nshould be designed to expose students to
\ndisadvantaged areas and needs.It is also im-
\nportant that access to health professions is
\nmade more equal.
\nWithin England, action across the areas
\ndiscussed above is the responsibility of
\nHealth Education England, Local Edu-
\ncation and Training Boards, the General
\nMedical Council,medical schools,NHS or-
\nganisations, and professionals and students
\nin advocacy roles. IHE will work with these
\norganisations to embed the recommenda-
\ntions below.
\nKey recommendations:
\nWorkforce Education and Training
\nKnowledge
\nA greater focus on information about
\nthe social determinants of health, and
\ninformation on what works to tackle
\nhealth inequities, should be included as
\na mandatory, assessed element of under-
\ngraduate and postgraduate education.
\nSkills
\nCommunication, partnership and advo-
\ncacy skills are all general areas that will
\nhelp professionals to tackle the social de-
\nterminants of health. Thereare also spe-
\ncific practice-based skills, such as taking
\na social history and referring patients to
\nnon-medical services, which should be
\nembedded in teaching in undergraduate
\nand postgraduate courses.
\nPlacements
\nStudent placements in a range of health
\nand nonhealth organisations, particular-
\nly in deprived areas,should be a core part
\nof every course.This will help to improve
\nstudents\u2019 knowledge and skills related to
\nthe social determinants of health.
\nContinued Professional Development
\nBoth knowledge about the social de-
\nterminants of health and skills to tackle
\nthese should be taught and reinforced as
\na compulsory element of CPD.
\nAccess
\nUniversities should take steps to ensure
\nthat students from all socio-economic
\nbackgrounds have fair access to health
\ncare careers.
\n208
\n2 Working with individuals and commu-
\nnities
\nThe Marmot Review showed that if the
\nconditions in which people are born, grow,
\nlive, work, and age are favourable, and dis-
\ntributed more equitably, people would have
\nmore control over their lives in ways that
\nwill influence their own health and health
\nbehaviours, and those of their families. In-
\ndividual health professionals can tackle the
\nsocial determinants of health by helping to
\ncreate the conditions in which their patients
\ncan have control over their lives.
\nIt is important that health professionals
\nbuild relationships of trust and respect with
\ntheir patients.This is good for the patient as
\ncontrol and reducing stress can have direct
\neffects on health (14).It can also improve the
\nuptake of public health messages and other
\nstrategies to reduce inequalities. Greater
\ncommunication and better relationships can
\nalso enhance practitioners\u2019 knowledge and
\nunderstanding of their patients and the lo-
\ncal community, thereby improving the care
\nthat they are able to offer. Techniques such
\nas motivational interviewing, a method that
\nincreases communication and collaboration
\nbetween patients and providers, can help to
\nbuild these relationships on an individual
\nlevel. On a community level, professionals
\nshould be promoting and engaging in col-
\nlaboration and communication with the lo-
\ncal population.
\nIn taking action to reduce inequalities,
\nhealth professionals can focus on two key
\nactivities: gaining information, and pro-
\nviding information. Gaining information
\nabout patients is important in order to un-
\nderstand how social and economic factors
\nare impacting on a patient\u2019s health.Taking a
\nsocial history can enhance a medical history
\nand enable professionals to provide the best
\ncare possible. This type of information is
\nalso essential on an aggregate basis, as it can
\nhelp to influence and inform local commis-
\nsioning and provision, both of health care
\nand of other services within the community.
\nLongitudinal social data can also enable
\norganisations to measure progress and the
\neffectiveness of interventions against health
\nequity indicators.
\nGiving information that can help to im-
\nprove the social determinants of health
\nmainly consists of referring patients to non-
\nmedical services.These should cover a broad
\nrange of sectors and issues, beyond lifestyle
\nand disease management programmes. For
\nexample,referral to Legal Aid,Relate,CAB,
\nemployment programmes or housing ad-
\nvice services can help patients to tackle the
\nsources of ill health. By connecting patients
\nto professional advice about state benefits,
\nhealth professionals can ease patient anxiety
\nand stress (15) and improve the context in
\nwhich they live. Other referrals can help to
\ntackle other social determinants of health.
\nSuch activity may reduce the number of
\nconsultations with and prescriptions from
\nGPs (16). Referral of this type is particu-
\nlarly successful where the services are read-
\nily accessible or medical and non-medical
\nservices are co-located \u2013 for example, where
\nCitizens Advice Bureaux are situated in GP
\nsurgeries.
\nThere will be two types of changes needed:
\nthose requiring increased resources of time
\nand money, and those that can be accom-
\nmodated within existing structures and
\nconstraints. In the first case, professionals
\nshould be advocating for change and help-
\ning to build an evidence base to support
\nthe case. However, some changes can and
\nshould be made within existing structures
\nand constraints.
\n3 NHS organisations
\nIn addition to actions taken to improve
\nthe health and wellbeing of their patients,
\nNHS organisations have a responsibility
\nto ensure that health inequities among
\ntheir employed staff are also tackled. The
\nNHS is the largest employer in the coun-
\ntry with 1.4 million staff (17), plus staff
\nemployed in non-NHS commissioned
\nservices. Health professionals have oppor-
\ntunities in their roles as managers, com-
\nmissioners and employers to ensure that
\nworkforce health and wellbeing are central
\nto their activities.
\nFirstly, NHS organisations should be places
\nof good quality work. Evidence has consis-
\ntently shown that employment is better for
\nmental and physical health than unemploy-
\nment. However, this only applies to good
\nquality work (2).Good quality work is char-
\nacterised by a living wage, having control
\nover work, being respected and rewarded,
\nbeing provided with good quality in-work
\nKey recommendations:
\nFiorking with Individuals and Commu-
\nnities
\nRelationships
\nHealth professionals should build rela-
\ntionships of trust and respect with their
\npatients. They should promote collabo-
\nration and communication with local
\ncommunities to strengthen these rela-
\ntionships.
\nGathering information
\nHealth professionals should be taking a
\nsocial history of their patients as well as
\nmedical information. This should then
\nbe used in two ways: to enable the prac-
\ntitioner to provide the best care for that
\npatient, including referral where neces-
\nsary; and at aggregate level to help or-
\nganisations understand their local popu-
\nlation and plan services and care.
\nProviding information
\nHealth professionals should refer their
\npatients to a range of services \u2013 medi-
\ncal, social services, other agencies and
\norganisations, so that the root causes of
\nill health are tackled as well as theback-
\ngrounds have fair access to health care
\ncareers.
\nHealth Equity
\n209
\nservices such as occupational health servic-
\nes, and with adequate support to return to
\nwork after absence.
\nThe importance of these areas was recog-
\nnised by Carol Black\u2019s review of the UK\u2019s
\nworking age population (18), and was ap-
\nplied to NHS workplaces in the Boorman
\nReview (19). Managers should be ensuring
\nthat all staff, including contracted staff, are
\nprovided with good quality work in line
\nwith the recommendations of the Boorman
\nReview. IHE have produced a strategy for
\nBarts and the London Trust which set out
\nhow to implement the recommendations
\nof the Boorman Review and the Marmot
\nReview (22). Implementing these strate-
\ngies across the workforce is likely to reduce
\ninequalities as there is a gradient in quality
\nof work: those from lower socio-economic
\ngroups currently tend to experience worse
\nquality work.
\nNHS organisations, and therefore their
\nstaff, have considerable influence through
\ntheir sizeable purchasing power, both as
\nemployers and contractors of staff and as
\ncommissioners of services. One literature
\nreview found that the health sector often
\naccounts for 15\u201320% of a local commu-
\nnity\u2019s employment and income (20). This
\ngives health organisations significant power
\nto affect the health and wellbeing of their
\nlocal population. Public bodies also have
\na legal duty to consider how procurement
\nmight improve the economic, social and
\nenvironmental wellbeing of their area (21).
\nEmployment should be designed to be par-
\nticularly beneficial for those from lower
\nsocio-economic groups, as this will reduce
\ninequalities. In addition to providing a good
\nquality place of work, this can be achieved
\nby ensuring that there is security and flex-
\nibility of employment and retirement age,
\nand that jobs are suitable for lone parents,
\ncarers and people with mental and physical
\nhealth problems (22).
\nThis report outlines many actions that can
\nbe taken by individual health professionals.
\nThey can start to take most of these actions
\nstraight away. However, in order for action
\nto be comprehensive, systematic and sus-
\ntained, these actions must be supported at
\nevery level. For this reason, managers and
\nleaders should ensure that strategies on or-
\nganisational health inequalities that incor-
\nporate the areas in this report are in place,
\nwith dedicated leads and budgets. They
\nshould be auditing proposed actions, moni-
\ntoring progress and sharing good practice.
\n4 Working in Partnership
\nIn order to take effective action to reduce
\ninequalities, working in partnership is es-
\nsential. Evidence shows that effective ac-
\ntion often depends on how things are de-
\nlivered, as much as what is delivered (2). A
\nkey element of this is collaborative, coop-
\nerative work that is either delivered jointly
\nby more than one sector, or draws on in-
\nformation and expertise from other sectors.
\nSince many of the causes of ill health lie
\nin social and economic conditions, actions
\nto improve health must be taken collab-
\noratively by a range of agencies that have
\nthe potential to affect social and economic
\nconditions.
\nMany health professionals work extensively
\nand successfully with other health care staff.
\nThese partnerships within the health system
\noften extend across primary, secondary and
\ntertiary care; between nurses, psychiatrists,
\ndoctors, surgeons and more; and are a core
\npart of day-to-day business for practising
\nprofessionals. Partnerships should occur be-
\ntween different organisations, for example
\nhospitals and community health services,
\nand different professionals in the same or-
\nganisation.They can help to improve patient
\nexperience and practitioner knowledge, and
\nreduce inequalities in outcomes.
\nHowever, perhaps more importantly, part-
\nnerships between health and non-health
\nprofessionals and organisations should be
\nestablished, supported and extended. Inte-
\ngrated work should be broad, and include
\npartnerships with local government, other
\npublic sector partners, the police and fire
\nservice, charities and other third sector or-
\nganisations, private companies and places of
\nwork, and schools (2). There is a legal duty
\non Clinical Commissioning Groups and the
\nNHS Commissioning Board to integrate
\nservices where this would reduce inequali-
\nties (23), and other professionals should
\nwork to support and extend this. Infor-
\nmation-gathering and monitoring systems
\nshould be collaborative where possible.Joint
\nplanning, commissioning and delivery are
\nparticularly important for effective partner-
\nships.Collaborative local strategies can pro-
\nvide effective ways of reaching shared goals
\nand providing excellent services, as well as
\nreducing inequalities, although partnerships
\nmust be carefully designed and assessed in
\norder to ensure effectiveness (24).
\nEarly years and childcare health are impor-
\ntant examples of the value and necessity of
\nKey recommendations:
\nNHS Organisations
\nHealth professionals should utilise their
\nroles as managers and employers to en-
\nsure that:
\n\u2022 Staff have good quality work, which
\nincreases control, respects and rewards
\neffort, and provides services such as
\noccupational health.
\n\u2022 Their purchasing power, in employ-
\nment and commissioning, is used to
\nthe advantage of the local population,
\nusing employment to improve health
\nand reduce inequalities in the local
\narea.
\n\u2022 Strategies on health inequalities are
\ngiven status at all levels of the organ-
\nisation, so the culture of the institu-
\ntion is one of equality and fairness,
\nand the strategies outlined elsewhere
\nin this document are introduced and
\nsupported.
\nHealth Equity
\n210
\npartnership working. In order to tackle the
\nroot causes of ill health effectively, action
\nearly on in life is essential. This can change
\nthe conditions in which children are born
\nand grow, and the care and opportunities
\nthat are made available to them. In order to
\ntake action in this area, partnerships should
\nbe established between Children\u2019s Centres,
\nschools,social care,health visitors,midwives
\nand other health professionals. When these
\ndifferent sectors communicate effectively,
\ndeliver joint programmes and tackle indi-
\nvidual problems in a collaborative way, out-
\ncomes tend to improve (25).
\nSince the passage of the Health and Social
\nCare Act 2012, a new form of partnership
\nhas been established \u2013 Clinical Commis-
\nsioning Groups (CCGs). These are locally
\nbased consortia, made up of GP practices,
\nwhich will commission care for the local
\ncommunity (26). The doctors and nurses
\nwho sit on CCGs have three important
\nways to tackle health inequalities: through
\ntheir actions as health professionals; in
\ntheir role on the CCGs, which includes
\nmaking commissioning decisions; and in
\nthe way they use the CCG as a local ad-
\nvocacy and community asset. If CCGs and
\nprofessionals are aware of and responsive
\nto the social determinants of health in
\ntheir local area, they will be able to tackle
\nhealth inequalities while delivering clinical
\nservices.
\n5 Workforce as advocates
\nEvery health professional has the potential
\nto act as a powerful advocate for individu-
\nals, communities, the health workforce, and
\nthe general population. Since many of the
\nfactors that affect health lie outside the
\nhealth sector \u2212 in early-years experiences,
\neducation, working life, income and living
\nand environmental conditions \u2212 health pro-
\nfessionals may need to use their positions
\nboth as experts in health and as trusted,
\nrespected professionals to encourage or in-
\nstigate change in other areas. The medical
\nRoyal Colleges have a clear advocacy func-
\ntion, and regularly petition government for
\npolicy changes on behalf of their members
\nand their patients. However, advocacy is
\nalso powerful and important for health stu-
\ndents, qualified professionals, CCGs, NHS
\norganisations and other professional bodies
\nsuch as unions.
\nActing as an advocate for individual pa-
\ntients and their families is often particu-
\nlarly helpful to improve the conditions in
\nwhich people live. Professionals can use
\ntheir understanding of the factors that are
\ninfluencing a patient\u2019s health, and act as
\nadvocate in order to help these patients to
\naccess services both within and outside the
\nhealth service. In a similar way, advocacy
\non behalf of communities is also impor-
\ntant.
\nThe actions proposed in this report will be
\nmost effective where they are adopted wide-
\nly and supported at all levels \u2013 from central
\nto local and individual arenas. This will en-
\nsure that strategies are in place to instigate
\nchange, to regulate action, to measure and
\nreward progress, and to learn from oth-
\ners. This will require, in some cases, action
\nthat is beyond the remit of the individual
\nprofessional. In these cases, professionals
\nshould use their position to advocate for the
\nchanges that are necessary,both within their
\nKey recommendations:
\nWorking in Partnership
\nWithin health sector
\nPartnerships within the health sector
\nshould be consistent, broad and focussed
\non the social determinants of health.
\nWith external bodies
\nPartnerships between the health sector
\nand other agencies are essential \u2013 they
\nshould be maintained, enhanced, and
\nsupported by joint commissioning, data-
\nsharing and joint delivery. They must,
\nhowever, be well designed and assessed
\nfor impact.
\nClinical Commissioning Groups
\nCCGs should make tackling health in-
\nequalities a priority area, and should
\nmeasure their progress against this aim.
\nThey can do this via their role as com-
\nmissioners, in partnership (particularly
\nwith Health and Wellbeing Boards), and
\nas a local community employer and ad-
\nvocate.
\nKey recommendations:
\nWorkforce as advocates
\nFor individuals
\nIndividual health professionals and
\nhealth care organisations should, where
\nappropriate, act as advocates for indi-
\nvidual patients and their families.
\nFor changes to local policies
\nIndividual health professionals and
\nhealth care organisations such as lo-
\ncal NHS Trusts should act as advocates
\nfor their local community, seeking to
\nimprove the social and economic con-
\nditions and reduce inequalities in their
\nlocal area.
\nFor changes to the health profession In-
\ndividual health professionals, students,
\nhealth care organisations such as NHS
\nTrusts and pro- fessional bodies such as
\nmedical Royal Colleges and the BMA
\nshould advocate for a greater focus on
\nthe social determinants of health in
\npractice and education.
\nFor national policy change
\nIndividual health professionals, students
\nand professional bodies such as medi-
\ncal Royal Colleges should advocate for
\npolicy changes that would improve the
\nsocial and economic conditions in which
\npeople live, and particularly those that
\nwould reduce inequalities in these con-
\nditions.They should target this advocacy
\nat central government, and bodies such
\nas the NHS Commissioning Board.
\nHealth Equity
\n211
\norganisation, and within other local bodies
\nor central systems. For example, changes to
\neducation, as outlined above, will need the
\nsupport and backing of health students and
\nprofessionals.
\nHealth professionals have great author-
\nity and expertise, and should also be us-
\ning this to advocate for policies that will
\nreduce health inequalities and against
\npolicies that will widen them. This should
\nbe targeted at central government depart-
\nments as they consider policy change, but
\nalso towards newly formed bodies such as
\nthe NHS Commissioning Board, which are
\ncurrently considering what to prioritise and
\nwhat strategies to adopt. With concerted
\npressure from health professionals and the
\nbodies that represent them, we have a great
\nopportunity to ensure that tackling health
\ninequalities is a central concern across the
\npolicy spectrum, and that all bodies con-
\nsider the health equity impact of new and
\nexisting policies.
\n6 The health system \u2013 challenges and op-
\nportunities
\nThe Health and Social Care Act of April
\n2012 has led to significant changes in
\nstructure, provision, incentives, regulation,
\ncommissioning and monitoring within the
\nhealth system (23). While the changes are
\nchallenging and disruptive, there are also
\nnew opportunities to tackle health in-
\nequalities and to embed an approach based
\non the social determinants of health across
\nthe new system.The new legal duties in the
\nHealth and Social Care Act can act as an
\nimportant lever in encouraging action. In
\nexercising their functions, the NHS Com-
\nmissioning Board and Clinical Commis-
\nsioning Groups must have regard to the
\nneed to reduce inequalities, both in terms
\nof access and health outcomes of patients.
\nThey must also secure integrated provision
\nof services, both within the health system
\nand beyond it, where this would reduce
\ninequalities in access or outcomes. In ad-
\ndition, there are duties on the Secretary
\nof State, Monitor and NHS Foundation
\nTrusts, all of whom must integrate these
\nduties into their plans and report progress
\non them annually (23). The Equality Act
\n2010 states that public sector bodies \u201cmust,
\nwhen making decisions of a strategic na-
\nture about how to exercise its functions,
\nhave due regard to the desirability of ex-
\nercising them in a way that is designed to
\nreduce the inequalities of outcome which
\nresult from socio-economic disadvantage.\u201d
\n(27). These duties mean that work by the
\nNHS workforce to tackle health inequali-
\nties should be integrated into organisa-
\ntional strategies and plans, as well as being
\nincentivised and monitored. Unfortunately,
\nother mechanisms may make this harder.
\nFor example, the Quality Outcomes
\nFramework is a powerful incentive sys-
\ntem but tends to measure certain outputs
\nrather than patient outcomes, weakening
\nits potential to reduce health inequalities.
\nOn the other hand, the Public Health
\nOutcomes Framework includes important
\nsocial determinants of health indicators,
\nbut is not linked to financial incentives
\nor requirements, decreasing its potential
\nto leverage change and increase impact.
\nThere are other mechanisms which may
\nprovide opportunities or challenges: the
\nNHS Commissioning Board and the NHS
\nmandate, the NHS constitution, funding
\nand allocation arrangements, monitoring
\nand data-sharing procedures, and various
\nmechanisms that impact on health edu-
\ncation. This chapter in the full report sets
\nout some initial conclusions from a work-
\ning paper, which is available on the IHE
\nwebsite (1). IHE will be developing this
\nanalysis as part of the \u2018Working for Health
\nEquity\u2019 programme.
\nPart B. Professions:
\nStatements for action
\nThe analysis set out in this report has been
\nlargely welcomed by health professionals
\nand their representative organisations. But
\nthere is a need for health professionals to
\nhave brief, practical guidance for tackling
\nhealth inequalities through the social de-
\nterminants of health. To inform this report
\nwe asked Royal Colleges and other organ-
\nisations to provide statements for action, to
\ngive practical accessible guides for particu-
\nlar professionals to develop and use in their
\nroles. The result of an enthusiastic response,
\nnineteen statements for action by different
\norganisations are set out in the main report.
\nThese statements also include a rationale
\nfor action, case studies and further read-
\ning. During the implementation phase of
\nour programme of work, we will be working
\nwith various organisations to drive uptake
\nof these practical actions.
\nThere are statements for each of the follow-
\ning professional groups:
\n\u2022 Nurses
\n\u2022 Social workers and social care
\n\u2022 Clinical Commissioning Groups
\n\u2022 General practitioners
\n\u2022 Paediatricians
\n\u2022 Midwives
\n\u2022 Obstetricians and gynaecologists
\n\u2022 Hospital doctors
\n\u2022 Dentists and oral health teams
\n\u2022 Psychiatrists
\n\u2022 Medical students
\n\u2022 Allied health professionals
\n\u2022 Music therapists
\n\u2022 Dieticians
\n\u2022 Occupational therapists
\n\u2022 Physiotherapists
\n\u2022 Speech and language therapists
\n\u2022 Paramedics
\n\u2022 Radiographers
\nCommitments and next steps
\nThis report also sets out a series of commit-
\nments by the health workforce and other
\norganisations to embed and develop action
\non the social determinants of health. These
\nform the basis of an on-going programme
\nof work led by IHE in partnership with
\nRoyal Colleges, the Academy of Medi-
\ncal Royal Colleges, and the British Medi-
\ncal Association among other organisations
\nHealth Equity
\n212
\nand institutions. The current commitments
\nare placed throughout the document at the
\nends of chapters. These commitments will
\nbe added to over time. Please see the IHE
\nwebsite for an up-to-date list of commit-
\nments (1).
\nIHE will lead a programme of work to dis-
\nseminate the messages in this report, en-
\ncourage their practical application across
\nthe workforce, and to extend the evidence
\nbase. We have been sent many examples
\nof excellent practice already taking place,
\nand the \u2018Working for Health Equity\u2019 pro-
\ngramme will be focussed on increasing the
\nsystematic and sustained implementation of
\nthis activity across the health system. This
\nwill be undertaken in partnership with or-
\nganisations that have already been involved
\nin the project by writing statements for ac-
\ntion and commitments. IHE also welcomes
\nother organisations to join the programme
\nand share their experience, working togeth-
\ner to achieve greater health equity through
\nactions by health professionals and related
\norganisations.
\nReferences
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\nAbbreviations
\nAoMRC \u2014 Academy of Medical Royal Colleges
\nBMA \u2014 British Medical Association
\nCAB \u2014 Citizens Advice Bureau
\nCCG \u2014 Clinical Commissioning Group
\nCMA \u2014 Canadian Medical Association
\nCPD \u2014 Continued Professional Development
\nGP \u2014 General Practitioner
\nIHE \u2014 UCL Institute of Health Equity
\nNHS \u2014 National Health Service
\nWMA \u2014 World Medical Association
\nwww.instituteofhealthequity.org
\nHealth Equity
\n213
\nIntroduction
\nGreat East Japan Earthquake:
\n14:46 March 11, 2011
\nWhen I returned to my hospital in Iwaki,
\nFukushima, there was a thunderous roar
\ncoming up from below, after which I was
\nassailed by violent shaking like I had never
\nexperienced before. The reinforced concrete
\nbuilding creaked as it shook widely with the
\nenormous waves of energy propagating re-
\npeatedly up from the bottom of the earth.
\nA tsunami warning was then issued, after
\nwhich a giant tsunami carrying a tremen-
\ndous amount of energy transmitted through
\nthe ocean water bore down upon one sea-
\nside community to the next, from the To-
\nhoku Pacific coast to Ibaraki and Chiba
\nprefectures.
\nMaking matters worse following this nat-
\nural disaster of a scale seen once in a thou-
\nsand years, the Fukushima Daiichi Nucle-
\nar Power Plant owned by Tokyo Electric
\nPower Company (TEPCO) experienced
\na melt-through and explosions starting
\nthe following day, March 12. This devel-
\nopment robbed 140,000 people from the
\nsurrounding communities of their places
\nto live and was a man-made disaster that
\nstruck the sharpest fear into many Japa-
\nnese, including those in the Tokyo metro-
\npolitan area.
\nThe disaster victims as well as we who were
\ntaking action onsite faced an overwhelm-
\ning dearth of information that is supposed
\nto be provided by the government during
\nan emergency. The hunger I felt with all
\nmy heart while leading all the support
\nefforts that I could, including the Japan
\nMedical Association Team (JMAT), as a
\ndisaster victim on the one hand and as the
\nJapan Medical Association (JMA) officer
\nin charge of disasters in the face of this
\nsituation is still engraved in my body and
\nsoul.
\nEvents Before the Great
\nEast Japan Earthquake
\nTokaimura nuclear accident:
\n10:35 Thursday, September 30, 1999
\nThe Tokaimura nuclear accident, in which
\nlarge amounts of neutron radiation and
\ngamma rays as well as fission products were
\nreleased for about 20 hours with the reac-
\ntor in criticality, began when alarms were
\nsounded in a conversion test building at the
\nfacility operated by JCO in the town of To-
\nkaimura.
\nResidents who passed nearby the accident
\nsite on the Joban railway line and the Joban
\nExpressway made inquire with medical in-
\nstitutions in the city of Iwaki. I\u00a0received lots
\nof information and many questions at that
\ntime, as I had been the director in charge
\nof emergency and disaster medicine at the
\nIwaki Medical Association since April
\n1998.
\nI immediately reported the situation to
\nthen-director of the Health Center, Shogo
\nAsahina, and made an urgent request. As a
\nresult, a radiation dose measurement service
\nusing a handheld Geiger counter was hast-
\nily arranged and provided from the follow-
\ning day at the Iwaki Health Center to resi-
\ndents who requested it. A total of over 800
\npeople came for the service, 10% of them
\nresidents from northern Ibaraki.
\nAlthough this was an inadequate response,
\nthere is no boundary to actions that can be
\ntaken for the peace of mind and safety of
\nresidents in a radiation disaster. This event
\nmade it clear that building disaster preven-
\ntion schemes based on this truth is funda-
\nmental.
\nThis had become my basic stance as some-
\none who participates every year in emergen-
\ncy drills for the group of TEPCO nuclear
\npower plants in Fukushima. It also became
\nthe basis for a request I made at a later date
\nfor the stockpiling, above and beyond the
\nnational regulations, of our own iodine
\npreparation for all Iwaki residents in case of
\na nuclear accident in the city. This stockpile
\nwas created before the TEPCO Fukushima
\nnuclear accident, put in place at the city\u2019s
\nhealth center, and distributed to residents
\nafter the accident.
\n9.11 Terrorist Attacks in NY and
\nWMA 2002 General Assembly
\nin Washington
\nIn April 2000 I was elected president of
\nthe Iwaki Medical Association and at the
\nsame time continued to be in charge of
\nemergency and disaster medical responses
\nas vice-president of the Fukushima Medi-
\ncal Association, a position to which I had
\nbeen appointed [1].The large-scale terrorist
\nGreat East Japan Earthquake
\nBefore and After
\nMasami Ishii
\nDisasterJAPAN
\n214
\nJAPANDisaster
\nattacks on the World Trade Center build-
\nings in New York and other targets on the
\nmorning of September 11, 2001 was an
\nevent that once again seared into the breasts
\nof relevant parties worldwide the impor-
\ntance of disaster preparedness against both
\nnatural and man-made disasters.
\nThe Scientific Session Program at the Gen-
\neral Assembly of the World Medical As-
\nsociation (WMA) held in Washington DC
\nfrom October 2\u20136, 2002 took up a wide va-
\nriety of subjects including preparedness to
\nlarge-scale disasters, infectious disease, and
\nterrorism under the central theme of \u201cRe-
\nsponding to the Growing Threat of Terror-
\nism and Biological Weapons\u201din light of the
\nhorrific tragedy of the previous year\u2019s inter-
\nnational terrorist attacks.
\nI voluntarily attended the assembly as
\nan associate member of the WMA and
\nwas deeply impressed by the stance of the
\nAmerican Medical Association and inter-
\nested parties who disclosed extremely prag-
\nmatic and full contents. I returned to Japan
\nwith many documents and a desire to es-
\ntablish the foundation of disaster medicine
\nin Japan.
\nOn the way home, my suitcase had been
\nprized open during the flight from New
\nYork and my commemorative WMA\u2019s con-
\ngress bag with all the documents related to
\ndisaster medicine had been stolen. Luckily,
\nmy wife Atsuko\u2019s suitcase was fine, and it
\ncontained a second set, as she had listened
\nto all the lectures with me.
\nAs I was filing a claim at Narita Airport,
\nI realized that the WMA bag and all the
\ndocuments had been distributed for free at
\nthe meeting venue. So, I ended up filing a
\nclaim only for the suitcase whose lock no
\nlonger shut. But this incident taught me
\nthe important lesson that truly important
\nthings are priceless and the importance of
\nbackups-things that we have to consider
\nwhen thinking about life and disaster medi-
\ncine.
\nAgreement regarding Medical
\nRelief during a Disaster:
\nJanuary 2004
\nOn January 5, 2004, Fukushima Prefec-
\nture and the Fukushima Medical Asso-
\nciation signed an Agreement regarding
\nMedical Relief during a Disaster based on
\nrepeated discussions on regional disaster
\nprevention planning for Fukushima pre-
\nfecture during disaster prevention meet-
\nings held at the prefectural government
\noffice [2].
\nThe Fukushima Medical Association is
\npositioned as a designated local public in-
\nstitution under laws such as the Basic Act
\non Disaster Control Measures (1961) and
\nwhat is called the Civil Protection Law
\n(Act concerning the Measures for Protec-
\ntion of the People in Armed Attack Situ-
\nations, etc.; enacted in 2004 and amended
\nin 2008).
\nIn settling the negotiations, the Medical
\nAssociation inserted a clause indicating that
\nwhile it would take responsibility for medi-
\ncal relief planning and medical relief teams,
\non the flip side, the Prefecture would grant
\nretrospective approval after the dispatch of
\nmedical relief teams deemed necessary by
\nthe Medical Association when faced with
\ncircumstances in which emergency action is
\nunavoidable.
\nThis clause ensures that the government
\naccepts our decisions and actions based on
\nphysicians\u2019 professional autonomy as stated
\nin the WMA Declaration of Seoul on Pro-
\nfessional Autonomy and Clinical Indepen-
\ndence [3].
\nIn addition, the agreement stipulates that
\nthe Prefecture shall bear expenses for medi-
\ncal team formation, participation in drills,
\nand for actual deployment, settlement of
\nactual costs such as medical supplies car-
\nried, and financial aid if by any chance team
\nmembers are injured, contract a disease, or
\ndie during medical relief efforts.
\nThis arrangement is grounded in the basic
\nconcept that team members act as quasi
\npublic servants throughout all medical re-
\nlief efforts. Moreover, a provision has been
\nincluded indicating the entire agreement
\nshall be reviewed every year, thereby pre-
\nventing the agreement from becoming a
\ndead letter.
\nEven before the agreement was signed with
\nthe Prefecture, I was an active participant
\nin prefectural emergency drills conducted
\nat Fukushima Airport in disaster scenarios,
\nbased on a disaster prevention agreement
\nmade directly between the airport and the
\nFukushima Medical Association.
\nThe annual emergency drill was usually
\nplanned for early dawn on a weekday so
\nas to not affect aircraft operations. To en-
\nsure that I made it on time from Iwaki,
\nI would take two days to participate,
\nstaying at the nearby Bobata hot springs
\nthe day before. It was by some curious
\nchance, in relation to radiation exposure
\nmedicine, that the inn I usually stayed at
\non those occasions was well know for its
\nradon hot springs.
\nIn Fukushima prefecture, the majority of
\nhydro-, thermal, and nuclear power gen-
\neration since the Meiji Restoration (1868)
\nhas been conducted under the control of
\nTEPCO and supplied roughly a third of
\npower consumed by the Tokyo metropoli-
\ntan area.
\nAdditionally,TEPCO also controls the wa-
\nter rights to Lake Inawashiro in the center
\nof the prefecture, creating a special environ-
\nment in which the prefectural government
\nconducts river administration while the
\nentire water system is under the control of
\nTEPCO.
\nIn other words, the entire prefecture is like
\na giant backyard for the Tokyo metropolitan
\narea. Within the prefecture, the Hamadori
\nregion in particular functioned as one of
\nthe world\u2019s leading nuclear energy stations,
\n215
\nJAPAN Disaster
\nhaving a total of 10 power-generating facili-
\nties: 6 reactors at TEPCO\u2019s Daiichi Nuclear
\nPower Plant and 4 reactors at its Daini
\nNuclear Power Plant. After I took charge
\nof emergency and disaster medicine at the
\nFukushima Medical Association, I had a
\nplace prepared for myself in a corner of the
\nprefectural government\u2019s medical team sta-
\ntioned at the Fukushima Prefecture Offsite
\nCenter in Okuma Town and participated in
\nannual emergency drills.
\nM6.9 earthquake off the Sanriku Coast:
\n6:39 November 15, 2005
\nAt 6:46 a tsunami advisory was issued for
\ncentral part of Hokkaido\u2019s Pacific coast
\nand the Pacific coast of the Tohoku region
\n(Iwate,Miyagi,and Fukushima prefectures).
\nTremors from 3 to 1 on the Japanese earth-
\nquake intensity scale of 1 to 7 were observed
\nfrom Hokkaido to the Kanto region and the
\nlargest tsunami, at 0.5 meters, struck the
\ncity of Ofunato at 7:35.
\nThis apparently harmless earthquake
\nhappened to occur on a morning for
\nwhich a nuclear disaster prevention drill
\nhad been planned at Fukushima\u2019s of Off-
\nsite Center.
\nSince April 2002, I have participated every
\ntime in the prefectural government\u2019s medi-
\ncal team during drills at the Offsite Center.
\nOn this day I had left Iwaki early and was
\nheading to the center, but arrived a little
\nlate because of traffic congestion.
\nMeanwhile, the Offsite Center was wait-
\ning for reserve firefighters, fire corps vol-
\nunteers and police officers, who had gone
\nto inspect the coast and estuary barrages
\nwhen the tsunami advisory was lifted at
\n8:38. I remember that the drill started
\nabout an hour late\u00a0\u2013 a little after 9:00\u00a0\u2013 as
\na result.
\nThe drill itself proceeded smoothly, but
\nconversation in the center turned to con-
\ncern that it would likely be hard to re-
\nspond, including the securing of person-
\nnel, in the event of a combined disaster
\nin which a nuclear accident occurred at
\nthe same time as an earthquake-induced
\ntsunami. Nevertheless, after complet-
\ning the planned drill, this concern was
\nnot brought up in successive discussion.
\nConsequentially, and unfortunately, the
\nreal meaning of this experience was not
\nrealized until after experiencing the Great
\nEast Japan Earthquake.
\n1st
\nWMA Asian-Pacific Regional Confer-
\nence: September 2006
\nIn April 2006, I was elected as an execu-
\ntive board member of the JMA and here
\ntoo took over emergency and disaster work,
\nwhere it became one of my heavy duties to
\nbe involved in disaster responses for all of
\nJapan.
\nSince then I promoted the dispatch and
\nputting into practice of information by
\nboth national agencies and prefectural
\nmedical associations so that the idea be-
\nhind of the above-mentioned Agreement
\nRegarding Medical Relief During a Disas-
\nter signed between Fukushima Prefecture
\nand the Fukushima Medical Association
\ncould be shared by all prefectural medi-
\ncal associations as a basic principle of the
\nJMA.
\nAt the same time, I repeatedly talked with
\nthe WMA as the JMA\u2019s international af-
\nfairs representative and as the secretary
\ngeneral of the Confederation of Medi-
\ncal Associations of Asia and Oceania
\n(CMAAO), which brought into shape the
\nidea of holding a regional conference of
\nthe WMA.
\nThe 1st
\nWMA Asian-Pacific Regional
\nConference, held at the Hotel Chinzanso
\nin Tokyo on September 10\u201311, addressed
\nthe two topics of earthquake and tsunami
\ncountermeasures and infectious disease un-
\nder the theme of disaster preparedness and
\nresponse.
\nThe conference also discussed, under the
\ntitle, \u201cState of the Profession,\u201d means of
\nincreasing the autonomy of physicians and
\nmedical association activities, rooted in pro-
\nfessional autonomy.
\nOther subjects also have significance today,
\nbut we narrowed the focus on earthquake
\nand tsunami and looked at responses to the
\n2004 Indian Ocean earthquake and tsuna-
\nmi,which had earlier struck Indonesia.Dis-
\ncussion started with an unavoidable mecha-
\nnism of the high earthquake and tsunami
\nrisk throughout the entire Asia and Oceania
\nregion, and widened to future preparedness
\nand possible responses [4].
\nJMAT creation proposal:
\nMarch 2010
\nRight away I asked that the JMA\u2019s Commit-
\ntee on Emergency and Disaster Medicine
\nbe composed not only of block representa-
\ntives of prefectural medical associations and
\nphysicians who are specialists in emergency
\nand disaster medicine, but also include the
\ndirector of the Self-Defense Forces Central
\nHospital as well as observer participation by
\nthe Guidance of Medical Service Division
\nin the Health Policy Bureau of the Ministry
\nof Health, Labour and Welfare (MHLW),
\nthe Fire and Disaster Management Agen-
\ncy of the Ministry of Internal Affairs and
\nCommunications, and the Japan Coast
\nGuard, plus the participation of Dr.\u00a0 Ma-
\nkoto Akashi, the Executive Director of the
\nNational Institute of Radiological Sciences
\nin order to respond to all conceivable situ-
\nations.
\nThe committee as well as a subcommittee
\norganized under Dr. Toshio Ido ( Immidi-
\nate Past president of Okayama Medical
\nAssociation) added ex-post verification of
\nexperiences during the Great Hanshin-
\nAwaji Earthquake of 1995, the Mid Ni-
\nigata Prefecture Earthquake of 2004, the
\nNoto Hanto Earthquake of 2007, and the
\nNiigataken Chuetsu-oki Earthquake of
\n2007.
\n216
\nThis resulted in the committee proposing,
\non March 10, 2010\u00a0\u2013 one year before the
\nGreat East Japan Earthquake\u00a0\u2013 the creation
\nof the JMAT. A press conference was held
\nthe same day and the JMAT creation an-
\nnounced. The nationwide announcement
\nof JMAT creation appeared on the JMA\u2019s
\nnewsletter the following day, by strange co-
\nincidence March 11 [5].
\nResponse to the Great
\nEast Japan Earthquake
\nSupport through cooperation in and
\noutside Japan
\nThe purpose of JMAT operations was to
\nprovide health support for the approxi-
\nmately 400,000 people who survived in a
\n150-km sphere in addition to the nearly
\n20,000 lives lost in the enormous damage of
\nthe Great East Japan Earthquake.
\nI will avoid saying much about this here,
\nas details have been published in the Ja-
\npan Medical Association Journal and else-
\nwhere [6, 7, 8, 9, 10].
\nHowever, the transport of medical supplies
\nto the afflicted areas, which came about
\nthrough the US military, the Japan Self-
\nDefense Forces, and the good will of many
\npeople, was the pioneering figure of the
\nUS\u2019s Operation Tomodachi [11].
\nThe JMA set up a disaster response head-
\nquarters on March 11, the first day of the
\nGreat East Japan Earthquake, and made a
\ncollective effort to respond around the clock
\nwith nearly 200 people, from officers to of-
\nfice staff.
\nThe JMA aimed to create a system for
\nJMAT operations that could meet chang-
\ning needs by acting as a coordinator be-
\ntween prefectural medical associations af-
\nflicted by the disaster and those dispatching
\nteams. As much as \u00a51.9 billion (approx.
\nUSD 20million as of April 2013) donated
\nmainly by sympathizers in medical associa-
\ntions around the country was delivered im-
\nmediately to afflicted medical institutions
\nthrough medical associations in the affected
\nareas.
\nMoreover, in addition to receiving reim-
\nbursement from the government for actual
\nexpenses of operations conducted under the
\numbrella of the JMAT and compensation
\nas the an activity of quasi public servants,
\nwith the consent of the MHLW, the JMA
\nstarted up its own accident insurance and
\nestablished an insurance system in all op-
\nerations.
\nThe JMA negotiated with the National
\nPolice Agency and obtained emergency ve-
\nhicle stickers that enabled teams to travel to
\nthe affected areas.
\nThe JMA also made it possible for teams
\ngoing on-site during the early phase to get
\nfree tickets on Japan Airlines and All Nip-
\npon Airways flights and to receive priority
\nsupplies of gasoline. Further, the JMA re-
\nquested the Ministry of Land, Infrastruc-
\nture, Transport and Tourism to reopen
\nexpressways running through the affected
\nareas.
\nThe JMA received support and assistance
\nfrom many and a wide variety of people and
\norganizations in and outside Japan, such as
\ndonations from outside Japan, including
\nfrom the Taiwan Medical Association, and
\nthe stationing of Dr. Maya Arii of the Har-
\nvard Humanitarian Initiative at the JMA\u2019s
\noffice. And the various problems occurring
\nbefore our eyes were dealt with, from health
\nsupport for evacuation shelters to coopera-
\ntion in dispatching autopsy teams, support
\nin establishing temporary clinics, and sup-
\nport in reconstructing afflicted medical in-
\nstitutions.
\nThanks to the well-intentioned efforts of
\nmedical personnel from throughout the
\ncountry, JMAT operations reached a total
\nof 1,398 teams on which 6,054 people par-
\nticipated, including 2,145 physicians, by the
\nend of operations on July 15, 2011.
\nSince then,the JMA has continued to be in-
\nvolved in support efforts, given the situation
\non the ground in the afflicted areas, which
\nhave not been able to recover completely
\nfrom the tremendous damage. Thirty-four
\nmedical-related groups (18 organizations)
\nas well as government-affiliated agencies
\nlaunched the Survivors Health Support Li-
\naison Council, for which the JMA serves as
\nsecretariat.
\nEfforts were switched over to JMAT II
\noperations, which carry on medical sup-
\nport activities that are broader than disas-
\nter support. As of February 4, 2013, a total
\nof 763 teams with 2,475 people, including
\n1,730 physicians, have been dispatched
\nand are carrying on operations even now
\n(Figs.\u00a01,\u00a02).
\nEfforts for better information sharing
\nThe Japan Medical Association Research
\nInstitute, which is the JMA\u2019s think tank,
\nalso responded to the Great East Japan
\nEarthquake with concerted efforts. These
\nincluded field investigations in areas dam-
\naged by the tsunami, collection of data re-
\nlating to JMAT operations, and consider-
\nation of the problem of compensation for
\nloss relating to the nuclear accident [12, 13,
\n14, 15].
\nIn order to prepare for potential complex
\ndisasters close to home, the JMA held, one
\nyear after the earthquake, a training course
\non JMAT activities in disaster medicine
\n[16] (which will be certified for the JMA\u2019s
\ncontinuing medical education credit) on
\nMarch 10,2012 and a symposium on health
\npolicy \u201cDisaster Medicine and Medical As-
\nsociations\u201d the following day [17]. Since
\nthen, content has been added and enriched
\nand made available on the JMA\u2019s website
\nand other sources.
\nJAPANDisaster
\n217
\nBased on reflections after the disaster of
\npersonnel in charge of information, it was
\nagreed that combining multiple informa-
\ntion media was realistic, as there is no
\nsingle medium that can definitively cover
\nmany different events, and within that the
\nneed to share information became a com-
\nmon view.
\nThat is why in 2012 the Liaison Council of
\nPrefectural Medical Associations on Disas-
\nter Medicine conducted an emergency com-
\nmunications demonstration that attempted
\nto link clinical records and evacuation shel-
\nter information during a disaster via cloud
\ncomputing, assuming disaster scenarios
\nsuch as an earthquake directly beneath the
\nTokyo Metropolitan area.
\nThe demonstration used the Wideband In-
\nterNetworking engineering test and Dem-
\nonstration Satellite (WINDS) called \u201cKI-
\nZUNA\u201d operated by the Japan Aerospace
\nExploration Agency (JAXA), with which
\nIwate Prefecture had past results, and also
\nincluded simultaneous Internet transmis-
\nsion to prefectural medical associations.
\nBased on the demonstration\u2019s good results,
\nthe JMA and JAXA signed an agreement
\non demonstration experiments using the
\nsatellite KIZUNA in disaster medical ac-
\ntivities and held a press conference at the
\nsame time on January 30, 2013.
\nAfter the Great East
\nJapan Earthquake
\nThe problem of radiation exposure and ra-
\ndioactive contamination
\nAccording to Dr. Jose Luiz Gomes do
\nAmaral, president of the WMA in 2012, it
\nis difficult to avoid the fact that disasters of
\na certain level take on the aspect of a com-
\nplex disaster in developed societies. It is also
\na fact that there is no place on Earth that
\ncould be called safe with absolute certain-
\nty\u00a0[17]. The problem of radiation exposure
\nand radioactive contamination resulting
\nJMAT: 1,398 teams;
\nJMAT II: 763 teams;
\n5 additional teams sent to
\nmultiple prefectures.
\nTop: JMAT
\nBottom: JMAT II
\nIwate
\n461 teams
\n558 teams
\nMiyagi
\n645 teams
\n82 teams
\nfukushima
\n275 teams
\n123 teams
\nIbaraki
\n12 teams
\nFigure 1. JMAT and JMAT II dispatches (updated as of February 4, 2013)
\n8.8% (534) 5.5% (135)
\n0.2% (6)
\n18.8% (1,139) 20.0% (494)
\n7.6% (458)
\n69.9% (1,730)
\n29.3% (1,775)
\n35.4% (2,145)
\nPhysicians Nurses Pharmacists Coordinators Medical technologists and others
\n100%
\n80%
\n60%
\n40%
\n20%
\n0%
\nJMAT JMAT II
\n4.4% (110)
\nFigure 2. Breakdown by occupation of JMAT and JMAT II participants in the Great
\nEastJapanEarthquake(updatedasofFebruary4,2013).(Numbersofpeoplearerepre-
\nsented in parenthesis)
\nJAPAN Disaster
\n218
\nfrom the Fukushima Daiichi Nuclear Pow-
\ner Plant accident following the Great East
\nJapan Earthquake, in particular, emerged at
\nan unprecedented scale. What is more, the
\nspread of contamination brought about a
\nmajor problem greatly exceeding the con-
\nventional administrative framework and
\npredictions and raised widespread anxiety
\nthat still has not been brought under con-
\ntrol.
\nConsidering the truth of responses that
\nwere actually made, although a disaster
\nresponse headquarters was set up in the
\nFukushima Prefecture government office
\nduring the Great East Japan Earthquake,
\nthe prefectural government was utterly
\nnegative regarding medical association par-
\nticipation and the building of a cooperative
\nrelationship. This is extremely difficult to
\ncomprehend, given the point of the already
\nsigned Agreement regarding Medical Re-
\nlief during a Disaster and considering the
\nlives and health support for citizens of the
\nprefecture.
\nOn October 22, 2008, the national govern-
\nment under the Taro Aso Administration
\nconducted a nuclear disaster prevention
\ndrill with the scenario that the emergency
\ncooling system failed after the usual reactor
\ncooling system had failed at the Fukushima
\nDaiichi Nuclear Power Plant, releasing ra-
\ndioactive material offsite.
\nOn October 20 and 21, 2010, during the
\nNaoto Kan Administration, disaster pre-
\nvention drills were conducted with a similar
\nscenario at the Hamaoka Nuclear Power
\nStation. Ahead of the later, a comprehen-
\nsive disaster prevention drill for the Iwaki
\nregion was held in the city of Iwaki in Au-
\ngust 2010 with the scenario of a large tsu-
\nnami triggered by a M7.7 earthquake (in-
\ntensity 6 lower on the Japanese scale) off
\nthe Fukushima coast. Assuming that these
\nkinds of drills were not made use of at all in
\nthe actual Great East Japan Earthquake of
\nMarch 11, 2011, there is a need to create a
\nsystem for improving skills through effec-
\ntive drills and ex-post verification, beyond
\nthe framework of routine work by the gov-
\nernment alone.
\nInternational Physicians for the Preven-
\ntion of Nuclear War World Congress: Au-
\ngust 2012
\nOn August 26, 2012, the International
\nPhysicians for the Prevention of Nuclear
\nWar (IPPNW) held its 20th
\nWorld Con-
\ngress at the International Conference
\nCenter Hiroshima. I was invited to the
\ncongress and gave a lecture on \u201cJMAT
\nOperations in Response to the Great East
\nJapan Earthquake and the Fukushima Nu-
\nclear Accident.
\n\u201dThis was an opportunity to present the pic-
\nture that JMAT activities were the realiza-
\ntion of a vision to provide continuous sup-
\nport from the acute phase,when teams work
\nin cooperation with the Disaster Medical
\nAssistance Team (DMAT), until medi-
\ncal care in the afflicted areas has recovered,
\nand convey the fact that the nationwide call
\nfor support activities for medical care at
\nfirst-aid stations for evacuees and for local
\nmedical institutions turned into an opera-
\ntion that was Japan\u2019s largest medical support
\neffort.
\nAdditionally, I reported on activities on
\nthe ground in the disaster-stricken area of
\nFukushima Daiichi Nuclear Power Plant
\naccident, including original information
\ngathering and disclosure. While there was
\na tumultuous atmosphere at the venue just
\nat that time, with remarks flying about from
\nan anti-nuclear movement, the program
\nwas run with a clear division between de-
\ntermined opposition to nuclear weapons,
\nwhich are an inhumane use of nuclear
\npower, and discussion of the peaceful use of
\nnuclear power.
\nI stressed that my report was based on ex-
\nperiences on the ground and also that we
\nphysicians, who practice the peaceful use of
\nnuclear power in clinical care, always strive
\nin future to minimize the risks while maxi-
\nmizing the benefits to patients of radiodi-
\nagnosis and during treatment. While there
\nwere opinions that completely deny the
\napplication of nuclear power and calls for
\npractical information disclosure on the Fu-
\nkushima Daiichi Nuclear Power Plant ac-
\ncident, those kinds of remarks disappeared
\nas the presentation proceeded.
\nConclusions
\nNeed for comprehensive health policy and
\nhealth support
\nMy heart truly aches at the fact that today,
\nnearly two years since the Great East Japan
\nEarthquake, the communities destroyed by
\nthe earthquake and tsunami have not been
\nrestored, let alone revived. Still more, the
\ndistrict where the nuclear power plant is lo-
\ncated and nearby areas from which whole
\ncommunities were forced to evacuate due
\nto the nuclear accident in Fukushima pre-
\nfecture and the subsequent radioactive con-
\ntamination, have only called for decontami-
\nnation; the disposal of rubble has hardly
\neven begun, to say nothing of the building
\nof new communities. In such a situation,
\nonly the delay in responding to the people
\nof the areas that accepted nuclear power
\nplants in compliance with national policy
\nstands out.
\nNuclear power stations, regardless of
\nwhether they decommission their reactors
\nor continue operations,need integrated pol-
\nicy making covering everything from fuel
\nrefinement through use to final disposal, a
\nscientific basis to underpin those policies,
\nand policy agreement that will carry them
\nout.Considering the Fukushima nuclear ac-
\ncident,which saw explosions and resulted in
\na major disaster even though the plant was
\nunder an emergency shutdown, work pro-
\ncesses that are assured to be safe and health
\nsupport for the workers engaged in that
\nwork will most likely be necessities for more
\nthan a few decades.
\nJAPANDisaster
\n219
\nFurther, there is a pressing need for com-
\nprehensive policy and health support for
\nevacuees from radioactive contamination
\nin addition to health support for evacuees
\nfrom natural disaster.
\nAbove all, active national involvement is
\nexpected in the creation of a long-term sup-
\nport system for young people\u00a0 \u2013 especially
\nchildren\u00a0\u2013 with the elimination of trivial-
\nized frameworks that are limited to Fuku-
\nshima prefecture and the inclusion of evac-
\nuees who have scattered around the country
\nand residents of areas with relatively high
\nradioactive contamination that spread from
\nthe Tohoku to the Kanto region.I also think
\nthat cordial and considerate accountability
\nmust continue to be fulfilled for the many
\nmembers of the general public that cannot
\nget rid of growing anxiety caused by looking
\nat the current situation.
\nPeaceful use of nuclear power
\nOn my way back from the UNESCO 8th
\nInternational Conference on Bioethics
\nEducation held in Tiberias, Israel on Sep-
\ntember 2-5, 2012, I had the opportunity to
\nstop by the Israel Academy of Sciences and
\nHumanities and stand face-to-face with
\nthe statue of Einstein in the garden. When
\nlooking back at the footsteps of Einstein,
\nI\u00a0am certain that humanity,which obtained
\nnew knowledge and a source of energy in
\nthe 20th
\nCentury, has an obligation and a
\nrole to raise its voice in strong opposition
\nto the misuse of science that harmed so
\nmany people with atomic bombs and has
\nan adverse effects on the global environ-
\nment.
\nOn the other hand, however, I reaffirmed
\nmy belief that Japan, precisely because it
\nsuffered the crippling damage of atomic
\nbombs and experienced the Fukushima
\nnuclear accident, should not abandon its
\nworld-leading role in contributing to the
\nfield of ensuring the peaceful use and safety
\nof nuclear power based on humanity\u2019s wis-
\ndom. I believe that because human civili-
\nzation, which established cultural life us-
\ning Prometheus\u2019 fire, set sail over the open
\nseas, made possible safe transport through
\nthe skies, and even bent its steps into outer
\nspace,accomplished today\u2019s development by
\nsincerely facing unforeseen accidents at ev-
\nery point in time and being cautious about
\nthe abuse of new technologies and power.
\nLastly, I offer heartfelt condolences for the
\npeople who lost their lives in the Great
\nEast Japan Earthquake and my sympathies
\nto the survivors. I should also like to ex-
\npress my respect and appreciation to all the
\nmedical personnel who were engaged in-
\ntently in medical operations in the afflicted
\nareas.
\nReferences
\n1. Ishii M. Emergency Medicine in Fukushima
\nPrefecture. Journal of the Fukushima Medical
\nAssociation. 2003;65(8) (in Japanese)
\n2. Ishii M. Regarding \u201cthe Agreement Regarding
\nMedical Relief During a Disaster\u201d. Journal of
\nthe Fukushima Medical Association. 2004;66(3)
\n(in Japanese)
\n3. World Medical Association. WMA Declaration
\nof Seoul on Professional Autonomy and Clinical
\nIndependence. 2008. https:\/\/www.wma.net\/
\nen\/30publications\/10policies\/a30\/index.html
\n4. JMAJ. 2007;50(1). http:\/\/www.med.or.jp\/
\nenglish\/journal\/pdf\/jmaj\/v50no01.pdf
\n5. JMA Committee on Emergency and Disaster
\nMedicine Report (March 10, 2010) http:\/\/www.
\nmed.or.jp\/shirokuma\/no1258.html (in Japanese)
\n6. Ishii M. Japan Medical Association Team’s
\n(JMAT)FirstCalltoActionintheGreatEastern
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\n154. http:\/\/www.med.or.jp\/english\/journal\/
\npdf\/2011_03\/144_154.pdf
\n7. Ishii M. Activities of the Japan Medical
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\nEast Japan Earthquake. JMAJ.2012;55(5):362-
\n367. http:\/\/www.med.or.jp\/english\/journal\/
\npdf\/2012_05\/362_367.pdf
\n8. Ishii M, Nagata T. The Japan Medical
\nAssociation\u2019s disaster preparedness: lessons
\nfrom the Great Eastern Japan Earthquake and
\ntsunami. Disaster Med Public Health Prep.
\n2013. (accepted)
\n9. Nagata T, Halamka J, Himeno S, Himeno A,
\nKennochi H, Hashizume M. Using a Cloud-
\nbased Electronic Health Record During
\nDisaster Response: A Case Study in Fukushima,
\nMarch 2011. Prehosp Disaster Med. 2013 Apr
\n26:1-5.
\n10. NagataT,Kimura Y,Ishii M.Use of a geographic
\ninformation system (GIS) in the medical
\nresponse to the Fukushima nuclear disaster in
\nJapan. Prehosp Disaster Med. 2012 Apr; 27(2):
\n213-215.
\n11. JMAT Kaku Funto Seri. Seiron. Oct. 2011.
\nhttp:\/\/www.tottori.med.or.jp\/secure\/2960\/
\nseiron2011.10.pdf (in Japanese)
\n12.Sameshima N. Japan Medical Association
\nResearch Institute (JMARI) Working
\nPaper No. 253:Research into the Effects on
\nand Responses by Hospitals and Clinics in
\nSchedule Power Outages and Electricity
\nSupply and Demand Measures Associated
\nwith the Great East Japan Earthquake.2012.
\nhttp:\/\/www.jmari.med.or.jp\/research\/summ_
\nwr.php?no=475 (in Japanese)
\n13. Deguchi M. JMARI Working Paper No.
\n254: The Role of Medical Associations in
\nJMAT Operations During the Great East
\nJapan Earthquake and Future Issues.2012.
\nhttp:\/\/www.jmari.med.or.jp\/research\/summ_
\nwr.php?no=476 (in Japanese)
\n14. JMARI. JMARI Working Paper No. 257:
\nResearch into Compensation for Loss in the
\nFukushima Nuclear Disaster and the State
\nof Restoration and Reconstruction.2012.
\nhttp:\/\/www.jmari.med.or.jp\/research\/summ_
\nwr.php?no=482 (in Japanese)
\n15. Eguchi N. and Deguchi M. JMARI Working
\nPaper No. 273: Attitude Survey of Physicians
\nabout Medical Care in Afflicted Areas \u2013
\nPhysicians in Three Tohoku Prefectures. 2013.
\nhttp:\/\/www.jmari.med.or.jp\/research\/summ_
\nwr.php?no=499 (in Japanese)
\n16. JMA Training Course on JMAT Activities
\nin Disaster Medicine (March 10, 2012)
\nhttp:\/\/dl.med.or.jp\/dl-med\/eq201103\/jmat\/
\njmat_20120310.pdf (in Japanese)
\n17. JMA Symposium on Health Policy \u201cDisaster
\nMedicine and Medical Associations\u201d(March
\n11, 2012). http:\/\/www.med.or.jp\/jma\/policy\/
\nsymposium\/000880.html (in Japanese)
\nMasami Ishii
\nExecutive Board Member,
\nJapan Medical Association,
\nTokyo, Japan
\nE-mail: jmaintl@po.med.or.jp
\nJAPAN Disaster
\n220
\nUNITED STATES OF AMERICAAir Pollution
\nPolycyclic Aromatic
\nHydrocarbons
\nEndocrine disruptors are chemicals that
\ninterfere with hormone signaling systems
\nin the human body, potentially affecting
\nreproductive, metabolic, nervous, and im-
\nmune system functions (1,2). Endocrine
\ndisrupting chemicals (EDCs), natural or
\nsynthetic, can be found in many different
\nenvironmental media: food, water, soil, and
\nair. Most indentified EDCs are produced
\nby indoor sources, and therefore indoor air
\nconcentrations may better predict a person\u2019s
\nexposure to EDCs than outdoor air con-
\ncentrations (3). However, outdoor air is a
\nsignificant source of exposure to one group
\nof EDCs, the Polycyclic Aromatic Hydro-
\ncarbons (PAHs). The health consequences
\nof these exposures for children include neu-
\nrodevelopmental disruption, DNA damage
\nleading to increased cancer risk,and epigen-
\netic changes that are potentially the basis
\nfor other diseases, including asthma.
\nWhat are PAHs?
\nPAHs are a family of chemicals formed as
\na by-product of incomplete combustion.
\nPAHs are created when organic material
\ncombusts, such as when fuel is burned, food
\nis cooked, or cigarettes are smoked. Signifi-
\ncant outdoor urban sources are coal-fired
\npower plants, incinerators, furnaces in resi-
\ndential buildings, and the internal combus-
\ntion engines of automobiles, trucks, buses,
\nand trains. PAHs can be found in gaseous
\nform or adsorbed onto particulate matter,
\nwith the tendency of each PAH to do so
\ndepending on its molecular weight.
\nThe PAHs which are suspected endocrine
\ndisruptors based on animal or human
\nstudies include: acenaphthylene, benzo
\n(a) pyrene, benzo (b) fluoranthene, benzo
\n(k) fluoranthene, 3-methylcholanthrene,
\nchrysene, dibenzo (a,h) anthracene, inde-
\nno (1,2,3-cd) pyrene, naphthalene, phen-
\nanthrene (1,4,5).
\nHealth Effects of Prenatal and
\nChildhood Exposures to PAHs
\nExposure to PAHs is a concern throughout
\nan individual\u2019s life; however, gestational and
\nchildhood exposures have been the focus
\nof several studies, and have revealed several
\nimportant health consequences in this pop-
\nulation. Perera et al. have studied prenatal
\nPAH exposure and its effects on cognitive
\nand behavioral development for a cohort of
\nchildren in New York City.
\nThey found that prenatal exposure to PAHs
\nabove the median of 2.26 ng\/m3
\nwas posi-
\ntively associated with developmental delay
\nat three years, reduced IQ at five years, and
\nsymptoms of anxiety\/depression and atten-
\ntion problems at seven years (6\u20139). A simi-
\nlar study in Tongliang, China, did not find
\nan independent association between PAH
\nexposure and impaired IQ, but found an in-
\nverse correlation between PAH-DNA ad-
\nducts in cord blood, a biomarker of prenatal
\nexposure to PAHs, and motor, language,
\nand overall development in children at two
\nyears old (10,11).
\nStudies in Krakow, Poland, similarly found
\na decrease in IQ for 5 year olds exposed in
\nutero to average air concentrations of PAHs
\nabove the median of 17.96 ng\/m3
\n(12). Pre-
\nnatal PAH exposures in Krakow, New York
\nAir Pollution: a New Concern. Polycyclic Aromatic
\nHydrocarbon Endocrine Disrupting Chemicals
\nin Urban Outdoor Air and Children\u2019s Health
\nA Brief Public Health Overview of Recent Literature
\nPeter Orris Erica Burt
\n221
\nUNITED STATES OF AMERICA Air Pollution
\nCity, and Tongliang were also associated
\nwith decreased fetal growth: birthweight,
\nlength, and\/or head circumference in Pol-
\nish-Caucasian, African-American, and
\nChinese populations (11,13,14). Studies in
\nthe Czech Republic support these associa-
\ntions (15,16).
\nHuman evidence also suggests that despite
\nan approximate 10-fold lower dose of PAHs
\nreceived by a fetus relative to the mother,
\nthe amount of carcinogenic DNA dam-
\nage caused by the exposure is greater to the
\nfetus (17). This damage is a covalent bond
\nbetween the PAH and DNA, known as a
\nDNA-adduct,and is a known biomarker for
\ncancer risk. The exact relationship between
\nthis carcinogenic damage and carcinogene-
\nsis is not clear in humans,but animal studies
\nclearly demonstrate a relationship between
\nin-utero PAH-induced DNA damage and
\ncancer of the liver,lung,nervous system,and
\nlymphatic system of the offspring (17\u201319).
\nIt is hypothesized that not only is a child\u2019s
\nDNA affected by in-utero exposure to
\nPAHs, but his\/her gene expression may
\nalso be altered. Such changes are associated
\nwith cancer and other diseases, and may
\nhave transgenerational effects. Evidence for
\nthese epigentic changes have come through
\nstudies looking at the methylation and de-
\nmethylation by PAHs of cord-blood cells
\n(20,21).
\nOne health end-point suspected to be a
\nresult of such PAH-induced epigenetic
\nchanges is childhood asthma.Asthma is one
\nthe most common chronic health problems
\nfacing children today, with approximately
\n14% of 13\u201314 year olds worldwide experi-
\nencing symptoms in the last year (22,\u00a023).
\nPAHs may help to initiate, exacerbate, and
\nhinder treatment of asthma. Initiation of
\nasthma could occur in several ways, one of
\nwhich is alteration of epigenics contributing
\nto asthma biomarkers.
\nA case control study in Saudi Arabia found
\nsignificant associations between serum
\nlevels of PAHs and biomarkers of asthma
\n(24). Another possible mechanism for ini-
\ntiation of asthma by PAHs, which may
\nalso contribute to continued asthma symp-
\ntoms, is through increasing a child\u2019s sensi-
\ntivity to certain allergens (25,26). There is
\nsome evidence for exacerbation of asthma
\nsymptoms by PAHS; a study in California
\nof the United States showed a mild trend
\nof increased wheeze in 6\u201311 year old chil-
\ndren with asthma after ambient exposure to
\nPAHs increased, but other studies have not
\nseen an association (26,27). Another New
\nYork study showed respiratory symptoms
\nand probable asthma are more prevalent
\namong children exposed to PAHs and en-
\nvironmental tobacco smoke in early child-
\nhood (28). Relatedly, prenatal exposures to
\nPAHs are suspected to increase the occur-
\nrence and duration of respiratory symptoms
\n(29). Furthermore, in vitro evidence sug-
\ngests that exposure to PAHs may decrease
\nthe responsiveness of lung tissue to asthma
\nmedication (30).
\nPrevention
\nWhile this paper has not highlighted the
\nsources of airborne PAHs in the indoor en-
\nvironment, reduction of these is often easier
\nthan tackling the job out of doors. Proper
\nventing or reduction of the use of organic
\nfuel use for cooking and heat within living
\nquarters is an important intervention in
\nmuch of the world where the indoor smoke
\npollution often rivals that generated com-
\nmunally.The elimination of cigarette smok-
\ning by adult family members is well known
\nto reduce the incidence of both asthma and
\ncancer in children.
\nMinimizing exposure to PAHs outdoors in
\nurban areas is of great importance despite its
\ndifficulty.The generation of energy utilizing
\nfossil fuels and the incineration of wastes
\nare major sources of PAHs that are able to
\nbe eliminated through sustainable urban
\nplanning. PAH concentrations emanating
\nfrom major roadways train tracks, or water
\ntransportation routes are again susceptible
\nto reduction through urban planning that
\ndistance housing units and accommodates
\nthe prevailing winds.
\nFactories and homes themselves are major
\nsources of outdoor PAHs when organic
\nheating fuel is used. Reduction or elimina-
\ntion of this ubiquitous exposure is reachable
\nonly through the substitution of wind, wa-
\nter, or solar energy generators. Such a sub-
\nstitution has been demonstrated to be ad-
\nequate for the world\u2019s energy needs through
\n2030 and at approximately the same cost as
\nallocated today (32). However, there may
\nbe some relevant policy solutions, and here
\nis a list of ideas for further exploration and
\nresearch:
\nThe immediate effect of such an interven-
\ntion is documented in Tongliang, China,
\nwhere the closing of a coal fired power plant
\nreduced the health effects associated with
\nprenatal PAH exposure in the community
\n(32).
\nConclusion
\nThrough the disruption of the endocrine
\nsystem and DNA damage, PAH exposure
\nfrom combustion sources such as power
\nplants, vehicles, and home-heating and
\ncooking systems can cause negative health
\nconsequences to the most vulnerable in our
\ncommunity, our children. PAH air pollu-
\ntion is associated with developmental delay,
\ndecreases in IQ, behavioral problems, in-
\ncreased cancer risk, and asthma. While in-
\ndoor exposures can be minimized through
\nfamily choices, outdoor exposures cannot be
\nreduced with such ease. Community, state,
\nand national policy changes are necessary to
\nreduce community air pollution exposures
\nto this class of compounds.
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\nErica Burt, MPH and Peter Orris,
\nMD, MPH, FACP, FACOEM
\nUniversity of Illinois at Chicago School of
\nPublic Health\u2019s Great Lakes Centers For
\nOccupational and Environmental Health
\nA WHO Collaborating Center
\nE-mail: porris@uic.edu
\nUNITED STATES OF AMERICAAir Pollution
\n223
\nAntimicrobial ResistanceSWEDEN
\nAntibiotics is a foundation for the provision
\nof modern health care but we have to de-
\nvelop strategies to better manage this great
\ndiscovery. In 2009 the Standing Committee
\nof European Doctors (CPME) adopted a
\nresolution addressing the need to invest in
\nresearch of finding not only new antibiotics,
\nbut also new ways of combining old antibi-
\notics.In the light of the increasing problems
\nwith antimicrobial resistance another reso-
\nlution was adopted in April 2013 encourag-
\ning member states to develop strategies for
\na sustainable use of antibiotics.
\nEven though Sweden is one of the countries
\nwith the lowest consumption of antibiotics
\nSwedes run the increasing risk of developing
\nresistant bacteria. Therefore, rational use of
\nantibiotics is of paramount importance. One
\nof the problems is the big regional differenc-
\nes in prescription rates as there is a lower rate
\nin rural areas and a higher rate in urban areas.
\nIn Stockholm, for example, the rate is about
\n410 recipes for antibiotics per 1000 inhab-
\nitants while in a rural area, such as V\u00e4ster-
\nbotten, the rate is about 290. The aim is to
\ndecrease the national average rate to 250.
\nVariation in the prescription rates between
\ncountries is substantial.The European Cen-
\ntre for Disease Prevention and Control
\n(ECDC) has revealed that the consump-
\ntion of antibiotics varies threefold between
\nthe countries consuming most compared to
\nthose consuming least.
\nIn Sweden we find a similar pattern in the
\nvariation of consumption in dental care. In
\nSk\u00e5ne regional council,where the consump-
\ntion is the highest, 35 out of 1000 inhabit-
\nants received a prescription of antibiotics by
\na dentist between July 2011 and July 2012.
\nStockholm had about the same rate while in
\nV\u00e4sterbotten the rate was only 15.
\nIn animal care and veterinary care in Swe-
\nden the consumption has declined from
\nabout 20 tons in 1996 to 12 tons in 2012.
\nAntibiotics of the right sort should be used
\nin the right doses and when there is a need
\nin order to decrease the pain of the animal.
\nSince 2006 antibiotics may not be used in
\nthe EU to increase the growth of the ani-
\nmal. It may only be used to treat bacterial
\ndiseases. The sale of antibiotics varies a lot
\nbetween the EU\/EEA-countries. For ex-
\nample, the use of antibiotics for animals is
\n269 milligram per kilo in Hungary com-
\npared to 8 milligram in Iceland.
\nIn 2010 about 90% of the sale of antibiotics
\nin the EU was intended for the medication
\nof animals. In Sweden the corresponding
\nshare was only 10 %.In many countries more
\nantibiotics are prescribed to animals than to
\nhumans which is the case, for example, in
\nDenmark. In countries with extensive use of
\nantibiotics the problems with antimicrobial
\nresistance is rather a rule than an exception.
\nThe key problem concerns the issue of pre-
\nscriptions.A survey by the CPME earlier this
\nyear shows that in several European countries
\nthere is a lack of guidelines for the prescrip-
\ntion of antibiotics in primary health care.
\nOnly doctors, dentists and veterinarians are
\nallowed to prescribe antibiotics. It is of ma-
\njor importance that the right to prescribe is
\nnot extended to other professions. In live-
\nstock farming it is of great importance that
\na veterinarian makes an examination be-
\nfore antibiotics is used and that antibiotics
\nshould be used on a case by case basis.
\nDoctors, dentists and veterinarians should
\nnot be allowed to sell antibiotics, a common
\npractice in some countries.To prescribe an-
\ntibiotics for earning money from their sale
\nis a harmful incentive when the goal is to
\ndecrease the consumption.
\nThe patient\u2019s right to choose the doctor or
\nthe dentist or the animal breeder\u2019s right to
\nchoose the veterinarian could also lead to an
\nincrease in the prescription of antibiotics.
\nOne usually tries to have a good relation-
\nship with the patient or the animal breeder.
\nInformed patients and animal breeders are
\ncrucial in order for the professionals to have
\na good dialogue with them regarding the
\nguidelines for a prudent use of antibiotics.
\nIn the basic medical training and the con-
\ntinuing professional development of doc-
\ntors, dentists and veterinarians there should
\nbe more focus on antibiotics, antimicrobial
\nresistance, and prevention of the spread of
\ndeceases.
\nIn the EU open labour market a lot of doc-
\ntors, dentists and veterinarians move across
\nthe borders. They have different medi-
\ncal backgrounds and experiences when it
\ncomes to antibiotics. As a tool for ensuring
\nqualitative use of antibiotics in Sweden we
\nhave proposed a requirement for continuing
\nprofessional development of doctors, den-
\ntist and veterinarians. Higher competence
\nis required to defeat resistance!
\nMarie Wedin,
\nPresident of the Swedish Medical Association
\nDefeating Resistant Bacteria with Knowledge
\nMarie Wedin
\n224
\nRegional News LATVIA
\nOn the Eastern shore of the Caspian Sea,
\nbetween Uzbekistan, Afghanistan and Iran
\ndevelops the great nation of Turkmenistan,
\nwisely led by Gurbanguly Berdimuhame-
\ndow.
\nI visited Turkmenistan accepting the invi-
\ntation from the Minister of Health. There
\nare no non-governmental organisations in
\nTurkmenistan, however, President Gur-
\nbanguly Berdimuhamedow has recently
\nannounced that they will be allowed and it
\nseems the first one to be established is the
\ndentists association with Gurbanguly Ber-
\ndimuhamedow as honorary president. The
\nMinister of Health hopes that in the nearest
\nfuture there will be a medical association, a
\nmedical journal and post-graduate educa-
\ntion.
\nThe Great President of the State Gurban-
\nguly Berdimuhamedow, a dentist by pro-
\nfession, was elected president of the state
\nsix years ago when Turkmenistan was in
\nmourning because of the death of the Fa-
\nther of the Nation, President for Life Sa-
\nparmurat Niyazov (T\u00fcrkmenba\u015fy). The for-
\nmer Minister of Health and Prime Minister
\nBerdimuhamedow had also served as the
\nDean of Medical University and he was
\nobliged to follow the traditions and rhetoric
\nfounded by his predecessor. However, there
\nis a difference \u2013 when Niyazov was still
\nalive, his gilded monuments were erected all
\naround the country, it does not take place
\nnow and the Constitution stipulates no
\npresidency for life.
\nI was invited to visit a conference and an
\nexhibition. Almost any stand in the ex-
\nhibition, including those of Siemens A.G.
\nor Bayer, was decorated with a large-scale
\nportrait of the Great President of the State
\nGurbanguly Berdimuhamedow.
\nMore than sixty companies were represent-
\ned in the exhibition. As it turned out later,
\nthere is a portrait of the President in a doc-
\ntor\u2019s white coat in every doctor\u2019s office. The
\nJuly page of monthly calendars reveals the
\nsame portrait and I have no reason to think
\nthat other pages display different photos.
\nIt was a surprise to see that after the open-
\ning speech, delivered by the Deputy Prime
\nMinister at 11 a.m., at 12 p.m. thousands of
\ndoctors entered the hall, most of them mid-
\ndle-aged ladies wearing traditional national
\ngowns and bright scarves around their
\nheads. It is almost impossible to inveigle
\ndoctors when an exhibition dominated by
\npharmacy companies takes place in Europe.
\nAll presentations in the conference started
\nand finished with expressions of thanks to
\nthe strategic leader, the President of the
\nState. It was widely reported on TV and
\nin newspapers accentuating the thanks not
\nmedical aspects of the reports. Along with
\nthe exhibition a new six-storey dental centre
\nin the form of a molar tooth was opened.
\nThe centre can be reached by a hundred
\nmetres long suspension bridge that crosses
\nthe yard.The premises, spacious lobbies and
\nconference halls, are decorated with Turk-
\nmen carpets and TV sets.
\nI had an opportunity to visit the neigh-
\nbouring health centres. There are at least 15
\nnewly-built centres-hospitals.The first one\u00a0\u2013
\ncardiological \u2013 was built in 1998 by the pre-
\nvious President and its six storeys host 27
\nbeds; it was built for the government needs.
\nToday the President acts as a trustee for a
\nnew block of the centre while the cardiology
\ndiagnostic is available to everybody.
\nThere is already a 500 beds Maternity
\nHealth Centre built, but there is a 600 beds
\ncentre planned to be constructed next year
\n(there is also Children Hospital and Mater-
\nnity Hospital). So it seems that the govern-
\nment is demonstrating its attitude to health
\nissues by enhancing the construction work.
\nTurkmenistan counts 5 million inhabitants
\nwhile 1.2 million live in Ashgabat.
\nAs it is expensive to transport patients
\nacross the deserts, similar centres are be-
\ning built in all major cities. The principle
\nof reconstruction is to start new buildings
\nafter the old ones have been destroyed. The
\nnew Emergency Hospital with 400 beds is
\ngoing to be opened this year, but a signifi-
\ncantly bigger Red Cross Hospital is already
\nfunctioning.
\nAs far as I know,there is no other country in
\nthe world with such a ratio of hospital beds
\nper capita. Technologies used are mighty,
\nmodern, mostly non-compatible and not
\neffectively used.
\nThe colleagues are open to conversations
\nand genuinely interested in modern medi-
\ncine, most of them have graduated from
\nMoscow or Minsk University. The white
\nand spacious building of Ashgabat Medi-
\ncal University fascinates with its enormous
\ngilded domes. I am not too modest and ask
\nabout the colleagues\u2019 personal attitude to
\ntheir President of the State. Many of them
\nhad met him during his doctor\u2019s, Dean\u2019s or
\nTurkmenistan on the Roud to Democracy
\nPeteris Apinis
\n225
\nRegional NewsLATVIA
\nhospital manager\u2019s career and remember
\nhim being hardworking and friendly, how-
\never, demanding. His two theses were su-
\npervised by Academician Leontyev (former
\nPresident of Russian Medical Association
\nand member of WMA) and defended in
\nMoscow.
\nThe foreign language skills of Turkmen
\ndoctors are surprisingly good, they speak
\nEnglish, Russian and German. It is con-
\ntrasting greatly with police officers one
\ncan meet on every corner and next to any
\nbuilding, as they do not speak any foreign
\nlanguage.
\nThere are numerous sanatoriums built by
\nthe state. To maintain their activities, at
\nleast one third of the nation has to visit
\nthem yearly and the expenses are covered
\nby the employer (usually a ministry or de-
\npartment). Health is promoted by apply-
\ning mud, salts and herbs. The method has
\na proper basis as Academician, Dr.med. and
\nDr.oec. Gurbanguly Berdimuhamedow has
\njust finished his monograph \u201cMedicative
\nHerbs of Turkmenistan\u201d in three volumes.
\nIt has already been translated into Eng-
\nlish, Russian and six other languages. The
\ndirections of health care in the country are
\ndetermined by the President\u2019s monograph
\n\u201cScientific Principles of Health Care in
\nTurkmenistan\u201d.
\nWhile the President was Minister of Health,
\na sixteen storey building for the Ministry of
\nHealth was constructed. A really significant
\npart of the state budget (which is not pub-
\nlicized in Turkmenistan) is spent on health
\nissues; doctors are supplied with apartments
\nin a special area close to the Ministry and
\nnewly built health centres.
\nThe state health care strategy exceeds ex-
\ntensive building of huge centres and quite
\nchaotic purchases of new technologies.
\nThe Great President is also an outstanding
\nsportsman, who personally supports sports
\nand healthy lifestyle. Women in Turkmeni-
\nstan never smoke or drink alcohol, which
\nis based on tradition, Islamic laws and the
\nPresident\u2019s instructions. However, they do
\nnot do any sports. Either it is the new times
\nor tradition to be blamed, but most women
\nare obviously overweight.
\nIn contrast to other Muslim countries, men
\nin Turkmenistan consume alcohol a lot,
\nwhich is heritage from the USSR. It is de-
\nclared that men practice martial arts, horse-
\nriding and football.
\nEight new sports stadiums and several ice
\nhalls have been built in Ashgabat. As the
\ncity is preparing to host the Asian Olym-
\npic Games or Asiade in 2017, a new sports
\nstadium with the capacity of 100, 000 seats
\nand many other sports premises are under
\nconstruction. However, one cannot see any-
\nbody running or cycling in the city.
\nThere is a special 8.6 km long Health Track,
\nparticularly favoured by the President, built
\nin the vicinity of the city; initially you have
\nto climb about 350 metres and the track
\nleads you over the hilltops, then it goes
\ndown near town Bagira where a mighty
\nfortress and a temple were erected before
\nChrist. From time to time it was invaded by
\nAlexander of Macedonia, Persian sultans or
\njust Kazakh or Mongolian warriors.
\nThe President is said to walk the track once
\na month together with all his ministers.The
\ntrack is covered by a concrete layer; its width
\nis about 1.5 metres, both sides are secured
\nwith metallic rails, stairs installed in steeper
\nparts and nice gazebos on hilltops. At the
\nvery top of the hill there is a landing field
\nfor helicopters in case someone gets faint
\nafter ascending the hill.The track is a work-
\nplace for several dozens of Turkmen \u2013 at
\nleast four militia officers guard both ends
\nof it, a group of men work on maintenance
\ncompacting concrete, while women carry
\nwater from big tanks in buckets.
\nThere are cedars, thujas and silvery pines
\nplanted on the hill that are taken care of
\nby gardeners. Actually, I did not meet any
\nhealth addicts on the track. It could be be-
\ncause even at 42\u00ba Celsius no water is sup-
\nposed to be supplied on the whole length
\nof 8.6 km.
\nThe main natural resource of Turkmenistan
\nis gas and oil. The economy of the state is
\nbased on gas fields that rank the 4th
\nlargest
\nin the world. Pipelines transport the gas to
\nthe whole world through Russia and Iran.
\nEvery inhabitant possessing a car is entitled
\nto 1.5 tons of petrol a year for free while
\npetrol costs about 25 US cents per litre.
\nFlat rent and public utilities billing is quite
\nsymbolic; for a spacious flat it makes about
\n10 USD per month. Gas is free and heat-
\ning during winter is free as well. Taxes on
\nincome make about 10%; however, mostly
\nfor foreigners.
\nThe capital city Ashgabat makes you feel
\nsurprised \u2013 the construction boom is more
\nimpressive than anywhere in the world.
\nMinistry buildings, blocks of flats, universi-
\nties, schools, factories \u2013 all kinds of build-
\nings are being erected everywhere. The
\nstreets are as smooth as glass with at least
\nthree lanes in each direction.
\nActually, there is a new twelve to sixteen
\nstorey white marble city standing next to
\nthe old one. Architects are French, con-
\nstruction managers and supervisors are
\nTurkish while the buildings resemble the
\nclassicism of the 20th
\ncentury of America in
\nthe thirties and Russia of the fifties. There
\nare thousands of snow-white buildings
\nwith stained glass windows illuminated at
\nnight; at least ten impressive obelisks glo-
\nrifying independence, neutrality, heroism
\nof ancient Turkmen, the former President
\nT\u00fcrkmenba\u015fy Niyazov etc.
\nThe fountains are illuminated at night-
\ntime as well.The ever biggest flag is hoisted
\nat the museum building the exposition of
\nwhich displays the Turkmen nation as one
\nof the largest and most significant in the
\nworld.
\n226
\nCHINANon-Communicable Diseases
\nThe city itself is fascinating. If there are no
\nconstruction works going on, new trees are
\nplanted (mostly pines and cedars); each tree
\ngets an individual water supply pipe.
\nIn twenty years Ashgabat will be green and
\nsurrounded by forests.
\nOur hotel is situated on the main road,
\nthe other three corners are occupied by the
\nPresident\u2019s Palace, the Ministry and Acade-
\nmy of Defence and the University.Thus, the
\npriorities of the former President are clearly
\nseen. Every country and nation has its own
\npath to follow. Turkmenistan is aiming at
\nbecoming the tiger of Central Asia, mostly
\nthrough construction and pomposity. How-
\never, no one could deny that a great deal of
\nprofit from the national land deposits re-
\nturns to its people.
\nThe President of the State is a doctor and
\nhis priority is people\u2019s health, the civil ser-
\nvice although poorly educated does their
\nbest to implement this priority. Doctors
\nare trained in-service in France and Ger-
\nmany, knowledgeable professionals come
\nto Turkmenistan to perform model opera-
\ntions, new directions in medicine are being
\ndeveloped. I believe that the Medical As-
\nsociation of Turkmenistan will be founded
\nthis year.
\nDr. P\u0113teris Apinis,
\nEditor-in-Chief of World Medical Journal,
\nPresident of Latvian Medical Association
\nToday, Non-Communicable Diseases
\n(NCDs) \u2013 cancer, diabetes, chronic respira-
\ntory and cardiovascular diseases lead to 63%
\nof annual deaths worldwide. They are rec-
\nognized as a global killer and major health
\nchallenge. They affect individuals as well as
\nsociety with an economic burden estimated
\nto reach $30 trillion over the next 20 years.
\nThe situation in low-and middle-income
\ncountries is no different in this regard; ac-
\ncording to WHO data,80% of NCDs occur
\nin low- and middle-income countries. Part
\nof the solution lies in the fact that NCDs
\nare preventable to a large extent through
\nbetter self-care as up to 80% of heart disease,
\nstroke and type-2 diabetes and over a third
\nof cancers could be prevented.
\nSelf-care is a holistic and very powerful con-
\ncept well known to doctors and other health
\npractitioners. It involves people making
\nhealthy lifestyle choices ranging from regu-
\nlar exercise, healthy eating, good hygiene,
\navoiding risky behavior such as smoking,
\nbut also getting vaccinated, using sunscreen
\nand the rational use of self-care products,
\nservices and medicines.This should go hand
\nin hand with improving health knowledge
\nand becoming more aware of physical and
\nmental conditions. If practiced 24\/7, self-
\ncare makes a huge difference to wellbeing
\nand longer life expectancy.
\nAlthough there has been some progress in
\nrecognizing the crucial role of self-care in
\nthe prevention of NCDs, it is still not suf-
\nficiently appreciated by the general public
\nglobally, to make a tangible difference. In-
\nternationally, 1 in 3 people smokes while
\ntobacco is the single greatest cause of pre-
\nventable deaths in the world today, killing
\nmore than 5 million people a year \u2013 more
\nthan HIV\/AIDS, TB and malaria com-
\nbined.
\nPart of the problem is that self-care is also
\nnot seen as integral part of effective and
\ncost-efficient health care systems, which are
\ncurrently oriented to disease treatment.Pre-
\nvention is understood mainly in the context
\nof disease and not encouragement of \u2018well-
\nness\u2019. We need to look on a global and na-
\nZhenyu Guo David Webber
\nHelping Put Self-care Center Stage with Patients and Policy-Makers
\nin Combating 21st
\nCentury Killer Diseases
\n227
\nMedical Students
\ntional level to reform health systems to shift
\nfrom treating the citizens as passive victims
\nof diseases to active shapers of their own
\nwell-being. We should support behavioural
\nchange by creating self-care friendly poli-
\ncies, also outside current health systems\u00a0\u2013
\nfrom town planning, through to transport
\nand education. This will not only help to
\nsave lives but also to reduce the burden on
\nhealthcare systems.
\nExchanging and promoting best practices
\namong different countries should be a part
\nof the way forward as well. We already see
\nsome optimistic tendencies. Initiatives in
\nsupport of self-care are taking place around
\nthe world. In 2011 the International Self-
\nCare movement, which celebrates 24 July as
\nInternational Self-Care Day to remind us
\nall of the benefits of self-care, was launched
\nin China and has since spread to Vietnam,
\nIndonesia, Myanmar, and Nigeria. Interest-
\ning activities are also taking place in Aus-
\ntralia, the United States and in the United
\nKingdom.
\nAs the challenge is global, the International
\nSelf-Care movement is calling on UN to
\nrecognize International Self-Care Day on
\n24 July each year. This could largely help
\nto raise awareness and encourage people to
\nbe active participants in their own self-care
\nand also motivate governments to create
\nself-care friendly policies.
\nIn the meantime, doctors and health prac-
\ntitioners have a key role to play in helping
\ntheir patients understand the need to take
\nresponsibility for their wellness. Patients
\nshould have a right to health but they also
\nhave a responsibility to play their part in it
\nand help avoid becoming a burden to fami-
\nlies and society. International Self-Care
\nDay can support health practitioners and
\nreinforce the message that Self-Care is not
\ndifficult.
\nWe invite doctors, nurses and other health
\npractitioners to join the self-care move-
\nment by passing on the word to their pa-
\ntients. Combining our efforts, we can not
\nonly support a grass roots movement and
\nwe can encourage policymakers to turn self-
\ncare into an integral part of a new collective
\ncompact for managing health, which will
\nhelp achieve healthier and more produc-
\ntive societies and focus public healthcare
\nbudgets in areas where there is the greatest
\nneed.
\nDr. Zhenyu Guo, Chairman,
\nInternational Self-Care Foundation,initiator
\nof the first Self-Care Day in China in 2012
\n\u00a0
\nDr. David Webber, founding director
\nInternational Self-Care Foundation
\nIFMSA has been at the forefront of cultural
\nexchange, building friendships, and health
\naction in young aspiring doctors for over
\n60 years. More than five hundred medical
\nstudents from around the world, represent-
\ning collectively as a Federation more than
\na 100 nations, gathered at the 62nd
\nGeneral
\nAssembly of the International Federation of
\nMedical Students\u2019 Associations (IFMSA),
\nAugust Meeting in Santiago, Chile to strive
\ntoward making a difference in the world.
\nHowever, this General Assembly was a de-
\nfining one in IFMSA history as IFMSA
\nhas taken milestone steps towards creating
\na new birth for a Federation, in hopes of
\ncreating a Federation that has greater reach
\ninto improving the health and well-being of
\ncommunities around the world.
\nIn this past year, IFMSA has been pri-
\noritizing its global advocacy in several key
\nareas, but not limited to: Universal Health
\nCoverage, Social Determinants of Health
\nwith a focus on Sustainable Development,
\nClimate Change, Open Access to Essential
\nMedicines and Research, Human Resourc-
\nes for Health and Post-2015 Development
\nAgenda.The Federation has represented the
\nemerging voice of future doctors and ac-
\ntively participated in more than fifty global
\nand regional meetings\u00a0\u2013 not only highlight-
\nIFMSA: Striving Toward an Future that
\nMedical Students Want
\n228
\nSpeaking Books
\ning the valuable role that young people can
\nhave, but demonstrating that young people
\nare leading the innovative drive for social
\nchange. For instance, IFMSA hosted the
\nfirst Pre-World Health Assembly (WHA)
\nworkshop for Youth on Global Health Di-
\nplomacy\u00a0 \u2013 where the Federation brought
\ntogether more than 40 young health leaders
\nfrom over 25 countries, six different disci-
\nplines to create joint strategy for the world
\nhealth assembly on health issues that are
\nimportant to young people. As a result of
\nthis multi-disciplinary and strategic col-
\nlaboration, IFMSA at the WHA66 has had
\nsignificant increase in meaningful engage-
\nment with member states and stakeholders.
\nMoreover,IFMSA held its first-youth host-
\ned side-event at the WHA66 on Investing
\nin Girl\u2019s Health, which was co-hosted by
\nthe World Medical Association, Norad and
\nUNFPA.
\nAs the global community strives to set the
\nnext global agenda on development and
\nhealth, medical students, as future doctors
\nand health leaders of the world, aspire for
\ncreating an IFMSA that has limitless op-
\nportunities, so they can achieve more for
\ntheir communities. IFMSA at the 62nd
\nGeneral Assembly, a meeting devoted to
\nIFMSA\u2019s Reform process, opened with a
\nannouncement of a collaboration agree-
\nment between IFMSA-PAHO by our
\nkey note speaker, the director of PAHO,
\nthe WHO regional office for the Ameri-
\ncas\u00a0\u2013 Dr. Carissa Etienne\u00a0\u2013 that \u201cit can-
\nnot be business as usual\u201d and to \u201cstrive for
\nchange.\u201d IFMSA President, Roopa Dhatt
\nechoed to IFMSA members to \u201clet us en-
\nsure that the Federation that emerges from
\nthis reform process to create the IFMSA
\nwe want and let us together be the genera-
\ntion that, with dynamism and optimism,
\nwith unity amidst diversity, will create a
\nbetter future for the world\u2019s medical stu-
\ndents to reach our communities for better
\nhealth.\u201d
\nDuring the assembly students, while partic-
\nipants focused on capacity building, project
\nbrainstorming, training and advocacy, they
\nalso explored greater questions of transpar-
\nency, institutional strengthening, financial
\nmanagement, sustainability, and operations
\nto further to the Federation. Additionally,
\nit was all historic in that the World Health
\nStudent Alliance, an agreement between
\nInternational Pharmaceutical Students\u2019
\nFederation (IPSF) and International As-
\nsociation of Dental Students (IADS) was
\nformalized\u00a0 \u2013 creating an alliance between
\nmedical, pharmacy and dental students for
\nadvocacy and collaboration. At the conclu-
\nsion, the general assembly, with consen-
\nsus, adopted the Santiago Resolution on
\nStrengthening IFMSA\u00a0\u2013 a commitment of
\nthe Federation to focus on addressing the
\nneeds of the Federation to create an IFM-
\nSA that the members want.
\nThe world had its eyes on this General As-
\nsembly, and more than 100 national mem-
\nbers organizations have been awaiting
\nthe conclusions that were accomplished
\nin Chile. It was amazing to see how all
\ndelegates, from all regions of the world,
\nregardless of cultural background, came
\ntogether to work on institutional change,
\nto take this dream and strive to create an
\nIFMSA a more sustainable, visionary Fed-
\neration.
\nIFMSA President
\nRoopa Dhatt 2012\/13
\nRotary International and UNICEF Paki-
\nstan, partners in the Global Polio Eradi-
\ncation Initiative since 1988, launched a
\nSpeaking Book titled \u201cA Story of Health\u2019\u201d
\nto mark World Polio Day on October
\n25th
\n. \u201cA Story of Health\u201d or Sehat ki Ke-
\nhani in Urdu is an educational tool that
\nenables community workers to inform
\nmen, women, children on the impor-
\ntance of sanitation, hygiene, and vacci-
\nnation in preventing the spread of polio.
\nThe Speaking Book has been developed
\nfor the Pushtun speaking communities
\nacross Pakistan.
\nThe launch ceremony, held at Indus Valley
\nSchool of Art & Architecture, had as Mas-
\nter of Ceremonies, Zubair Anwar Bawany,
\nUNICEF Pakistan\u2019s Lead for CSR, Corpo-
\nrate Engagement & Partnerships. Speakers
\nincluded prominent guests like the Senior
\nMinister for Education, Sindh Mr. Nisar
\nAhmed Khuhro,who applauded Rotary and
\nUNICEF\u2019s initiatives and stressed the need
\nfor more of this type of education as key in
\npolio eradication.
\nThe District Governor, Dr. Pir Syed Ibra-
\nhim Shah, gave a regional perspective on
\nhaving no polio cases in Balochistan since
\nlast year versus having three in Sindh. He
\nurged Rotarians to renew efforts to eradi-
\nRotary and UNICEF Launch a Speaking Book to Prevent
\nthe Spread of Polio on World Polio Day
\n229
\nSpeaking Books
\ncate polio from Pakistan just as they have
\nbeen instrumental in polio eradication
\nworldwide,particularly taking the lead from
\nefforts in Manilla, Philippines which were
\nlater expanded to a global initiative.
\nDr. Andro Shilakadze, Chief Field Office,
\nUNICEF Sindh, thanked Rotary for their
\ncollaboration on the Speaking Book, saying
\nthat UNICEF is proud to be part of this in-
\nnovative initiative and particularly pleased
\nthe launch involved school children. He
\noffered UNICEF\u2019s continued support to
\neradicate polio and educate Pakistani chil-
\ndren,commending Pakistanis for their resil-
\nience and commitment to education.
\nThe National Chair, Polio Plus Committee,
\nAziz Memon, discussed the global collabo-
\nration effort among partners throughout the
\ndevelopment and production of the Speak-
\ning Book. He described how the Speaking
\nBook was first pioneered by a South Caro-
\nlina Rotarian, then sponsored by Rotary
\nInternational, designed in South Africa,
\nwritten, illustrated, voiced over in Pakistan,
\nand finally printed in China. The National
\nChair also pointed out that literacy is the
\nfirst step towards polio eradication, men-
\ntioning Sri Lanka, with 100% literacy level,
\ncompletely eradicating polio 20 years ago,
\nand other nations with high literacy levels
\nhaving similar success.
\nFollowing the speeches, the National Chair
\nofficially launched the Speaking Book and
\npresented it to the Chief Guest and Dr. Al-
\ntaf Bosan, who then read a few pages from
\nA Story of Health to the children huddled
\naround him in the garden, listening atten-
\ntively. All of the children from the local
\nschool were given polio mobilization items
\nsuch as pencils, badges, plastic mugs, and
\nbooks.
\nThe Speaking Books team is thrilled and
\nencouraged by the phenomenal collabo-
\nration between Speaking Books, Rotary
\nInternational, and UNICEF. We under-
\nstand and promote the power of education
\nin enabling people to live healthier and
\nmore productive lives. We see this Speak-
\ning Book as another incredible initiative
\nto help improve lives. We\u2019re proud to be a
\npart of this effort and look forward to con-
\ntinuing the work to wipe out polio around
\nthe world.
\nAlina Visram, Pakistan
\nE-mail: polioplus11@gmail.com
\nBrian Julius, USA and Africa
\nE-mail: bj@speakingbooks.com
\n230
\nCPME News
\nThe Standing Committee of European Doc-
\ntors (CPME) represents the National Medical
\nAssociations of 32 countries in Europe. We are
\ncommitted to contributing the medical profes-
\nsion\u2019s point of view to EU and European pol-
\nicy-making through pro-active cooperation on
\na wide range of health and healthcare related
\nissues.
\nCPME leading a tender on
\nContinuous Professional
\nDevelopment
\nFor this reason, the CPME has recently
\nappliedto and won a call for tender issued
\nby the European Commission, concerning
\nthe review and mapping of continuous pro-
\nfessional development (CPD) and lifelong
\nlearning for health professionals in the EU
\nand the EFTA\/EEA countries. The final
\nresult of the study aims to explore the ex-
\nisting evidence base on CPD practices and
\nidentify emerging trends to provide a more
\ncomprehensive European overview.
\nThe active participation of every member
\nrepresented by the CPME and experts in
\nhealth policy will be fundamental to col-
\nlect data and information and have a bet-
\nter picture of the situation on CPD in
\nEurope. Anotherimportant achievementis
\nthe provision of greater transparency and
\nthe improvement of mutual understand-
\ning of CPD systems and practices in the
\nEU. The CPME, as leader of a Consor-
\ntium composed of European Council of
\nDentists (CED), European Federation of
\nNurses (EFN), European Midwifes Asso-
\nciation (EMA), European Public Health
\nAlliance (EPHA) and European Group of
\nPharmacists(PGEU), will be involved in
\nthis project for 12 months.
\nEthics committees and informed
\nconsent under serious threats
\nThe European Union is currently legis-
\nlating on two major pieces of legislation:
\nthe General Data Protection Regulation
\n(2012\/0011 (COD)) which aims at secur-
\ning the processing,storage and exchanges of
\npersonal data at a European level \u2013 includ-
\ning health and medical data; and the Clini-
\ncal Trials Regulation (2012\/0192 (COD))
\nwhich is meant to facilitate the conduct
\nof research and foster the development of
\nmedicines in Europe.
\nCPME has been actively monitoring the
\ndevelopment of negotiations and fueled
\nthe debates with the views of the medical
\nprofession.Both draft regulations have been
\nadopted by the European Parliament, now
\nthe next step is for the Parliament to reach
\nagreement with the Council \u2013 representing
\nthe 28 EU Member States. The objective is
\nfor these regulations to be formally adopted
\nin the first half of 2014.
\nHowever, even if the legislative process is
\nnot over yet, CPME is extremely worried
\nabout the orientation of negotiations. We
\ndo see a tendency of the legislators to put
\ninto question and even weaken the founda-
\ntions of medical ethics, in particular ethics
\ncommittees and informed consent in re-
\nsearch.
\nFirst, the role foreseen for ethics commit-
\ntees in the course of a clinical trial\u2019s approval
\nprocedure, is being dangerously diminished.
\nIndeed, the current text of the clinical trial
\nregulation limits the function ethics com-
\nmittee to a sole examination role of the
\ntrial protocol. In otherwords, the final deci-
\nsion of the ethics committee based on the
\nassessment of the protocol, is not binding
\nany longer. We fear that in practice, this
\nwill result in clinical trials being conducted
\ndespite the negative assessment of the trial
\nprotocol by the ethics committee.
\nSecond, the widely agreed ethical standard
\nby which an individual who is about to take
\npart in a medical research study should be
\nsubstantially informed of the characteristics
\nof the study before he consents to it, is at
\nstake.
\nThis is the case both in the data protec-
\ntion and the clinical trial regulations. In
\nthis context, identifiable health data of an
\nindividual could indeed be accessed by a
\nresearcherwhile the concerned individual
\nhas never given his informed and explicit
\nconsent to it. We believe this is a very dan-
\ngerous step which will without doubt have
\ndisastrous effects on research integrity, but
\nalso on the patients themselves.
\nThe World Medical Association\u2019s Decla-
\nration of Helsinki which was renewed at
\nthe WMA meeting in Fortaleza, Brazil in
\nOctober 2013 and which highlights these
\nkey ethical principles is to be respected.
\nThe CPME together with WMA has lob-
\nbied and will continue to lobby in favour of
\nthose principles. When research involves
\nhuman beings, ethical principles are not
\nnegotiable.
\nFor further information on CPME\u2019s activi-
\nties and policies: www.cpme.eu
\nDr Katr\u00edn Fjeldsted,
\nPresident of the Standing Committee
\nof European Doctors
\nMs Birgit Beger,
\nSecretary General of the Standing
\nCommittee of European Doctors
\nNews from the CPME: Up-date on policy
\ndevelopments in the European Union
\n231
\nWMA News
\nMemorandum of Understanding
\nEuropean Forum of Medical Associations \u2013 World Medical
\nAssociation Handbook
\nThe European Forum of Medical Associa-
\ntions (EFMA) was established in Decem-
\nber 1984, following an invitation from the
\nWHO European Region to a joint meeting
\nwith the National Medical Associations to
\ndiscuss Health for All in Europe and other
\ncommon issues. From this date until the
\npresent, a joint annual meeting has been
\nheld, hosted by different NMAs.
\nInformation about participating National
\nMedical Associations, their aims and ac-
\ntivities was first collected in a printed hand-
\nbook (herein \u201cthe handbook\u201d), as a joint
\nventure between the Norwegian Medical
\nAssociation and EFMA-WHO in 1991.
\nThe handbook was updated and published
\nby the Norwegian Medical Association ev-
\nery year since then until 2009, when it was
\ntransferred to the EFMA website: www.ef-
\nma-forum.com and www.efma-forum.org.
\nIn 2012, the Norwegian Medical Associa-
\ntion decided that they are no longer able to
\nmaintain and update the EFMA handbook.
\nAt the EFMA Forum in Riga in March
\n2013, it was decided that this will be taken
\non by the World Medical Association.
\nThis agreement is between the European
\nForum of Medical Associations (herein
\n\u201cEFMA\u201d) and the World Medical Associa-
\ntion (herein \u201cWMA\u201d).
\nIn consideration of the mutual promises
\ncontained herein, the parties agree as fol-
\nlows:
\nThe handbook will be co-branded as the
\nEFMA-WMA handbook and will be
\nposted on the WMA platform. The Ser-
\nbian Medical Chamber will undertake
\nthe upkeep of the handbook and will host
\nthe handbook on their server. The EFMA
\nwebsite, which includes details of EFMA
\nmeetings and activities will be separated
\nfrom the EFMA-WMA handbook and will
\nalso be hosted and updated by the Serbian
\nMedical Chamber.
\n1. The handbook will include all members
\nof EFMA and the WMA, including
\nthose who are members of only one of
\nthe two organizations. The WMA will
\nwork to extend the handbook to include
\nassociations from other parts of the
\nworld.
\n2. Both parties, EFMA and the WMA,
\nwill appoint representatives to form a
\nreview committee. It is the responsibil-
\nity of each party to ensure that they are
\ninvolved in the upkeep of the handbook
\nand encourage their members to update
\ntheir profiles.
\n3. The handbook will consist of two parts:
\nthe names, addresses and contact details
\nof the NMAs and a more descriptive
\nsection about the role of each associa-
\ntion and its activities.The handbook will
\nalso include a section where associations
\nstate which international organisations
\nthey are a member including but not ex-
\nclusive to: EFMA, WMA, CPME and
\nUEMS.
\n4. The WMA will clarify in the handbook
\nthat they are listing the true number of
\ndoctors in their country and not the de-
\nclared numbers the WMA asks for in
\ntheir membership. WMA members will
\nnot be penalised if there is a discrepancy
\nbetween the two figures.
\n5. The handbook will include the logos of
\nboth EFMA and the WMA, and will
\nclearly state that the handbook is the
\nproduct of joint cooperation between
\nEFMA and the WMA.
\n6. If the WMA add accompanying sec-
\ntions to the handbook they will receive
\nsole credit for such additions.
\n7. If either party intends to revise or pub-
\nlish future editions of the handbook,
\nthat party hereby grants the right of first
\nrefusal to the other association to par-
\nticipate in the modification or editing of
\nthe work. If either association does not
\nprovide an acceptable revision within a
\nmutually agreed upon reasonable time,
\nor should one of the associations be
\nunable or unwilling to revise the hand-
\nbook, the other party may revise or edit
\nthe future edition. The associations will
\nconsult with each other when the hand-
\nbook is considered for uses other than
\nthe ones for which it was produced.
\n8. If the Serbian Medical Chamber or the
\nWMA decide to end their involvement
\nin the publication of the handbook,
\nEFMA will do its utmost to find a re-
\nplacement.
\n9. This Agreement constitutes the entire
\nunderstanding between EFMA and
\nthe WMA with respect to the EFMA-
\nWMA handbook, supersedes any and
\nall prior understandings and agree-
\nments, oral and written, relating hereto,
\nand may be amended at any time only in
\na writing signed by both parties.
\nSigned by
\nDr. Otmar Kloiber
\nSecretary General, WMA
\nAdv Leah Wapner
\nSecretary General, EFMA
\n232
\nWMA News
\nNew WMA Cooperating Center
\nThe Steve Biko Centre for Bioethics, University of the Witwatersrand,
\nJohannesburg, South Africa has been awarded the title WMA Cooperat-
\ning Center. WMA Cooperating Centers are academic institutions that
\nsupport the WMA with scientific advice and on specific projects. The
\nWMA currently has five cooperating centers. The Steve Biko Centre for
\nBioethics is the first in Africa.
\nWMA Executive Committee decided to award the title WMA
\nCooperating Center to the Steve Biko Centre for Bioethics, Uni-
\nversity of the Witwatersrand, Johannesburg, South Africa. This is
\nremarkable in several ways. Steve Biko was an anti-apartheid activ-
\nist who died in police custody as a result of torture. The failures of
\nthe (white) medical community in South Africa at that time finally
\nled to a split in the World Medical Association. The failure of the
\nMedical Association of South Africa and the WMA to clearly stand
\nup for human rights at that time was certainly one of the serious
\nmistakes of these organizations.\u00a0 Steve Biko\u2019s death was one of the
\ncritical events that finally led to the isolation of the apartheid re-
\ngime.\u00a0
\nThere has been increasing cooperation between the Steve Biko
\nCentre for Bioethics and the WMA for more than a decade. We
\nhave continuously worked together on issues of research involving
\nhuman beings,with a focus on questions of placebo use and research
\nin resource poor settings, and on new ways to empower illiterate
\ncommunities using speaking books that bring health education to
\nthem. Prof. Ames Dhai, the head of the Steve Biko Centre, is cur-
\nrently President of the South African Medical Association. By af-
\nfiliating ourselves with an organisation bearing this name, we not
\nonly pay tribute to an academic partner we have held in high estime
\nfor many years now, but also to a man to whom we owe praise for
\nhis sacrifice: Steve Biko.
\nWorld Medical Association has, for the first time, issued a joint
\npress statement with the UN Special Rapporteur for the Right to
\nHealth, Armand Grover. Following the protests at Gezi Park in
\nIstanbul and in other Turkish cities last summer, the government
\nhas now prepared a law that would require special permission and
\nregistration to provide assistance in extraordinary circumstances like
\ncatastrophes and riots. The intention is very obvious: the govern-
\nment wants to discourage health professionals from providing first
\naid and medical assistance to government opponents or, if they do
\nregister, to be able to easily get hold of them and the names of those
\nthey treated.This is an old trick. In the nineties, the Turkish govern-
\nment required those treating torture victims to hand over the names
\nof their patients. Intimidation is a powerful tool for denying access
\nto health care to political opponents.\u00a0
\nAs then, so too now Turkish doctors are resisting, and we stand
\nby them.\u00a0 The Special Rapporteur and the WMA are extremely
\nconcerned about the new law which contains draconian sanctions
\nfor those who do not comply. Grover warned that, \u201cEnacting laws
\nand policies criminalizing provision of medical care to people op-
\nposing the State, such as political protestors, will certainly deter
\nhealthcare workers from providing services due to fear of prosecu-
\ntion\u201d.\u00a0
\nThe Turkish Government is taking an absurd route in fighting its
\nown civil society. We need to stand by our Turkish colleagues in up-
\nholding medical neutrality and support their commitment to pro-
\nviding aid in critical situations. We are convinced that we stand on
\nthe side of righteousness. But for our Turkish colleagues this is not
\nwithout peril. As Voltaire put it, \u201cIt is dangerous to be right when
\nthe government is wrong.\u201d
\nDr. Ames Dhai Director of the Steve Biko Centre for Bioethics
\nand WMA President Dr. Margaret Mungherera
\nHuman Rights
\nThe World Medical Association has, for the first time, issued a joint press
\nstatement with the UN Special Rapporteur for the Right to Health, Ar-
\nnand Grover. Following the protests at Gezi Park in Istanbul and in
\notherTurkish cities last summer, the government has now prepared a law
\nthat would require special permission and registration to provide assis-
\ntance in extraordinary circumstances like catastrophes and riots.The Spe-
\ncial Rapporteur and the WMA are extremely concerned about the new
\nlaw which contains draconian sanctions for those who do not comply.The
\nlaw is designed to deter healthcare workers from providing services to
\ngovernment opponents due to fear of prosecution.
\n(09.12.2013)\u00a0 GENEVA \u2013 The UN Special Rapporteur on the
\nright to health, Anand Grover, and the World Medical Associa-
\n233
\nWMA News
\ntion (WMA) urged today the Turkish Grand National Assembly
\n(Meclis) to reconsider a draft law that would criminalize the provi-
\nsion of medical care by qualified independent practitioners during
\nemergencies after the arrival of a state ambulance.
\n\u201cIf adopted, Article 33 will have a chilling effect on the availability
\nand accessibility of emergency medical care in a country prone to
\nnatural disasters and a democracy that is not immune from demon-
\nstrations,\u201d Special Rapporteur Grover said.
\n\u201cEnacting laws and policies criminalizing provision of medical care
\nto people challenging State authorities, such as political protestors,
\nwill certainly deter healthcare workers from providing services due
\nto fear of prosecution,\u201d Grover warned, quoting his latest report* to
\nthe UN General Assembly on the enjoyment of the right to health
\nin conflict situations. \u201cSanctioning such laws and policies will also
\ndiscourage other segments of the population from seeking health
\nservices due to fear of being suspected in the involvement in pro-
\ntests,\u201d he stressed.
\n\u201cThe mere presence of ambulances would be considered grounds
\nnot only to prevent emergency medical care by competent,indepen-
\ndent physicians, but also to prosecute those medical responders up
\nto three years of imprisonment and a hefty administrative fine for
\nacting under the International Code of Medical Ethics to provide
\ncare to those in need,\u201d the WMA\u2019s Secretary General, Otmar Kloi-
\nber, underlined.
\nDr. Kloiber pointed out that \u201cin times of urgency, from earthquakes
\nto floods to protests and demonstrations, the international stan-
\ndards for emergency medical care are based on the medical need of
\nthe wounded and sick rather than the presence of official medical
\ntransport.\u201d
\nThe two experts noted that international medical and human
\nrights standards make it clear that it is a humanitarian duty of
\ndoctors, nurses, paramedics, and other health workers to give
\nemergency care to those in need. \u201cThey must be able to carry out
\ntheir professional responsibilities without interference or fear of
\nreprisal,\u201d they said.
\nThe Special Rapporteur and the WMA had written individually to
\nthe Turkish Government expressing their grave concern about the
\nrequirements of Article 33 of the draft health bill. \u201cNow we urge
\nthe Meclis to consider the right of the Turkish people to emergency
\ncare and ensure the respect for medical ethics and independence
\nhealth workers in Turkey.\u201d
\n\u201cWe hope parliamentarians will make the right call on the Article
\n33 and scrap it, as it should be,\u201d the experts said.
\nSuccessful Climate and Health
\nSummit in Warsaw
\nOn 16 November the 2nd
\nInternational Climate and Health Summit
\ntook place in Warsaw alongside the official UNFCCC\u00a0 COP19 cli-
\nmate\u00a0negotiations.
\nThe Summit was organised by the\u00a0Global Climate and Health Alliance
\n(GCHA)\u00a0together with the World Medical Association and supported by
\nthe WHO. Prof. Vivienne Nathanson (British\u00a0Medcial Association) rep-
\nresented the\u00a0WMA at the event.\u00a0
\nWarsaw 15\/11\/2013 \u2013 Health and medical organizations from
\naround the\u00a0world are convening in Warsaw this week to emphasize
\nthe urgent need\u00a0to prioritize the protection and promotion of health
\nwithin global and\u00a0national policy responses to climate change.
\nThe Global Climate and Health Summit 2013 will take place on
\n16\u00a0November 2013, during the UNFCCC\u2019s COP19 meetings in
\nPoland, and is\u00a0organized by the Global Climate & Health Alliance
\n(GCHA) together with\u00a0the World Medical Association and with
\nsupport form the World Health\u00a0Organization.
\nThe Summit will highlight the dangerous impacts of climate change
\non\u00a0human wellbeing, the health benefits of mitigation and current
\nefforts\u00a0to make the health system more sustainable. It will build a
\nroad-map\u00a0for the international health community to work towards
\nin the run-up\u00a0to the 2015 climate negotiations in Paris.
\nResearch shows that climate change already contributes to over
\n400,000\u00a0deaths every year. If there is a continued lack of political
\nwill,\u00a0these figures are expected to increase dramatically as the im-
\npacts of\u00a0climate change worsen:
\n\u2022 Populations at risk of infectious diseases such as malaria may
\ngrow\u00a0to 170 million in Africa by 2030 whilst those at risk of den-
\ngue fever\u00a0may increase to over 2 billion globally by 2080
\n\u2022 Climate change will worsen the impact of urban air pollution
\nwhich\u00a0is already directly responsible for over 1.2 million deaths
\neach year
\n\u2022 The impact of coal plant emissions in Europe alone contributes
\nto\u00a018,000prematuredeathsandfourmillionlostworkingdays\u00a0\u2013with
\nall\u00a0healthcostscombinedtotalingnearly43billionEuroseveryyear\u00a0
\n\u2022 By 2080, over 100 million more people each year risk being ex-
\nposed\u00a0to coastal flooding by predicted sea level rises.
\n234
\nWMA News
\nHuman health is profoundly threatened by our global failure to
\nhalt\u00a0emissions growth and curb climate change. GCHA argues that
\nstrategies\u00a0to achieve rapid and sustained emissions reductions and
\nto protect\u00a0health must be implemented in a specified time frame to
\navert further\u00a0loss and damage.
\nIn addition to calling on governments to commit to a binding treaty
\nat\u00a0the 2015 COP in Paris, GCHA is also encouraging the interna-
\ntional\u00a0community to ensure the resulting political, legislative and fi-
\nnancial\u00a0frameworks reflect the full impacts of climate change on health
\nand\u00a0ensure public health is protected by governments around the world.
\nIRCT defines way forward to
\nrealise the right to rehabilitation
\nBeirut, Lebanon, 27\u201328 June 2013
\nVictims of torture have a right to rehabilitation. But how can we ensure
\nthat this right becomes a reality in which victims enjoy access to appropri-
\nate, holistic rehabilitation services that are funded through states?
\nThis was the major question addressed at the pioneering scientific
\nconference The Right to Rehabilitation, co-organised by the Inter-
\nnational Rehabilitation Council for Torture Victims and Restart
\nCenter for Rehabilitation of Victims of Violence and Torture.
\nThe experiences, best practices, lessons learned and priority path-
\nways forward are now available in the conference report.
\nIn collaboration with speakers and participants from 50 countries,
\nthe IRCT has gathered the input to move forward on ensuring the
\nright to rehabilitation for all victims of torture. The IRCT recom-
\nmends that rehabilitation services be:
\n\u2022 State funded: Most significantly for the sustainability of the re-
\nhabilitation movement, states are obligated to provide or ensure
\nprovision of rehabilitation services to victims of torture,regardless
\nof resources or where the torture took place.
\n\u2022 Victim-centred: As mentioned by the UN Committee against
\nTorture in their General Comment No. 3, rehabilitation services
\nmust consider the totality of the victim\u2019s context and needs.
\n\u2022 Linked to national health and educational systems: To ensure the
\ncontinued growth of high-quality care,rehabilitation services must
\nbuild sustainability and quality through on-going collaboration
\nwith current health and education systems. In addition, links with
\nhealth systems builds in improved referral systems for victims of
\ntorture when they seek treatment through general practitioners.
\n\u2022 Multi-faceted services: Rehabilitation treatment should be holis-
\ntic, or multi-faceted, to encompass the multiple needs of victims,
\nincluding medical, psychological, legal, social, economic and asy-
\nlum needs. Furthermore, multi-faceted health organisations for
\nvictims of torture may lessen the stigma for those needing to ac-
\ncess mental healthcare services.
\nCall to Action from Bellagio
\nConference on Protection of
\nHealth Workers, Patients and
\nFacilities in Times of Violence
\nIn November 2013, the Center for Public Health and Human Rights of
\nthe Johns Hopkins Bloomberg School of Public Health convened 19\u00a0ex-
\nperts from the fields of humanitarian practice, human rights, human
\nsecurity, academic research, government, and philanthropy, along with
\nUN representatives and leaders from health professional associations, at
\nBellagio, Italy to address the problem of attacks on and interference with
\nhealth care, particularly in times of armed conflict and internal distur-
\nbances. WMA President, Dr Margaret Mungherera, was one the experts
\nand a keynote speaker.
\nNoting that Violations undermine the human security and health of
\nconflict-affected populations, disrupt health systems and undermine eq-
\nuitable access to health care, resulting in avoidable loss of life and human
\nsuffering, the experts agreed that urgent action is needed to address the
\nproblem and call upon the international community to advance the se-
\ncurity of health, particularly in situations of armed conflict and internal
\ndisturbances through several actions.
\nCall to Action
\nBellagio Conference on Protection of Health Workers,
\nPatients and Facilities in
\nTimes of Violence
\nBellagio, Italy
\nNovember 19\u201321, 2013
\nInternational humanitarian and human rights law recognizes the
\nobligation and\/or the responsibility of governments and non-state
\nactors to respect and protect health workers,facilities,medical trans-
\nports, and the people they serve. Violations undermine the human
\n235
\nWMA News
\nsecurity and health of conflict-affected populations, disrupt health
\nsystems and undermine equitable access to health care, resulting in
\navoidable loss of life and human suffering.
\nWe, the assembled, believe urgent action is needed to address the
\nproblem and call upon the international community to advance the
\nsecurity of health, particularly in situations of armed conflict and
\ninternal disturbances, through the following actions:
\n1. States and armed groups at all times, including during armed
\nconflicts and internal disturbances, respect health care workers,
\nfacilities, transports, and services, and persons seeking care, by
\nnot attacking, interfering with, threatening or obstructing them;
\nrefrain from punishing health workers for providing treatment
\nto individuals in need of medical care on account of the patient\u2019s
\nethnic,religious,national,political or military affiliation or other
\nnon-medical considerations; and ensure availability of safe and
\nsecure access to and equitable distribution of quality health care.
\n2. States train their military, police forces and other law enforce-
\nment agents to adhere to legal standards and assure protection of
\nhealth services, health workers and people seeking care; armed
\ngroups similarly raise awareness among their forces to comply
\nwith their international obligations to respect health care work-
\ners, facilities, transport, and services, and persons seeking care.
\n3. States, with the support of the UN, take action to stop attacks
\nand hold perpetrators to account in national and, where appro-
\npriate, international courts and\/or special tribunals.
\n4. States make explicit in national law the respect for and protec-
\ntion of the delivery of health care and health workers in times
\nof armed conflict and internal disturbances, and reaffirm and
\nreinforce these norms through the UN General Assembly, the
\nSecurity Council and the Human Rights Council.
\n5. States, through Ministries of Health and other relevant agen-
\ncies and UN bodies, establish, strengthen and provide resources
\nfor systematic monitoring and reporting of attacks on health
\nworkers, facilities and transports, and individuals seeking care;
\nand support the implementation of ongoing initiatives by the
\nUN Special Representative for Children and Armed Conflict
\nand the World Health Organization designed to collect and dis-
\nseminate data on attacks on health services and encourage field-
\nbased reporting by the High Commissioner for Human Rights.
\n6. States, through the UN, engage in processes such as Universal
\nPeriodic Review, treaty body review and mechanisms for the
\nprotection of civilians and children affected by conflict to pro-
\nmote compliance with international law and accountability for
\nperpetrators.
\n7. States, relevant UN entities, NGOs and professional health or-
\nganizations and ministries of health promote, disseminate and
\nimplement recommendations of the International Committee
\nof the Red Cross Health Care in Danger project to increase
\nsecurity of health care services and health workers in the field.
\n8. Health professional organizations at the national and global
\nlevel promote universally accepted standards of professional
\nconduct among health workers in armed conflict and internal
\ndisturbances,including training health workers on human rights
\nand medical ethics and advocating for protection and security of
\nhealth services and health workers.
\n9. States, WHO and the Global Health Workforce Alliance as
\npart of the UN post-2015 development agenda process incorpo-
\nrate strategies to address the problem of interference with health
\ncare and attacks of health workers in the human resources for
\nhealth agenda and related initiatives.
\n10. Civil society actors actively engage States and relevant inter-
\nnational organizations to advance protection of health care in
\narmed conflict and internal disturbances.
\n11. States and donors support civil society engagement through ca-
\npacity building, technical assistance and funding.
\n12. States and other research funding bodies sponsor and research-
\ners and practitioners conduct in-depth studies on the nature of
\nviolations, the perpetrators, as well as the consequences of lack
\nof protection of health care functions on the health and devel-
\nopment of the population. Current research gaps are identified
\nin Annex 2 to this statement.
\n2013 Global Health Forum,
\nTaipei,Taiwan
\nFrom WMA Leaders\u2019 blogs
\nWMA Secretary General Dr. Otmar Kloiber travels around the world
\ntalking about the WMA\u2019s work representing the millions of physicians
\nworldwide. Acting on behalf of patients and physicians, the WMA en-
\ndeavors to achieve the highest possible standards of medical care, ethics,
\neducation and health related human rights for all people. This blog will
\nchronicle these travels and important issues. (www.wma.net).
\nTaipei, Taiwan to Frankfurt, Germany. Should all ministers be
\nhealth ministers? For sure, at least in a way\u2026
\nThere is no sector of government that does not have relevance for
\nhealth and health care.Whether the actions of a ministry have direct
\neffects, such as setting financial budgets for health care or payments,
\nor indirect effects for example upon peace, the availability of work
\nand housing, social protection, road safety, education, occupational
\nand environmental safety, international cooperation, trade and aid,
\nclimate change, or research financing, there is virtually no section of
\ngovernment that is not connected in some way with health.
\n236
\nWMA News
\nNext generation had a strong representation at the Global Health
\nForum: Roy Jen-Hsiang Shen, WMA-JDN-Member, Dr. Ot-
\nmar Kloiber, WMA, Dr. Yung-Tung Wu, Past-President TMA,
\nDr.\u00a0Andy Hsieh, (Dental Surgery), Dr. Ray Wu, (Dental Surgery).
\nBut how to get health into the minds of the politicians? This awfully
\ndifficult question was debated at the invitation of the Taiwanese gov-
\nernment at the 2013 Global Health Forum in Taipei from November
\n23-24,2013.In a section on the \u201cPhysicians\u2019role and response to pro-
\nmoting Health in All Policies in an NCD era\u201d I\u00a0stressed our holistic
\napproach to tackling non-communicable disease (NCDs). This has
\ntwo major pillars: Firstly, the right to health as a human right, and
\nsecondly a focus upon the social determinants of health as the under-
\nlying causes of many diseases in this world.
\nThe WMA was irritated when in 2011 the World Health Organiza-
\ntion went back to the old silo approach of listing four disease areas
\n(cancer,cardio-vascular and lung diseases and diabetes) in their pro-
\ngram on NCDs.Just three years previously in 2008,thirty years after
\nthe Alma Ata Declaration of the WHO, a ground breaking World
\nHealth Report on \u201cPrimary Care \u2013 Now more than ever\u201d clearly
\ndemonstrated that the sectorial approach,tackling a limited number
\nof infectious diseases, had not shown the desired effects. And yet,
\nwhile finally tackling NCDs after decades of ignoring them, the
\nWHO now falls back on the same old and insufficient strategy.
\nThis is even more startling since, at the same time, the WHO has
\nnot only made a new start on primary care (World Health Report
\n2008) \u2013 much more realistic than ever before \u2013 and developed a
\nreport on Social Determinants of Health (\u201cClosing the Gap in one
\nGeneration\u201d WHO 2008) under the chairmanship of Sir Michael
\nMarmot, it has also embarked on health system strengthening and
\nis advocating loudly for universal health coverage.
\nThe challenges are overwhelming – we still don\u2019t see enough poli-
\ncies taking account of their effects upon health, whether they are
\ndirectly related to public health, such as fostering tobacco control,
\nor indirectly, such as providing enough funding for affordable and
\nhigh quality education for all. While Africa still has a homeopathic
\naverage per capita health expenditure of around 100 USD per year,
\nproblems of equity exist within all nations, regardless of whether
\nthey are rich or poor.
\nThe Taipei conference ended with a call upon the politicians of this
\nworld to be aware of their responsibilities regarding health. How-
\never, as the conference was mainly attended by experts on public
\nhealth, this was a bit like preaching to the converted. One positive
\naspect was the presence of a lot of young people at the conference.
\nMedical students, young physicians and other young health profes-
\nsionals gave the conference a strong youthful perspective, and the
\nhope that our voices will be heard in the future. And of course it is
\nalways good to meet up with members of the WMA Junior Doctors
\nNetwork (JDN).
\nThe fact that Taiwan, having been a very poor country just few
\ndecades ago, is now a leader in health system development, pro-
\nviding comprehensive and efficient health care to all of its people,
\nis really very inspiring. And it is also clear that the health of the
\nnation is not merely a result of strong economic development, but
\nrather a condition for it. For all those who are struggling to build
\na health care system, the bottom line is: Yes, it can be done, even
\nagainst all odds.
\nA big thanks to the Taiwan Government, the Minister for Health
\nand Welfare, Dr. Wen-Ta CHIU for inviting the WMA again and
\nthe Taiwan Medical Association for facilitating this!
\nMeetings
\nHealth care in danger: From consultation to
\nimplementation
\nWMA President Dr Margaret Mungherera gave a key note address
\non the importance of healthcare in times of conflict and violence at
\nthe expert conference organized by the International Committee
\nof the Red Cross (ICRC), together with the Conflict and Catas-
\ntrophes Forum of the Royal Society of Medicine (RSM) and the
\nBritish Red Cross on 3 December in London.
\n197th
\nWMA Council Session, April 2014
\nThe 197th
\nCouncil session will be held from 24\u201326 April 2014 at the
\nHotel Nikko Tokyo, in Tokyo, Japan. The registration is open and
\nhigher fee will be applied after 24 March.
\nWMA General Assembly, Durban 2014
\nThe General Assembly in 2014 will be held from 8\u201311 October
\n2014 at the Durban International Convention Centre, in Durban,
\nSouth Africa. Please save these dates in your calendar.
\n200th
\nWMA Council Session, April 2015
\nThe 200th
\nCouncil session will be held from 16\u201318 April 2015 in
\nOslo, Norway. Please save these dates in your calendar.
\n237
\nWMA News
\nWorld Health Professions Regulation Conference 2014
\nTo be held in Crowne Plaza Hotel, Geneva, Switzerland 17\u201318
\nMay 2014. WMA is co-organizer.
\nInternational update
\nCall to end attacks on health workers
\nOn 24 October 2013, the UN Special Rapporteur on the Right to
\nHealth, Anand Grover, presented the latest report to the General
\nAssembly, dedicated to the right to health obligations of States and
\nnon-State actors towards persons affected by and\/or involved in
\nconflict situations. It describes a wide range of abuses against health
\nworkers and highlights the need for better monitoring and account-
\nability.The Special Rapporteur\u2019s report is the first UN human rights
\nanalysis to describe the responsibilities of countries to provide and
\nprotect health workers and services in conflict.
\nResolution supports torture victims\u2019 right to rehabilitation
\nOn 12 November, 193 States of the UN General Assembly adopted
\na resolution reiterating the absolute prohibition of torture and, sig-
\nnificantly, the obligation on states to ensure victims have prompt
\naccess to appropriate rehabilitation services. This resolution is par-
\nticularly important since not all countries around the world have
\nratified the UN Convention against Torture.
\nThird Global Forum on Human Resources in Health (HRH)
\nThe Forum, held in Recife, Brazil, emphasized the importance of
\nHRH in implementing universal health coverage and discussed
\nwhat universal health coverage means for various stakeholders.
\nWHO Member States adopted the Recife Political Declaration,
\nwhich outlines the type of actions and commitment required at na-
\ntional and global levels to address international HRH challenges.
\nEducation and training for 21st
\ncentury
\nWHO has developed a website on \u201cTransforming and scaling up
\nhealth professionals\u2019 education and training\u201d. The guidelines are
\nexpected to give rise to regional- and country-based policy and
\ntechnical dialogues with key stakeholders across education, health,
\nfinance and labour, on how best to finance health professional train-
\ning and prepare health professionals for the 21st
\ncentury.
\nGreen news
\nWHO calls to phase out mercury from measuring devices
\nOn 11 October 2013, to mark the signing of the Minamata Con-
\nvention on Mercury, WHO and Health Care without Harm joined
\nforces to launch a new initiative to have mercury removed from all
\nmedical measuring devices including fever thermometers and blood
\npressure by 2020. WHO media release
\nNew UNEP Website of the Minamata
\nConvention on Mercury
\nThe Minamata Convention for Mercury is a global treaty to pro-
\ntect human health and the environment from the adverse effects of
\nmercury.
\nPublications, courses,
\nconferences, calls for papers
\nResearch Ethics Course \u2013 TRREE
\nResearch Ethics Course \u2013 Training and Resources in Research
\nEthics Evaluation (TRREE) in collaboration with the Institute
\nof Health Law, University of Neuch\u00e2tel, is available on the WMA
\nwebsite.
\nThe Prince Mahidol Award Conference (PMAC)
\nThe Prince Mahidol Award Conference is an invitation-only con-
\nference hosted by the Prince Mahidol Award Foundation and the
\nRoyal Thai Government in cooperation with several partners. The
\nConference, entitled \u201cTransformative Learning For Health Equity,\u201d
\nwill be held in Bangkok, Thailand, 27-31 January 2014. WMA is
\npart of the conference advisory committee helping develop the con-
\nference program.
\nAmbulance and pre-hospital services in risk situations
\nWritten by the Norwegian Red Cross with support from the In-
\nternational Committee of the Red Cross (ICRC) and the Mexican
\nRed Cross, this report sets out ways to make pre-hospital care and
\nambulance services operating in areas of armed violence safer.
\n238
\nPersonal Opinion NIGERIA
\nState of the World Population Report 2013
\nThe State of the World Population Report 2013 \u201cMotherhood in
\nChildhood:Facing the Challenge of Adolescent Pregnancy\u201dreleased
\nby UNFPA finds that more than 7 million girls in poor countries
\ngive birth before 18 years old each year with two million of them
\n14 or younger. The report, which focuses on adolescent pregnancy,
\nhighlights its challenges and consequences on the health, education,
\nemployment and rights of millions of girls around the world.
\nGuidance note on disability & emergency
\nrisk management for health
\nThe WHO and partners have launched a guidance note on disabil-
\nity and emergency risk management for health \u2013 a short, practical
\nguide that covers actions across emergency risk management.
\nNew Detention Monitoring Tool
\nThis tool developed by Penal Reform International (PRI) and the As-
\nsociation for the Prevention of Torture (APT) addressing risk factors to
\nprevent torture and ill-treatment.It aims to provide analysis and practi-
\ncal guidance to help monitoring bodies to fulfill their preventive man-
\ndate as effectively as possible when visiting police facilities or prisons.
\nRecognizing Victims of Torture in
\nNational Asylum Procedures
\nA new report by the International Rehabilitation Council for Tor-
\nture Victims (IRCT), conducted an 18-country overview of asylum
\nsystems in Europe, North America and the Pacific. It gives a com-
\nparative overview of early identification of victims and their access
\nto medico-legal reports in asylum-receiving countries.
\nGuidelines on Human Rights Education for Health Workers
\nThese guidelines present approaches to be adopted when planning or
\nimplementing human rights education for health workers related to six
\nkey structural areas: the human rights-based approach to human rights
\neducation; core competencies; curricula; training and learning process-
\nes; evaluation; and professional development and support of trainers.
\nNew database of health and human rights syllabi
\nTo assist university-based teachers and others teaching health and
\nhuman rights,the University of Southern California (USA) has cre-
\nated a database of syllabi on health and human rights concepts and
\nmethods. In providing these syllabi, the initiators hope to stimulate
\nand support efforts to integrate health and human rights into a wide
\nvariety of specific and general curricula.
\n150th
\nAnniversary of the World Veterinary Association
\nThe 31st
\nWorld Veterinary Congress (WVC) took place in Prague
\n(Czech Republic) from 17 to 20 September. This year, the WVC
\nwas marked by World Veterinary Association\u2019s 150 years Anniver-
\nsary celebrations.This year, the WVA-WHO-OIE-FAO 2nd
\nGlobal
\nSummit focused on strengthening institutional collaboration and
\ncooperation between animal and public health in education and re-
\nsearch.
\nPrologue
\nThe United Arab Emirates consist of seven
\nsemi-autonomous emirates with three li-
\ncensing bodies for medical and paramedical
\nprofessionals.
\nThe Dubai Health Authority (DHA) li-
\ncenses doctors and other paramedical profes-
\nsionals to work in the Emirate of Dubai.The
\nHealth Authority of Abu Dhabi (HAAD) li-
\ncenses doctors and paramedical professionals
\nto work in the Emirate of Abu Dhabi and Al
\nAin city.The United Arab Emirates Ministry
\nof Health (MOH) licenses doctors and para-
\nmedical professionals to work in the remain-
\ning five emirates namely Sharjah,Ajman,Um
\nal Quwain, Ras Al Khaimah and Fujairah.
\nThe Scene
\nI am a Nigerian general medical practitioner
\nwith thirty-seven year unbroken experience
\nin private medical practice. I desire to retire
\nfrom hospital practice at age sixty-five, and
\nstart a medical tourism business. In pursu-
\nance of this, I opted to work in the United
\nArab Emirates few years before this venture,
\nin order to have firsthand knowledge of the
\nhealth establishments\/institutions relevant
\nto this ambition, gain knowledge of the
\nlaws guiding hospital practice and business
\nin the country, be familiar with the coun-
\n\u201cA Doctor\u2019s Experience of Injustice in the
\nUnited Arab Emirates, a Caveat\u201d
\n239
\nPersonal OpinionNIGERIA
\ntry\u2019s financial institutions and know the
\ntraditions and customs of its people. Also
\nworking in the UAE will give me the much
\nneeded base for the take off of the venture,
\nsince I already have enough field experience
\nin my country which is to be used as the
\nmain field for take-off.
\nI flew into Dubai in June 2011 to complete
\nthe necessary formalities to be a DHA-
\nlicensed practitioner. I was scheduled for
\nan academic interview on September 14,
\n2011, which I passed. I had my result and
\ncertificate issued online two days after.
\nI was in Dubai on 14th
\nmay 2012 to search
\nand start work. I had non-attractive job of-
\nfers necessitating my decision to return to
\nmy country, after staying in Dubai for two
\nmonths.
\nA day before i exited Dubai, precisely on
\n11th
\nJuly 2012, I decided to trade in my
\nDHA certification for an MOH certifica-
\ntion, a recently introduced and permitted
\nprocedure. In pursuance of this, I filled a
\nministry of health form online and upload-
\ned all requested documents. The third item
\non the first page of the form was my date
\nof birth which I clearly inserted as May 19,
\n1951.
\nAlso uploaded on the form was my passport
\npage on which my date of birth was clearly
\nstated.
\nAfter waiting for four months, and without
\nany information from the ministry on the
\napplication inquired and was told by the
\nministry that I am yet to pay its application
\nfee of Aed 100! (about $30).In other climes,
\nthe application would have been formally
\nacknowledged as received and request made
\nfor the application fee.
\nBy the time the ministry processed the ap-
\nplication, my DHA certificate has lapsed
\nand the ministry then claimed it could
\nnot use a lapsed certificate to grant me its
\nMOH certification.It requested i sat a fresh
\nassessment by entering for its prometric on-
\nline examination. It gave me the guidelines
\nfor the examination, and also requested
\nI\u00a0visit its website to peruse its requirements
\nfor certification. In all the information it
\ngave to me including that on its website, the
\nword age was NEITHER mentioned NOR
\nappeared on them.
\nI entered for the ministry\u2019s examination and
\npaid the necessary fees. I sat for the exami-
\nnation on 16th
\nFebruary 2013 and passed. It
\nsent me a letter of congratulations the next
\nday. By an email dated 1st
\nApril 2013, the
\nministry requested I visited its customer
\ndepartment to collect my evaluation certifi-
\ncate.
\nI arrived in UAE on 17th
\nAugust 2013, col-
\nlected the certificate on the 21st
\n, instantly
\nand immediately started applying online
\nfor jobs. I attended interviews and had good
\noffers. However the procedure in UAE re-
\nquires an employer to apply to the ministry
\nfor the release of the licence of any prospec-
\ntive employee, paying a non refundable fee
\nof AED 2600 (about $800).
\nAs a precaution not to lose such money,
\nan employer will normally make prelimi-
\nnary enquiry on whether a prospective
\nemployee\u2019s licence will be released to it or
\nnot. Such preliminary enquiries by employ-
\ners regarding me were not responded to by
\nthe ministry. After not responding to my
\nformal enquiry on this behaviour, the min-
\nistry head of licensing eventually told me
\non phone that I am over aged to work in
\nthe UAE!
\nMy age was on the application form; like-
\nwise the passport page uploaded on the
\nform. Age was not even mentioned in its
\n\u201cconditions for evaluation of physicians\/
\ndentists\u201ddisplayed on its website.In this age
\nof the versatility of the computer, why did
\nthe ministry fail to programme its computer
\nto screen off overage applicants? Why ask
\nme to travel all the way from my country to
\npick up an evaluation certificate when you
\nhave already predetermined i wouldn\u2019t be
\nallowed to use it to gain employment? Why
\ncollect money for application and examina-
\ntions? Why make me go through the physi-
\ncal, mental and financial stress of an ex-
\namination? Four air trips to the UAE, four
\nmonths stay in UAE idling while searching
\nfor jobs, TWO UAE licensing bodies\u2019 cer-
\ntifications passed and yet I cannot work?
\nWHAT ELSE IS INJUSTICE IF NOT
\nTHIS?
\nTo call this an injustice is an understate-
\nment. There are demeaning and ap-
\npropriate words to describe this action
\nwhich civility will not allow me to use in
\nthis article. It is worse than a swindle!
\nI have written more than two dozen letters
\nseparately to the UAE Prime minister, the
\nministers of health, justice and foreign af-
\nfairs, without the courtesy of a single reply
\nfrom any of them. I even wrote to them that
\nI was no longer interested in working in the
\nUAE, but requested compensation for the
\nexpenses incurred, time lost and wasted in
\nthis venture spread over three years,Through
\nthe ministry\u2019s administrative incompetence,
\nsheer ignorance, deliberate misguidance or
\nall combined.
\nI DID NOT HAVE ONE REPLY. At
\na certain point in time the ministry of
\nhealth even shut off its computer from ac-
\ncepting my e-mails! This was the same
\nministry that could not programme its
\ncomputer to screen overage applicants!
\nI learnt that my experience wasn\u2019t the first
\ncase. I learnt of a Spanish surgeon that was
\ntreated similarly.
\nI even appealed to the ministry to amend
\nthe information on its website to reflect age;
\nit simply ignored the advice. I have made a
\ndecision to make colleagues to beware and
\nbe aware by writing this article, lest they fall
\ninto similar predicament or do we call it
\nthe ministry\u2019s \u201ctrap\u201d if they are intending to
\nwork in the UAE. If a government ministry
\ncan so treat an individual, what can one not
\nexpect or experience with private organisa-
\ntions?
\n240
\nSRI LANKARegional and NMA News
\nEpilogue
\nThe fortune or misfortune of not being
\nallowed to work in UAE is least of my
\nproblems. I have done well in life without
\nleaving my country. What i find very repul-
\nsive and damning, and which mutates my
\nindifference to the whole saga, is the com-
\nplacency of the ministry in not accepting
\nits blunder and offering a simple apology;
\nalso its set agenda to continue to mislead
\nand misguide doctors who may want to seek
\nits services. Why did it refuse to amend the
\nwrong information it placed on its website?
\nI write this article in good faith and with
\nan unbiased and unperturbed mind. All as-
\nsertions in this article are backed by docu-
\nments which are available on request.Please
\ndo not ask me if i intend being in UAE in
\nfuture? I may in the next world!
\nLike a friend once remarked. Being re-
\nferred to as a developed country or nation
\ntakes more than skyscrapers and boule-
\nvards! Respect for humanity, rights and
\ndignity are key requirements for a nation
\nor country to be labelled and acknowl-
\nedged as a developed and civil country.
\nDr. Francis Olubunmi Ilori
\nThe Sri Lanka Medical Association
\n(SLMA) is the apex academic medical
\ninstitution in Sri Lanka and is the oldest
\nsuch institution in Asia and Australasia.
\nThe SLMA has been in existence for 126
\nyears from 1887. The registered address
\nof the organisation is Wijerama House,
\nNo.6, Wijerama Mawatha, Colombo 7, Sri
\nLanka. All doctors registered with the Sri
\nLanka Medical Council are eligible to be-
\ncome members of The Sri Lanka Medical
\nAssociation.
\nThe SLMA is a purely academic organisa-
\ntion concerned with Continuous Profes-
\nsional Development of doctors and policy
\ndiscussions on all aspects of healthcare. It
\nhas also performed an important function
\nin an advocacy and advisory role for the
\ngovernment of the Democratic Socialist
\nRepublic of Sri Lanka.
\nMany of the activities of the organisation are
\ncarried out be Expert Committees and Work-
\ning Groups. The functioning of the institu-
\ntion are overseen by an Executive Committee.
\nThe current members of this committee are:
\n1. President: Dr. B.J.C.Perera
\n2. Immediate Past President: Professor
\nVajira H.W. Dissanayake
\n3. President Elect: Dr. Palitha Abeykoon
\n4. Vice Presidents: Professor Rohan Jayas-
\nekera, Dr. Kalyani Guruge
\n5. Hony. Secretary: Dr. Samanmaali Su-
\nmanasena
\n6. Hony. Asst. Secretaries: Dr. Shyamali
\nSamaranayake, Dr. B. Kumarendran,
\nDr.\u00a0Navoda Atapattu, Dr. Sanjeeva Gu-
\nnasekera
\n7. Hony.Treasurer: Dr. Ruvaiz Haniffa
\n8. Hony. Asst.Treasurer: Dr. Leenika Wi-
\njeratne
\n9. Hony. Social Secretaries: Suriyakanthi
\nAmerasekera, Dr. Gamini Walgam-
\npaya
\n10. Public Relations Officer: Dr. Deepal
\nWijesooriya
\nThe Association has its Anniversary Sci-
\nentific Medical Congress in July every
\nyear and the Foundation Scientific Ses-
\nsions in October every year. In addition
\nmany Provincial Academic Meetings are
\norganised in collaboration with Regional
\nClinical Societies. All these are designed
\nto bring state-of-the-art knowledge and
\nthe latest developments in medicine to
\ndoctors from all over the island. Over the
\nlast couple of years the SLMA has ex-
\npanded its activities to allied healthcare
\nprofessionals as well.
\nThe SLMA can be accessed at
\nhttp:\/\/www.slmaonline.info\/
\nhttps:\/\/www.facebook.com\/SLMAonline and
\nhttp:\/\/www.linkedin.com\/in\/slmaonline
\nSri Lanka Medical Association
\nIII
\nROMANIA Regional and NMA News
\nOver 10,000 professionals from the Roma-
\nnian health system (doctors, dentists, phar-
\nmacists, nurses, psychologists, biologists,
\nbiochemists) protested in Bucharest for an
\nincreased budget for health and professional
\ndignity. The protest was called The March of
\nSilence, and it took place on November 2nd
\n2013,on a 3 km route \u2013 Romanian Govern-
\nment \u2013 Romanian Parliament.
\nSince it was a silent march, protesters only
\nmarched and displayed boards with mes-
\nsages such as: \u201cI\u00a0 will deal with the Inter-
\nnational Monetary Fund,\u201d \u201cI want to work
\nin Romania\u201d, \u201cI\u2019m a Romanian doctor and
\nI care\u201d, \u201cI won\u2019t be silent anymore\u201d, \u201d6% of
\nGDP for health\u201d.
\nThe March of Silence was organized by
\nthe Coalition of Health Professionals, after
\nthe picketing the Ministry of Health and
\nMinistry of Finance for 10 days at the end
\nof September with 150 health profession-
\nals each day, coming form all parts of the
\ncountry. Following these pickets, we began
\nnegotiations with the Ministry of Health,
\nMinistry of Finance and Ministry of Labor,
\nnegotiations which are still held.
\nIn Romania, the current situation of health
\nprofessionals in general,and doctors,in par-
\nticular, is difficult from many perspectives.
\nOne of them is that the number of doctors
\nis not enough for the 19.000.000 people
\nliving in Romania. In present, only 39.800
\nphysicians and 14.000 residents are working
\nin the health system. Only 14.487 of them
\nare working in hospitals (in 2011 the num-
\nber of physicians working in hospitals was
\n20.648).
\nBecause of the difficult situation, all the
\nhealth professional organizations decided
\nto gather in the Coalition of Health Pro-
\nfessionals, which includes: The Romanian
\nCollege of Physicians, Sanitas Federa-
\ntion, The Romanian College of Dentists,
\nThe Romanian College of Pharmacists,
\nThe Romanian College of Psychologists,
\nthe Romanian Order of Nurses and Mid-
\nwives, the Romanian Order of Biologists,
\nBiochemists and Chemists, the Federation
\nof Physicians \u201dDr. Ioan Cantacuzino\u201d, the
\nAssociation of Resident Doctors, The Fed-
\neration of Medical Students, the Romanian
\nSociety of doctors working in collectivities
\nof children and young people, the Associa-
\ntion of Ambulance Services, The National
\nAssociation of Pharmacists from Hospitals
\nin Romania.
\nThe Health Professionals Coalition advo-
\ncates for getting at least 6% of GDP for the
\nhealth care system, legislation to guaran-
\ntee the professional independence of those
\nworking in the public and health sector, a
\nwage law specific for the health system (in-
\ncreased wages),double wage for the resident
\ndoctors,defending the dignity and giving up
\ndenigration of professionals by the authori-
\nties; organization of medical units with beds
\nin the public system to ensure prompt and
\nquality services for patients; real consulta-
\ntion with the Health Professional Coalition,
\nregarding any measure which may affect the
\nfunctioning of the health system.
\nWe obtained the recognition that with-
\nout health professionals, the health sys-
\ntem is unsustainable, scholarship for
\nresidents in the amount of 150 Euros,
\nlegislative changes (on going) to pro-
\ntect doctors from external interferences,
\nthe release accompanied by funding of more
\nthan 1200 posts in the health system, the
\nreturn to the payment of work during the
\nweekends and legal holidays, the refinanc-
\ning of services in dental medicine (this year
\nthe budget of dental medicine covered only
\ntwo months).
\nWe didn\u2019t succeed to obtain the increas-
\ning of the salaries for the physicians, we
\nreceived only promises that the additional
\nfunds that occur during 2014 will be di-
\nrected to Health\u2019s budget and that some of
\nthem will be used to increase revenues doc-
\ntors.We didn\u2019t obtain an increase of health\u2019s
\nThe Physician\u2019s Situation in Romania
\nIV
\nContents
\nbudget to 5% of GDP in
\n2014, which now is only
\n4,3% of GDP.
\nUnfortunately, the an-
\nnounced strike was can-
\ncelled because SANITAS
\nFederation (the trade union
\nfrom the Coalition, made
\nup mostly from Nurses) de-
\ncided to sign the Collective
\nLabor Agreement, which
\nmeans they are not al-
\nlowed to trigger strike. The
\nFederation of Physicians
\n\u201dDr. Ioan Cantacuzino\u201d is
\nnot nationally representa-
\ntive and cannot trigger the
\nstrike by herself.
\nBut, maybe the most im-
\nportant gain of this period
\nis the changing attitude
\nof the physicians. If, until
\nnow, they were pessimists,
\nthey always used to say:
\nwe can\u2019t win anything, it
\nis no use going on strike,
\nthe physician\u2019s place is not
\nin the street, now they are
\nmore united and prepared to fight. That is
\nthe reason for what in present we are trying
\nto build a powerful physician\u2019s trade union,
\nin order to have a better represented cause
\nand to fight for physician\u2019s rights.
\nProf. dr. Vasile Ast\u0103r\u0103stoae
\nPresident of Romanian College of Physicians
\nCommunication of Results and Incidental Findings
\nin Medical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
\nWorking for Health Equity: The Role of Health
\nProfessionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
\nGreat East Japan Earthquake . . . . . . . . . . . . . . . . . . . . . . 213
\nAir Pollution: a New Concern . . . . . . . . . . . . . . . . . . . . . . 220
\nDefeating Resistant Bacteria with Knowledge . . . . . . . . . . 223
\nTurkmenistan on the Roud to Democracy . . . . . . . . . . . . . 224
\nHelping Put Self-care Center Stage with Patients and
\nPolicy-Makers in Combating 21st
\nCentury Killer Diseases . . . 226
\nIFMSA: Striving Toward an Future that Medical
\nStudents Want . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
\nRotary and UNICEF Launch a Speaking Book to Prevent
\nthe Spread of Polio on World Polio Day . . . . . . . . . . . . . . 228
\nNews from the CPME: Up-date on policy developments
\nin the European Union . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
\nMemorandum of Understanding European Forum
\nof Medical Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
\nNew WMA Cooperating Center . . . . . . . . . . . . . . . . . . . . 232
\nHuman Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
\nSuccessful Climate and Health Summit in Warsaw . . . . . . 233
\nIRCT defines way forward to realise the right to
\nrehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
\nCall to Action from Bellagio Conference on Protection
\nof Health Workers, Patients and Facilities in Times
\nof Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
\n2013 Global Health Forum,Taipei,Taiwan . . . . . . . . . . . . 235
\nMeetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
\nInternational update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
\nPublications, courses, conferences, calls for papers . . . . . . . 237
\nGreen news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
\n\u201cA Doctor\u2019s Experience of Injustice in the United Arab
\nEmirates, a Caveat\u201d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
\nSri Lanka Medical Association . . . . . . . . . . . . . . . . . . . . . 240
\nThe Physician\u2019s Situation in Romania . . . . . . . . . . . . . . . . . iii<\/p>\n"},"caption":{"rendered":"

wmj201306 COUNTRY \u2022 Communication of Results and Incidental Findings in Medical Research \u2022 Working for Health Equity: The Role of Health Professionals vol. 59 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 6, December 2013 Cover picture from Latvia Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, […]<\/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\/wmj201306.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/es\/wp-json\/wp\/v2\/media\/3660"}],"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=3660"}]}}