wmj201301

COUNTRY
• President Elect of WMA, Margaret Mungherera,
Health Care in Uganda
• Prison Health
vol. 59
MedicalWorld
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Nr. 1, February 2013
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1
Editorial
A draft Regulation of the European Union on Clinical Trials falls back
in the time before the Declaration of Helsinki
All new medical drugs need testing in humans. Experimentation
with human beings has become a matter of international atten-
tion after World War II, when in the Nuremberg Doctors’Trial an
American Military Tribunal set up ten rules for such experiments.
Interestingly enough the so-called Nuremberg Code did not find
wide reception until nearly half a century later, when historians
rediscovered it. However, in the late 50s and early 60s the World
Medical Association began working on rules for experimentation
on humans resulting in the Declaration of Helsinki in 1964.
The Declaration of Helsinki since then is being regarded as the gold
standard for experiments on humans and it has directly or indi-
rectly made its way into many national and international regula-
tions and laws.In 1964 the mayor step forward was the requirement
of informed consent. Not only should nobody be subjected to an
experiment, but he or she should know what it is means for them
personally to be subjected to an experimental situation.This concept
was not new – at least in a few countries – but for the first time it
was demanded by an international policy. In 1975 the World Medi-
cal Association went a step forward to include the concept of ethics
reviews by independent ethics committees.
To bring new medicines to the market is a highly expensive process.
Extreme scrutiny is being applied not only to make the drugs safe
(and hopefully effective) but also to make the process of testing safe
and ethically acceptable. The protection of the subjects in a clinical
trial preceding the marketing authorization as well as the patients
receiving the medicines later should be paramount. On the other
hand there are at least three reasons to make this process as fast as
possible: First, if new medicines are better than old ones, patients
everywhere should benefit from them as soon as possible. Let’s not
forget, until today many, if not most diseases wait for a final cure.
Second, the high development cost and a limited patent lifetime
favour an early market access to produce a return on investment.
Third, having innovations first secures an economic advantage over
your international competitors.
Competition in this global market requires clear structures in the
process of bringing new drugs to the market. In the late 90s the Eu-
ropean Union (EU) started to develop a common set of rules for the
testing of new drugs now including 27 European States resulting in
the Clinical trials Directive (CTD) from 2001.
However, the legislative approach fell short of the expectations.The
process of getting a new drug to the market appears being still too
long.The European Commission has now presented a draft regula-
tion that is meant to replace the 2001 CTD.
This draft however has (or reveals) three major problems:
• Ethics reviews by independent ethics committees are no longer
expressively mentioned as an obligatory requirement,
• the timelines to authorize a clinical trial by the ethics committees
are very short and appear non-workable in practice, and
• one member state will be in charge taking the final decision on the
acceptability of a trial, which may happen even, if other member
states find them scientifically or ethically unacceptable.Although,
member states can opt out from a specific trial under certain cir-
cumstances, they have to accept a marketing authorization finally
resulting from this process.
In a common effort with the Standing Committee of European
Doctors (CPME) the President of the World Medical Association,
Dr. Cecil Wilson and the Chairperson of the WMA Council, Dr.
Mukesh Haikerwal, raised their concerns to the Members of the
European Parliament currently dealing with the draft regulation.
The WMA leadership also stressed the potential effect of the EU
Regulation for non-EU countries. It would be a fatal signal, if the
European authorities no longer require an ethics review in all coun-
tries where trials are being performed.
Mrs. Glenis Willmott MEP, lead rapporteur on the draft regulation
for the European Parliament proposed to reintroduce the manda-
tory ethics review by ethics committees and referred to the WMA
Declaration of Helsinki. Many of the national governments have
raised their concerns against the short timelines dictated by the draft
regulation. There is hope that the draft regulation as incomplete as
it is will not pass the Parliament and Council (the representation of
the national governments) without major changes.
However the third problem of forcing member states to accept what
they believe are marketing authorizations based on insufficient sci-
entific or ethical standards remains. It may lead to an “ethics shop-
ping”, which means that producers of new drugs could try to find
the “least critical”country for their trial. Fixing those problems may
require additional amendments in the laws on marketing authoriza-
tion, but starting now to deal with that problem would be a good
sign. Not only for Europe.
Otmar Kloiber
Back to the 50s?
2
WMA news
Distinguished ethicists, educators and gov-
ernment officials from around the world
met in Cape Town, South Africa, Decem-
ber 5, 2012 for a three-day conference to
evaluate potential revisions of the Declara-
tion of Helsinki (DOH).
The DOH was first adopted by the World
Medical Association (WMA) in1964 and is
a statement of ethical principles for medical
research involving human subjects, includ-
ing research on identifiable human material
and data. It is widely recognized as a core
standard for ethical research.
The DOH is the loadstone; the North Star
if you will that guides physicians, govern-
ments and industry in the area of advice on
doing medical research on human subjects.
The DOH has undergone multiple revisions
over the years, not to change core principles
but to determine whether more guidance in
the importance area of medical research in
this area is needed to deal with the com-
plexities of today’s world.
The process by which the WMA is con-
ducting work on potential changes in the
DOH is to draw on the expert opinion of
a wide spectrum of leaders in ethics around
the world and to work in a public, transpar-
ent way to reach agreement.
What gives added significance to this work
is that 2014 will mark the fifty-year anni-
versary of this important document.
87 delegates from 26 countries were in at-
tendance at the conference and provided
rich discussions that were for me reassuring
confirmation that physicians as a profession
care deeply about ethics. The diversity of
attendees and the quality of presentations
validated the worldwide importance of the
DOH to those in the field.
The South African Medical Association
under the leadership of Dr. Zephne M. van
der Spuy,president who along with Precious
Matasoso, Director General, South African
Ministry of Health,provided welcoming re-
marks, ably hosted the conference.
Those participating in the conference in-
cluded among others representatives from the
World Health Organization,US Department
of Health and Human Services (HHS), Eu-
ropean Medicines Agency (EMA), The So-
ciety of Swiss Physicians (FMH), Medicines
Control Council South America,Internation-
al Federation of Pharmaceutical Manufactur-
ers and Associations,(IFPMA),the European
Clinical Research Infrastructures Network
(ECRIN), academic medical centres from
around the world and representatives from
member associations of the WMA.
Topics discussed related to the DOH includ-
ed vulnerable groups, bio banks, post-study
arrangements, and ethics committees. There
was also consideration about whether the
DOH should provide additional guidance
in insurance/compensation/protection, use
of proven interventions,placebos,broad con-
sent and medical research involving children.
Urban Wiesing,Director Institute for Ethics
and History of Medicine University of Tub-
ingen described the process for revising the
DOH and the history of previous similar ef-
forts.The questions, debate and engagement
of attendees responding to the speakers were
probing, passionate and persuasive.
As part of this process I think it is impor-
tant to remember some of the core prin-
ciples specified in the introduction to the
Declaration of Helsinki as follows:
• Although the declaration is addressed
primarily to physicians, the WMA en-
courages other participants in medical re-
search involving human subjects to adopt
these principles.
• It is the duty of the physician to promote
and safeguard the health of patients, in-
cluding those who are involved in medi-
cal research.
• The Declaration of Geneva binds the
physician with the words. “The health of
my patient will be my first consideration”.
• The International Code of medical Eth-
ics declares, “A physician shall act in the
patient’s best interest when providing
medical care.”
• In medical research involving human
subjects, the well being of the individual
research subject must take precedence
over all other interests.
• Medical research is subject to ethical stan-
dards that promote respect for all human
subjects and protect their health and rights.
• Physicians should consider the ethical,
legal and regulatory norms and standards
for research, involving human subjects in
their own countries as well as applicable
international norms and standards.
In remarks at the opening session I shared
with the participants my enthusiasm about
the process being undertaken with the fol-
lowing remarks:
• On behalf of the member associations of
the World Medical Association and the
patients and physicians we represent let
me express my appreciation for your will-
ingness to take time out of very busy lives
to be a part of this effort.
• I am awed by the experience, expertise
and the international reputations you
bring to this conference.
• I thank you for your interest in this im-
portant subject and for your participation
in this endeavour. I look forward over the
next three days to being educated and im-
pressed.
The WMA Council last year established a
Working Group to lead the effort of evalu-
ating the DOH for possible changes. The
Working Group has scheduled an additional
expert conference to be held inTokyo in Feb-
ruary (2013) to receive input and perspec-
tives from experts in the Far East geographic
region. It is anticipated that draft document
will be submitted to the WMA Council in
the spring, followed by solicitation of public
comment. Plans are for presentation of a re-
vised DOH in conjunction with celebration
of its fiftieth anniversary in 2014.
Thanks again to the South African Medical
Association for hosting the DOH Expert
Conference. I was educated and impressed.
Cecil Wilson, MD, MACP, President, WMA
Declaration of Helsinki. Expert Conference
3
CAM in OncologyGERMANY
Cancer patients often turn to complemen-
tary (CAM) therapies because they believe
these will improve their body’s ability to fight
cancer and therefore their chances of survival
or at least will ameliorate quality of life.This
article suggests recommendations which
represent a framework for advice on and safe
application of CAM methods in oncology.
In oncology safety with regard to CAM is
even more important than in other areas of
medicine because data on effectiveness are
mostly missing and any intervention that is
able to enhance cancer cell survival either
directly or indirectly by interactions could
also reduce patient’s chance of cure or longer
survival. In contrast to other disciplines in
oncology any delay in effective therapy may
enhance the possibility of resistance of the
disease, incurability and progress. Wrong
decisions taken during primary (or later)
treatment of most types of cancer can not be
compensated for later on. This very reason
makes it important to monitor cancer treat-
ments continuously and carefully so that pa-
tients receive the best chances of a therapy.
Introduction
Treatment of cancer disease remains one of
the greatest health challenges, and although
great strides have been made in some treat-
ments, the prognosis for many patients re-
mains poor. Cancer patients often turn to
complementary (CAM) therapies because
they believe these will improve their body’s
strength to fight cancer and therefore their
chances of survival. Many consider that
CAM therapies will improve their emo-
tional or physical well-being, help to avoid
aggressive treatment, or at least make it
more easily tolerated.
The poor prognosis of many cancer patients
and their desire to participate actively in
any therapy which might ameliorate their
condition have motivated CAM therapists
to search for new therapeutic approaches.
Many CAM practitioners are integer and
their intentions are entirely honourable.
However, others appear to be less prin-
cipled. They seem to view CAM practice
as a way of making easy money and exploit
the fact that some patients with a poor out-
look may try anything, often ignoring the
expense, if they think it might help them.
These practitioners of dubious motivation
often justify their activities with claims that
they are pursuing “therapeutic freedom”and
that conventional medicine is often unable
to cure the disease.
Conventional medicine has always had diffi-
culty in knowing how to judge and evaluate
CAM methods,and how to deal with CAM
therapies and therapists. Mainly it has cho-
sen to ignore it. Meanwhile the US- Ameri-
can National Academy of Sciences regards
being informed on CAM methods with fre-
quent usage as an ”obligation“ for physicians
(http://www.nap.edu/catalog/11182.html;
Ethical Framework for CAM). This means
that experts on CAM in oncology recom-
mend physicians to inform patients on data
concerning safety and efficacy. Physicians
should point at the missing proof of efficacy
of CAM as well as the relation of chances
and risks of conventional therapy [6].
Adams [1] denotes aspects of ethical de-
cisions: Severity and acuteness of disease,
chance of cure by conventional therapy, side
effects of conventional therapy, existence,
quality and evidence for efficacy and safety
of CAM, patient’s understanding of risks
and usefulness of CAM and the voluntary
consent of patients to accept the risks. “If
evidence (concerning the CAM therapy)
supports both safety and efficacy, the phy-
sician should recommend the therapy but
continue to monitor the patient conven-
tionally. If evidence supports safety but is
inconclusive about efficacy, the treatment
should be cautiously tolerated and moni-
tored for effectiveness. If evidence supports
efficacy but is inconclusive about safety, the
therapy could still be tolerated and moni-
A Guideline for Treatment Decisions
on CAM in Oncology: Prerequisites
for Evidence Based Integration
Karsten Münstedt Jutta Hübner
4
CAM in Oncology GERMANY
tored for safety. Finally, therapies for which
evidence indicates either serious risk or
inefficacy obviously should be avoided and
patients actively discouraged from pursuing
such a course of treatment” [1].
Figure 1 shows 4 possible ways how to man-
age CAM use based on its safety and evi-
dence [4].If patient and physician consent to
an alternative therapy, omitting or delaying a
conventional therapy a close follow up has to
be done (Ernst 2001, Cohen 2002). In order
to do this he has to have profound knowledge
on remission, progression and time intervals
and the diagnostic measures to take in order
to provide maximum security for the patient.
Only experienced oncologists with thorough
knowledge on oncology as well as CAM will
be able to follow this rule.
There is another obstacle to this rule: pa-
tients who adhere to complementary and
alternative medicine are likely to omit
follow-up visits at their oncologists. One
reason for this is inherent with their seek-
ing for alternatives: the oncological setting
does not provide the holistic approach they
are looking for. Another reason might be
that they want to avoid any testimony of
failure of alternative therapy and therefore
prefer diagnostics done by healers or other
persons. Finally, patients are told by their
dubious protagonists that they should avoid
contact with conventional oncologists. This
is one reason why patients should be active-
ly informed about CAM in the first place.
Regarding communication on CAM in on-
cology [5] developed a guideline for such
discussions with patients. This guideline is
based on a systematic review of the litera-
ture concerning patient-doctor communi-
cation in general and on CAM. 10 steps are
recommended in this guideline (table 1).
Why a guideline for
CAM use is needed
All above mentioned recommendations and
guidelines focus on the discussion with the
patient and not on the treatment itself. In-
deed, many CAM methods can be applied
by the patient himself.So the discussion may
lead to the decision on what the patient will
do. But there are methods which the patient
cannot apply without the aid of his physi-
cian. These are likely to be based on techni-
cal devices (f. e. bioresonance, hyperthermia)
or are medical therapies with substances
with side effects.Here the patient has to rely
on the physician and in such a situation the
physician has to accept a higher medical as
well as ethical responsiveness than in a mere
discussion on CAM. Thus it is important to
establish ways which assure that treatments
are given which are both well founded on
medical knowledge and also in accordance
with ethical values.The problem is that spe-
cific guidelines which have been issued for
some tumour entities do not meet the indi-
vidual situation of the patients. Since most
patients also want that their etiologic con-
cept behind the development of cancer is
considered, it is important to suggest ways
for such individualized treatments without
the risk of composing something totally irra-
tional. Such a guideline is missing. It would,
once established, not only improve individ-
ual counselling but also regulate treatment
decisions and allow addressing the problem
of “charlatans and quacks”.
Advancing to a guideline on CAM use by
physicians:
We have to consider three constellations:
1. Administration of CAM in conjunction
with conventional treatments in a cura-
tive or palliative situation
2. Administration of CAM after comple-
tion of adjuvant therapy in a curative
situation
3. A highly palliative setting with a patient
facing death asking for an alternative
For all three situations we have to ask for the
benefit and risks for the patient. In order to
define benefit we should look at the scientific
Table1. 10 steps as a guideline for discussing Complementary and alternative medicine with patients [5]
1. Elicit the person’s understanding of their situation
2. Respect cultural and linguistic diversity and different epistemological frameworks
3. Ask questions about CAM use at critical points in the illness trajectory
4. Explore details and actively listen
5. Respond to the person’s emotional state
6. Discuss relevant concerns while respecting the person’s beliefs
7. Provide balanced, evidence-based advice
8. Summarize discussions
9. Document the discussion
10. Monitor and follow-up
Low or missing evidence Reliable clinical evidence
High
safety
OPTION B
• Tolerate
• Provide caution and
• Closely monitor effectiveness
OPTION A
• Recommend and
• Continue to monitor
Low
safety
OPTION D
• Avoid and
• Actively discourage
OPTION C
• Consider tolerating
• Provide caution and
• Closely monitor safety
Figure 1. Possible options how to cope with CAM based on its safety and evidence et al. [3,5]
5
CAM in OncologyGERMANY
data concerning influence on disease, quality
of life and side effects. Strength of evidence
regarding CAM, aspects of safety and the
comparison of chances and risks between
conventional medicine and CAM has to be
scrutinized thoroughly. In the past, several
problems have been encountered in studying
CAM. These are summarized in table 2. But
the inherent problem of CAM is missing evi-
dence – if we had evidence, it would be easy
to define a method as conventional or alterna-
tive.Thuswehavetosetupruleshowtoconfer
recommendations on an insecure fundament.
In this context it seems appropriate to define
a set of principles which will enable the devel-
opment of the guideline.These principles are
based on logical and ethical considerations.
Ethical fundament for a
guideline: Principles for
CAM in oncology
Definition: There is a clear distinction be-
tween complementary and alternative medi-
cine, the former being part of scientifically
based treatment strategies the latter sug-
gesting an “alternative” way to cure. Only
the complementary approach is scientifically
evaluable and can thus be discussed.
Principle 1: Any method in complemen-
tary medicine has to be tailored to the in-
dividual. This means that benefit only can
be defined if it has been proven in a setting
similar to the situation of the patient.
Principle 2: In cases of unknown benefits,as
is typical for most methods of complemen-
tary medicine, safety is the most important
issue.
Principle 3: Cancer is a deadly disease with
points of no return; therefore use of any ex-
perimental treatment is unethical as long as
a proven treatment option exists. In cases of
advanced palliative settings, palliative medi-
cine is the standard with which any other
treatment has to be compared.It is unethical
to deny or delay palliative care in this setting.
Principle 4: Conventional medicine and
CAM must be assessed equally. This means
that both must prove their efficacy and ef-
fectiveness following the rules of evidence
based medicine.
Principle 5: In case of missing evidence
both in conventional as well as complemen-
tary therapy in a given setting the physician
should make his recommendations accord-
ing to principle 1 and 2. Shared decision
making is the recommended way of com-
munication in this situation.
Principle 6: Physicians giving advice on
CAM must adhere to honesty and sincerity.
No undue hope should be evoked by false
promises.
Principle 7:Patients’autonomy has to be con-
sidered.Complementary medicine should be
a means to strengthen autonomy and should
not be abused to enhance dependency.
These seven principles follow the ethical
rules of Beauchamp and Childress:
• Autonomy – patients have the right to
choose, but not obligation to choose
• Nonmaleficiency
• Beneficence
• Honesty
Developing a guideline by syn-
thesis from the principles and the
evidence based recommendations
concerning discussion on CAM
A synthesis of the ethical principles pre-
sented above and the recommendations
from Shoffield and others which sum up the
evidence on counselling patients on CAM
in oncology is the fundament for a guide-
line on CAM use.
A comparison of both shows, that they are
complementary to each other as they focus on
communication on the one side and action on
the other.There is only a small overlap in the
field of patient’s autonomy.Table 3 provides a
comparison of the recommendations [5] and
the principles suggested in this article. In or-
der to achieve maximum safety and efficacy
in CAM, ten steps can be identified. They
describe the whole process of counselling,de-
cision making and administration of CAM.
Each step is accompanied by requirements
which are mandatory for its realization.These
steps are explained as follows:
1. Counselling
All patients with cancer should be counselled
about CAM, especially about the methods
most frequently used, so that they are able
Table 2. Problems in studying CAM. Up to the present, studies on CAM in oncology have limited
themselves to a very general exploration
1. CAM literature is not always published in mainstream journals and listed in f.e.Medline.
2. Articles often are written in native language and only accessible as abstract in English.
3. Mostly it is not clear whether a CAM method is applicable to every type of tumour
and medical condition or is only suitable for certain settings.
4. Most studies on supportive treatment issues do not look for long term safety as follow-
up of the studies is too short.
5. Reviews are often out of date soon after they have been published.
6. Published reports are not revisited and updated regularly and frequently enough.
7. Not all CAM methods are covered and in the meantime, new ones are invented or old
ones modified.
8. Furthermore most reviews rely on only few studies if any and therefore tend to be nar-
rative reviews instead of systematic.
6
CAM in Oncology GERMANY
to judge critically any promises and offerings
of dubious therapists and can thus avoid any
potentially harmful influences of the meth-
od itself or when it is given in combination
with other treatments. If desired, patients
should be advised about methods which are
likely to have beneficial effects. Counsel-
ling should be done according to the rec-
ommendations of Shoffield and colleagues.
Underlying requirements: Oncologists need
greater knowledge of CAM therapies.There
must be ongoing education in CAM,begin-
ning with undergraduate medical training
and continuing during specialisation.
2. Evidence in CAM
Selection of a treatment method must take
into the account the levels of evidence and
the credibility of the data and its authors.
Both have to be evaluated critically. The
levels of evidence and grades of recom-
mendations apply as much to CAM as they
do to conventional medicine. Generally,
the method which has yielded best results
should be the one be selected.
Underlying requirement: There must be con-
tinuing reviews in the field of CAM,aiming
to identify new and perhaps rational treat-
ment approaches and also potentially risky
or ineffective methods.
3. Selection of CAM treatment
Selection of CAM methods must be done
rationally and objectively. Only methods
which have been investigated in clinical tri-
als and have shown positive effects should
be chosen. Methods based on philosophical
or pseudo-religious beliefs can not be ac-
cepted unless their efficacy has been proven
in such trials.
If this clinical proof is missing, preclinical
data should not be the bases for an active
recommendation, yet they can be used as a
refererence to inform patients who are ac-
tively asking about a certain method.
CAM is used in two intentions: as support-
ive agent or as antitumor agent. Since there
is no universal cancer “drug”in conventional
medicine, the selection of antitumor treat-
ment should focus on methods which have
been tested in the type of tumour being
treated.
CAM should only be used if it has been
studied in a setting similar to the one dis-
cussed with the patient.
Underlying requirement: Therapeutic con-
cepts for treating different tumours in vari-
ous treatment situations or supportive situ-
ations should be developed.
4. Applying CAM methods
In a curative setting and during active
treatment, the use of any CAM therapies
should be restricted to those methods
which have high clinical evidence. In a
palliative situation and after all reasonable
conventional treatments have been tried
more poorly investigated, other methods
may be used if patients actively demand
for them. However, there always must
be some rational to support the use of a
method. If this is only based on preclini-
cal data the same rules of counselling as
in informing patients on a phase I study
must be applied.
Underlying requirements: Physicians in-
forming patients on CAM use in advanced
palliative care without clinical data or with
the intention of using a method’s antican-
cer effects must have excellent knowledge
Table 3. Comparison of the principles suggested in this article to the recommendations of Shoffield
et al. [5]
Principle Recommendation of Shoffield et al.
1: Therapy has to be individualized No equivalent
2: Safety is of highest importance No equivalent
3: Do not deny therapies with known
benefit
No equivalent
4: Evidence on CAM follows the rules of
Evidence based medicine
7. Provide balanced, evidence-based advice
5: In case of missing evidence in conven-
tional as well as complementary therapy
follow principles 1 and 2
No equivalent
6: Ethical principles to follow are honesty
and sincerity
No equivalent
7: Respect patient’s autonomy
1. Elicit the person’s understanding of their
situation
2. Respect cultural and linguistic diversity
and different epistemological frameworks
6. Discuss relevant concerns while respect-
ing the person’s beliefs
No equivalent
3. Ask questions about CAM use at critical
points in the illness trajectory
No equivalent 4. Explore details and actively listen
No equivalent 5. Respond to the person’s emotional state
No equivalent 8. Summarize discussions
No equivalent 9. Document the discussion
No equivalent 10. Monitor and follow-up
7
CAM in OncologyGERMANY
of all preclinical data of the method. Inclu-
sion of patients in ongoing clinical studies
could also be discussed as a true alternative
for the patient.
5. Safety
CAM methods must have proven benefits
and must be safe in relation to drug interac-
tions. If drug interactions are suspected, the
CAM treatment must be discussed criti-
cally and patients must be advised not to
use it.These considerations refer to all kinds
of conventional treatments (chemotherapy,
radiotherapy, hormonal and immunological
therapies).
Underlying requirement: Checklists should
be developed which can help to exclude the
most common causes of drug interactions
in oncology.
6. Costs
There must be a reasonable relationship be-
tween expected benefits and costs. Poorly
studied methods should only be considered
when costs are low. Patients should be ad-
vised to avoid expensive CAM treatments
unless they have proven efficacy.
Underlying requirement: A list of CAM
methods with evidence which fulfils the
rules for reimbursement should be set up
and funding by a defined process discussed
with stakeholders.It must be made sure that
this discussion will not open the process to
the reimbursement of methods with low
evidence.
8. Shared decision making, informed con-
sent and documentation
The whole process of counselling and
therapy has to be discussed thoroughly
with the patient. The principles of shared
decision making should be obeyed. Any
communication which increases patients’
dependence on the physician must be
avoided.
Patients should provide written informed
consent to their records being used for re-
search purposes. Monitoring of patients
during CAM use assessing the course of the
disease and adverse effects as well as quality
of life is mandatory.
Underlying requirement: The physician must
have sound knowledge about the course of
the disease and the use of adequate diag-
nostic means. He must also know the side
effects of ongoing conventional therapy as
well as the CAM method selected and he
must be highly sensitive to any sign of in-
teraction.
10. Generating Evidence: Studies and Pub-
lication
Case reports and case series on CAM
methods should be published once a con-
clusive situation was reached. Practitioners
with experience of certain CAM methods
should be encouraged to analyse their data.
Furthermore, CAM therapists should col-
lect data on certain methods for subsequent
analysis.
Underlying requirements: As most practitio-
ners do not have experience with publica-
tion cooperation with scientists could be
helpful. A consented reporting system with
defined data sets would enable scientists to
find all necessary information in order to
decide whether the case report gives hints at
the effects of the CAM method used. Case
reports and case series can be important
when they refer to new medical situations
or report new side effects. Clinical studies
on CAM must be encouraged. Also trials
in conventional medicine should assess the
prevalence of CAM methods in order to
detect possible positive or negative effects.
There also must be greater awareness of
CAM, including the willingness to grant
money to support studies in the field and to
cooperate with the scientific study groups.
Studies should be published in peer-re-
viewed journals.
Conclusion
These recommendations represent a frame-
work which should enable the safe applica-
tion of CAM methods in oncology. Adopt-
ing recommendations such as these seems
particularly important for cancer patients
since they, unlike patients in other areas of
medicine, will not perhaps have a second
chance. Wrong decisions taken during pri-
mary treatment of most types of cancer can
not be compensated for later on. This very
reason makes it important to monitor can-
cer treatments continuously and carefully
so that patients receive the best chances of
a cure. Furthermore, only a rational and evi-
dence based approach to CAM in oncology
can make this field more generally respected.
References
1. Adams KE, Cohen MH, Eisenberg D, Jonsen
AR. Ethical considerations of complementary
and alternative medical therapies in convention-
al medical settings. Ann Intern Med. 2002 Oct
15;137(8):660-4.
2. Beauchamp TL, Childress JF. Principles of
Biomedical Ethics. 6. Aufl., Oxford University
Press, 2008, ISBN 0-19-533570-8.
3. Cohen MH, Eisenberg DM. Potential physician
malpractice liability associated with comple-
mentary and integrative medical therapies. Ann
Intern Med. 2002 Apr 16;136(8):596-603.
4. Ernst E, Cohen MH. Informed consent in com-
plementary and alternative medicine. Arch In-
tern Med. 2001 Oct 22;161(19):2288-92.
5. Schofield P, Diggens J, Charleson C, Marigliani
R,Jefford M.Effectively discussing complemen-
tary and alternative medicine in a conventional
oncology setting: communication recommenda-
tions for clinicians. Patient Educ Couns. 2010
May;79(2):143-51.
6. Sugarman J, Burk L. Physicians’ ethical obliga-
tions regarding alternative medicine. JAMA.
1998 Nov 11;280(18):1623-5.
Prof. Dr. Karsten Münstedt
Universitätsfrauenklinik
Giessen Klinikstrasse 33
E-mail: karsten.muenstedt@
gyn.med.uni-giessen.de
Dr. Jutta Hübner
Klinikum der J.W. Goethe Universität
8
Regional and NMA news CHINA
Missions set in the three-year plan for Chi-
na’s healthcare reform from 2009 to 2011
have been completed on schedule. Now,
please, allow me to introduce you to the ba-
sic facts of the current healthcare reform in
China.
I. By achieving periodical
goals as scheduled, the
three-year healthcare reform
achieved remarkable effect
In April 2009, the central government initi-
ated the new round of healthcare reform. In
the past three years, we have been sticking
to the philosophy of providing basic health-
care system to our people as public goods.
Guided by the principle of ensuring the
basic, strengthening the grass-roots and es-
tablishing the mechanism, providing meth-
odology for coordinating arrangements,
emphasizing the priorities, and advancing
in a stepwise manner, we intensified leader-
ship,increased input,innovated the working
mechanism and improved policy support.
The key priorities of the health care reform
have been pushed forward and obvious
progress has been achieved.
Firstly,residentsinurbanandruralareashave
benefited as seen fron the National Health
Indicators. Maternal mortality rate dropped
from 34.2/100,000 to 26.1/100,000, infant
mortality rate went down from 14.9‰ to
12.1‰, and average life expectancy has also
increased. Urban and rural residents have
access to 41 basic public health care services
in 10 categories.The out-of-pocket medical
payment for rural residents who have joined
the New Rural Co-operative Medical
Scheme (NRCMS) decreased from 73.4%
three years ago to 49.5% in 2011. The ac-
cessibility and affordability of medical care
service has been improved. Secondly, health
care resource allocation and utilization have
been optimized.With preferential public fi-
nance policy towards the grass-roots, rural
areas, and public health, the gap of medical
care and health development between urban
and rural areas has been narrowed gradually.
There emerges the tendency of increased
utilization of primary healthcare services,
and research and science are developed in
the health sector. Thirdly, the framework
of basic healthcare system has been pre-
liminarily established. Medical insurance
for urban employees, urban residents and
the NRCMS have covered over 95% of the
population, which forms the largest basic
medicare security and safety net. The na-
tional essential drug system has been im-
plemented in all government-run medical
and health institutions at grass-roots level,
thus meeting the people’s basic needs for
essential medicine. Primary health delivery
system has been enhanced with improved
service quality. Public hospital pilot reform
has been pushed forward actively in good
order. Access to basic public health services
has been enhanced by institutional arrange-
ments with emphasis on prevention. Tra-
ditional Chinese Medicine (TCM) plays a
more important role in health care and pre-
vention. Fourthly, major structural changes
have taken place in total health expenses.
Proportion of individual health expendi-
ture dropped from 40.4% in 2008 to 35.5%
in 2010 due to more reasonable health fi-
nancing and led to enhanced health care
equity. Excessive growth in public hospital
expenses has been effectively controlled, as
calculated in comparable price, the annual
rise of in-patient and out-patient expenses
in public hospitals have been brought down
by 3–4% average.
In the past three years, five reform priori-
ties have been promoted and great improve-
ments have been achieved in the healthcare
field.
1. Basic medical insurance system
has been established and
consolidated, being a critical step
forward to the goal of universal
access to health care service
Universal access to medical insurance is
the top priority in the healthcare reform.
It plays an important role in safeguard-
ing people’s health and providing healthy
workforce for sustainable development. At
present, medical insurance for urban em-
ployees, urban residents and the NRCMS
have covered 1.3 billion people (over 95%),
and the coverage of the NRCMS reached
97.5%. The NRCMS fund pooled has
reached 243 RMB Yuan per capita, out
of which 208 RMB Yuan is subsidized by
governments of various levels.This year, the
per capita fund will reach 290 RMB Yuan
and the subsidy will be 240 RMB Yuan. In
rural areas out-patient expenses have been
covered by the NRCMS, and maximum in-
patient compensation has been set 6 times
higher than rural per capita net income and
no lower than 50,000 RMB Yuan. In 86%
of the rural areas covered by the NRCMS,
the reimbursement rate within the scheme
has reached over 70%. Medical insurance
pilot on catastrophic diseases also advances.
Since the initiation of including leukemia
and child congenital heart disease in 2010,
till the end of 2011, 93% of the NRCMS
areas have started pilot work. In some areas,
6 more major diseases including holergasia,
tuberculosis, cervical cancer, breast cancer,
end-stage renal disease and HIV/AIDS are
also covered, having benefited more than
200,000 patients.
2. National essential drug system
has been preliminarily established,
grass-roots level health care service
operated under new mechanism
In accordance with the reform plan, by
implementing essential drug system, com-
prehensive reform of the grass-root level
medical and healthcare institution has been
Healthcare System Reform in China
9
Regional and NMA newsCHINA
carried out. It aims to build a public man-
agement system, to set competitive employ-
ment and incentive distribution mecha-
nism, to adopt regulated drug purchasing
and long-acting multi-channels compensa-
tion mechanism.
Under joint efforts, essential drug system
has been implemented in government-run
grass-roots medical and healthcare institu-
tions, where essential drugs are distributed
and sold with zero markup. The practice of
subsidizing medicine services with drugs
sales profits has been eliminated. Essential
drug system also extends to county level
health care institutions and non-govern-
mental grass-roots healthcare institutions.
A total of 307 kinds of drugs have been
included in the national essential drug list,
while additional drugs are added by prov-
inces (autonomous regions, municipal cit-
ies). Average 210 kinds of drugs have been
added and 29 provinces (autonomous re-
gions, municipal cities) have adopted new
measures for the purchase of essential drugs.
Meanwhile, we promote the comprehensive
reform of the grass-roots level medical and
healthcare institutions. Government-run
grass-roots level medical and healthcare
institutions are defined as public institu-
tions, provided with special fiscal subsidy
and regular balance of payment subsidy.
Staffing system of total amount control
and dynamic management is adopted while
staffing checking and posts adjustment has
been carried out. Hence a new employment
mechanism is founded offering employees
entry and exit, promotion and demotion. In
government-run grass-roots level medical
and healthcare institutions, comprehen-
sive quantified performance evaluation and
performance-based salary system have been
implemented, linking the evaluation results
with the government subsidy and the in-
come of the healthcare staff. Preliminarily,
the compensation channel mainly support-
ed by fiscal investment and health care in-
surance payment has been formed in grass-
roots medical and health care institutions.
The subsidy to village doctors for providing
public health services has been realized and
essential drug system is promoted in village
clinics.
3. Healthcare delivery system at
grass-roots level has been effectively
consolidated and the goal of
“strengthening the grass-roots”
has been preliminarily realized
During the past three years of the reform,
the central government had invested 47 bil-
lion RMB Yuan to support 35, 000 hous-
ing construction programs of the grass-root
medical and health care institutions. Grass-
roots healthcare service delivery system has
been strengthened; poor medical facilities
and weak service capability in rural and
remote areas has been greatly improved;
qualification, knowledge and the number of
personnel recruited are all improved.By ini-
tiating the general practitioner cultivation
plan, 36,000 health workers in grass-roots
medical and health institutions received on
the job training to become general practi-
tioners. Through the central/western rural
area-oriented cultivation plan, more than
10,000 medical students were trained free of
tuition for grass-roots health institutions in
central and western rural areas. In the three
years, visits to township hospitals, commu-
nity health centers or stations, village clin-
ics amounted to 10.81 billion person times,
61.4% of the total number of visits to medi-
cal institutions at all levels.
4. Equal access to basic public
health services has been enhanced
In the past three years, the coverage of the
basic public health services has been ex-
panded and planned mega public health
programs have been accomplished ahead
of schedule. Major communicable disease
prevention has been improved with the
principle of prioritizing prevention put into
good practice. The basic public health ser-
vice fund reaches unified standard in both
urban and rural areas and is increasing year
by year, from 15 RMB Yuan in 2009 to 25
RMB Yuan in 2011 per capita. A total of
982,000,000 residents now have health
records and 62.9% of them have standard-
ized electronic health records. Mega public
health service programs in total have cov-
ered nearly 0.2 billion people.
5. Public hospital pilot reform
is advancing systematically,
experience in institutional
reform has been accumulated
The reform exploration has been carried out
in 17 national pilot cities,37 provincial pilot
cities and 2000 public hospitals, and posi-
tive progress has been achieved in service
delivery, institutional innovation, internal
management and diversified pattern of hos-
pital running. Through reducing the elimi-
nating drug markup, payment mode reform
and separation of revenue and expenses,
we are exploring ways to separate medical
services from drug sales. By improving the
supervision system and emphasizing the
government’s function in supervision, we
are actively searching for an effective model
of administration reform in public hospitals.
Comprehensive pilot reform of county-level
hospitals has started, featuring eliminating
the practice of subsidizing medical services
with profits from drug sales, and advancing
comprehensive reform in management sys-
tem, compensation system, human resource
system, purchasing mechanism and pric-
ing mechanism. All these measures aim to
gradually set up a new public hospital oper-
ation mechanism that maintains the public
welfare nature, motivates health profession-
als and ensures sustainable development.
II. Reflection of the three-
year healthcare reform
The three-year health care reform practice
proves that the guiding ideology, principle
10
Regional and NMA news CHINA
methodology and basic pathway set out by
the central government are fully in line with
our national circumstances, health care de-
velopment rule, and the wish and needs of
our people. We summarize our experience
and reflection as follows:
1. Strengthen the policy
implementation and promote
the establishment of basic
healthcare system
The guiding documents on healthcare re-
form of the central government explicitly
stipulated that basic medical and healthcare
services be provided to the people as pub-
lic goods. This demonstrates the significant
change of our health development from
ideology to mechanism. It shows the deter-
mination of the Party and the government
to improve people’s well-being by taking
measures in the health sector. The health
system carries out the deployment from
the party central committee and the State
Council unswervingly, follows the principle
of the central government document with
perseverance. These are the fundamental
guarantees to achieving the expected results
of the healthcare reform.
2. Increase input and promote
institutional reform
Institutional reform has a comprehensive,
fundamental and long-term influence on
the development of the health sector. In or-
der to obtain success, we must not only in-
crease input, but also pay attention to insti-
tutional transformation in order to reform
the old improper interest pattern.
3. Insist on the leading role of the
government and promote inter-
department coordination
As the healthcare reform is a critical trans-
formation in society, powerful leadership
and working system secure its smooth
progression. Leading groups and inter-de-
partment coordination mechanism set up
by the central and local government have
played an important role in overall plan-
ning, consensus building and the reform
promotion.
4. Highlight top-level policy
design and advance each reform
task in a coordinated manner
Adhering to the masterstroke of the health-
care reform document from the central
government, insisting on the five key re-
form priorities, we promulgated series of
guiding policy measures. Every slight move
may affect the work as a whole. Hence we
must make an overall plan and take all fac-
tors into consideration. We must gradually
carry forward the work with the supporting
policy, through close coordination, by high-
lighting the key points.
5. Enhance policy implementation
and motivate medical professionals
Whether we can accomplish the reform
and make breakthrough in the key tasks or
not depends on arousing the enthusiasm,
creativity and activeness of medical profes-
sional to let them devote to the reform with
heart and soul. Therefore, we must improve
the relevant policies and set up salary sys-
tem, performance evaluation system and
incentive distribution system compatible
with the features of this profession. Related
issues as welfare and benefits, career devel-
opment and practicing environment should
also be addressed appropriately.
6. Strengthen the joint actions of
central and local governments and
respect the local pioneering spirit
Along with the implementation of health-
care reform policies of the central govern-
ment, local experiences have been drawn
and transformed into national policy. This
leads to the interaction between the guid-
ance of central government and the practice
of local health departments. This three-year
reform journey reveals that the driving force
and sources of practice are at the grass-roots
level. Thus, we shall emphasize that local
governments should explore to make break-
throughs, and experiences in this regard can
lead to central-local interaction and make
national breakthroughs.
III. Continuously promote
the healthcare reform
The twelfth five-year period serves as a
linkage between the past and the future
in the healthcare reform. Guided by the
healthcare reform spirit and principles en-
shrined in the address of Vice Premier LI
Keqiang at the National Working Meet-
ing on Deepening the Healthcare Reform,
we shall intensify our efforts in the three
priorities stipulated in the twelfth five-year
plan of the healthcare reform, namely, ac-
celerating the construction of the basic
medical insurance system, improving es-
sential drug system and enhancing new op-
eration mechanism in grass-roots medical
and health institutions. We shall focus on
medical insurance, medicine and medi-
cal services and take well-coordinated ac-
tion jointly in these three aspects so as to
achieve greater progress in the healthcare
reform.
1. Accelerate the construction of the
basic medical insurance system
Firstly, consolidate the coverage and en-
hance the basic medical insurance level.
On the one hand, a stable fund increase
mechanism should be set up. With the ris-
ing income of urban and rural residents,
subsidy from the government shall rise
accordingly. By 2015, yearly subsidy for
urban residents’ medical insurance and the
11
Regional and NMA newsCHINA
NRCMS shall have reached above 360
RMB Yuan per capita. On the other hand,
with the increased funding, insurance
package shall be expanded and the com-
pensation proportion shall be raised, fea-
turing about 75% of the in-patient expens-
es paid within the urban employee medical
insurance, residents’ medical insurance and
the NRCMS and the out-of-pocket medi-
cal payments for residents shall continue to
be reduced.
Secondly, promote reform in medical in-
surance payment. The payment system
reform is an important way to control ex-
penses. In order to replace the current
pay-by-item, such payment methods as
total prepaid, diagnosis-related grouping,
fee-for-service and/or capitation shall be
adopted. New ways of payment will further
regulate the medicare service, control the
expenses and promote the comprehensive
reform of the medical institutions.
Thirdly, improve basic medicare manage-
ment and service. Information manage-
ment should be forwarded to avail resident
health card, realize immediate accounting
in overall planned regions and speed up
trans-regional immediate accounting. We
are also to level up the overall planning of
the NRCMS and increase fund risk resis-
tance. The NRCMS funding is encouraged
to be used for purchasing commercial medi-
care insurance as complementing the medi-
care insurance system.
Fourthly, explore to build medical insur-
ance for catastrophic diseases. By linking
the NRCMS fund and medical aid, the
compensation rate for catastrophic diseases
shall reach 90%. By the end of this year,
the insurance scheme of 8 major diseases
including child congenital heart disease
and leukemia will be implemented entirely
and in 1/3 of the overall planned regions,
12 kinds of diseases including lung cancer,
acute myocardium infarction, hemophilia
and hyperthyroidism will also be included
to maximally prevent disease-led poverty
and disease-led back to poverty for the
NRCMS peasants.
2. Consolidate and improve
essential drug system and new
grass-roots operation mechanism
Firstly, consolidate national essential
drug system. Based on the previous 3-year
work, the system shall be expanded to all
village clinics this year. In the meantime,
essential drugs shall be given priority in
terms of distribution and use in other
medical institutions. The national essential
drug list shall be improved, local essential
drug list amendment, drug use by medi-
cal institutions and purchase mechanism
shall be further regulated in order to ensure
safety, efficacy and timely supply of essen-
tial drugs.
Secondly, keep promoting comprehensive
reform in grass-root medical and health-
care institutions. Improve the long-term
stability of the multi-channel compensa-
tion mechanism and implement the fiscal
input policy to the letter. Carry out the gen-
eral consultation fee and medical insurance
payment policy and ensure a long-term
stabilized operation of grass-root medical
and health care institutions. By means of
improving the performance evaluation sys-
tem, salary and distribution system in line
with medicare character, there should be a
reasonable gap in salary in order to motive
health professionals.
Thirdly, improve grass-root medical and
healthcare service. Standardized construc-
tion of grass-root medical and health care
institutions will be supported continually,
aiming to cover more than 95% of them
by the end of the twelfth five-year period.
General practitioner (GP) team building
will be promoted to cultivate over 150 000
GP by 2015, featuring more than 2GPs for
each 10 000 urban residents and a GP in
every health clinics in towns. Free medical
students orientation training and GP spe-
cial duty plan will also be continued to en-
courage talents serve in grass-root areas.The
issues of rural doctors in terms of function
positioning, working environment, com-
pensation and pension should be properly
addressed to build a solid foundation for
rural healthcare system.
3. Advance comprehensive
public hospital reform
Public health reform shall focus on the
county level. Efforts should be made to
promote institutional reform and to pro-
vide convenient and accessible health
services to the people. According to the
recently issued opinion on comprehensive
pilot reform in county level public hospital by
the General Office of the State Council,
the reform should follow the principle of
joint action of the central and local gov-
ernments with inner vitalization and outer
thrust. According to the requirements of
the reform to separate administration from
service, management from running, medi-
care from medicine, the for-profit from the
non-for-profit, we shall eliminate the prac-
tice of subsidizing medical services with
profit from drug sales as the key link, the
compensation system reform and indepen-
dent management of hospitals as the break-
through points. We shall promote reforms
in the administration, compensation, per-
sonnel distribution, pricing, medical insur-
ance payment, purchasing and supervision
systems.
Firstly, eliminate the practice of subsidiz-
ing medical services with profit from drug
sales, a compensation mechanism formed
under special historical conditions. At
present, this mechanism has cast negative
influence, hurt the public nature of public
hospitals and become a malady need to be
eliminated in the healthcare field. Public
hospital is the main body to provide medi-
care services in China while issues of ac-
cessibility and affordability mainly occur
here. Unless we eliminate the malady, it is
12
Regional and NMA news CHINA
hard for us to eradicate the prescription of
excessive and costly drugs, and to suppress
the improper increase of medicare expenses
from the root. This mechanism hurts not
only the interests of the people but also the
doctor-patient relationship. With its exis-
tence, it is hard to form the mechanism of
grass-root gatekeeper, dual referral, preven-
tion-treatment combination, acute-chronic
separation and inter-institution coordina-
tion.
Secondly, improve comprehensive com-
pensation mechanism. Income reduced
by eliminating the practice of subsidiz-
ing medical services with profit from drug
sales should be compensated by setting up
multi-channel compensation mechanism
of medicare insurance-finance joint action.
We need to properly adjust the medicare
service pricing system, to improve cost ac-
counting of public hospitals, to increase
general service fee, nursing fee and opera-
tion fee that give expression of the medi-
cal professionalism and to fully respect
the professional dedication and values of
medicare service. At the same time, we
should control the total amount and adjust
the structure, and reduce large equipment
examination fee to achieve total balance.
Since medical insurance has become the
main funding for public hospitals, we must
give full play of its compensating function,
to promote payment reform, to include
the increasing expenses into insurance re-
imbursement and to avoid adding burden
to the people. Meanwhile, governmental
investment shall be increased, including
subsidies for public hospital infrastruc-
ture construction, large medical equipment
purchase, personnel training, key discipline
development, pension and policy-related
loss.
Thirdly, motivate the medical profession-
als. As medical professionals are the major
driving force of the healthcare reform, a
salary system in which special features of
this profession are taken into consideration
should be set up. To ensure an income in-
crease after the reform, we should explore
to reform the current total wage limit in
public institutions and raise the expendi-
ture ratio on personnel over operation. In
the meantime, to provide medicare staff a
promising career development, we should
create a good environment, improve pro-
fessional qualification system and develop
key clinical disciplines. Furthermore, to
build a harmonious doctor-patient rela-
tionship, we should adopt more training
on humane care, enhance mutual trust and
build the third-party negotiation mecha-
nism.
Fourthly, improve medical care services
in public hospitals. We will strive to re-
cruit talented personnel, and formulate
favorable policies on staffing administra-
tion, professional qualification appraisal,
salary and welfare, so as to attract the
talents to practice in public hospitals. By
enhancing performance evaluation and
incentive mechanism, implementing stan-
dardized resident-training and on the job
training for medical professionals, we shall
improve the overall medicare services in
public hospitals. A special post will be set
up in county level hospitals and badly-in-
need high level talents will be recruited. In
the meantime, central-local government’s
joint action will continue to target support
at designated areas, and first diagnosis at
primary health facilities, graded diagnos-
tic and treatment, and dual referral system
will be developed.
4. Promote other healthcare reform
work in a coordinated manner
Firstly, improve equal access to public
health service. We shall proactively re-
spond to population aging and disease
model transformation, strengthen chronic
non-communicable disease management,
innovate working methods and enrich the
services we provide, gradually expand the
package of basic and mega public health
services and benefit more people.The role of
Traditional Chinese Medicine (TCM) shall
be given full play in preventive medicine
while proper TCM preventive technique
shall be promoted. By 2015, expenditure
on basic public health service shall reach 40
RMB Yuan per capita.
Secondly, accelerate the process of en-
couraging multi-sectors to run medical
institutions. We are to further improve
medical practicing environment and im-
plement the policy encouraging private
sectors to run medical institutions. Priority
support will be given to private nonprofit
medical institutions which are encour-
aged to develop towards higher level and
larger scale. Qualified medical profession-
als are encouraged to open private clinics.
By 2015, non-public medicare institutions
beds and service shall take up 20% of the
total.
Thirdly, innovate personnel cultivating
and utilization system. Standardized resi-
dent training system shall be built and con-
tinuing medical education system shall be
improved. Meanwhile special talents in ur-
gent need and high level personnel shall be
cultivated. Improvement is also expected to
be made in doctor multi-site practicing and
in medical insurance perfection as well as in
the third-party negotiation mechanism set-
ting medical disputes.
Fourthly, promote health informatiza-
tion. We shall further promote the creation
of electronic resident health record and
electronic medical record, based on which
to promote examination results recognition
among different medicare institutions, re-
mote consultation and in-time supervision
over medical practice. Meanwhile, resident
health cards will be spread to facilitate
seeking medical service and health man-
agement.
Chen Zhu, Health Minister of China
Report at the China Bio-industry
Convention, June 28, 2012
13
Regional and NMA newsUGANDA
This is a story with pictures of my visit to
Kampala, the capital city of Uganda, to find
out more about how and where the President
Elect of WMA, Margaret Mungherera, lives
and works. 
On 27th
December, 2012, I flew into En-
tebbe airport from Kenya, and in just a
couple of days I was able to visit Margaret’s
home, her parent’s home, Butabika Hos-
pital, a mental hospital where she worked
for 19 years and Mulago National Referral
Hospital where she currently works as Se-
nior Consultant Psychiatrist. I also visited
the Ministry of Health headquarters, her
primary school, her medical school, Mak-
erere University main campus and Kampala
International University, a private institu-
tion where she serves as Council member.
I also had an opportunity to meet her hus-
band, Richard, her parents and some of her
siblings, co-workers, students and Rotary
club members. I was driven around in a
car which though provided for her by the
Ministry of Health, she has to pay for the
driver’s salary and the fuel.
When European or American doctors
think of Uganda, usually two stereotypes
cross their mind. The first  – medicine in
Africa is very charlatan, they use frog’s skin
to treat burns, and soil  – to get rid of diar-
rhoea, but a very ill person gets visited by
a shaman who dances around the patient
six times first. The other stereotype – well,
if you are a doctor and, god forbid, went to
Cambridge, then you are just like all of us,
so go ahead and pay the same conference
fees as we do, start giving your patients all
the necessary drugs and stop those excuses!
Something like this can be heard from col-
leagues who read in the business news that
each year the economic growth of Uganda
is 3.5%. But what they can’t read among the
lines is that just a couple of years ago, the
economy of Uganda which was about a hun-
dred times behind the leading economies,
and even now is still far behind, is rapidly
growing due to coffee and fish as the ma-
jor exports and that Southern Sudan relies
on Uganda for its food and basic essentials.
There are only 4700 physicians for a popula-
tion of approximately 32 million people! In
rural areas of the country, the health centres
are mainly headed by nurses and in some
places by clinical officers who are known
elsewhere as medical assistants or physician
assistants. A large part of the population
can only have access to a nursing assistant
who is someone who has had a few weeks of
basic medical training.The number of phar-
macists is very low and so drugs are often
dispensed by lay people.
Every year, about 250 young doctors gradu-
ate from the four medical schools in the
country with most of them shunning em-
ployment in the public hospitals opting to
join the private sector or leave the country
with the hope of finding better working con-
ditions.In the past,the majority of Ugandan
doctors migrated to the Republic of South
Africa, but more recently many are migrat-
ing to neighbouring Rwanda and Southern
Sudan.Some of those who manage to obtain
employment in South Africa have moved on
to the USA, Canada and Australia.
Margaret’s brother, Andrew works as an or-
thopaedic surgeon in South Africa and her
youngest sister is doing her PHD in Pub-
lic Health in Australia while she does her
Family Medicine residency in Auckland,
New Zealand. Another sister, Lydia, also a
physician, is a well known HIV/AIDS ac-
tivist. She returned to Uganda from South
Africa where she worked as a Medical Of-
ficer for about 20 years. Margaret herself
chose to stay in Uganda where she has made
her name in the field of mental health.
Margaret Mungherera was born in Jinja, a
town located on the shores of the largest
lake in Africa, Lake Victoria, and the source
of the River Nile which is the longest river in
Africa. Uganda or Kenya is the place where
2 million years ago our ancestors got off a
tree and sharpened a stick to chase leopards
away. Now that is what actually started our
way to space travels in the 20th
century and
a rapid spreading of the Internet in the 21st
.
Never Say Never, Uganda!
14
Regional and NMA news UGANDA
About a million years ago, here in Kenya (or
Uganda) our ancestor learned how to start
a fire and had the first “barbeque”, and in
another half million years packed his back-
pack and went ahead to explore the rest of
the globe – Europe and Asia at the begin-
ning, then Australia, Americas and Antarc-
tica. Being at Lake Victoria in the city of
Jinja makes it easy to imagine how it actu-
ally happened when our ancestor got up,
stretched, took his axe and said he was go-
ing away to see and explore other countries.
Uganda should be the Holy Land to come
to feel your roots.
Uganda is full of contrasts. Just next to a
fancy colonial building with lots of marble
is a simple and tiny shack where the owner
sells live chicken to be able to make a living.
The side roads in Kampala are like arteries –
full of life. They sell everything – drinking
water, meat, fish, bananas, vegetables, fruits,
beds, reclining chairs that are being made
right there in front of your eyes. They sell
fire wood, construction materials, gasoline,
paints, but considerably more than any-
where else in the world  – fashion goods.
Nearly every store is proudly showing off
gorgeous and fancy dresses. I have to admit
that never ever on Europe’s streets will you
see as many women dressed in long evening
gowns as I saw here in Uganda. Ugandan
women go to church dressed up like Euro-
pean women would do for,say,a presidential
reception. And I have to admit those dress-
es are absolutely wonderful, designed with
such taste! Local designers are lost to the
rest of the world, Armani and any other top
fashion designer would just die of jealousy
seeing what Africa’s colours have to offer.
Margaret Mungherera is a true patriot, and
carries her WMA brooch attached to a
blouse of all shades of yellow,orange and red.
We all come from different families. I am
very lucky to have met Margaret›s parents,
Seth and Joyce Mungherera. They live ap-
proximately 6 kilometres outside the city.
Two sons and a daughter still live with
them, a son, Dan  is a graphics artist, the
other, Peter a journalist trained in Zambia
and with many years of working experience
in Germany, speaks fluent German. The
family itself is very conservative and car-
ries strong traditions – the father plays the
piano, while the daughters sing.
Margaret’s mother keeps all Margaret’s lo-
cal and international awards which include
a certificate of her Honorary Doctor of Sci-
ence degree and another from the Ministry
of Health in recognition of her advocacy
efforts. Since the Ministry of Health does
not have enough funds to adequately pay
Margaret for the work she does as Senior
Consultant she has been assigned an official
vehicle which she fuels herself.
15
Regional and NMA newsUGANDA
Margaret’s father is a retired public ser-
vant and her mother worked for more than
40 years as General Secretary for Uganda
YWCA and for several years was executive
member of the World YWCA represent-
ing Eastern, Central and Southern Africa.
She is therefore widely travelled.The family
belongs to the Anglican Church, so Mar-
garet and I visited St. Paul’s Cathedral, very
beautiful, simple, spacious and mighty, and
located on top of a hill.
We found the choir singing in a manner that
will make any organist plain jealous. Men-
delssohn would have been quite surprised to
know how vocally rich, polyphonic, beauti-
ful and rhythmic his Wedding March can
be. However, the choir sang it faster than
we are used to hear it in Europe (a wedding
ceremony was being held in the cathedral
during our visit).
Most Ugandans are either Anglican or
Catholic with a small number belonging to
the Moslem faith. Each of the three reli-
gious groups has its main house of worship
situated on a hill.
We visited the primary school which Mar-
garet had attended and it had formerly
been known as Kampala European Primary
School.
During the whole time she was there, there
was only one black teacher. We found ex-
tensive renovation work being done, but the
old school bell is still in its place though no
longer used. More than 50 year old tradition
of holding an assembly for the whole school
is being continued. It was introduced during
the time of an English headmaster who was
strict and insisted on punctuality.The current
headmaster believes punctuality should not
be instilled by using a school bell. Children
should simply use their own watches to learn
to keep time. The lawn around the school is
neatly mowed, bushes carefully trimmed.
Margaret had her secondary school educa-
tion at a famous girls school, Gayaza High
School,approximately 10 km from Kampala
city centre.Then she was admitted to Mak-
erere University Medical School, the oldest
medical school in Eastern and Central Af-
rica known for its research and training. At
one time it was the only medical school for
Kenya and Tanzania.
Naturally, a lot has changed since the time
Margaret graduated. There are now four
medical schools in Uganda. Margaret was
very instrumental in founding one of them,
Kampala International University (KIU).
We visited the main campus of KIU which
has several large buildings and the grounds
are green and clean.
Burglar proof windows and doors and se-
curity guards are common in public build-
ings and homes,a reminder of the insecurity
often experienced by the population during
the times of Idi Amin.
Margaret started her working life in But-
abika Hospital, the only mental hospital
for a population of more than 30 million
people.
16
Regional and NMA news UGANDA
She worked there for 19 years before she
requested to be transferred to Mulago Hos-
pital where she is currently based. Butabika
Hospital is a 700 bed hospital located about
9 kilometres from Kampala city centre and
has a beautiful view of Lake Victoria. The
Hospital is incredibly clean, has beautifully
kept green lawns, decorative bushes, flower
gardens and gravel walkways. The male and
female wards are separated by the office
buildings. The environment reminds one of
a European resort. Margaret’s former co-
worker, David, now acting as Executive Di-
rector, gave us a brief tour of the Hospital.
Margaret and David are 2 of the small
number of psychiatrists, 34 to be exact,
for a population of 35 million people. Yet,
mental health problems such as depression
are common in Uganda with approximately
40% of the population affected.This may be
the reason why Margaret is in high demand,
constantly receiving referrals and consulta-
tion from colleagues all over the country.
When she responds to the calls in Lugan-
da, the most commonly spoken vernacular,
I am only able to pick up names and doses
of common antidepressants and antipsy-
chotics. In addition to the severe shortage
of mental health specialists, there are often
inadequate supplies of drugs and hospital
beds in the rural parts of the country where
the majority of people live.
On the other hand, Uganda has made im-
pressive progress in fighting HIV/AIDS
with the prevalence dramatically going
down from 30% in the 1990s to the cur-
rent 7.3%. Maternal mortality is still a huge
problem and so is malaria and TB. Yet, ac-
cording to the UN, Ugandans are amongst
the most optimistic people in the world.
They see a lot more light and hope in the
world than people in rich European coun-
tries and North America.
Margaret got married to her husband Rich-
ard who is a retired banker. On our way
to the Hospital she pointed out to me the
house they lived in for 9 years.
Although she left the Hospital 9 years ago,
manypeopleinthenearbytradingcentrestill
recognize her and wave to her. Store own-
ers are eager to welcome us in their stores.
Margaret Mungherera now works at Mu-
lago National Referral Hospital as Senior
Consultant Psychiatrist in the Department
of Psychiatry.
She also has additional administrative re-
sponsibilities of the Clinical Head in charge
of the Departments of Internal Medicine,
Psychiatry and Community Health. She
still maintains an office in the Department
of Psychiatry, but the emptiness of the of-
fice shows that she hardly spends time
there. All the doctors we met seemed free
to consult her which is a sign that they
consider Margaret more as a friend than an
administrator.
17
Regional and NMA newsUGANDA
Her main administration office is located
in the offices of the Department of Inter-
nal Medicine because it is the largest of
her three departments. It is not too big and
has a maroon sofa set, four chairs and one
table.
There are several files on the shelves, some
for the Hospital, others for the Uganda
Medical Association of which she is Presi-
dent and others are for the Commonwealth
Medical Association where she was once
Vice-president and is now Treasurer.
Other documents are from the Medical
Associations of Uganda, Kenya, Zambia,
Rwanda and Burundi.These countries form
the East African Community and the na-
tional medical associations (NMA) have
been working together to ensure quality
standards in training and health care. The
NMAs have accomplished much as regards
bringing their regulatory bodies together
to harmonise the training of doctors in-
cluding the curriculum. As a result there is
joint inspection of medical schools in the
five countries with reciprocal recognition of
qualifications so doctors graduating from a
medical school in any country in the region
can work in any of the other four countries
without doing pre-registration exams. Mar-
garet has been at the forefront of this de-
velopment.
One of many problems that Margaret had
to solve during our tour round the city is
evidence of the state of affairs as regards
the political governance of the country. The
government is investigating the death of an
outspoken member of the Parliament and
a member of the ruling party. A patholo-
gist acting on behalf of the family and the
Parliament was arrested by the police as he
tried to leave the country to take the speci-
mens to South Africa. As President of the
NMA, Margaret has had to make state-
ments in the media about the opinion of the
medical profession.
I am not saying Parliament members die
every day in Uganda, but when they do,
questions like this do come up.
It is obvious from her conversations with
doctors, nurses and other medical staff that
Margaret Mungherera is a strict boss, there
is none of that sparkling humour we are
used to at the WMA meetings. Although
I  do not understand the local vernacular,
I can sense from her tone dissatisfaction
about the care of patients, the wet floor and
the conditions of the wards. The wards are
congested with some patients sleeping in
the hallways. Visiting relatives, many with
young children, of patients sit patiently out-
side on the grass, waiting to see their be-
loved ones. The hospital grounds are beau-
tiful – plenty of trees, bushes, long legged
marabou storks walking around. My seem-
ingly innocent question about correlation
between the Pathology Anatomy unit and
those marabou storks on the roof went by
unanswered.
Meanwhile,the marabou storks at the Mak-
erere University main campus have decided
to build their nests in the trees of the alley
right in front of the main building, making
the trees dry due to the many nests in the
tree.
The exodus of physicians from Uganda to
elsewhere is determined by two impor-
tant aspects – first of all, an experienced
senior doctor working for government is
paid approximately USD 1000 per month,
while their colleagues in Kenya make
about 4-5 times more, and the situation is
even better in Rwanda where the salaries
are 5-6 times better. This means doctors
18
Regional and NMA news UGANDA
have to supplement their meagre pay by
doing private practice. Margaret is not an
exception. She supplements her income
by seeing private patients in the evenings
at a clinic owned by a friend who is a pae-
diatrician.
The second aspect is the incredible workload
due to the lack of physicians. More than
60% of the population receives health care
from the government hospitals and health
centres. This covers tuberculosis, cancer and
HIV/AIDS.This is a huge workload for the
few doctors available.
Though free, still the services often lack
drugs and investigative facilities.This means
patients often have to be prescribed drugs
so they procure them at their own expense
from local drug shops. This makes doctors
feel uncomfortable because the majority of
patients are poor.
As I watched her friend examining a small
child, I was reminded of the infant mortal-
ity rate which is still alarmingly high and is
largely due to diarrhoeal diseases, malaria,
malnutrition and HIV/AIDS. Being a large
city, Kampala is very different from the
other parts of the country. This is because
the health care services are more accessible.
Uganda has very few medical specialists if
compared to the United Kingdom for in-
stance that is approximately the same size.
That being said, the average life expectancy
is approximately 45 years mainly because of
HIV/AIDS and the high maternal mortal-
ity rate which is around 490 women dying
for every 100,000 live births and the high
infant mortality rate. Indeed, healthcare has
to come first, then statistics.There are many
private clinics in Kampala and outskirts,but
primary care is still in high demand.
All these issues seem to be important
enough for us to go visit the Ministry of
Health of Uganda. I do have to tell, it was
an early afternoon of December 27, when
the rest of the world is stuck between cel-
ebrating Christmas and New Year’s.
Unfortunately, the security measures at
the Ministry of Health headquarters seem
more relaxed than elsewhere where anyone
coming in has to be searched or scrutinised
by the security guards. Here, the doors are
open and anyone is free to go in and out.
The doors of the Minister of Health and
her deputies are locked which as Marga-
ret points out is because of the Christmas
season. We run into a a Commissioner who
politely advises us to come back the follow-
ing week when the holiday season is over.
But here is the good news  – it is nice to
watch Margaret Mungherera walk freely
into the Ministry, a sign that the President
of the National Medical Association means
a lot to the country.Of course,it would have
been nice to see the  Minister of Health
jump out of her chair to welcome Margaret
but she just was not there…And I do under-
stand that she does not always have to just
sit in her office signing documents. There
is so much work to be done away from the
Ministry head offices.
Meanwhile, an Irish doctor who came to
work in Uganda as a missionary several
years ago, has built a state-of-the-art hos-
pital near the city centre. Even though he
has been elected as one of the four mayors
of the city, he still has time to spend some
time at his hospital even during the holiday
season.
19
Regional and NMA newsUGANDA
Rotary is a very important part of Marga-
ret’s life. During her time as Country Chair,
she was able to have a total of nine new
Rotary clubs formed. Rotary has supported
the equipping of hospitals and Rotarians
are even constructing a new Cancer Ward
at one of the Catholic church-run hospitals.
My personal impression was that Ugandan
Rotarians are generally not wealthy people
compared to the average European but they
are keen to be involved in charity work and
to donate generously.
Everywhere we go, we are greeted by many
people who know Margaret and are eager
to talk to her. These include members of
her Rotary Club, lawyers, bankers and gov-
ernment officers. A few people introduce
themselves as her former patients or fam-
ily members of her former patients and re-
spectfully greet her from a distance.
I enquired of Margaret as to her priorities
during her term as President of the WMA.
Her interest is increasing access to health
care. A patient should be able to see a doc-
tor regardless of his/ her status,age or where
in the country they live. She is concerned
that Africa suffers from human resources
for health crisis. She is however quick to
add that the crisis is also affecting other
parts of the world, including Europe.
As a doctor working in Africa, Margaret is
concerned about the high maternal mortal-
ity and infant mortality rates in many of
the African countries. Infectious diseases
continue to be the major cause of morbidity
and mortality. However, non-communica-
ble diseases (NCDs) including hyperten-
sion, cardiac diseases, cancer are on the rise
in Africa. This is largely due to the chang-
ing life style including increased consump-
tion of alcohol and tobacco products. Many
Ugandans are not able to access a doctor
and in the best scenario may be able to see
a nurse.
Margaret is participating in the process to
revise the Declaration of Helsinki (DoH).
These important ethical guidelines for re-
search involving human subjects will be
clocking 50 years during her term as Presi-
dent of the WMA.
She recently attended an experts meet-
ing in Cape Town, South Africa, and will
be attending review meetings to be held in
Tokyo and New York. Her brief discussion
about the DoH shows that she is concerned
about the adverse effects the DoH is likely
to have on poor countries.
There is a large resort hotel on the suburbs
of Kampala city and on the shores of Lake
Victoria where the Commonwealth Head
of Government Meeting (CHOGM) was
recently held. It is a popular venue for in-
ternational meetings with ample conference
facilities and a scenic view that according to
Margaret can easily host a General Assem-
bly of the WMA.
To my mind the costs would be too high
but Margaret believes the government
and international organisations would be
willing to support a meeting that attracts
medical professionals from all over the
world.
To date, South Africa is the only country
in Africa that has hosted a WMA event,
moreover, only two WMA presidents have
ever visited Uganda.
I put it to Margaret that the Uganda Medi-
cal Association might not be able to afford
such an event and asked her about the As-
sociation’s financial situation. For the last
few years the government has not supported
the Association financially as it used to do
in the past. Occasionally some departments
sponsored doctors in rural areas to attend
the annual meetings of the UMA.
Government regional hospitals have some-
times provided the UMA with space for
CPD seminars. A few District Health Of-
ficers have sponsored their doctors to be
able to travel to Kampala and occasion-
ally paid the conference registration fees.
Some of the costs are covered by the fees
pharmaceutical companies pay to exhibit at
the conference venue. Every so often a cor-
poration will offer to sponsor such events,
for instance, the electricity distribution
company has recently offered the UMA
support for CPD seminars for doctors in
remote areas.
The members of the Association recently
registered a savings and credit society for its
members and have already received a small
contribution from the President of Uganda.
The Association is a shareholder in the soci-
ety and will use funds obtained from savings
to put up the UMA House.
The office block which was given to the
UMA by President Idi Amin in the 1970s
was repossessed by the previous owners in
the early 2000s. Since then the Association
has been renting offices.
20
Regional and NMA news UGANDA
The biggest more recent accomplishment of
the Association has been the almost 300%
raise in salaries of junior doctors working in
remote areas. The salary of those doctors is
now higher than that of a specialist working
in the national referral hospital in Kampala.
Margaret believes that the number of doctors
working in the rural areas where the majority
of people live needs to be increased. Increas-
ing access to doctors in rural areas will have
a significant impact on the morbidity and
mortality of people living there and lead to
economic growth and development.
Margaret witnessed the signing of the
memorandum of understanding by the
WMA and the World Veterinary Associa-
tion. As a result the UMA and the Uganda
Veterinary Association will be holding a
One Health Conference in Kampala. The
theme of the conference is “Disease Eradi-
cation: What will it take?”and the areas
to be covered include disease surveillance,
policy, advocacy, communication, disease
prevention and control. The conference
has received tremendous support from the
WHO, UNICEF, USAID and the Uni-
versity of Minnesota, USA. Margaret plans
to spend her year as President encouraging
the NMAs in low income countries in Af-
rica and the Middle East to participate in
the WMA activities. She would like to see
stronger NMAs twinning with and men-
toring the smaller NMAs. Her specific ar-
eas of emphasis will be the human resources
for health crisis, maternal health, mental
health,HIV/AIDS and non-communicable
diseases (NCDs).
On the 28th
December, I briefly visited the
apartment complex where Margaret lives
with her husband Richard.
The apartment complex is located in the
eastern part of the capital city, Kampala,
and is near the shores of Lake Victoria.
Right across from where Margaret lives is
an elementary school for Moslem girls. Is-
lam is commonly practised in Uganda espe-
cially with the large influx of refugees from
Eritrea and Somalia. The large mosque on
one of the hills of Kampala was donated
to Uganda by Muammar Gaddafi and was
named after him.
She collects wooden mementoes from all
the African countries she visits. I  laugh
because I believe they are made in China
which she says is not true.
Margaret’s husband Richard has a firm
handshake, a low voice, a friendly smile and
a keen interest in Margaret’s activities.
He knows the names of all the leaders of
the WMA, what they look like and what
they do. He sits in the passenger seat by the
driver in the car, Margaret sits behind him.
Our destination is the source of the River
Nile, where it comes out from Lake Victo-
ria. I have “googled”Jinja and so I am aware
the distance is approximately 80-90 kilo-
metres. They rush me saying that the term
“highway” has a whole different meaning in
Africa….
The traffic made of passenger minibuses,
large trailers on their way to Kenya, oc-
casionally pedestrians and large herds of
cattle, sheep and goats and even chicken
crossing the main road make our travel
much slower than it should be on a highway.
Toyota minivans rule the road – they are the
most popular mode of public transportation
in Uganda.
21
Regional and NMA newsUGANDA
Where in Europe oncoming cars would
slowly pass by each other, here it’s com-
mon to see two cars in one lane pass
each other with the side mirrors collid-
ing. Wherever there is a speed limit of
20 km/h, there is a hawker trying to sell
some food through the window. The sides
of the road are also popular meeting plac-
es for motorcyclists.
Margaret’s driver Ibrahim is also Moslem
and is very polite and calm. One can learn
a lot from him on the highway of Uganda.
Driving here is not as difficult as it is for
instance in India where there seems to be
no traffic rules.
Many of the roads are of bad quality and
there are traders on the sidewalks often
on both sides narrowing the roads even
more.
It is not unusual to find a truck parked by
the roadside with the driver selling pine-
apples from it.
Normally, there are three people on a mo-
torcycle but sometimes the kids are seated
on top of it. And their riding makes me
worry about Uganda as an organ donor
country…
We drive through woods (even there are a
lot of pedestrians).
It is a broadleaf forest – Uganda is more
than 1 km above the sea level and the air
temperature is not burning hot. Informa-
tion available for public states that Ugan-
da is constantly planting new forests, but
Margaret disagrees – she thinks that even
the existing ones are very poorly main-
tained.
Also, she is not happy about Uganda›s re-
sults in preserving gorillas and chimpan-
zees, let alone savanna animals. Especially
hard is her take on military’s destructive
actions against preserving forests and ani-
mals. Being green is just another Marga-
ret’s interest amongst many, she is ready
to fight the global warming because in
her opinion, rain forests play an essential
role in the climate change and producing
oxygen. In general, Uganda is a very green
country – there are big trees in the cities, a
beautiful lawn and bushes surround every
house.
After a two hour ride, we arrive in Jinja,
where Margaret was born in the local hos-
pital. Jinja was once the most industrious
town in the country but all this changed
with the coming of Idi Amin. Some of the
areas still look clean while others are run
down and there is evidence of rehabilitation.
There is evidence that there are ongoing ef-
forts to improve the sanitation standards of
the town. The reconstruction is a common
sight in many of the towns in Uganda in
between large residential houses with beau-
tiful gardens.
We get out of the car, pay the parking fees,
then go down to the River Nile where we
eat delicious fried tilapia fresh from Lake
Victoria accompanied by a cold Nile Gold
beer.
As we take in the cool breeze from the
source of the longest river in Africa, the
President Elect continues to share her as-
pirations for the WMA. I wish her the best
knowing that with her energy and charisma,
the Annual General Assembly will come to
Uganda sooner than later.
Dr. Peteris Apinis
Editor in Chief, WMJ,
President of Latvian Medical Association
22
Healthcare
The vaccination rates among healthcare pro-
fessionals are shockingly low. Yet, these are
individuals who are most frequently exposed
to communicable diseases.Our member orga-
nizations should be informed about these in-
consistencies among healthcare professionals.
Even in the developed world there are sig-
nificant inconsistencies in vaccination rates
of healthcare professionals (HCPs) [1, 3,
4, 5]. For example, according to a survey
conducted at a major teaching hospital in
France, the rate of fully immunized HCPs
and other healthcare workers (HCWs) was
around 30 percent [4]. In some developed
nations, statistics regarding the vaccination
rates of HCPs were unavailable despite the
policy encouraging specific vaccinations for
HCPs [1, 5]. These disparities are mostly
due to a considerable lack of understanding
of specificity of vaccines,fear of the vaccina-
tion itself, and inconvenience in obtaining
vaccinations [2, 4, 6, 9].
Even the policy recommendations for
HCPs and HCWs vary greatly between
countries. Thus, in the European Union the
vaccination recommendations for HCPs
and HCWs were nearly universal for sea-
sonal influenza, as well as hepatitis B, but
only 9 of the 27 member states recom-
mended pertussis vaccination [5].It would
be reasonable to assume that the policies
regarding HCPs protection are relatively
comprehensive in comparison to recom-
mendations for the general population of
these states. It would also be expected that
HCPs as well as their employers would
monitor such policies closely. As it has been
demonstrated, neither is the case with many
developed nations.
The reasons for HCPs to be fully vaccinated
are not just the obvious ethical reasons per-
taining to the concept of “do no harm,” but
also for the economic reasoning of avoid-
ing aggregate productivity losses associated
with illness. This is true in both developed
and underdeveloped nations. For instance,
productivity loss of USD 1.2 billion could
be avoided in the decade preceding 2020 in
LMEs if caretakers alone were updated on
vaccinations [10].
The fluctuation in vaccination rates in
the underdeveloped world due to lack of
knowledge, convenience, or understanding
is secondary. These variables do still affect
the vaccination rates of HCPs and HCWs
in the underdeveloped world, and should
be addressed. However, the deficits in im-
munization rates are primarily due to low
political commitment by respective gov-
ernments, civil unrest, weak health delivery
infrastructure, underfunding, poor develop-
ment, and low levels of further research and
development of vaccines needed for these
nations [11]. In addition to these problems,
there are matters of standardizing the injec-
Susceptible Healthcare Professionals
Alley Ronaldi
0
5
10
15
20
25
30
Hepatitis B
Tuberculosis
(BCG vaccine)
Hepatitis A
Poliomyelitis
Pertussis
Diptheria/Tetanus
Varicella
Measles/RuellaMumps
Influenza Meningococcus
(tetravalent vaccine)
Figure 1. Number of Countries with Vaccine Recommendations for Healthcare Workers (by disease). Source: “Vaccination policies for health-
care workers in acute health-care facilities in Europe.” (Vaccine): 27 EU member countries as well as Norway, Russia, and
Switzerland surveyed
23
Healthcare
tion safety itself. Nearly half of the vaccines
administered in Sub-Saharan Africa are be-
lieved to be unsafe [11].
The administration problems, as well as the
data inconsistency have resulted in reported
outbreaks of specific preventable diseases in
the least developed nations of the world. Ac-
cording to WHO’s 2010 monitoring system
report, between the years 2008–2009, the
number of reported cases of measles, mumps,
and rubella actually increased significantly
among the general population of the least de-
veloped nations. Since this is the case for the
general population, and because data regard-
ing the vaccination rates of HCPs are nearly
non-existent in such countries, it can be as-
sumed that the HCP vaccination rates are
correspondingly lower in developing nations.
The dangers of HCPs not maintaining vac-
cinations while spending most of daily life
exposed to communicable diseases are ob-
vious. There are not only personal risks in-
volved for the HCPs, but also risks to their
patients. Physicians should do everything
in their power to make healthcare settings
safe for their patients. It is their ethical duty
as professionals. Hospitals and other stake-
holders could work to ensure that high lev-
els of vaccination rates among their employ-
ees are maintained to ensure a safe setting
for the provision of healthcare. Such actions
could also serve to protect their organiza-
tions from large productivity losses from
incapacitation of HCPs due to vaccine-pre-
ventable illnesses. As is the case with many
public health dilemmas, physicians should
be made aware and use their leadership po-
sitions to help augment discussions regard-
ing HCP vaccination policy.
References
1. Gargalianosb, Panagiotis, Pavlos Nikolaidisc,
Panos Katerelosa, Natasa Tedomaa, Efstratios
Maltezosd, and Marios Lazanase. “Attitudes to-
wards Mandatory Vaccination and Vaccination
Coverage against Vaccine-preventable Diseases
among Health-care Workers in Tertiary-care
Hospitals.” Journal of Infection 64.3 (2012): 319-
24. Print.
2. Hollmeyer, Helge G., Frederick Hayden,
Gregory Poland, and Udo Buchholz. “Influenza
Vaccination of Health Care Workers in Hospi-
tals – A Review of Studies on Attitudes and Pre-
dictors.” Vaccine 27.30 (2009): 3935-944. Print.
3. Lindley, M., G. Horlick, A. Shefer, F. Shaw,
and M. Gorji. “Assessing State Immunization
Requirements for Healthcare Workers and Pa-
tients.” American Journal of Preventive Medicine
32.6 (2007): 459-65. Print.
4. Loulergue, P., F. Moulin, G. Vidal-Trecan,
Z. Absi, C. Demontpion, C. Menager, M. Goro-
detsky, D. Gendrel, L. Guillevin, and O. Launay.
“Knowledge, Attitudes and Vaccination Cover-
age of Healthcare Workers regarding Occupa-
tional Vaccinations.”Vaccine 27.31 (2009): 4240-
243. Print.
5. Maltezou, Helena C., Sabine Wicker, Michael
Borg, Ulrich Heininger, Vincenzo Puro, Maria
Theodoridou, and Gregory A. Poland. “Vaccina-
tion Policies for Health-care Workers in Acute
Health-care Facilities in Europe.” Vaccine 29.51
(2011): 9557-562. Print.
6. Murray, S. B., and S.A. Skull. “Infectious Dis-
ease: Poor Health Care Worker Vaccination
Coverage and Knowledge of Vaccination Rec-
ommendations in a Tertiary Australia Hospital.”
Australian and New Zealand Journal of Public
Health 26.1 (2002): 65-68. Print.
7. Ozawa, Sachiko, Meghan L. Stack, David
M. Bishai, Andrew Mirelman, Ingrid K. Friberg,
Louis Niessen, Damian G. Walker, and Orin
S.Levine. “During The ‘Decade Of Vaccines,’ The
Lives Of 6.4 Million ChildrenValued At $231 Bil-
lion Could Be Saved.” Health Affairs 30.6 (2011):
1010-020. Health Affairs. Web. .
8. Prato, Rosa, Silvio Tafuri, Francesca Fortu-
nato, and Domenico Martinelli. “Vaccination in
Healthcare Workers: An Italian Perspective.”Ex-
pert Review of Vaccines 9.3 (2010): 277-83. Print.
9. Seale, H., J. Leask, and CR Macintyre.“Do They
Accept Compulsory Vaccination? Awareness,
Attitudes and Behaviour of Hospital Health
Care Workers following a New Vaccination
Directive.”Vaccine 27.23 (2009):3022-025.Print.
10. Stack, Meghan L., Sachiko Ozawa, David
M.  Bishai, Andrew Mirelman, Yvonne Tam,
Louis Niessen, Damian G. Walker, and Orin
S. Levine. “Estimated Economic Benefits Dur-
ing The ‘Decade Of Vaccines’Include Treatment
Savings,Gains In Labor Productivity.”Estimated
Economic Benefits During The ‘Decade Of Vaccines’
Include Treatment Savings, Gains In Labor Pro-
ductivity 30.6 (2011): 1021-028. Print.
11. Jamison, Dean Tecumseh., and John T. Sentz.
“Chapter 12: Vaccine-Preventable Diseases.”
Disease and Mortality in Sub-Saharan Africa. 2nd
ed.Washington, DC: World Bank, 2006. N. pag.
Print.
Alley Ronaldi
E-mail: aronaldi@me.com
Figure 2. Self-Reported Susceptibility Rates (Tertiary-Care Hospital Employees).
Source: “Attitudes towards mandatory vaccination and vaccination coverage
against vaccine-preventable diseases among health-care workers in tertiary-care
hospitals” (Journal of Infection): Survey taken in Greece
24
Healthcare
Under the umbrella of the WHO Emer-
gency and Essential Surgical Care program
aimed at strengthening surgical care sys-
tems, WMA participated in a global forum
called the Global Initiative for Emergency
and Essential Surgical Care. This Forum
was established with multidisciplinary
stakeholders – professionals, academic in-
stitutions, societies, NGOs – interested in
collaborative activities to reduce death and
disability from injuries, pregnancy-related
complications, congenital anomalies and
other surgical conditions.
Introduction
The WHO Integrated Management for Emer-
gency & Essential Surgical Care (IMEESC)
e-learning toolkit (CD) has been developed
by the WHO Emergency & Essential Sur-
gical Care program with input from mem-
bers of the Global Initiative for Emergency
and Essential Surgical Care. The target
audience is policy-makers, managers, and
health-care providers (especially surgeons,
anaesthetists, non-specialist doctors, health
officers,nurses,and technicians).This toolkit
contains WHO recommendations for mini-
mum standards and best practice protocols
in emergency,surgery,trauma,obstetrics and
anaesthesia at first-referral level healthcare
facilities. Also contained are WHO best
practice protocols for minimum standards
in disaster management and equipment at
first-referral health facilities. Training tools,
a trainer’s guide, teaching slides, self-evalu-
ations, needs assessments, quality and safety
tools, and a planning tool for district-level
managers complete the toolkit.
The WHO Integrated Management for Emer-
gency & Essential Surgical Care toolkit has
been introduced in 38 low- and middle-
income countries (LMICs) through WHO
and Ministry of Health partnerships, to
identify and address development needs in
national and district-level surgical capacity.
The tool has also been used to teach safety
during clinical procedures, infection control
and HIV prevention as well as management
of disaster situations.
Training and educational tools
The WHO IMEESC toolkit aims to address
the healthcare workforce shortage in much
of the developing world through its train-
ing materials. The most comprehensive tool
provided in the toolkit is the WHO Surgi-
cal Care at the District Hospital, which cov-
ers the full compendium of first-referral
level surgical practice and procedures. This
manual is a practical resource for frontline
providers and also a potential teaching in-
strument at the undergraduate and post-
graduate levels.
In addition,the toolkit offers training work-
shops which are geared towards equipping
frontline health care providers with the
appropriate skills to address surgical emer-
gencies and routine procedures. Teaching
and reference materials are available for
the workshop leader, including a Trainer’s
Guide, a workshop agenda, and teaching
slides. Following the training, participants
can evaluate the workshop through a formal
assessment and can assess their own knowl-
edge through a self-learning module. The
toolkit also contains seven practical videos
on general principles of wound manage-
ment, head and back injuries, and fracture
management along with special topics such
as fractures in children.
Implementation of best
practices at the point of care
An integral component of the IMEESC
toolkit are the Best Practices Protocols.These
protocols are in the form of posters to be
displayed throughout hospitals and health
facilities. Messages for the best practices
is informed by WHO standards and rep-
resent the basic skills and trainings for
practicing emergency, obstetrics, trauma,
anaesthesia and other surgical proce-
dures. There are eleven protocols which
cover diverse topics including safety and
sanitation, wound and burn management,
post-operative care, female genital injury
management, intensive care settings, and
emergency resuscitation.
Disaster management
guidelines
In relation to Clinical Procedures Safety for
disaster planning, guidance is offered to de-
termine trauma team responsibilities, per-
form a disaster-centered needs assessment,
manage anaesthesia, and treat gunshot and
landmine injuries.
Equipment lists & quality/
safety management
Equally important to training surgical care
professionals is the availability of high qual-
ity, safe resources. The Essential Emergency
Equipment list offers a guideline for the
minimum equipment needs at the first re-
ferral health facility in LMICs.This generic
list outlines both capital outlays as well as
renewable items. A similar list is provided
for anaesthesia materials, including access
to general supplies, medicines, and infra-
structure-based resources such as oxygen.
Both these equipment lists can serve as in-
ventory tools at higher level facilities to im-
prove quality and safety, through a careful
assessment of the quantity and functioning
of available equipment.
Implementing Surgical Care at the National
Level:TheWHO Integrated Management for
Emergency and Essential Surgical CareToolkit
25
Regional and NMA newsTURKEY
Research tool
Health facilities can easily assess their surgi-
cal capacity through two components of the
Integrated Management for Emergency & Es-
sential Surgical Care toolkit – the Situational
AnalysisTool to Assess Emergency and Essential
Surgical Care and the Needs Assessment for
Essential Emergency Room Equipment. Both
tools enable health care providers and hospi-
tal managers to conduct research on poten-
tial gaps in surgical care provision.The Needs
Assessment evaluates human and physical
resources, quality and safety of available re-
sources and also policy measures in place at
the facility. The Situational Analysis Tool
takes a comprehensive approach to identify-
ingpersonnelcapabilities,proceduralbreadth,
and material resources at the health facility.
Policy management
Aide-Memoire: Well-organised surgical,
obstetric, trauma care and anaesthetic ser-
vices are essential within the framework
of a country’s and a district’s health care
infrastructure as they substantially reduce
the death and disability from trauma and
pregnancy-related complications.The over-
all responsibility of establishing and main-
taining effective district surgical services
requires government support and national
policies.
Planning Tool: The WHO Planning Tool for
Emergency and Essential Surgical Services
provides advice for first referral level facili-
ties on how to develop a national plan for
district-level surgical services.
Quality and Safety
Establishing quality and safety of emergen-
cy and essential surgical care is tantamount
to its appropriate delivery. The WHO In-
tegrated Management for Emergency & Es-
sential Surgical Care toolkit provides docu-
ments on safety protocols for anaesthesia
and obstetrics – a step-by-step guide for
components of safe practice.
A Monitoring and Evaluation tool is also
available to measure the progress and the
impact of various trainings in health facili-
ties. It relates to those that address person-
nel, infrastructure, equipment functionality
and availability, continuing education op-
portunities, and Best Practice Protocols for
Clinical Procedures safety.
More information about the IMEESC
toolkit and its resources is available at http://
who.int/surgery.
Bonnie Chien
Stanford University School of Medicine,
Stanford, California, USA
Unwanaobong Nseyo
Duke University School of Medicine,
Durham, North Carolina, USA
Health is considered a basic human right.
Each country in the world is trying to
provide health care “for all” its citizens. In
2006 the European Council outlined the
aims for its member states: universal cover-
age, solidarity in financing, equity of access
and provision of high quality health care.
On the other hand health care is getting
more expensive every year in connection
with developing technology and increas-
ing life span. These huge health spending
costs must be somehow funded. Realisti-
cally, there are only a few recognized ways
to cover the health care costs. They can be
funded by the state from general tax rev-
enues or by a mandatory health insurance
program backed by a payroll tax. Health
care funding can also be based on private
sector health insurance plans as in the
USA, and in many countries there are sys-
tems where these are combined. Personal
out of pocket spending far exceeds private
pooled and government health spending in
low income countries [1].
As beginning with the 1970s the “welfare
state” developed problems with funding,
a new wave of privatization began. It was
claimed that the state provided services, in-
cluding health and education, should be run
by the private sector because the state run
services were inadequate, ineffective, prone
to corruption, and resistant to new technol-
ogies and developments. Moreover, money
spent for health and social security was re-
garded as going into a “big black hole” and
thus creating a great burden for the govern-
ment budgets.
The United Nation’s Millennium Devel-
opment Goals are focused on improving
overall health outcomes, securing financial
protection against impoverishment and
Health Care Reform: Does One Size Fit All
A.Ozdemir Aktan
26
Regional and NMA news TURKEY
ensuring long-term sustainable financing.
In the developing countries steps to be
taken to accomplish these are framed and
funded by the World Bank and the Interna-
tional Monetary Fund (IMF).
The biggest problem in financing is obvi-
ously its long term sustainability. Continu-
ous economic growth is necessary to main-
tain the percentage of health spending at
an acceptable percentage of the gross na-
tional income (GNI). On the other hand,
for fiscal sustainability public revenues
should be gradually increased. The model
implemented by the World Bank to ac-
complish this for East European members
of the European Union (EU) (some of
them being former Soviet States) and Tur-
key (which is not a member of the EU) and
many other countries is to establish a man-
datory health insurance system financed
by payroll tax, as well as encourage private
insurance and increase cost sharing (user
charges). At the same time, privatization of
the government health care system is en-
couraged including the state run medical
facilities [2].
In Turkey, the first step in this process was
taken when the legislation on establishing
a payroll tax financed mandatory health in-
surance fund was passed in 2006.This fund,
run by the Social Security Institution (SSI)
is the only state financer of health. Turkey
spends 6.0% of its GNI for health while the
average for 31 OECD countries is 9.0%.
Per capita health expenditure in Turkey is
USD 767 which is the lowest among the
OECD countries.This breaks down as 69%
for the state and 31% for the private sector.
In comparison,in the USA government and
private expenditures are 45.5% and 54.5%
respectively as reported in 2010 OECD re-
port and the WHO database.
As of June 2010, the unemployment rate in
Turkey was 13.6% and it is estimated that
roughly 50% of the working population is
unregistered and pays no tax.This obviously
is a very big problem to finance the health
care system through the SSI. At present,
the premiums collected can only support
less than half of the total SSI spending
(see Fig) [3]. The rest comes from the state
budget. The current Social Security Law
defines as “poor” anyone with an income
less then 1/3 of the minimum wage which
is around USD 400. With these figures, the
best estimate is that less than 50% of the
population can receive the SSI provided
health care. Private health insurance covers
only one million in a population of 72 mil-
lion. In Turkey, the uninsured and poor are
covered by a “green card” which enables the
holder to access health care through the SSI
and run by the government. However, in
this ill defined and politically manipulated
system, the number of green cards increases
to 11 million just before elections,and drops
to 5 million thereafter.
A new law which is expected to go into
effect soon will open the way to privatiza-
tion of all state hospitals that are now run
by the Ministry of Health. These activities
are being pursued in nearly all developing
countries in a standard fashion. General
Agreements on Tariffs and Trade (GATT)
aimed at increasing and regulating interna-
tional trade prohibit the states to form mo-
nopolies on any service given and encourage
privatization.
Privatization of the health care system
has certain advantages such as effective
and timely implementation of new tech-
nologies and a better quality health care in
addition to decreasing the burden on the
general budget. On the other hand, over-
all health spending and population un-
able to receive health care increase while
premiums required for health care rise. In
Turkey and similar countries spending on
health care has been steeply rising. When
the governments can no longer compen-
sate the health deficit, someone must pay.
This means more out of the pocket spend-
ing and charging more, accompanied by
reduced health care coverage. In private
health care systems, spending must be
lowered to increase profits that lead to re-
duced fees for physicians and other health
professionals.
President Obama’s health care reform in the
USA was aimed at providing health care to
around 50 million who could not afford
health insurance.Through a state owned in-
surance fund financed by taxes, health care
will be provided to those who cannot af-
ford it, which essentially is a great turn back
from a completely private system. Another
aim of the health care reform is to decrease
the prohibitively high health care costs in
the USA. Among other steps taken, the
most prominent is to reduce the physician
fees.The USA is the biggest economy in the
world, while the GDP is about five times
that of Turkey.If a completely private health
system cannot work effectively in a country
like the USA, how can anyone expect it to
be successful in developing countries?
In Turkey overall infant mortality rate has
been constantly decreasing, down from 52.6
in 1993 to 20.7 in 2007 per 1000 live births.
40
47
51 50 48
44 42
46 47
43
0
40
50
60
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Figure. Collected Premiums/Social Security Health Payment (%)
27
Prison Health
However, in 1978, 1.2 infants died in rural
areas for every one infant from urban areas.
This ratio rose to 1.7 in 2007 [4]. The same
trend is observed when the richer western
part of Turkey is compared with the poorer
eastern part, being a clear indicator of the
poor not receiving proper health care. The
big problem is that the rich are getting rich-
er every year and the gap between the rich
and the poor is increasing.
Health care should not be completely priva-
tized, especially in developing countries,
and one single model of health care reform
will not solve health care problems. Primary
health care is essential in these countries
and must be provided by the state. In addi-
tion to the poor, the combination of unreg-
istered labor force and high unemployment
rates form a large group of population that
cannot afford private health care. This fact
alone makes a payroll tax financed system
unrealistic. Health care in these countries
should be provided mainly by the state at
least until these countries join the “devel-
oped” countries.
References
1. Thomson S, Foubister T, Mossialos E. Financing
health care in the European Union: challenges
and policy responses.World Health Organization,
Copenhagen,Denmark.Observatory Studies No:
17. (2009) ISBN 9789289041652
2. Fleisher L, Gottret P, Leive A Schieber GJ,
Tandon A,Waters HR. Assessing good practice
in health care reform. In: Gottret P, Shieber GC,
and Waters HR, eds Good practices in health
care financing; lessons from low and middle
income countries. 2008 World Bank Report.
www.sitesourcesworldbank.org
3. Financial Statistics of Social Security Institu-
tion. (accessed at http://sgk.gov.tr/wpr/portal/
anasayfa/istatistikler)
4. Turkey Health Statistics of the Ministry of
Health. (accessed at http://saglik.gov.tr/TR/
Genel/BelgeGoster.aspx)
A.Ozdemir Aktan MD
Professor of Surgery
President, Turkish Medical Association
Introduction
The act of fasting for a prolonged period
of time as a form of protest goes back more
than a century. It has been used since the
suffragette movements in the UK and the
US in the early 20th
century. Hunger strikes
occurred sporadically in Ireland during the
long protracted struggle between the Irish
Nationalists and the British authorities. In
the first half of the last century, Mahatma
Gandhi, in Britain’s Imperial India, went
on and off hunger strikes many times, both
when in and out of prison. It was Gandhi
who perhaps actually gave hunger strikes
their lettre de noblesse as a means of mak-
ing the protest known to the general pub-
lic. Hunger strikes attracted world-wide
attention in the late 20th
century in Belfast
and Turkey. Ten much politicized deaths in
Northern Ireland and several dozens deaths
in Turkey put hunger strikes back in the
news. In this century, the vast media atten-
tion given to hunger strikes by the inmates
at Guantánamo Bay did not center on the
phenomenon of the protest, but of the very
controversial “solution” applied  – force-
feeding the hunger strikers. There have also
been other, less highly publicized, hunger
strikes in Europe, the Middle East and
elsewhere, which have attracted particular
media attention, and have raised different
controversies.
The 21st
century hunger strikes put the spot-
light onto the high-level,often heated argu-
ments between two antagonistic authorities.
On the one hand, there are the Prison au-
thorities, responsible for keeping prisoners
confined, and also legally responsible for
their welfare.Then there are the judicial au-
thorities, judges and lawyers that apply and
process the rule of law in the wide sense of
the term, including appeals and demarches,
for sentenced and remand prisoners. Both
prison and “judicial” authorities are non-
medical entities. To simplify the text, both
shall hereafter come under the generic
term of “custodial authorities”, unless one
of the two needs to be specified. On the
other hand, there are the “medical authori-
ties”, the physician(s) in charge of caring for
prisoners who go on hunger strike, and by
extension the national medical association,
and further up the World Medical Associa-
Physicians and Hunger Strikes in Prison: Confrontation,
Manipulation, Medicalization and Medical Ethics (part 1)
Hernán Reyes George J. AnnasScott A. Allen
28
Prison Health
tion (WMA). The recent confrontations on
hunger strikes have been between these two
groups of authorities,“custodial”and “medi-
cal”. In some cases, it has almost been as if
the actual hunger striker, as an individual
person, has become an afterthought. The
conflict has been mainly around the “cus-
todial” authorities who have decreed and
imposed force-feeding, and those who are
the only ones who can perform it, the actual
physician(s), who often object, with the im-
plicit support of the WMA.The controversy
has in fact not been so clear cut, as there
have been physicians willing to perform
force-feeding of hunger strikers, taking
sides with the “custodial”authorities, and, as
shall be seen,against their ethical principles.
The controversy around this force-feeding,
which has essentially been a major issue in
just one context – Guantánamo Bay – but
has been the Damocles sword in many oth-
ers, is a major issue, but it is just the tip of
the iceberg. As shall be shown, the force-
feeding controversy is indeed a serious bone
of contention for the medical profession.
However, the true role of the physician has
been corrupted and co-opted. By “medical-
izing” the situation with the contentious
solution of force-feeding, the “custodial”
authorities have shifted the onus onto the
doctors to “solve the issue”, i.e. to make the
protest fasting cease. Physicians have been
ordered to intervene, artificially feeding fully
conscious and mentally competent prisoners
against their will. This is what constitutes the
force-feeding which shall be one of the focal
points of this paper. The real role the doc-
tors should be playing in the vast majority
of cases will also be defined and illustrated.
From and ethical, practical and clinical per-
spective, in many if not most cases, there are
better options than force-feeding available
in the competent management of a hunger
strike. We will describe them in this paper.
The reason the “custodial” authorities have
shifted the responsibility for making the
hunger strike stop is obviously because pro-
longed fasting is undoubtedly not good for
health. The physician’s role, however, is not
just about monitoring calorie intake (or the
lack thereof), controlling blood pressure
and weight-loss – and ultimately inserting
a tube down a hunger striker’s throat to de-
liver nutrients by force. As shall be demon-
strated, the physician can and should play
much more important role, which in most
cases will facilitate to avoid getting close to
the need for any feeding.This role, however,
requires having a relationship of trust, as
there should be in any doctor-patient re-
lationship. Imposing any solution perverts
this relationship, perhaps irretrievably, and
prevents physicians from carrying out their
task of intermediary, towards a compromise,
and a solution acceptable to all. This is the
practical basis for the ethical prohibition of
force-feeding. Forced treatment against the
competent informed consent of the patient
destroys trusting and functioning doctor-
patient relationship. The practical conse-
quence of that destruction is the elimina-
tion of almost all non-coercive solutions to
the hunger strike. Furthermore, the practice
of force-feeding corrupts the already fragile
foundation of trust between all correctional
physicians and their patients, and may have
the effect of undermining the efficacy of the
profession in the prison at large.
Ethical framework: the “WMA
2006 Malta declaration”
The World Medical Association (WMA),
is the “international organization created in
1947 to ensure the independence of physi-
cians, and to work for the highest possible
standards of ethical behaviour and care by
physicians,at all times”1
.At the time of writ-
ing this, it comprised about one hundred
national medical associations, including the
American Medical Association (AMA),one
of its founding members. The WMA issued
specific medical ethical principles relating to
hunger strikes in its Declaration of Malta
of 1991 (“Malta 1991”), updating them in
1 www.wma.net What we do
20062
(“Malta 2006”), together with an ac-
companying Background paper and Glos-
sary3
. The WMA guidelines recognize that
hunger strike situations are complex and
require the physician to make individualized
clinical judgements. Discussions around the
WMA guidelines for dealing ethically with
hunger strikes have led to heated confron-
tations between custodial and judiciary au-
thorities, on the one hand, and physicians
on the other. In some cases local medical
authorities, not familiar with the WMA
guidance, of choosing not to follow it, have
added to the confrontation. Heated argu-
ments, sometimes in the full spotlight of
the media and general public, have even dis-
tracted from the plight of the actual hunger
striker(s). As shall be seen, these confronta-
tions may in some cases have pushed fasting
prisoners into adopting positions more radi-
cal than they initially intended to take. It is
this phenomenon, and how to avoid it, that
this paper ultimately intends to document
and so to provide practical recommenda-
tions for constructive action.
How and why “Malta 2006” evolved from
the original “Malta 1991” relates directly to
the complexitiy of hunger strike manage-
ment, and is discussed in the second section
of this paper.
Definitions: what are hunger
strikes – and what they aren’t
There is a vast literature on hunger strikes,
making it almost futile to ask, “what a hun-
ger strike is.” Nonetheless our experience
around the globe has shown time and again
that many fundamental misunderstandings
and misconceptions about hunger strikes
2 https://www.wma.net/en/30publications/
10policies/h31/index.html
3 WMA Declaration of Malta – A Background Paper
on the Ethical management of Hunger Strikes., In:
World Medical Journal, Vol 52, N° 2, June 2006,
hereafter WMJ. One of the authors of this paper
was co-author of the background paper, together
with the British Medical Association (AS).
29
Prison Health
persist. It is first necessary to recall what
is meant by a “hunger strike”, what is not
meant… what benchmarks need to be de-
fined, and finally how such fasting is in-
tended to “work.”
Hunger strikes fundamentally are a form
of protest against the custodial authority
where the hunger striker is attempting to
draw attention to a grievance by creating an
urgent situation that may bring unwanted
attention or shame upon the authority as a
means of moral leverage.
Perhaps the earliest recorded hunger strike,
in the sense of a political protest against the
custodial authority, was that of the revo-
lutionary Vera Figner in Czarist Russia in
1889. At the beginning of the 20th
century,
in the UK, countless suffragettes suffered
ignoble force-feedings ordered by the Brit-
ish judiciary authorities, widely reported and
vehemently criticized at the time. Eloquent
posters showed how these brave women were
submitted to force-feeding, a tube being in-
serted by a doctor into their stomachs while
they were held down,struggling.It was how-
ever Mahatma Gandhi, protesting against
the government of his Majesty “Emperor of
India” who gave hunger strikes their titre de
noblesse, in the first half of the 20th
century.
There have been many hunger strikes in
the past thirty or so years. However, not
all prisoners “who-refuse-to-eat” should
be considered hunger strikers. The generic
term “hunger strike” is used to cover a va-
riety of very different situations in which a
prisoner refuses to take nourishment as a
form of protest. Two main types of fasting
protesting prisoners can be distinguished,
differing essentially by their modus operandi,
the “food refusers”on the one hand, and the
(true) “hunger strikers” on the other. The
vast majority of what prison directors, law-
yers,judges,the media and even most physi-
cians call “hunger strikers”, are in fact food
refusers. The difference, as shall be seen, is
a major one, as in the case of the “refusers”,
those prisoners do not have the slightest in-
tention of hurting themselves by fasting “to
the brink” so to say. Therefore, there will be
no question of forcing them to take food,
force-feeding them, and hence little or no
ethical dilemma involved at all.
Food refusers are what a senior medical col-
league working in the prisons of Northern
Ireland used to call “the blokes who give hun-
ger strikes a bad name!”… These are prisoners
who for any motive, great or small, justified
or not, important or petty, declare themselves
to be on “hunger strike”; make a big fuss
over it; ensure that the prison director, the
prison staff, the doctor, if possible their fam-
ilies, and above all the media, know they are
“on strike”. The key concerns here are that
this type of the so-called “hunger strike” is
always short-lived. Food refusal as defined is
quite common amongst common-law pris-
oners, generating a “lot of noise”, but most
often not much else.Such prisoners trumpet
whatever their complaints are, but in fact
they have not the slightest intention of hurt-
ing themselves by their fasting.Medical staff
who are used to this category of prisoners
call them the “professional hunger strikers” –
“who go on strike at the drop of a hat”…
Others less kindly call their action “nuisance
fasting”, as it generates extra work for the
medical staff,but essentially for no purpose.1
Who, then, is a “true” hunger striker? Are
there different “categories” of hunger strik-
ers? Are there “real” hunger strikers and
“phoney” hunger strikers, as some authori-
ties have asked2
. Before the Turkish protests
at the end of last century, hunger strikers
were often classified as “serious”, when like
Bobby Sands, they were effectively ingest-
ing only water, and thus posed a risk to
1 Owing to the fact that most of these actions
are short and self limited, optimal management
often involves little to no response by either
custodial or medical authorities for the first 72
hours assuming the patient is healthy at baseline.
The clinical rationale for this approach will be
explained later in this paper.
2 The author’s own personal experience of twenty-
eight years working as a doctor with the ICRC…
their lives by their action.Any other form of
fasting was deemed “not-so-serious”. These
other forms were by far the most common
among prisoners who were fasting, but who
also took nourishment “on the side” and
were thus deemed to be “cheating” on their
strike. This vast majority had their strikes
catalogued as “not-so-serious”. One of the
authors of this paper fell into that trap at
the time. While the Irish hunger strikers
fasted totally and died after eight to ten
weeks from acute malnutrition, the Turk-
ish hunger strikers obviously did take some
nourishment on the side, as they survived
much longer than the Irishmen. The Turks
did this to make their protest last as long as
possible, to extend the moral pressure put
on the authorities, and on public opinion.
A  great many of them died anyway, from
prolonged and not acute malnutrition, af-
ter up to several months. Thus, simplistic
distinctions cannot be made when dealing
with this complex issue.
A “hunger striker”, as we use the term here,
is thus a prisoner who uses fasting as a way
of protesting, and is willing to place his
health – and perhaps his life – “on the line”,
so as to be heard by an authority that does
not allow any other meaningful way for him
to make his grievances known. The mascu-
line form is used here to ease the reading
of this text, as the great majority of hunger
strikers in the world are indeed males, with
all due apologies and respect to the suf-
fragettes, and even more so to the Irish and
Turkish women hunger strikers who died.
The determination of a hunger striker to
carry through with his actions is subject to
many factors and pressure from many sides.
It is therefore unfair to judge the “serious-
ness”of a hunger strike on any one criterion
alone. Each context, and each individual,
must be judged on its, or his, own merits.
It is paramount to realize that the hunger
striker, in the vast majority of cases, does
not fast with the intention of dying! Thus,
to compare hunger strikes to “suicidal
behaviour” is a major error, made by many,
30
including judges and senior physicians who
should know it better. Going on a hunger
strike is not an attempt to commit suicide.
A hunger striker wants to make his case
known, to protest, and to change his situa-
tion or perhaps change the world. He wants
to live better in that world, not to die in
it. Bobby Sands was as determined as any
hunger striker could be, yet if he had ob-
tained from Margaret Thatcher a concession
to his demands the day before he died, he
would have taken nourishment.The Green-
peace activists who used to sail their boats
into the atoll where French nuclear tests
were being carried out in the Pacific Ocean,
in the early and mid-1990s, were not seek-
ing to get themselves blown up. They were
most certainly not suicidal.They were, how-
ever,willing to risk their lives as a last resort,
in order to publicize their protest against
nuclear weaponry. Indeed, soldiers often
enter the battle with full knowledge that
their mission carries with it the high risk of
death. But they are not suicidal. Death is a
risk of the form of protest called “hunger
strike.” It is not the goal, and therefore, a
death by hunger strike is not suicide.
As will be developed further on, this
comparing determined hunger strikes to
“suicide” is a common misunderstanding
through lack of knowledge in many cases,
but also through “bad faith”. In the case
of the hunger strikes at Guantánamo Bay,
Department of Defence (DoD) directive
2310.08e specifically classifies any hunger
strike as an “attempted suicide” or an at-
tempt to “self-harm.” This is an improper
and inaccurate classification that has per-
sisted in the face of efforts by a number of
outside health professionals to correct the
Department’s policy.
In most cases when the term “hunger strik-
er”is used, there is a political connotation to
the protest fasting.The common denomina-
tor between Emily Pankhurst, suffragette;
Bobby Sands, IRA leader and member of
Parliament; Holger Meins, member of the
German “Baader-Meinhof ” group in Ger-
many in the 1970s; and the already men-
tioned Turkish hunger strikers, is that all of
them evoked political motives for ceasing to
take nourishment, and steadfastly “stuck to
their guns”.Less well-known prisoners have
to consider the probability of their protest
being heard, and how far they really want to
go to get attention.
To conclude, a prisoner who goes on a hun-
ger striker, determined to pursue the fasting
for a certain length of time, does so because
s/he feels, rightly or wrongly, that such an
action is a “last resort” to be heard. The de-
mands will vary considerably according to
the time and context, but the protest fast-
ing most often seen as the “only way” to be
taken seriously. As shall be seen, it is up to
the physician to determine “how seriously a
hunger striker wants to be taken seriously”…
Clinical Framework:
Diet and Time
The benchmarks that need to be clearly de-
fined concern diet and time frame. It may
seem a bit ludicrous to define any “diet”,
since it would seem that hunger strikes
imply a lack of any intake of nutrition.
However, as shall be seen, a majority of the
so-called “hunger strikes”involve less-than-
total fasting. Therefore some definitions are
called for. The time frame will define when
a hunger strike should attract attention, and
how long a span of time one can actually
last.
Diet
There are different kinds of fasting and dif-
ferent concepts of “eating”, but for our pur-
poses only three are important.1
• The dry hunger striker takes no food or
water of any kind. This is often put for-
1 See WMA Internet Course for Prison Doctors.
Hunger Strike, Chapter 5; accessible at http://
www.wma.net/en/70education/10onlinecourses/
20prison/index.html
ward, by the hunger striker wanting at-
tention, or by the authority to justify
intervention, as a “very dangerous” form
of hunger strike, as a body cannot survive
very long without any water.No “dry hun-
ger striker” will survive more than a few
days at most, depending on climate and
temperature. Hunger strikes need time
if they want to exert any effect, thus this
kind of strike is by definition counterpro-
ductive. It may be either a “gimmick” to
attract publicity, or the manifestation of
a possible psychological problem.There is
no known record of a hunger striker dy-
ing on a “dry” strike.
• Total fasting means no solid food, and
only ingestion of water. This differs from
the US definition, which uses the term
“total fasting” for what has been defined
above as “dry hunger strike”.This is unfor-
tunate because the concept of “Voluntary
Total Fasting” is in fact what a hunger
strike is all about. Two litres of drinking
water a day is the suggested quantity,with
or without salt, preferably mineral water…
In a “rigorous”,i.e.strict hunger strike,à la
Bobby Sands,there would be no other ad-
dition to the water, no sugar, no vitamins
and certainly no nutritive concoction.
Non-total fasting simply means a “less
rigorous”hunger strike,and includes prac-
tically any other type of fasting, e.g. with
vitamin and mineral intake; sometimes
liquid nutrients taken in addition to plain
water; or other supplements. The term is
not strictly defined, as it also includes a
supposedly strict, “total”, hunger strike –
with unofficial (“on the sly”…) intake of
food.The physician must know what type
of a hunger strike the prisoner is on as
this will change the approach he may
have in dialogues with the prisoner(s).
The determination and hence “seriousness”
of a hunger strike depends on its duration
and not alone on its being total or not.
A non-total hunger strike may be just as de-
termined as a total one – and lead to deaths
as well,only at a much later stage,as was the
case in Turkey in the nineties.
Prison Health
31
The fact that a non-total hunger strike allows
more time for negotiations is a positive – not
an inconsistent – position. Physicians need
to keep this in mind, as prison authorities
tend to malign non-total fasting as “cheat-
ing”. Some even may deny a declared hun-
ger striker any access to food as if they were
“calling his bluff”.Although this may “break”
some hunger strikes, it may radicalize others
and may uselessly lead to loss of life.Denying
access to nutrition is of course unacceptable
as a medical intervention.
These distinctions are emphasized here as a
question of credibility for medical staff, as
terms of reference. Anyone, claiming that
hunger strikers have been on total fasting
for six or nine months, de facto proves that
the fasting was not total.This in itself is not
a problem, and the physician should abstain
from the arguments some prison authori-
ties, or the media, would like to get him
into – whether the fasting is “genuine” or
not…A physician needs to clearly state that
any form of fasting can indeed be prejudi-
cial for health, and that the doctor’s role is
to see what the best solution is in each case.
He should not fall into the trap of “confirm-
ing”a hunger striker is indeed “eating on the
sly”as this will destroy his credibility for ne-
gotiating both with the hunger strikers and
those around him. Any partial fasting for a
lengthy period of time will provide much
more time to perhaps finding a face-saving
solution for all involved – and thus be in-
strumental in avoiding fatal outcomes.
Timeframe
“When does a hunger strike begin”? Skip-
ping several meals may well be a form of
food refusal – and therefore a form of pro-
test – but such short-lived, often episodic,
fasting certainly does not qualify for the
term hunger strike. There are no set criteria
for the minimum duration for protest fast-
ing, so reference can be made to physiol-
ogy. A healthy, normally nourished adult,
without any medical contra-indication to
prolonged fasting, should have no problem
whatsoever fasting totally (i.e. taking only
water) for around 72 hours.This is when the
onset of ketosis, the presence of metabolites
known as “ketone bodies”, usually occurs,
for physiological reasons1
.
Ketosis is discernible clinically on the
breath by what has been described a “pear-
like smell”. Ketosis subdues the voracious
sensation of hunger,“hunger pangs”,experi-
enced during the first 2–3 days of total fast-
ing. It could thus be argued that, as a simple
“rule of thumb”, total fasting (i.e. taking
water only) for longer than 72 hours quali-
fies on metabolic grounds for the term hun-
ger strike. The appearance of ketone bodies
in the breath will depend on many factors,
including body mass and fat, but this rule of
thumb has been found to work in the ma-
jority of cases. Strictly fasting for 72 hours
does absolutely no harm to anyone in good
health, but does need some determination,
and thus allows separating so to say “the
wheat from the chaff ”.
The purpose of this “test”is to eliminate any
confusion with short-lived fasting, which
should not even qualify as “food refusal” –
most cases petering out by themselves be-
fore 72 hours. It will not be relevant – and
may even be counter-productive – to insist
on distinguishing between somewhat more
determined food refusers (but food refusers
nonetheless) and hunger strikers immedi-
ately after the 72 hours. Such food refusers
will not want to lose face by appearing to
be less determined than real hunger strikers.
At the other end of the spectrum, there can
be another rule of thumb. The fatal out-
comes of terminal total fasting were medi-
cally documented during the 1981 hunger
strikes in Northern Ireland. Death occurred
during these total hunger strikes anytime
between 55 and 75 days. During the 1981
Irish hunger strikes one of the “Ten Men”
died at 46 days, according to one account
1 WMJ; op. cit. p.32
because he could no longer ingest water2
only one exception at 46. Similar experienc-
es have confirmed this time bracket – the
three-week span being due to differences in
initial physical constitution, and individual
adaptation. It is not possible to precisely
predict when, within this time span, death
may or is “most likely” to occur.
Death caused by ingesting only water does
not occur before six weeks, and usually later
if the person was in good health at the start
of the fasting, and after a specific phase of
the total hunger strike, called the “ocular
motility” phase3
.The clinical manifestations
during this phase last about a week, roughly
between 35 and 42 days according to the
very few contexts where it has been medi-
cally observed, and are troubles of ocular
motility due to progressive paralysis of the
oculo-motor muscles:
• uncontrollable nystagmus
• diplopia
• extremely unpleasant sensations of ver-
tigo
• uncontrollable vomiting
• extremely difficult to swallow water
• converging strabismus
The onset of this phase has been described
as the most unpleasant stage by those who
have survived prolonged fasting, and is the
one most dreaded by prisoners who envis-
age beginning a hunger strike.
What is essential for the clinician to know
here is that the beginning of the final stages
of fasting occur after the “ocular” phase”,
hence roughly from six–seven weeks on-
wards. It is during the weeks following the
ocular phase that the hunger striker may
progressively become no longer capable of
clear discernment. Survival any time after
ten weeks of total fasting is practically im-
possible.
2 Walker R.K. (2006) The Hunger Strikes. Belfast:
Lagan Books; p. 126
3 See WMA Internet Course for Prison Doctors,
Chapter 5, www.wma.net
Prison Health
32
In short,the “72–72”rule holds: seventy two
hours should be the minimum for any fast-
ing to be taken seriously; and 72 days are
the maximum a hunger striker taking only
water can hope to last. This knowledge is
indispensable for the physician so he can
realistically modulate his interventions as
needed. Total fasting is the form of hunger
strike that can pose a vital threat as early as
six weeks into the hunger strike; and death
occurs between the 8th
and 10th
week.
Physicians should not be overly obsessed
by these benchmarks. On the one hand,
they should be alert to the global clinical
situation, as it has been mentioned. On the
other hand, and they should remember that
the vast majority of hunger strikers do not
come anywhere close to the “ocular phase”.
The main point is that there is time before
things theoretically can become alarming,
and the physician will need to use this time
constructively for the benefit of all.
Understanding how
hunger strikes “work”
Hunger strikes in prisons can become effec-
tive forms of protest only in countries where
there is some respect for basic human rights
values1
or at the very least a desire to appear
to have such respect. If such values do not
exist, or are flouted, hunger strikes will ei-
ther be repressed, or all and any knowledge
about them be stifled.If a hunger strike is to
have any effect, by “shaming”the authorities
into action, it is necessary for it to become
public knowledge. If it does not, “protest
fasting” is unlikely to have any impact at all
and custodial authorities may well choose to
ignore it – rendering any such fasting moot.
1 Reyes, H. Medical and Ethical Aspects of Hunger
Strikes in Custody and the Issue of Torture (1998)
In: Maltreatment and Torture, Oehmichen M.
(ed.) Lübeck: Schmidt-Römhild; J. P. Restellini
(1989) Les gr→ves de la faim en milieu pénitentaire
.Staempfli (ed) In:Revue Pénale Suisse (Bern),
Geneva, Vol. 106
Confrontations between the custodial/ju-
dicial authorities and the medical staff thus
imply a hunger strike that is in the public
eye. Such a clash does not always occur.The
hunger strikes in Northern Ireland in the
1980s and in Turkey in the 1990s created
vociferous confrontations – but not with the
physicians. Force-feeding was not an issue
either in Northern Ireland, as the authori-
ties and physicians decided to acknowledge
patient Autonomy. If a prisoner refused to
take food,it was his or her right,and as long
as that person was capable of discernment
in taking the decision, it was to be respect-
ed. In Turkey, the situation was very much
more complex, but force-feeding was not an
option either. Hunger strikes in other con-
texts have been a mixture of different mod-
els, the vast majority of them “benign”, with
short-lived confrontations.
A hunger strike is a way to protest against
the detaining authority. A prisoner may
feel, rightly or sometimes wrongly, that
all means of making his or her grievances
known have been thwarted. By refusing to
eat, such a prisoner tries to retain, or regain,
some “control” over what is left to him or
her – the body and its nourishment. A hun-
ger striker thus uses control over bodily in-
tegrity as a “last resort” for protesting. Any
custodial authority, with the support and all
the weight of the judicial (or in the case of
Guantánamo Bay, “military”) authority, will
attempt to control all aspects of prisoners’
lives. In a (real) hunger strike, the authori-
ties consider this protest fasting tantamount
to a “hostage situation”, where hostage taker
and hostage is one and the same person.
They consider it as a form of “blackmail”.
This is what they find intolerable and can-
not accept. It has to be stated here clearly
that a competent prisoner, that is to say, ca-
pable of discernment, and not submitted to
any pressure or coercion, direct or indirect,
has the right to autonomy. This includes
accepting or refusing any treatment, once
informed of the pros and cons. This also
includes fasting as a way of protest, as this
can be considered as a last resort the pris-
oner has to make a message known or to
make a demand. As has been mentioned,
the maximum authority on medical ethics
has decided that patient autonomy trumps
beneficence in such a case, and that a phy-
sician should respect not to force a hunger
striker to eat. Some voices have tried to cir-
cumvent the right to autonomy by stating
that prisoners are never in a position to take
any decisions freely.This is not tolerable. As
is generally accepted2
, “prisoners are sent to
prison as punishment, not for punishment”,
and this includes prisoners still having the
right to make decisions about their welfare.
As prolonged fasting can arguably become a
medical problem, the “custodial” authorities
often medicalize the issue by order force-
feeding. Their argument is that the reason
physicians should intervene is to “save lives”.
They thus “throw the hot potato”, so to say,
into the medical camp, and ordering the
physician to solve their problem and thus
quell the protest. The counter argument to
this is relatively simple, as the weight of the
ethics is in favour of the physicians. The
physician’s role is not to “resolve the prob-
lem” with an unethical invasive procedure
against the patients informed refusal. The
power to “resolve the problem” lies with the
authorities; only they have the power to en-
gage in negotiations regarding the grievanc-
es of the hunger striker. The physician’s role
is to counsel the patient about the health ef-
fects of the various options and even make
recommendations for what would be best
for the health of the patient.In addition,the
physician must communicate the general
health status of the patient to the authori-
ties as needed. While not the mediator for
the grievances per se, the physician, as a pro-
fessional, has the ability to calm the situa-
tion by injection of reason and rationality as
an intermediary regarding the health status
of the patient as well as the various permis-
sible clinical options. However, there needs
2 Reyes H. (1996) Doctors at Risk. In: Healthy
prisons: A vision for the future. Report at the 1st
International Conference on Healthy Prisons.
Liverpool
Prison Health
33
to be a full and careful assessment in every
case, as shall be seen.
Second, and more important still, the vast
majority of hunger strikers,as has been stated,
do not want to “die”. Hence, there should be
no need to use force to feed them.During the
first weeks of the hunger strike there is time.
The physician needs to obtain their trust, by
talking to them and having them accept the
physician in an additional role of confident,
mediator, neutral intermediary or something
similar as the case may be. The physician
should never appear as the one who is there to
implement the will of the custodial authority.
Some, very few hunger strikers, may have
sufficient motivation to pursue their fasting,
and will not allow the physician to intervene.
They constitute a very small minority. The
physician responsible for the patient, and not
an “outsider” who only arrives once a critical
stage has been reached, should then act ac-
cording to the guidance provided by “Malta
2006”.This shall be discussed in detail further
on with reference to examples from the field.
The majority of controversial cases are pre-
cisely in between these extremes – and the
controversy is most often due to custodial
authorities clashing with the physicians.
Role of the Physician spelled out
The physician has a role to play when a pris-
oner decides to fast for longer than 72 hours.
Whether the prisoner is a “food refuser” as
defined above, or a real hunger striker, the
physician has to determine whether any ini-
tial medical factors need assessment or in-
tervention. An insulin-dependent diabetic,
or a prisoner with a history of gastric ulcer
should not be fasting, whether seriously or
“food refusing.”If the physician has the trust
of the prisoner, in most cases the prisoner
will understand, and relent from fasting.
The physician has a more crucial role to play
when caring for a prisoner who decides to go
on a serious hunger strike. In this case, the
physician has certain ethical principles to
respect, as set down in the guidelines estab-
lished by the World Medical Association1
.
Even more important however – the physi-
cian has a different role to play, if s/he has
the trust of the hunger striker, as stated pre-
viously. The physician is in an ideal position,
and has the time,to try to find a compromise
solution, calm everyone down and ultimately
defuse the conflictual situation. In the very
few hunger strikes involving die-hard or
desperate hunger strikers  – respecting the
ethics of the situation will be paramount. In
the majority of cases,the situation gets out of
hand by the blundering and often bad faith of
custodial or judicial authorities – and some-
times of those physicians who do not follow
the ethical guidance. An ethical physician is
able to act constructively – but only if she or
he knows how to avoid the many pitfalls in-
volved, and defends the ethical high ground
against the non-medical authorities who
may try to force unethical conduct. Finally,
the physician needs also to know that prison-
ers, the hunger strikers, can also attempt to
manipulate him.Here the physician needs to
stand firm, and defend “physician autonomy”
as well as “patient autonomy”2
.
Thus, the physician’s role is twofold. First,
there is the clinical and “technical” evalua-
tion of the situation, initially after 72 hours,
and on an on-going basis. Second, there is
the ethical framework within the doctor-
patient relationship, the essential element
here being that of trust between the hunger
striker and the physician. It is this second
aspect that has been skewed in recent well-
publicized hunger strikes, for reasons that
shall be illustrated with examples.
The doctor-patient relationship
Any hunger strike fasting should be a vol-
untary action undertaken by a prisoner as
1 Malta, op. cit.
2 Allen S. dixit.
an individual without coercion from any-
one. This is not always easy to determine in
a prison setting. Pressures on hunger strik-
ers come from many directions3
. The prison
authorities; the prison officers; family mem-
bers; often the media; other prisoners; and
even sometimes medical staff, all have some
sort of influence, and can exert pressure
on the hunger striker(s). The physician re-
sponsible for caring for the fasting prisoner
should appreciate this fact, and be prepared
to deal each entity as the case requires. The
voluntary nature of the hunger strike is thus
an imperative factor to determine.Whatever
decision a hunger striker makes has to be his
or her own.The prisoner’s bodily integrity is
involved, and the physician has to be certain
that no outside coercion is exerted on the
prisoner. It is not uncommon for prisoners
to be “volunteered” to go on a hunger strike,
by their peers or by an unofficial prisoner
hierarchy. In extreme cases, such hierarchy
may even “force” a prisoner to keep fasting
way beyond whatever moment he or she
would have stopped. The physician has a
duty to detect such a case, so as to help him
or her break loose from such coercion.
Thus during on-going discussions between
doctor and patient, it will be necessary to
find out how serious the prisoner is about
not taking any nourishment for how long a
period of time.The physician and the medi-
cal team need this information to act effi-
ciently in the best interests of all4
.
Physicians should not let their overall view
of the situation be obscured by the obsession
of the hunger striker dying in the early stag-
es of a hunger strike. Even considering the
shortest time frame,there is at least a month,
thirty full days, before the afore-mentioned
“ocular”phase which flags the passage to the
3 WMA Internet course for prison doctors; op. cit.;
Chapter 5.
4 Gravier B., Wolff H. et al. Une gr→ve de la faim
est un acte de protestation – Quelle est la place des
soignants?, In: Bulletin des Médecins Suisses
2010 N° 39 , pp 1521-25.
Prison Health
34
more dangerous second stage of a prolonged
total hunger strike. During these 30 or more
days there is plenty of time for the physi-
cian to play a constructive role.All too often,
and because of the hubbub around “V.I.P.”
(very important prisoner) hunger strikes, it
is the authorities who become nervous and
make decisions or issue feeding orders that
are unwarranted and premature. The physi-
cian thus has a duty to inform the custodial,
and if need be the judicial, that there is no
medical emergency looming.
The doctor-patient relationship in any con-
text implies that the patient, in this case the
prisoner hunger striker, trusts the physi-
cian. This is not a moot point. Relations be-
tween prisoners and medical staff are always
fraught with uncertainties, and a degree of
mistrust. If the physician is seen as part of
the coercive system any prison of necessity is,
then any relationship of trust will be in jeop-
ardy. In prisons, inmates cannot choose their
physician; nor can the doctors choose their
patients. Conscientious prison doctors know
this and do their best to demonstrate they are
there to care for prisoners,and not to enforce
discipline. In many countries, unfortunately,
this principle has yet to be accepted, and is
seen still as foreign to local culture.
It should further be anticipated here that
any bond of empathy between the doctor as
healer and his patient is obviously skewed,
if not eliminated altogether, if physicians
have participated in abusing prisoners or
in military cases (e.g. Guantánamo) par-
ticipated in interrogations. Whether the
methods used for interrogation “qualify” as
ill-treatment or torture is beyond the scope
of this paper – what matters is their being
perceived as such by the prisoners. In such
cases, developing a relationship of trust may
just not be realistic. In such cases, prisoner
access to outside physicians may be the only
solution.This type of case will be considered
in the final recommendations.
The main point to make here, in discussing
the doctor-patient relationship is upstream
from such intervention. It is to draw the
prison doctors’ attention to the fact that
they are the ones who can make a differ-
ence, and can in most cases avoid getting
into the force-feeding controversy. The vast
majority of prisoners neither want to die
nor “hurt themselves”, as it has been stated.
The custodial authorities resent the protest,
and want it ended. Furthermore, they do no
want any prisoner to die “on their watch”
because they are on hunger strike.The phy-
sician obviously wants also to avoid any fatal
outcome of the hunger strike. One wonders,
then, how it is that heated confrontations
do ensue, though everyone agrees to the es-
sential fact that deaths must be avoided.
The answer is a complex one, and has many
facets that are not acknowledged by one or
the other of the participants.The custodial au-
thorities cannot accept that a prisoner holds
him/herself  – and therefore the whole sys-
tem – hostage,by threatening to fast to death.
In addition,judges and prison governors most
usually have no knowledge about the medical
evolution of total fasting, and fear “losing” a
prisoner on their watch. Finally, the custodial
authorities have no ethical obligation to re-
spect the principle of patient autonomy,not to
mention physician autonomy and usually do
not understand this medical position.
Physicians, hold the key to solving the im-
passe in most cases. Before entering into
considerations about exceptional cases of
“diehard” hunger strikers, one should con-
sider the much more frequent case that has
been mentioned. A physician, if s/he can
have a meaningful discussion in private
with the fasting prisoner, should be able to
determine what exactly the hunger striker
is prepared – and is not prepared – to do.
Once it becomes clear that the prisoner
does not intend to go “all the way”, the issue
becomes that of serving as useful interme-
diary between the hunger striker(s) and the
custodial authorities.
This is not necessarily an easy matter.
A physician may be able to convince a hun-
ger striker to accept an intravenous drip, for
example, with or without nutrients, but at
least with minerals and vitamins. Or even a
naso-gastric tube in some cases. The point
is, if the hunger striker has declared (not
necessarily publicly) that s/he does not want
to die, the whole issue of “force-anything”
becomes moot. An agreement, even only
tacit and unspoken, between the hunger
striker and the doctor takes the latter off the
hook, and allows for any and all measures to
be taken. The physician then has the “dip-
lomatic” task of weighing the sensitivities
of both sides, and trying to avoid any side
losing face as much as possible. This may
entail, for example, inserting an intravenous
line, while “allowing” the hunger striker to
declare vociferously that the “hunger strike
continues…” The physician may have to
calm down a cantankerous prison governor,
assuring him that all is for the better, and
that the measures taken will eventually de-
flate the conflict and end the fasting.
The key element here is time. Hunger
strikes only “work” if there is enough time
for negotiation and for communication.
(This is the main reason why a “dry” hunger
strike is an aberration, leaving no time at all
for any appeasement to be found.)
What the physician then has to do is main-
tain this relationship of trust – both with
the hunger striker and with the nervous
custodial authorities who are itching to “do
something” to make the protest stop.
Hunger strikes à la Bobby Sands, i.e. going
all the way with strict total fasting are an
extremely rare occurrence. The reason the
whole argumentation about hunger striking
and force-feeding has inflated to what it has
is mainly because of the custodial authorities
increasing tendency to enforce force-feeding,
leaving the physicians no leeway at all to act
as intermediaries.In the case of military phy-
sicians, they may be less than knowledgeable
about the ethical guidelines that were being
flouted, or they agree on principle to fol-
low superior orders whatever they entailed.
Prison Health
35
If indeed a hunger striker is adamant about
not giving in at any cost, then the physician
must theoretically weigh the principle of
patient autonomy (informed consent and
the right to refuse treatment) against that of
beneficence before deciding what to do. In
fact, this discussion has already taken place
within the World Medical Association, and
the guidance given for doctors in “Malta
2006” is quite clear.
When such a conflict exists, it is the autono-
my of the informed, competent patient that
is the governing principle. Beneficence, in
the words of the WMA, “includes respect-
ing individuals’ wishes as well as promoting
their welfare…” Avoiding harm “means not
only minimising damage to health but also
not forcing treatment upon competent peo-
ple nor coercing them to stop fasting. Be-
neficence does not involve prolonging life at
all costs, irrespective of other values.”1
Thus,
a competent individual who is informed
and able to understand the implications of
his/her choice cannot be treated against h/h
will. They can refuse contemporaneously or
in advance of losing mental capacity2
.
Examples shall be given in the second part
of this paper that fully illustrate the correct
ethical conduct of a hunger strike, in the
event that it does go to its final resolution.
What is perhaps infinitely more important
is that the physician most often has the
power to avoid the conflictual situation get-
ting anywhere near death by starving. This
will be developed in the “Way Forward”
section below.
The clinical role of the physician
when caring for hunger strikers
The medical evaluation of the prisoner on
hunger strike requires an accurate assess-
ment of both his/her physical and mental
1 Malta, op. cit., Article 19
2 Medical EthicsToday,2nd
ed.(2004) British Medical
Association, London; pp. 602-607, 623-625
health, and first of all a precise and candid
history. Any ailments or diseases should be
diagnosed and if necessary documented.
The prisoner should be given accurate clini-
cal information about the foreseeable ef-
fects of fasting in his or her particular case.
The fasting prisoner needs to be aware that
heretofore-unknown underlying health
problems may come to the foreground be-
cause of the total fasting,and should indicate
whether they accept treatment or pain relief
for these. Some diseases, such as gastritis,
any kind of ulcer,duodenal or gastric,diabe-
tes,other metabolic diseases,to mention but
the most obvious ones, should be contra-in-
dications to going on hunger strike. As pre-
viously stated, if the physician can explain
this to the prisoner convincingly and so s/
he does not get the (false) impression that it
is all merely a ploy to get the hunger strike
to stop, in most cases the hunger strike will
quickly desist.
This first evaluation should also determine
the mental state and competency. If refusal
of food is a manifestation of some mental
disorder, such as severe depression, psycho-
sis, or anorexia, then the situation is not that
of a hunger strike.The authors of this paper
have argued that most mental disorders dis-
qualify a prisoner from the “status”of hunger
striker, and make him a full-fledged patient
requiring medical attention. A prisoner, re-
fusing to eat because of a mental affliction,
may be reasonably declared incompetent to
refuse treatment. A psychiatrist may even
prescribe medically prescribed feeding, if
and when such feeding is necessary to sus-
tain such a patient’s life. To the extent that
individual competency assessment has been
properly conducted, this may be medically
indicated. The physician should direct care
at treating the underlying mental disor-
der or illness. For this reason, when in any
doubt, a full psychiatric assessment of the
fasting person is an essential feature of the
evaluation.
An examination of the hunger striker’s
psychiatric and medical history may reveal
factors affecting decision-making abilities
and cognitive processes3
. It has already been
mentioned above that a hunger striker, al-
most by definition, does not want to die, s/
he is not trying to commit suicide by fast-
ing to death.There is often confusion in the
minds of prison authorities and judges, who
are steadfastly determined against any pris-
oner “killing himself ”or “escaping justice by
committing suicide”.
The psychiatrists M. Wei and J.W. Bren-
del have stated, “Most commonly, hunger
strikers do not have mental disorders…”. The
distinction is paramount between behav-
iours intended to kill oneself and behav-
iors undertaken to protest as a last resort.
A politically motivated hunger striker may
pursue a total fast with a very positive goal
in mind, for himself, or his community –
so as to “live better”, even risking death if
his plea not be heard4
. The Turkish prison-
ers who went on repeated and prolonged
hunger strikes in the late nineties did not
want to die – even if though they were vo-
ciferous in declaring they were on “death
fasts”. The suicide excuse does not apply
to prisoners at Guantánamo, even though
some could arguably have multiple reasons
to feel desperate and hopeless. As Major
General Jay W. Hood, the camp’s com-
mander, told a group of visiting physicians
in the fall of 2005, “the prisoners at Guan-
tánamo are protesting their confinement;
they are not suicidal”5
.
The already mentioned more difficult role
for the physician is the all-important task
of acting as medical intermediary if consis-
tent with the patient’s wishes.This does not
mean negotiating the terms of the hunger
3 Wei M., Brendel J.W..Psychiatry and Hunger
Strikes. In: Harvard Human Rights Journal, Vol.
23, 2010.
4 WMJ Case example 1; op. cit.; Wei M. Brendel
J.W., op. cit., Footnote 16
5 Okie, S Glimpses of Guantánamo – Medical Ethics
and the War on Terror. In: N Engl J Med 2005;
353:2529-34.
Prison Health
36
In Memoriam
strike, nor interceding on behalf of either
party.It may imply determining what possi-
ble alternatives to harm-causing, prolonged
total fasting can be acceptable. In this way
the physician acts in the hunger striker’s
best interests, while respecting freely taken
decisions.This will,again,require a relation-
ship of trust.
The custodial authority sometimes sees the
physician as being the “final umpire – the
one charged with informing the hunger
striker that fasting “to the end” can result
in irreversible harm and death. This limited
role of the doctor misses the main point.
Too much is focused on what should be
done late in the fasting, and not enough on
what should be done during the less pres-
sured time earlier on in the fasting – where
better solutions exist. In fact, in the col-
lective experience, the best opportunities
to de-escalate and resolve a hunger strike
occur long before there is any real risk of
serious harm or death. The more technical
and monitoring roles for medical staff in
the supervision of hunger strikes, concern-
ing laboratory exams, weight monitoring,
electrolyte intake are fairly straight-forward
have been largely documented elsewhere1
and shall not be repeated here.
To be continued…
1 Assistance in Hunger Strikes: a Manual for
Physicians and Other Health Personnel Dealing
with Hunger Strikers. (1995 ) Johannes Wier
Foundation for Health and Human Rights;
Amersfoort, Netherlands, ISBN 90-733550-
122
Dr. Hernán Reyes,
MD, Medical coordinator for the
International Committee of the Red Cross,
specializing in medical and ethical aspects
of Human Rights, Prison Health, and in
the field of MDR TB in prisons. Observer
for the ICRC on issues of medical ethics.
Prof. George J. Annas,
Chair of the Department of Health
Law, Bioethics & Human Rights of
Boston University School of Public
Health; Prof. Boston University School
of Medicine, and School of Law.
Scott A. Allen, MD, FACP, School of
Medicine,University of California, Riverside
E-mail: manzikert@gmail.com
Ian Field, a past Secretary General of the World Medical Association
died on 23 December 2012 after a long illness.
Ian was born in Rawalpindi, then in British India (now in Paki-
stan) in 1933. His father was a Regular Army Officer, not medi-
cally qualified, serving there during the dying days of the British
Raj. Ian childhood and early education were in India. During the
second World War he remained in India, while his father was
reported killed in action but was in fact captured by the Japanese
and held in Changi for 3 years. During this time Ian was admit-
ted to a military school in Poona alongside the younger sons of
maharajas. He had been given the aristocratic Hindu caste of a
warrior to fit with the princely hierarchy.
When his father was eventually freed the family returned to the
UK and settled in Bournemouth where Ian completed his school
education.After school he undertook national service in the Roy-
al Engineers, starting an interest which remained all his life.
Having decided to study medicine Ian applied to medical school.
His choice of Guys Hospital, University of London was cement-
ed when they presented him with tea in a china cup when he
attended his interview in military uniform.
Guys was the ideal choice; not least as he met there Christine
who was to become his wife for 52 years.
After qualifying and the usual round of house posts Ian entered
General Practice, becoming a GP principal. He joined the BMA
staff as an assistant secretary in 1964, rising to Undersecretary
before leaving in 1974/5 to work in International Health first
with the Department of Health (then DHSS) and later with the
Overseas Development Agency (ODA) where he rose to Chief
Medical Adviser. Ian rejoined the BMA in 1985 as Deputy Sec-
retary for National Medical Services, the trade union “arm”of the
BMA, and because BMA Secretary in 1989.
Amongst many other significant achievements while working at
DHss and the ODA Ian was responsible for relationships with
the WHO and with the Council of Europe. At that time the lat-
ter in particular was emerging as an important voice that would
influence health policy within the UK,and Ians deep understand-
ing of the processes and politics as well as of the policies was
invaluable.
In the ODA Ian was advising ministers on how the UK could use
its influence, and money, to improve the health lot of the poor in
developing countries. This included work on some of the great
killers of those, and indeed of these, times. He chaired the WHO
Global Advisory Committee on Malaria; he was the only mem-
ber who had personally had malaria and he remembered the toll
it took from his childhood in India.
Along with those roles came exotic travel. I was exciting o visit
China officially, to be taken to Bokhara and Samarqand by the
Russians and to be wined and dined with the Japanese.But along-
side the fun of meeting new people and exploring new places he
Ian Trevor Field
37
In Memoriam
never lost his commitment to health in developing countries. In
Zanzibar he zoomed in on a maternity ward that had been given
modern incubators for premature babies but had no electricity or
oxygen to put them to use.The survival of the babies still depend-
ed on loving care and their isolation. On the mainland of Africa
he noted how bedsores were treated with honey and exposure to
sunlight.
In this work Ian was using his childhood experiences, which were
far more diverse than the average senior civil servant or British
doctor, to see further and to connect better with the people his
department were seeking to help.
Returning to the BMA Ian inherited an organisation expand-
ing rapidly and consolidating its member-facing services, helping
doctors in employment difficulties. At the same time relation-
ships with the UK government were going through a difficult
phase with changes to the National Health Service that were
deeply unpopular with most and to which the BMA was vocally
opposed. The Association needed a steady hand at the top, keep-
ing diverse interests together, and that is what Ian delivered.
The BMA had always had strong international links; many of the
medical associations in the former British Empire were now in-
dependent bodies in their own independent countries. But many
remained then (and now) attached to memories of working with
the BMA and Ian was always delighted to meet and host col-
leagues from around the world. His genuine respect and affection
for people from all over the world shone through.
Ians knowledge of the way international organisations worked,
including WHO, was especially helpful as the BMA increased its
public health lobbying internationally on matters such as tobacco
control. Help in identifying the right routes to influence were in-
valuable and always available.
By the time he retired the BMA had raised its membership to
over 100,000 for the first time and was continuing to expand both
its political and professional activities. In recognition of his ser-
vice the BMA appointed Ian a Vice President, one of its most
senior honours.
As a broader recognition of his service to health, including his
enormously important work while at the Department of Health
and the ODA Ian was homoured by her Majesty the Queen who
made him a Commander of the Order of the British Empire.
(CBE).
As soon as Ian left the BMA he was snapped up by the World
Medical Association. He and Christine moved to Ferney Voltaire
and Ian set about persuading lapsed members to rejoin, and to
take an active part in developing WMA policy and direction.
A number of member associations had left the Wma in the early
1980’s in protest at a number of matters, including voting sys-
tems. Ian cajoled them back into active membership promising
that, as always, he would listen to their concerns and ensure real
problems were fair-
ly addressed. This
was a significant
period of growth
for the WMA.
Ian also encour-
aged engagement,
and many more
members began to
develop hew poli-
cies for the WMA.
As always Ian was
a strong source of
advice as well as en-
couragement; new
members knew he
was always there to
help with drafting,or with help in understanding how to get poli-
cies through the byzantine and confusing processes of the WMA.
Ian loved the opportunity to travel with the WMA, and was a
popular visitor at national medical association meetings where he
never failed to promote membership of and engagement with the
WMA.
After Ian retired his many friends hoped he would have a long
period in which to enjoy life, including his family. His involve-
ment in the Worshipful Society of Apothecaries, a livery com-
pany in the City of London that had long had the right to grant
medical licences, culminated in its highest honour when Ian be-
came master.
Sadly Ian suffered a stroke in the late 1990s which severely cur-
tailed his ability o travel,but he remained active in his community.
Among other things Ian enjoyed helping Primary School chil-
dren with their reading.
Ian was, throughout his life, a committed Christian. Raised in the
Jesuit tradition he later embraced the Benedictine traditions. As
a community activist Ian played an important part in both local
church management and in Ecumenism. His faith was a part of
everything he did.
Ian was also a family man. He was devoted to his partner, wife
Christine, their three sons and daughters in law and 8 grandchil-
dren. All took part in his funeral showing their deep love for heir
devoted grandfather.
(With grateful thanks to Sir Colin Imray whose Eulogy
offered great help in compiling this obituary.)
Vivienne Nathanson
29 January 2013
38
Order of Physicians of Albania
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encolombia.com
Website: www.encolombia.com
Conseil National de l’Ordre des
Médecins du RDC, B.P. 4922,
Kinshasa, Gombe
CONGO, DEMOCRATIC
REPUBLIC
Dr. Antoine MBUTUKU
MBAMBILI, President
Tel: (243-12) 24589
Fax: (243) 8846574
E-mail: cnomrdcongo@gmail.com
Unión Médica Nacional
Apartado 5920-1000, San José
COSTA RICA
Dr. José Federico ROJAS
MONTERO, President
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: junta@unionmedica.com
Ordre National des Médecins
de la Côte d’Ivoire
Cocody Cite des Arts,
Bâtiment U1, Escalier D, RDC,
Porte n°1, BP 1584, 01 Abidjan
CÔTE D’IVOIRE
Dr. Florent Pierre AKA KROO,
President
Tel: (225) 22486153/22443078/
02024401/08145580
Fax: (225) 22 44 30 78
E-mail: onmci@yahoo.fr
Website: www.onmci.org
Croatian Medical Association
Subiceva 9, 10000 Zagreb
CROATIA
Dr. Zeljko METELKO, President
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: tajnistvo@hlz.hr
Website: www.hlz.hr
Colegio Médico Cubano Libre
717 Ponce de Leon Boulevard,
P.O. Box 141016,
Coral Gables, FL 33114-1016
CUBA
Dr. Enrique HUERTAS, President
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
E-mail: info@sirspeedy5551.com
WMA Directory of Constituent Members
39
Cyprus Medical Association
14 Thasou Street, 1087 Nicosia
CYPRUS
Dr. Andreas DEMETRIOU, President
Tel. (357) 22 33 16 87
Fax: (357) 22 31 69 37
E-mail: cyma@cytanet.com.cy
Czech Medical Association
Sokolská 31 – P.O. Box 88
120 26 Prague 2
CZECH REPUBLIC
Prof. Jaroslav BLAHOS, President
Tel: (420) 224 266 201-4
Fax: (420) 224 266 212
E-mail: czma@cls.cz
Website: www.cls.cz
Danish Medical Association
9 Trondhjemsgade, 2100 Copenhagen
DENMARK
Dr.Mads Koch HANSEN, President
Tel: (45) 35 44 82 29
Fax: (45) 35 44 85 05
E-mail: er@dadl.dk
Website: www.laeger.dk
Egyptian Medical Association
Dar El Hekmah
42 Kasr El-Eini Street, Cairo
EGYPT, ARAB REPUBLIC
Prof. Ibrahim BADRAN
Tel: (20-2) 27 94 09 91
Fax: (20-2) 27 95 78 17
E-mail: ganzory@tedata.net.eg
Colegio Médico de El Salvador
Final Pasaje N° 10, Colonia Miramonte
San Salvador
EL SALVADOR
Dr. Rodolfo Alfredo Canizález
CHÁVEZ, President
E-mail: marnuca@hotmail.com
juntadirectiva@colegiomedico.org.sv
Website: colegiomedico.org.sv
Estonian Medical Association
Pepleri 32, 51010 Tartu
ESTONIA
Dr. Andres KORK, President
Tel: (372) 7 420 429
Fax: (372) 7 420 429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
Ethiopian Medical Association
P.O. Box 2179, Addis Ababa
ETHIOPIA
Dr. Fuad TEMAM, President
Tel: (251-1) 158174
Fax: (251-1) 533742
E-mail: ema.emj@ethionet.et
ema@eth.healthnet.org
Fiji Medical Association
304 Wainamu Road, G.P.O. Box 1116,
Suva
FIJI
Dr. Ifereimi WAQAINABETE,
President
Tel: (679) 3315388
Fax: (679) 3315388
E-mail: fma@unwired.com.fj
Finnish Medical Association
P.O. Box 49, 00501 Helsinki
FINLAND
Dr. Raija NIEMELÄ, President
Tel: (358-9) 393 091
Fax: (358-9) 393 0794
E-mail: riikka.rahkonen@fimnet.fi
fma@laakariliitto.fi
Website: www.medassoc.fi
Association Médicale Française
180, Blvd. Haussmann,
75389 Paris Cedex 08
FRANCE
Michel LEGMANN, President
Tel: (33) 2 99 38 55 88
Fax. (33) 2 99 38 15 57
E-mail: international@cn.medecin.fr
Website: www.assmed.fr
Georgian Medical Association
7 Asatiani Street, 0177 Tbilisi
GEORGIA
Prof. Gia LOBZHANIDZE,
President
Tel. (995 32) 398686
Fax. (995 32) 396751/398083
E-mail. georgianmedicalassociation
@gmail.com
Website: www.gma.ge
Bundesärztekammer
(German Medical Association)
Herbert-Lewin-Platz 1, 10623 Berlin
GERMANY
Dr. Frank Ulrich MONTGOMERY,
President
Tel: (49-30) 4004 56 360
Fax: (49-30) 4004 56 384
E-mail: international@baek.de
Website: www.baek.de
Ghana Medical Association
P.O. Box 1596, Accra
GHANA
Dr. Kwabena OPOKU-ADUSEI,
President
Tel. (233-21) 670510/665458
Fax. (233-21) 670511
E-mail: gma@dslghana.com
Website: www.ghanamedassn.org
Association Médicale Haitienne
1ère Av. du Travail #33 – Bois Verna
Port-au-Prince
HAITI
Dr. Marie Ginette RIVIERE LUBIN,
President
E-mail: secretariatamh@gmail.com
Hong Kong Medical Association, China
Duke of Windsor Social Service Building
5th
Floor, 15 Hennessy Road
HONG KONG
Dr. Gabriel K. CHOI, President
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.orgoui
Website: www.hkma.org
Association of Hungarian Medical
Societies (MOTESZ), P.O. Box 200,
H-1364 Budapest
HUNGARY
Dr.Tibor ERTL, President
Tel: (36-1) 312 2389 – 311 6687
Fax: (36-1) 383-7918
E-mail: nagy.dora@motesz.hu
Website: www.motesz.hu
Icelandic Medical Association
Hlidasmari 8, 201 Kópavogur
ICELAND
Dr.Thorbjörn JÓNSSON, President
Tel: (354) 864 0478
Fax: (354) 5 644106
E-mail: icemed@icemed.is
Website: www.icemed.is
Indian Medical Association
Indraprastha Marg, 110 002 New Delhi
INDIA
Dr.K.VIJAYAKUMAR,National President
Tel:(91-11) 23370009/23378819/23378680
Fax: (91-11) 23379178/23379470
E-mail: nationalpresident.imahq@gmail.com
Website: www.ima-india.org
Indonesian Medical Association
Jl. Samratulangi No. 29, 10350 Jakarta
INDONESIA
Dr. Zaenal ABIDIN, President
Tel: (62-21) 3150679/3900277
Fax: (62-21) 390 0473
E-mail: pbidi@idionline.org
Website: www.idionline.org
Irish Medical Organisation
10 Fitzwilliam Place, 2 Dublin
IRELAND
Dr. Ronan BOLAND, President
Tel: (353-1) 6767273
Fax: (353-1) 662758
E-mail: imo@imo.ie
Website: www.imo.ie
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, 52136 Ramat-Gan
ISRAEL
Dr. Leonid EIDELMAN, President
Tel: (972-3) 610 0444
Fax: (972-3) 575 0704
E-mail: michelle@ima.org
Website: www.ima.org.il
Japan Medical Association
2-28-16 Honkomagome,
113-8621 Bunkyo-ku,Tokyo
JAPAN
Dr. Yoshitake YOKOKURA, President
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
Website: www.med.or.jp/english
National Medical Association
of the Republic of Kazakhstan
117/1 Kazybek bi St., Almaty
KAZAKHSTAN
Dr. Aizhan SADYKOVA, President
Tel. (7-327 2) 624301/2629292
Fax. (7-327 2) 623606
E-mail: doktor_sadykova@mail.ru
Korean Medical Association
302-75 Ichon 1-dong
140-721 Yongsan-gu, Seoul
KOREA, REPUBLIC
Dr. Hwan Kyu ROH, President
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190/795 1345
E-mail: intl@kma.org
Website: www.kma.org
Kuwait Medical Association
P.O. Box 1202, 13013 Safat
KUWAIT
Dr. Abdul-Aziz Al-ENEZI, President
Tel. (965) 5333278, 5317971
Fax. (965) 5333276
E-mail. kma@kma.org.kw
alzeabi@hotmail.com
Latvian Medical Association
Skolas Str. 3, Riga 1010
LATVIA
Dr. Peteris APINIS, President
Tel: (371) 67287321/67220661
Fax: (371) 67220657
E-mail: lma@arstubiedriba.lv
Website: www.arstubiedriba.lv
Liechtensteinische Ärztekammer
Postfach 52, 9490 Vaduz
LIECHTENSTEIN
Dr.Remo SCHNEIDER,Secretary LAV
Tel: (423) 231 1690
Fax. (423) 231 1691
E-mail: office@aerztekammer.li
Website: www.aerzte-net.li
40
Lithuanian Medical Association
Liubarto Str. 2, 2004 Vilnius
LITHUANIA
Dr. Liutauras LABANAUSKAS,
President
Tel./Fax. (370-5) 2731400
E-mail: lgs@takas.lt
Website: www.lgs.lt
Association des Médecins et Médecins
Dentistes
du Grand-Duché de Luxembourg
(AMMD)
29, rue de Vianden, 2680 Luxembourg
LUXEMBOURG
Dr. Jean UHRIG, President
Tel: (352) 44 40 33 1
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Macedonian Medical Association
Dame Gruev St. 3, P.O. Box 174,
91000 Skopje
MACEDONIA, FYR
Prof. Dr. Jovan TOFOSKI, President
Tel: (389-2) 3162 577/7027 9630
Fax: (389-91) 232577
E-mail: mld@unet.com.mk
Website: www.mld.org.mk
Society of Medical Doctors of Malawi
Post Dot Net, PO Box x387,
Crossroads
30330 Lilongwe
MALAWI
Dr. Douglas Komani LUNGU,
President
E-mail: dlungu@sdnp.org.mw
Website: www.smdmalawi.org
Malaysian Medical Association
4th
Floor, MMA House,
124 Jalan Pahang
53000 Kuala Lumpur
MALAYSIA
Dr. Mary Suma CARDOSA, President
Tel: (60-3) 4041 1375
Fax: (60-3) 4041 8187
E-mail: info@mma.org.my
Website: www.mma.org.my
Ordre National des Médecins du Mali
Hopital Gabriel Toure
Cour du Service d’Hygiène
BP .E 674, Bamako
MALI
Prof. Alhousseïni AG MOHAMED,
President
Tel. (223) 223 03 20/222 20 58/
E-mail: cnommali@gmail.com
Website: www.keneya.net/cnommali.com
Medical Association of Malta
The Professional Centre,
Sliema Road, Gzira GZR 06
MALTA
Dr. Steven Fava, President
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: martix@maltanet.net
Website: www.mam.org.mt
Colegio Medico de Mexico
Adolfo Prieto #812, Col. Del Valle,
D. Benito Juárez, Mexico 03100
MEXICO
Dr. Ramon MURIETTA, President
E-mail: colegiomedicomexico.
federacion@gmail.com
Website:www.colegiomedicodemexico.org.mx
Associacao Medica de Mocambique
Avenida Salvador Allende, n. 560,
1 andar, Maputo
MOZAMBIQUE
Dr. M. Rosel SALOMAO, President
Tel: (258) 843 050 610
Fax: (258) 213 248 34
E-mail: rsalomao@teledata.mz
Myanmar Medical Association No. 249,
Theinbyu Road Mingalartaungnyunt,
Township, Yangon Region
MYANMAR
Dr. Khine Soe WIN, Secretary General
E-mail: mmacorg@googlemail.com
Website: www.mmacentral.org
Medical Association of Namibia
403 Maerua Park, POB 3369,
Windhoek
NAMIBIA
Dr.Reinhardt SIEBERHAGEN,President
Tel. (264) 61 22 4455
Fax. (264) 61 22 4826
E-mail: man.office@iway.na
Website: www.man.com.na
Nepal Medical Association
Siddhi Sadan, Post Box 189,
Exhibition Road, Katmandu
NEPAL
Dr. Kiran Prasad SHRESTHA,
President
Tel. (977 1) 4225860, 4231825
Fax. (977 1) 4225300
E-mail: mail@nma.org.np
Website: www.nma.org.np
Royal Dutch Medical Association
P.O. Box 2005, 3502 LB, Utrecht
NETHERLANDS
Dr. R.J. VAN DER GAAG, President
Tel: (31-30) 282 32 67
Fax: (31-30) 282 33 18
E-mail: j.bouwman@fed.knmg.nl
Website: www.knmg.nl
New Zealand Medical Association
P.O. Box 156, Level 13 Greenock
House, 39,The Terrace,
Wellington 1
NEW ZEALAND
Dr. Paul OCKELFORD, Chairman
Tel: (64-4) 472 4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa,
Crescent, Wuse Zone 4,
FCT, PO Box 8829, Wuse Abuja
NIGERIA
Dr. Akpufuoma L. PEMU, Secretary
General
Tel: (234-1) 480 1569, 876 4238
Fax: (234-1) 493 6854
E-mail: nationalnma@yahoo.com
Website: www.nigeriannma.org
Norwegian Medical Association
P.O.Box 1152 sentrum, 0107 Oslo
NORWAY
Dr. Geir RIISE, Secretary General
Tel: (47) 23 10 90 00
Fax: (47) 23 10 90 10
E-mail: Bjorn.Hoftvedt
@legeforeningen.no
Website: www.legeforeningen.no
Asociación Médica Nacionalde la
República de Panamá
Apartado Postal 2020, Panamá 1
PANAMA
Dr. Alfredo MACHARAVIAYA,
President
Tel: (507) 263 7622/263-7758
Fax: (507) 223 1462
E-mail: amenalpa@cwpanama.net
Colegio Médico del Perú
Malecón Armendáriz N° 791,
Miraflores, Lima
PERU
Dr. Julio Castro GOMEZ, President
Tel: (51-1) 213 1400
Fax: (51-1) 213 1412
E-mail: prensanacional@cmp.org.pe
Website: www.cmp.org.pe
Philippine Medical Association
2/F Administration Bldg.,
PMA Compound, North Avenue,
1105 Quezon City
PHILIPPINES
Dr. Oscar TINIO, President
Tel: (63-2) 929 63 66
Fax: (63-2) 929 69 51
E-mail: philmedas@yahoo.com
Website: philippinemedicalassociation.org
Polish Chamber of Physicians and
Dentists
(Naczelna Izba Lekarska)
110 Jana Sobieskiego, 00-764 Warsaw
POLAND
Dr. Konstanty RADZIWILL,
President
Tel. (48) 22 55 91 300/324
Fax: (48) 22 55 91 323
E-mail: sekretariat@hipokrates.org
Website: www.nil.org.pl
Ordem dos Médicos (Portugal)
Av. Almirante Gago Coutinho 151,
1749-084 Lisbon
PORTUGAL
Dr. José Manuel SILVA, President
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: intl@omcn.pt
Website: www.ordemdosmedicos.pt
Romanian College of Physicians
Bulevardul Timisoara nr. 15,
061303 Sector 6, Bucarest
ROMANIA
Prof. Dr. Vasile ASTARASTOAE,
President
Tel: (40-21) 413 88 00
Fax: (40-21) 413 77 50
E-mail: office@cmr.ro
Website: www.cmr.ro
Russian Medical Society
Udaltsova Street 85, 119607 Moscow
RUSSIAN FEDERATION
Dr. Sergey BAGNENKO, President
Tel: (7-495) 734 12 12
Fax: (7-495) 734 11 00
E-mail. info@russmed.ru
Website: www.russmed.ru/eng/
who.htm
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health Services,
Apia
SAMOA
Dr. Viali LAMEKO, President
Tel. (685) 778 5858
E-mail: viali1_lameko@yahoo.com
Ordre National des Médecins du
Sénégal
Institut d’Hygiène Sociale
(Polyclinique)
BP 27115 Dakar
SENEGAL
Prof. Lamine SOW, President
Tel. (221) 33 822 29 89
Fax: (221) 33 821 11 61
E-mail: lamsow@orange.sn
Website: www.ordremedecins.sn
Lekarska Komora Srbije
(Serbian Medical Chamber)
Kraljice Natalije 1-3, Belgrade
SERBIA
Dr.Tatjana RADOSAVLJEVIC,
General Manager
E-mail: lekarskakomorasrbije@gmail.com
Singapore Medical Association
Alumni Medical Centre, Level 2
2 College Road 169850
SINGAPORE
Dr. Jing Jih CHIN, President
Tel. (65) 6223 1264
Fax. (65) 6224 7827
E-mail. sma@sma.org.sg
Website: www.sma.org.sg
Slovak Medical Association
Cukrova 3, 813 22 Bratislava 1
SLOVAK REPUBLIC
Prof. Peter KRISTÚFEK, President
Tel. (421) 5292 2020
Fax. (421) 5263 5611
E-mail: secretarysma@ba.telecom.sk
Website: www.sls.sk
Slovenian Medical Association
Komenskega 4, 61001 Ljubljana
SLOVENIA
Prof. Dr. Pavel POREDOS, President
Tel. (386-61) 323 469
Fax: (386-61) 301 955
E-mail: matija.cevc@trnovo.kclj.si
Somali Medical Association
7 Corfe Close, Hayes,
UB4 0XE Middlesex, United Kingdom
SOMALIA
Dr. Abdirisak DALMAR, Chairman
E-mail: drdalmar@yahoo.co.uk
The South African Medical Association
P.O. Box 74789, Lynnwood Rydge
0040 Pretoria
SOUTH AFRICA
Prof. Zephne VAN DER SPUY,
President
Tel: (27-12) 481 2037
Fax: (27-12) 481 2100
E-mail: VusiM@samedical.org
Website: www.samedical.org
Consejo General de Colegios Médicos
de España
Plaza de las Cortes 11 4a,
28014 Madrid
SPAIN
Dr. Juan José RODRIGUEZ-
SENDIN, President
Tel: (34-91) 431 77 80
Fax: (34-91) 431 96 20
E-mail: internacional@cgcom.es
Website: www.cgcom.es
Sri Lanka Medical Association
Wijerama House, 6 Wijerama
Mawatha 00700 Colombo
SRI LANKA
Dr. B.J.C. PERERA, President
Tel: +94-112-693 324
Fax: +94-112-698 802
e-mail: office@slma.lk
Website: www.slma.lk
Swedish Medical Association
(Villagatan 5) P.O. Box 5610,
SE – 114 86 Stockholm
SWEDEN
Dr. Marie WEDIN, President
Tel: (46-8) 790 35 01
Fax: (46-8) 10 31 44
E-mail: info@slf.se
Website: www.slf.se
Fédération des Médecins Suisses
Elfenstrasse 18, C.P. 170, 3000 Berne 15
SWITZERLAND
Dr. Juerg SCHLUP, President
Tel. (41-31) 359 11 11
Fax. (41-31) 359 11 12
E-mail: saqm@fmh.ch
Website: www.fmh.ch
Taiwan Medical Association
9F,No 29 Sec.1,An-Ho Road,10688Taipei
TAIWAN
Dr. Ming-Been LEE, President
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@tma.tw
Website: www.tma.tw/EN_tma
Medical Association of Tanzania
P.O. Box 701, 255 Dar es Salam
TANZANIA
Dr. Rodrick KABANGILA, President
E-mail: kajuna2010@gmail.com
Website: www.mat-tz.org
Medical Association of Thailand
2 Soi Soonvijai, New Petchburi Road,
Huaykwang Dist., 10320 Bangkok
THAILAND
Dr. Wonchat SUBHACHATURAS,
President
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: www.mat.or.th
Trinidad andTobago Medical Association
The Medical House, #1 Sixth Avenue,
Orchard Gardens, Chaguanas
TRINIDAD AND TOBAGO
Dr. Rohit DASS, President
Tel: (868) 671-5160
Fax: (868) 671-7378
e-mail: medassocS@tntmedical.com
Website: www.tntmedical.com
Conseil National de l’Ordre des
Médecins de Tunisie, 16,
rue de Touraine, 1002 Tunis
TUNISIA
Dr. Mohamed Néjib CHAABOUNI,
President
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: cnom@planet.tn
Website: www.ordre-medecins.org.tn
Turkish Medical Association
GMK Bulvari, Sehit Danis Tunaligil
Sok. N° 2 Kat 4, 06570 Maltepe,
Ankara
TURKEY
Dr. Eris BILALOGLU, President
Tel: (90-312) 231 31 79
Fax: (90-312) 231 19 52
E-mail: Ttb@ttb.org.tr
Website: www.ttb.org.tr
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874, Kampala
UGANDA
Dr. Margaret MUNGHERERA,
President
Tel. +256 772 434 652
Fax. (256) 41 345 597
E-mail. mmungherera@yahoo.co.uk
Ukrainian Medical Association
7 Eva Totstoho Street, PO Box 13,
01601 Kyiv
UKRAINE
Dr. Oleg MUSII, President
Tel: (380) 50 355 24 25
Fax: (380) 44 501 23 66
E-mail: sfult@ukr.net
British Medical Association
BMA House,Tavistock Square,
WC1H 9JP London
UNITED KINGDOM
Mr.Tony BOURNE, Secretary
General
Tel: (44-207) 387-4499
Fax: (44-207) 383-6400
E-mail: vnathanson@bma.org.uk
Website: www.bma.org.uk
American Medical Association
515 North State Street,
60654 Chicago, Illinois
UNITED STATES
Dr. Jeremy A. LAZARUS,
President-Elect
Tel: (1-312) 464 5291/464 5040
Fax: (1-312) 464 2450
E-mail: ellen.waterman@ama-assn.org
Website: www.ama-assn.org
Sindicato Médico del Uruguay
Bulevar Artigas 1515,
CP 11200 Montevideo
URUGUAY
Dr. Martin REBELLA, President
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
Website: www.smu.org.uy
Medical Association of Uzbekistan
Str. Parkenentskay 51,
Tashkent City 100007
UZBEKISTAN
Prof. Abdulla KHUDAYBERGENOV,
President
E-mail: info@avuz.uz
Website: www.avuz.uz
Associazione Medica del Vaticano
Stato della Citta del Vaticano,
00120 Città del Vaticano
VATICAN STATE
Prof. Renato BUZZONETTI,
President
Tel: (39-06) 69879300
Fax: (39-06) 69883328
E-mail: servizi.sanitari@scv.va
Federacion MedicaVenezolana
Av. Orinoco con Avenida Perija,
Urbanizacion Las Mercedes,
1060 CP Caracas
VENEZUELA, RB
Dr. Douglas Leon NATERA, President
E-mail: sgeneral@saludfmv.org
Website:www.federacionmedicavenezolana.
org
Vietnam Medical Association
68A Ba Trieu-Street, Hoau Kiem
District, Hanoi
VIETNAM
Dr.Tran Huu THANG, Secretary
General
Tel: (84) 4 943 9323/943 1866
Fax: (84) 4 943 9323
E-mail: vgamp@hn.vnn.vn
Zimbabwe Medical Association
P.O. Box 3671, Harare
ZIMBABWE
Dr. Billy RIGAWA, President
Tel. (263-4) 791553
Fax. (263-4) 791561
E-mail: zima@zol.co.zw
www.zima.org.zw
IV
Contents
EFMA (European Forum of Medical As-
sociations) meeting will take place in the
capital city of Latvia – Riga on March 21–
22, 2013. Already for 30 years EFMA has
organized this meeting together with Re-
gional Office for Europe.The 2010 EFMA
meeting took place in St. Petersburg, 2011
in Brussels and 2012 in Yerevan.
Meeting is organized by the EFMA Pres-
ident Lea Wapner form Israel and Latvian
Medical association.
The EFMA meeting 2013 is supported by
the World Health Organization, Ministry
of Health of the Republic of Latvia and
World Medical Association
The Medical Associations, Unions and
Chambers of the European Union, the
Medical Associations of the Economical
Zone of Europe are going to participate
in EFMA.
EFMA is the only forum where not only
European Union members and medical
organizations which belong to countries
based on classical European values comes
together, but also medical associations
from former Soviet Union countries like
Belarus, Tajikistan, Turkmenistan, Mol-
dova, Armenia and Albania, Kosovo, Is-
rael are represented.This is an opportunity
to discuss among different systems, tradi-
tions and possibilities.
The goal of Latvian Medical association
for the meeting in Riga is to create a dia-
logue or a kind of bridge between different
medical organizations in Europe and put-
ting emphasis on exchange of experience
among medical associations of Western
Europe, Central Europe, new participants
of European Union, CIS countries, Israel
and perspective members.
There is quite different experiences among
European countries regarding issues con-
cerning possibilities of medical NGO’s to
solve problems connected to public health
in their respective countries.
More information: liene@arstubiedriba.lv
EFMA meeting March 21–22, 2013 Riga, Latvia
Back to the 50s?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Declaration of Helsinki. Expert Conference . . . . . . . . . . . 2
A Guideline for Treatment Decisions on CAM
in Oncology: Prerequisites for Evidence Based
Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Healthcare System Reform in China . . . . . . . . . . . . . . . . . 8
Never Say Never, Uganda! . . . . . . . . . . . . . . . . . . . . . . . . . 13
Susceptible Healthcare Professionals . . . . . . . . . . . . . . . . . 22
Implementing Surgical Care at the National
Level: The WHO Integrated Management for
Emergency and Essential Surgical Care Toolkit . . . . . . . . . 24
Health Care Reform: Does One Size Fit All . . . . . . . . . . . 25
Physicians and Hunger Strikes in Prison: Confrontation,
Manipulation, Medicalization and Medical Ethics . . . . . . 27
Ian Trevor Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
WMA Directory of Constituent Members . . . . . . . . . . . . 38