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wmj18<\/a><\/p>\n

In keeping with our new tradition of featuring one of our mem-
\nber countries on each cover of the World Medical Journal, I am
\npleased to have Norway on our cover this month. Our cover shows
\na Norwegian doctor who has arrived by sled to care for a sick child.
\nNorway can be proud of its exemplary medical care and its social
\nconscience. Medicine in Norway today is characterized by impec-
\ncable ambulatory facilities and super-modern clinics. The Norwe-
\ngian Medical Association was ahead of its time 25 years ago when
\nit undertook the goal of eliminating smoking in Norway. Although
\nthis goal has only partially been reached, Norwegians can be proud
\nof having the lowest rate of smoking and alcohol consumption not
\nonly in Europe but also in the world, as well as having among the
\ngreatest longevity and lowest morbidity rates in the world.
\nWhen we look at the World Medical Association today, we see an
\norganization that has matured in 60 years to be a global force. Since
\nits foundation, the main goal of the World Medical Association has
\nbeen to establish and promote the highest possible standards of eth-
\nical behavior and care by physicians.The WMA has adopted policy
\nstatements on many ethical issues related to medical professional-
\nism, patient care, research on human subjects and public policies,
\ntaken a leadership role against smoking, detecting cervical cancer
\nearly, increasing physical activity and exercise.
\nAs doctors,we are aware of the deleterious e\ufb00ects of smoking and as
\na medical organization, the World Health Organization has taken
\na very strong stand against smoking. I would like to urge us to take
\nan even stronger stand against exposure of children to secondary
\nsmoke (passive smoking), as well as children smoking. Smoking in
\nan enclosed space \ufb01lls the air with noxious substances such as am-
\nmonia, arsenic, benzene, benzoapyrene, butane, cadmium, formal-
\ndehyde, lead, nicotine, propylene glycol and turpentine. In addition
\nto being carcinogenic, these harmful chemicals lead to vascular dis-
\neases and pulmonary disorders. Toxins from cigarettes are inhaled
\nnot only by the smoker, but also by non-smokers in the same room.
\nIf the non-smoker is a child, subjecting the child to such poison
\ncould be viewed as being as serious an o\ufb00ense as physical violence,
\nparamount to sexual abuse, psychological trauma or other cruelty
\nto children. Punishment for any abuse against children, including
\nsubjecting them to passive smoking, could be seen as a criminal of-
\nfense.
\nThe Latvian Medical Association has endorsed laws that would
\nprohibit smoking in automobiles in which children are passengers.
\nSuch laws have been enacted in Australia, 21 states in the United
\nStates, parts of Canada, Cyprus and in other countries. We should
\nencourage the health organizations in our countries to prohibit
\nsmoking in vehicles in which any passenger is younger than age 18,
\nin all public buildings, in all educational institutions and facilities
\nthat deal with children, and in any building or room, including in
\nprivate homes, in which children are present.
\nSmoking in the presence of children should be recognized as child
\nabuse, since it is clear that passive smoking causes physical harm
\nto the child. We cannot allow the excuse that a person, even in his
\nown home, has the right to smoke if such smoking causes harm to
\na child.
\nPhysicians should take a leadership role in the battle against ciga-
\nrette smoking and set an example of a healthy lifestyle by not smok-
\ning. It goes without saying that a doctor who smokes is an anachro-
\nnism. Let us lead by example and protect our next generation.
\nDear colleagues!
\nP\u0113teris Apinis, M.D.
\nEditor-in-Chief of the World Medical Journal
\nDr. J\u00f3n SN\u00c6DAL
\nWMA President
\nIcelandic Medicial Assn
\nHlidasmari 8
\n200 Kopavogur
\nIceland
\nDr. Kazuo IWASA
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nDr. Yoram BLACHAR
\nWMA President-Elect
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Eva NILSSON-
\nB\u00c5GENHOLM
\nWMA Chairperson of the Medical
\nEthics Committee
\nSwedish Medical Assn.
\nP.O. Box 5610
\n11486 Stockholm
\nSweden
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Nachiappan ARUMUGAM
\nWMA Immediate Past President
\nMalaysian Medical Assn.
\n4th Floor, MMA House
\n53000 Kuala Lumpur
\nMalaysia
\nDr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nDr. Edward HILL
\nWMA Chairperson of Council
\nAmerican Medical Assn
\n515 North State Street
\nChicago, ILL 60610
\nUSA
\nDr. Jos\u00e9 Luiz GOMES DO
\nAMARAL
\nWMA Chairperson of the Socio-
\nMedical-A\ufb00airs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\nWorld Medical Association O\ufb03cers, Chairpersons and O\ufb03cials
\nwww.wma.net
\n33
\nEditorial
\nIn announcing the topic for World Health
\nDay 2008, Dt. Margaret Chan, DG WHO,
\nsaid \u201cHealth professionals are in the front
\nline in delaying the impacts of climate change.
\nThe most vulnerable are in countries where
\nthe health sector struggles to prevent ,detect,
\ncontrol and treat diseases and health condi-
\ntions. including malaria, malnutrition and
\ndiarrhoea\u2026.. we need to put public health at
\nthe heart of the climate change agenda\u201d and
\non World Health Day 7th
\nApril 2008 she said \u201c
\nThe warming of the planet will be gradual but
\nthe e\ufb00ects of extreme weather events \u2013 more
\nstorms, \ufb02oods, droughts and heat waves- will
\nbe abrupt and acutely felt. Both trends can af-
\nfect some of the most fundamental determinants
\nover the past years faced major problems
\nover and above those arising from its basic
\nrole in providing health care to individu-
\nals, to which we have referred in previous
\neditorials \u2013 such as those associated with
\nhealthcare organisation, structure and func-
\ntion, changing roles, scienti\ufb01c advances
\nand their application to medical; practice \u2013
\nnot to mention HIV\/AIDs, the threat of
\npandemic spread of disease, (see editorial
\nWMJ53(4)).
\nNow new problems also threaten to add
\nto the burdens of providing health care to
\nthose in need.
\nAlready there has been increasing interna-
\ntional concern about the e\ufb00ects of climate
\nchange, which have become more apparent
\nin the context of the \u201cnatural disasters\u201d af-
\nfecting many countries both in the east and
\nthe west. These have added to the calls for
\nemergency medical care and other assist-
\nance, including food and water supplies.
\nNow the problem of sustaining adequate
\nfood supplies is extending beyond those
\ncountries a\ufb00ected by natural disasters, not
\nonly increased by the e\ufb00ects of armed con-
\n\ufb02icts but by the realities of a wider problem
\nof producing enough food for an expanding
\nglobal population.
\nWhile international aid has been directed
\nto dealing with the consequences of natu-
\nral disasters and the consequences of armed
\ncon\ufb02ict, looking to the future the problem
\nof coping with the diseases associated with
\nmalnutrition and starvation may well be en-
\nlarged beyond those countries a\ufb00ected by
\narmed con\ufb02ict and natural disasters in the
\npast…
\nAs if this were not enough, the current
\nuncertain \ufb01nancial climate, with potential
\nthreats to global \ufb01nancial structures, also
\nposes additional problems to those already
\nfacing existing healthcare systems. While
\nthe current trend to look towards preventive
\nmeasures to reduce the incidence of some
\ndiseases and contain the \ufb01nancial burden
\nof providing healthcare to treat them o\ufb00ers
\nmuch for the future,the burden of such dis-
\nease in likely to continue for some decades
\nto come. To meet this need the concept of
\n\u201c task shifting\u201d to o\ufb00er some alleviation of
\nthe problems of scarcity of human health-
\ncare resources needs careful consideration,
\nnot only to address the inequitable shortage
\nof health professionals in some countries,
\nbut in all countries. This calls for realistic
\napproaches by all the health professions.
\nLikewise those responsible for health care
\npolicies have a di\ufb03cult task in attempting to
\nbalance the \ufb01nancial burden needed to meet
\nthe immediate and mid-term needs of the
\npresent global population and the invest-
\nment needed to extend disease preventive
\naction required to contain the health care
\ncosts of future generations. For those suf-
\nfering disease, whatever its cause, care and
\ntreatment are priorities, they do not have
\ntime to engage in mid- to long-term strate-
\ngies to avoid disease. While lifestyle factors
\nplay an important role in the development
\nof a number of diseases.it cannot be disre-
\ngarded that in the working lifetime of many
\npractising physicians the burden of disease
\nhas been increased not only by the substan-
\ntial increase in scienti\ufb01c knowledge and its
\napplication in diagnosing and treating dis-
\neases, but also by the substantial increase in
\nlife expectancy in much of the world. This
\nis now reaching the stage in some countries
\nwhere the size of the retired population is
\napproaching if not exceeding that of those
\nwho actively engaged in gainful employ-
\nment, resulting in increasing strains on the
\n\ufb01nancial resources which can be applied to
\nthe provision of healthcare services to meet
\nWhile most of these considerations have
\nbeen addressed by economists, healthcare
\nproviders and policy makers, they will now
\nassume an even greater urgency than they
\nhave over the past few decades.
\nThe combination of the possibility of im-
\npending widespread recession coupled with
\nthe growing inadequacy of basic food sta-
\nples a\ufb00ecting even bigger populations than
\npotential to not only increase the burden
\nof disease but also to threaten the nature
\nof medical care and treatment society will
\nbe able to sustain. It is therefore incumbent
\non NMAs to monitor and engage, where
\nappropriate, in discussions on the e\ufb00ects of
\nclimate change and the maintenance of ad-
\nequate resources for services to meet both
\nshort and long term needs.
\nWhile the monitoring of such activities
\nfall naturally within the responsibilities of
\nNMAs, at this time of increased threats to
\n\ufb01nancial systems,those arising from climate
\nchange and to food supplies extending be-
\nyond national and regional limits, the need
\nfor a united voice from the leadership of
\nthe medical profession address these issues
\n(where appropriate) is essential to inform
\nand in\ufb02uence the political decisions which
\nwill be taken both nationally and globally.
\nDr. Alan J. Rowe
\nCo-Editor of the World Medical Journal
\nof health; air, water, food, shelter and freedom
\nThe medical profession has increasingly
\nfrom disease.\u201d
\ntheir needs.
\nhave previously been experienced, has the
\n34
\nThis is the name on a Forum organised
\nby the Global Health Workforce Alliance
\n(GHWA) in Kampala, Uganda 2-7 March
\n2008. The intention was to bring to light
\nthe problems of critical shortage of health
\nworkers in over 50 countries in the world
\nand what forces dictate the migration from
\nlow income countries to high income coun-
\ntries. In the analysis of the problem during
\nthe meeting it became obvious that this
\nproblem is more complicated than it seems
\nat \ufb01rst sight. Migration is also taking place
\ninside countries, where health professionals
\nleave the o\ufb03cial health service and either
\nmove to the private health sector or leave
\nthe health service altogether. Migration is
\nalso taken place regionally from one low
\nincome country to another. The push and
\npull factors were discussed and to what ex-
\ntent these factors could or should be regu-
\nlated. Furthermore, the role of the various
\nstakeholders in this global problem was
\ndiscussed.
\nThe Forum was attended by several stake-
\nholders. It was organised by the GHWA
\nand as this is an agency established by the
\nWHO, many o\ufb03cers of that organisation
\nwere involved. The major focus was on the
\nsituation of the health workforce in Africa
\nand therefore governmental o\ufb03cers; mostly
\nfrom African health authorities were pres-
\nent but also some from the \ufb01nancial de-
\npartments. There were also representatives
\nof development agencies and from sev-
\neral NGO\u00b4s, not least from associations of
\nhealth professionals, both national and in-
\nternational. The aim of the Forum was to
\ncome to some mutual understanding of this
\nenormous problem by issuing a declaration
\nand in that regard, the meeting turned out
\nto be successful.
\nBefore we go any further into this issue it
\nis important to look into the vocabulary
\nused. The WHO and the GHWA use the
\nterm \u201chealth workers\u201dwhich opens the pos-
\nsibility to include individuals with limited
\nor nonprofessional education and training,
\nbut are nevertheless working in the health
\nservice. The WMA and other Associations
\nof health professionals on the other hand
\nstress the importance of looking speci\ufb01cally
\nat the migration of health professionals and
\nthe reasons for their choices. It is of impor-
\ntance to realise that migration is an individ-
\nual choice based on reasons which are very
\ndi\ufb00erent from case to case and it is only
\nwhen the total picture is analyzed that it is
\npossible to see a pattern.It is very important
\nthat there will be no constraints by laws or
\nregulations on individual choices and it was
\na relief to realise that no such ideas were put
\nforward in the discussions.
\nThose who gathered in Kampala are not
\nthe only ones concerned were the problem.
\nThe Lancet has recently published a spe-
\nci\ufb01c number on this issue (Vol. 371; 9613:
\nFebruary 23-29 2008). On the front page
\nof this number there is one sentence which
\ncaptures this huge problem very well: \u201cAf-
\nrica carries 25% of the world\u2019s disease bur-
\nden yet has only 3% of the world\u2019s health
\nworkers and 1% of the world\u2019s economic
\nresources to meet that challenge.\u201d This is
\nthe problem in a nutshell this continent is
\ndealing with in the \ufb01rst decade of the new
\nmillennium.
\nWhat are the driving forces behind migra-
\ntion of health professionals? They are of
\ncourse many, but can be analysed separately
\nby using the terms \u201cpush factors\u201d meaning
\nfactors increasing the possibility to leave a
\ncountry or a profession and by \u201cpull factors\u201d
\nmeaning those factors that are at play in the
\nrecipient countries or services. The aim of
\nthe meeting was not only to discuss prob-
\nlems but also to \ufb01nd solutions.
\nAmongst problems and solutions to pull
\nfactors discussed at the meeting were the
\nfollowing:
\nLack of health professionals in the\u2022 recipi-
\nent countries. Countries receiving health
\nprofessionals from low income countries
\nshould increase the number of educated
\nand trained health professionals in their
\nown country and subsequently be self
\nsu\ufb03cient and not in need of recruitment
\nfrom other regions.
\nEthical recruitment. There should be a\u2022
\ngenerally accepted and respected ethical
\nconduct for recruitment of health profes-
\nsionals in order not to \u201cattack\u201d vulnerable
\npopulations and strip them of well edu-
\ncated and trained people. However it is
\nacknowledged that individual freedom of
\nchoice should not be constrained.
\nAmongst problems and solutions speci\ufb01c
\nfor the push factors were:
\nNeed for investment.The source countries\u2022
\nshould increase investment in health, both
\nthrough theirown means and by outside
\ncontribution.
\nInvestment in proper health education.\u2022
\nThis investment should be in education
\nand training of health professionals, in
\nincreasing the o\ufb00ers of jobs after training
\nand in making the work in the health ser-
\nvice attractive.
\nThe role of International \ufb01nancial agen-\u2022
\ncies. There is compelling evidence that
\nthe \ufb01nancial requirements of the Interna-
\ntional Monetary Fund for investment in
\nthe source countries makes investment in
\npublic health di\ufb03cult and it will be very
\nHuman Resources for Health
\nJon Snaedal
\nPresident of the WMA
\n35
\nIn an unprecedented move, the global or-
\nganizations of nurses, pharmacists, physio-
\ntherapists, dentists and physicians, and the
\nInternational Hospital Federation, joined
\nforceswiththesupportoftheGlobalHealth
\nWorkforce Alliance to tackle a root cause of
\nthe global shortage of health professionals.
\nPoor working conditions rank second only
\ntoinsu\ufb03cientwagesasthekeyreasonhealth
\nprofessionals are leaving their countries
\nin such large numbers, creating this global
\ncrisis. Even wealthy countries are witness-
\ning emigration of health workers in search
\nof better working environments. Through
\ntheir campaign on Positive Practice Envi-
\nronments (PPE), these global partners are
\ncommitted to promoting and facilitating
\nsafer,more secure and more attractive work-
\ning environments and practice conditions
\nfor health care workers.
\nhard to increase the GDP proportion to
\nhealth without some deviation from these
\nrequirements.
\nTask shifting. An increase in mid-level\u2022
\nhealth workers and community health
\nworkers is needed in the short term in
\nareas of most critical shortage, but task
\nshifting should not be a long term solu-
\ntion. There is a di\ufb00erence in opinion on
\nthis part of the solution and it will be dis-
\ncussed separately.
\nIn addition to these possible solutions to the
\nproblem there are other issues that \u201cbridge\u201d
\nthe push and pull factors or are part of both.
\nOne is to make contracts between agencies
\nin both resource and recipient countries.
\nThese can be hospitals which agree to ex-
\nchange health professionals for work and
\ntraining, to provide technical material and
\ntraining and other issues. These agencies
\ncan also be health regions or other speci\ufb01c
\nhealth service agencies.Examples of this are
\nto be seen in several arrangements between
\nhospitals in the UK and in South Africa,
\nleading to a substantial decrease in migra-
\ntion from South Africa to other countries
\nin recent years.
\nPositive Practice Environment is a speci\ufb01c
\nconcept which includes various factors that
\nmake work places attractive to work in. In
\na pre-meeting organised by associations of
\nhealth professionals this was speci\ufb01cally ad-
\ndressed.There are many factors or incentives
\nthat can be tailored for work places which
\nincrease the likelihood of retention of health
\nprofessionals. These incentives can be cate-
\ngorised as \ufb01nancial or non-\ufb01nancial. Finan-
\ncial incentives are wages, bonuses, pensions,
\ninsurance and other things, but there are
\nalso various non-\ufb01nancial incentives. Those
\nmight include safe and clear workplace,
\nprofessional autonomy, sustainable employ-
\nment, \ufb02exibility in work time, support and
\nsupervision, and occupational health and
\ncounselling services. One issue speci\ufb01cally
\nmentioned was the fact that the prevalence
\nof HIV and AIDS is higher amongst health
\nprofessionals in many regions of Sub-Sa-
\nharan Africa than in the communities they
\nserve, but they do not receive the support
\nand counselling they need.
\nTask shifting is an issue that the WHO has
\nput on the agenda as a part of the solution
\nand this was discussed separately at a pre-
\nvious meeting in Addis Ababa last January.
\nTask shifting involves the transfer of tasks
\nin the health service from individuals or
\nprofessionals with high level of education
\nand training to those with lower level of
\nknowledge. That means, in practical terms
\n,that tasks are shifted from doctors to oth-
\ners, but never the other way. This might
\nbe a solution to an urgent problem, but is
\nproblematic in the long run.One risk is that
\nhealth authorities would see this as a means
\nto decrease the cost of health services, but
\nthen without thinking of the quality of ser-
\nvice provided. Another is that the shift of
\npriorities from longer professional educa-
\ntion and training to a shorter one will lead
\nto diminishing number of properly educat-
\ned and trained work force. In the long run
\nthis will lead to segregation of health service
\nbetween countries with di\ufb00erent level of
\nservice, based on di\ufb00erent levels of knowl-
\nedge. It was clear that the health ministers
\nof Africa attending the Task shifting meet-
\ning in Addis realised this and they stressed
\nthat it was very important to prioritise the
\ntraditional training and education.
\nA draft to the Declaration and an action
\nplan was distributed on the \ufb01rst day of the
\nForum in Kampala and after adjusting the
\npapers according to comments and critics;
\nthe Declaration was accepted by all. In a
\nroundtable session of Health Ministers and
\nhigh representatives of WHO, the WMA
\ncriticised however, the lack of transparency
\nand consultation in the preparation of these
\ndocuments as the drafts had been prepared
\nwithout any consultation with the global
\nassociations of health professionals even
\nthough the problem was so closely associ-
\nated with them. We, the representatives of
\nthe WMA, proposed several amendments
\nmost of which were principally accepted in
\nthe \ufb01nal version. The WMA could then ac-
\ncept the declaration in spite of lack of clar-
\nity on many points.
\nThe Declaration and the Action plan are
\nprimarily aimed at governments and it was
\nstated that due to the severity of this crisis,
\nit should be a priority of the heads of gov-
\nernments, not only of health authorities.
\nIt was \ufb01nally decided that in two years time
\nthe situation should be evaluated in order
\nto see the e\ufb00ect of the Declaration and the
\nAction plan.
\nThis article is based on a report made after the
\nKampala meeting and re\ufb02ects the views of the
\nauthor.
\nPositive Practice Environments (PPE) –
\nQuality Workplaces for Quality Care
\n36
\nToday,many countries have desperate short-
\nages of health care professionals, impacting
\nnegatively on patient care and health out-
\ncomes and creating sub-standard practice
\nenvironments for those who provide care.
\nCountries in sub-Saharan Africa and in
\nparts of Southeast Asia have a particularly
\nlow health profession-to-population ratio.
\nThe reasons are complex: in most case low
\nwages and even concerns about whether
\nthere will be a paycheque each month are
\nmajor factors driving out health profession-
\nals,especially physicians.Poor working con-
\nditionsundermineprofessionalperformance,
\nput both patients and health workers at risk
\nand compel health professionals to search
\nfor better, safer working environments. For
\nhealth professionals capable of speaking the
\nlanguage of one of the rich countries in the
\nnorthern hemisphere, a ticket for a move is
\npractically already printed.
\nThe World Health Organization\u2019s (WHO\u2019s)
\ncore strategy to address the health workforce
\ncrisis depends on what it calls Task Shifting.
\nTask Shifting is the substitution of health
\nprofessionals by lay persons and ultimately
\nassigns minimally trained community health
\nworkers with the tasks of physicians, nurses
\nand midwives. With part of their jobs giv-
\nen away to lay persons, physicians may be
\nforced out of the public sector into private
\npractice, or out of the country. Even when
\nthey remain in-country, this e\ufb00ectively cre-
\nates a two-tiered health system in which the
\nwealthy have access to quali\ufb01ed physicians
\nin the private sector while the health of ma-
\njority of the population is left in the hands of
\na non-professional workforce. The preferred
\napproach of PPE campaign members, who
\nrepresent the various health professions,is to
\nfocus on stronger retention of health profes-
\nsionals through better working conditions.
\nGathering the Professions
\nWhen the Global Health Work Force Alli-
\nance held its 1st Global Health Workforce
\nForum in Kampala in March 2008, the PPE
\ncampaigners took the opportunity to assem-
\nble for the \ufb01rst PPE workshop. Health pro-
\nfessionals from all over Africa, Europe and
\nNorth America gathered to discuss and ex-
\nchange views about how to strengthen health
\nsystems through better working conditions.
\nAs keynote speaker of the meeting, WMA
\npresident, Dr Jon Snaedal, began by re-
\nminding the group of the alarming short-
\nage of health professionals worldwide, but
\nmore critically in Sub-Saharan countries.
\nHe reviewed the three key actions currently
\nidenti\ufb01ed and developed by decision-makers
\nto address this workforce crisis: education,
\ntask shifting and retention. Unfortunately,
\nof these three strategies, task-shifting has
\nemerged as the prime focus of most e\ufb00orts.
\nDr. Snaedal outlined the objections that
\nmany \u2013 including African health ministers \u2013
\nhave against using task shifting as the pri-
\nmary solution to the health workforce short-
\nage. He referred participants to a response
\ndeveloped by the World Health Profes-
\nsional Alliance and the global organizations
\nof midwifes and physiotherapists, to the
\nWHO strategy on task shifting. Presented
\nin Kampala, this resolution outlines twelve
\nkey principles necessary to avoid disastrous
\nconsequences from task shifting. (See Insert
\n2 for full text.) Dr.Snaedal emphasized that
\neducation and retention are equally, if not
\nmore important than task shifting,especially
\nwhen the objective is to build comprehensive
\nand sustainable health care systems. Positive
\nPractice Environments, he explained, is one
\nof the retention strategies.
\nThe African participants shared the very
\nstrong concerns on task shifting, yet recog-
\nnizeditasapossiblecomplementaryresponse
\nto health workforce shortage,if pursued with
\nthe following approach:
\nTasks must be shifted from one educated
\ngroup to another educated group (e.g., physi-
\ncians to nurses,nurses to assistant nurses,etc.).
\nWhen tasks are shifted to unquali\ufb01ed person-
\nnel \u2013 referred to as \u201ccommunity health work-
\ners\u201d\u2013 the creation of a second-class health care
\nsystem is inevitable. Task shifting should not
\nbe used as a means to replace health profes-
\nsionals, but rather as a way to complement
\ntheir work. Task shifting requires signi\ufb01cant
\nsupervision of community health workers by
\nhealth professionals and therefore does not
\nlead to a decrease in the workload for already
\noverworked health professionals. Even with
\ntask shifting, a strong increase in the number
\nof health professionals is necessary.
\nIt was clear that the current approach to task
\nshifting, as driven by WHO and donor or-
\nganizations, is far removed from these prin-
\nciples.
\nQuality Workplaces for Quality Care is the campaign title to promote Positive Practice Environments. The
\n5-year global campaign is spearheaded by key stakeholders – International Council of Nurses, International
\nHospital Federation, International Pharmaceutical Federation, World Confederation for PhysicalTherapy,
\nWorld Dental Federation, World Medical Association and the Global Health Workforce Alliance. Its purpose
\nis to ensure safe, cost-e\ufb00ective and healthy workplaces worldwide, thereby strengthening health systems and
\nimproving patient safety.
\nPositive practice environments (PPE) is a recognized strategy to address the global health workforce crisis.PPE
\nare health care settings that support professional excellence by providing good working condition.They have the
\npower not only to attract and retain sta\ufb00, but also to improve patient satisfaction and outcomes, cost-e\ufb00ective
\nservices and most important health care safety.
\nThe objectives of the PPE campaign are to:
\nMake the case\u2022 for healthy, supportive work environments, through evidence of their positive impact on
\nsta\ufb00 recruitment and retention, patient outcomes and health sector performance.
\nBuild a global platform \u2013\u2022 share examples of good practices for healthy, supportive and e\ufb03cient workplaces.
\nFor that the campaign will provide materials including an advocacy toolkit presenting evidence of the
\nbene\ufb01cial impact of PPE, a web based, user-friendly library of PPE reference materials or best practice
\nguidelines for the health workplace.
\nDrive a sustained trend\u2022 in establishing and applying the principles of positive practice environments
\nacross the health sector.
\nBe open\u2022 to all countries, settings and health disciplines.The global campaign materials are open for adap-
\ntation to suit local preferences and to engage indigenous support and action.
\nCelebrate success\u2022 in support of e\ufb00ective strategies that promote sustainable health systems.
\n37
\nParticipants then turned their attention to
\nthe PPE campaign and identi\ufb01ed some as-
\npects that must be addressed:
\nWhile health professionals work under
\nvery di\ufb03cult circumstances to serve their
\npatients, their own health is often neglect-
\ned. PPE should include proper access to
\ngood quality health care for health profes-
\nsionals.
\nInstead of tolerating or even accepting bad
\nworking conditions, health professionals
\nmust advocate for, and actively drive, change.
\nIn all countries,working conditions for health
\nprofessionals could be signi\ufb01cantly improved.
\nAs conditions and priorities in each country
\ndi\ufb00er,planning and implementation for PPE
\nmust be undertaken at the national level.
\nAfter careful analysis, with particular atten-
\ntion to the situation in Africa, participants
\nidenti\ufb01ed two complementary strategies
\nto respond to the health workforce shortage
\nand to promote PPE:
\nCapacitybuilding:Currently,nationalorga-
\nnizations of the various health professional
\ngroups are not equipped to create the strong
\nadvocacy force required to impact decision-
\nmaking at the national level. Strong health
\nprofessional organizations could help to
\npropose, promote and implement e\ufb03cient
\nhealth policy. Capacity building for national
\nhealth professional organisations is there-
\nfore a critical priority.
\nNational coalitions: Even where profes-
\nsional organizations are e\ufb00ectively working,
\ntheir impact could be improved by better
\ncollaboration at the national level. Many
\nparticipants recognized the value of meet-
\ning as a global coalition in Kampala. Cre-
\nating similar national forums where health
\nprofessionals\u2019 organisations can meet and
\nexchange good practices, combine resources
\nand pursue common strategies, would be
\nextremely useful. Some suggested establish-
\ning formally a national body composed of
\nrepresentatives of health professions or-
\nganisations to pursue joint actions, develop
\ncampaigns and exert political leverage. In
\naddition, the need to promote a change of
\nmindset toward more solidarity and joint
\nmobilisation among nurses, physicians and
\nother health professionals was clearly evi-
\ndent and strongly supported.
\nClarisse Delorme
\nAdvocacy advisor, World Medical Association
\n28 February 2008
\nJoint Health Professions Statement
\nOn Task Shifting
\nWe,the representatives of more than 25 million health
\nprofessionals, are committed to providing safe, acces-
\nsible health care to the world\u2019s people. We understand
\nall too well the impact of shortage of personnel, sup-
\nplies and equipment on patients, families and provid-
\ners. We witness the impact daily of not enough sta\ufb00,
\nnot enough clean water,not enough drugs,not enough
\nmoney to access services or to a\ufb00ord life\u2019s staples. We
\nsee health professionals mentally and physically ex-
\nhausted daily. We struggle with the dilemma of re-
\nsource restrictions and meeting the needs of everyone
\n– and the evidence that shows that better health out-
\ncomes occur when higher numbers of professionals are
\nengaged in direct care.
\nWe understand the need to address today\u2019s human re-
\nsource crisis. At the same time we are concerned that
\ntask shifting and adding new cadres of workers result
\nin fragmented and ine\ufb03cient service through reduc-
\ntionist and vertical approaches. We believe that for
\ntask shifting to be e\ufb00ective:
\nSkill mix decisions should be country-speci\ufb01c and
\ntake account of local service delivery needs, quality
\nand e\ufb00ectiveness factors, e\ufb03ciency, the current con-
\n\ufb01guration of health services and available resources, as
\nwell as production and training capacity, and include
\nthe health professions in decision-making.
\nRoles and job descriptions should be described on the
\nbasis of the competencies required for service deliv-
\nery and constitute part of a coherent, competency-
\nbased career framework that encourages progression
\nthrough lifelong learning and recognition of existing
\nand changing competence.
\nThere needs to be su\ufb03cient health professionals to pro-
\nvide the required selection, training, direction, supervi-
\nsion, and continuing education of auxiliary workers.
\nRegulations for assistive personnel and task-shifting
\nneed to be set with the professions involved. It should
\nbe clearly stated who is responsible for supportive su-
\npervision to assistive personnel. In any case the cur-
\nriculum development, the teaching, supervision and
\nassessment should always involve the health profes-
\nsionals from whom the task is being shifted.
\nThere must be adequate planning and monitoring
\nto avoid the danger of generating a fragmented and
\ndisjointed system that fails to meet the total health
\nneeds of the patient,o\ufb00ers a series of disconnected and
\nparallel services that are both ine\ufb03cient and confus-
\ning, and may lead to de-motivation and high attrition
\nrates.
\nAssistive personnel need compensation and bene\ufb01ts
\nthat equal a living wage, a safe workplace and ad-
\nequate supplies to ensure their own safety and that of
\npatients. At the same time they should be expected to
\nwork within the code of conduct of their employer.
\nDeploying assistive personnel will increase demand
\non health professionals in at least three ways: (1)
\nincreased responsibilities as trainers and supervisors,
\ntaking scarce time away from other tasks; (2) higher
\nnumbers will be needed to take care of the new pa-
\ntients generated by successful task-shifting; and (3)
\nhealth professionals will be faced with patients who
\nhave more complex health needs (the simpler cases
\nwill be covered by task-shifting) and thus require
\nmore sophisticated analytical, diagnostic, and treat-
\nment skills.
\nThere needs to be credible analysis of the economic
\nbene\ufb01t of task shifting to ensure equal or better ben-
\ne\ufb01t, i.e. health outcomes, cost e\ufb00ectiveness, productiv-
\nity, etc. Ongoing evaluation, particularly in skill-mix
\nchanges and the introduction of new cadres and or
\nnew models of care, should systematically consider the
\nimpact on patient and health outcomes as well as on
\ne\ufb03ciency and e\ufb00ectiveness.
\nWhen task shifting occurs in response to speci\ufb01c
\nhealth issues such as HIV, regular assessment and
\nmonitoring should be conducted on the entire health
\nsystem of the country concerned. In particular, quality
\nassessment linked to overall health outcomes of the
\npopulation is essential to ensure that programs are im-
\nproving the health of patients across the health care
\nsystem.
\nAssistive workers should not be employed at the ex-
\npense of unemployed and underemployed health
\nprofessionals. Task-shifting should be complemented
\nby fair and appropriate remuneration of health profes-
\nsionals and improvement of their working conditions.
\nWhere task shifting is meant as a long-term strategy
\nit needs to be sustainable.If meant as short term,there
\nneeds to be a clear exit strategy.
\nAssistive workers need to be integrated into health
\ncare delivery systems and treated as part of the team.
\nConclusion
\nIn geographical areas facing a critical shortage of
\nhealth professionals, e\ufb00orts should be made and sup-
\nported to increase professional training opportunities
\n(undergraduate and graduate), and to provide incen-
\ntives for the retention of health professionals.
\nWhatever the strategy selected, task-shifting should
\nnot replace the development of sustainable, fully func-
\ntioning health care systems. It is not the answer to en-
\nsuring comprehensive care, including secondary care,
\nis accessible to all.
\nInternational Confederation of Midwives
\nInternational Council of Nurses
\nInternational Pharmaceutical Federation
\nWorld Confederation of Physical Therapists
\nWorld Dental Federation
\nWorld Medical Association
\n38
\nA comprehensive prevention strategy for
\nreducing the threat of cervical cancer has
\nbeen called for by the World Medical As-
\nsociation and the Medical Women\u2019s Inter-
\nnational Association.
\nIn a joint statement to mark international
\nwomen\u2019s day (March 8), the two organisa-
\ntions demand action for women and girls
\naround the world to have equal access to the
\nhighest quality prevention and treatment
\noptions for cervical cancer and say that such
\na strategy should include screening and vac-
\ncination.
\nDr. Shelley Ross, Secretary-General of
\nthe Medical Women\u2019s International Asso-
\nciation, said: \u2018Cervical cancer is the second
\nmost common cancer among women. But
\nit is now preventable due to the availability
\nof a vaccine against human papillomavirus
\n(HPV)\u2019.
\nShe said that every year cervical cancer af-
\nfected 500,000 women and took the lives
\nof a quarter of a million women worldwide.
\nWomen in poor countries were the most af-
\nfected, with 80 per cent of the deaths from
\ncervical cancer due to extremely limited
\nscreening and treatment availability.
\nDr. Ross added: \u2018When re\ufb02ecting back on
\nmajor advances in women\u2019s health in years to
\ncome,HPVvaccinewillbelistedasoneofthe
\nmajor breakthroughs. It is urgent that gov-
\nernments across the world start prioritizing
\ncervical cancer with sustainable political and
\n\ufb01nancial commitments.Not doing so means
\nlosing lives. It means also not granting to
\nwomen and girls in poor countries the right
\nto equal access to life-saving technologies\u2019.
\nFour of the common types of HPV could
\nbe prevented through vaccination although
\nthere was currently no treatment available
\nwhich could cure an HPV infection. HPV
\nvaccine therefore had the potential to sub-
\nstantially reduce the prevalence of cervical
\ncancer, although not to eradicate it.
\nDr. Jon Snaedal, President of the WMA,
\nsaid \u2018Medical associations have a key role to
\nplay in this strategy in making information
\non HPV vaccine available to physicians and
\nto encourage physicians to alert their pa-
\ntients on this innovation\u2019.
\n\u2018Cost must not be a barrier to making the
\nvaccine available to women and girls world-
\nwide. We are calling for a strong mobilisa-
\ntion of decision-makers, international or-
\nganisations,international donor community
\nand development partners, as well as medi-
\ncal associations, civil society and industry to
\nact now for a change, to stop cervical can-
\ncer\u2019.
\nIn April 2008 the British Medical Asso-
\nciation (BMA) published \u201cHealth profes-
\nsionals taking action on climate change\u201d,
\na web based resource which calls on health
\nprofessionals to take a lead in tackling cli-
\nmate change. As ambassadors of health,
\ndoctors have both the opportunity and a
\nresponsibility to highlight the public health
\nrisks of climate change. The resource aims
\nto provide an overview of the science of
\nclimate change and the resulting implica-
\ntions, particularly for health in the UK. The
\nkey purpose is to highlight what practical
\nactions health professionals and healthcare
\norganisations can take in order to reduce
\ntheir carbon footprint. Some of the sim-
\nplest measures include turning appliances
\no\ufb00 stand-by, reducing unnecessary heating,
\nrepairing leaking taps, minimising waste,
\nand reusing items and recycling where pos-
\nsible.The resource also includes examples of
\ngood practice and links to sources of further
\ninformation.
\nAs well as reducing their own carbon foot-
\nprint, health professionals are well placed to
\nin\ufb02uence and promote social change. With
\na history of combating major public health
\nconcerns, health professionals can play a vi-
\ntal role in tackling climate change and the
\nrelated adverse e\ufb00ects on health. By high-
\nlighting the numerous health bene\ufb01ts asso-
\nciated with more environmentally friendly
\nactivities and lifestyles, they can empower
\nindividuals to become greener and encour-
\nage public debate.
\nHealthcare organisations are signi\ufb01cant
\ncontributors to carbon emissions.In the UK
\nfor example, the NHS is the largest single
\norganisation, with an annual purchasing
\nbudget of around \u00a317 billion. It employs
\nover one million people and emits around
\none million tonnes of carbon every year.
\nThere is huge potential for NHS to promote
\ncombating climate change, through taking
\npractical steps to reduce carbon emissions
\nand by raising sta\ufb00 and public awareness to
\nthese initiatives.
\nThe BMA believes it is essential that all
\ndoctors and healthcare organisations lead by
\nexample in reducing their negative impact
\non the environment; work together to re-
\nduce the carbon emissions of healthcare or-
\nganisations; and promote greener lifestyles
\nto ensure a healthy, sustainable future.
\nThe web resource can be accessed by visiting
\nthe BMA website at http:\/\/www.bma.org.
\nuk\/ap.nsf\/Content\/climatechange
\nCall for Equal Access to Cervical Cancer
\nTreatment for All Women and Girls
\nHealth Professionals Taking Action
\non Climate Change
\nA web report from the British Medical Association\u2019s Board of Science
\n39
\nIntroduction
\nMercury,one of the world\u2019s most ubiquitous
\nheavy metal neurotoxicants, has been exten-
\nsively used in health care since antiquity. It
\nhas been an integral part of many medical
\ndevices, most prominently thermometers
\nand sphygmomanometers. These both add
\nto the global burden of mercury removed
\nfrom its below ground repository and spread
\nabout on the surface to form highly neuro-
\ntoxic organomercury compounds. Further,
\nthese devices break or leak with regularity,
\nexposing health care workers to the acute
\ne\ufb00ects of the inhalation of the metal itself.
\nIn view of this, as part of a global initiative
\nto reduce the use and spread of mercury in
\nall aspects of society, health care providers
\nand institutions have begun to replace mer-
\ncury-based medical devices with a\ufb00ordable,
\naccurate and safer alternatives.
\nIn 2005 the World Health Organization
\nadvised, in its eloquently crafted policy pa-
\nper on the topic, a global transition of the
\nhealth care sector toward the use of mercury
\nfree care alternatives. Speci\ufb01cally, the paper
\nprojected a 3 step approach:
\n\u201cShortTerm: Develop and implement plans
\nto reduce the use of mercury equipment and
\nreplace it with mercury-free alternatives.
\nAddress clean-up, storage and disposal.
\nMediumTerm:Increase e\ufb00orts to reduce the
\nuse of unnecessary mercury equipment in
\nhospitals.
\nLong Term: Support a ban of mercury-con-
\ntaining devices and promote alternatives.\u201d
\nIn Europe, re\ufb02ecting the elimination of the
\nuse of mercury devices by all major provid-
\ners, several countries, including Sweden, the
\nNetherlands, and Denmark have banned
\nthe use of mercury thermometers, blood
\npressure devices and a variety of other mer-
\ncury containing equipment. In 2007, the
\nEuropean Parliament extended the ban on
\nmercury thermometers to the entire Union.
\nIn the United States, Canada, Mexico, Ar-
\ngentina and countries in between,thousands
\nof hospitals, pharmacies and medical device
\npurchasers have switched to digital ther-
\nmometers along with mercury free aneroid
\nand digital sphygmomanometers.These ini-
\ntiatives have become so widespread in the
\nU.S. that the health care market has been
\nfundamentally restructured toward mercury
\nfree devices for all applications.
\nIn Sao Paulo, Brazil, more than 92 hospi-
\ntals have signed agreements committing
\nto eliminate mercury-based thermometers
\nand sphygmomanometers \u2013 more than 42
\nhave already done so. The Buenos Aires city
\ngovernment, which runs the largest health
\ncare system in Argentina, is implementing a
\npolicy to phase out mercury-based medical
\ndevices in 33 major hospitals and 38 small-
\ner health care centres and three Provinces
\nhave issued letters of intent to phase-out
\nmercury-based medical devices. Cuba has
\nreplaced nearly all of its mercury sphygmo-
\nmanometers with aneroid devices.
\nIn Asia and Africa as well, despite economic
\nconstraints, a growing number of hospitals
\nhave committed to going mercury-free, and
\na number of large cities, states, and national
\ngovernments are developing model policies
\nfor mercury-free health care. In India, the
\nDelhi city government is pursuing a mercury
\nfree policy for its health facilities. The Prov-
\nince of Kwa Zulu Natal in South Africa has
\nissued directives banning the purchase of mer-
\ncury thermometers and sphygmomanometers.
\nOn a national level,the Philippines are devel-
\noping an Administrative Order to phase-out
\nmercury in health care andTaiwan has banned
\nmercury fever thermometers.
\nThe transition to mercury free health care
\ntoday is neither smooth nor universal. It
\npresents a series of challenges to the health
\ncare sector that must be practically con-
\nfronted with evidence based solutions that
\nneither increase patient risks nor contribute
\nto the increasing costs of health care. Yet so-
\nlutions are available that permit health care
\ninstitutions to reduce their contribution to
\nthis toxic environmental exposure that risks
\npatients\u2019health and well being. Health Care
\nWithout Harm, an international coalition of
\nmedical providers, nurses, health care insti-
\ntutions, professional organizations, and envi-
\nronmentalists seeking to reduce the environ-
\nmental impact of health care, has taken on
\nthe challenge presented by these issues.
\nPhysicians have a special role to play in this
\ne\ufb00ort to improve the public\u2019s health through
\nprimary prevention. They are uniquely able
\nto translate the toxicologic and epidemiologic
\ninformation in the medical literature for the
\npublic and policy makers. They are often the
\nleaders of health care institutions, always are
\nthe key and deciding element in the provi-
\nsion of patient care, and they hold in\ufb02uential
\npositions in most countries as community
\nleaders. National and international medical
\nsocieties are playing and will continue to play
\nan important role in this global process.
\nThe Problem
\nMercury in the Environment
\nMercury is a naturally occurring heavy met-
\nal. At ambient temperature and pressure,
\nmercury is a silvery-white liquid that read-
\nily vaporizes. When released into the air,
\nmercury may stay in the atmosphere for up
\nto a year, and is transported and deposited
\nglobally. It is within this environment that
\ninorganic and organic compounds of mer-
\ncury are formed.
\nMercury-free Health Care
\n40
\nSince the start of the industrial era, the
\ntotal amount of mercury circulating in the
\nworld\u2019s atmosphere, soils, lakes, streams and
\noceans has increased by a factor of between
\ntwo and four. This increase has been a\ufb00ect-
\ned by human endeavours, which include the
\nremoval of mercury from its subterranean
\nhome through mining and the extraction
\nof fossil fuels. Human exposure to mercury
\ncan result from a variety of sources, includ-
\ning, but not limited to, consumption of \ufb01sh
\nrich in methyl mercury, and due to spills or
\nleaks of the metallic element itself.
\nMercury causes a variety of signi\ufb01cant ad-
\nverse impacts on human health and the
\nglobal environment. Mercury vapour may
\nproduce pneumonitis and pulmonary edema
\nif inhaled and toxic levels can be absorbed
\nthrough the skin due to handling of the liq-
\nuid metal especially if the epithelial barrier
\nhas been broken due to cuts or abrasions.
\nTarget organs other than the lungs include
\nkidneys, nervous system and GI tract. An-
\necdotal reports from hospitals utilizing mer-
\ncury thermometers report breakage ranging
\nfrom several to several hundred a month.
\nThese reports are paralleled by those noting
\nleakages of mercury containing sphygmo-
\nmanometers as well with the potential for
\nsigni\ufb01cantly larger amounts released.
\nYet, of even more concern is potential for
\ndevelopmental neurotoxicity produced by
\nlow dose methyl mercury exposure through
\nfood. Elemental mercury accumulates in
\nlake, river, stream, and ocean sediments,
\nwhere it is transformed into methyl mer-
\ncury, which then accumulates in \ufb01sh tis-
\nsue. This contamination of \ufb01sh stock is
\nubiquitously present in oceans and lakes
\nthroughout the world, concentrating sev-
\neral hundred thousand times as it moves
\nup the aquatic food chain.
\nMethyl mercury is of special concern for
\nfoetuses, infants, and children because it
\nimpairs neurological development. When
\na woman eats seafood that contains mer-
\ncury, it accumulates in her body, requiring
\nmonths to years to excrete. If she becomes
\npregnant within this time, her foetus is
\nexposed to methyl mercury in the womb,
\nwhich can adversely a\ufb00ect the foetus\u2019 cen-
\ntral nervous system. Impacts on cognitive
\nthinking, memory, attention, language, and
\n\ufb01ne motor and visual spatial skills have been
\ndocumented in children with exposure in
\nutero to levels of methyl mercury commonly
\nfound in women of child bearing age.
\nAlong with WHO, the United Nations
\nEnvironment Programme (UNEP) has
\nidenti\ufb01ed the adverse e\ufb00ects of mercury
\npollution as a serious global environmen-
\ntal and human health problem. The UNEP
\nGoverning Council, representing all UN
\nrepresented countries, has targeted reducing
\nmethyl mercury accumulation in the global
\nenvironment as a major global priority.
\nSources of Mercury Pollution:
\nThe health care sector is far from the great-
\nest source of organic mercury compounds in
\nthe environment. Rather, coal-\ufb01red power
\nplant emissions and mercury cell chlor-alkali
\nplants, along with artisanal gold mining and
\nbattery disposal are all far more signi\ufb01cant
\npolluters. However, the health care sector
\ndoes play an important role as a source of
\nglobal emissions, as well as a source of low-
\nlevel, chronic and acute elemental mercury
\npoisoning.
\nMercury can be found in many health care
\ndevices and present in \ufb02uorescent lamps as
\nwell as dental amalgams. Mercury is also
\nfound in many chemicals and measure-
\nment devices used in health care laborato-
\nries. Medical waste incinerators, as well as
\nmunicipal waste incinerators, emit mercury
\ninto the atmosphere when they burn wastes
\nthat contain mercury. According to the U.S.
\nEnvironmental Protection Agency (EPA),
\nin 1996, prior to the mercury phase-out in
\nU.S. health care, medical waste incinerators
\nwere the fourth largest source of mercury
\nemissions to the environment. Hospitals
\nwere also known to contribute 4-5% of the
\ntotal wastewater mercury load. And mer-
\ncury fever thermometers alone contributed
\nabout 15 metric tons of mercury to solid
\nwaste land\ufb01lls annually.
\nIn 2005, Transande et al. using national
\nblood mercury prevalence data from the
\nUS Centers for Disease Control estimated
\nthat between in this century 316,588 and
\n637,233 US children each year have cord
\nblood mercury levels > 5.8 \u03bcg\/L, a level as-
\nsociated with loss of IQ. They estimated
\nthat lost productivity due to this amounts
\nto $8.7 billion annually (range, $2.2\u201343.8
\nbillion).
\nWhile no comprehensive \ufb01gures are avail-
\nable, anecdotal evidence suggests that in
\nmost of Asia, Africa and Latin America,
\nmercury spills are not properly cleaned, nor
\nis the waste segregated and managed prop-
\nerly. Rather, it is either incinerated, \ufb02ushed
\ndown the drain, or sent, via solid waste, to
\na land\ufb01ll.
\nThermometer breakages on a case-by-case
\nbasis pose some harm to patients, nurses
\nand other health care providers when mer-
\ncury is absorbed through the skin or mer-
\ncury vapour is inhaled. Only a relatively
\nsmall amount of mercury \u2013 roughly one
\n41
\ngram \u2013 is released when each thermometer
\nbreaks. However, when taken cumulatively
\non a hospital ward, in an entire hospital, na-
\ntionally and globally, the situation takes on
\nmore serious dimensions.
\nIn Buenos Aires, for instance, the city
\ngovernment, which runs 33 hospitals and
\nmore than 38 clinics, was purchasing nearly
\n40,000 new thermometers a year,until it be-
\ngan to switch over to alternatives in 2006.
\nGiven that nurses and other health care
\nprofessionals often buy their own thermom-
\neters to supplement the city\u2019s procurement,
\nthe city\u2019s health system was using well over
\n40,000 thermometers a year, most of which
\nwould break, and some of which would be
\ntaken home (where most would ultimately
\nbreak as well). The system was ultimately
\nemitting in excess of 40 kilograms of mer-
\ncury into the local hospital environment
\nand into the global ecosystem every year.
\nIf one were to use this \ufb01gure and extrapo-
\nlate for the entire country, one can estimate
\nthat until recently thermometers broken in
\nArgentina\u2019s health care system were spilling
\n826 kilos, or nearly 1 metric ton of mercury,
\ninto the global environment every year.
\nIn Mexico City, the 250-bed \u201cFederico
\nGomez\u201d Children\u2019s Hospital is a medical
\nservice, teaching, and research hospital af-
\n\ufb01liated with the National Autonomous
\nUniversity of Mexico. This prestigious chil-
\ndren\u2019s hospital documented a thermometer
\nbreakage rate of 385 per month, or well
\nover 4,000 per year (see Table 1). The total
\nnumber of estimated broken thermometers
\nin this one hospital between 2002 and early
\n2007 is nearly 22,000 \u2013 the equivalent of 22
\nkilograms of mercury.
\nWhile the Federico Gomez hospital has
\nnow committed to substitute its mercury
\ndevices with alternatives, when it undertook
\nits initial assessment there was no clean-up
\nprotocol for mercury spills. Rather, mercury
\nwaste was deposited with both infectious
\nand biological hazardous wastes, or with
\nmunicipal wastes. Broken \ufb02uorescent lamps
\nwere also treated as municipal waste. Mer-
\ncury containing equipment was not repaired
\nif broken,and the procedure followed was to
\nmerely register the loss and replace it with
\nnew equipment.
\nThe regular and ongoing breakage of ther-
\nmometers and the lack of mercury waste
\nmanagement protocols and practices found
\nat the Federico Gomez hospital is not an
\nexception, but more generally the rule in
\nhospitals throughout much of the Global
\nSouth,where patients and health care work-
\ners are regularly and unknowingly exposed
\nto this toxin.
\nThis is the case, for instance, in India, where
\nfar fewer thermometers are employed in
\nmany hospitals). In a study of New Delhi
\nhospitals, the NGO Toxics Link found dan-
\ngerously high levels of mercury in a series
\nof indoor air samples. They found the \u201csub-
\nstantial presence of mercury in ambient air
\nof both the hospitals\u201d studied. These levels,
\nwhich ranged from 1.12 microgram per cubic
\nmeter to 3.78 microgram\/m3
\n, were all higher
\nthan numerous international standards.
\nOne of the biggest mercury hot spots that
\nToxics Link found in its study was the room
\nused to calibrate blood pressure devices
\n(sphygmomanometers), which contain 80-
\n100 grams of mercury or 80-100 times the
\namount found in a single fever thermometer.
\nMercury release and contamination from
\nsphygmomanometer calibration is a com-
\nmon problem throughout the world. Louis
\nHavinga, Manager of Health Technology
\nServices for the KwaZulu Natal Province
\nDepartment of Health in South Africa ex-
\nplained:
\nThis is the most important point why the
\nHealth Technology Services has moved
\naway from the use of mercury products.
\nThe technicians were exposed to mercury
\nwhen they repaired mercury column sphyg-
\nmomanometers. Special precautions and
\nequipment is needed if working with mer-
\ncury products like a dedicated fume\/vapour
\nextraction unit within the maintenance
\ndepartment. The mercury is extracted from
\nthe device and placed in a special marked
\ncontainer. The container must be able to
\nseal and should remain inside the fume\/va-
\npour extraction unit. Once the container is
\nfull, the container must be disposed of in a
\nwell documented and controlled manner by
\nmaking use of a recognized hazardous waste
\ndisposal company which is very costly.
\nAnd while sphygmomanometers break less
\nfrequently than thermometers, the spill-
\nage is signi\ufb01cant and therefore problematic
\nfrom an environmental health perspective.
\nAt the Mayo Clinic in the U.S., between
\n1993 and 1995, 50 spills were documented
\nTable 1
\nMonthly Mercury Thermometer Breakage at
\nFrederico Gomez Children\u2019s Hospital Mexico
\nCity
\nSevices Broken
\nper month
\nIntensive care unit 20
\nPostoperatory recovery 20
\nEmergency Room 30
\nOut-patient studies recovery 6
\nSurgery 15
\nPediatric ICU 15
\nSurgery ICU 15
\nNephrology 30
\nExternal consultation 20
\nGeneral consultation 30
\nOut-patient surgery 2
\nPediatrics I 15
\nPediatrics II 30
\nImmunosuppressive illnessis 30
\nChemotherapy 2
\nUrogical surgery 45
\nSpecial care 30
\nOrthopedics 30
\nTotal:
\nApproximate yearly total:
\n385
\n4.620
\nSource; HCWH\/CAATA, 2007
\n42
\nrelating to leakage and spills from sphyg-
\nmomanometers.
\nOvercoming the Obstacles:
\nAccuracy, A\ufb00ordability, Disposal
\nIt is clearly in the interest of public health
\nand the environment to replace mercury-
\ncontaining measuring devices in the health
\ncare sector. However, actually implement-
\ning such a transition runs into three funda-
\nmental challenges.
\nFirst, is that the long term use of healthcare
\nmercury devices has helped to support a be-
\nlief that mercury products are accurate and
\ndo not need calibration. Together with this
\nbelief, there is a deep scepticism in much of
\nthe medical community regarding the accu-
\nracy of alternatives. Second, replacing mer-
\ncury-based medical devices is often seen as
\nan expensive proposition that is unobtain-
\nable for cash-strapped health care sectors in
\nthe developing world. Third, is the thorny
\nquestion of what to do with mercury that
\nis taken out of circulation in the health care
\nsetting. Many governments lack the infra-
\nstructure to manage mercury waste, so it is
\noften not clear what to do with this toxic
\nelement once a hospital takes it out of cir-
\nculation.
\nThese are relevant concerns and good ques-
\ntions, yet there are answers and proven ap-
\nproaches to replacing these devices.
\nAccuracy
\nSome medical professionals still consider
\nmercury to be the only accurate and consis-
\ntent method of measuring temperature and
\nblood pressure. Yet,as peer reviewed studies
\nfrom the last decade demonstrate,this is not
\ncurrently the case, and in fact our attitude
\ntoward the accuracy of mercury thermome-
\nters and sphygmomanometers was probably
\noverly positive in years past as well.
\nThe mercury \ufb01lled glass thermometer,
\nthough easily and frequently broken, is one
\nof the simplest and most widely used diag-
\nnostic tools. It was therefore the \ufb01rst clini-
\ncal mercury device to be evaluated for accu-
\nracy in comparison with a growing number
\nof available alternatives.
\nAfter considerable debate in the 1990s,
\nLeick-Rude and Bloom, during routine ac-
\ncuracy testing in a study, reported that 25%
\nof the glass\/mercury thermometers tested
\ndi\ufb00ered from the reference thermometer by
\n>0.2 degrees Centigrade. This \ufb01nding was
\nconsistent with the authors\u2019 review of prior
\nwork. Indeed, another recent study had re-
\njected 28% of glass\/mercury thermometers
\ndue to inaccuracy.
\nDigital thermometers, the most commonly
\nused mercury-free temperature device, use
\na thermistor to convert temperature into a
\nknown electrical resistance, and are highly
\nsensitive. As with most products (mercury
\nor mercury free) their accuracy is dependent
\non manufacturing quality and techniques.
\nStandards organizations such as the ASTM
\nInternational have developed protocols that
\nwill help the healthcare community identify
\naccurate alternatives. It is imperative that
\nthe healthcare community and governments
\nensure that thermometers are purchased
\nfrom manufacturers that follow techniques
\nand testing protocols that are independently
\ncerti\ufb01ed by ASTM or other internationally
\nestablished regimes, so as to provide a prod-
\nuct that provides the accuracy required.
\nSphygmomanometers represent the larg-
\nest reservoir of mercury in current medi-
\ncal use. As with thermometers, mercury
\nand non-mercury blood pressure devices
\nprovide accurate measurement so long as
\nboth instruments are calibrated. Examples
\nof both inaccurate mercury and mercury-
\nfree sphygmomanometers can be found
\nin the medical literature, though this in-
\naccuracy is typically related to poor main-
\ntenance and calibration. A large number
\nof scienti\ufb01c studies have concluded that
\nmercury-free measuring devices produce
\nthe same degree of accuracy as mercury
\ndevices, provided they are properly main-
\ntained and calibrated. For instance, a study
\nat the Mayo Clinic in the US concluded
\nthat aneroid sphygmomanometers provide
\naccurate pressure measurements when a
\nproper maintenance protocol is followed.
\nSome have argued that for accurate blood
\npressure measurement the reference de-
\nvice used for calibration must be a mercury
\nblood pressure device (with a typical error of
\n\u00b13 mm of mercury). Yet, when calibrating
\na device the error of the reference pressure
\nshould be added to the speci\ufb01ed accuracy
\nof the instrument under test (\u00b13 mm Hg)
\nto determine the working accuracy of a
\ncalibration set-up. As a result, if using a
\nmanometer (mercury column or aneroid
\ngauge) rated at \u00b13.0 mm Hg as a reference,
\none will be able to determine the accuracy
\nof the gauge being tested to only \u00b16.0 mm
\nHg. This is outside the range of \u00b15 mm
\nof mercury typically desired by medical
\nprofessionals. Many facilities and device
\nmanufacturers are using a device (e.g., digi-
\ntal pressure standard) rated at \u00b10.1 mm Hg,
\none will be able to determine the accuracy
\nof the gauge being tested to within \u00b13.1
\nmm Hg. This has been well documented to
\nbe far less than the inter or intra provider
\ndi\ufb00erences on multiple readings.
\nA U.S. study from 2003 concluded in sum-
\nmary that \u201cresearch on sphygmomanom-
\neters suggests that there are numerous good
\nalternatives to mercury sphygmomanome-
\nters. Aneroid sphygmomanometers are cost
\ncompetitive, have a long history in the \ufb01eld,
\nand have been found acceptable by many
\nhospitals.\u201d
\nIn a UK study, an aneroid device achieved
\nan A grade for both systolic and diastolic
\npressures and ful\ufb01lled the requirements of
\nthe Association for the Advancement of
\nMedical Instrumentation. The conclusion
\nwas that the aneroid device could be recom-
\nmended for use in an adult population.
\nThe UK Medicines and Healthcare Prod-
\nucts Regulatory Agency (MHRA) states
\nthat aneroid and mercury sphygmomanom-
\neters both need to be checked regularly in
\norder to avoid errors in blood pressure mea-
\nsurement; the British Hypertension Society
\nrecommends testing every 6 to 12 months.
\n43
\nFrequently lost in the discussion over de-
\nvice accuracy, and equally important is the
\nissue of measurement technique. A 2002
\nWorking Meeting on blood pressure mea-
\nsurement in the United States highlighted
\nnumerous studies which found that basic
\nmeasurement technique, inappropriate cu\ufb00
\nsize and poor cu\ufb00 size were providing sig-
\nni\ufb01cant errors in measurement.
\nSwitching to mercury free sphygmoma-
\nnometers in clinical settings has not caused
\nproblems in clinical diagnosis and monitor-
\ning in Sweden or Brazil. The Swedish gov-
\nernment, in fact, has completely eliminated
\nmercury column sphygmomanometers.
\nOne problem that several hospitals in de-
\nveloping countries have encountered as
\nthey substitute mercury-containing sphyg-
\nmomanometers is that many aneroid and
\ndigital devices are of poor quality yet many
\ndevices currently produced satisfy the cri-
\nteria of professional organizations such as
\nthe British Hypertension Society, the Eu-
\nropean Hypertension Society and the As-
\nsociation for the Advancement of Medical
\nInstrumentation. The British Hypertension
\nSociety (BHS) has created a list of vendors
\nof sphygmomanometers that have met the
\nBHS criteria and are suitable for clinical
\npractice and posted it on their web site.
\nAs health care sectors in developing coun-
\ntries begin their substitutions, many are
\n\ufb01nding the non-mercury alternatives to
\nbe viable. As Louis Havinga, Manager of
\nHealth Technology Services for the Kwa-
\nZulu Natal Province Department of Health
\nin South Africa observes, before they de-
\ncided to phase out mercury-based medical
\ndevices in the province, \u201cclinical trials and
\ntechnical trials were conducted and various
\nelectronic sphygmomanometers were found
\nto be consistent and within acceptable ac-
\ncuracy range for clinical use.\u201d
\nA\ufb00ordability
\nMany healthcare practitioners are concerned
\nabout the availability of alternatives. In fact,
\nthere are many mercury-free thermometers
\nand sphygmomanometers available from
\nmajor medical equipment suppliers who
\nservice the global market.
\nYet the issue of a\ufb00ordability is still a chal-
\nlenging one, especially where the costs of
\nhuman and environmental impacts of mer-
\ncury releases are not included in the health
\ninstitution\u2019s accounts or budgets. From a
\ndeveloping economy\u2019s perspective, these
\ncosts must be taken into account in national
\nstrategic planning.
\nIn countries such as the United States,
\nwhere market demand for mercury alter-
\nnatives has begun to be felt and clean up
\ncosts quantitated a mercury free purchas-
\ning policy has become the most economic.
\nTable 3
\nCosts of Mercury vs Digital Termometers. he experience of Posadas Hospital, Buenos Aires
\nArgentina: April-June 2006\/ Before Mercury Replacement
\nTotal thermometers Cost per Unit in $ US
\nequipment
\nTotal cost
\nMercury Thermometers 3152 1,33 4.192
\nDigital Thermometers 0 4,00 0
\nTotal 3152 4.192
\nApril-June2007\/ as Digital Thermometers are Introduced
\nTotal thermometers Cost per Unit in $ US
\nequipment
\nTotal cost
\nMercury Thermometers 335 1,33 445
\nDigital Thermometers 188 4,00 752
\nTotal 523 1.197
\nTotal savings for 3 months u.S.$ 2.995
\nTable 4
\nEstimated Costs of Replacing Mercury Equipment in Hospital Sao Luiz, Sao Paulo Brazil
\nYear 1 Year 2 Year 3 Year 4 Year 5
\nDigital Devices
\nInitial investment 9.412
\nAnnual Maintnance 2.630 3.892 3.892 3.892 3.892
\nTotal costs adjusted by 12%
\nannually for in\ufb02ation
\n12.040 17.381 23.360 30.054 37.560
\nMercury Devices
\nAnnual Maintnance 5.923 5.923 5.923 5.923 5.923
\nTotal costs adjusted by 12%
\nannually for in\ufb02ation
\n5.923 12.559 19.991 28.314 37.37
\ndi\ufb00erence 6.125 4.829 3.377 1.751 69
\nAnnual savings after Year $2,031
\nFigures in US $ converted from Brasilian reals
\nTable 5
\nA Comparison of prices of Mercury and Digital Clinical
\nfever Thermometers in Selected Countries 52
\nArgen-
\ntina
\nBrazil Mex-
\nico
\nIndia China Philip-
\npines
\nSouth
\nAfrica
\nUSA Eng-
\nland
\nCzech.
\nRep
\nMercury
\nThermom-
\neters
\n$1.33 1.52 1.24 0.62 0.41 0.55 0.80 1,50 1.00
\nDigital
\nThermom-
\neters
\n4.00 10.52 3.77 5.35 4.65 4.67 4.37 2.09 7.00 5.00
\nPrice ratio 3:1 6.9:1 3:1 8.6:1 11.3:1 8.5:1 5.5:1 0:1 4.6:1 5:1
\n44
\nIn a study done by Kaiser Permanente, the
\nlargest not-for-pro\ufb01t Health Maintenance
\nOrganization (HMO) in the United States,
\nit was determined that when associated life-
\ncycle costs are included (compliance, liabil-
\nity, training, etc.) the total cost per unit of
\nan aneroid sphygmomanometer is about \u2153
\nthat of a mercury-containing device. Mer-
\ncury-containing devices are no longer being
\npurchased by Kaiser Permanente.
\nYet in the global market, mercury-based
\nmedical devices are still signi\ufb01cantly less
\nexpensive than their digital or aneroid
\ncounterparts. In the absence of strict en-
\nvironmental health regulations, and with
\nlimited healthcare budgets, many health
\ncare systems and hospitals today still face
\nthe challenge of deciding between a mer-
\ncury device and its alternative. Those facili-
\nties with limited budgets have been able to
\nsuccessfully avoid this road block through
\noperational strategies.
\nFor example, when planning future budgets
\nhospitals are counting the frequent mercury
\nthermometer breakages for inclusion in the
\ncost of current practices for comparison
\nwith the cost of a digital or mercury-free
\nalternative. Frequently, the additive cost is
\ncomparable to the replacement cost of the
\nmercury thermometers, as the alternatives
\nare typically more durable.
\nThe Hospital Posadas in Buenos Aires, Ar-
\ngentina pursued just such a strategy and re-
\nported signi\ufb01cant savings when it replaced
\nall of its thermometers. Table 3 shows that
\nbetween April and June 2006, this 450 bed
\nhospital purchased 3,152 mercury ther-
\nmometers. A year later, during the same
\nperiod in 2007, it purchased 355 mercury
\nthermometers and 188 digital devices. The
\ncost savings totalled nearly U.S. $3,000.
\nAt the Federico Gomez Children\u2019s Hospi-
\ntal in Mexico, it is estimated that this 250
\nbed institution will save a minimum of U.S.
\n$10,000 over six years when replacing mer-
\ncury thermometers. This estimate includes
\nthe costs of digital device and battery re-
\nplacement, as well as mercury and battery
\ndisposal.
\nIn the Hospital Sao Luiz in Sao Paulo,
\nBrazil, a 116 bed hospital, health care of-
\n\ufb01cials found that the costs of maintenance
\nand calibration of digital and aneroid ther-
\nmometers and sphygmomanometers were
\nsigni\ufb01cantly lower than the costs of main-
\ntaining existing mercury devices. In fact,
\nthey determined if they were to replace all
\nsphygmomanometers, wall thermometers
\nand clinical thermometers in the hospital
\nwith alternative devices, that the savings
\non maintenance and calibration would pay
\nback the initial capital investment of more
\nthan U.S. $9,000 in \ufb01ve years, while saving
\nanother U.S. $2,000 a year thereafter (see
\nTable 4).
\nHowever, in some parts of the world, the
\neconomic calculus is not yet as positive.
\nMercury thermometers, most of which are
\nproduced domestically, cost around U.S. $
\n0.62 in India \u2013 or half of what they cost in
\nmany other places in the world. Meanwhile
\na decent quality digital thermometer, most
\nof which are imported, costs USD $5.35, or
\n33 percent more than in much of the rest of
\nthe world. The situation in China is similar
\n(see Table 5).
\nDisposal
\nThe problem of what to do with other
\nmercury waste remains a vexing one. This
\nincludes waste from spills that occur until
\nreplacements are made, waste from mercury
\ndevices that are taken out of use, the ongo-
\ning collection of dental amalgam waste, and
\nwaste from used digital thermometer bat-
\nteries that contain trace amounts of mercury
\nand \ufb02uorescent bulbs.
\nOne option for disposal, though not ideal,
\noccurs in North America and many Euro-
\npean countries, where governments have
\ndeveloped infrastructure for the collection
\nof mercury waste products. These wastes
\nare \u201crecycled\u201d into new mercury-containing
\nproducts. Ideally, these products involve
\nessential uses of mercury for which alter-
\nnatives do not currently exist. While this
\nscenario provides healthcare facilities and
\nothers with a means of removing mercury
\nwaste from their facility\u2019s waste stream, the
\ncontinued sale and use of mercury-contain-
\ning products will invariably result in break-
\nage and escape to the environment during
\nproduct life or end of life.
\nThe preferred scenario is one in which mer-
\ncury and mercury-containing products are
\nno longer used, and the mercury in use is
\ncollected and no longer returned to the mar-
\nketplace in products.There is no one simple
\nsolution to the mercury problem, and until
\nthe goal of mercury elimination is realized,
\na variety of strategies must be implemented
\nthat move toward this solution.
\nConclusion
\nWith Europe, North America, and individ-
\nual countries, provinces, and cities through-
\nout the world well on the road to mercury-
\nfree health care, shifting the production
\nand consumption patterns in developing
\ncountries as a whole is the largest remaining
\nchallenge to this transition.
\nMercury free health care is not only pos-
\nsible, but if the right forces converge, the
\nday is not far o\ufb00 when most health care
\ninstitutions will be virtually mercury free.
\nIndividual physicians, their specialty soci-
\neties, and national medical associations are
\nand will continue to play a leading role in
\nthis transition.
\nIn October 2007 a resolution on control of
\nmercury pollution was passed from com-
\nmittee to the World Medical Association\u2019s
\nCouncil at a meeting in Copenhagen,which
\nsays in part:
\n\u201cMajor institutions around the world have
\ndemonstrated that safe, e\ufb00ective alterna-
\ntives exist for nearly all traditional health
\ncare uses of mercury. Historical concerns
\nabout the inaccuracy of mercury-free al-
\nternatives, and the belief that the mercury
\nsphygmomanometer is the gold standard,
\n45
\nare not borne out by the experiences of the
\nmultitude of institutions that have elimi-
\nnated their mercury sphygmomanometer
\nunits.\u201d
\nThe resolution was approved for distribu-
\ntion and discussion amongst the WMA\u2019s
\nnational medical associations. It will be
\nacted upon with \ufb01nal action at the 2008
\nAssembly meeting in Seoul Korea.
\nJoshua Karliner (josh@hcwh.org),
\nJamie Harvie, PE, (harvie@isfusa.org) and
\nProf. Peter Orris, MD, MPH (porris@uic.edu)
\nUniversity of Illinois at Chicago School of
\nPublic Health with Health Care Without Harm
\nIntroduction
\nIn recent years,much attention has been paid
\nto issues of healthcare in essentially every na-
\ntion in the world. The tasks of controlling
\nknown chronic diseases, caring for those af-
\n\ufb02ictedwithinfectiousdiseases,andingeneral,
\ndelivering healthcare to the masses, continue
\nto be a major \ufb01nancial and social problems
\nfor us all.A portion of the world\u2019s population
\nthat needs immediate attention is the elderly
\n(over the age of 65). They represent one of
\nthe fastest growing proportions of world
\npopulation. The reasons for this growth in
\npopulation are multi-factorial including bet-
\nter healthcare in some areas of the world,
\nmore e\ufb00ective treatments and prevention of
\nchronic disease, and in many cases, improve-
\nment of social economic status which has
\nallowed individuals of age to thrive. With
\nthe increase in numbers of the elderly, the
\nnormal physiologic changes that occur with
\naging need to be recognised by the medical
\ncommunity along with how these changes
\nin\ufb02uence speci\ufb01c disease processes and inju-
\nries. Many countries in the world have fully
\ndeveloped specialties and subspecialties in
\nGeriatrics and Gerontology. As this portion
\nof the population in these countries increase,
\none of the many issues in providing health-
\ncare to the aged is the supply of healthcare
\nproviders available. In emerging countries,
\nthe issue is a need for recognition of the
\nelderly as a separate population; having dif-
\nferent physiological responses and requiring
\nspecialised care. To e\ufb00ectively care for the
\nelderly population, it is important that we
\nrecognise the normal changes that occur in
\nthe human body over time. It is important to
\nremember that these changes are outside the
\nde\ufb01nition of acute and chronic disease, and
\nfor the purposes of this discussion, also out-
\nside the e\ufb00ects of any medications that may
\nbe administered to the elderly.
\nIn this discussion, we will focus speci\ufb01cally
\non the physiologic changes that occur in the
\nhuman body that increased an elderly pa-
\ntients\u2019tendency to fall.In the literature,a fall
\nis de\ufb01ned as \u201ca situation where a person comes
\nto rest inadvertently on the ground or a lower
\nlevel\u201d.1
\nFalls are one of the most common
\nthreats to the health and longevity of the
\naged.It is also a signi\ufb01cant cause of death in
\nthis population. Most of the discussions on
\nfalls do not include those caused by a loss of
\nconsciousness (i.e. syncope or seizures). Ap-
\nproximately 40 per cent of the elderly popu-
\nlation in the community over 65 experience
\none fall.That percentage increases to 60 per
\ncent if there is a prior history of a fall. Fif-
\nteen per cent of falls result in serious injury.
\nThe overall ideology of falls is often multi-
\nfactorial. This complex interaction of many
\nfactors intrinsic to the individual including
\nage related changes; chronic disease; illness;
\nmedication; changes of postural control; in-
\ncreased risk-taking behaviour; underlying
\nmental status; and other mediating factors.
\nThe purposes of this discussion will be to
\nfocus on multi-physiologic changes intrin-
\nsic to the individual.
\nAging and Physiology
\nThe normal physiologic changes in the el-
\nderly relevant to our discussion here include
\nchanges in the muscular\/skeletal system,
\nthe neurological system, cardiovascular as
\nwell as other constitutional environmental
\nchanges that occur to the human body dur-
\ning the normal aging process.
\nThe Musculoskeletal System and its physi-
\nological changes with aging comprise one of
\nthe most important systems to consider.The
\nchanges in skeletal muscle itself include a de-
\ncrease in muscular strength, endurance and
\nbulk involving essentially all of the muscles
\nof the body except, interestingly, the dia-
\nphragm and cardiac muscles. These changes
\nobviously decrease an elderly person\u2019s abil-
\nity to react swiftly and with the amount of
\nphysical strength needed to avoid certain
\nsituations.The connective tissues in the body,
\nparticularly those lining the joints and sup-
\nporting the joint spaces containing collagen
\nover time become more dry and brittle. This
\nchange leads to sti\ufb00ening and produces a sig-
\nni\ufb01cant change in the mechanical function
\nof joints and their articular surfaces. When
\none considers these changes and their e\ufb00ect
\non something as simple as the posture, the
\nfollowing e\ufb00ects are observed. Elderly indi-
\nviduals are found to have \ufb02exion at the hip
\nand knee joints which gives rise to the typical
\nNormal Physiologic Changes with Aging:
\nIn\ufb02uence on Falls in the Elderly
\nMark D. Darrow, MD FACP
\nPresident and CEO of SEAHEC (South
\nEast Health Area Education Center,
\nNorth Carolina)
\n46
\nposture seen in an elderly person; one needs
\nto simply watch an elderly individual walk
\nacross a room. While their joints retain nor-
\nmal range of motion,they are sti\ufb00 and there-
\nfore, \ufb02exion of the major joints in the hips
\nand legs persists with ambulation. A simple
\nsolution is to prescribe a range of motion
\nand stretching exercises before even the most
\ncommon and rudimentary activities. In the
\nelderly female, it is common to see a kypho-
\nsis of the upper thoracic spine which further
\n\ufb02exes her frame forward and forces her into
\nthe commonly observed \u201cforward slumped
\nposture\u201das she walks across the room. Given
\nthis change and the postural change they
\nproduce, along with the hip and legs joint
\nchanges named above, it is easy to see how
\nthere is an increased tendency toward falls in
\nthe elderly female. In fact, it has been docu-
\nmented that wrist and hip injuries are more
\nsevere in the elderly female population.
\nThe second category of signi\ufb01cant change
\nwith time is in the Neurological System.
\nThere is a documented decrease in pro-
\nprioception in the extremities of elderly
\npatients. The vestibular system undergoes
\nchanges that lend a tendency to an increase
\nin sway during ambulation. Additionally
\nthere is a decrease in muscle activation and
\nco-ordination in this population as well.
\nThese changes as a group place elderly in-
\ndividuals in a situation where they become
\nmore dependent on visual cues for placing
\ntheir extremities while ambulating. Older
\npersons also become more dependent on vi-
\nsual reference points and on the use of their
\nhands and arms for stabilisation when walk-
\ning than their younger counterparts because
\nof the issue of increased sway in their gait.
\nSigni\ufb01cant neurological change occurs in the
\neyes.There is a gradual decrease in visual acu-
\nity with age such that subtle changes in the vi-
\nsual \ufb01eld may go unnoticed.The best example
\nof how this change may manifest is when one
\nconsiders a long hallway that ends in a set of
\nstairs.Often,the \ufb02oors of the hallway and the
\nstairs have the same material covering them,
\nif the pattern is subtle and without contrast,
\nan elderly person may misjudge the distance
\nto those stairs because they are unable to see
\nthem or distinguish them for the rest of the
\nhallway. This simple subtle fact may dramati-
\ncally increase their risk of falling,as again their
\ndependence on visual acuity is high. Another
\nvision change is Presbyopia, which is the in-
\nability to see near objects because of sti\ufb00ness
\nin the lens of the eye of the elderly. It is easy
\nto see how this can further create problems
\nfor the older person.The most signi\ufb01cant and
\ncommon visual change with age is in light\/
\ndark adaptation. An elderly person\u2019s ability
\nto visually adapt from a dark room to bright
\nsunshine, or its reverse, is dramatically slowed
\nwhen compared to a younger person.It is easy
\nto imagine how this increases fall risk during
\ncommon daily activities. Imagine an elderly
\nperson emerging out into bright sunshine
\nfrom inside a structure, particularly in unfa-
\nmiliar settings. The bright light immediately
\nremoves the visual cues for that elderly indi-
\nvidual. If they proceed without allowing for
\nadaptation to that new level of light, a fall or
\ninjury usually ensues.
\nChanges in hearing are well documented.
\nIn the elderly there is a decrease in pitch
\ndiscrimination on the high and low ends of
\nthe scale, as well as a dramatic increase in
\nthe hearing threshold. Particularly in public
\nsettings, this leads to issues of being unable
\nto hear when there is a loud level of ambi-
\nent noise. This hearing loss can lead to di-
\nrectional confusion and an inability to avoid
\nfalls when auditory cues that potentially
\nwarn cannot be heard.
\nThe Cardiovascular System undergoes dra-
\nmatic change in the elderly. While there are
\nmany issues that one could discuss in the
\ncardiovascular system, the major focus needs
\nto be on the regulation of systolic blood pres-
\nsure and the maintenance of blood pressure
\nduring activity and postural change. Regula-
\ntion of systolic blood pressure becomes more
\ndi\ufb03cult in the elderly patient for several rea-
\nsons. There is a decrease in total body water
\nas the elderly person\u2019s physiologic make-up
\nshifts more toward increased adipose tissue
\nas opposed to water soluble tissue; decreasing
\nthe amount of total body water.This is further
\na\ufb00ected by a slowing in the response of the
\nrenin-angiotensin axis and a decrease in the
\naldosterone responsiveness. These changes
\nmake the elderly patient less tolerant to hot
\nenvironments, allow them to become more
\neasily weakened and fatigued during times of
\nhigh musculoskeletal activity, and therefore
\nmake them more prone to falls and injuries
\nat those times.
\nPostural changes in blood pressure response
\nalso vary quite signi\ufb01cantly in the elderly.
\nOne good example is post-prandial blood
\npressure drop. This is a blood pressure drop
\nthat naturally occurs in virtually all elderly
\npatients in mid-afternoon. It appears to be
\nassociated with several normal physiologic
\noccurrences such as the swings in the renin-
\nangiotensin, aldosterone system as it varies
\nthroughout the day, as well as the increased
\nactivity of the digestive system after the
\nnoon meal. This is thought to lead to a pe-
\nriod of time in the mid-afternoon when the
\nelderly may be more vulnerable to decreases
\nin blood pressure with postural change. Of
\nnote, this time of the day also tends to be a
\nperiod of time when morning medications
\ngiven for blood pressure, diuresis or other
\ncardiovascularly active drugs reach their
\npeak activity. As one might expect, this is a
\ncommon time, particularly in nursing facili-
\nties, when there are more reports of falls.
\nWhile there are many other physiologic
\nchanges that occur with aging that may,
\nin a minor way, contribute to falls we have
\nfocused above on the major ones. It should
\nbe noted that the elderly population does
\nnot have a natural understanding of these
\nchanges,and because these changes occur to
\nan individual over time, they often go un-
\nnoticed. It is this lack of education, lack of
\nmodi\ufb01cation of environmental factors, and
\nrecognition of home safety hazards that fur-
\nther contribute to the multi-factorial nature
\nof falls in this population.
\nWe wish to stress again, that we did not de-
\ntail here the age-related associated diseases
\nthat are very common in the elderly such as
\nParkinson\u2019s disease, osteoarthritis, and cata-
\nracts, which a\ufb00ects the major systems we
\nhave outlined above and further place an in-
\ndividual at risk of a fall. Lastly, medications
\n47
\nincluding prescribed, over the counter, and
\nhome remedies, are also major contributors
\nto falls. The good news here is that they are
\nthe most easily modi\ufb01ed group of risk fac-
\ntors in this population.
\nEvaluation
\nIt is in the area of patient evaluation that
\nknowledge of the changes in aging by a
\nhealthcare provider trained in the area of
\nGeriatrics is most important. Elderly indi-
\nviduals must be evaluated for their fall risk.
\nThis evaluation involves assessments of many
\nof the issues outlined above and then the de-
\nvelopment of a multi-factorial intervention
\nprocess to help prevent or decrease the risk.
\nUnfortunately, most elderly individuals usu-
\nally present for medical care after the initial
\nfall.Ideally,however,as we develop awareness
\nfor the speci\ufb01c and unique issues with aging,
\nthis assessment needs to occur as a part of
\nthe wellness evaluation of an elderly person.
\nThe evaluation should include a thorough
\nhistory: gathering information, not only
\nabout medical issues, but support, social and
\neconomic issues that may be obstacles in the
\ncare of the elderly patient.Finding out about
\nthe person\u2019s medications are also a part of this
\nhistory as is the recording of any risky be-
\nhaviours or substance abuse habits that may
\nexist. A thorough assessment of their vision
\nwith emphasis placed on their visual acuity,
\nlight\/dark adaptation, and the in\ufb02uence of
\npresbyopia in their vision is important. One
\nshould also get a sense of how dependent
\nthe individual is on their vision by assessing
\nsome of the other systems outlined above. It
\nmay be necessary to test a patient to assess
\nhow dependent they may be on visual in-
\nputs for activity and locomotion. A gait and
\nbalance assessment is important, keeping in
\nmind the physiologic changes noted above.
\nSimple observation of the gait is important,
\nas well as paying close attention to the use of
\nvisual cues, arms and hands during ambula-
\ntion. A decrease in a person\u2019s ability to reach
\nout may also place them at higher fall risk if
\nthey are quite dependent on arms and hands
\nas they walk.Evaluation of lower limb joints,
\nrange of motion, and particularly sti\ufb00ness of
\nthose joints must be documented. A screen-
\ning neurological evaluation is needed in-
\ncluding an assessment of the ability of the
\npatient to transfer out of a chair.
\nCardiovascular evaluations involve the as-
\nsessments of the included organ systems,
\nbut in addition need to include an assess-
\nment of blood pressure, as well as the mea-
\nsurement for the presence of orthostatic
\nblood pressure changes. There are no stan-
\ndard laboratory diagnostic tests and evalua-
\ntions of an elderly person with a history of
\nfalls or a high risk of falls.Obviously any ar-
\neas of concern that come to light during the
\nhistory and physical examinations should
\nguide the physician towards any relevant
\nlaboratory studies that may be required for
\nan individual elderly patient.
\nTreatment and Prevention
\nTreatment and prevention usually involves
\nmulti-factorial interventions. An individual
\nprovider using the information collected,
\ncan often times set the interventions in mo-
\ntion to address many of the risk factors and
\nnatural de\ufb01cits that occur in this popula-
\ntion. Interventions including exercise and
\nphysical therapy particularly focused towards
\nstrengthening of the leg and torso muscu-
\nlature, as well as range of motion exercises
\nand stretching activity is important. Modi-
\n\ufb01cations of home hazards in consideration
\nof gait and visual di\ufb03culties; instructions
\nabout patterns on carpeting, loose electrical
\ncords, and other pieces of furniture which
\nmay present problems or obstructions in the
\npath of an elderly patient should be assessed
\nand ways to avoid these hazardous situations
\ncan be taught. On occasion, cognitive behav-
\nioural intervention is e\ufb00ective, particularly in
\nindividuals who may have particular habits
\nor activities that place them at higher risk of
\nfalls. Frank conversations and education of
\nthe individual about these activities can lead
\nto dramatic changes and habits. Adjustment
\nof medications, withdrawal of many medi-
\ncations in the elderly, particularly of those
\nwith chronic disease is another important
\nand as mentioned before easily modi\ufb01able
\nrisk factor. Nutritional support is important
\nparticularly, as relates to an individual\u2019s abil-
\nity to maintain their blood pressure. One
\nmust assure that they hydrate and consume
\nthe proper numbers of calories and protein
\nas physiologically required. We have stressed
\nthe importance of visual acuity in an elderly
\npatient and certainly any elderly patient who
\nis ambulatory should have a referral for cor-
\nrection of any visual de\ufb01ciencies that they
\nhave.Referral is also important in individuals
\nwho may be signi\ufb01cantly hearing impaired.
\nMulti-disciplinary teaching, multi-factorial
\nhealth and environmental risk factor screen-
\ning in intervention is always important,
\nparticularly in this population of individu-
\nals. Instruction regarding support at home,
\ninvestigations into the type of care givers
\nand support an elderly individual has around
\nthem at any given time is important to de-
\ncrease their potential of getting into high risk
\nactivity or situations where they are in dan-
\nger of falling and causing serious injury. Re-
\ncently,there have been many studies showing
\nthe bene\ufb01t to the prescription of hip protec-
\ntors in elderly individuals who are high-fall
\nrisks or compliance with these garments.
\nWhile putting them on is at times di\ufb03cult
\nand while adherence to the use of the device
\nis low, some studies have shown bene\ufb01ts in
\ndecreasing hip fractures during falls in very
\nhigh risk ambulatory individuals.
\nSummary
\nIn summary, while we have not intended
\nthis article to be an outline all of the normal
\nphysiologic changes that occur in the el-
\nderly and certainly have not undertaken an
\nexhaustive discussion of falls in the elderly,
\nit is important that these types of discus-
\nsions begin on the world stage to help us
\nrecognise the unique issues and problems
\nthat develop with aging of our populations,
\nand how the medical community needs to
\nand responds to these new challenges.
\nReferences
\n1. American Geriatrics Society. British Geriatrics Society and
\nAmerican Academy of Orthopaedic Surgeons Panel on Falls
\nPrevention. Guideline for the prevention of falls in older per-
\nsons. J Am Geriatr Soc. 2001;49(5):664-672
\n2. Geriatrics Review Syllabus, 6th
\nedition. American Geriatrics
\nSociety, 2006; pgs 201-209.
\n48
\nThe Migration of Health Professionals
\nand its Impact on Patient Safety
\nBoth European institutions \u2013 UEMS and
\nthe European Parliament are at the same
\nage, both are well known in Europe and
\nbeyond. At the same time, being a represen-
\ntative from one of the so- called new EU
\nMember States \u2013 Latvia \u2013 a professor who
\nhas spent 30 years in post-graduate medical
\ntraining, I have to admit that those states,
\nwhich were for 50 years behind the Iron
\nCurtain, could fully recognize the value and
\nsigni\ufb01cance of the work of both institutions
\nonly during the last decades.
\nMy beloved speciality was anaesthesiology
\nand intensive care. Today it may sound an-
\necdotic, but, under Soviet rule, we had to
\nprovide so called primary specialization in
\n6 months time! For the next step in post-
\ngraduate medical training \u2013 so called im-
\nproved quali\ufb01cation \u2013 some more months
\nwere added.
\nSlowly, step by step and with the help of the
\nEuropean Academy of Anaesthesiology, we
\ntried to change the situation even before
\nthe Soviet system collapsed. Today the pe-
\nriod of training in my speciality in Latvia
\nexceeds by two years the minimum,required
\nin the Directive 2005\/36\/EC of the Euro-
\npean Parliament and the Council of 7 Sep-
\ntember 2005.
\nThat gives our Ministry of Health the
\nchance to plan a shortening of the period
\nof training in accordance with the proposed
\nminimum of three years. The Latvian As-
\nsociation of Anaesthesiologists is convinced
\nthat, taking into account the dramatic
\nchanges \u2013 not only the new technologies,
\nthat it is time to review and update the
\nlength of training. But, it is of course up to
\nyou to decide and to advise the European
\nCommission on this matter.
\nAs many of you already know,the European
\nParliament as a whole is quite often involved
\nin solving di\ufb00erent medical and health care
\nproblems. In spite of the fact that the deliv-
\nery of health services lies primarily within
\nthe competence of the Member States, the
\nEU, adhering to the principles of subsidiar-
\nity and proportionality, in accordance with
\nArticle 152 of the EU Treaty, has a respon-
\nsibility where necessary to act so as to sup-
\nport Member States to co-operate and to
\nco-ordinate their activities.
\nEven more so, in the light of a January
\n2008 survey conducted by Eurostat in all
\n27 Member States, entitled \u201cCitizens views
\nof the European Parliament: perceptions,
\nknowledge and expectations\u201d where 39% of
\nall respondents answered that they would
\nlike to see improvement of consumer and
\npublic health protection given a priority
\nstatus.
\nThe re\ufb02ections on the Communications put
\nforward by the European Commission to
\nthe European Parliament and the Council
\nwhich address health issues, falls within
\nthe duty of the Rapporteur from the Com-
\nmittee on the Environment, Public Health
\nand Food Safety (ENVI). Di\ufb00erent health
\ntopics are systematically discussed within
\nthe framework of the Working Group on
\nHealth which is a specialized Group set
\nup within the ENVI Committee. Apart
\nfrom that there are several di\ufb00erent inter-
\nest groups, meeting regularly under the pa-
\ntronage of MEPs (for example MAC \u2013 or
\nMembers Against Cancer, the MEP Heart
\nGroup or the Working Group on Diabetes).
\nI mentioned only those Groups in which
\nI myself am very active as is the case with
\nMAC or the other two which I have the
\nhonour of being the co-chairman.
\nWorking in close contact with correspond-
\ning patient groups, medical and other ex-
\nperts as well as with representatives from
\nthe Commission, it is possible to initiate
\nquestions to the Commission, and to table
\ndi\ufb00erent Motions for Resolutions or Dec-
\nlarations.
\nAs an example of such a Motion for a reso-
\nlution,which by the way deals also with your
\ncompetence, is the European Parliament
\nResolution of 10 April 2008 on combat-
\ning cancer in the enlarged European Union
\nwhich was adopted at the plenary meeting
\nwith 621 votes in favour, 10 votes against
\nand 6 abstentions.
\nI want to quote just Recital S and Article 22
\nof this Resolution:
\nRecital S: \u201cwhereas oncology is recognised
\nas a medical speciality not in all Member
\nStates, and whereas continuing medical
\neducation needs to be provided\u201d,
\nArticle 22: \u201cUrges the Commission and the
\nMember States to recognise oncology as a
\nmedical speciality and to make provision for
\nlifelong learning for medical oncologists in
\naccordance with agreed guidelines.\u201d
\nAnd now, some thoughts about the migra-
\ntion of health professionals and its impact
\non patient safety: The European Commis-
\nsion launched on 25 March of this year an
\neight week public consultation on patient
\nsafety in order to help in the development
\nProf. Georgs Andrejevs FRCA, MEP
\nThe speech on the UEMS \uf6aeThe Union
\nof European Medical Specialists) 50th
\nAnniversary Conference. Brussels,
\n18 april 2008
\n49
\nof the Commission\u2019s proposal for general
\npatient safety issues planned for the end
\nof 2008. Patient safety is de\ufb01ned as free-
\ndom for a patient from unnecessary harm
\nor potential harm associated with health-
\ncare. Although patient safety is narrower in
\nits de\ufb01nition than healthcare quality more
\ngenerally, it is the foundation of any high
\nquality health system.
\nAs such it is recognised as a major concern
\nfor governments and competent authori-
\nties, as well as health professionals and civil
\nsociety across Europe. The type of health-
\ncare setting itself will also be an in\ufb02uencing
\nfactor on safety levels. Therefore, the focus
\nshould be a broad one. As it is well known
\nhuman resources are an essential factor in
\nthe provision of health care, directly in-
\n\ufb02uencing the performance of health care
\nsystems. Accessible health care requires a
\nwell-trained and well-motivated workforce
\nof physicians and nurses \u2013 of an adequate
\nsize \u2013 that are able to deliver safe, high-
\nquality medical services. However, concerns
\nhave been voiced in many EU countries, es-
\npecially in the new Member States, that a
\ngap is increasing between demands for and
\nsupply.
\nDue to an aging population, technological
\nadvances and higher expectations from pa-
\ntients, demand is likely to increase. On the
\nother hand,supply is expected to fall as a re-
\nsult of physician and nurse workforce aging,
\ntrends towards early and partial retirement
\nand the mobility of the highly skilled \u2013
\neven Brain Drain of medical specialists and
\nnurses.
\nMigration of Health Professionals was the
\nmain topic at the ENVI Working Group on
\nHealth meeting in October last year. Our
\nguest speaker, Jean-Christophe Dumont
\n(representing the International Migration
\nDivision at the OECD, Paris) gave us an
\noverview on recent migration \ufb02ows and
\nmigration policies for health workers in the
\nOECD countries where a potential com-
\npetition to attract and retain health profes-
\nsionals exist. The question of \u201cBrain drain\u201d
\nfrom Central and Eastern Europe to the
\nNorthern and Western Europe was also de-
\nbated. Although no precise data is available,
\nit is known that tens of thousands of doc-
\ntors and nurses have left their home coun-
\ntries because their national health systems
\ncannot compete with the salaries o\ufb00ered by
\nother EU Member States and other coun-
\ntries, like the USA.
\nHaving said this, I would like to mention
\nsome of the available data to give you a
\nclearer idea about the scope and signi\ufb01cance
\nof this problem, especially in regards to the
\nsituation within the new Member States.
\nIn Ireland, the employment of nationals
\nfrom the new Member States (excluding
\nMalta and Cyprus, also called the EU8)
\nin the health sector doubled between Sep-
\ntember 2004 and 2005, from 700 to ap-
\nproximately 1300 persons; in Finland, 432
\nauthorisations were issued to physicians
\nand dentists from the EU8 countries until
\nDecember 2005,and in Sweden the number
\nof authorisations granted to EU doctors
\njumped from 230 in 2003 to 740 in 2004.
\nAvailable data from countries of origin
\ncon\ufb01rm these trends: In Estonia, by April
\n2006, 4.4% of all health care professionals
\nhad applied for a certi\ufb01cate to leave (61% of
\nthem were physicians); in my home country,
\nLatvia, in 2005 more than 200 doctors ex-
\npressed their intention to leave; in Poland,
\nbetween May 2004 and June 2006 more
\nthan 5000 certi\ufb01cates were issued to doc-
\ntors (which is 4.3 % of the active workforce)
\nand 2800 to nurses (this equals 1.2 % of the
\nactive workforce). Furthermore, some spe-
\ncialities seem to be more directly a\ufb00ected
\nsuch as anaesthesiologists in Poland (16 %
\nwere issued a certi\ufb01cate) or for instance
\nplastic and reconstructive surgeons in Esto-
\nnia where 30 % were issued a certi\ufb01cate.
\nUnfortunately, this study, although being
\nsupported by a grant provided by the Eu-
\nropean Commission, re\ufb02ects the situation
\nonly in 18 EU countries \u2013 which are mem-
\nber States of the OECD. At this time, no
\nsurvey is available on this issue that would
\nre\ufb02ect the situation in all EU member
\nStates. A representative from DG SANCO
\ninformed the participants, however, that
\nthe mobility of health professionals would
\nbe a priority issue in the Commission An-
\nnual Policy Strategy for 2008.It was assured
\nthat the Commission needs to look into this
\nmatter – even if it is in principle a responsi-
\nbility of the Member States.
\nWithin the EU, the last enlargement has
\nhad a considerable impact on the migration
\nof health professionals. There is, however,
\nlittle data on the actual migration \ufb02ows
\nand the OECD study is the \ufb01rst one on
\nthis subject. The collection of data is due
\nto improve, since the 7th
\nResearch Frame-
\nwork Programme will fund studies relating
\nto this issue. DG SANCO will also adopt a
\nnon-legislative document on the mobility of
\nhealth professionals in the EU in 2008.
\nWe have to deal with two sides of the same
\ncoin called e\ufb00ective health care and pa-
\ntient\u2019s safety.
\nOn one side is written that \u201cthere are im-
\nmense bene\ufb01ts to health systems in Europe
\nand the health of European citizens from
\nthe free movement of health professionals,
\nmost of whom make a strong contribution
\nto delivering high quality healthcare\u201d.
\nOn the other side one must see the prob-
\nlem and the consequences of the Brain
\ndrain. According to the Terminology on
\nInternational Mobility of Skilled Work-
\ners, Brain Drain may occur if emigration of
\ntertiary educated persons for permanent or
\nlong-stays abroad reaches signi\ufb01cant levels
\nand is not o\ufb00set by remittances, technol-
\nogy transfer, and investments trade. A Brain
\nDrain reduces economic growth through
\nunrecompensed investments in education
\nand depletion of a source country\u2019s human
\ncapital assets.
\n50
\nHistory of UEMS
\nThe Union of European Medical Specialists
\n(UEMS) was established in 1958, following
\nthe signing of the Treaty of Rome in 1957.
\nIn the Treaty of Rome harmonisation and
\nmutual recognition of diplomas is foreseen.
\nThe objective of the UEMS has always been
\nbringing together the medical specialists of
\nthe member states and reaching consensus
\non content and quality of medical specialist
\ntraining and practice. The outcome of this
\nprocess was meant to serve as foundation
\nfor EU legislation.
\nThe start was slow, but in the seventies the
\nEU moved towards legal provisions in this
\nmatter. The Specialist Sections were estab-
\nlished from 1962 onwards and the UEMS
\nwith its Sections was instrumental in the
\nshaping of the \u201cDoctors Directive\u201d in 1975,
\nwhich established the mutual recognition
\nof medical diplomas between the member
\nstates of the EU.
\nHowever, in the follow-up little attention
\nwas paid to the contributions of the UEMS,
\nand quality requirements in the Directive
\nbasically remained limited \u2013 also in Direc-
\ntive 93\/16\/EEC, the consolidation of later
\nupdates \u2013 to the minimum duration of train-
\ning (art. 26-27) and the requirement of rec-
\nognized training institutions (art. 24).
\nThe EU blocked progress of implementa-
\ntion of quality requirements in the Directive
\nduring the eighties and a new approach was
\nrequired.
\nNineties
\nThe UEMS emphasis moved away from
\nproviding the EU with recommendations
\ntowards broadening the work on harmonisa-
\ntion and improvement of content of quality
\nof training and practice on the shop \ufb02oor of
\nmedical specialists.
\nFor this purpose European consensus docu-
\nments were developed during the nineties
\nconcerning key-issues as professional train-
\ning, continuing education, quality assess-
\nment and tools like logbooks and visitation
\nof training centres.The outcome of this pro-
\ncess was embodied in the UEMS Charters.
\nThese Charters were presented to the profes-
\nsional authorities in the European countries
\nas models and recommendations for national
\npolicy. Although the Charters do not have
\nlegal value, their in\ufb02uence upon national
\nregulations has been considerable.
\nFollowing charters were proposed by the
\nUEMS: a Charter on Continuous Medical
\nEducation, a Charter on Quality Assur-
\nance in Specialist Practice in the European
\nUnion, a Charter on Visitation of Training
\nCenters, a Charter on Continuous Profes-
\nsional Development (also called the Basel
\nDeclaration), the Declaration on Promoting
\nGood medical Care, Ensuring the Quality
\nof Medical Care (also called the Budapest
\nDeclaration) and the Policy Statement on
\nAssessments during Postgraduate Medical
\nTraining.
\nActual situation
\nThe philosophy of all national professional
\nmedical organisations is that patient care
\nis best served when quality and content of
\nmedical training and practice are the domain
\nof the medical profession. In each country
\nthe profession is defending this position.
\nUnfortunately we are experiencing that this
\ndefence is becoming more and more di\ufb03-
\ncult. Governments, insurances, commercial
\ninterests are eager to take over the quality
\nagenda.
\nA strong continuing e\ufb00ort of the profession
\nis needed if the profession wants to maintain
\nand improve quality in the proper way.In or-
\nder to do this unity of purpose and action is
\nnecessary. This requires balancing of profes-
\nsional and political views and interests.
\nNational level
\nUni\ufb01cation of policy has to start at national
\nlevel. The professional societies in the spe-
\ncialties at national level are doing a great
\njob in quality improvement. But this has
\nto be implemented at each level of medical
\npractice, all the way from individual private
\npractise to hospital management, training
\nrequirements, certi\ufb01cation, validation, pro-
\nfessional regulations, national legislation.
\nThe Union of European Medical Specialists
\nDr. Hannu Halila, Dr. Cillian Twomey, Dr. Alexander Kuttner, Dr. Leonard Harvey, Dr.Zlatko Fras
\n51
\nClose cooperation of the professional societ-
\nies with the political national medical asso-
\nciations and societies is necessary to achieve
\nimplementation of quality policy in a proper
\nway. Only with unity of purpose and policy
\nresults can be achieved.
\nUnfortunately in many European countries
\nthisunityofpurposeandpolicyisnotthatwhat
\nit should be,and a greater e\ufb00ort on this issue is
\nnecessary. National professional organisations
\nshould be more aware of the signi\ufb01cance of a
\nstrong European representation.
\nEuropean level
\nThe lack of national unity of polic y re\ufb02ects
\nitself immediately in the representation of
\nthe medical profession on European level.
\nToo often delegates of organisations of the
\nsame country are bringing opposing views in
\ndi\ufb00erent European medical organisations.
\nEuropean medical organisations
\nOn the European scene there is the UEMS
\nwith its UEMS Sections and European
\nBoards, the European professional Societies
\nin each specialty, but there are also the um-
\nbrella organisations of the national medical
\nassociations (Comit\u00e9 Permanent of Europe-
\nan doctors CPME), and other independent
\nmedical organisations such as the European
\nassociations of junior doctors (PWG), hos-
\npital doctors (AEMH), salaried doctors
\n(FEMS). Basically each group started out
\nas a lobbying group for its own interests, but
\nprogress in the unity of purpose and policy
\nhas been made.This process of confederation
\nhas to be pursued.
\nFuture
\nThe UEMS with its Sections and Boards is
\nby far the largest of all political European
\nMedical Associations,and it has an extensive
\ngrass-root support.It has done a lot,but more
\nis needed.So far each country is autonomous
\nin health care matters,but European integra-
\ntion is gaining momentum. The profession
\nmust be ready to play its role in a future inte-
\ngrated European health care policy.
\nIn order to meet the challenge of increas-
\ning involvement of the European Union in
\nhealth care matters in an enlarging Europe,a
\nstronger position of the profession is needed.
\nIt has to start at national level:
\nUnity of purpose and policy of national\u2022
\norganisations,
\nCoordination of separate national organi-\u2022
\nsations,
\nEnlargement of investment by national\u2022
\nmedical organisations in European medi-
\ncal matters, in imagination, in people, ex-
\npertise and \ufb01nancial means.
\nAt European level a more uni\ufb01ed voice of
\nthe medical profession is needed, leaving
\nintact the professional independence of sec-
\ntoral groups like medical specialists, general
\npractitioners, etc. Here the same unity as at
\nnational level should be achieved.
\nPresently the Directorate Health and Con-
\nsumer Protection (SanCo) has only author-
\nity in the \ufb01eld of Public Health. Its main is-
\nsues currently are health surveillance, health
\nthreats and health determinants.
\nVery likely EU authority will expand in the
\nfuture. The medical profession should bring
\nforward its views on the quality issue in one
\nvoice. It should prepare itself to be ready to
\nprovide the EU in the future with construc-
\ntive and well founded recommendations on
\nkey issues.
\nStructure of the UEMS
\nTo simplify UEMS can be seen as three dif-
\nferent structures. First, the Council where
\nthe National Medical Associations are meet-
\ning, secondly, the Sections and Boards based
\non the Specialties and thirdly, the youngest
\n\u201cchild\u201dof the UEMS, the EACCME, Euro-
\npean Accreditation Council for Continuous
\nMedical Education.
\nThe Council is the oldest structure of the
\nUEMS and was called in the past Manage-
\nment Council. It is the political body where
\nthe decisions are made and statements are
\ntaken on issues in the \ufb01eld of Specialist Med-
\nicine. The National Medical Associations are
\nmainly organizations that represent Medical
\nSpecialists in the di\ufb00erent European Union
\nMember States and the European Economic
\nArea and Switzerland. We have also repre-
\nsentatives of countries of Europe that are not
\nMember of the European Union.
\nThe Sections and Boards were created more
\nrecently but some of them have also a long his-
\ntory. They are based on the di\ufb00erent Special-
\nties that are present in Europe and are made
\nup of two delegates of the countries where
\ntheir specialty exists. It represent so quite well
\nthe \ufb01eld of each Specialty in Europe and is
\nresponsible for the harmonisation of training
\nthroughout Europe, and the defence of their
\nspecialty. This of course is also important for
\nthe patient because quality of health care is
\nalso in the bene\ufb01t of the patient.
\nIn 1999 the UEMS created the EACCME
\nthat started its operations in 2000.This struc-
\nture of the UEMS tries to harmonize the
\nCME-CPD in Europe by helping the doc-
\ntor to have his credits earned at international
\nevents approved by UEMS-EACCME ac-
\ncepted in all UEMS Member States.
\nAccreditation
\nCME\/CPD is an important part of the
\nmedical practice today. When we look at
\nthe training to become a (specialist) doctor,
\nit starts with undergraduate and graduate
\ntraining at the University followed by the
\nPostgraduate Training that is done in coop-
\neration between the Profession and the Uni-
\nversity ideally.
\nIn the past this was the end of the process
\nbut it is more than obvious that a long life
\nDr. Bernard Maillet, Dr.Zlatko Fras
\n52
\nlearning has to be done in order to maintain
\nknowledge and skills for the practitioner.
\nHere CME \/ CPD is an important factor.
\nIt started with Continuous Medical Educa-
\ntion where mainly theoretical courses and
\ncongresses were organized.
\nNowadays this is completed by the improve-
\nment of communication, IT, managerial and
\nsocial skills and is more concentrated on the
\npractice of each individual practitioner and
\nhis or her needs.
\nThe CME \/ CPD needs and the way it has
\nto be organized is a duty of the National
\nAccreditation Authority in each European
\nUnion Member State and can be National
\nor Regional (or a combination of both).
\nThe NAA has to de\ufb01ne how many \u201ccredits\u201d
\nand which kind of credits are needed each
\nyear or each period of time.
\nIt is more than obvious that one can not gain
\nall his or her credits by following only one
\nmeans of CME \/ CPD, meaning that for in-
\nstance not all credits may be earned by follow-
\ning Long Distance Learning Programs only.
\nOther means such as Live Events, Enduring
\nMaterial, like CD-ROM\u2019s, or articles have
\nalso a certain role to play in the whole picture
\nof the CME \/ CPD of a (specialist) doctor.
\nIt is clear that this remains a responsibility
\nof each NAA.
\nUEMS has started the EACCME\u00ae
\nin order
\nto help the European Medical Specialist to
\nhave the credits he or she has earned by go-
\ning to International Meetings approved by
\nhis or her NAA in order to avoid a duplica-
\ntion of the process.
\nFor instance when I as a Pathologist go to
\na meeting organized by the British Division
\nof the International Academy of Pathology
\nand that has been approved for CME by the
\nRoyal College of Pathologists of the UK,
\nwhy should the Belgian Accreditation Au-
\nthority starts the process of approval again.
\nThis was the start of the EACCME\u00ae
\nwhere
\nwe proposed to have a clearing house where
\nrequests for European Accreditation could
\nbe sent to.
\nThe aim was to have an approval of both the
\nresponsible NAA and the involved UEMS
\nSpecialist Section.
\nThe responsible NAA is the NAA of the
\ncountry (or of the region) where the event
\ntakes place.
\nThe involved Section is the Section of the
\nSpecialty that is most involved with the
\nmeeting for instance as a target audience.
\nAs the Sections are constituted by two del-
\negates representing the Specialty in each EU
\nMember State, they can be considered as
\ngiving a quite representative opinion of the
\n\ufb01eld on each evaluation.
\nHistory and political background
\nof European Accreditation
\nCouncil for Continuous Medical
\nEducation (EACCME\u00ae
\n)
\nContinuing Medical Education (\u201cCME\u201d)
\nand Continuing Professional Development
\n(\u201cCPD\u201d) have always been one of the
\nmajor key elements of UEMS as it notably
\npromotes the quality of care and the best
\nlevel of training for medical specialists. This
\nbecame concrete in 1993 when \u201cUEMS
\nCharter on CME\u201d was adopted. Since then,
\nfurther work has been laid down in the \ufb01eld
\nof CME and CPD and other declarations
\nand position papers were adopted such as
\nthe \u201cBasel Declaration on CME\u201d (2001) or
\n\u201cUEMS Declaration on the promotion of
\ngood medical care\u201d(2004).
\nAt the same time, many European countries
\nhave been taking steps towards mandatory
\nCME together with legal or professional
\nre-certi\ufb01cation or re-licensing, \ufb01nancial in-
\ncentives or contracts with insurances and
\nhospitals. Even though UEMS defends vol-
\nuntary CME, it was felt appropriate to help
\nEuropean medical specialists in this respect.
\nTherefore, in October 1999, UEMS Council
\nset up the European Accreditation Council
\nfor CME (EACCME\u00ae
\n), with a view to:
\nFacilitating access to quality CME for\u2022
\nEuropean doctors;
\nContributing to the quality of CME in\u2022
\nEurope; and
\nExchanging CME credits in Europe\u2022
\neasily.
\nThe quality control of CME activities is a key
\nelement in this process. It was thus decided
\nto operate in a decentralised way by using the
\nexpertise of existing European and national
\nprofessional bodies involved in accreditation.
\nThe everyday management of European ac-
\ncreditation by EACCME\u00ae
\nprovides this link
\nbetween European and national levels. One
\nhas to remind the political necessity to comply
\nwith the political authority of national profes-
\nsional regulatory bodies,as these bodies are re-
\nsponsible for registering doctors\u2019CME-CPD
\nand awarding licences to practice.
\nEACCME\u00ae
\nStructure
\nEACCME\u00ae
\nwas founded in 1999 as a sepa-
\nrate entity from UEMS even if it was ruled
\nby its Management Council. In the revised
\nStatutes, it was proposed by the Executive
\nupgrading EACCME\u00ae
\nas one of the \ufb01ve
\ngenuine bodies of UEMS in order to stress
\nthe importance of this body.
\nEACCME\u00ae
\nmanagement would though re-
\nmain as it is:
\nThe governing body is UEMS Council,\u2022
\nwhich is made up of representatives from
\nnational associations of each UEMS
\nmember country.
\nAn Advisory Council provides recom-\u2022
\nmendations with regard to the manage-
\nment of European accreditation. This
\nbody is made up of representatives from:
\nNational professional CME authori-\u2022
\nties, including national CME accredit-
\ning bodies;
\nUEMS, including its Sections and\u2022
\nBoards;
\n53
\nProfessional specialist organisations\u2022
\nand societies.
\nThis Advisory Council provides full ex-
\nchange of expert-knowledge and collabora-
\ntion between the various partners involved
\nin accreditation at European level. UEMS
\nconvenes a meeting of this committee each
\nyear as it is committed to the further evolve-
\nment of EACCME\u00ae
\nprocedures in coop-
\neration with the members of this advisory
\ncommittee.
\nThe daily proceedings of the EACCME\u00ae
\nare
\nmanaged by UEMS Executive in its Brussels
\nSecretariat.
\nRight from the start, it was clear that na-
\ntional professional regulatory bodies would
\napprove a structure, such as EACCME\u00ae
\n,
\nwhich would make CME credits in Eu-
\nrope exchangeable. The only condition was
\nthat these bodies would remain in charge of
\nevents in their own country and would have
\na major input in the process of EACCME\u00ae
\n.
\nThis is a political reality. Moreover, it is ex-
\npected that within a few years mandatory re-
\ncerti\ufb01cation would apply in several countries.
\nCME credits would then be the instrument
\nused in this respect.
\nPractical operation
\nEACCME\u00ae
\nreceived its mandate from na-
\ntional regulatory bodies together with sev-
\neral distinct conditions.
\nNational authorities are maintained.\u2022
\nEACCME\u00ae
\ndoes not become a suprana-
\ntional body, but a link and clearing-house
\nbetween national regulatory bodies.
\nThe \ufb01nal word concerning accreditation of\u2022
\neach activity remains the decision of the
\nnational regulatory body in the country
\nwhere the activity takes place.
\nThe Brussels administration should be as\u2022
\nlean as possible.
\nQuality assurance and determination of\u2022
\nnumber of credits of separate CME ac-
\ntivities would be decentralised, EACC-
\nME\u00ae
\nrelying upon the expertise of profes-
\nsional bodies in each specialty (such as the
\nUEMS Sections and\/or Boards and Eu-
\nropean Speciality Accreditation Boards).
\nThis aims to avoid duplication of quality
\nassurance proceedings.
\nThere would be no accreditation of com-\u2022
\nmercially biased activities, internet activi-
\nties and for the time being each activity
\nshould be judged separately. So providers
\nare not accredited for series of activities
\nstretching over years.
\nAdministrative expenses of EACCME\u2022 \u00ae
\nare borne by the providers of activities
\napplying for European accreditation. Ex-
\npenses would be limited, avoiding dupli-
\ncation in Brussels of work already done by
\nother accreditation bodies.
\nThe recognition of EACCME\u00ae
\ncredits (EC-
\nMEC\u2019s) is only guaranteed by national au-
\nthorities within the framework of these condi-
\ntions. EACCME\u00ae
\nstrictly complies with this
\nset and operates according to the procedure:
\nThe accreditation process in Europe involves
\ntwo partners, on the one hand the National
\nAccreditation Authorities and on the other
\nhand the UEMS Specialist Sections and\/or
\nBoards. The responsible National Authori-
\nties are determined according to the place
\nwhere the meeting is organized and the in-
\nvolved Specialist Sections are determined
\nbased on the specialty that is most involved
\nor to the target audience of the event.
\nLet us now look how the process works in
\npractice.
\nThe organizer of an event send the request
\nform with all the relevant and needed docu-
\nments to the UEMS \u2013 EACCME\u00ae
\nO\ufb03ce
\nin Brussels or \ufb01lls in the webbased request
\nform.
\nHere the request form will be distributed to
\nthe two partners.
\nThe relevant UEMS Section and\/or Board
\nassess the scienti\ufb01c value of the CME activ-
\nity. This evaluation strictly follows UEMS
\nQuality criteria de\ufb01ned in D-9908.
\nBoth partners are requested to give in a well
\ndetermined time scale an approval or a re-
\nfusal for accreditation, the number of credits
\nbeing determined by UEMS \u2013 EACCME\u00ae
\n.
\nFlowchart of the process
\nOrganiser
\nRequest
\n> 3 months
\nUEMS – EACCME
\nN.A.A. Sections
\nEvaluation < 3 weeks Evaluation\nUEMS - EACCME\nCerti\ufb01cate of Recognition\nOrganiser\nCredit system\nAs the di\ufb00erent National Accreditation Au-\nthorities apply di\ufb00erent credit systems, the\nEuropean CME Credits (ECMEC) were\nintroduced in order to harmonise the num-\nber of credits on the following basis: :\n1 ECMEC per hour;\u2022\n3 ECMEC for half a day; and\u2022\n6 ECMEC for a full-day event.\u2022\nNational authorities can then convert these\ncredits into national units, following the\nNational rules.\nWhen both partners agree on the approval,\nthe organiser will receive a letter con\ufb01rming\nthe approval of the European Accreditation.\nThis letter contains three sentences : the \ufb01rst\nstating the approval and precises which part-\nners have been involved.\nThe second sentence gives the number of\nECMEC\u2019s granted to the event (and eventu-\nally the number of National Credits granted\nfollowing the rules of the National Accredi-\ntation Authority of the country where the\nevent takes place).\nThe third sentence informs about the mu-\ntual recognition of credits between UEMS \u2013\nEACCME\u00ae\nand AMA PRA Class 1 credits.\n54\nEvaluation of events\nIt is very di\ufb03cult (if not impossible) to fully\nevaluate an event before it is held based on\ndocuments that are provided by the orga-\nnizer. Therefore in the future e\ufb00orts will be\nconcentrated to ask the organizers to have an\nevaluation of the event by the participants.\nThis evaluation can be quite simple because\nat the end a too much detailed evaluation\nwill be problematic to analyze. The main\nquestions could be:\nwas the event well organized.\u2022\ndid I learned something from the event.\u2022\nwill what I learned from the event change\u2022\nmy practice.\ndid I felt any bias.\u2022\nThe evaluation can be graded from \u201cfully\nagree\u201d to \u201cfully disagree\u201d by \ufb01ve steps for in-\nstance.\nThe principal aim of this evaluation is not\nto retrospectively throw away the allocated\ncredits but rather help in the evaluation of\nthe next meeting of the same kind orga-\nnized by the same people.\nEACCME is mostly involved in the evalua-\ntion of big international events that are recur-\nring events so this will help in the process.\nWhich added value?\nAs shown, the added value of EACCME\u00ae\nlies in the link set up between the profes-\nsional societies, the CME providers and the\nnational regulatory bodies. Any change to\nthis procedure would need the consensus\nof national regulatory bodies. Any devia-\ntion from this consensus would defeat the\npurpose of the EACCME\u00ae\nand it would\nalso mean loss of the agreement with the\nAmerican Medical Association concern-\ning mutual recognition of EACCME and\nAMA credits.\nFrom the point of view of the organizers of\nevents, the added value sits in the interna-\ntional dimension that would be given to an\nevent. More participants from abroad and\nalso from the USA would be interested in\njoining their meetings.\nThe agreement with the American Medical\nAssociation has been renewed and is now\nvalid from July 1st\n2006 for a period of four\nyears.\nThe long term bene\ufb01t is the link with the\nnational regulatory bodies. These bodies are\nvery keen to preserve their national author-\nity in the awarding of credits to the doctors\nin their own countries. The EACCME\u00ae\nof-\nfers an institution in which they participate\nand have authority. In this way the profes-\nsion facilitates exchange of CME credits\nin Europe in a similar way as postgraduate\ndiplomas are mutually recognised according\nto European law.\nAt the end it are the National Accredita-\ntion Authorities together with the National\nLicensing Authorities that gives to license\nto practise.\nThe ultimate goal is to develop a system that\nmakes life easier for our colleagues and to\nprovide them with recognised quality CME\nwith the guarantee that they can use their\nCME credits to meet national require-\nments.\nFee\nThe UEMS \u2013 EACCME asks a fee for the\nprocessing of the applications. This fee is\nbased only on the number of participants\nand is a sliding scale. As we have two equal\nmajor partners in the European Accredita-\ntion, they also share their part of the fee.\nDr. Bernard Maillet\nSecretary General\nI. Establishment of CMAAO\nCMAAO (Confederation of Medical As-\nsociations in Asia and Oceania) is a con-\nfederation currently comprising 17 medi-\ncal associations. Established around 1958,\nCMAAO initially held Congresses once\nevery two years, but now meets every year,\nwith Congresses and Midterm Council\nMeetings held in alternate years.\nThe objectives of CMAAO, as stated in its\nconstitution, are to raise the health stan-\ndards of people living in the Asia-Paci\ufb01c\nregion by promoting exchange between\nphysicians in the region and establishing\nrelationships and exchanging information\nwith other world organizations, and to pro-\nmote friendship between member medical\nassociations mainly through information\nexchange and discussion regarding shared\nmedical issues.\nCMAAO began as the Southeast Asian\nMedical Confederation (SAMC) advocat-\ned by Dr. Rodolfo P. Gonzalez of the Phil-\nippine Medical Association (PMA), which\nplayed a central role in creating the organi-\nzation together with Dr.Taro Takemi men-\ntioned below. With the Australian Medical\nAssociation joining the SAMC, the organi-\nzation\u2019s name was changed to the Confed-\neration of Medical Associations in Asia &\nOceania (CMAAO), and the 1st\nCMAAO\nCongress was hosted in Tokyo in 1959 by\nthe Japan Medical Association (JMA) un-\nder the presidency of Dr. Gonzalez.\nHistory and Recent Activities\nof the CMAAO\n(Confederation of Medical Associations in Asia and Oceania)\n55\nAt this Congress, it was decided that the\nconfederation would initially operate on\nvoluntary donations as the budget was as yet\nundecided, with the JMA donating $1,000\nand the PMA donating $500. Furthermore,\nit was decided to base the CMAAO Secre-\ntariat permanently in Manila in the Phil-\nippines and Dr. Victorino de Dios of the\nPMA was appointed as the inaugural Sec-\nretary\/Treasurer who serves as both secre-\ntary and \ufb01nancial o\ufb03cer.\nThe JMA President at that time was Dr.\nTaro Takemi, a leader who served as JMA\nPresident for 25 years (1957-1982). Dr.\nTakemi said that one of the major objectives\nfor establishing CMAAO was to create an\norganization in Asia to ensure the opinions\nand ideas of the medical profession in these\nareas to be re\ufb02ected in the activities of the\nWorld Medical Association (WMA).\nCMAAO membership as recorded at the\ntime of the 1st\nCongress comprised 11\nnational medical associations: Australia,\nBurma, Taiwan, Indonesia, the Philippines,\nJapan,the Republic of Korea,Iran,Pakistan,\nThailand, and India. In discussions, the is-\nsue of international medical licensing was\nraised. At the 2nd\nCongress, held in Ma-\nnila in 1961, Dr. Takemi was appointed as\nCMAAO President. At this meeting, dis-\ncussion themes included prevention and\neradication of malaria in the Philippines,\nresearch on Japanese encephalitis,Tsutsuga-\nmushi disease (trombidiasisi), and indepen-\ndent physicians and military medicine in\nthe Philippines.\nThis is how CMAAO operated in its early\ndays.\nII Consolidation of the basis of\nthe activities of CMAAO\nFor the theme of the 10th\nCMAAO Con-\ngress, held in Tokyo in 1977, Dr. Takemi\nchose the issue of population aging, with\nparticular emphasis on the need for health\neducation in aging societies. He also point-\ned out the seriousness of the e\ufb00ect of pol-\nlution and waste as well as the huge impact\nof changes in the global environment, as\nwell as the unavoidable problem of global\nhealthcare economics as the burden of\nhealthcare on government \ufb01nances grew\nas health costs escalated with technologi-\ncal advances in medicine and the aging of\nsociety. He also mentioned the necessity of\nexamining the issue of development and al-\nlocation of medical resources in relation to\nescalating costs and of providing welfare\nthat enables better living conditions. These\nconcerns clearly show Dr. Takemi\u2019s far-\nsightedness, and it was under this vision-\nary leader that CMAAO continued its ac-\ntivities. In commemoration of Dr. Takemi\u2019s\ntremendous contribution since the incep-\ntion of CMAAO, a special lecture entitled\nthe \u201cTaro Takemi Memorial Oration\u201d was\nestablished and is presented at each Con-\ngress by a distinguished expert in the medi-\ncal \ufb01eld from the host country. At the 17th\nCMAAO Congress held in Hong Kong in\n1991, the Takemi family and the JMA pre-\nsented CMAAO with a fund named \u201cTake-\nmi Memorial Fund\u201dto support the Oration.\nAt the 2007 Congress held in Thailand, this\nOration was presented for the 8th\ntime.\nIII. Recent CMAAO Activities\nand Future Perspectives\nAt the 18th\nCongress, held in Malacca in\nMalaysia in 1993, the CMAAO Secretariat\nwas moved from the Manila to Malaysia.\nThe role of Secretary\/Treasurer was also\npassing from the Philippines to Malaysia.\nFollowing some subsequent reorganiza-\ntion, the Secretariat was relocated to Tokyo\nwhere Executive Board member of the JMA\nin charge of international a\ufb00airs took o\ufb03ce\nof Secretary General supported by Interna-\ntional Manager.\nCMAAO is now reaching its 50th\nanniver-\nsary, and the time has come to reconsider\nthe organization\u2019s role and activities. Initial-\nly, CMAAO was established with the clear\npurpose of creating an organization that\nwould represent the voices of Asian within\ntheWMA.Since then,CMAAO operations\nhave expanded based on this objective, and\nwithin this framework,the JMA had striven\nto further invigorate CMAAO activities.As\npart of these e\ufb00orts, the CMAAO SARS\nNetwork O\ufb03ce was set up within the JMA\nSecretariat to work to gather information\nabout SARS and avian in\ufb02uenza in Asian\ncountries. There are still many common is-\nsues for CMAAO to consider in the future,\nincluding issues unique to the Asia region.\nSome of the common problems are move-\nment of physicians across borders,standard-\nization of medical education in relation to\nmedical licenses, continuing professional\ndevelopment, provision of healthcare ser-\nvices to foreign-national residents, and\nmedical accidents or patient safety and\nthose unique to these regions include vari-\nous issues related to newly-emerging infec-\ntious diseases and the problems of medical\nassistance in the event of natural disasters\nsuch as tsunamis or earthquakes.\nRecently, together with proactive e\ufb00orts to\nresolve issues such as these, there have also\nbeen moves to revise the CMAAO Consti-\ntution and By-laws to be used for the next\n50 years. As the CMAAO Secretariat, the\nJMA is working to devise the most ap-\npropriate way to manage the activities of\nCMAAO to improve healthcare in the\nAsia-Paci\ufb01c region based on our long expe-\nrience as a WMA member as well.\nMasami Ishii, MD\nSecretary General of CMAAO,\nExecutive Board Member of the JMA\nand\nHisashi Tsuruoka,\nManager,\nInternational A\ufb00airs Division, JMA\n56\nThe Permanent Working Group of Euro-\npean Junior Doctors (PWG) was formally\ncreated in Bad-Nauheim, Germany, in May\n1976. Since then, the PWG has become the\nEuropean medical organisation with the\nmost comprehensive national membership,\nrepresenting the junior doctors of 26 Euro-\npean countries.\nThe PWG\u2019s initial objectives include safe-\nguarding the interests of the junior doctors\nin Europe, improving relations between its\nmember organisations and narrowing the\ngap between the junior doctors of the Eu-\nropean Union and those of other European\ncountries. Over the last three decades, the\nPWG has actively intervened in defence of\nthe medical profession in Europe with the\npurpose of contributing to the development\nof junior doctors\u2019 work and education and\nhas had an important role as a background\ngroup for the organisations of junior doctors\nin countries preparing to join the European\nUnion. From the beginning of the PWG\u2019s\nexistence, it became evident that the junior\ndoctors of the various countries have many\nsimilar experiences and di\ufb03culties.Therefore,\nafter pooling the information and exchanging\nideas,the PWG was able to identify the main\nareas of interest to junior doctors in Europe.\nThe status of the medical workforce was one\nof the most important issues in the PWG\u2019s\nearly years. The PWG conducted several\nstudies that drew the medical profession\u2019s\nattention to the fact that this issue is not\nstatic and that long-term planning, though\ndi\ufb03cult, is essential. The di\ufb00erent perspec-\ntives within the European Union in\ufb02uence\nthe migration of doctors, as well as the\nworking conditions, quality of training and\nquality of patient care.Therefore, the PWG\nhas endeavoured to gain a better insight of\nthe workforce policy of its member coun-\ntries in order to, where necessary, in\ufb02uence\npolicy makers by providing examples of\nmore successful planning. Other major ar-\neas of interest to junior doctors, and to the\nPWG, have been temporary migration for\neducational purposes,postgraduate training,\ncontinuing medical education, future medi-\ncal work and working conditions.\nIn its \ufb01rst years, the PWG embarked on the\nimportant task of compiling information to\nfacilitate the migration of doctors in training\nin Europe.The objective of this work was to\nprovide true freedom of movement, in ac-\ncordance with the principles established by\nthe Medical Directives in 1976.The PWG\u2019s\ngreatest contribution was the publication of\na series of booklets containing relevant in-\nformation for doctors wishing to seek em-\nployment or complement their training in a\nforeign country.\nIn 1995, at its conference on \u201cPostgraduate\nTraining: a European Future\u201d, the PWG\npublicly presented its most recent policy\non this issue, which is still a reference for\nEuropean doctors. This policy statement\nbrings to light a signi\ufb01cant number of prin-\nciples concerning the structure and quality\nof this phase of medical education, which\ncoincide with several points in one of the\nmost important o\ufb03cial documents on this\nissue, the 4th report of the Advisory Com-\nmittee on Medical Training (ACMT),\npublished in 1997. In the same year we\nhad the opportunity of disseminating an\nimportant new paper on \u201cFuture Medical\nWork\u201d, which has proven fully up-to-date.\nThis paper concerns the organisation of\nwork in health services and its in\ufb02uence on\nthe working conditions of junior doctors.\nThe greater expectations of patients, allied\nwith factors such as ageing, migration and\nmobility, have led to a progressive increase\nin healthcare costs. As a result, most Eu-\nropean countries have undermined doctors\u2019\nworking conditions with policies of eco-\nnomic management and redistribution of\nresources. Our recommendations include\nconcepts such as the creation of a positive\nworkplace, organisational development,\nproject management and other strategies\nthat enhance the structure, process and\noutcomes of health promotion for patients\nas well as doctors.\nIn May 2000, the PWG published a policy\nstatement on Continuing Medical Educa-\ntion\/Continuous Professional Development\n(CME\/CPD) and organised a conference\nin which it was possible for experts from\nvarious European medical organisations to\nexchange their views on CME\/CPD before\nan expert audience. We have recently wit-\nnessed the publication of several di\ufb00erent\ndocuments on CME\/CPD that generally\ndefend the principles that became evident\nduring the Conference. Fundamentally, the\nmedical profession believes that CME\/\nThe Permanent Working Group\nof European Junior Doctors\n57\nCPD is both a moral obligation and a right,\nand that access to appropriate CME\/CPD\nmust be ensured for all doctors, including\nthose in training. The PWG\u2019s Policy State-\nment opposes a system of recerti\ufb01cation and\nstates that it is a misconception that such a\nsystem would contribute to the identi\ufb01ca-\ntion of unsuitable doctors, hence defending\nthe concept of quality improvement, as op-\nposed to quality control.\nThe PWG was actively involved in \ufb01nding\na solution to the problem that was created\nwhen the European Working Time Di-\nrective (Directive 93\/104\/EEC) excluded\ndoctors in training from certain aspects of\nthe organisation of working time. In De-\ncember 1995, the PWG, in collaboration\nwith the European Commission, organised\na major conference in Brussels to address\nthe issue of junior doctors\u2019 working condi-\ntions. In the year 2000, after many years\nof intense negotiations with the European\nauthorities, the European Parliament and\nthe European Council \ufb01nally agreed to in-\nclude doctors in training within the scope\nof the European Working Time Directive\n(Directive 2000\/034\/EC). Although the\nPWG considers this agreement a posi-\ntive step forward in protecting the health\nand safety of doctors and their patients,\nit deplores the unnecessary delays to the\nfull implementation of the Directive. The\nEuropean Parliament and the European\nCouncil established a total transition pe-\nriod of nine years to reach the 48-hour\nweek, which the PWG regards as unnec-\nessarily long because junior doctors often\nwork until exhaustion in several European\ncountries, jeopardising their health and\nsafety, as well as that of their patients. The\nPWG continues to draw the attention of\nEU Member States to the need for real re-\nductions in junior doctor\u2019s working hours\nand the full implementation of this Direc-\ntive within the shortest possible time.\nCuriously, our organisation was founded as\nthe \u201cPermanent Working Group of Euro-\npean Junior Hospital Doctors\u201d, which later\nproved inappropriate because the PWG in-\ncludes doctors in training in non-hospital\n\ufb01elds and there was no organised body of\njunior doctors in the \ufb01eld of primary care.\nTherefore, in 1996, during an important re-\nvision of our statutes, by a working group\ncoordinated by Dr. Kirsi Ailus (SF), we\ndropped the word \u201chospital\u201d and became\nthe Permanent Working Group of Euro-\npean Junior Doctors.\nFrom the beginning, the PWG has sought\nto develop productive relations with vari-\nous European medical organisations and\nauthorities. We have had formal relations\nwith the Standing Committee of European\nDoctors (CPME) since 1983 and we were\ngranted consultative status in the Council\nof Europe in 1986. We also have good rela-\ntions with the Regional O\ufb03ce of the World\nHealth Organisation, the European Parlia-\nment and the European Commission. Since\n1991 each UEMS Specialist Section and\nEuropean Board has welcomed a represen-\ntative from PWG to represent European\ndoctors in training. At the Executive meet-\ning of UEMS in May 2007 it was agreed\nthat PWG delegates also are invited to rep-\nresent doctors in training in UEMS Mul-\ntidisciplinary Joint Committees. The PWG\nhas regular meetings with the most impor-\ntant European medical and medical stu-\ndents\u2019 organisations to coordinate activities\nand increase e\ufb03cacy. In November 2000,\nthese organisations approved a protocol\ngoverning the relations between them and\nthe CPME. The PWG is now a member of\na group of institutions that speak with one\nvoice and represent the medical profession\nin Europe, although it is aware of the fact\nthat it must maintain its independence and\ncapacity of negotiation with the European\nauthorities.\nOur top project at the moment is the Eu-\nroMedMobility; this a joint PWG\/EMSA\nproject that, among other objectives, aims\nto improve the mobility of doctors in train-\ning within European countries, increasing\nthe diversity in training opportunities for all\nEuropean medical professionals.\nDuring the \ufb01rst 31 years of the PWG\u2019s ex-\nistence, it has organised numerous plenary\nAssemblies all over Europe and the rota-\ntion of meetings has ensured mutual under-\nstanding and the exchange of information.\nSince its beginning, in Bad-Nauheim in\n1976, the PWG has been presided over by\nDr. Per Vagn-Hansen (DK), the \ufb01rst Co-\nordinating Secretary of the PWG for the\n1976-1979 triennium, followed by Dr. An-\nton Seiler (CH), Mr. Douglas Gentleman\n(UK) and Dr. Hans-Ueli W\u00fcrsten (CH).\nDr. Jesper Poulsen (DK) was the \ufb01rst per-\nson to be elected President of the PWG\n(1994-1997), an indication of the positive\ndevelopment of this organisation. Eduardo\nMarques (P) was the second President of\nthe PWG (until 2001) and the Dr. Nina\nTiainen (SF) as the third (2001-2005). At\nthe moment the president is under Portu-\nguese Presidency, Rui Guimar\u00e3es (P). Many\njunior doctors from all over Europe have\nhad greater or smaller roles in the PWG\u2019s\nwork and some are now accredited leaders\nin national or European medical organisa-\ntions. Some non-medical participants, who\nhave witnessed the life of this organisation\nfrom the beginning, have generously placed\ntheir knowledge on issues of medical policy\nat our disposal. The junior doctors of 26\nEuropean countries now have an in\ufb02uential\norganisation that defends their interests ef-\nfectively and, due to the hard and dedicated\nwork of many individuals, we are all proud\nof its achievements.However,there is always\nmuch to be done and we are aware that the\nstructure of our organisation must evolve if\nwe wish to maintain our recognised role and\ncapacity of intervention.\nRui Guimaraes\nwww.juniordoctors.eu\n58\nThe Taiwan Medical Association\nThe Taiwan Medical Association (TMA)\nwas established in 1930 to advance medi-\ncal knowledge, to uphold members\u2019 rights,\nto strengthen physician-patient relations,\nas well as to advocate social services. The\nTMA is composed of regional medical as-\nsociations from 23 counties around Taiwan.\nIts membership is compulsory for every\npracticing physician. Among the total 36\n991 TMA members (\ufb01gure for the end of\n2007), 30% practice in medical centres, 13%\nin regional hospitals, 18% in local hospitals,\nand 39% in private clinics. The physician-\npatient ratio is 1:653.\nThe TMA has formed ten committees to\ncarry out its various missions and duties.\nThese include Health Care Policy Commit-\ntee, National Health Insurance Commit-\ntee, Health Industry Advisory Committee,\nMedical Laws and Regulations Committee,\nAcademic Committee, Member Welfare\nCommittee, Medical Ethics and Discipline\nCommittee, International A\ufb00airs Commit-\ntee, Public Relations Committee, and Pub-\nlications Committee. In many areas, ad hoc\ntask forces are set up to study relevant issues\nand to provide policy suggestions for the\nExecutive Board.\nFor more than a decade, the TMA has ac-\ntively participated in several key areas to\npromote the health of all Taiwanese, in-\ncluding the formulation and revision of a\npatient-centred National Health Insurance\nPolicy in Taiwan, the advocacy of quality\nof care and patient safety, the implementa-\ntion of continuing medical education, and\nthe uplift of moral standards of health care\nprofessionals. In the international forum,\nthe TMA joins forces with the rest of the\nworld through the World Medical Associa-\ntion and CMAAO to increase its visibility,\nand to express Taiwan\u2019s good will to serve\nthe international community. In time of di-\nsasters and emergency around the globe,the\nTMA has taken little time in mobilising its\nmembers to provide emergency relief and\nmedical aid to people in need.\nThe TMA has established close interaction\nwith the WMA in recent years by partici-\npating in various programs and activities.\nThe translation and publication of \u201cManual\nof Medical Ethics\u201d of WMA enables TMA\nmembers to share WMA\u2019s policy changes,\nits functions and the contribution to all\nphysicians around the world. By working\nwith the WMA in devising declarations\nand policies, the TMA acquires updated in-\nformation on medicine, ethics, and medical\neducation.\nThe TMA strongly believes in the col-\nlaboration among all national medical as-\nsociations under the auspice of the WMA.\nThe sharing of information and resources,\nand the joint e\ufb00ort in international medi-\ncal assistance will enable us to create a truly\nglobal village.\nDr. Ming-Been Lee, the President of TMA\nTaiwan Medical Assembly in 2007\n59\nMedical Association of Uzbekistan was the\n\ufb01rst a non-state non-commercial medical or-\nganisation (NGO) created in the Republic of\nUzbekistan in 1992.The initiators of the As-\nsociation were: Khudaybergenov A.M., Ko-\nsimov E.J., Asadov D.A., Rizaev M.N., Ir-\ngashev S.B., Mustafaev H.M., Sidikov Z.U.,\nJunusov M.M., Akbarov A.A., Vajnshtejn\nV.S., Nurullaev L.D., Usmonhuzhaev A.H..\nThe Association was registered by the Min-\nistry of Justice of the Republic of Uzbeki-\nstan on 11th\nNovember 1999. The mission\nof the Association is - assistance to the\ndevelopment of medical practice and sci-\nence for the preservation and strengthening\nof the health of citizens of the Republic of\nUzbekistan.\nAccording to the Charter of Association its\nprimary goals are:\nParticipation in reforming the system of\u2022\npublic health services of the Republic of\nUzbekistan;\nMedical, economic and legal aid to mem-\u2022\nbers of Association;\nSupport for private practice and private\u2022\nmedical institutions in medicine;\nParticipation in the development of uni-\u2022\nform standards for control and quality in\npublic health services;\nSupport of doctors of veterans and use of\u2022\ntheir experience;\nImprovement of international co-oper-\u2022\nation, holding of conferences, seminars\nand symposiums.\nThe Association has 14 regional branches in\nwhich have been registered as members 20\nthousand doctors, and also a publication \u2013\n\u201cThe Bulletin of the Medical Association of\nUzbekistan\u201d, which 4 times a year which has\nbeen regularly printed already for more than\n10 years. In the publication are printed arti-\ncles devoted to management, economy, law,\nmarketing, new methods of diagnostics and\ntreatment, information on seminars, confer-\nences and to the private sector in public health\nservices. The general circulation of the publi-\ncation is more than 5 thousand,which extends\nto all medical institutions in the Republic of\nUzbekistan.The president of the Medical As-\nsociation of Uzbekistan is Doctor of medical\nsciences, Professor Abdulla Khudaybergenov,\nand his assistants are Academician Tulkin\nIskandarov and Candidate of Medical Sci-\nences Zafar Sidikov. The executive director\nof the Association is Zakhid Abdurakhimov.\nThe Medical Association of Uzbekistan since\n1997 is a member of the European Forum\nMedical Association and takes part in them\n(Copenhagen, the Vienna, Berlin, Warsaw,\nOslo,Lisbon and Israel).\nFor the last the Medical Association of\nUzbekistan took part in several grant aided\nprojects and in 2008 has \ufb01nished the grant\nof the World Bank on \u201cMonitoring of\nrendering of medical aid in jails\u201d. The ba-\nsic purpose was the monitoring of jails re-\ngarding protection and maintenance of the\nrights of prisoners to medical aid.Informing\nthe public on the condition and problems\nof public health services in jails will allow\nthe taking active actions by various NGOs,\ninitiative groups and funds on improvement\nof the health of prisoners. In turn improve-\nment of preventive and medical work in\nprisons will allow the reduction of disease,\nphysical inability, and also the death rate\namong prisoners, which will allow them to\njoin more quickly civilian life after being re-\nleased from jail. As a result, we would like\nto emphasise, that reform in the sphere of\npublic health services spent by Uzbekistan,\nis carried out everywhere, including in the\ncorresponding services of prisons.\nThe measures directed to strengthening of\nhealth of citizens being held in prisons, car-\nrying out preventive and explanatory work\namong prisoners concerning a healthy way\nof life, developing of the activity of the\nmedical personnel, and increasing their\nknowledge in the sphere of maintenance\nand protection of the rights of prisoners,\nwill allow the reduction of the burden on\nthe system of public health services of the\ncountry as a whole and keep what is most\nvaluable the health of a person.\nThe Medical Association of Uzbekistan be-\ning the representative of a civil society is not\nindi\ufb00erent to problems of the health of the\nnation, and so systematically and consist-\nently carries out activities on improving of\nthe public health of society and citizens of\nthe Republic of Uzbekistan and also pro-\ntects the interests of medical workers and\ntheir associations.\nProfessor Abdulla Khudaybergenov\nMedical Association of Uzbekistan \u2013\nExperience and Perspectives\nPresidentof MedicalAssociationof Uzbekistan,\nProfessor Abdulla Khudaybergenov\n60\nThe Canadian Medical Association (CMA)\nwas born in October 1867, barely three\nmonths after the birth of Canada, and it has\nbeen the main national body representing\nCanada\u2019s physicians since then.\nFollowing that \ufb01rst meeting, the CMA\nhad 167 members. Today, it has more than\n67,000 members living in Canada\u2019s 10\nprovinces and three territories, and approxi-\nmately 50 other countries. Membership is\nvoluntary, and approximately 70% of eli-\ngible physicians choose to join.\nThe online archive of the Canadian Medi-\ncal Association Journal (www.cmaj.ca), which\ncontains all articles published since the jour-\nnal\u2019s launch in 1911, provides a fascinating\nlook at how far Canada, its physicians and\nthe CMA have come since then.\nIt also provides a suitable backdrop for the\nCMA\u2019s two-part Vision Statement, \u201cA\nhealthy population and a vibrant medical\nprofession.\u201d One of CMAJ\u2019s \ufb01rst reports in-\ndicated that the infant mortality rate in the\ncity of Ottawa \u2013 the nation\u2019s capital \u2013 stood\nat 224 deaths per 1,000 live births in 1908.\nOne hundred years later, Canada\u2019s nation-\nwide infant mortality rate is 4.63\/1,000.\nThe CMA was the national medical voice\nthat helped make many such improved\nhealth outcomes possible. It was the driving\nforce behind the creation of national bod-\nies to regulate medical education and certify\nnew doctors, which in turn set the stage for\nthe development of a science-driven, rig-\norously regulated medical profession that\nquickly earned the public\u2019s con\ufb01dence.\nOnce that con\ufb01dence was earned,the public\nlistened when the CMA supported public\nhealth initiatives such as the pasteurization\nof milk and the need for safe, reliable drink-\ning water. In 1961, the CMA told members\nthey had a duty to warn patients about the\nlink between smoking and cancer, and the\nproportion of smokers has fallen to less than\n20% of adults. Today, Canadians\u2019 average\nlife expectancy of 80.34 years is among the\nhighest in the world.\nThe second part of the Vision Statement, \u201ca\nvibrant medical profession,\u201d also occupies a\nlarge share of CMA e\ufb00orts because the coun-\ntry\u2019s health care system is under considerable\nstress due to funding issues, human resource\nshortages and an aging population.\nOne sign of this stress became clear when\nthe CMA conducted a survey in 2003 and\nfound that 46% of physicians considered\nthemselves \u201cburned out\u201d by their work. The\nCMA responded by creating the world\u2019s\n\ufb01rst Centre for Physician Health and Well-\nBeing, which also links physician health\nprograms across the country.\nOn the human resource front,Canada is still\npaying for a 1992 decision to cut medical\nschool enrolment in the face of rising gov-\nernment de\ufb01cits and a perceived \u201csurplus\u201dof\nphysicians.Today that surplus has turned in\nto a serious shortage, with an estimated \ufb01ve\nmillion Canadians having no regular access\nto a family physician. The CMA recently\nlaunched a national public relations cam-\npaign to draw attention to the issue.\nThe CMA has also enjoyed unique success\namong medical organizations because of its\nearly and successful e\ufb00orts to help members\nin areas such as retirement and \ufb01nancial\nplanning. The CMA entered the \ufb01eld in\n1957 after its extensive lobbying of the fed-\neral government meant Canadians could set\naside tax-free retirement savings for the \ufb01rst\ntime. The CMA launched its \ufb01nancial sub-\nsidiary that same year with an investment of\n$50,000. Today that company \u2013 MD Man-\nagement \u2013 manages more than $25 billion\nin investments for CMA members and\ntheir families.\nIn 2008, with Canada\u2019s population having\npassed 33 million, the CMA remains the\nnational voice for the country\u2019s physicians,\nand it works closely with its divisions in the\nprovinces and territories to respond to and\ndeal with members\u2019 priorities.\nIts message does appear to be getting\nthrough. A recent survey of Canadian politi-\ncians and senior public servants found that,\namong a dozen major national organizations\nin \ufb01elds ranging from health care to brewing\nand broadcasting, the CMA ranked \ufb01rst in\nall categories, and that 79% of respondents\nconsidered it \u201cvery\u201dor \u201csomewhat\u201din\ufb02uential\nin setting the country\u2019s national priorities.\nThe CMA has also been an active participant\nin the World Medical Association since its\ninception.Recent contributions include revi-\nsion of several key WMA policy documents,\nindividually or as part of working groups,and\nthe chairmanship of the WMA\u2019s Ad Hoc\nCommittee on Advocacy by Dr. Dana Han-\nson, a CMA past president.\nDr. Henry Haddad, another CMA past\npresident, also chaired the Sociomedical\nCommittee for several years, and in this role\nwas instrumental in introducing the consent\nagenda to the WMA.\nThe CMA looks forward to hosting the\nWMA General Assembly in Vancouver in\nOctober 2010. This will mark the third time\nthe meeting has been held in Canada,and the\n\ufb01rst time since it was held in Ottawa in 1998.\nBarbara Drew, Associate Secretary General\nand Chief Operating O\ufb03cer\nThe Canadian Medical Association\n140 Years and Counting\n61\nFirst, we would like to thank the people in\ncharge of the World Medical Journal for\nthe space o\ufb00ered to the Medical Union of\nUruguay in order to be able to brie\ufb02y up-\ndate on the general situation of health in\nour country and of the doctors in particular.\n2008 has begun and the sector of health\nhas been immersed in a process of change,\nof transformation. The Medical Union of\nUruguay on many occasions has speci-\n\ufb01ed its opinion in relation to this issue\nand has participated in all the events to\nwhich it was invited by the sanitary au-\nthorities. For the Union it is of historical\nimportance and related to the commit-\nment to healthcare of the Uruguayans, so\nnon-participation was out of the question.\nWe have applauded the \ufb01rm stand of the\ngovernment on healthcare reforms and the\ncreation of a coordinated and e\ufb03cient Na-\ntional Healthcare System,which would pro-\nvide a rational use of resources, focusing on\nthe most vulnerable groups of population.\nThe position that the national medical body\nhas expressed through the Medical Union\nof Uruguay has not always been well under-\nstood. We recognise the necessity for change\nand this is so because the general and basic\nprinciples of transformation of the health sys-\ntem have been originated by this very Union.\nThese principles were not only generated but\nalso defended, considering that they form the\nsolid base of the Healthcare System.\nThe complementary and di\ufb00erent vision\nof the proposed reform as o\ufb00ered by the\nMedical Union of Uruguay does not con-\nstitute an obstacle but a contribution which\nwe considered essential to reach the goals\nin the shortest time possible, to meet the\nexpectations of the Uruguayan society to\nenjoy better care constructed on \ufb01rm basis.\nDoctors constitute the foundation on\nwhich a health system would be built;\nthey are the central axis of the structure\nand a very complex organisation united\nby a common and principal mission to\nmaintain health and to \ufb01ght diseases. The\ndoctor is the professional who is suitable,\ntrained and quali\ufb01ed to ful\ufb01l this task.\nTherefore the Medical Union of Uruguay\nmaintains that all reforms, all changes\nin the healthcare system must take into\nconsideration the medical profession-\nals, from the pre-degree to the retire-\nment group. This practice cannot be op-\ntional; it must be the rule if we really\nwish to a\ufb00ect the health-disease process.\nThe conditions and form of work of the\ndoctors must change; it is essential to im-\nprove labour concentration, also education-\nal and investigation activities, establishment\nof a principal national award, the search of\nreal alternatives for the introducing of the\nyoung doctor into the labour market, solu-\ntions that give opportunity for a worthy re-\ntirement from the medical profession, the\nrelation between the professionals and the\nadministration of institutions, considering\nthe essential necessity that nowadays for\ndoctors to stay quali\ufb01ed, they have to be en-\ngaged in lifelong education.\nThe implementation of these changes will\nensure a new form of work for the doctor but,\nmore importantly, it will give an answer to\nmanyofthecomplaintsraisedbythepatients\nand their relatives in relation to medical care.\nThere are many and varied instances on\nwhich, throughout its history, the Medical\nUnion of Uruguay has indicated the ne-\ncessity that the healthcare system should\nbe considered an object for urgent trans-\nformation because it has been delayed.\nIt is obvious for the patients and doctors\nalike, that the present system has de\ufb01cien-\ncies which make a change essential.\nFragmented, unavailing and with super-\nstructures that make it ine\ufb03cient, this\nsystem (asistema or \u201cnon-system\u201d as some\nprefer to call it to demonstrate how little\nsystem that it has), implies for a good part\nof Uruguayans the serious problems of fair\ntreatment and access,whereas for the doctor\nit is strongly indicative of wide conspiracy\nagainst the quality of life of the profession-\nals, the capacity of their performance, suit-\nable attention and institutional attachment.\nIn view of the accomplishment of the last\nConsultative Council (the nucleus of all the\nactors involved in the health-disease pro-\ncess) in the past year we left the position of\nthe medical union in the sense that obvi-\nously the year of 2008 had to be the year of\nthe change in the conditions and the form\nof work of the doctors and that this had to\nbe considered by all healthcare actors as a\nbasic and fundamental element to really ob-\ntain consolidation of the reform process.\nThe MUU (SMU) is going to put in maxi-\nmum e\ufb00ort and will dedicate all the re-\nsources that are at their disposal so that\nthe change in the conditions of work of the\ndoctors is a reality in the short term, thus\ncontributing to the overall consolidation\nof the healthcare system as a whole and in\nparticular, o\ufb00ering the best-quality care to\nthe patients.\nDr. Alfredo Toledo Ivaldo\nMedical Union of Uruguay\nDr. Alfredo Toledo Ivaldo,\nPresident of the Medical Union of Uruguay\n62\nThe Malaysian Medical Association (MMA)\nis the \ufb01rst and currently the largest pro-\nfessional medical association in Malaysia.\nThough many medical associations have\nsprung up after that, representing various\ninterest and speciality groups, the Malaysian\nMedical Association still remains the largest\nand one of the more active associations in\nthe country. It was formed with a commit-\nment to promote the highest possible pro-\nfessional and ethical standards of health care.\nThe MMA has ever since played a promi-\nnent role in promoting quality and equitable\nhealth care, while preserving the autonomy\nand professional integrity of the physician.\nThe forerunner to the MMA was the Straits\nMedical Association (SMA) which was\nthe o\ufb03cial association of the then Malaya\nand the Straits Settlements. The SMA was\nstarted and operated by expatriates working\nhere and this was later replaced by the Ma-\nlaya Branch of the British Medical Associa-\ntion (BMA). When Malaya became inde-\npendent in August 1957, Singapore chose\nto remain a British Colony, but the BMA\nMalaya Branch still remained the only pro-\nfessional medical association for both these\ncountries. In 1958 two separate associations\nrepresenting the two countries were formed\nnamely the \u2013 The Malayan Medical Associ-\nation and The Singapore Medical Associa-\ntion. The Malayan Medical Association in\n1971 grew to become the Malaysian Medi-\ncal Association with the inclusion of the\nstates of East Malaysia.\nCurrently there are many sections and so-\ncieties under the MMA representing the\nvarious activities of the association. There are\ntwo main sections of the MMA namely the\nSCHOMOS and PPS. The SCHOMOS or\nSection Concerning House O\ufb03cers and Spe-\ncialists was formed in 1981,creating an o\ufb03cial\nchannel of communication between govern-\nment and doctors in the public sector. Since\nits formation SCHOMOS has had protract-\ned and di\ufb03cult negotiations on behalf of the\ngovernment doctors with di\ufb00erent authorities\nchampioning their cause. The results reached\nthrough these negotiations have made many\npositive changes to the working conditions,\nallowances, promotions and other issues ben-\ne\ufb01ting all government doctors.\nThe Private Practitioners Section (PPS) was\no\ufb03cially registered in 1991 to address the\nvarious issues faced by the private practitio-\nners. The terms of reference for this section\nwas \u2013 \u201cTo represent views, interests and as-\npirations of members of the MMA in pri-\nvate practice. \u2013 To study problems faced by\nprivate practitioners and commend solutions\nto the MMA Council. \u2013 To encourage the\nactive participation of private practitioners in\nactivities related to healthcare and to assist\nthem to adequately respond to changes.\u201d\nEthics Committee\nThis was one of the \ufb01rst committees to be\nformed after the registration of the MMA.\nThe initial task of this committee was to\ndraw up the ethical code of ethics, in the\ncontext of the local medical situation and\nculture. The ethical code has been exten-\nsively revised twice, once in the year 1998\nand again in 2001, to incorporate emerging\nethical issues. The Association has encour-\naged the correct behaviour of the mem-\nbers of the profession, by guiding and giv-\ning advice on good medical practice while\nreprimanding unethical conduct. An essay\ncompetition on di\ufb00erent aspects of medi-\ncal ethics is organised annually in conjunc-\ntion with the world ethics day of the World\nMedical Association to create an interest in\nethics among medical students. The ethics\ncommittee is active in organising seminars\nand updates on ethics of medical practice on\na regular basis to update the members.\nMedical Education\nThe training of su\ufb03cient and appropriate\nnumber of doctors has been a challenging\ntask for many countries including Malaysia.\nThe \ufb01rst medical college was established in\nthe University of Malaya in 1964 and was\nthe only college for many years. Over the\nlast few years there has been a \ufb02urry to open\nnew medical colleges both public and pri-\nvate.The rapid expansion of medical colleg-\nes in the last few years is a cause for concern\nas it has stretched the available resources of\nboth manpower and facilities. The Malay-\nsian Medical Association has on a few occa-\nsions brought together all interested parties,\nuniversities, Ministry of Health, Ministry\nof Education and held Medical Education\nConferences to chart the future of Medical\neducation in the country.\nEstate Medicine Committee\nHealthcare provision in the rubber and palm\noil estates has generally lagged behind na-\ntional healthcare provision in the country\nand has been semi-independent. Though\nsome larger estates had reasonable healthcare\nfacilities and personnel most estates only had\na rudimentary service.The distance of estates\nfrom hospitals and government health fa-\ncilities made it di\ufb03cult for estate workers to\nobtain proper medical care.The MMA com-\nmissioned study, on the availability of health\nfacilities for the estate workers, painted a\nbleak situation and the study was presented\nto government and concerned authorities.\nThough there were some remedial measures\ntaken as a result, health care provision in the\nestates remains inferior to that of the coun-\ntry. The MMA continues to champion the\nright of health for the estate workers and for\nThe Malaysian Medical Association\nDr. Nachiappan Arumugam\nWMA Immediate Past President\n63\nestate health system to be incorporated into\nthe mainstream healthcare delivery system of\nthe country.\nPhysicians for the Prevention\nof Nuclear War committee\nThe Physicians for the Prevention of Nuclear\nWar committee has highlighted the dangers\nof nuclear warfare and its disastrous e\ufb00ects on\nhealth. It has persistently lobbied against the\nproduction and stockpiling of nuclear arms.\nThe committee and its long standing chair-\nman Datuk Dr Ronald McCoy, also a past\npresident of the MMA, received interna-\ntional recognition by being appointed to the\nCanberra Commission on the Elimination\nof Nuclear Weapons in 1996. The Canberra\nCommission on the Elimination of Nuclear\nWeapons was established as an independent\ncommission by the then Australian Govern-\nment in November 1995 to propose practical\nsteps towards a nuclear weapon free world\nincluding the related problem of maintaining\nstability and security during the transitional\nperiod and after this goal is achieved.\nContinuing Professional\nDevelopment Committee (CPD)\nThe MMA has in collaboration with Uni-\nversities, hospitals and pharmaceutical com-\npanies been organising medical meetings\nfor many years to update the members on\nthe developing trends in medicine. Initially\nthe Continuing Medical Education (CME)\ncommittee was formed to co-ordinate the\nactivities and latter the name was changed\nto Continuing Professional Development\nCommittee (CPD) committee to be more\nre\ufb02ective of the work it was doing. In 1995,\nthe CPD was formalised with the Malay-\nsian Medical Council and the MMC-CPD\nGrading system was introduced and the\nMMA was made the secretariat for running\nthe system.This voluntary system enabled all\ndoctors to register all their continuing medi-\ncal education and professional development\nactivities with the MMA and the MMC is-\nsued certi\ufb01cates of attendance annually.\nInternational Medical Associations\nThe Malaysian Medical Association is a\nmember of important regional and inter-\nnational organisations namely, Medical\nAssociations of South East Asian Nations\n(MASEAN), Commonwealth Medical\nAssociation (CMA), Confederation of\nMedical Associations in Asia and Oceania\n(CMAAO) and World Medical Association\n(WMA). The MMA has taken an active\npart in the activities of these associations\nand some of the leaders of the MMA have\nheld various posts in these organisations. It\nwas indeed a historic occasion for MMA\nwhen Datuk Dr Arumugam was elected\nand installed president of the WMA in\n2007.It was also an honour when Datuk Dr\nT.P. Devaraj was chosen as one of the Car-\ning Physicians of the World by the WMA.\nPublic Health and Community Service\nThe Malaysian Medical Association has been\nin the forefront of public education. It has\ninitiated and carried out many public health\ncampaigns to raise awareness of the public to\nvarious diseases and healthy living.\nAction on Smoking and\nHealth (ASH) Committee\nOne of its earliest public health activities was\nto discourage students from picking up the\nsmoking habit and to encourage smokers to\nquit smoking. MMA was one of the pioneer\norganisations in this country to have started\nthe anti-smoking campaigns through the\nMMA\u2013ASH committee and has continued\nto be committed to this activity till today.The\nMMA has over the years promoted the An-\nnual No-Smoking Day and incessantly high-\nlighted the dangers of smoking to the citi-\nzens of the country. The association has also\norganised scienti\ufb01c meetings and workshops\nto stimulate interest in anti smoking activi-\nties among the doctors and allied health sta\ufb00.\nThe MMA-ASH committee has over the\nyears helped to draft and successfully lob-\nbied for the implementation of various rules\nand laws to discourage and curb smoking in\n\ufb02ights, restaurants and public places.\nAdolescent Health Committee\nAdolescent Health has now become an im-\nportant sub-specialty with its unique set of\nproblems and needs. The MMA adolescent\nHealth sub committee organised courses to\nupgrade the understanding of the health\nneeds of this group in di\ufb00erent states for\nhealth personnel. The committee also had\nawareness programmes and hepatitis B im-\nmunisation for some school children.\nHealth of the Older Person Committee\nIn view of the increasing number of older per-\nsons in the country, a Committee was formed\nto create an interest in the health of the aged\namong the profession and awareness in the\nsociety of the problems and challenges faced\nby this population. In 2005 a \u2018Senior Citizen\u2019s\nCharter\u201dwas launched by the MMA. As this\nolder population face special medical prob-\nlems the committee has ventured in educating\ndoctors on these common conditions a\ufb00ecting\nthis group of patients.The association also has\nactivities to mark Senior Citizens Day on 1st\nOctober 2006. The association, as the largest\nprofessional medical organisation in the coun-\ntry, through representation in many govern-\nment and non-government organisation and\nmany of it committees like theTraditional and\nComplimentary medicinecommittee(TCM),\nSociety of occupational and Environmental\nHealth (SOEM), Ophthalmological society,\nPublic health society,Sports Medicine society,\nAccident prevention committee has not only\nadvanced the interests of its members and\nprofession, but also the health and welfare of\nthe citizens of the country.\nDr. Nachiappan Arumugam\n64\nThe Finnish Medical Association (FMA)\nwas founded in 1910 and is already prepar-\ning for its centennial celebration that takes\nplace in just under two years. Since its es-\ntablishment the association has defended\nthe professional, social and economic inter-\nests of its members and strived to develop\nhealth care and advance medical expertise,\nsafeguarding thereby the interests of both\ndoctors and their patients.\nThe Finnish health care system\nIn Finland the organization health care is a\npublic responsibility. The system is \ufb01nanced\nboth by taxes and through a statutory health\ninsurance scheme.User charges exist also,and\nthey are relatively high in a European com-\nparison. The organizational model is decen-\ntralized; the local government (municipality)\nlevel is responsible for arranging health and\nmedical care for the citizens.There are about\n400 municipalities and they are relatively\nfree to choose how they organize primary\nhealth care. In addition to the public service\nthat is available to everyone, employers are\nobliged to provide occupational health ser-\nvices to all their employees. Primary care is\nmainly arranged in health centres that the\nmunicipalities operate either individually or\ntogether. Physicians working in health cen-\ntres are therefore municipal employees, even\nthose who work under the system of \u201cper-\nsonal doctors\u201d, a Finnish variant of the fam-\nily doctor. For specialized medical care the\ncountry is divided into 20 hospital districts.\nAll municipalities are obliged to belong to\none of these through federations formed by\nthem. Each of the districts is responsible for\nproviding and coordinating the specialized\nservices within its area. The quality of ser-\nvices and health care facilities are of a high\nstandard. The population of 5.3 million in-\nhabitants is also in general satis\ufb01ed with the\nservices, although regional variations exist.\nFinland was the \ufb01rst country in Europe to\nintroduce a law on patients\u2019 rights in 1993.\nThe main challenges facing the system are\nrelated to manpower planning and the co-\nordination of operational costs and capital\ninvestments.\nRole and Structure of the FMA\nThe FMA acts both as a professional or-\nganisation and a trade union. It is a proac-\ntive and well respected consultation partner\nfor the government and parliament in all\naspects of health policy. Developing educa-\ntion of physicians together with the medi-\ncal faculties forms an important part of the\nassociation\u2019s activity. It also has a major role\nin organising and overseeing continuous\nprofessional development of its members.\nAs a trade union the FMA negotiates the\nsalaries and working conditions of the phy-\nsicians working in the public sector. The\nFMA membership is voluntary and indi-\nvidual.Some 94 % or 21.400 of all physicians\nlicensed to practice in Finland are members.\nThe association forms an umbrella structure\nboth for the specialists\u2019, GP\u2019s and junior\ndoctors\u2019 national associations, as well as foe\norganisations based on geographical loca-\ntion or specialty. The FMA therefore truly\nunites the opinions of doctors in Finland\nand enables the profession to speak with one\nvoice.The decision-making is based on elec-\ntions held every three years, where all mem-\nbers choose their representatives to the 60-\nmember FMA \u201cparliament\u201d, called Delegate\nCommittee. That then elects the board and\nits members, including the president who\nhas a one-year renewable term.\nThe FMA o\ufb03ce has some 70 members of\nsta\ufb00, who serve the members in various\nways, prepares the policies for the board\nto adapt and implements them. The FMA\npublishes a weekly journal that reaches the\nwhole membership free of charge.The FMJ\nis a scienti\ufb01c journal as well as a major fo-\nrum of health policy discussion in Finland.\nEthics and the professional oath\nA core activity of the FMA throughout its\nexistence has been to promote and develop\nmedical ethics. In 1910, the \ufb01rst President\nof the association expressed the hope that\nthe FMA would become the heart and con-\nscience of the medical profession.That wish\nhas since become a reality. The FMA pub-\nlishes a regularly updated book on medical\nethics. This compilation of ethical thinking\nand approved guidelines o\ufb00ers the members\na toolkit that helps them to make di\ufb03cult\ndecisions in their everyday work. The book\nis published in both the o\ufb03cial languages\n(Finnish and Swedish) and it is distributed\nto all the members of the FMA, as well as\nto medical students. An ancient tradition of\nthe honorary position of the Archiater, the\neldest of the medical profession still exists\nin Finland.This title,which can only be held\nby one person at a time and is awarded by\nthe President of Finland, has existed since\nthe days Finland was part of the kingdom\nof Sweden, over 200 years ago. Today the\nArchiater is the moral leader of the profes-\nsion and actively participates in the public\nThe Finnish Medical Association\nApproaching One Hundred Years of Promoting good\nQuality Healthcare and Physicians\u2019 Interests\nDr. Heikki P\u00e4lveDr. Olli Meretoja\n65\nThe Foederatio Medicorum Helveticorum\n(FMH) or Swiss Medical Association is the\numbrella organisation for the medical pro-\nfession in Switzerland. Just over 90% of the\napprox.30,000 physicians in the country are\nsigned-up members. As a professional or-\nganisation, the FMH aims to:\n\u2022 ensure a high standard of medical care in\nSwitzerland;\n\u2022 promote the professional development of\nphysicians;\n\u2022 foster relations between its members; and\n\u2022 actatthepoliticalleveltocreateaframework\nin which physicians can work e\ufb00ectively.\nStructure and bodies at the FMH activities\nLegally speaking, the FMH is an association.\nIts two main bodies are the Medical Council\nwhich has 200 delegates and acts as the\u2018parlia-\nment\u2019, and the 11-member Central Commit-\ntee which serves as the \u2018government\u2019. A 33-\nmember Delegates General Meeting (DGM)\nadvises and supports the Central Committee\nin all important subject areas. The DGM is\nalso authorised to make decisions itself, espe-\ncially in the \ufb01eld of health policy.To become\nan ordinary member of the FMH, the ap-\nplicant must be able to show that he or she\nhas a Swiss medical degree or its equivalent,\nworks in the healthcare sector in Switzer-\nland, and is of reputable character. Ordinary\nmembers automatically become members of\none of the local organisations.\nThe FMH\u2019s General Secretariat in Bern has\na dual role of a service centre and the head\no\ufb03ce. About 75 people work there in the\nvarious departments which include:\nMembers Services\u2022\nUndergraduate, Postgraduate &\u2022\nContinuing Medical Education\nFees Guidance\u2022\nLegal Service\u2022\nData, Demographic Information &\u2022\nQuality Management\nPrevention\u2022\nCommunications & PR\u2022\nOne of the main tasks at the FMH is to\nmonitor the specialist training of physicians\nafter their state examinations.In most cases,\nthis training leads to the title of \u2018specialist\u2019.\nThe FMH is also active in the \ufb01elds of qual-\nity management, working closely with the\nspecialist medical associations and the par-\nties involved in negotiating doctors\u2019 fees.\nThe Schweizerische \u00c4rztezeitung (\u2018Swiss\nMedical Journal\u2019) is a major platform and\nsource of information for the medical pro-\nfession in Switzerland. Published by Edi-\ntiones Medicorum Helveticorum in Basel,\nthe FMH\u2019s o\ufb03cial journal comes out on a\nweekly basis (www.saez.ch). On behalf of\nits members, the FMH campaigns exten-\nsively and maintains close networks with\npoliticians and the media. Its motto \u2013 \u201cNo\nhealthcare policy without the FMH!\u201d \u2013\ncomes over loud and clear.\nThe President\u2019s O\ufb03ce\nAs President and Chairman of the Central\nCommittee, Jacques de Haller has been in\ncharge at the FMH since 2004. Under his\nmanagementoverthelastfouryears,theFMH\nhas succeeded in shaping a coherent policy for\nthe medial profession in Switzerland and in\ncreating a distinct and credible pro\ufb01le,both in\nthe eyes of the public and of other major play-\ners in the Swiss healthcare sector.\nOne great challenge facing the FMH is\nsafeguarding the \u2018freedom of occupational\npractice\u2019, a right which is increasingly com-\ning under attack from many a side \u2014 the\ninsurance companies and the state in its role\nas regulator, for example. The task of the\nFMH here is and will be to organise politi-\ncal campaigns and lobby on a broad basis to\nensure that traditional values are maintained\nand that relevant threats are averted.\nOnly with a united association, speaking\nwith one voice and represented by a strong\nand professional leadership, can these aims\nbe achieved.\nD. Herzog, General Secretary of the FMH\nSwiss Medical Association\ndiscussion on medical ethics in the country.\nThe association has also reintroduced the pro-\nfessional oath, which was earlier a part of the\nmedical degree in the faculties. The swearing\nof the oath is now voluntary,but practically all\nthe graduates choose to swear it at their grad-\nuation ceremony,where the Archiater and the\npresident of the FMA are present.\nInternational activities\nThe values and tasks of the FMA are not\nbound by the borders of Finland. The as-\nsociation is an active member of several\ninternational medical organisations, most\nimportantly the World Medical Association\n(WMA), Standing Committee of European\nDoctors (CPME),European Union of Med-\nical Specialists (UEMS),European Union of\nGeneral Practitioners (UEMO) Permanent\nWorking Group of Junior Doctors (PWG)\nand the Nordic Medical Council (NLR).\nDr. Olli Meretoja,\nDr. Heikki P\u00e4lve, Dr. Jukka Siukosaari\nDr. Jacques de Haller, President FMH\nThe FMH: the Professional Association for\nPhysicians in Switzerland\n66\nThe Polish Chamber of Physicians and\nDentists (Naczelna Izba Lekarska) and\nthe regional chambers of physicians and\ndentists (okr\u0119gowe izby lekarskie) are the\norganisational bodies of the professional\nself-government of physicians and den-\ntal practitioners who are associated in the\nchambers with equal status.\nThe professional self-government of physi-\ncians and dental practitioners in Poland was\nfounded in 1922, dissolved in 1952 and re-\nestablished in 1989.\nThere are currently 23 regional chambers\nand a separate chamber of military physi-\ncians and dentists that has legal status of the\nregional chamber although it is active in the\nentire country. Chambers of physicians and\ndentists deal with all kinds of matters con-\ncerning the exercise of medicine and den-\ntistry in Poland.\nThe highest authority of the Polish Cham-\nber of Physicians and Dentists is the General\nMedical Assembly whereas the regional med-\nical assemblies are the highest authorities of\nthe regional chambers. In the period between\nassemblies \u2013 the Supreme Medical Council\nand regional medical councils respectively.\nThe Supreme Medical Council represents\nthe medical professions at the state level,\nand regional councils at regional levels.\nMembership in the chambers is mandatory.\nEvery physician and every dental practitio-\nner who holds the right to practice the pro-\nfession in Poland is a member of the cham-\nber by virtue of the law.\nNumber of members of the chambers in\n2007:\nPhysicians \u2013 appr. 128 000\u2022\nDental practitioners \u2013 appr. 34 500\u2022\nPersons with both professional titles \u2013\u2022\nappr. 550\nThe tasks of the self-government of physi-\ncians and dentists include:\nsupervising the proper and conscientious\u2022\nexercise of the medical professions;\ndetermining the principles of professional\u2022\nethics and deontology binding all physi-\ncians and dentists and looking after their\ncompliance;\nrepresenting and protecting the medical\u2022\nprofessions;\nintegrating the medical circles;\u2022\ndelivering opinion on matters concerning\u2022\npublic health, state health policy and or-\nganization of healthcare;\nco-operating with scienti\ufb01c associations,\u2022\nuniversities and research institutions in\nPoland and abroad;\no\ufb00ering mutual aid and other forms of \ufb01-\u2022\nnancial assistance to physicians and den-\ntists and their families;\nadministering the estate and managing\u2022\nthe business activities of the chambers of\nphysicians and dentists.\nThe Chambers:\naward the right to practice the profession\u2022\nof a physician or dentist and keep the reg-\nister of physicians and dentists;\nnegotiate conditions of work and remu-\u2022\nneration;\nmake decisions on matters relating to \ufb01t-\u2022\nness to practice as a physician or dentist;\nco-operate in the \ufb01eld of continuous\u2022\nmedical education;\ndeliver opinion on draft legislation con-\u2022\ncerning health protection and exercise of\nthe medical professions;\ndelivering opinions and making motions\u2022\nregarding under- and postgraduate train-\ning of physicians and dentists;\nact as medical courts in matters involv-\u2022\ning professional liability of physicians and\ndentists;\ndefend individual and collective interests\u2022\nof members of the self-government of\nphysicians and dentists;\nco-operate with public administration\u2022\nagencies, political organisations, trade\nunions as well as other social organisa-\ntions in matters concerning protection of\nhuman health and conditions of exercis-\ning the medical professions.\nInternational Policy of the Polish\nChamber of Physicians and Dentists\nOne of the main priorities of the Polish\nChamber of Physicians and Dentists is to\ntake active part in international organisa-\ntions of physicians and dentists and to ac-\ntively co-operate with the medical and den-\ntal organisations and chambers abroad. The\nChamber is active in the works of the fol-\nlowing international organisations of doc-\ntors and dental practitioners:\nStanding Committee of European Doc-\u2022\ntors (CPME);\nEuropean Union of Medical Specialists\u2022\n(UEMS);\nEuropean Forum of Medical Associa-\u2022\ntions and the World Health Organiza-\ntion (EFMA\/WHO);\nSymposium of Medical Chambers of\u2022\nCentral and Eastern Europe;\nCouncil of European Dentists (CED);\u2022\nWorld Dental Federation (FDI);\u2022\nEuropean Regional Organization of the\u2022\nWorld Dental Federation (ERO\/FDI).\nOrganisation of Professional Self-government\nof Physicians and Dentists in Poland\nO\ufb03ce of the Polish Chamber of Physicians\nand Dentists in Warsaw\nMeeting of the Supreme Medical Council\n67\nMedical Confederation of the Argentine Republic\nAs a consequence of the implemented neo-\nliberal policies, the repetitive budget cuts\nhave damaged the social, political and in-\nstitutional situation not only in our country,\nbut in the entire Region.\nHealth services have been deteriorating\ngradually, public healthcare spending is de-\ncreasing in terms of the income per capita\nratio, and the scarce resources had to be\nadapted by giving importance to treatment\nover prevention.\nAt the same time, new changes have been\nintroduced in the \ufb01nancial aspect, and there\nis a rising tendency to privatization and the\noperating expenditure belongs to the user\nnow.\nWithin the framework of these neoliberal\npolicies, several reasons were stated which\nprivilege the following: expenditure is now\na\ufb00orded by the users of the system, private\nresources are excessively used and the public\nservices administration is decentralized.\nIn addition to the aforementioned, the sec-\ntor shows extreme sanitary anarchy, and a\nlack of co-ordination between the public\nand the private sector, which results in the\ndoubling and superposition of services and\nthe low use of resources.\nSocial Security de\ufb01nancing is a consequence\nof the unreleaved unemployment rate. The\nunemployed population lost their health in-\nsurance coverage, which led to an overload\nof Public Hospitals, as well as a fall in the\nprivate sector provision of services. As a re-\nsult, doctors who perform in this subsector\nhave been directly a\ufb00ected.\nGiven that the infrastructure and the public\nsector supplies are in a bad condition, doc-\ntors lack all kinds of support before patients.\nThe latter not only demand a medical assis-\ntance that doctors cannot provide on their\nown, but also take legal action against them\nmore frequently. Thus, a patient\u2019s right\nbefore an undesired treatment result was\nturned into the so-called \u201cmedical malprac-\ntice insurance industry\u201d.\nIt is even worse when faced by the lack of-\nstraint of relatives or the same patient, since\nthey are becoming more and more aggres-\nsive, and may end up assaulting physically.\nApart from these unfortunate situations, it\nmust also be mentioned the doctor\u2019s prole-\ntarianization, caused by several factors:\nProfessional plethora which shows a doc-\ntor to patient ratio of approximately 360.\nIn some large places, big urban centres, the\nratio is 120 inhabitants per doctor.\nIncrease of professional medical licenses up\nto 5 times faster than the population.\nNo planning of geographical distribution.\nHigh percentage of specialists (80%,70% out\nof this 80% are in the big urban centres)\nAfter the proposal of the National Inte-\ngrated Health System in 1973, which was\ninjected, and laws 23660\/61of the National\nHealth Insurance (last essays on national\npolicies), there was a crisis in the service\nprovider which still continues, and signs in-\ndicate it will get worse.\nThis deep crisis demands a health system\nreform in accordance with a State Policy\nunder consensus of all participants, basing\nthe system program on the following pro-\nposals:\nGive priority to Primary Attention (Moth-\ner & Child Programs, Special Plans for the\nneeded, etc) as a response to the emergency.\nComplement all subsectors in order to shift\nthe fragmenting system by using the idle\ninstalled capacity.\nCoverage based on an Obligatory Medical\nInsurance.\nState administration and regulation which\ncomprises:\nHigh Complexity\u2022\nHigh Medical Technology.\u2022\nMedicine.\u2022\nRegulation of professional practice which\ncomprises:\nAdaptation of programs of study in the\u2022\nMedical Schools.\nPlanning the number of students who\u2022\nenter Schools according to the needs of\nthe system.\nPlanning access to the work source.\u2022\nProgramming geographical distribution.\u2022\nProfessional certi\ufb01cation and recerti\ufb01ca-\u2022\ntion.\nProfessional Career.\u2022\nRegulation of specializations.\u2022\nDr. Jorge Carlos Ja\u00f1ez\nDr. Jorge Carlos Ja\u00f1ez,\nPresident of the Medical Confederation\nof the Argentine Republic\n68\nMOTESZ \u2013 the Association of Hungarian\nMedical Societies \u2013 the largest organisa-\ntion based on voluntary membership \u2013 was\nfounded in 1966 with the participation of\n36 associations. During the almost forty\nyears of existence, the objectives in the By-\nlaws have only been changed by completing\nthem with new ones meeting the require-\nments of changing needs. The activity of\nMOTESZ can be seen at several levels\nmanifested in co-operation with numerous\norganisations (governmental and public or-\nganisations, universities).\nAt the moment MOTESZ has 125 mem-\nber-societies facilitating the connection of\nsome 30 000 Hungarian medical doctors\nto the Association, and the most important\naims of MOTESZ are to co-ordinate ac-\ntivities, collaboration of member-societies\nat the Association\u2019s level, and to help with\nsolving mutual problems.\nLevels of the activity\nFederal Council (consists of Presidents of\nmember-societies, having meetings quar-\nterly);\nPresidium (consists of 9 members, having\nmeetings monthly);\nThe operative work is executed by Working\nCommittees leading by vice presidents and\nmembers of the Presidium of MOTESZ\nand ad hoc committees.\nNational activities\nThe MOTESZ makes e\ufb00orts to represent\nthe interests of the member-societies in the\nNational Health care legislation and imple-\nmentation, and as a standing invited del-\negate follows the legislation process of the\nHealth Care Committee of the Hungarian\nParliament expressing its own standpoints\nin issues in\ufb02uencing the Medical Society in\na direct and signi\ufb01cant way.\nOn request the MOTESZ has regularly\nbeen taking part in giving opinions to draft\nregulations a\ufb00ecting Health Care forwarded\nby the Ministry of Health, and working out,\nforming and discussing those topics which\na\ufb00ect all the stakeholders of the Hungarian\nHealth Care.\nIt is provided by law that the MOTESZ or-\nganises and implements the election of the\nNational Advisory Boards, which are advi-\nsory bodies of the Minister of Health. This\ntask was accomplished for the \ufb01rst time in\n2004 and for the next time it will be man-\naged in the \ufb01rst half of this year.\nIn 2006 MOTESZ had a major role in\ninserting one of the most important pro-\ngrammes,the Heart and Cardiovascular Pro-\ngram into the row of National Health Pro-\ngrammes. MOTESZ also gained the task of\nco-ordination of all the four National Health\nPrograms from the minister of that time.The\nremaining three are: Child Health, National\nProgramme against Cancer, National Pro-\ngramme of Emergency care.\nIn 2006-2007 the Association was partici-\npating actively in the preparation and imple-\nmentation process of Health Reforms.Upon\ninvitation of the Ministry of Health and\nHealth Care Committee of the Hungarian\nParliament the MOTESZ established ad\nhoc committees for development, reporting\nparticular topics and drew representatives\nof member-societies and co-partners into\nthe Committees\u2019 work. In the framework\nof legislator\u2019s support, the Association took\npart in seven working groups, which groups\nreviewed some areas of Health Care, out-\nlined the most important tasks, and deter-\nmined the action program.\nSome of the proposals drafted with the help\nof MOTESZ co-ordination were put into\npractice during the Reform process. The\nworking groups established for assessment\nin primary care, out-patient care, in-patient\ncare, human resources, public health and\nreform acts prepared working documents\nand informed the members of the Fed-\neral Council continuously about the work\ncompleted. The MOTESZ also organised\na National Forum in relation to issues of in-\nAssociation of Hungarian Medical Societies\nMOTESZ delegation in Beijing\n69\npatient care structure and prepared compre-\nhensive summary about it.\nOn 1st\nMarch 2007, the Association was\nasked by the State Secretary of the Prime\nMinister\u2019s O\ufb03ce to help in the activity of\nthe Monitoring Working Group established\nwithin the Prime Minister\u2019s O\ufb03ce, in order\nto follow the implementation of ongoing\nHealth Care Reform. The Association in-\nvited its co-partners to share their thoughts,\nproposals about current issues, di\ufb03culties,\nimpact of modi\ufb01cations in legislation \u2013 that\nconcern and a\ufb00ect all of us \u2013 concerning\nhealth care. Every week the MOTESZ re-\nceived reports, completed by the comments\nof experts and forwarded them to the Prime\nMinister\u2019s O\ufb03ce.The Association then reg-\nularly was informed about the implementa-\ntion of the proposals.\nIt is important to mention that MOTESZ\nhas Agreements of Co-operation with four\nMedical Faculties.\nBesides the Association\u2019s basic tasks, the\nMOTESZ Congress and Travel Agency\nplay an important role in its activity. The\nMOTESZ not only facilitates participation\nof Hungarian doctors in events with inter-\nnational participation, as well as in interna-\ntional conferences, in international recogni-\ntion of their knowledge, achievements, but\nthese events are very important pillars for\nthe domestic continues medical education.\nAnother pledge of the successful and con-\ntinuous running of the programmes is the\norganisation of travelling, hotel accommo-\ndation of doctors, researchers and profes-\nsionals, as well as other programmes.\nThe Association is proud of the MOTESZ\nMagazine, the informative professional\njournal which includes scienti\ufb01c, health\npolicy issues and is published in 25 000\ncopies. In 2007 the International Editorial\nAdvisory Board was established and promi-\nnent foreign experts were invited to partici-\npate in its work in order to accomplish in\nthe best possible way the tasks ahead of the\nMOTESZ. For those who follow modern\nsources of information, they could visit the\nMOTESZ website where besides others the\nlatest issue of the Journal can be found.The\ntopical issues are linked to the forums, so\nthe visitor could participate in its formation\nin a direct way. Both the Magazine and the\nwebsite give the opportunity for partners to\ncommunicate issues of health care policies\nto the public.\nThe Association continuously makes e\ufb00orts\nto facilitate that its proposals, opinion and\nlobbying activity be included with due em-\nphasis in all processes that could modify e.g.\nthe provision of health care or the health\ncare structure itself etc, however the main\ngoal remains unchanged: representation of\nprofessional interests of its member-societ-\nies,putting forward the professional work in\nany activity that could e\ufb00ect Medical Policy\nand Health Care.\nInternational activities\nThe Association attaches great importance\nthat its activities be integrated into national\nand international professional organisations.\nThe most essential international relations at\nmultilateral level are the following:\nStanding Committee of European Doc-\ntors (CPME); European Working Group\nof Practitioners and Specialists in Private\nPractice (EANA); European Forum of\nMedical Associations and WHO (EFMA\/\nWHO); European Union of General Prac-\ntitioners (UEMO); European Union of\nMedical Specialists (UEMS); World Medi-\ncal Association (WMA).\nSince 1988 the MOTESZ has been taking\npart in the WMA as a full member and is\nproudthatithostedandorganizedtheWMA\nGeneral Assembly in 1993. It is a great plea-\nsure that the MOTESZ representatives were\nelected Vice Presidents in two Organizations\n\u2013 UEMS and UEMO. Due to the broad in-\nternational activity and WMA membership,\nthe Association plays a major role in health\ncare related legislation in Hungary.\nMOTESZ has bilateral agreements with the\nGerman Medical Chamber, the Royal Soci-\nety of Medicine, Chinese Medical Associa-\ntion (CMA) and the Heilongjiang Univer-\nsity of Chinese Medicine (HLJUCM). The\nAssociation has very good relations besides\nothers with the American Medical Asso-\nciation, Conseil National de L\u2019Ordre des\nM\u00e9decins. On the basis of the outstanding\ninternational relations, MOTESZ is able\nto follow in an up-to-date manner and in-\n\ufb02uence to a certain extent the evolution of\nEuropean guidelines that determine Hun-\ngarian professional policy.\nIn 2007 due to \ufb01nancial di\ufb03culties the As-\nsociation was not able to participate at some\nmeetings of International Organisations;\nhowever it sincerely believes that this year\nit will continue this activity under more fa-\nvourable conditions.\nSome suggestions relating future activi-\nties of the WMA\nThe MOTESZ would appreciate receiv-\ning adequate information from the WMA\nrelating to care of the elderly, genetics, and\nethics of molecular bio-research.\nIt would be also useful if the WMA could\nmonitor the situation of health care workers\nin member countries, and could give guide-\nlines regarding competence levels, and min-\nimum terms\/conditions for their members.\nProf. P\u00e9ter S\u00f3tonyi, Past President\nProf. K\u00e1lm\u00e1n Magyar, Vice President,\nPresident of International Committee\nProf. Tibor Ertl, Vice President\nDr. Ferenc Oberfrank,\nVice President of InternationalCommittee\nProf. K\u00e1lm\u00e1n Magyar\n70\nTurkey is located between Europe and Asia\nwith its geopolitical signi\ufb01cance. Accord-\ning to o\ufb03cial statistics the population is\n70,586,000. Acording to recent statistics\ngiven by the Ministry of Health and Higher\nEducation Council there are 103 000 active\npracticing physicians (1).With these \ufb01gures\nwe can estimate that there is 147 physician\nper 100 000 population, but there are sig-\nni\ufb01cant variances between the regions and\nbetween the urban and rural areas. About\n45 000 of these physicians are specialists.\nTurkish Medical Association is organized\nvoice of doctors in Turkey, under the con-\nstitutional guarantee as a non-pro\ufb01t, non-\ngovernmetal, public association, founded by\nlaw in 1953 in Istanbul. Then the associa-\ntion was moved to Ankara in 1983. Mem-\nbership to the Turkish Medical Association\nis throught the Medical Chambers located\nin provinces with more than 100 physicians.\nCurrently there are 64 medical chambers.\n80% of physicians are members of the Turk-\nish Medical Association.\nAim\nTurkish Medical Association was established\nwith the aim to maintain and protect deon-\ntology and soldarity between physicians, to\npromote medical practice for the bene\ufb01t of\nthe public and the individual and to protect\nthe rights of the phsicians as a public profes-\nsional association. The Turkish Medical As-\nsociation besides these primary aims has the\nduty to promote health for the bene\ufb01t of citi-\nzens in Turkey and work for a high quality\nhealth care which is achieveble for everybody\nwith suitable cost, promote professionalism,\nwork on improving medical education at\nall levels and establish guidelines for ethical\nconduct among the members.\nStructure\nThe Turkish Medical Associaion is an\numbrella orgaization of 64 Chambers of\nMedicine. These chambers are founded in\nprovinces with more than 100 physicians.\nEach chamber will have executive, auditing\nand discipline committees. Chambers with\nless than 500 members will have 5 members\nand those with more than 500 members\nwill have 7 members in the execuive com-\nmittee.Each chamber will elect its delegates\nfor the formatin of the main congress. The\nPresident of each chamber is a member of\nthe main congress.The main congress is the\nmain decisional organ guiding the council\nfor political decisons. The other important\nduty of the main congress is election of the\nCouncil of Turkish Medical Associaton\nwith the central auditing and high disic-\npline committee. The number of delegates\nare determined by the number of members\nof that chamber. The Council of Turkish\nMedical Association is composed of 11\nmembers who are elected by the delegates.\nThe elected members both for the chambers\nand the council serve for two years and can\nbe elected for only two terms. All these po-\nsitions are on voluntary basis without any\npayment.\nWhat does Turkish Medical\nAssociation do for the profession?\nOne of the most imporant task and respon-\nsibilities of Turkish Medical Association is\ncolloborate with the national authorities and\ngive feed-back about issues and \/or politics\nwhich may e\ufb00ect the public health and the\nrights of the physicians. It has been the pri-\nmary force as the voice of the profession and\nthe public against the signi\ufb01cant changes\nin the health system and politics that have\nbeen proposed and tried to be implemented\nin coordination with other associations,\nsyndicates or unions. Various reports have\nbeen published on di\ufb00erent relevant issues,\nsuch as consequences of changes in health\nsystem, vital statistics, directives and laws in\nmedicine, professional ethics etc.\nTurkish Medical Association has an impor-\ntant mission on improving medical educa-\ntion at all levels. It is puttinga report on\nundergraduate medical education everyoth-\ner year based on a questinnaire \ufb01led by the\nmedical schools.These reports is detailed on\nthe current state of medical education re-\ngarding the infrastructure, manpower, cur-\nriculum and developments in a quatitative\nmanner. This year an qualitative evaluation\non medical education was conducted based\non Global Standards of WFME European\nSpeci\ufb01cations.\nTogether with the specialty societies Turk-\nish Medical Association has been involved\nin forming specialty boards to improve the\nquality of postgraduate training in Turkey.\nTo date, 28 member specialty societies have\nfounded boards and commissions in their\nsections, 21 have prepared curriculums, 23\nhave prepared log-books, 17 have organised\nboard examinations,and 2 have begun a vis-\nitation program in its own section\u2019s teach-\ning hospitals. These numbers are increasing\nevery year and we aim to have active work-\ning boards on education in every specialist\nsection in our country. Currently re-licens-\ning does not occur. However, re-licensing is\nbeing discussed now in various boards and\nwe believe it will start to be used within the\nnext 7-10 years.\nTurkish Medical Association was the driv-\ning force for implementation of CME\/\nCPD in Turkey. After organizing a work-\nshop on CME it created awareness in the\n\ufb01eld in 1991. A CME\/CPD Accreditation\nCouncil of the Turkish Medical Associa-\ntion was founded in 1994 for accreditation\nof CME\/CPD activities , provided the or-\nganizer applies for accreditation. The coun-\ncil has reviewed the by-laws and changed\nvarious aspects parallel to the EACCME\nprinciples.The Turkish Medical Association\nhas signed an agreement with the UEMS\n(February 2006) for mutual recognition of\nCME credits and CME accreditation. An-\nnually, 1,000-1,200 CME\/CPD activities\nare reviewed for accreditation and 800-\n1,000 of these activities are accredited by\nthe council. A total of 7,560 activities have\nbeen accredited and the Council has award-\ned 81,088 CME\/CPD credits since 1994.\nTurkish Medical Association\n71\nAnnually, on average 8-9,000 CME\/CPD\ncredits are being awarded when the last 6\nyears are evaluated.The activities accredited\nbetween the years of 2002-2006 were pro-\nvided by the professional societies in 38 % of\nthe cases, and respectively, medical faculties\nin 32 %, chambers of medicine\/medical as-\nsociation in 19 %, teaching hospitals in 6 %\nand others in 5 % of the cases. 27 activities\nin 2007 have been accredited jointly with\nEACCME: A recent workshop was organ-\nized to create awareness and promote CPD\nactivities for life-long learning.\nTurkish Medical Society organizes coner-\nences, workshops, symposia, working group\nmeetings and publishes various publications\nboth for informing the members and con-\ntributing to their education.\nPolitics\nTurkish Medical Association contributes to\nthe health politics by representation in vari-\nous commisions and committes. The asso-\nciation gives their opinion regarding various\nprofessional issues and health politics. The\npublic is informed as well. It is involved in\nthepreparation of various laws in the parlia-\nment and other related institutions.\nInternational Relations\nAt the international level,the Turkish Med-\nical Association is a member of the World\nMedical Association, associate member of\nthe UEMS.\nEthics\nEthics is one of the major areas in the Turk-\nish Medical Association. The association\nhas prepared a code of professional ethics to\nguide the members. The ethics committee\nprepares statements regarding various issues\nfor medical practice, medical research and\npromotional activities (physician-pharma-\nceutical industry relations).\nTurkish Medical Association informs the\npublic about on various medical issues\nthrought its publications both as hard copy\nand on the web site. It releases \ufb01les to the\npress both for information and creation of\nawareness. Prepares reports regarding public\nhealth issues to inform the public.Radiation,\nclean water supply, environmental medicine,\ninfectious diseases, smoking are some of the\n\ufb01elds of information delivered. It prepares\nand shares reports on criticism of health re-\nforms which are related to the public.\nHuman Rights\nHuman rights have been another major area\nof interest for the Turkish Medical Associa-\ntion. The major areas are the right of living,\npatients rights, torture and hunger strikes\nand activities against war. In 1997 because\nof the activities related to human right the\nTurkish Medical Association was awarded\nHuman Rights Award by the Physicians for\nHuman Rights. National awards have also\nbeen given regarding the activities on hu-\nman rights.\nIskender Sayek M.D., FACS. Council\nMember, Turkish Medical Association\nThe Haitian Medical Association\nThe Haitian Medical Association is an In-\nstitution created on 8th\nApril 1948, which\ngathers the whole of the Haitian doctors\nmilitant on the territory in the various\nbranches of medicine. It was recognised as\npublic utility by presidential decree on 5th\nAugust 1974.\nThe goals of the Haitian Medical Associa-\ntion are:\nTo reinforce the links which exist between\u2022\nthe Haitian doctors\nTo defend the medical interests of the\u2022\nHaitian community\nTo work with the advance of medicine in\u2022\nHaiti and the establishment, on the sci-\nenti\ufb01c and medical level, of relations with\nforeign companies;\nTo co-operate with national and inter-\u2022\nnational institutions concerned with the\nwellbeing of the Haitian population\nThe Statutes and Rules of procedure of As-\nsociation envisage the existence of the fol-\nlowing Committees which are elected for a\ntwo (2) years mandate:\nThe Board of Management of seven (7)\u2022\nmembers;\nThe General Council;\u2022\nThe Council of Mediation;\u2022\nThe Scienti\ufb01c Council.\u2022\nThe Haitian Medical Association includes\ndi\ufb00erent members: active,adherent and hon-\norary and these statutes are acquired follow-\ning the handing-over of the form of adhesion\nand the payment of the annual contribution.\nHowever, only the active members and ad-\nherents are compelled with the payment of\nthe annual contribution that gives them the\nright to become candidates at the elective\nstations within the Association and to also\nvote at the time of the elections which are\nheld ewery two (2) years.In the rules of pro-\ncedure, in order to be an active or adherent\nmember, the medical licensed doctor of Hai-\ntian nationality must submit to the Board of\nManagement a completely \ufb01lled form which\nis regarded as a request written for inscrip-\ntion.\nIn its article III, the association is de\ufb01ned as\n\u201ca Company grouping a professional sector\nwith an economic and social life and whose\npurpose is to defend the common interests\nof the doctors from the point of view of\ntheir profession\u201d. There also local Commit-\ntees which function like peripheral antennas\nplaced in the various geographical depart-\nments of the country.They gather the doctors\npracticing in these areas who are informed of\nthe scienti\ufb01c activities programmed and\/or\ncarried out by Association. Since its creation\nto date,the Association opened doors to the\noutside while being registered as a member\nof: The Association of the Doctors of the\n72\nLatin America (CONFEMEL) and the\nWorld Medical Association (AMM).\nThe Association almost never misses the oc-\ncasions to take part in work of these various\nentities and regularly pays the annual con-\ntribution.It maintains with them a relation-\nship marked under the seal of the dynamic\nand e\ufb00ective partnership. It establishes and\nmaintains relations with the Haitian doctors\npractitioner living overseas who are gath-\nered under the term of Association of the\nHaitian Doctors living Abroad (AMHE).\nThe projects and activities carried out by\nthe members of the AMHE on the Haitian\nterritory, particularly those addressed to the\nyoung Haitian doctors who specialise at the\nHospital of the Haitian State University,\nare done in co-ordination with the AMH\nand the agreement of the Ministry of Public\nhealth and Population and the Vice-chan-\ncellorship of the UEH.\nThe Association exists only by and for its\nmembers and for this reason its interven-\ntions are always addressed to them. In a\nspeci\ufb01c way, it always gives itself the means\nto ensure the continuing formation of its\nmembers at the time of the various con-\ngresses, seminars and workshops organised\non the actual health problems which strike\nthe population.The colleagues practicing in\nprovince are not always forsaken. Besides\nthe local antennas in which they belong,\nthey are also invited to share their fellow-\nmember\u2019s experiences working in a more\nfavorable professional environment. The\nregular publication of the bulletin of the\nassociation constitutes an open window on\nthe doctors practicing here and elsewhere\nsince through this channel of communica-\ntion, the members are aware of the activities\nplanned and organised by the association.\nIn this same order of ideas, the relationship\nwith the population is established directly\nwith the doctors in their consulting-rooms.\nHowever, each time the need is felt, par-\nticularly at the time of natural disasters or\nothers, the Association answers always fa-\nvorably the call of the authorities to place at\ntheir disposal the competences of its mem-\nbers and in these particular cases, gifts in\ncash and in kind are sometimes collected to\nbe distributed through the quali\ufb01ed struc-\ntures existing in the country.\nThe relationships with the Ministry of Pub-\nlic Health and Population are always marked\nunder the seal of the mutual respect for the\nbene\ufb01t of the Haitian population. The As-\nsociation is an active member of the various\ncommissions and committees created by\nthe Ministry to re\ufb02ect on the great medi-\ncal challenges confronted in Haiti and its\nvoice is very listened. A partnership is also\nestablished not only with other socio-pro-\nfessional organizations of health (ASPHA\nand ANILH) which militate in the country\nin the defense of the interests of health of\nthe community, but also with the agencies\nof technical and \ufb01nancial co-operation like\nthe OPS\/OMS, the UNICEF, the ACDI,\nUSAID etc. Always in the same tread, an\nagreement of partnership was signed with\nthe Association of the Dominican Doctors\n(AMD) and this results in technical and\nscienti\ufb01c exchanges between the two asso-\nciations on the basis of their own availabil-\nity and expertise.\nHowever, the Association knew dark mo-\nments and one of them was the suspension\nof its activities for approximately ten years.\nAt the time of the great sociopolitical events\nwhich shook the Haitian nation during\nthese two last decades, the Association has\nto take serene positions recalling to the re-\nspect of fundamental freedoms and human\nlife. The wind even badly turned during this\nsame time for certain fellow-members who\nwere embanked by political violence which\ncontinues to mark the Haitian landscape.\nThe association still remembers some of its\nmembers who were assassinated within their\nprivate clinics or sometimes even inside their\nresidences. However, the wisdom and the\nsolidarity of our members made it possible to\novercome these inherent di\ufb03culties.\nThus, this spirit of mutual aid allowed the\nAssociation, sixty years after its creation, to\nconcretize a dream cherished a long time\nand so expensive with several of our pre-\ndecessors; it acts in the acquisition of our\nown registered o\ufb03ce which now became\na reality. This new building is a legitimate\nreason for pride for all the members since\nit was bought thanks to their contributions\nwhereas work of re\ufb01tting was \ufb01nanced with\na support of the USAID through Project\nMSH. This building is located in a very\nstrategic zone with: a room of conference\nwhich can contain a hundred participants,\ntwo other small rooms for approximately\n25 people for companies and the subsidiary\ncompanies to hold their meetings,the presi-\ndent\u2019s o\ufb03ce and his secretariat.\nOne of the major challenges which crossed\nall the existence of the Association consists\nin its possibilities of gathering the whole of\nthe medical brotherhood since until date it\nnever could cross the threshold of the \ufb01ve\nhundred (500) active members whereas there\nare more than one thousand medical doctors\npracticing in the country. In addition, the\nrenovation of the executives also represents\nanother shelf to be crossed because the young\ndoctors graduated from the various Faculties\nof Medicine are rare to register like members\nand that in spite of the e\ufb00orts of bringing\ntogether authorised by the leaders and of the\ngoodwill expressed by the chairmen of these\nschools of basic training to open to us the\ndoors of these centers of knowledge and aca-\ndemic excellence.\nToday, the AMH can be proud to have\ncrossed the years and turpitudes of an ex-\nistence full of enriched experiments for the\nmedical world. It became now a space of\nre\ufb02exion and together with the o\ufb03cial sec-\ntors and other organizations it can continue\nto carry out this permanent combat against\nthe war of diseases and su\ufb00ering. It has still\nmany ways to traverse and it must continue\nto actively play its role of leader in the \ufb01eld\nof health. May it obtain the instruments\nnecessary to better serve its members and\nthe Haitian Population. It is only thus and\nonly as it will be able to continue to live\nagain for another sixty (60) years.\nDernst Eddy Jean Baptist\nGeneral Secretary\nContents\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33\nHuman Resources for Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34\nPositive Practice Environments (PPE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35\nCall for Equal Access to Cervical Cancer Treatment for All Women and Girls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38\nHealth Professionals Taking Action on Climate Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38\nMercury-free Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39\nNormal Physiologic Changes with Aging: In\ufb02uence on Falls in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45\nThe Migration of Health Professionals and its Impact on Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48\nThe Union of European Medical Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50\nHistory and Recent Activities of the CMAAO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54\nThe Permanent Working Group of European Junior Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56\nThe Taiwan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58\nMedical Association of Uzbekistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59\nThe Canadian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60\nMedical Union of Uruguay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61\nThe Malaysian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62\nThe Finnish Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64\nThe FMH: the Professional Association for Physicians in Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65\nOrganisation of Professional Self-government of Physicians and Dentists in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66\nMedical Confederation of the Argentine Republic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67\nAssociation of Hungarian Medical Societies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68\nTurkish Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70\nThe Haitian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71\nEditor in Chief\nDr. P\u0113teris Apinis\nLatvian Medical Association\nSkolas iela 3, Riga, Latvia\nPhone +371 67 220 661\npeteris@nma.lv\nCo-Editor\nDr. Alan J. Rowe\nHaughley Grange, Stowmarket\nSu\ufb00olk IP143QT, UK\nCo-Editor\nProf. Dr. med. Elmar Doppelfeld\nDeutscher \u00c4rzte-Verlag\nDieselstr. 2, D-50859 K\u00f6ln, Germany\nAssistant Editor Dr. Ilze H\u0101znere\nwmjeditor@yahoo.com\nJournal design by J\u0101nis Pavlovskis\nCover painting : Is father at home?\n(Dr. Axel Johannesen in his sledge) 1891\nOil on canvas, 72x100 cm\nPainter: Erik Werenskiold,\nPhoto: Stian Solum\nWith kind permission of the Norwegian\nMedical Association.\nAcknowledgement to the Norwegian Medical\nAssociation\nLayout and Artwork\nThe Latvian Medical Publisher \u201cMedic\u012bnas\napg\u0101ds\u201d, President Dr. Maija \u0160etlere,\nHospit\u0101\u013cu iela 55, Riga, Latvia\nPublisher\nThe World Medical Association, Inc. BP 63\n01212 Ferney-Voltaire Cedex, France\nPublishing House\nDeutscher-\u00c4rzte Verlag GmbH,\nDieselstr. 2, P.O.Box 40 02 65\n50832 K\u00f6ln\/Germany\nPhone (0 22 34) 70 11-0\nFax (0 22 34) 70 11-2 55\nBusiness Managers J. F\u00fchrer, D. Weber\n50859 K\u00f6ln, Dieselstr. 2, Germany\nIBAN: DE83370100500019250506\nBIC: PBNKDEFF\nBank: Deutsche Apotheker - und \u00c4rztebank,\nIBAN: DE28300606010101107410\nBIC: DAAEDEDD\n50670 K\u00f6ln, No. 01 011 07410\nAt present rate-card No. 3 a is valid\nThe magazine is published quarterly.\nSubscriptions will be accepted by\nDeutscher \u00c4rzte-Verlag or\nthe World Medical Association\nSubscription fee \u20ac 22,80 per annum (inkl.\n7%MwSt.). For members of the World Medical\nAssociation and for Associate members the\nsubscription fee is settled by the membership\nor associate payment. Details of Associate\nMembership may be found at the World\nMedical Association website www.wma.net\nPrinted by\nDeutscher \u00c4rzte-Verlag\nK\u00f6ln, Germany\nISSN: 0049-8122\nwww.wma.net\nO\ufb03cial Journal Of The World Medical Association\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily re\ufb02ect WMA policy or positions\n\n<\/p>\n"},"caption":{"rendered":"

wmj18 In keeping with our new tradition of featuring one of our mem- ber countries on each cover of the World Medical Journal, I am pleased to have Norway on our cover this month. Our cover shows a Norwegian doctor who has arrived by sled to care for a sick child. Norway can be proud […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj18.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3569"}],"collection":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media"}],"about":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/types\/attachment"}],"author":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/comments?post=3569"}]}}