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vol. 56
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 1, February 2010
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@nma.lv
\neditorin-chief@wma.net
\nCo-Editor
\nDr. Alan J. Rowe
\nHaughley Grange, Stowmarket
\nSuffolk IP143QT, UK
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor Velta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by J\u0101nis Pavlovskis
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas\u00a0apg\u0101ds\u201d, President Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nThis oil painting, entitled \u201cRocky Mountains
\n1936\u201d, hangs at the offices of the Canadian
\nMedical Association (CMA) in Ottawa. It
\nwas painted by Sir Frederick Banting, who,
\nalong with Dr. Charles Best, discovered insulin
\nin 1921. Banting, born in Canada in 1891,
\nwas an accomplished artist and may have had
\na\u00a0successful career as a painter were it not for
\nhis work in medicine. He was killed in February
\n1941 while serving his country in the Second
\nWorld War.The painting was donated to the
\nCMA by his widow, Lady Henrietta Banting.
\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
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\nAt present rate-card No. 6 a is valid
\nThe magazine is published bi-mounthly.
\nSubscriptions will be accepted by
\nDeutscher \u00c4rzte-Verlag or
\nthe World Medical Association
\nSubscription fee \u20ac 22,80 per annum (incl.
\n7%\u00a0MwSt.). 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
\nDr. Dana HANSON
\nWMA President
\nFredericton Medical Clinic
\n1015 Regent Street Suite # 302,
\nFredericton, NB, E3B 6H5
\nCanada
\nDr. Masami ISHII
\nWMA Vice-Chairman of Council
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nDr. Mukesh HAIKERWAL
\nWMA Chairperson of the Finance
\nand Planning Committee
\n58 Victoria Street
\nWilliamstown, VIC 3016
\nAustralia
\nProf. Ketan D. Desai
\nWMA President-Elect
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nI.M.A. House
\nIndia
\nProf. Dr. J\u00f6rg-Dietrich HOPPE
\nWMA Treasurer
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGermany
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
\nMembers
\n14 rue des Tiennes
\n1380 Lasne
\nBelgium
\nDr. Yoram BLACHAR
\nWMA Immediate Past-President
\nIsrael Medical Assn
\n2 Twin Towers
\n35 Jabotinsky Street
\nP.O. Box 3566
\nRamat-Gan 52136
\nIsrael
\nDr. Jens Winther Jensen
\nWMA Chairperson of the Medical
\nEthics Committee
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nDenmark
\nProf. Dr. Karsten VILMAR
\nWMA Treasurer Emeritus
\nSchubertstr. 58
\n28209 Bremen
\nGermany
\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-Affairs Committee
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nRua Sao Carlos do Pinhal 324
\nBela Vista, CEP 01333-903
\nSao Paulo, SP
\nBrazil
\nDr. Otmar KLOIBER
\nWMA Secretary General
\n13 chemin du Levant
\nFrance 01212 Ferney-Voltaire
\nFrance
\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nSigns are good that the economic downturn is behind us, and the
\nchallenges before us will not allow us to continue lamenting about it.
\nHowever, it will be interesting to see whether there are real lessons-
\nlearned from this crisis or whether we all fall back to business as
\nusual, unable to process those lessons, unable to implement change.
\nDuring the UN Climate Change Conference in Copenhagen, in
\nSeptember of last year, politicians achieved results which, in scien-
\ntific terms,would be considered as \u201csuboptimal\u201d. Yet their delay will
\ngive us more opportunities to emphasize the health effects of cli-
\nmate change.To mitigate those effects will be crucial, but our ability
\nto respond to climate change also must be examined. Regardless
\nwhether we will have to react to the spread of diseases around the
\nworld, the drastic changes to the human habitat in many regions, or
\nto natural disasters – Haiti has shown that we still can improve. \u2013
\nThis is a little weird. How does Haiti show us anything about the
\nspread of disease or changes in the human habitat? Also, are you
\nsaying that our response to Haiti shows that we have improved, or
\nthat there are still improvements we need to make? I can\u2019t quite
\nfigure out what you\u2019re saying here. I\u2019m also not sure how it all fits in
\nwith climate change, which is the topic of the paragraph. If you can
\nclarify your thinking on this, I\u2019ll smooth it out as soon as I receive it.
\n(Or, as soon as I wake up. Just wrapped another 16 hour work day
\nhere and there\u2019s another one coming tomorrow!)
\nThe resources that have been leveraged and delivered to help Haiti
\nare a good sign for global solidarity and we applaud those who have
\nengaged personally to do relief work in the country. But Haiti also
\nreminds us how unequally resources, including medical resources,
\nare distributed in the world and that our efforts to expand the quali-
\nfied, adequately equipped health work force still have far to go. Nu-
\nmerous countries are in a perpetual state of emergency,without hav-
\ning experienced an earthquake or other calamity, and they deserve
\nour attention and help as well. People are suffering and dying across
\nthe globe. And when some say they never have seen a catastrophe
\nequal to the one Haiti,maybe it is because we are constantly turning
\nour eyes away from places like Darfur and certain areas of Sub-
\nSaharan Africa.
\nFor the last few years we have been examining the question \u201cWhy
\ndo physicians go away?\u201d The answers have been plenty, but they all
\nboil down to the same basic premise: because of poor working and
\nliving conditions and insufficient pay. Still, we see that many of our
\ncolleagues continue to fight the uphill battle every day and remain
\non their job, often under staggering conditions. The question we
\nwould like to ask them is \u201cWhat makes you continue?\u201d Physician
\nresilience will be one of the interesting topics WMA President. Dr.
\nDana Hanson, will help us address this year.
\nAnother under-appreciated problem before us is the growing in-
\nfluence governments exert on health care, especially with respect
\nto our professional independence. Diminishing the professional
\nstatus of self-governing bodies by taking away sovereign func-
\ntions and putting them under government direction, or abolishing
\nobligatory membership in order to weaken them are just a couple
\nof examples of what we currently observe. If physicians wish to
\nremain a respected profession with a protected relationship between
\nourselves and our patients, then we must act now and with author-
\nity. Governments around must not succeed in reducing physicians
\nto \u201cservice providers\u201d or simple technicians who are subject to the
\norders handed down by \u201cpayers\u201d \u2013 whether they are governments
\nthemselves or private insurance companies.
\nThe WMA is committed to continuing our educational work on
\nMultidrug-Resistant Tuberculosis, which we combine with efforts
\nto improve infection control, and we will step up together with our
\npartners in the World Health Professions Alliance against counter-
\nfeit and substandard medicines that threaten the health and safety
\nof our patients.
\nIt is difficult to predict all that 2010 has in store for us, but it will
\nnot be boring. We have had a few highlights already and there are
\nmore to come, including:
\nOn the occasion of the 126th World Health Organization Ex-\u2022
\necutive Committee Session from 18-27 January, WMA, togeth-
\ner with our partners in the World Health Professions Alliance,
\nurged that the draft \u201cGlobal Code of Practice on International
\nNo time for depression \u2013 a busy year ahead for WMA
\nEditorial
\n2
\nWMA news
\nIn order to discuss the implications of the fi-
\nnancial crisis for health, the World Medical
\nAssociation in cooperation with the Latvian
\nMedical Association will organise the two
\ndays conference on \u201cThe Financial Crisis \u2013
\nImplications for Health Care. Lessons for the
\nfuture\u201d. Conference will take place in Riga,
\nLatvia on 10th and 11th September, 2010.
\nThe financial crisis has affected the econo-
\nmies of nearly all countries around the
\nworld. While some countries experienced
\n\u201conly\u201d a recession, some countries are still
\nin deep recession leading some countries to
\nfactual insolvency. However, now after the
\nbillions invested in rescue packages for fi-
\nnancial institutions and a first wave of eco-
\nnomic recovery programmes the situation is
\nshowing some signals of stabilisation. One
\nof the sectors of economy, which is also suf-
\nfering is health care. Health care systems in
\nmany countries seem to be rather stable and
\nonly moderately affected while others expe-
\nrience significant budget cuts, which leads
\nto terminating essential health care services
\nin some areas. In the process of economi-
\ncal recovery it is important to invest also in
\nhealth care to keep people healthier so they
\ncan work more productively, which leads to
\nfaster economical recovery. Since the begin-
\nning of the crises, analyses of its impact on
\nthe health sector have been undertaken in
\nmany countries and a range of recommen-
\ndations and strategies has been suggested to
\nthe governments. Clearly, the responses will
\nvary from country to country. Nevertheless,
\nstrategies will need to combine measures to
\nprotect the health budget and to prioritise
\nsectors and groups and to preserve and even
\nstrengthen the quality and efficiency of the
\nhealth sector performance.
\nThe conference is expected to gather be-
\ntween 300 and 400 professionals from Eu-
\nrope, Asia and America. Based on evidence
\ndrawn from international experience and
\nresearch, the Conference, with the partici-
\npation of health experts and health profes-
\nsionals,will provide an overview of the major
\nthreats and challenges to the health systems
\ncaused by the economic crisis. Participants
\nwill identify current key problems and chal-
\nlenges faced by the health systems in Europe
\nand globally. Speakers at the conference will
\noutline responses that countries so far have
\ndeveloped in addressing these problems and
\nchallenges and look into some priority ar-
\neas to assess the effect of the economic re-
\ncession and to explore effective policies in
\nresolving the main problems created. The
\nvalue of this conference will be experience
\ngained and finding the best possible solu-
\ntions for leading health care systems out of
\nthe crisis for faster improvement of health
\nand recovery of economy.
\nMore information about the conference is
\navailable at www.riga-wma.lv .
\nRinalds Muci\u0146\u0161,
\nLatvian former Minister of Helth
\nWMA Conference in Riga
\nRecruitment of Health Personnel\u201dbe discussed at the next World
\nHealth Assembly.
\nIn Sao Paulo from 1-3 February, assisted by our member orga-\u2022
\nnization from Brazil, we brought together the most high-profile
\ninternational experts to discuss some of the most difficult ethical
\nissues associated with placebo use in clinical trials.
\nWMA convened the third Caring Physicians Leadership Course\u2022
\nwith INSEAD \u2013 this time at the INSEAD Campus in Singapore
\n(February 8-13).
\nThe World Health Professions Alliance will discuss regulation of\u2022
\nthe health profession during the second World Health Profes-
\nsions Conference on Regulation (Geneva February 18-18) and
\nFrom 3-4 May, the third Conference on Person Centred Medi-\u2022
\ncine will gather in Geneva.
\nThe leaders of the nursing, dentistry, pharmacy and medical pro-\u2022
\nfessions will meet in Geneva the day before the World Health
\nAssembly to evaluate and celebrate the first 10 Years of our alli-
\nance (May 16).
\nWMA Council will convene in Evian, France from 20-22 May.\u2022
\nIn September (tentative 10-11), in Riga, Latvia, we will examine\u2022
\nthe effects of the global economic crisis on the world\u2019s health care
\nsystems and what we can learn from our experiences.
\nOctober 13-16 will bring together the members of the World\u2022
\nMedical Association for our WMA General Assembly in Van-
\ncouver, Canada.
\nDr. Otmar Kloiber, WMA Secretary General
\n3
\nWMA news
\nOn November 28th, the Brazilian Medical
\nAssociation in partnership with the Univer-
\nsity of S\u00e3o Paulo Medical School and the
\nInstitute Health and Sustainability, orga-
\nnized a conference on climate change called
\n\u201cDoctors for the Environment\u201d.
\nDr. Dana Hanson, president of World
\nMedical Association (WMA), was invited
\nto open the conference. He spoke about the
\nneed to examine climate change from the
\nperspective of patient health. \u201cWe’re not
\nhere to find out who is guilty or to judge
\nanybody.We put individuals at the center of
\ndiscussions. Why the health of the popula-
\ntion is not the focus of Cop 15?\u201d. During
\nthe presentation, Dr. Hanson highlighted
\npoints of the Declaration of Delhi, which
\nwas translated into Portuguese and released
\nduring the event by the Brazilian Medical
\nAssociation. Finally, he called on Brazilian
\ndoctors to engage with this issue.
\nThe second block of the event began with
\na talk by Dr. Paulo Saldiva, head professor
\nof pathology at the University of S\u00e3o Paulo.
\n\u201cAlthough Brazil has advanced legislation
\nof the environmental point of view, man
\nwas not included\u201d. To Saldiva, there is not
\nan engagement with human health and this
\nis largely to blame on doctors. \u201cFew man-
\nagers understand health. In Brazil, we are
\nbetter prepared to deal with hepatitis B or
\nwith H1N1 than, understand the effects of
\nclimate change on health\u201d. The pollution,
\naccording to data presented by Dr. Saldiva,
\ncaused the death of 4 million people last
\nyear in S\u00e3o Paulo, far more people than the
\nH1N1 outbreak. \u201cPhysicians should use the
\ncredibility and their work to do something,
\nas they may be guilty of the sin of omission
\nin a near future\u201d.
\nAfter an analysis from the perspective of
\nhealth, Carlos Nobre, a chief researcher at
\nthe National Institute for Space Research
\n(INPE), presented an overview of climate
\nchange in terms of the environment. For
\nhim, the changes in climate are the biggest
\nchallenge that humanity has ever faced.\u201cThe
\nEarth’s natural capital is being squandered\u201d.
\nIn a comparison with the economic crisis,
\nthe researcher said that the planet is being
\nmortgaged to subprime loans. \u201cThe amount
\nof money needed to mitigate some effects of
\nclimate change is less than required to help
\nthe banks.\u201dFor him, the planet passed many
\npoints of no return and if the developing
\ncountries cross the line of sustainability the
\nsituation will get even worse. \u201cWe need to
\ninvent a new model of development\u201d.
\nEduardo Jorge, S\u00e3o Paulo\u00b4s Secretary of the
\nEnvironment, followed the discussion by
\nsaying that the responsibility is no longer
\nonly on the hands of the more developed
\ncountries.\u201cIn all areas we can do something
\nto reduce the damage\u201d. He presented some
\nenvironmental projects that the city of S\u00e3o
\nPaulo is working on: Construction of en-
\nergy plants at landfills to convert methane
\ninto energy, a city\u00b4s initiative to reduce the
\nemission of pollutants through the vehicle
\ninspection, protection of water sources and
\nincreasing the number of parks.
\nHelena Fernandes,
\nCommunication Department,
\nBrazilian Medical Association
\nDoctors for the environment
\nThe medical profession and governments have
\nbeen urged to pay more attention to the issue
\nof stress and burn out among physicians, ac-
\ncording to the President of the World Medical
\nAssociation.
\nDr. Dana Hanson, a Canadian dermatolo-
\ngist, said that the medical profession must
\nstrive to remove the stigma surrounding
\nburn out, while governments must address
\nthe problem, since healthy resilient physi-
\ncians equalled longer professional lives and,
\nmore importantly, more accessible care for
\npatients.
\nDr. Hanson, addressing The Global Forum
\nof Health Leaders conference in Taipei,
\nTaiwan, said that according to surveys in
\nCanada and elsewhere some 45 per cent of
\nphysicians were in an advanced state of burn
\nout, with an even higher figure in develop-
\ning countries.
\nBut why did one physician thrive in his or
\nher career while another experience stress?
\nThe answer lay in part in being able to man-
\nage and recover from adversity. Resilience
\nmeant rising to challenges, responding cre-
\natively, learning and growing.
\nPhysicians, he said, should not have to
\nchoose between saving themselves and
\nserving their patients. Many physicians who
\nwere outwardly patient and enthusiastic
\nwere inwardly burning and finding their
\nwork less rewarding. The global shortage of
\nphysicians was leading to chronic overwork
\nand stress.
\nDr. Hanson said that healthy physicians
\nmeant healthier patients, greater satisfac-
\ntion, safer care and a sustainable work-
\nforce.
\nPhysicians were generally healthy when it
\ncame to tobacco use, and contrary to pop-
\nular belief, drug and alcohol use was no
\ngreater in the medical profession than it was
\nin other occupations.
\n\u201cPhysicians suffering from silent
\ndesperation\u201d, says WMA leader
\n4
\nMedical Ethics, Human Rights and Socio-medical affairs
\nYet more demands on physicians and their
\nincreasing lack of control were leading to a
\nsilent desperation among physicians. Wom-
\nen in the profession in particular appeared
\nto be at greater risk of suicide, and a signifi-
\ncant proportion of all physicians had symp-
\ntoms of depression and anxiety,according to
\nsurveys.
\nDr. Hanson said that the image and profes-
\nsionalism of physicians, the threat to their
\nself regulation, patient safety and account-
\nability without authority all contributed to
\nmental stress.
\nHe said it was time the profession’s leaders
\nand governments recognised these facts and
\ntook action to support physicians, through
\nnational leadership, raising awareness of the
\nproblems and reducing the stigma of burn
\nout and education.
\nNigel Duncan,WMA Public
\nRelations Consultant
\nFrom a European perspective, the debate on
\nwhat is commonly (and often mistakenly)
\ncalled task-shifting has crystallised around
\nthe European Commission\u2019s recent \u201cGreen
\nPaper\u201d on the European Workforce. The
\nmain drivers for this are seen as the demo-
\ngraphic changes in the population, the in-
\ncreasing use of information technology in
\nhealthcare, and the changing expectations
\nof patients. The amount of time a doctor is
\navailable to patients is also affected by the
\nimpact of the European Working Time Di-
\nrective, an increasing proportion of women
\ndoctors, and a change in attitude on the
\n\u201cwork-life\u201d balance that doctors, like other
\nmembers of society, should enjoy.
\nDemographic changes affect both doctors
\nand patients. Both groups are ageing to-
\ngether,with a consequent increase in chron-
\nic diseases and a reduction in the number of
\nphysicians available to treat them.
\nOne key issue in any debate about how a
\nworkforce should be reconfigured is, essen-
\ntially \u2013 who does what? What tends to get
\nin the way of such a debate is an impression
\nthat doctors are resistant to change, and
\nhold on to old patterns of working in or-
\nder to retain power. This perception is often
\ndifficult to shift, but a more useful and re-
\nsponsible way of approaching the \u201cwho does
\nwhat?\u201d question is to start with two prin-
\nciples that are unarguable. The first is that
\nshifting tasks from one group to another has
\nto be conditional on also shifting the train-
\ning. The second is that task-shifting should
\nnever be done for purely financial reasons,
\nas to do so will undermine care through the
\ndelivery of sub-optimal services.
\nAnother major but variable demographic
\nfactor is migration. Movement of doctors
\nfrom Eastern to Western Europe has been
\npredominantly driven by economic factors.
\nThe EU\u2019s long-term goal must be to convert
\nthat into a two-way migration based on a
\ndesire for professional self-improvement.
\nThe predicted increase in the number of pa-
\ntients with long-term chronic illness is a di-
\nrect result of increased longevity and prog-
\nress in treating or containing acute illness.
\nThe influences of obesity, smoking, alcohol
\nexcess and income inequalities will long be
\nwith us. Better screening will identify more
\ntreatable disease, and much of this disease
\nload will be added to the burden faced by
\nhealthcare systems, whose budgets will be
\nstretched. The depressing evidence from
\nthe work done to date on health inequali-
\nties is that much of this healthcare spending
\nwill have a marginal impact on the overall
\nhealth of many groups of EU citizens.
\nOur patients will expect more information,
\nmore involvement in their care, and greater
\nfreedom to be treated in a place \u2013 or even a
\ncountry \u2013 of their choice. The central im-
\nportance of the doctor\/patient relationship
\nwill not change, but improved interoper-
\nability between IT systems, greater access
\nto information and more freedom of choice
\nwill dramatically alter the way this is con-
\nducted.
\nHow should the EU and its doctors ap-
\nproach the way these influences will affect
\nus? From the European Commission\u2019s
\npoint of view, a large stumbling block will
\nbe the familiar tension between Member
\nState autonomy and what is often seen as
\nEU interference. All the countries in the
\nEU jealously guard their right to run their
\nhealthcare systems; the EU has a role in
\n\u201cadding value\u201d where it can do things that
\nmember states cannot do alone. Public
\nhealth issues such as global warming, and
\ncommunicable disease monitoring are ex-
\namples of this. The Green Paper\u2019s approach
\nto a \u201cEuropean\u201d workforce is limited by this
\nconcept of subsidiarity,leaving the Commis-
\nsion some room for influence in areas such
\nas professional mobility and cross-border
\nhealthcare. But with increasing mobility of
\nTask-shifting or task-sharing? \u2013 Reflections
\nfrom within the European Union (EU)
\nMichael Wilks
\n5
\nMedical Ethics, Human Rights and Socio-medical affairs
\npatients and doctors, the influence of eco-
\nnomic migration, and an opening up of the
\nmarket for health, can the EU allow itself to
\ncontinue to think in terms of twenty-seven
\nworkforces instead of one?
\nThe terms \u201cskill-mix\u201d, \u201ctask-shifting\u201d and
\n\u201ctask-sharing\u201d are often deployed without
\nadequate definition or context. In CPME\u2019s
\n(Standing Committee of European Doc-
\ntors) view, tasks can never be \u201cshifted\u201d from
\none healthcare professional group to anoth-
\ner for purely economic reasons, tempting
\nthough this is for governments squeezed
\nbetween the twin pressures of financial crisis
\nand increased demand for care. CPME and
\nits fellow European Medical Organisations
\nhave always emphasised that the right train-
\ning for the task is essential, and that when it
\ncomes to transferring responsibility for any
\naspect of care to another professional, there
\nare two \u201cnon-negotiables\u201d to protect patient
\nsafety. The first, as mentioned, is training,
\nbut equally important is that any sharing or
\nshifting of tasks takes place within the con-
\ntext of a team, in which skills are defined,
\nand lines of accountability exist.
\nHere it is important to stress a funda-
\nmental difference between doctors and all
\nother healthcare professionals, based on the
\nconcept of the acceptance of risk. Doctors
\nare trained to accept risk; perhaps the best
\npractical example of this is the uncertainty
\ninherent in a list of differential diagnoses a
\ndoctor works through, eliminating one in
\nfavour of another on the basis of experience,
\ntraining and investigation. Uncertainty
\nis a feature of all healthcare provision, but
\nthe risk associated with this is mitigated in
\nthe way much of other health professionals\u2019
\nwork involves the use of protocols.Protocols
\nwill define or limit practice and also risk,
\nbut their existence also demands that when
\nthe limits or boundaries of what a protocol
\nallows are reached, then the risk has to be
\nhanded on. In most practical scenarios this
\nwill involve a doctor, so while doctors can
\nwork in isolation (although they rarely do),
\nmost other healthcare professionals have to
\nbe based within a team hierarchy. Another
\nimportant factor is that doctors and other
\nhealth professions whose tasks are shifted
\nwill also need to be confident that other
\nmembers of the team to whom they are
\nshifted do possess the necessary skills.
\nApart from creating differences in profes-
\nsional behaviour, this fact also adds a new
\nelement to the workforce dilemma. High
\nstandards of care, especially in highly spe-
\ncialised centres, are not usually produced
\nby individuals but by teams. The levels of
\ncare achieved will be built up over time as
\nteamwork, experience and training evolve.
\nThere is therefore a need for the preserva-
\ntion of teams and not just their individual
\nelements. This provides an opportunity,
\nthrough the support that can be given to
\nprofessional development, and through
\nprofessional migration, for a new approach.
\nWhat needs to be developed, rather than
\nthe somewhat woolly concept of an ethical
\nrecruitment policy, is a real and sustainable
\ntransfer of skills, knowledge and experience
\nbetween specialist centres.
\nInformation technology (referred to as \u201cE-
\nHealth\u201d in Europe) is transforming health-
\ncare delivery, although we are still in the
\nfoothills of a transforming journey. There
\nare three main challenges that this revolu-
\ntion is delivering to patient care. The first is
\nthe quantity (but not necessarily the quality)
\nof data. The second is how IT systems com-
\nmunicate, within and across organisational
\nand national borders. Thirdly, this informa-
\ntion needs to be contextualised so that it is
\nuseable in, for instance, providing relevant
\ninformation to patients and assisting them
\nto be better involved in their care. Develop-
\ning the last of these offers part of a solution
\nto the workforce dilemma.
\nThe European Commission\u2019s Green Paper
\nextended the definition of the workforce to
\ninclude carers. One could ask: \u201cwhy stop
\nthere; why not include patients?\u201d If we are
\nserious about more patient involvement and
\nself-management \u2013 and we should be \u2013 on
\nprinciple alone \u2013 then information is key.
\nThe electronic patient record will provide
\na powerful tool, not just for improving pa-
\ntient safety by sharing information across
\nthe healthcare team, but in also providing
\na route for better monitoring through tele-
\nmedicine, targeted information flows to as-
\nsist self-management, and (with appropri-
\nate consent) the use of data for healthcare
\nservice planning and for research.
\nWe can see these types of developments in
\nmany countries. In Europe their particular
\nfocus is to support cross-border healthcare.
\nAlthough the right of free movement is a
\nfundamental EU principle, creating the op-
\nportunity for patients to obtain care across
\nMember States\u2019borders has been limited by
\nthe organisational and financial problems it
\nposes. However, as patients move around
\nmore, relevant information to support their
\ncare must also be transferable. Large-scale
\npilots are being developed in up to twelve
\nEU member states to test the technical, le-
\ngal and ethical aspects of sharing electronic
\nsummaries and \u201ce-prescribing\u201d.
\nThere are enormous advantages (and risks)
\nin these developments. The greatest advan-
\ntage is in safer patient care, supported by
\nimproved information-sharing. Using the
\nelectronic patient record as a vehicle for en-
\nhancing information flow to doctors and to
\ntheir patients is a clear benefit, but the chal-
\nlenge will be to \u201ctranslate\u201d that information
\nin a way that is useful and relevant.
\nThe obvious risk is that breaches of patient
\nconfidentiality will destroy confidence in the
\nsystem, leading to withholding of informa-
\ntion. At present, doctors are more sceptical
\nof the risk of data leakage than patients. Pa-
\ntients see the benefit of not having to repeat
\ntheir history to a variety of different health-
\ncare professionals, while doctors are suspi-
\ncious of unauthorised access for purposes
\nother than patient care.
\nIn relation to the role of the doctor, the
\ninformation revolution opens up access to
\n6
\nEmerging disciplines
\nmedical records by a wider number of pro-
\nfessionals with involvement in the immedi-
\nate care of patients. With widening access
\nwill come the desire to take on new roles, so
\nthe central question \u2013 \u201cWhat is a doctor?\u201d\u2013
\nis not just a theoretical one. In the EU we
\nwill soon be looking at the review of the Di-
\nrective on the Recognition of Professional
\nQualifications (Directive 2005\/36). Up to
\nnow, the ability of doctors to move around
\nthe EU has been conditional on possess-
\ning relevant qualifications. As the demand
\nincreases for doctors to demonstrate cur-
\nrent competence, appraisal, revalidation and
\nlicensing are going to appear on the EU\u2019s
\nagenda. This will sharpen the focus on what
\nconstitutes the core work of a doctor.
\nDr. Michael Wilks,
\nPresident CPME (2008-2009)
\nMWilks@bma.org.uk
\nIn the past ten years, resistant forms of
\nTuberculosis, and particularly Multi-Drug
\nresistant Tuberculosis*
\n(MDR-TB), have
\nbecome a health menace of epidemiologi-
\ncal proportions, recognized as such by all
\ninternational medical organisations such
\nas WHO, CDC, IUATLD, WMA, MSF**
\n,
\nand many more. The World Medical As-
\nsociation, at its Annual Assembly in New
\nDelhi in October 2009, underlined the im-
\nportance of this issue by putting it on the
\nagenda of its Scientific Session***
\n.
\nTB specialists around the world have been
\nand are still debating how best to tackle
\nMDR-TB and its even more serious de-
\nrivative, Extensive Drug Resistance (XDR).
\nDiagnostic procedures, classification of dif-
\nferent categories of resistance patterns, and
\nactual management and treatment of the
\ndisease are among the many priority issues
\nundergoing constant review.
\nIn prison settings, all the major issues that
\nconstitute \u201cpitfalls\u201d to good TB manage-
\nment are enhanced when dealing with
\nMDR forms of TB [1,2]. A few additional
\nconsiderations need to be addressed, taking
\n* Defined as being resistant to at least Isoniazid (H)
\nand Rifampicin (R).
\n** World Health Organization; Center for Disease
\nControl and Prevention;International Union against
\nTuberculosis and Lung Disease; World Medical As-
\nsociation; M\u00e9decins Sans Fronti\u00e8res (Doctors w\/o
\nBorders).
\n*** See the WMA website for additional information
\non the Scientific Session: www.wma.net
\ninto account the communications received
\nat the WMA 2009 Scientific Session, in the
\nlight of the specific constraints encountered
\nin prisons and other custodial settings.
\nThree separate (but, of course, linked) issues
\nare here considered:
\ndiagnosis of TB and its resistant forms,\u2022
\nand particularly the use of Drug Suscep-
\ntibility Testing (DST)
\nindividual treatment vs. standardized\u2022
\ntreatment regimens
\nadditional issues specific to custodial set-\u2022
\ntings
\nDiagnosis and selection of anti-
\nTB drugs according to DST
\nThe greatest risk for TB transmission is
\nposed by patients with undiagnosed or
\nunrecognized infectious TB [3], hence the
\nimportance of diagnosis of the disease, and
\nselection of the correct anti-TB drugs to use
\nfor treatment. Both should always be based
\non two complementary criteria: first, the
\nhistory of previous anti-TB therapy, and
\nsecond, reliable DST, meaning testing that
\nhas been subject to quality control according
\nto internationally approved standards [4].
\nThe taking of the patient history of previ-
\nous therapy, is often problematic, and dif-
\nficult\u00a0\u2013 if not outright inadequate or even
\nsometimes totally absent in prison settings.
\nThe reasons for this are more complex than
\nmere negligence,and are sometimes difficult
\nto grasp in developed, high-resource coun-
\ntries, without the many problems described
\nfurther on.
\nAs is well-known, the definition of a \u201cnew
\npatient\u201d, as someone who has never taken
\nany anti-TB drugs, or taken them for less
\nthan 30 days time, is an essential compo-
\nnent in the diagnostic procedure of \u201cnor-
\nmal\u201d, i.e. drug-susceptible TB.This is all the
\nmore important for drug-resistant forms of
\nthe disease.
\nAs has been amply described elsewhere\u00a0[5],
\nbefore the passage of at least 30 days, there
\nis simply not enough time for a sufficient
\nnumber of spontaneous mutations to con-
\nstitute a sufficient population of resistant
\nforms of Mycobacterium Tuberculosis. It is
\ntherefore essential to have this situation
\nMulti-Drug Resistant TB in prisons
\nHern\u00e1n Reyes
\n7
\nEmerging disciplines
\nclearly defined at the start. In the best of
\nscenarios, a health professional, physician
\nor nurse, may inform the prisoner\/patient
\nabout TB disease, and why it is crucial to
\nhave the exact information, and (hopefully)
\nwhy any deviant responses may be detri-
\nmental not only to the patient but also to
\nfellow inmates and to any visiting family
\nmembers.
\n\u201cInitiation of drug therapy in patients with
\nproven MDR-TB requires assessment of
\nthe history of treatment as well as meticu-
\nlous laboratory studies to characterize the
\nsusceptibility of the specific strain.\u201d
\nIseman MD. Treatment of Multidrug-
\nResistant Tuberculosis. N Eng
\nJ Med 1993; 329: 784-91
\nIn prison settings, inmates may or may not
\ntell the truth about their history and many
\nother issues, for different reasons. While
\nlogical reasoning may seem straightforward
\nenough to health workers unfamiliar with
\nprisons, custodial settings differ greatly
\nfrom the \u201coutside world\u201d. There is a broad
\nrange of factors influencing the way a pris-
\noner answers the questions posed to them.
\nThe first obstacles to obtaining quality
\npatient history relate to the actual health
\nprofessional asking the questions. Prisons
\nin low-resource countries \u2013 most often the
\nvery countries with a high prevalence of TB
\nand also of MDRTB \u2013 are often notoriously
\nunderstaffed, particularly regarding health
\nstaff. Experience has shown that poorly
\npaid, insufficiently trained, and, hence,
\npoorly motivated health staff are not well
\nequipped for dealing with complex health
\nissues such as TB \u2013 a fortiori resistant forms
\nof TB. Poor history-taking is a major short-
\ncoming in many prison health services. It is
\nalso still the sad reality in many prison sys-
\ntems worldwide, that National TB Control
\nPrograms (NTPs) do not visit the prisons in
\ntheir country, or, if they do, they most often
\ndo not have a clear picture of the realities
\ntherein.NTPs are sometimes not allowed to
\nenter prisons, for administrative or security
\nreasons. Quite often, NTPs have a passive
\nattitude towards prisons, and tend to ignore
\nthem. Therefore, medical staff working in
\nthe prisons often lack training on \u201cnormal\u201d
\nTB \u2013 let alone its resistant forms. Such
\nmedical staff, even prison doctors, often fail
\nto diagnose tuberculosis because they lack
\nthe proper training and supervision that
\nwould put TB in the forefront of differen-
\ntial diagnosis of respiratory diseases.
\nEven those prison systems that have quali-
\nfied, motivated staff (i.e., that provide ad-
\nequate salaries and on-going training), are
\noften, nonetheless, under-staffed. In these
\nsituations, overworked health personnel
\nsimply do not have the time to take an ad-
\nequate case history for TB cases. Ideally, in
\ncontexts where resistant TB is a reality in
\nthe outside world (and consequently would
\nneed to be actively looked for in prisons),
\nprevious treatment history should be taken
\nby a highly trained physician. To take an
\nadequate history of treatment, this person
\nshould know about first and second line
\nTB drugs; their availability and use in the
\ncountry and their adverse effects (so as to
\nrecognize them as required). There should
\nbe sufficient time per patient, even up to
\npossibly an hour or so, to ensure all aspects
\nare duly addressed. It has been often sug-
\ngested that there be at hand a display of the
\ndifferent pills available in the country (and
\ntheir boxes!), so that the physician can pres-
\nent the patient with a choice of visual possi-
\nbilities and increase the likelihood they will
\nrecognize drugs they have taken previously.
\nAs anyone who has worked in most prisons in
\ndeveloping countries will know, the ideal situ-
\nation described above is, unfortunately, merely
\nwishful thinking, and is not about become a
\nreality in most prisons of developing countries
\nany time soon.
\nAn additional issue that may negatively af-
\nfect treatment decisions is one that can arise
\nin both low and high-income countries.
\nPrisoners are not the most cooperative of pa-
\ntients. For a whole panoply of reasons, from
\nwanting to obtain perceived \u201cprivileges\u201d; to
\ndesiring transferral to hospital; to other con-
\nsiderations of a totally non-health related na-
\nture; prisoners may knowingly provide false
\ninformation to health staff. Experience from
\nICRCTB programmes in different countries
\nhave shown that prisoners can and do give
\nthe answers to the questions that they believe
\nwill lead to the\u201cgeographical\u201d****
\nor categorical
\nclassification that the prisoner has decided
\nhe or she wants \u2013 and not according to medi-
\ncal criteria, which should be the determining
\nfactor.
\nThe need for Drug Susceptibility Testing
\nhardly requires any justification in the man-
\nagement of Tuberculosis and its resistant
\nforms, even though many factors still limit
\nits widespread use in developing countries
\n[4; 5]. The difficulties inherent to the delay
\nin obtaining results, the possible mishaps
\nin the technical performances necessary,
\nand the real problems inherent to the ad-
\nequate interpretation of results have all been
\ndescribed. The additional complications of
\ndifferentiating DST in vitro results from in
\nvivo treatment realities are yet another ele-
\nment the argumentation. *****
\nIn prisons, the first snag regarding DST is
\ntwofold: first the cost; second the training of
\nlab staff. Monetary considerations should
\ntheoretically no longer be an obstacle, now
\nthatTB and MDRTB have been recognized
\nby the WHO and practically all countries
\n****\u201cGeographically\u201dmeaning\u201cbeingsenttoaspecific
\nprison, which the prisoner wants to be sent to, re-
\ngardless of any health consideration\u2026\u201d
\n***** 10 years ago, both WMA in its \u201cDeclaration of
\nEdinburgh on Prison conditions and the spread of
\nTuberculosis and other communicable diseases\u201d(Oct
\n2000),and EFMA\/WHO in its \u201cWarsaw Statement
\non Tuberculosis and Prisons\u201d ( March 2000 ) called
\non national medical associations to urge govern-
\nments to take urgent action on these issues.
\nWhile there has been some progress in influenc-
\ning improvement in healthcare and disease control
\nin hospitals as Dr. Reyes warns the difficulties in
\nachieving change persist and the need for NMAs to
\nact remains. ED.
\n8
\nEmerging disciplines
\nas real health emergencies, and given the
\navailability of financial resources from such
\nentities as the \u201cGlobal Fund\u201d(GFATM*
\n).In
\nreality, however, prisons are often last on the
\npriority list for funding of any kind**
\n.
\nDST, even for First Line Drugs (FLD),
\nneeds some form of laboratory setup, and
\nlab staff. Even Sputum Smear Microscopy
\n(SSM), the basic of basics in TB diagnosis,
\nrequires a lab technician trained to cor-
\nrectly do a Ziehl-Neelsen stain \u2013 and other
\nstaff trained and qualified to read the slides.
\nDST of course is more complex of course
\nthan SSM, and involves a more significant
\ninvestment in both money and training.
\nWhile nobody argues that such investments
\nare not necessary; the point is that prisons
\nare way behind in developing the adequate
\ninfrastructures, in recruiting and training
\nadequate staff, and retaining them by pay-
\ning them correctly so they do not leave to
\ngo into the private sector. Most impor-
\ntant: prisons need to create and develop a
\nworking relationship with, and receive sup-
\nport and supervision from, their respective
\nNTPs. DST for Second Line Drugs (SLD)
\nis problematic, difficult, costly and some-
\ntimes unreliable in the best of settings \u2013 and
\nwould be even more so in prisons.This is all
\nthe more regrettable, as prisons are assured-
\nly a high-risk environment for development
\nof resistant forms of tuberculosis.
\nBased on ICRC experience working in
\nprisons in different countries,even adequate
\nlaboratories and trained staff need constant
\nsupervision. In many cases, visibility into
\nthe prison system from outside, and strong
\naccountability, will also be necessary. There
\nare many forms of \u201ccorruption\u201d that can
\noccur within the laboratory component,
\n* Global Fund to Fight AIDS, Tuberculosis and
\nMalaria
\n** With the exception of high-security prisons, per-
\nhaps, in those countries concerned by the so-called
\n\u201cwar on terrorism\u201d\u2026
\nIt has not yet been considered nor documented
\nwhether TB is a significant worry among such \u201cspe-
\ncial\u201d inmates\u2026
\nwhich have been described elsewhere [2].
\nHowever, if the \u201crigging\u201d of lab results was
\nconsidered as a major shortcoming for \u201cnor-
\nmal TB\u201d, the issue becomes of overriding
\nimportance when the much more deadly
\nforms of TB, MDR or XDR, are the issue.
\nThe old DOTS acronym, no longer in use,
\ncould be perhaps used to remind local staff
\nof the need to supervise theobtaining of
\nsputum:
\nDirectly Observed Taking of Sputum\u2026
\nTo have true and interpretable results
\nfor all patients in MDR-TB cohorts, it is
\nthus essential that there be no \u201ccheating\u201d
\nof any kind. Sputum exchanges between
\nprisoners have now been documented in
\nmany countries and measures to prevent
\nany such deception. Less straightforward
\nis the thwarting of \u201cfake\u201d results, obtained
\nby threats or \u201carm-twisting\u201d of lab staff or
\neven medical personnel. This phenomenon
\nhas been observed in ICRC field work, but
\nis for obvious reasons very difficult to docu-
\nment, let alone publish. It is essential how-
\never to keep such possibilities in mind, and
\nfor those responsible for TB programmes
\n(above all the NTP) to do everything pos-
\nsible to avoid them.
\nIndividual treatment vs.
\nstandardized treatment regimens
\nThe issue of individual vs. standardized
\ntreatment is an on-going controversy across
\nthe TB realm that also has implications for
\nthe prison setting. For some of the obvious
\nreasons already outlined above, it will be
\nmuch easier to implement a standardized
\nregimen in a custodial setting. Medical and
\nhealth staff, particularly if under-staffed,
\nwill better be able to handle a standardized
\nregimen. With the advance of MDR and
\neven XDR TB, there will be understandable
\narguments for Individual Treatment Regi-
\nmens (ITRs) for specific patients. It will
\nthus be necessary to provide the staff and
\ntraining \u2013 as well as all the safeguards nec-
\nessary \u2013 for adequate management of these
\nmore complex cases in prisons.
\nIt is in this context that the matter of ad-
\nequate and direct supervision can be men-
\ntioned. Directly Observed Treatment
\n(DOT) is a must in a prison setting. Pris-
\noners may decide, for reasons of their own,
\neither not to take their full prescribed treat-
\nment, or to take, \u201con the sly\u201d, a different
\ntreatment, smuggled in from outside, by
\noften well-meaning family members. Stan-
\ndardized treatments often rely on \u201cblister
\npacks\u201d for observance of adequate posology.
\nWhile the system has obvious advantages for
\nthe patient outside prison, the inverse argu-
\nment cannot be made for prisoners. Health
\nstaff cannot simply rely on the absence of
\nthe pill in the blister pack to \u201cconfirm\u201d ad-
\nherence to treatment. All tablet swallowing
\nneeds to be controlled, individually, and
\nwith the \u201cnurse insistence\u201d tailored to each
\nindividual patient. This applies not only to
\nthe initial phase of treatment,but also to the
\ncontinuation phase.
\nThe old acronym can also be used as a
\nreminder to Health Staff supervising
\ntreatment:
\nDirectly Observed Tablet Swallowing\u2026
\nThe \u201cspine-numbing\u201d scene of a tin vat,
\nplaced in the middle of a collective cell for
\nsome twenty inmates, in a prison in Central
\nAsia, half filled with a collection of different
\npills and blisters of all sorts of medicines,
\ndumped there literally by the inmates who
\nhad received them in their continuation
\nphase of TB treatment, and \u201csorted out\u201dand
\ntaken (or not) as desired, without any con-
\ntrol whatsoever, is hopefully a vision from
\nthe past***
\n. However, inadequate supervision
\nof treatment, fostered by negligence, igno-
\n***The\u201ctin vat\u201dincident is no\u201cmetaphor\u201d:it describes
\nan actual situation seen by the author in 2000.
\n9
\nEmerging disciplines
\nrance,orfearofviolencefromsomepatients****
\nstill does occur, and needs to be addressed
\nby providing more, better trained, and bet-
\nter supervised staff for TB programmes*****
\nin
\nprisons.
\nAdditional issues specific
\nto custodial settings
\nMany additional issues have already been
\nstated and detailed in previous publications.
\nTheir relevance for the management of
\n\u201cnormal TB\u201dtreatment is even more signifi-
\ncant for all resistant forms of TB, including
\nMDR TB & XDR.
\nManagement of adverse
\neffects of treatment
\nCorrect management of adverse effects of
\ntreatment, and, in fact, their identification
\nin the first place, has significant importance
\nin the prison setting. FLDs are known to
\nhave effects that lead to self-interruption of
\ntreatment by prisoners, if these patients are
\nnot properly coached, counselled and assist-
\ned by the medical and nursing staff. In the
\ncase of MDR TB, as is well known, SLDs
\nhave even greater adverse effects. Further-
\nmore, because the duration of treatment is
\n24 months or more, such adverse effects can
\nand will become even more annoying to pa-
\ntients, increasing the importance of ensur-
\ning sufficient support and expertise in their
\nmanagement.
\nErratic treatments are one of the main
\ncauses of the selection of resistant strains of
\n**** In some countries, prisoner \u201cbosses\u201d or \u201cbullies\u201d
\nwill steal drugs given to patients, either forcefully,
\nif they have not yet been swallowed and are being
\ntaken back to the cells, or by threatening patients
\nto conceal them from health staff, and deliver them
\nup\u2026
\n***** Two nurses in different contexts told the author
\n(only last year, 2009!) of how they had been threat-
\nened by inmates, who did not want to take their Ri-
\nfampicin, so as to sell it or trade it off somewhere\u2026
\nAgain, for obvious reasons, these menaces were
\nimpossible to \u201cdocument\u201d fully. Supervision was of
\ncourse tightened.
\nTB bacilli. It is therefore vital that health
\nstaff working with TB patients in prisons be
\nsufficiently trained in all aspects of adverse
\neffect management, and be suitably firm in
\ntheir dealing with often difficult patients
\nwho \u201cwant to have it their way\u201d.
\nContact management
\nand identification
\nA final issue arising in prisons, particularly
\nin overcrowded ones, is that of difficul-
\nties in contact finding. Indeed, even where
\nstaff and resources are sufficient, it can be
\nan overwhelming task to identify contacts
\nwhen a prisoner identified as having conta-
\ngious pulmonary TB has been living in an
\nimpossibly overcrowded cell, and mingling
\nwith dozens or even hundreds of other in-
\nmates. When staff and resources are lim-
\nited, this effort is even more difficult.
\nApart from the simple fact that there may
\nnot be enough personnel to determine
\nwhich prisoners are at the highest risk for
\ncontagion, there will again be additional
\ncomplications of the motives of the subjects,
\nsimilar to those factors that complicate an
\ninitial diagnosis for TB. As soon as inmates
\nrealize that there is an effort underway to
\nidentify contacts of a diagnosed peer, they
\nmay decide that there is something to be
\ngained from being identified as one (such
\nas a free trip to the hospital for investiga-
\ntions; better food in a health setting; being
\nexcused from work; fewer security mea-
\nsures; etc.). Thus prisoners may present
\nthemselves and (falsely) declare themselves
\nto be \u201ccontacts\u201d, when, in fact, they are not.
\nThese complications may be very difficult
\nto overcome, but health staff should at least
\nbe aware of the different possibilities and
\nNTPs need to determine how factor them
\ninto their overall evaluation of the TB situ-
\nation in the prison.
\nAll factors that have been mentioned here
\nneed to be addressed by the relevant author-
\nities. Administrative and structural consid-
\nerations, such as overcrowding, are a threat
\nto prison health and hence to public health.
\nThe recruiting, training, supervision, and
\nadequate salaries of prison health staff need
\nto be addressed as well, and the resources
\nnecessary to ensure them must be obtained.
\nThere is no place for complacency in the
\nmanagement of tuberculosis \u2013 all the more
\nso now that the much more deadly forms of
\nresistant TB are a growing menace to the
\nprison population, and community at large!
\nIn Conclusion
\nPrisons have recently, that is in the past ten
\nyears or so, finally been recognized as fo-
\ncal points in the fight against Tuberculosis.
\nMany (one would like to say \u201cmost\u201d, but
\nsuch is not yet the case) major International
\nfora on Tuberculosis now have at least one
\nafternoon, or even a full day, on specific
\nprison issues regarding TB, MDR TB and
\nTB-HIV Co-infection.
\nIt has been the objective in these few mod-
\nest pages, to underline once again the many
\nissues \u2013 some already well-understood and
\nothers arising from the difficulties inherent
\nto the evolving disease itself \u2013 that need to
\nbe known regarding prisoners and prisons
\nin the fight against TB and its dangerous,
\ncontinuous evolution to increasingly resis-
\ntant strains. Knowledge of the problems is
\nhalf the battle. Dr Jos\u00e9 Caminero stated at
\nthe 2009 WMA Assembly Scientific Ses-
\nsion on MDR TB:
\n\u201cIf this is already true in the \u201coutside world\u201d,
\nit is even more so in the prison world, and in
\n10
\nEmerging disciplines
\ncustodial settings in general. It is hoped that
\npondering the few comments made here will be
\nuseful to all dedicated medical staff working in
\nthese difficult situations.\u201d
\nFinally, as a final impetus for government
\nhealth and political authorities to dedicate
\nsufficient attention to the issues mentioned
\nhere, it must be reiterated that tuberculosis
\nis not an isolated issue that concerns only
\nsecond-class outcasts (sic) who are locked
\nup behind walls, bars and fences. Epidemics
\nin prisons,including TB and the continuing
\nemergence of drug-resistant forms of the
\ndisease, can and will spread to the outside
\ncommunity. In addition, control of the TB
\npandemic has been further complicated by
\nthe co-existing HIV pandemic.
\nAll stakeholders must remember that:
\nGood Prison Health is Good Public
\nHealth !
\nReferences
\nConinx R, Reyes H. Pitfalls of tuberculo-1.
\nsis programmes in prisons. BMJ. 1997 Nov
\n29;315(7120):1447-50.
\nPearson M .Tuberculosis (TB) infection control:2.
\na key strategy in the era of MDR-TB: presen-
\ntation at WMA scientific session. New Delhi;
\n2009.
\nReyes H. Pitfalls of TB management in Prisons.3.
\nInt J Prison Health. 2007; 3(1): 43-67.
\nGuidelines for Control of Tuberculosis in Pris-4.
\nons: TB\/CTA*
\nand ICRC**
\n, 2009; Dara M;
\nGrezmska M; Kimerling M; Reyes H; Zagors-
\nkiy\u00a0A.
\nCaminero, J: Approach to diagnosis of a patient5.
\nsuspect of drug-resistant TB: training of trainers
\nworkshop, Indian Medical Association \u2013 World
\nMedical Association. New Delhi, 12-14 Oct,
\n2009
\nHern\u00e1n Reyes, MD,
\nMedical coordinator, Health in
\nDetention, International Committee
\nof the Red Cross, Geneva (Switz)
\ne-mail: hreyes@icrc.org
\n* Tuberculosis Coalition for Technical Assistance;
\n** International Committee of the Red Cross
\nElkhonon Goldberg
\nWe are all familiar with the terms neurolo-
\ngy, psychiatry, neuroradiology, psychology,
\netc., however a few decades ago a new term
\nappeared – \u201cneuroscience.\u201d Neuroscience
\nis an eclectic interdisciplinary field devot-
\ned to the studies of the brain. Sometime
\nmore recently, perhaps two decades ago or
\nso, yet another term was born \u2013 \u201ccognitive
\nneuroscience.\u201d Cognitive neuroscience is
\ndevoted to the study of the brain mecha-
\nnisms of higher-order mental functions:
\nlanguage, attention, memory, and even
\ndecision-making. Even relatively recently,
\nthese complex functions of the brain were
\nregarded as too intricate to allow rigorous
\nscientific investigation. They were the pur-
\nview of classic psychology whose adherents
\nnot only did not know anything about the
\nbrain but took pride in not wanting to
\nknow. It was assumed that cognition could
\nbe studied as a Platonic object without
\nbothering to relate it to the biological ma-
\nchinery that makes it run.
\nTo a large extent it was a \u201csour grapes\u201d
\nsituation, since even if they desired the
\ninformation, there was not much in the
\nscientific research arsenal that would en-
\nable one to study the brain mechanisms
\nof the mind with any degree of precision
\nand rigor.To the extent that this was pos-
\nsible at all, our understanding of the rela-
\ntionship between the brain and cognition
\nwas inferred from the observations of the
\neffects of various forms of brain damage
\non behaviour.
\nAll this began to change with the advent of
\npowerful neuroimaging tools. It has been
\nsaid that the advent of these methodologies
\nwere to neuroscience what the invention of
\ntelescope had been to astronomy, or the in-
\nvention of the microscope to biology. Neu-
\nroimaging completely revolutionized the
\nways the brain mechanisms of higher-order
\ncognition are studied.
\nWe distinguish between two broad classes
\nof technologies: structural neuroimaging
\nand functional neuroimaging. Structural
\nneuroimaging includes Computerized
\nAxial Tomography of the brain (CT) and,
\nparticularly, Magnetic Resonance Imaging
\n(MRI) of the brain. Whereas in clinical
\npractice a neuroradiologist usually \u201ceye-
\nballs\u201d the images generated by these tech-
\nnologies, in research, CT and MRI data
\nare subject to precise quantitative measure-
\nments, called quantitative morphometry,
\nwhich make much more precise character-
\nization of various features of normal and
\nabnormal brain possible. More recently,
\nvarious methods, Diffusion Tensor Imag-
\ning (DTI) among them, have been devel-
\noped to examine pathway architecture in
\nthe brain.Owing to these various neuroim-
\naging methods, we now know that gender
\ndifferences exist in normal brains. The two
\nhemispheres are more symmetric in fe-
\nNeuroimaging and the birth of
\ncognitive\u00a0neuroscience
\n11
\nEmerging disciplines
\nmales than in the males; certain aspects of
\nthe corpus callosum are thicker in females
\nand certain long intrahemispheric path-
\nways are thicker in males. We know that
\nthe hippocampi may exhibit size reduction
\nin people likely to develop Alzheimer\u2019s
\ndisease long before any clinical symptoms
\nemerge. We know that the brains of people
\nwho eventually develop schizophrenia ex-
\nhibit abnormal neurodevelopmental couse
\nyears before the first clinical symptoms
\nemerge. We know that chronic anxiety is
\nassociated with hippocampal atrophy and
\nPost-Traumatic Stress Disorder (PTSD) is
\noften linked to a reduction in size of the
\nventromedial prefrontal cortex. We know
\nthat the effects of experience-driven neu-
\nroplasticity may result in an actual size
\nincrease of the brain regions involved in
\nparticularly vigorous cognitive activities.
\nThese are but a few examples of the find-
\nings obtained with the methods of quanti-
\ntative morphometry and tractometry.
\nFunctional neuroimaging includes Positron
\nEmission Tomography (PET),Single Pho-
\nton Emission Computerized Tomography
\n(SPECT), Near-Infrared Optical Imag-
\ning, and, particularly, functional Magnetic
\nResonance Imaging (fMRI). These tech-
\nnologies are based on different underlying
\nphysical principles and their discussion is
\noutside the scope of this review, but they
\nall permit direct examination of activity
\npatterns in a living brain. While character-
\nizing regional patterns of neural activity
\nis the ultimate goal pursued by functional
\nneuroimaging, this is accomplished, as a
\nrule, through various \u201cproxy measures\u201dpre-
\nsumed to be highly correlated with neural
\nactivity levels. Blood oxygen levels in fMRI
\nor glucose metabolism levels in PET are
\nexamples of such proxy measures. In prin-
\nciple, functional neuroimaging can be used
\nboth in a resting state and during various
\nmental activities.
\nAs mentioned earlier, functional neu-
\nroimaging has revolutionized both cogni-
\ntive and clinical neuroscience. In clinical
\nneuroscience functional neuroimaging
\nwas particularly instrumental in helping
\ncharacterize disorders devoid of clear-cut
\nmacroscopic focal brain lesions, e.g. various
\nneuropsychiatric and neurodevelopmental
\ndisorders. Studies using PET and SPECT
\nhelped clarify the mechanisms of various
\nsuch disorders. Aberrant activity in the
\nstriatum (putamen and caudate nuclei) in
\nObsessive-Compulsive Disorder (OCD)
\nand Tourette\u2019s syndrome; \u201chypofrontal-
\nity\u201d in schizophrenia and certain affective
\ndisorders; and exceptional frontal-lobe
\nvulnerability in closed Traumatic Brain In-
\njury (TBI) are but a few examples of such
\nfindings.
\nFor a variety of technical and conceptual
\nreasons, cognitive neuroscience has fo-
\ncused predominantly on activation para-
\ndigms using fMRI, where brain scanning
\ntakes place while the subject is engaged
\nin various cognitive tasks. An elaborate
\nresearch methodology has developed to
\nsupport such studies, sometimes referred
\nto as \u201csubtraction methodology.\u201d The spe-
\ncific findings acquired with this method-
\nology are too numerous to list here. These
\nfindings have permitted direct test and
\nvalidation of many of the assumptions
\nabout functional organization of the brain
\ninferred in the decades past from the le-
\nsion studies, and have served to infuse our
\nunderstanding of the brain mechanisms of
\ncomplex cognition with an unprecedented
\ndegree of neuroanatomical precision.
\nFor the first time in the history of brain
\nresearch, it became possible to directly ex-
\namine the temporal dynamics of complex
\nmental processes as they unfold in time in
\nthe course of learning. It became possible to
\nexamine how particular brain regions work
\nin concert as interactive neural networks un-
\nderlying complex cognition and how these
\nnetwork interactions may become aberrant
\nin various disorders.Furthermore,it became
\npossible to study various higher-order func-
\ntions often referred to as \u201cmetacognitive,\u201d
\nsuch as complex decision making, social
\ncognition, and the mechanisms of insight
\ninto other people\u2019s minds (\u201cmentalizing\u201d),
\nboth in normal individuals and in various
\npoorly understood disorders such as au-
\ntism.
\nThis, in turn, expanded the frontiers of
\ncognitive neuroscience into the areas of
\ninterface with other disciplines, such as
\neconomics, politics, social interactions, and
\nethics. As a result, entirely new areas of in-
\nquiry have coalesced on these boundaries
\nbetween traditional disciplines, and we hear
\nabout \u201cneuroeconomics\u201d, \u201cneuromarketing\u201d,
\n\u201cneurolaw\u201dand other \u201cneuro\u2019s\u201dunimaginable
\neven a few decades ago,which are concerned
\nwith the brain mechanisms underlying cog-
\nnition and behaviour in these diverse arenas
\nof human endeavour.
\nDifferent eras are characterized by differ-
\nent directions of thrust of scientific inquiry.
\nJust as the first half of the twentieth cen-
\ntury was the era of physics and the second
\nhalf of the twentieth century was the era
\nof biology, the foreseeable beginning of the
\ntwenty-first century is shaping up as the
\nera of neuroscience in all its multiple and
\nconstantly expanding applications. If, as it
\nhas been said, the brain is science\u2019s \u201clast
\nfrontier\u201d, then we are finally on the verge
\nof piercing and eventually conquering this
\nfrontier.
\nElkhonon Goldberg, Ph.D., ABPP
\nNew York University School of Medicine
\nNew York, NY, USA
\ne-mail:egneurocog@aol.com
\n12
\nMedical Ethics, Human Rights and Socio-medical affairs
\nThe draft of the WHO Global Strategy to
\nReduce Harmful Use of Alcohol (GAPA)
\nis now available at the WHO website
\n(document EB126\/13 in English, Spanish,
\nFrench, Arabic, Russian & Chinese): www.
\nwho.int\/substance_abuse\/activities\/global-
\nstrategy\/en\/index.html, and here: apps.who.
\nint\/gb\/e\/e_eb126.html
\nThe document consists of three parts: The
\nreport by the secretariat, including a draft
\nresolution for consideration by the WHO
\nExecutive Board, the Draft Strategy itself,
\nand a two page summary of the evidence for
\nthe effectiveness and cost-effectiveness of
\nthe proposed interventions. In addition, the
\ndocument contains a bibliography on evi-
\ndence on harmful use of alcohol, published
\nseparately on the WHO Substance Abuse
\nwebsite.
\nAlthough some of the sections of the draft
\nstrategy should be improved and strength-
\nened,we believe that the Strategy effectively
\naddresses issues that will be critical in public
\nhealth efforts to reduce the toll of alcohol
\nthroughout the world. The attached GAPA
\nresponse provides general and specific com-
\nments regarding both the strengths and
\nweaknesses of the existing draft.
\nThe draft Strategy will be submitted to
\nWHO Executive Board January session for
\ndiscussion and approval. The international
\ndrinks industries and their social aspect or-
\nganisations have launched several initiatives
\nto influence the Strategy process. Those
\ninitiatives include industry front-group
\nInternational Center for Alcohol Policy
\n(ICAP)\u2019s recent publication of \u201cWorking
\nTogether to Reduce Harmful Drinking\u201d,
\nan attempt to strengthen industry\u2019s role in
\nthe development and implementation of a
\nGlobal Strategy.
\nGAPA expects that some Member States
\nmight attempt to weaken the scope and
\ncontent of the Strategy, and may even block
\nits adoption. The Executive Board meeting
\nbegins on January 18 in Geneva and NOW
\nis the time for concerned GAPA partners
\nand other nongovernmental organisations
\nto act at country-level in support of the
\nadoption of the Strategy. May we also sug-
\ngest that you spread this action alert to oth-
\ners in your network.
\nACT NOW
\nWe strongly urge you to contact your Health
\nMinister (or health ministry) now in sup-
\nport of the Global Strategy. Please ask for
\na meeting with the Minister, or members of
\nthe delegation that will attend the WHO
\nExecutive Board meeting. We encourage
\nyou to raise the following points in your
\ncontacts with your Minister and\/or EB del-
\negation, depending on the situation in your
\ncountry:
\n1.\t Express your support for the Draft
\nGlobal Strategy as a key starting point
\nin addressing the global threat to health
\nrepresented by the harmful use of alco-
\nhol;
\n2.\t Make your strong recommendation that
\nthe Strategy should be adopted in its
\ncurrent version at the minimum, and
\npossibly with amendments strengthen-
\ning it in the way outlined in the attached
\nGAPA response document;
\n3.\t Assert that the harmful use of alcohol
\non the global level is a long-overdue re-
\nsponsibility of Member States and the
\nWHO;
\n4.\t Emphasize that the involvement of non-
\ngovernmental organisations is essential
\nin policy development and implementa-
\ntion and that NGOs are willing to col-
\nlaborate fully with WHO and Member
\nStates in this process;
\n5.\t Address the need to limit economic op-
\nerators\u2019 involvement in the Strategy and
\nto insure that policies and programs at
\nall levels are developed by public health
\ninterests independent of commercial
\nconflicts;
\n6.\t Recognize that additional resources will
\nbe required at all levels to implement
\neffective national, regional, and global
\nstrategies to reduce the harmful use of
\nalcohol, and countries in the developed
\nworld should make the necessary funds
\navailable to WHO;
\n7.\t Convey the information that represen-
\ntatives of the Global Alcohol Policy
\nAlliance (GAPA) will be attending the
\nExecutive Board meeting and look for-
\nward to conferring with country delega-
\ntions at that time.Please encourage your
\nHealth Minister and delegates to get a
\nglobal NGO perspective during the EB
\nsession.
\nGAPA contacts:
\nGeorge Hacker: ghacker@cspinet.org
\n\u00d8ystein Bakke: oystein.bakke@forut.no
\nAction alert
\nCountry-levelsupportneedednowfortheglobal
\nstrategy to reduce the harmfuluseofalcohol
\n13
\nMedical Ethics, Human Rights and Socio-medical affairs
\nIn January 2010, the Executive Board of the
\nWorld Health Organization will consider a
\nDraft Global Strategy to Reduce the Harmful
\nUse of Alcohol.This proposal comes none too
\nsoon, considering the enormous impact that
\nalcohol has on global public health.The exces-
\nsive use of alcohol is the third-leading risk fac-
\ntor for premature deaths and disabilities in the
\nworld,accounting for some 2.5 million deaths
\nin 2004.That equates to 3.8% of all deaths and
\n4.5% of the global burden of disease as mea-
\nsured in disability-adjusted life years lost.
\nTheGlobalAlcoholPolicyAlliance(GAPA)*
\nstrongly supports the December 3, 2009
\nDraft Global Strategy and recommends it
\nto the Executive Board and Member States
\nfor approval. Although some of its sections
\nshould be improved and strengthened (as
\nindicated below), we believe that the Strat-
\negy effectively addresses issues that will be
\ncritical in public health efforts to reduce the
\ntoll of alcohol throughout the world.In par-
\nticular,we note the following essential com-
\nponent strengths of the Strategy:
\nIts foundation rests on strong, evidence-\u2022
\nbased policies that can provide guidance
\nfor Member States;
\nIt recommends, in accordance with the\u2022
\nevidence base, essential policy interven-
\ntions regarding price, availability, drink-
\ndriving countermeasures and marketing;
\nIt addresses the need for resource devel-\u2022
\nopment and issue prioritization in imple-
\nmenting alcohol prevention strategies at
\nthe global and national levels;
\n* The Global Alcohol Policy Alliance (GAPA) is a world-
\nwide coalition of NGOs, medical professionals, and re-
\nsearchers who work to prevent alcohol problems and reduce
\ntheir toll on society. GAPA, which includes representation
\nfrom all inhabited continents, was formed in 2003 and is
\nheadquartered in London, England.
\nIt recognizes that the involvement of civil\u2022
\nsociety is essential in creating the political
\nwill to address alcohol issues and imple-
\nment national and global prevention
\nstrategies;
\nIt acknowledges the responsibility for\u2022
\nhealth-sector leadership within multisec-
\ntoral collaboration on efforts to combat
\nalcohol problems at all levels;
\nIt suggests a special focus on protecting\u2022
\nthe young, non-drinkers, and populations
\nat risk from harmful use of alcohol, such
\nas women, indigenous peoples and other
\nlow-income or minority groups;
\nIt anticipates the involvement of all par-\u2022
\nties, including \u201ceconomic operators\u201d,
\nin implementing strategies at all levels,
\nwhile pointing to reasonable distinctions
\nin their roles, depending on commercial
\ninterests involved.
\nGAPA believes that the Strategy\u2019s Aims
\nand Objectives, Guiding Principles, and
\nPolicy Options and Interventions are clear,
\nbalanced, and comprehensive. They express
\na vision that can begin to address global
\nharm from alcohol.
\nGAPA Concerns
\nAlcohol Marketing Issues
\nGAPA is disappointed by the weakness of the
\npolicy discussion concerning the marketing of
\nalcoholic beverages. In particular, we note that
\nthe suggested policy interventions include co-
\nregulation and industry self-regulation as \u201cap-
\npropriate\u201dparts of the strategy.Neither of these
\nhas an evidence base of effectiveness \u2013 in fact,
\nseveral studies of self-regulation have found it
\nineffective.Voluntary codes of good marketing
\npractice are routinely violated, nearly impossi-
\nble to enforce in a timely manner,and condone
\nmuch of the advertising and promotion, such
\nas sports sponsorship and trans-national mar-
\nketing messages, about which Member States
\nhave expressed concern.
\nGAPA believes that self-regulation and\/or
\nco-regulation are hopelessly inadequate sub-
\nstitutes for strong governmental regulation
\nof alcohol marketing, and that the Strategy
\nshould reflect that reality. The strategy also
\nweakens the specific recommendations in
\nthis section by removing the word \u201cban\u201dand
\nleaving \u201crestrict\u201das the only option.The evi-
\ndence base is strongest in support of bans on
\nmarketing, and various forms of marketing
\nare already banned in numerous Member
\nStates. Therefore, bans should be explicitly
\non the table as options for Member States.
\nAppropriate Roles for Different Parties
\nThe document contains several references
\nto the need for \u201cpartnerships\u201d and GAPA
\nwelcomes the call for various governmental
\nand non-governmental entities to partner
\nwith WHO to address these problems. The
\ndocument also addresses the appropriate
\nroles of different parties concerned about
\nalcohol policies. GAPA believes that the
\nDraft Global Strategy should be improved
\nby explicitly addressing the \u201cappropriate\u201d
\nrole of \u201ceconomic operators\u201d in the process
\nof developing and implementing evidence-
\nbased, preventionoriented policies to reduce
\nthe harmful use of alcohol.
\nTo avoid conflicts of interest, the strategy
\nshould clearly state that policies and pro-
\ngrammes to reduce alcohol-related harm
\nneed to be developed independent of com-
\nmercial interests. Economic operators
\nshould avail themselves of opportunities to
\nbe in dialogue with WHO and other gov-
\nernmental bodies regarding their contribu-
\ntions,in their roles as alcohol producers,dis-
\ntributors, sellers, promoters to the reduction
\nof alcohol problems. Such contributions to
\nthe implementation of alcohol strategies at
\nall levels should be consistent with a duty to
\navoid interfering with public health objec-
\ntives and public health policy.
\nResponse of the Global Alcohol Policy
\nAlliance to WHO\u2019s
\nDraft Global Strategy to the Reduce the Harmful Use of Alcohol
\nDecember 2009
\n14
\nRegional and NMA news
\nWhen the Monet\/Schumann inspired
\ninitiatives extended the early post-second
\nWorld War agreements in some States
\n(such as the Coal and Steel Treaty, Paris
\n1951) to build structures which would
\nmilitate against any further European
\nconflicts culminated in the Treaty of
\nRome (1957) and the establishment of the
\nEuropean Economic Community (EEC),
\nthe medical profession reacted by forming
\na \u201cComit\u00e9 Permanente des M\u00e9decins de la
\nCEE\u201d (CPME or CP). This year CPME
\ncelebrates its 50th
\nanniversary.
\nThe various Treaties signed by Member
\nStates had created a political economic
\ncommunity with legislative powers on de-
\nfined topics (which have increased as the
\nCommunity has expanded and subsequent
\nTreaties and changed new or amended
\nlegislation have been adopted). This ar-
\nticle provides some information on the
\nbackground to the CPME\u2019s foundation,
\nits work and some of the problems it faced
\nin the following years.
\nThe following short glossary of terms used in
\nthis article will assist those not familiar with
\nthe EEC and associated institutions.
\nEuropean Economic Community (EEC)
\nlater known as the European Union (EU)
\nThe Council of Ministers (The Council) con-
\nsists of Ministers from Member States who
\nadopt legislation, Regulations, Directives and
\nDecisions etc.
\nRegulation: European Legislation which has
\nto be directly incorporated into national law.
\nDirective: European legislation, the effect of
\nwhich has to be incorporated in national law.
\nDecision: Specific measures which are binding
\non those to whom they are addressed.
\nEuropean Commission is effectively the Ex-
\necutive of the EU, comprising representatives of
\nthe Member States appointed as Commission-
\ners with specific responsibilities for differing
\nsectors (Directorates General (DG\u2019s) within
\nthe European Commission. It is responsible for
\nproposing legislation and guarding the imple-
\nmentation of the provisions of the Treaties.
\nAfter 50 years of impressive activity the
\nCPME (referred to in its early years as the
\n\u201cCP\u201d, an acronym used in the early part
\nof this article), has good reason to look
\nback and reflect on the wisdom and work
\nof those who, in the light of the Treaty of
\nRome (Tof R) 1957, recognised the need
\nwere responsible for its foundation, and to
\nthose individuals who over the years have
\nmade huge contributions to the work of the
\nCP. The tasks which CP has undertaken
\non behalf of the medical profession (and
\nthe citizens) of the European Union have
\ncontributed enormously to the realisation
\nof the principles and evolving ambitions of
\nthe European Community which, amongst
\nits many other objectives, were to meet the
\nsocial,healthcare and safety needs of its citi-
\nzens and the facilitation of free movement
\nof workers,including the medical,paramed-
\nical and pharmaceutical professions.
\nFoundation
\nThe \u201cComit\u00e9 Permanent des M\u00e9decins de la
\nC.E.E.\u201d (Standing Committee of Doctors
\nof the EEC, ultimately changed to Standing
\nCommittee of European Doctors), was found-
\ned in Amsterdam in 1959 by the original Six
\nNational Medical Associations (NMAs) of
\nthe Member States of the European Eco-
\nnomic Community, Belgium, France, Ger-
\nmany, Netherlands, Italy and Luxembourg,
\nall of them members of the World Medical
\nAssociation (WMA).
\nThe founding NMAs\u2019 activities were es-
\nsentially to defend the principles on which
\nmedical practice should be based, both in
\nthe interests of healthcare of all the citi-
\nzens of Six member states of the European
\nCommunity which also meant engagement
\nas \u201cthe patient\u2019s advocate\u201d (a role often re-
\nferred to in CP debates), in addition to
\nsafeguarding the standards of the medical
\nprofession in sustaining its role and func-
\ntions in the European Community.
\nThe CP Statutes (1960) initially provided
\nfor each NMA to undertake the Presidency
\nand Secretariat in rotation annually. This
\nwas soon changed to 2 then to 3 years, and
\nis currently two years (2010).
\nFrom the earliest meetings of the CP, in ad-
\ndition to the formal members, a represen-
\ntative of the Austrian Medical Association
\nand a representative of the World Medi-
\ncal Association were present as Observers.
\nThey were joined as observers by the British
\nMedical Association in 1961 and soon after
\nby the NMAs of those countries with ap-
\nplications to join the EEC including Den-
\nmark, Ireland and Norway. Norway with-
\ndrew its application when the referendum
\nrejected membership at the first community
\nenlargement when Denmark, Ireland and
\nthe UK joined the EEC (1972). Thereafter
\nobserver status was offered to those NMAs
\nReflections on the Standing Committee
\nof\u00a0European Doctors\u2019 (CPME)
\nFiftieth Anniversary 1959-2009
\nAlan Rowe
\n15
\nRegional and NMA news
\nwhose countries were seeking membership
\nof the EC.
\nThe structure, organisation and activities of
\nthe CP over the years has naturally been in-
\nfluenced not only by major events and EEC
\nlegislation in the evolving European Com-
\nmunity and its society,but also increasingly by
\nglobal events and developments,including ad-
\nvances in scientific and technical knowledge,
\npolitical, social and demographic change, the
\ncommunication revolution, natural disasters
\nand new challenges in disease control.
\nLanguage and Interpretation
\nThe CP, comprising representatives from
\nvarious member states speaking different
\nlanguages, had a particular need for clear
\nunderstanding of the draft legislation they
\nwere dealing with. From the beginning a
\nteam of interpreters were necessary. Both
\nsimultaneous translation and on occasions
\nconsecutive translation were used, although
\nthe latter was abandoned as it was so time
\nconsuming. The expertise of the interpreta-
\ntion team with their particular knowledge
\nboth of medical technical language and that
\nassociated with legal and community affairs
\n(many also worked in the European institu-
\ntions) made a huge contribution to the work
\nof the committee. Now the CPME works
\nmainly in English.
\nCP – The early period
\nIn one sense, the first period of CP activity
\nwas largely focused on problems associated
\nwith Freedom of Movement, Professional
\nRecognition and Practice in the European
\nEconomic Community (EEC). Essentially
\nthis period began in 1959 (The EEC officials
\nresponsible for the drafting of legal Direc-
\ntives providing for the freedom of movement
\nof professionals referred to in article 57 (also
\n48.4 and 60) of the 1957 Treaty of Rome had
\nbegun their enquiries in 1958).
\nThe full implications at this time of the
\nmost important article 57 (see box ) and
\nthe problems with which the CP were faced
\nneed to be put into context.
\nArticle 57 ( Treaty of Rome)
\n1.\t In order to facilitate access to and engage-
\nment in non-wage-earning activities, the
\nCouncil shall issue directives for the mutual
\nrecognition of diplomas,certificates and other
\nevidence of qualifications. The Council shall
\nso act, on a proposal of the Commission and
\nafter the Assembly has been consulted,during
\nthe first stage unanimously and subsequently
\nby qualified majority vote.
\n2.\t With the same object, the Council, on a
\nproposal of the Commission and after con-
\nsulting the Assembly. shall before the tran-
\nsitional period ends .issue directives for the
\nco-ordination of the legislation, regulations
\nand administrative rules of Member States as
\nregards persons taking up non-wage-earning
\nactivities. Voting must be unanimous on the
\nfollowing matters: i.e. those which are the
\nsubject of legislation in at least one Member
\nState; those concerned with the protection of
\nsavings, in particular the granting of credit
\nand the carrying on of the banking profes-
\nsion; and the conditions governing the car-
\nrying on of the medical, para-medical and
\npharmaceutical professions in the various
\nMember States. In all other cases, the Coun-
\ncil shall act unanimously during the first stage
\nand subsequently by qualified majority vote.
\n3.\t In the case of the medical,para-medical and
\npharmaceutical professions, the progressive
\nremoval of restrictions shall be dependent
\nupon the conditions for exercising them
\nbeing co-ordinated in the various Member
\nStates
\nIn the late 1950\u2019s there were a few limited
\nbilateral agreements between individual
\ncountries for mutual recognition of medi-
\ncal degrees and qualifications (somewhat
\nlater, the Nordic Agreement on Cultural
\nCo-operation (1971) laid the grounds for
\nmutual recognition in the Scandinavian
\ncountries, fulfilled in 1975. The decision
\nin article 57 of the TofR therefore raised
\nconsiderable problems. Hence, in part, the
\nspecial provisions for mutual recognition of
\nqualifications and coordinating provisions
\nfor health professionals\u2019 activities set out in
\narticle 57. These required unanimous deci-
\nsion by the Council of Ministers initially in
\nadopting proposed legislation and decisions
\n\u00adthereafter by qualified majority; also that
\nprogressive abolition of restrictions for the
\nmedical, paramedical and pharmaceutical
\nprofessions be dependant upon coordina-
\ntion by Member States.
\nClearly the Commission needed some form
\nof Medical Advisory Body providing the
\nvoice of the medical profession and other
\nhealth professions in the process of produc-
\ning draft proposals for Directives. (In fact
\nit did not officially establish one until the
\n1975 Doctors Directives were finally ad-
\nopted, when a Council Decision set up an
\nAdvisory Committee on Medical Training
\n(ACMT)in the Commission).
\nThe NMA\u2019s, however, foresaw the need for
\nthe profession\u2018s views to be coordinated and
\npromoted to the EEC authorities and thus
\nthe CPME was founded in 1959.The Com-
\nmission accepted discussions\/communica-
\ntions with the CP, recognising the value of
\ninformation and opinions from such a body
\nand its importance in representing the physi-
\ncians in Member States. (In this connection it
\nis of interest to note that in the original Stat-
\nutes,article 1 referring to the national delega-
\ntions from each country determined represen-
\ntation of member associations as \u201c6 delegates
\nand 6 alternates are to be nominated by the
\nNMA or national professional organisation
\nin such a manner that the delegation is repre-
\nsentative of the medical body of its country\u201d).
\nOther European bodies representing specific
\nareas of medical practice, AEMH (hospital
\ndoctors, FEMS (Salaried doctors),UEMO
\n(general practitioners) PWG (Junior doc-
\ntors) became CP observers and appointed
\nliaison officers to the CP.
\nBy 1972\/3 the relevant time the EEC Com-
\nmissioner, Professor Ralf Dahrendorf (later
\nLord Dahrendorf), recognised that more
\nrapid progress needed to be made and that
\nthere were still basic problems to be solved.
\nHe therefore convened the famous \u201cDah-
\nrendorf Hearing\u201d (October 1973) in which
\nparties from the Old Six and the three new
\nacceding countries were included. Other
\n16
\nRegional and NMA news
\ninterested parties included the Universities,
\nthe practicing Medical Profession, other
\nhealth professions, the EEC institutions,
\nConsumer organisations, National govern-
\nments and other bodies. From this Hear-
\ning emerged the concept of an Advisory
\nCommittee on Medical Training (ACMT).
\nThereafter, progress was more rapid.
\nHowever, only in 1975 (after 16 years of
\ndiscussion of drafts and redraft of propos-
\nals from the Commission!) was there suf-
\nficient agreement amongst Member States
\nfor Directives to be adopted by the Council
\nof Ministers as the basis for mutual recog-
\nnition of both basic and specialist medical
\ndegrees and diplomas, as well as coordinat-
\ning provisions for those wishing to migrate
\nwithin the European Community.
\nThese directives (75\/363\/EC & 75\/364\/
\nEC) covered mutual recognition of basic
\nmedical qualifications and a number of
\nspecified specialties, as well as the necessary
\ncoordinating provisions.
\nAlthough there had been CP representations
\nconcerning specific training for General Prac-
\ntice in the early 60\u2019s,it was not until 1986,af-
\nter nearly 20 years of continual consideration,
\ndiscussion and representations, that an initial
\nDirective (86\/457\/EEC) was adopted. Even
\nso recognition for the purposes of practice as
\na general practitioner in a national social se-
\ncurity system was only to be complied with by
\n1995.The directive also provided for a report
\nby the Commission on developments and
\nexperience in the intervening years on which
\nthe Council should act to extend the training
\nto all general practitioners.
\nSome of the proposals made by the CP
\nand other bodies on the various draft pro-
\nposals were not included in the final texts
\nadopted by the Council in 1975. Notably,
\nthe idea of an obligatory \u201cperiod of adap-
\ntation\u201d in the host country before a mi-
\ngrating physician would be free to practice
\nindependently in medical practice. Such a
\n\u201cperiod of adaptation\u201d was strongly sup-
\nported by the CP, a view also supported
\nby both the European Parliament and the
\nEconomic and Social Committee. (This
\nview has been subsequently raised again
\nin various EEC institutions from time to
\ntime) It would be many years before the
\nCommission incorporated such an idea
\nin the General Service Directive covering
\nthose professions for whom no specific
\nDirective had been adopted.
\nDirectives for Nurses, Midwives, Pharma-
\ncists and Veterinary Surgeons were soon
\nadopted in the years following 1975. All of
\nthese were subject to coordinating directives
\nfor these health professionals on more than
\none occasion. At all stages of the processes
\nleading to the adoption of these directives,
\ntheir amendments and co-ordination, the
\nCP\u2019s work included scrupulous monitoring
\nof the texts and their implications and dis-
\ncussions with the European Commission.
\nThe \u201cdoctors\u2019 directives\u201d can be regarded as
\nthe foundation Directives for freedom of
\nmovement of health professionals in the Eu-
\nropean Union.They continue to be discussed
\nand revised, dealing with changes in the spe-
\ncialties, clarification and expansion of issues
\nin the \u201875 Directives (such as occasional non-
\nestablished provision of services,cross board-
\ner medical practice, recognition of certain
\nspecialties) and incorporated in coordinating
\ndirectives. They will no doubt continue to
\ndevelop from time to time, reflecting other
\nmajor changes and developments.
\nIn this connection it is significant to
\nnote that in 1976, the concerns of the le-
\ngal profession (who had no directives at
\nthat time) were discussed at a conference
\ncelebrating the 10th anniversary of the
\n\u201cCahiers de Droit Europ\u00e9ene\u201d entitled
\n\u201cThe free movement of lawyers and doc-
\ntors in the European Economic Com-
\nmunity\u201d, The conference considered the
\nlawyers concerns about possible directives
\nfor their own profession) in the light of
\nthe approach adopted in the doctors\u2019 di-
\nrectives. At this conference many of the
\nproblems of the 1975 doctors\u2019 directives
\nwere reflected in the concerns of the law-
\nyers. (\u201cCahiers de Droit Europ\u00e9en\u201d 1976,
\nSuppl\u00e9ment)
\nCP and Other European Directives
\nWhile questions arising from the 1975 doc-
\ntors directives added considerably to the work
\nof the Standing Committee,it must be recog-
\nnised that in addition to the work associated
\nwith the medical directives (especially the role
\nof Occupational Health which profession-
\nally had already been involved in the context
\nof the 1951 Coal and Steel and later in the
\n1957 Euratom Treaties), and work on Social
\nSecurity, the CP increasingly had to monitor
\nand act on many non-medical directives ad-
\nopted by the EEC but having implications
\nfor medical practice both in healthcare and
\nother fields than medicine, Examples in-
\nclude the Directive on \u201cLiability for Defective
\nProducts\u201d,a draft Directive on \u201cLiability for
\nDefective Services\u201d which \u2013 eventually aban-
\ndoned \u2013 re-emerged again some years later,
\nand the so called \u201cAdvertising Directive\u201d on
\npharmaceutical products,notably article 3.
\nCPME The Middle period \u2013
\nMaastrecht, Amsterdam
\nThe second period of the CPME\u2019s activity,
\nstarting in the early 8o\u2019s, was influenced by
\na number of factors. In one sense, the most
\nimportant event relating to health in the EU
\nin this period was the formal reference to
\nPublic Health in Title X, article 185 of the
\nTreaty of Maastricht (1993) (the first time
\nthat actions in the health field had been
\nmentioned in the European Treaties!)\u00a0\u2013 and
\nthe inclusion of an article in Title XI on
\nConsumer Protection.The political changes
\nin Europe in the early 90\u2019s and the rather
\nlater enlargements of the membership of the
\nEuropean Community were also to impact
\non the CP, its organisation and member-
\nship. In this period the CP had continued
\nto enlarge its membership,first from 9 to 12
\nand then 15, plus many observers, most of
\nwhom later became members.
\n17
\nRegional and NMA news
\nAlthough already dealing with an enlarged
\nagenda in the early 80\u2019s and 90\u2019s subsequent
\nevents, notably the establishment of DG
\nSANCO (General Directorate, Health and
\nConsumer Affairs) in the late 90\u2019s, increased
\nthe workload on the CP in responding to EU
\npolicies and activities even more. In addition
\nby the late 1970\u2019s and early 80\u2019s the CP had
\nalready extended its activities to include is-
\nsues arising from organisations outside the
\nEU,including the Council of Europe,WHO,
\nthe GATT negotiations etc. In a globalising
\nworld, towards the end of the 20th century
\nand beyond, the incidence of diseases such as
\nAIDS in the 80\u2019s,SARS in 2003 and MRSA,
\nas well as rapidly increasing scientific devel-
\nopments such as those arising from genetic
\nresearch and the genome project, have raised
\nmore clinical and ethical problems.All of this
\nhas been in addition to the expanding work
\nof the EU in the field of Information Tech-
\nnology and more recently on E-health,which
\nrequires considerable CPME engagement.
\nA Brussels Office
\nFor over 30 years the CP from time to time
\nhad heated debates about establishing an of-
\nfice in Brussels or Strassburg. The increased
\nworkload eventually led to work being start-
\ned to review and consolidate the CPME\u2019s
\nposition in 1992. It developed by way of es-
\ntablishing a Brussels office and staff, a Board
\nand an Executive Committee and ultimately
\nan employed Secretary General.
\nThese major decisions approved in 2002,
\nreflected the increasing achievement of the
\nCPME over the preceding decades of its
\naim to respond to and influence develop-
\nments in the European Community.
\nCommittees
\nIn order to carry out its work the CP had,
\nfrom its earliest days established commit-
\ntees or working groups. In the first four
\ndecades of its existence these reflected the
\nfundamental planks of medical practice, its
\nengagement with society, as well as various
\nmore specialised areas. For many years the
\nlist was extensive comprising the following:
\nProfessional
\nTraining
\nOccupational
\nHealth
\nHospital Doctors Paramedical
\nProfessions*
\nSocial Security Doctors the
\nPharmaceutical
\nIndustry
\nSalaried Doctors Juristes**
\nMedical Ethics General Practice
\nWhile the functions of most of these com-
\nmittees are clear, and can be related to the
\nstructures mentioned later which have re-
\nplaced them, the following notes indicate
\nthe functions and value of two committees
\nwhich have disappeared.
\n* The Paramedical Committee (also no lon-
\nger existing) reflected the provisions of Ar-
\nticle 57 of the Treaty of Rome referring to
\nthe medical, paramedical and pharmaceuti-
\ncal professions\u201d. The CP by the late 60\u2019s had
\nestablished a committee on the Paramedical
\nProfessions, in whose role and education the
\nmedical profession had considerable interest.
\nAt a very early stage in the late 70\u2019s however,
\none incident is worth recording as it reflect
\na widely held attitude at that time \u2013 an atti-
\ntude which has radically changed since then.
\nIt should be noted that for at least two thirds
\nof the last century amongst the old Six and
\na number of other countries of continental
\nEurope, doctors played a major role in con-
\ntrolling the schools of nursing.The emphasis
\nwas on nurses and others as \u201cparamedicals\u201d,
\nwho were to assist and be responsible to doc-
\ntors. On one occasion, when the committee
\nwas discussing the paramedical professions,
\nit was pointed out that \u201cjust as the organisa-
\ntion and functions of the medical profession
\nwere evolving, so also were the roles of the
\nparamedical professionals and this was natu-
\nrally to be expected. It was further pointed
\nout that the first two Chairs of Nursing had
\njust been established in European Universi-
\nties and that no doubt this trend would ex-
\ntend and also be reflected in other paramedi-
\ncal fields. Despite support from one of the
\nlawyers this produced an explosion from the
\nChairman who castigated both speakers and
\ncommented: \u201cNo-one will interfere with the
\nacts reserved as fields of activity for special-
\nists.\u201dHow things have changed!
\n** The Juristes Committee (legal assistance is
\nnow sought when it is specifically required)
\nwas of particular importance, especially in
\nthe consideration of the many initial drafts
\nof the Doctors Directives in the late 60\u2019s, the
\n70\u2019s and early 80\u2019s. At the time of the CP\u2019s
\nfoundation, all delegations in the CP were
\naccompanied by their lawyers.This was large-
\nly a consequence of the Treaty of Rome, the
\nconsequential legislation and its implications
\nfor National Law in Member States and for
\nmedicine. It\u2019s work expanded with the de-
\nvelopment of legislation from other sectors
\nof the Commission which had implications
\nfor medicine and as advances in technol-
\nogy (such as data storage), medical research,
\nhealthcare services \u2013 their provision and
\nsafety, took place. This committee\u2019s advice
\non the Doctors\u2019 Directives was invaluable,
\nboth in the drafting period and also with the
\nproblems continually arising once they had
\nbeen adopted,or as various proposed amend-
\ning directives appeared. This also applied to
\ntheir assistance on wide ranging directives
\nwith implications for medicine and health-
\ncare. Unsurprisingly, the Juristes also greatly
\nassisted in the formulation of Charters and
\nDeclarations relating to the work of the com-
\nmittees and,of course,the drafting of the CP
\nStatutes and their various revisions.
\nToday, following the review referred to
\nabove, a smaller number of committees, re-
\nflecting the broad areas of engagement, are
\ncurrently as follows:
\nMedical Training, continuing profession-\u2022
\nal development and quality improvement
\nEthics and professional codes\u2022
\nOrganisation of health care, social secu-\u2022
\nrity and health economics
\nPublic health, prevention and environ-\u2022
\nment
\n18
\nRegional and NMA news
\n2000 and beyond*
\nIn a European Union now enlarged to 27
\nMember States, the CPME today has a
\nBrussels office, is registered as an Interna-
\ntional Association under Belgian Law and
\nhas a membership of 27 National Medical
\nAssociations,2 Associated Members,2 Ob-
\nservers and 9 Associated bodies. One look
\nat its website today (www.cpme.eu) shows
\nits continuing engagement with other Eu-
\nropean Medical bodies, its policies**
\n, state-
\nments and decisions; its engagement with
\nand representations to the major Institu-
\ntions of the European Union; participation
\nwith European non-EU bodies both medi-
\ncal and non-medical,and its inclusion in the
\nEuropean Commission\u2019s consultations. All
\nof this recognises the importance attached
\nto its opinions by the relevant EU institu-
\ntions, demonstrates the significance of the
\nCPME\u2019s work, its growth in stature and its
\ninfluence over the past fifty years.
\nOver the past 50 years there were occasions
\nwhen there were substantial differences of
\nopinion both between national delegations
\nand even within delegations, and there were
\nfrank and often forceful expression of views
\nin the early and middle phases of CP\u2019s exis-
\n* A More detailed account will appear in a history of the
\nCPME in preparation.
\n** The Policies of the CPME can be found at www.cpme.
\neu\/policy\/php
\ntence.However,there were few occasions on
\nwhich unanimous or substantial consensus
\nin the debates were not eventually reached.
\nDiffering legal systems and social security
\nprovisions (both affecting medical practice)
\ncontributed substantially to the problems of
\nensuring that adequate discussion recogn-
\nised the difficulties and the problems they
\nmight pose in particular member states.
\nHealthcare provision in certain individual
\nmember states had not, for financial, politi-
\ncal, administrative or other reasons, devel-
\noped to the general standards of the major-
\nity of member states. Cultural, linguistic,
\nnational and even philosophical factors all
\nplayed a part in achieving agreed positions.
\nTo achieve this called for understanding by
\nall parties of the real problems of certain
\nNMAs., These were sometimes medico-
\npolitical, sometimes cultural, which led to
\nsome delegations\u2019difficulties in understand-
\ning the difference between influencing pro-
\nposed supranational legislation, as opposed
\nto national legislation or regulation relating
\nto healthcare and professional practice.
\nNational Delegations sometimes approach
\ndiscussions with a strictly national posi-
\ntion based on their own experience. This
\nhas called for considerable diplomacy in
\nexplaining overall trends within the Euro-
\npean Community. For some countries this
\nwas more difficult than for others. Never-
\ntheless eventually decisions had to be taken,
\nsometimes involving compromise – a pro-
\ncess which could take a considerable time in
\norder to achieve a form of words acceptable
\nto the majority. On occasions this might
\nrequire agreement that representation be
\nmade by the CP directly to appropriate in-
\nstitutions on specific problems which some
\naspects of draft proposals for Community
\nlegislation would pose for national authori-
\nties and NMAs in certain member states.
\nAs the Community has substantially en-
\nlarged in the last two phases of its develop-
\nment and bearing in mind the increasingly
\nglobalising world, the need for diplomacy,
\nreadiness to appreciate and understand
\nthe contributions, the manner and back-
\nground against which such expressions of
\nopinion are made from other EU coun-
\ntries, has become even more important.
\nUnfortunately there is currently evidence of
\na failure by some NMAs to recognise the
\nimportance of full participation by all the
\nEU national medical associations (includ-
\ning respect for these qualities) by the rep-
\nresentative NMA\u2019s in influencing proposed
\nEU legislation and other actions affecting
\nthe medical profession through the open
\ndialogue and professional positions reached
\nby the CPME. Such attitudes disregard
\nsome of the fundamental aims and objec-
\ntives of the EU set out in its Treaties.
\nDr. Alan Rowe, Co-Editor WMJ
\ne-mail: member@rowe110.fsnet.co.uk
\nEPF was founded in 2003 and has become
\nthe \u2018umbrella\u2019 of patient organisations in
\nEurope. Our foremost aim is to be a united
\nand influential patients\u2019voice in Europe and
\nto promote the patients\u2019 perspective in EU
\nhealthcare debates. We try to reflect the pa-
\ntients\u2019, their carers\u2019 and families\u2019 unique and
\ndirect experience and expertise in healthcare
\nthrough member organisations\u2019 links with
\nrepresentative national, regional and local
\npatient organisations in all 27 EU Member
\nStates. Currently we represent 39 patient
\norganisations, which are chronic disease-
\nspecific patient organisations working at
\nEU level and national platforms of patient
\norganisations.
\nThe European Patients\u2019 Forum focuses on
\ngenuine patient involvement in EU health
\npolicy and projects, as well as exchange of
\ngood practice and peer support among and
\nwithin patient organisations at European
\nlevel. We try to promote a holistic, patient-
\ncentred, non-discriminatory interpretation
\nThe European Patients\u2019 Forum (EPF)
\nNicola Bedlington
\n19
\nRegional and NMA news
\nof healthcare, to include prevention and the
\nsocial, economic, environmental, cultural
\nand psychological aspects of health.
\nOur vision is high quality, patient-centred,
\nequitable healthcare for all patients across
\nthe European Union. Our activities and ac-
\ntions are driven by five fundamental goals:
\nEqual access for all patients to best qual-\u2022
\nity information and healthcare;
\nPatient involvement in health-related\u2022
\npolicymaking and assessments, programs
\nand projects;
\nPatients\u2019perspective to be included in de-\u2022
\ncisions on health economics and health
\nefficacy;
\nSustainable and inclusive patient organi-\u2022
\nsations to effectively represent patients
\nand their interests;
\nPatient unity as part of a patient move-\u2022
\nment at European level.
\nIn the light of these goals,the European Pa-
\ntient Forum produces targeted communica-
\ntion tools, engages in evidence-based sur-
\nveys linked to patient-centred healthcare,
\ndevelops qualitative and credible evidence
\non patients\u2019 experience, participates con-
\nstructively in major external health events
\nand works in cooperation with appropriate
\nresearch networks and other NGOs in the
\nhealth care sector to enhance grass-roots
\nevidence based argumentation for campaign
\nand policy work.
\nWe organise annual regional advocacy
\nseminars in different parts of Europe. Our
\nnext one will take place in Sofia, Bulgaria
\nand will involve 50 patient leaders from that
\nregion. We also hold an annual conference
\nto help to profile our core policy priorities.
\nIn 2007, the EPF Conference focused on
\n\u201cEmpowerment, Information, Sustainabil-
\nity\u201c, and in 2008 on \u201cHealth Literacy\u201d .
\nWe respond on a regular basis to consulta-
\ntions by the European Commission on leg-
\nislative proposals such as the Pharmaceuti-
\ncal package on information to patients, fake
\nmedicines and pharmacovigilance.
\nWe work closely with the European Parlia-
\nment, the European Council, the Member
\nStates and the European Commission to an-
\nchor a patient-centred health care policy in a
\nlong-term European strategy.In this context,
\nwe do not limit our campaign work to EU
\ninstitutions, but also try to build relation-
\nships with other important institutions such
\nas the World Health Organization \u2013 Europe
\nRegion, Council of Europe and the OECD.
\nIn 2008, we launched \u201cThe Patients\u2019 Mani-
\nfesto \u2013 150 million reasons to act\u201d that calls
\nfor vital new measures in three fundamental
\nareas to improve the quality of health care
\ndelivered across the European Union:
\nEqual and timely access to safe, effective\u2022
\ndiagnosis, treatments and support;
\nBetter information and resources allow-\u2022
\ning patients to be partners in determining
\ntheir care;
\nProvision for a patient’s voice to be heard\u2022
\nin Brussels and throughout the European
\nUnion.
\nThe Manifesto is linked to the European
\nCommission\u2019s \u201cEurope for Patients\u201d cam-
\npaign. It has been widely distributed among
\nEPF Member organisations, the European
\ninstitutions, and other relevant stakeholders
\nat both national and European level,and has
\nsucceeded in raising significant interest at
\nnational level. For example, in co-operation
\nwith national parliaments, Poland, Lithu-
\nania and Romania have hosted activities in
\nsupport of this initiative. EPF has also re-
\nceived enquiries from patient organisations
\nin Serbia and Turkey who wish to use the
\nManifesto as a basis for their own advocacy
\nwork at a national level.
\nEPF has actively participated in the Pharma-
\nceutical Forum, a three year process involv-
\ning the European Commission, the Member
\nStates and representatives from other stake-
\nholders to explore the future of pharmaceu-
\nticals and public health in terms of informa-
\ntion to patients, pricing and reimbursement
\nand relative effectiveness. The conclusions
\nand recommendations of the Pharmaceuti-
\ncal Forum received political endorsement
\nduring a high level ministerial meeting in
\nOctober 2008; and EPF co-organised with
\nthe European Commission a Conference in
\nMarch 2009 on using the outcomes of the
\nPharmaceutical Forum effectively.
\nRegarding the directive on cross-border
\nhealthcare that passed its first reading
\nin the European Parliament on 23 April
\n2009, EPF worked with MEPs, Ministers
\nof Health from all EU countries, health
\nattach\u00e9s and permanent representatives,
\nand supported a series of amendments of
\ninterest to patients, including the need for
\nstronger co-operation between Member
\nStates on cross-border healthcare and ex-
\nchange of information and good practices,
\nthe legal anchoring of principles of quality
\nand safety of health care, the introduction
\nof a European Patients\u2019 Ombudsman, the
\nactive involvement of patient organisations,
\npatient involvement in health technology
\nassessment etc. to ensure that the directive
\nbecomes as inclusive and equitable as pos-
\nsible.
\nCurrently, EPF is implementing the project
\nVALUE+ on the meaningful involvement of
\npatients in EU health projects,that is funded
\nunder the Public Health Programme,as well
\nas the project RESPECT, that tries to iden-
\ntify the needs of children and their families
\nin clinical trials and to elaborate methods
\nby which these needs can be translated into
\nempowering and motivating participants in
\nfuture clinical trial research.
\nEPF is growing as a pan-European patient
\nbody that defends the patients\u2019interests and
\nneeds in the European health debates. We
\nwill enlarge our advocacy work and active
\ninvolvement in relevant health projects and
\nfight for patient-centred, equitable health
\ncare throughout the European Union.
\nFor more information on the Euro-
\npean Patients Forum please consult:
\nwww.eu-patient.eu
\n20
\nRegional and NMA news
\nEPF\u2019s Value+ conference on meaningful pa-
\ntient involvement on December 9\u201310, 2009
\nin Gothenburg reported on the outcomes
\nof the two-year Value+ project, co-funded
\nby the European Commission. The Value+
\nproject showed the need for enhanced po-
\nlitical commitment to patient involvement
\nin EU health-related policies and projects at
\nall levels from local to EU level. Meaning-
\nful patient involvement means putting the
\npatient at the centre of healthcare projects.
\nThis results in positive project outcomes
\nwhich in turn contributes to patient-cen-
\ntred equitable healthcare policy-making
\nthroughout the EU.
\nPerhaps more than any other policy area,
\nhealth policymaking has a huge impact on
\nthe lives of individual citizens and patients.
\nPatients and patient organisations should
\nhave a role in those decisions that will af-
\nfect their own lives and the community as a
\nwhole. Patients\u2019knowledge and personal ex-
\nperience bring clarity and a unique insight
\nto policy discussions.
\nPolitical representatives from the Swedish
\nPresidency and Poland, and officials from
\nthe Member States, EU institutions, pa-
\ntient leaders and other stakeholders came
\ntogether at the conference for the unveiling
\nof three project deliverables which include
\nthe Value+ Toolkit to support patient and
\npatient organisations in getting involved
\nin health related projects and policy, the
\nValue+ Handbook aimed at project coor-
\ndinators and leaders to show them how to
\ninvolve patient organisations and work ef-
\nfectively with them. And thirdly, the Policy
\nRecommendations which are the result of
\nthe findings in relation to the assessment of
\npatient involvement in health projects sup-
\nported by the European Commission.
\nPatient organisations support the policy
\nrecommendations aimed at the European
\nCommission, European Parliament, Euro-
\npean Council and Member States. Through
\nthe recommendations,EPF is calling for ac-
\ntion to ensure patient involvement is inte-
\ngrated in the health policy-making process
\nand programmes.
\nA new EU level policy instrument should\u2022
\ninclude a code of best practice and guide-
\nlines to guarantee patient involvement at
\nall levels.
\nEPF believes that financial assistance\u2022
\nshould be required from the EU budget
\nto support patient groups in their partici-
\npation in the political process.
\nThe EU should create a European Centre\u2022
\non Patient Involvement to facilitate the
\ntransfer of best practice to provide infor-
\nmation and capacity building.
\nSpeaking at the conference, G\u00f6ran H\u00e4g-
\nglund, Swedish Minister of Health and
\nSocial Affairs reflected on patient centred
\nequitable healthcare in Sweden and noted
\nsome important measures taking place that
\nreflect increasing patient empowerment
\nand patient involvement. He highlighted
\nshortening waiting times for access to dif-
\nferent treatments, increasing in the number
\nof healthcare providers, patient safety, and
\nthe importance of reaching an agreement
\nregarding patient rights on the cross border
\nhealthcare directive as key priorities.
\nThe European Commission has recognised
\nthe need for patient involvement in health-
\nrelated policymaking in its White Paper
\n\u2018Together for Health: A Strategic Approach
\nfor the EU 2008-2013\u2019 which claims that
\nhealthcare is becoming increasingly patient-
\ncentred. Community health policy needs to
\nbegin with patients\u2019 rights, which include
\nparticipation and influence on decision-
\nmaking. Although there is a growing trend
\nwithin the European Commission towards
\npatient involvement, more needs to be done
\nnot only within the Institutions. Support
\nfrom other stakeholders and patient groups
\nin understanding the role of patients is also
\nneeded.
\nEPF President Anders Olauson stated that
\n\u201cduring recent years, the patients\u2019 voice and
\nviews have been recognised increasingly
\nas not just important, but a core require-
\nment in health policy development. There
\nis however a gap between the recognition
\nthat the patients\u2019 experience and expertise
\nare a crucial part of the quality\/sustainabil-
\nity equation, and how to do this effectively
\nand transparently in policy and in practical
\nterms\u201d.
\nThe conference may have marked the end of
\nEPF\u2019s 2-year EU-funded project on patient
\ninvolvement, but in many ways it marked
\nthe beginning of new networks, new part-
\nnerships and a new way of thinking on pa-
\ntient involvement.
\nFor further information and updates of
\nthe project deliverables, visit the European
\nPatients\u2019 Forum (EPF) website at www.
\neu-patient.eu. EPF is a not-for profit, in-
\ndependent organisation and an umbrella
\nrepresentative body for patients\u2019 organisa-
\ntions throughout Europe. Representing the
\nEU patient community we advocate for pa-
\ntient-centred equitable healthcare and the
\naccessibility and quality of that healthcare
\nin Europe.
\nNicola Bedlington, EPF\u2019s Executive Director
\nEPF value+ conference confirms
\nthe importance of patient
\ninvolvement in EU health-
\nrelated policies and programmes
\nG\u00f6ran H\u00e4gglund, Swedish Minister
\nof Health and Social Affairs and EPF
\nPresident Anders Olauson
\n21
\nRegional and NMA news
\nIsabel Caixeiro
\nThe European Union of General Practitio-
\nners\/Family Physicians (UEMO) represents
\nthe European General Practitioners and
\nSpecialists in Family Medicine in Europe.
\nCreated in 1967, our members are the in-
\ndependent and most representative national
\norganizations representing General Practi-
\ntioners\/Family Physicians in the European
\ncountries. At present, the following coun-
\ntries are represented at the UEMO:
\nAustria Iceland Slovakia
\nBelgium Ireland Slovenia
\nBulgaria Italy Spain
\nCroatia Lithuania Sweden
\nCzech
\nRepublic
\nLuxembourg Switzerland
\nDenmark Malta Turkey
\nFinland
\nThe
\nNetherlands
\nUnited
\nKingdom
\nGermany Norway
\nHungary Portugal
\nThe UEMO\u2019s core mission is to study and
\npromote the highest standards of training,
\npractice and patient care within the field
\nof general practice\/family medicine and to
\ndefend the role of general practitioners\/
\nfamily physicians in the healthcare systems.
\nUEMO advocates for the ethical, scientific,
\nprofessional, social and economic interests
\nof European GP\/FPs and protects their
\nfreedom of practice, all in the interest of
\ntheir patients.
\nUEMO stands for the united views of its
\nmembers and represents them through the
\nappropriate channels before the relevant
\nEuropean authorities and international or-
\nganisations. In this context, UEMO seeks
\nto work closely with other European medi-
\ncal organizations (CPME, UEMS, FEMS,
\nPWG) and WHO-Europe.
\nIn the period 2007-2010,Portugal is respon-
\nsible for the presidency of UEMO, with the
\ninvolvement of the UEMO steering team:Is-
\nabel Caixeiro (President), Lu\u00eds Filipe Gomes
\n(Secretary General) and Manuela Santos
\n(Treasurer). The Board is also composed of
\nVice-Presidents Henry Finnegan (Ireland),
\nEirik B\u00f8 Larsen (Norway), Ferenc Hajnal
\n(Hungary) and Francisco Toquero (Spain).
\nThe current presidency has set ambitious
\ngoals for this four-year mandate. Hence,
\ndefinition of priorities, strategies and main
\nactions are being actively defined and pur-
\nsued with the involvement of all UEMO
\nmembers.
\nThe Portuguese Presidency highlighted as
\npriorities for UEMO:
\nRecognition of the General Practice\/\u2022
\nFamily Medicine as a specialty with the
\ndevelopment of specialist postgradu-
\nate training curriculum in all European
\nUnion countries, and update of Directive
\n2005\/36\/EC, of 7 September 2005 on
\nprofessional qualifications;
\nFull development and implementation\u00a0\u2013\u2022
\nin accurate technical terms (job\/tasks
\ndescription) \u2013 of the core content for the
\nEuropean General Practitioner\/Family
\nPhysician and its implications at ethical,
\norganisational, training, quality assurance
\nand appropriate technology levels;
\nDevelopment of the status of General\u2022
\nPractice in Europe, at all levels;
\nPromotion of General Practice\/Family\u2022
\nMedicine in the undergraduate medical
\ncurriculum;
\nInternational co-operation within Gen-\u2022
\neral Practice\/Family Medicine organisa-
\ntions and with other medical organisa-
\ntions in Europe
\nUEMO\u2019s activities and main areas of in-
\ntervention are:
\nThe value of highly qualified General Practi-
\ntioners\/Family Physicians
\nThere are many opportunities for General
\nPractitioners\/Family opportunities to de-
\nvelop their professional role and ensure that
\ntheir full potential is realized. They are in-
\ncreasingly involved in promoting the best use
\nof health systems resources and continuity of
\ncare for the benefit of patients.Ideally,every-
\none should have the possibility to choose a
\npersonal Family Physician and to maintain
\na solid relationship with that practitioner for
\nas long as they wish. The Family Physician is
\nthe critical first contact for most health prob-
\nlems as well as for continuing care.
\nUEMO \u2013 A common European voice for
\nGeneral Practicioners\/Family Physicians
\nThe Presidency team of the UEMO:
\nAt the centre, Dr. Isabel Caixeiro, President.
\nTo her right side, Dr. Luis Filipe Gomes, Sec-
\nretary-General and to her right Dr.\u00a0Manuela
\nSantos, Treasurer.
\n22
\nRegional and NMA news
\nAt the same time, there are many compel-
\nling reasons to promote wide dialogue be-
\ntween General Practitioners\/Family Phy-
\nsicians and other specialists, fostering the
\nperformance of complementary roles,which
\nis essential for the interests of patients.
\nBecause General Practitioners\/Family Phy-
\nsicians cover a wide range of tasks within
\nthe framework of healthcare systems, con-
\ncerns may arise related to how to address
\nthe quality and status of general practice in
\nthe different countries.
\nA glance to the recent history of General
\nPractice\/Family Medicine clearly demon-
\nstrates that this activity is gradually becom-
\ning one of the more complex areas in the
\nmedical practice. The risk of falling into
\nlower practice standards must be mitigated.
\nGeneral Practitioners\/Family Physicians
\nmust deal effectively with undifferentiated
\nproblems, co-morbidity, polipharmacy, so-
\nphisticated biomedical and psycho-social
\nphenomena, and psychosomatic problems.
\nThey must also be attentive to opportunities
\nfor preventive interventions, health promo-
\ntion and health education.
\nThis broad professional role requires high-
\nlevel training programmes, continuing edu-
\ncation and quality assurance activities, simi-
\nlar to those associated with other medical
\nspeciality training \u2013 an issue that is crucial
\nfor health systems\u2019response and sustainabil-
\nity across Europe.
\nIn some European countries, the recogni-
\ntion of General Practice\/Family Medicine
\nas a medical speciality remains an ongoing
\ndebate, involving medical organisations,
\ngovernments and academic bodies. Nev-
\nertheless, there is a consistent movement
\ntowards the specialization of General Prac-
\ntitioners\/Family Physicians, which is a new
\nlandmark in health systems\u2019 organization
\nand will contribute new approaches to pri-
\nmary care settings. A recent survey carried
\nout of UEMO members reports as follows:
\nCountry
\nNational recognition
\nof GP\/FM as speciality
\nAustria NO
\nBelgium NO
\nBulgaria NO
\nCroatia YES
\nCzech Republic YES
\nFrance YES
\nDenmark YES
\nFinland YES
\nGermany YES
\nHungary YES
\nIceland YES
\nIreland YES
\nItaly NO
\nLuxembourg NO
\nMalta YES
\nThe Netherlands YES
\nNorway YES
\nPoland YES
\nPortugal YES
\nSlovakia YES
\nSlovenia YES
\nSpain YES
\nSweden YES
\nSwitzerland YES
\nTurkey YES
\nUnited Kingdom YES
\nUEMO has actively promoted a number
\nof activities aiming to encourage the GP\/
\nFM specialty to be acknowledged as a peer
\nof the other medical specialties at EU level,
\nnamely in common provisions of the Direc-
\ntive 2005\/36\/EC, dated as of September
\n7, 2005 on the recognition of professional
\nqualifications. UEMO also supports na-
\ntional efforts in those countries seeking to
\ndevelop GM\/FM specialty.
\nMobility of health care professionals and patients
\nThe European health systems face a set of
\nnew challenges resulting from the abolition
\nof borders across the European territory,
\nglobalisation, and migration of populations
\nlooking to raise their socio-economical sta-
\ntus. Well-prepared General Practitioners\/
\nFamily Physicians have a major role to per-
\nform in this new era, in which primary care
\nmust be the anchor of affordable and sus-
\ntainable health care systems.
\nFreemovementofdoctorsandofotherhealth
\ncare professionals due to mutual recognition
\nof diplomas, in particular within the EU, still
\nraises some questions associated with qual-
\nity, professional liability, and transparency of
\nqualifications. Regardless of the significant
\nmoves forward, countries and authorities
\nhave yet to effectively reinforce mutual co-
\noperation in a way that best safeguards the
\npublic interest, establishes efficient and suit-
\nably dimensioned health care services, and
\nensures patient safety. The global shortage
\nof health professionals cannot be solved by
\nencouraging mobility, which will only lead
\nto brain drain in the less developed countries
\nthough massive migration of their much
\nneeded medical workforce.
\nAt the Primary Care level, health systems
\nstill need to work on their mutual coopera-
\ntion to promote a comprehensive and ra-
\ntional approach on mobility. As mentioned
\nabove, the recognition of the specialty of
\nGeneral Practice\/Family Medicine by the
\nEuropean legal framework is fundamental
\nto promote actual mobility of General Prac-
\ntitioners\/Family Physicians. Without that
\nprovision, GP\/FPs\u2019mobility will be reduced
\nand based on lower qualification require-
\nments.
\nPatients\u2019 interests must also be assured by
\nmeans of clear and accountable measures
\nthat on one hand allow patient mobility
\nacross borders as an option for the patient,
\nbut which on the other hand do not force
\nhim to seek health care in another country.
\nThere may be good and various reasons to
\nseek health care in another country, but pa-
\ntients should be able to find continuity of
\ncare in or close to his or her community.
\n23
\nRegional and NMA news
\nEmpowerment and autonomy of citizens con-
\ncerning personal and collective health matters
\nPromotion of patients\u2019 rights in Europe is a
\nstrong social and political issue. Patients are
\nalso being asked to take more responsibil-
\nity for their own health. This requires more
\neducation and information, and efforts to
\nprotect patients from an uncontrolled self-
\nmedication market and the risk of polip-
\nharmacy.The empowerment of patients can
\nonly be effective if it is grounded in a solid
\ndoctor-patient relationship in a system ca-
\npable of providing personalised, affordable
\nand qualified health care.
\nThese are clearly subjects already ap-
\nproached by the UEMO and that require
\ncontinuous attention in the near future. As
\na partner of European Institutions in health
\nfields, UEMO will monitor and advise on
\nall issues related to primary care impacts
\nand enhanced health care provided by Gen-
\neral Practitioners\/Family Physicians, in the
\ninterest of patients and for the purpose of
\nhealth interventions towards health gains.
\nIncreasing demand for cost-effectiveness and
\nquality, grounded in universal access to health
\ncare
\nThere is currently some tension around the
\n\u201cgate-keeper\u201d concept that exists in some
\nEuropean countries,as a result of very differ-
\nent medical cultures that vary from country
\nto country. Because the tradition of free ac-
\ncess to any specialised care has been a reality
\nfor many years, concern has been expressed
\nthat General Practitioners\/Family Physicians
\ncould be advocating misuse and promoting
\nlimited access to other medical specialized
\ncare merely for cost-containment reasons.
\nHowever, the increasing labyrinth of medi-
\ncal technology available to the population
\nand its significant impact at social and eco-
\nnomical levels demand that General Practi-
\ntioners\/Family Physicians support and guide
\npatients through a range of complex options.
\nThe success of health systems in these top-
\nics should be promoted through informa-
\ntion and education, rather than by coercion
\nor prohibition. Facilitator mechanisms can
\nbe more helpful to meet the demand of uni-
\nversal access to quality and cost-effective care
\nthan administrative restrictions.
\nFunding models and specific interests of the
\nvarious health care players have established
\ndistinct organisational lay-outs in which
\ncompetition inhibits cooperation. Never-
\nending debates will continue around major
\nthemes like sustainability, funding, qual-
\nity, and health provision. However an effort
\nshould be made to find innovative solutions
\nemphasising co-operation over competition.
\nConsidering this scenario,General Practitio-
\nners\/Family Physicians are clearly indispens-
\nable to achieving cost-effectiveness in health
\ncare and to co-operating and coordinating
\nefforts in the best interest of patients.
\nInformation & communication technologies in
\nhealthcare
\nThe widespread integration of information
\ntechnologies into daily health care environ-
\nment raises a broad range of expectations,
\nnevertheless one should be aware that, while
\nthey may solve some health problems, they
\nmay magnify others, and that they may
\ncause added strain to health systems, profes-
\nsionals and patients. Recently implemented
\nfeatures such as electronic health records,
\ntelemedicine and remote medicine, expert
\nsystems, smart cards and data protection are
\nundoubtedly influencing and shaping the
\nfuture of General Practice\/Family Medicine.
\nEuropean countries have been trying to deal
\nwith this unceasing influx of technologies
\nby developing a number of national projects
\nalongwithglobalEuropeanprojects.UEMO
\nhas a clear vision of this emerging field and
\nconsiders the appropriate use of technology
\nas an improvement. It is clearly a valuable
\ntool in facilitating primary care investigation
\nfaster when needed and improving com-
\nmunication between primary and second-
\nary care levels, though major aspects such as
\ndata protection and confidentiality of health
\nrecords must be carefully considered.
\nThe future role & strategy of the UEMO
\nAs the main representative of General
\nPractitioners\/Family Physicians in Europe,
\nUEMO continues to establish itself as a
\ncritical link to the EU health institutions,
\nthe European Parliament and the European
\nCommission. UEMO is already fully incor-
\nporated as a non-profit organisation under
\nthe Belgian law, which will significantly re-
\ninforce the voice of General Practitioners\/
\nFamily Physicians at the EU level.
\nThe UEMO seeks to represent all European
\nGeneral Practitioners\/Family Physicians
\nand is therefore actively looking for new
\nmembers coming from as yet unrepresented
\ncountries. Wider representation allows the
\norganisation to circulate its input more ac-
\ntively from the practice level in GP\/FM to
\nthe policy and steering level. UEMO also
\nunderstands that closer cooperation with
\nother European Health Organisations as
\nwell as with global health entities such as
\nthe World Medical Association and the
\nWorld Health Organisation is fundamental
\nto the common development of a clear pri-
\nmary care agenda at EU level.
\nThat is the reason why the UEMO has
\nbeen seeking to improve coordination with
\nWONCA and EURACT \u2013 as a first step,
\nworking together with these entities will
\ninfluence positively the qualification of cur-
\nrent and future General Practitioners\/Fam-
\nily Physicians, in the area of more appro-
\npriate and evidence-based interventions in
\nhealth care and patient interest.
\nUEMO is also involved in fostering recruit-
\ning strategies and policies for new GP\/FPs
\nand has therefore engaged in strengthening
\nbonds with the Vasco da Gama Movement
\nthat emerged from coordinated efforts of
\nWONCA-Europe and EURACT to dis-
\nseminate, promote, and develop the GP\/
\nFM specialty in Europe.
\nAs a representative medical organisation,
\nUEMO maintains and promotes united
\n24
\nRegional and NMA news
\nviews amongst medical organizations and
\nregularly meets and debates common posi-
\ntions with CPME, UEMS, FEMS, EANA,
\nCEOM, AEMH and PWG. A strong,
\ncoherent and active position of all doctors
\nis a paramount to reinforcing trust of the
\nEuropean health systems and the provided
\nhealth care services among patients and
\nother health stakeholders.
\nAfter 40 years of continued activity pro-
\nmoting primary care and General Practi-
\ntioners\/Family Physicians medical practice,
\nUEMO\u2019s Portuguese Presidency is currently
\nengaged in further developing this mission.
\nEach and every one of the UEMO activities
\nis a solid contribution to the overall goal of
\n\u201cserving the interests of patients\u201d, which is
\nnot only the mandatory requirement for all
\nmedical interventions, but should also be the
\ndriving force behind the policy and political
\nactivities of the medical profession. General
\nPractitioners\/Family Physicians, like Prima-
\nry Care itself,are committed to ensuring that
\nhealth care activities are driven by the needs
\nof citizens and further the objectives of dis-
\nease prevention and health promotion.
\nWe work today to prepare the future.
\nDr. Isabel Caixeiro, President
\nJ. James Rohack
\nFrom the influenza pandemic and Fort
\nHood shootings to the unforgettable trag-
\nedies of Sept. 11 and Hurricane Katrina,
\nour country has endured a number of cata-
\nstrophic events and public health emergen-
\ncies in recent years.The good news is that as
\nthese events continue to surface, physicians
\nand communities nationwide have contin-
\nued their preparation for effective response.
\nIn conjunction with the Health and Human
\nServices Public Health Emergency Medical
\nCountermeasures Enterprise Stakeholders
\nWorkshop, the AMA recently hosted the
\nThird National Congress on Health Sys-
\ntem Readiness. Physicians and other stake-
\nholders in medicine, as well as government
\nand community leaders, joined the nation\u2019s
\nleading public health preparedness experts
\nin Washington, D.C., to review current re-
\nsearch and science related to recent disasters
\nand public health emergencies worldwide,
\nand to establish a framework for response.
\nAnd they discussed how to manage and re-
\nspond to a real, yet unpredictable crisis we
\nnow face \u2013 the 2009 H1N1 influenza pan-
\ndemic.
\nThe pandemic has received global attention
\never since the virus emerged in April 2009.
\nThe AMA\u2019s Disaster Medicine and Public
\nHealth Preparedness journal just published
\na special issue about the pandemic, includ-
\ning articles on point-of-care testing and
\nbiothreats, pediatric considerations in ex-
\ntending and rationing care in public health
\nemergencies, and operational consider-
\nations in mass prophylaxis work force plan-
\nning. And the AMA\u2019s Pandemic Influenza:
\nA primer and resource guide for physicians
\nand other health professionals provides in-
\nsightful recommendations on preparedness
\nand response to an influenza pandemic.
\nIn light of recent events, a group of phy-
\nsicians agreed during the AMA\u2019s disaster
\nmedicine caucus at the Interim Meeting
\nof the AMA House of Delegates in Hous-
\nton that all health professionals and local
\ncommunities need the proper training and
\nresources to know what to do in these situ-
\nations. Fortunately, the right tools and edu-
\ncation are already under way.
\nThe AMA, in cooperation with four major
\nmedical centers,established the National Di-
\nsaster Life Support\u2122 (NDLS\u2122) Program
\nin 2003 to standardize emergency response
\ntraining and strengthen our nation\u2019s public
\nhealthsystem.Summoningmorethan75,000
\nparticipants, the program has 70 training
\ncenters throughout the United States that
\noffer the NDLS\u2122 Program courses.
\nOne component of this program, the Ad-
\nvanced Disaster Life Support\u2122 (ADLS\u00ae)
\nCourse, has been revised to include train-
\ning in mass triage, hospital response and
\nplanning, surge capacity, and skills stations
\nand clinical scenarios, and is expected to be
\navailable to the public in June.
\nFor individual citizens, the CitizenReady\u2122
\nprogram, developed collaboratively by the
\nAMA, the Federal Emergency Manage-
\nment Agency and the National Disaster
\nLife Support Foundation, Inc., is being pi-
\nloted in cities and towns across the country
\nvia an initial program that focuses on the
\ninfluenza pandemic.
\nAs we\u2019ve seen from experience, disaster can
\nstrike at any time \u2013 and without notice.The
\nbest way to ensure that our patients, homes
\nand communities are safer is preparation.
\nHave a plan. Practice it. And be ready.
\nJ. James Rohack, MD, President of the AMA
\nThis column originally appeared in
\nthe\u00a0Dec. 4\u00a0edition of AMA eVoice.
\nGearing up for emergencies \u2013 a vital
\ncomponent to our nation\u2019s health
\n25
\nRegional and NMA news
\nThe 26th
\nConfederation of Medical Asso-
\nciations in Asia and Oceania (CMAAO)
\nCongress and 45th
\nCouncil Meeting was
\nheld in Bali, Indonesia, from November 5th
\nto 7th
\n, 2009. The Congress was attended by
\n50 representatives from 12 NMAs (Japan,
\nHong Kong, India, Indonesia, Republic of
\nKorea, Malaysia, Myanmar, New Zealand,
\nPhilippines, Singapore, Taiwan, and Thai-
\nland). The Council Meeting took place on
\nthe 5th
\nand the Congress Grand Opening
\nCeremony and Assembly Meeting were
\nheld on the 6th
\n,with the meeting continuing
\non the 7th
\n, followed by the symposium.
\nOne of the main events of the Congress
\nwas the passing of the Presidential Medal
\nfrom Immediate Past-President Dr. Somsri
\nPausawasdi of the Medical Association of
\nThailand to the President-Elect,Dr.Fachmi
\nIrish of the Indonesian Medical Associa-
\ntion, during the Grand Opening Ceremony
\non the 6th
\n.Following that,the 9th
\nTaro Take-
\nmi Memorial Oration was presented. This
\nis an oration event commemorating Dr.
\nTaro Takemi, a Japanese doctor who served
\nas president of JMA for 25 years and con-
\ntributed to the establishment of CMAAO.
\nDr. Azrul Azwar, Professor at University of
\nIndonesia, CMAAO Past-President, and
\nWMA Past-President spoke on \u201cThe Role
\nof Primary Physician in Achieving the Mil-
\nlennium Development Goals (MDGs)\u201d.
\nAt the Council Meeting, I presented a
\nreport, as Secretary General, of the main
\nCMAAO activities for the past years. In
\nthe report I spoke about the discussion
\nfocused on the topic of the economic cri-
\nsis and healthcare, which was the theme of
\nthe symposium during the Congress. I also
\ntouched upon the topics of task-shifting
\nand prescription rights, which are also be-
\ncoming issues for the WMA, and the anti-
\nsmoking issue, which is an issue common to
\nall countries. Representatives of the NMAs
\nalso delivered a Country Report of their
\nNMA\u2019s activities for the past year.
\nThe application of the Myanmar Medical
\nAssociation for CMAAO membership was
\napproved, bringing CMAAO membership
\nto 18 NMAs.
\nThe main agenda for the Congress also
\nincluded some organizational issues, such
\nas consideration of how and when future
\nCongresses and Mid-term Council meet-
\nings should be held and how executive
\nboard members should be selected with a
\nview to strengthening CMAAO\u2019s organi-
\nzational structure. Since these reforms in-
\nvolve matters requiring broad changes to
\nthe CMAAO Constitution & By-laws for
\noperation, it was decided that the Constitu-
\ntion & By-laws Committee would take the
\ncentral role in preparing a draft proposal,
\nand that revision would be carried out at
\nfuture CMAAO meetings.
\nWith regard to the main items currently
\nbeing considered by CMAAO, it was de-
\ncided to divide the responsibility of pre-
\nparing proposed statements on important
\ntopics among NMAs. In particular, it was
\nagreed to make the anti-smoking problem,
\nwhich is common to all member NMAs, a
\npermanent theme and continue discussions
\nat future meetings. Moreover, to facilitate
\nmore efficient utilization of the CMAAO
\nwebsite, a decision was made that all mem-
\nber NMAs should prepare reports of their
\nactivities and proactively send them to the
\nSecretariat at the Japan Medical Associa-
\ntion.
\nWith respect to future meetings, the 46th
\nCMAAO Mid-term Council Meeting will
\nbe held Kuala Lumpur, Malaysia, in 2010
\nand the 27th
\nCMAAO Congress will be
\nheld in Taipei (Taiwan) in 2011.
\nA symposium entitled \u201cImpact of the Fi-
\nnancial Crisis on the Health System\u201d was
\nalso held, with presentations by representa-
\ntives of nine NMAs.
\nIn addition, elections were held for Office
\nBearers for 2009-2011, the results of which
\nare shown below.
\nMasami Ishii, MD
\nSecretary General of CMAAO
\nVice-chair of WMA
\nReport of the 26th
\nCMAAO Bali Congress
\nNote by the Secretary General
\nCMAAO Office Bearers for 2009\u20132011
\nPresident Fachmi Idris Indonesia
\nPresident-Elect Ming-Been Lee Taiwan
\nImmediate Past-President Somsri Pausawasdi Thailand
\n1st Vice President David Kwang-Leng Quek Malaysia
\n2nd Vice President Dong Chun Shin Korea
\nChairman Wonchat Subhachaturas Thailand
\nVice-Chairman Peter Foley New Zealand
\nTreasurer Yee Shing Chan Hong Kong
\nSecretary General Masami Ishii Japan
\nAssistant Secretary General Hisashi Tsuruoka Japan
\nAdviser Tai Joon Moon
\nYung Tung Wu
\nKorea
\nTaiwan
\n26
\nRegional and NMA news
\nIntroduction
\nThe official English-language Journal of the
\nJapan Medical Association, JMAJ was first
\npublished in 1958 as Asian Medical Jour-
\nnal (AMJ) to advance medical science and
\nhealthcare in Asia and to strengthen the in-
\nfluence from abroad on Japan\u2019s health poli-
\ncies by introducing JMA\u2019s policies. At that
\ntime, JMA had a strong leader, Dr. Taro
\nTakemi, who served as the JMA president
\nfor an exceptionally long period of 25 years
\n(1957-1982).He was actively engaged in in-
\nternational affairs, held the WMA General
\nAssembly Tokyo in 1975 and became the
\n29th
\nWMA president. Under his leadership,
\nthe foundation of international activities of
\nthe JMA was built including participation
\nin the World Medical Association (WMA,
\n1951), creation of Confederation of Medi-
\ncal Associations of Asia and Oceania
\n(CMAAO, 1956), and the establishment
\nof Takemi International Health Program in
\nHarvard School of Public Health (HSPH,
\n1983)\u00a0[1].
\nThe JMA publishes another journal in Japa-
\nnese, the Journal of the JMA. The Japanese
\njournal has a peer review system for original
\ncontributions while JMAJ currently does
\nnot. Both journals mainly publish invited
\nreview articles, but the readership of the
\nJapanese journal is mainly JMA members
\nwhile JMAJ is published for global readers,
\nmostly outside of Japan.
\nScientific journals on general medicine
\npublished in Japan are not so highly eval-
\nuated internationally. Some people argue
\nthat the JMA should publish a medical
\njournal that would be internationally rec-
\nognized.Therefore, we decided to conduct
\na survey questionnaire on periodicals pub-
\nlished by National Medical Associations,
\nin collaboration with the Takemi Program
\nin HSPH, to clarify what periodicals
\nNMAs publish, with a focus on explor-
\ning unique approaches and effective ways
\nto transmit useful health information to
\nglobal readers.
\nSummary of the Survey
\non NMA Journals
\nThis section presents some results related to
\nthe NMA characteristics and their journals
\non general medicine.The full report is avail-
\nable in the JMAJ 2009;52(4) [2].
\nIn October 2008 we emailed a question-
\nnaire to all 92 NMAs in the WMA and
\nCMAAO, and received responses from 31
\n(34%).
\nTable 1 provides the numbers of NMA
\nmembers and staff. Membership ranged
\nfrom the smallest, Luxembourg (1,150) to
\nthe largest, Germany (395,000). Of the 29
\nNMAs that reported their type of member-
\nship, 86% (25) responded that it was vol-
\nuntary.The US had the largest staff (1,000),
\nfar more than that of the runner-up, the
\nUK (450) and other NMAs. Staff density is
\nthe number of staff per thousand physician
\nmembers.
\nApproximately 71% of the journals (20\/28)
\nhad five staff members or fewer. The jour-
\nnals with the largest staffs were JAMA (100,
\nUS),BMJ (40,UK) and CMAJ (32,Canada)
\n[2], followed by India and Norway (20) and
\nthe Netherlands (15).
\nSources of published articles in NMA jour-
\nnals are shown in Table 2. Overall, the ma-
\njority of published articles were contributed
\nby \u201coutside authors\u201d or general manuscript
\nsubmissions from authors who did not work
\nfor the journal. Among the 29 journals that
\nreported the peer review percentage, 66%
\n(19) peer reviewed more than 90% of their
\narticles [2].
\nThe official languages of the WMA are
\nEnglish, Spanish and French (the official
\nlanguage of the CMAAO is English).In all,
\n69 NMAs (75%) used English as their of-
\nficial language, followed by Spanish (16\/92,
\n17%) and French (7\/92, 8%). Approximate-
\nly 71% (22\/31) of journals were published
\neither partly or fully in English [2].
\nAmong the 26 journals that reported online
\navailability, full text was available for free in
\n73% (19) (Figure 1). In the case of JMA,
\nthe English journal is freely available, but
\nthe Japanese journal is open to its members
\nonly.
\nWhat can medical journals
\ndo for global health?
\nMieko HamamotoMasami Ishii
\n27
\nRegional and NMA news
\nThus, we have found that the numbers of
\npeople and participation rates of NMAs
\nvaried widely, but approximately 70% of
\nthe NMA journals had five or fewer staff
\npersonnel, used English at least partly, and
\nwere freely available online. According to
\nthe self-reported classification, 16 journals
\nwere defined as journals published mainly
\nfor domestic readers and 15 journals were
\nfor global readers [2]. Of the 26 NMAs,
\nonly 4 NMAs, including Japan, published
\ntwo or more general medical journals both
\nin their native language and English [2].
\nThe survey did not capture the complete
\nglobal picture on NMAs and their periodi-
\ncals, with only 2 responses out of 16 NMAs
\nin Latin America, none from Africa (12),
\nand missing data on each question. Never-
\ntheless, it has strength as the first interna-
\ntional comparative survey of this sort,which
\ncollected a wide range of data, with friendly
\ncooperation of WMA and CMAAO \u2013 the
\ntwo international organizations represent-
\ning physicians.
\nFactors for Success
\nWhat is success for journals published by
\nmedical associations, and how do we mea-
\nsure it? As Sir William Osler once said,
\n\u201cthe practice of medicine is an art, based on
\nscience\u201d[3]. Here we review two journals
\nfrom the concepts, science and art.
\nNew England Journal of Medicine
\nThe NEJM is one of the most successful
\nscientific journals on general medicine, with
\nthe oldest history since 1812 and the high-
\nest impact factor (52.589 in 2007) [4]. The
\npublisher, the Massachusetts Medical So-
\nciety, has 21,291 members as of 2008 and
\nover 400 staff members [5], with high staff
\ndensity of 18.79.
\nThe secret of the journal\u2019s success is acci-
\ndental \u2013 Mr. Stephen Morrissey, Manag-
\ning Editor of the NEJM responded, after
\na little pause, in the interview conducted
\nby Hamamoto in May 2009. He also char-
\nacterized the journal by its operation with
\nalmost all sections in-house except print-
\ning, and especially emphasized the graphic
\nsection producing superb illustrations. Un-
\nlike typical commercial publishers, they are
\nbasically citable for free, creating a virtuous
\ncircle where citations breed citations.
\nTable 2. Sources of Published Articles (n=29)
\nArea* Journal**
\nOutside
\nAuthors
\nEdi-
\ntors
\nInvited
\nArticles
\nPacific G 98% 0% 2%
\nPacific G 90% 5% 5%
\nPacific G 90% 2% 8%
\nAsia G 90% 0% 10%
\nEuro D 90% 5% 20%
\nAsia G 90% 5% 5%
\nAsia G 90% 5% 5%
\nLatin Am D 85% 10% 5%
\nEuro D 80% 20% 0%
\nEuro G 70% 15% 15%
\nEuro D 70% 20% 5%
\nEuro D 70% 15% 15%
\nEuro D 68% 0% 6%
\nAsia G 65% 0% 35%
\nAsia D 50% 40% 10%
\nNorth Am G 33% 33% 33%
\nEuro D 30% 20% 40%
\nPacific D 30% 50% 20%
\nEuro G 5% 90% 0%
\nPacific D 5% 0% 95%
\nPacific
\n(J of the JMA)
\nD 3% 0% 97%
\nPacific D 0% 50% 50%
\nPacific
\n(JMAJ)
\nG 0% 0% 100%
\nEuro G yes yes yes
\nAsia G yes yes yes
\nEuro G yes yes yes
\nNorth Am G yes yes no
\nAsia D yes yes yes
\nEuro D yes yes yes
\nMean 57% 17% 25%
\nMedian 70% 5% 10%
\n* Journal names have been kept anonymous except Japan.
\n** G stands for global journal and D for domestic journal,
\nbased on the NMA\u2019s definition.
\nTable 1. Numbers of NMA Members and Staff
\nNo. of Members Participation Rate
\n(%)
\nNo. of Staff Staff Density
\nAustralia 26,000 (50) 42 1.62
\nAzerbaijan 1,480 (5) 8 5.41
\nBangladesh 35,000 (80) 120 3.43
\nBelgium – (25) 10 –
\nBrazil 120,000 (36) 45 0.38
\nCanada 69,000 (70) 170 2.46
\nCzech Republic – – 23 –
\nGermany 395,200 (100) 100 0.25
\nHong Kong 7,557 (70) 25 3.31
\nHungary 30,000 (95) 11 0.37
\nIceland 1,254 (99) 5 3.99
\nIndia 175,000 (27) 85 0.49
\nIsrael 18,000 (94) 70 3.89
\nJapan 165,086 (60) 189 1.14
\nKorea 75,476 (80) 137 1.82
\nLuxembourg 1,150 (73) 3 2.61
\nMacedonia 4,500 (75) 3 0.67
\nMalaysia 7,897 (36) 22 2.79
\nNetherlands 38,906 (58) 137 3.52
\nNew Zealand 4,000 (40) 10 2.50
\nNorway 22,055 (97) 120 5.44
\nPhilippines 28,000 (50) 22 0.79
\nSpain 206,000 (96) 25 0.12
\nSri Lanka* 3,000 (20) 10 3.33
\nSwitzerland 33,655 (98) 71 2.11
\nTaiwan 37,518 (100) 32 0.85
\nUnited Kingdom 138,000 (64) 450 3.26
\nUnited States 231,000 (33) 1,000 4.33
\nUruguay 8,500 (60) 26 3.06
\nNo. of responses n=27 n=28 n=29 n=27
\nMean 69,749 (64) 102 2.37
\nMedian 30,000 (67) 32 2.5
\n* Sri Lanka is a member of CMAAO only.
\n28
\nRegional and NMA news
\nBut the journal obviously has a geographical
\nadvantage; in addition to an editorial board
\nconsisting of international members, it has
\neditors, most of whom are practicing in
\nhospitals in the Boston area or teaching in
\nHarvard and other schools. They attend the
\neditorial meeting every Thursday afternoon.
\nHowever common online communications
\nhave become, it is a great advantage to have
\neditors and staff within a short distance that
\nenables them to meet face to face easily. Its
\nlongstanding success must be an accident
\ncaused by that certain environment in Bos-
\nton, USA.
\nWorld Medical Journal
\nThe WMJ must have gone through vari-
\nous transitions since the first publication
\nin 1949 [6]; a discussion as to the title of
\nWMA\u2019s official publication [7] and a pro-
\nposal to transform the WMJ into an inter-
\nnational peer-reviewed journal [8] in 2006
\nare still fresh in our minds.
\nDr.P\u0113teris Apinis,the new Editor-in-Chief
\nsince 2008, President of the Latvian Phy-
\nsicians Association and the former Health
\nMinister of Latvia, reported that the WMJ
\naims to become a powerful information
\nspreader of world medicine, with three key-
\nwords: informative, interdisciplinary \u00a0 and
\nactual [9]. He actively asks colleagues for
\ncontribution of manuscripts, and was wit-
\nnessed walking around the rooms with a
\ncamera in his hands to patiently excavate
\nthe faces of participants and information
\nfrom all parts of the world in the WMA
\nmeetings.
\nThe WMA General Assembly New Delhi
\n2009 adopted WMA Declaration of Delhi
\non Health and Climate Change,and elected
\nDr. Ketan Desai from India as President of
\nthe WMA for 2010-11. Many participants
\nmust have felt a growing interest in social
\nmedical issues, and the power of India, a
\nrising nation with more than one billion
\npeople.
\nFor the WMJ to achieve its goal, scientific
\nevaluation is hard to make, and whether
\nthe title should be journal or bulletin is not
\nimportant. It will have a significance and
\noriginality in the art of medicine including
\nhuman nature, by covering WMA\u2019s reality
\nand voices of physicians across the globe.
\nConcluding remarks
\nMedical journals have various directions to
\nhead, and we often know little about what
\nis necessary to go in that direction. It is not
\neasy to make the journal sustainable and of
\nthe highest quality because our resources are
\nlimited. NEJM represents an ideal form of
\nscientific journals, and WMJ has strength
\nin human network spreading around the
\nglobe. JMAJ will maintain the current poli-
\ncy, closely associated with WMJ. We believe
\nthat NMAs can turn information accumu-
\nlated in each country into a shared asset of
\nthe world through more vocal, online and
\noff-line communication.
\nAcknowledgments
\nWe would like to express our sincere ap-
\npreciation to all the NMAs, Otmar Kloiber
\nand Sunny Park for their cooperation to the
\nsurvey.We would also like to thank Michael
\nR. Reich and Hisashi Tsuruoka for their
\nvaluable comments.
\nReferences
\n1. \u0007Takemi Program in International Health. http:\/\/
\nwww.hsph.harvard.edu\/research\/takemi\/\u00a0(accessed
\nDec 2009).
\n2. \u0007Hamamoto M, Jimba M, Halstead D, et al. Can Na-
\ntional Medical Association Journals Make Greater
\nContributions to Global Health? An international
\nsurvey and comparison. JMAJ.2009;52(4): 243\u2013258.
\n3.\u0007Osler W.Aequanimitas with other addresses to medi-
\ncal students, nurses and practitioners of medicine.
\nPhiladelphia: P. Blakiston\u2019s Son & Co; 1905:36.
\n4. \u0007Journal Citation Reports. ISI Web of Knowledge
\n(JCR Science Edition 2007. Subject category: Medi-
\ncine, General & Internal). Thomson Reuters.
\n5. \u0007AbouttheMassachusettsMedicalSociety.http:\/\/www.
\nmassmed.org\/AM\/Template.cfm?Section=About_
\nMMS (accessed Dec 2009).
\n6. \u0007Boston L.The National Medical Journal as Interme-
\ndiary. Journal of the JMA.1980. (Japanese translation
\nfrom WMJ 1979;26(6).
\n7. \u0007Rowe A. The Title of the World Medical Associa-
\ntion House Regular Publication. (WMA Document.
\nFPL\/WMJ Title\/May2007). Nov 2006.
\n8. \u0007Davis R. Proposal to Revamp and Relaunch the
\nWorld Medical Journal. (WMA Document: Propos-
\nal to Change the Format of The WMJ. FPL\/WMJ
\nFuture\/May2007). Nov 2006.
\n9. \u0007Apinis P. Dear colleagues throughout the world!
\nWMJ. 2008;54(1):1
\nMieko Hamamoto, International Affairs
\nDivision, Japan Medical Association,
\nMasami Ishii, MD, Executive Board Member,
\nJapan Medical Association.
\nVice-chair, World Medical Association.
\nSecretary General, CMAAO
\nFigure 1. Online Availability of NMA Journals (n=26)
\n29
\nRegional and NMA news
\nIn recent years many have asserted that the
\nright to health is a critical element of peace-
\nful societies and that health professionals
\nhave a role to play in peace processes. In
\n1998 the 51st World Health Assembly for-
\nmally accepted Health as a Bridge for Peace
\nas a feature of the \u201cHealth for All in the
\n21st Century\u201d strategy. According to the
\nWorld Health Organization \u201chealth can be
\na neutral meeting point to bring conflicting
\nparties to discuss mutually beneficial inter-
\nventions\u201d.
\nEfforts to engage the medical profession
\nacross geographic and political boundaries
\nhave been underway for several years. The
\nNorwegian Medical Association organized,
\nunder the auspices of the World Health
\nOrganization, five meetings from 1993 to
\n1997 among the medical associations from
\nthe new republics in former Yugoslavia.
\nThe underlying theory for these meetings
\nwas that physicians have ethical standards
\nin common that go beyond ethnic and na-
\ntional interests.
\nIn 2007 Brazil, France, Indonesia, Senegal,
\nSouth Africa,Thailand and Norway formed
\nan alliance to put health on the global for-
\neign policy agenda. They stated that \u201cThe
\nworld is facing many common problems re-
\nlated to health, and therefore foreign policy
\nmust be more health sensitive.\u201d This group
\nidentified a number of elements that de-
\nserve greater attention:
\ndevelopment and use of health indicators\u2022
\nto better assess peace and reconstruction
\nprocesses;
\nroadmaps for health recovery as a peace-\u2022
\nmaking tool;
\nmore empirical knowledge of the effect of\u2022
\nhealth intervention at different stages in
\nconflicts.\u00a0
\nMost recently, from 27-30 October 2009,
\nthe World Medical Association and medi-
\ncal associations and health and human
\nrights organizations from Egypt, Iraq, Is-
\nrael, Netherlands, Norway, Palestine and
\nTurkey met in Ku\u015fada\u015fi in Turkey to discuss
\nhealth as a bridge to peace in the region.
\nThe purpose was to stimulate and improve
\ncommunication among health profession-
\nals in the region, as a first step in a process
\nwe hope will establish collaboration struc-
\ntures among medical associations in Middle
\nEast.
\nBefore the conference in Turkey, all partici-
\npating organizations completed a question-
\nnaire on the right to health in their country.
\nThe meeting began with a presentation of
\nthe survey results. Each organization high-
\nlighted two or three items related to health
\nand human rights, which then formed the
\nbasis for the discussion agenda.
\nThe conference provided a forum for valu-
\nable dialogue and exchange of information
\nand experiences in the area of the right to
\nhealth. Different countries face different
\nchallenges and during the discussions the
\npolitical realities, particularly in Israel and
\nPalestine, often surfaced. One of the main
\nobjectives of the meeting was to establish a
\ncommon project on which the participants
\ncould collaborate. Various suggestions for
\nfuture projects were discussed:
\ntraining physicians on ethics and human\u2022
\nrights;
\ninitiating activities to increase the profes-\u2022
\nsional capacities of physicians who play
\nan important role in the prevention of
\ntorture;
\nmonitoring the implementation of two\u2022
\nrecent WHO resolutions \u2013 the first on
\nthe revitalization of primary health care
\nas the key element of comprehensive
\nhealth care systems and the second on the
\nsocial determinants of health;
\naddressing the negative impact of war,\u2022
\nconflict and violence on the health of the
\npopulation;
\nanalysing health disparities in different\u2022
\ncountries of the Middle East;
\nholding governments accountable for re-\u2022
\nalizing the right to health.
\nToward the end of the conference it became
\nclear that it was difficult to find one project
\nall could agree on. The participating or-
\nganisations found the meeting valuable, but
\nwould need more time for building trust and
\ngetting to know each other better. However,
\nthe participants agreed to continue to meet,
\nand realised the necessity of dialogue in
\norder to establish sustainable collaboration
\nstructures on the issue of right to health.
\nIt was decided that the topic for the next
\nmeeting should be: The role of health per-
\nsonnel in health and human rights.
\nThe meeting was co-organized by five orga-
\nnizations: two National Medical Associations
\n(the Norwegian Medical Association and the
\nTurkish Medical Association),one national hu-
\nman rights organization (the Human Rights
\nFoundation of Turkey) and two international
\nnetworks: the International Federation of
\nHealth and Human Rights Organizations and
\nthe World Medical Association.
\nBjorn Oscar Hoftvedt,
\nMetin Bakkalci,
\nOtmar Kloiber,
\nEline Thorleifsson,
\nAdrian van Ees
\nThe right to health as a bridge to peace in the
\nMiddle East
\n30
\nRegional and NMA news
\nThe Polish (Supreme) Chamber of Physi-
\ncians and Dentists (Naczelna Izba Leka-
\nrska) and the regional chambers of physi-
\ncians and dentists (okr\u0119gowe izby lekarskie)
\nare the organizational bodies of the profes-
\nsional self-government of physicians and
\ndental practitioners who are associated in
\nthe chambers with equal status.
\nThe professional self-government of phy-
\nsicians and dental practitioners in Poland
\nwas founded in 1922, dissolved in 1952 and
\nreestablished in 1989. There are currently
\n23 regional chambers and a separate cham-
\nber of military physicians and dentists that
\nhas the legal status of a regional chamber,
\nthough its members span the entire country.
\nChambers of physicians and dentists address
\na range of matters concerning the practice
\nof medicine and dentistry in Poland.
\nThe highest authority of the Polish Cham-
\nber of Physicians and Dentists is the Gen-
\neral Medical Assembly, and the regional
\nmedical assemblies are the highest authori-
\nties of the regional chambers. In the period
\nbetween assemblies, the Supreme Medical
\nCouncil and regional medical councils are
\nthe decision-making bodies at the state and
\nregional levels,respectively. Every physician
\nand every dental practitioner who holds the
\nright to practice the profession in Poland is
\na member of one of the regional chambers
\nby virtue of the law.
\nNumber of members of the chambers in
\n2009:
\nPhysicians \u2013 132\u00a0694;
\nDental practitioners \u2013 36\u00a0633;
\nPersons with both professional titles \u2013 594.
\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 overseeing compli-
\nance;
\nrepresenting and protecting the medical\u2022
\nprofessions;
\nintegrating the medical circles;\u2022
\ndelivering opinions on matters concern-\u2022
\ning public health, state health policy and
\norganization of healthcare;
\nco-operating with scientific associations,\u2022
\nuniversities and research institutions in
\nPoland and abroad;
\noffering mutual aid and other forms of fi-\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:
\ncertify 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 fit-\u2022
\nness to practice as a physician or dentist;
\nco-operate in the field of continuous\u2022
\nmedical education;
\ndeliver opinion on draft legislation con-\u2022
\ncerning health protection and exercise of
\nthe medical professions;
\ndeliver opinions and make motions re-\u2022
\ngarding undergraduate and postgraduate
\ntraining 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 organizations, trade
\nunions as well as other social organiza-
\ntions in matters concerning protection of
\nhuman health and conditions of practic-
\ning medicine.
\nOrganization of the Professional
\nSelf-Government of Physicians and
\nDentists in Poland
\nThe organs and members of the Supreme Chamber
\n(term of office: 2006 – 2010)
\nSupreme Medical Council
\nConsists of 75 members \u2013 representatives of Polish physicians and dental practitioners
\nelected at the General Assembly.
\nPresident Dr. Konstanty Radziwill
\nSecretary Dr. Mariusz Janikowski
\nVice-Presidents: Dr. Ryszard Gola\u0144ski,
\nDr. Anna Lella,
\nDr. Andrzej Wlodarczyk
\nDeputy Secretary Prof. Jerzy Kruszewski
\nTreasurer Dr. Andrzej Sawoni
\nMembers of the Presidium: Dr. Zdzis\u0142aw
\nAnnusewicz, Dr. Romuald Krajewski,
\nDr. Wojciech Marquardt,
\nDr. Andrzej Matyja
\nSupreme Screener for Professional Liabil-
\nity Dr. Jolanta Orlowska-Heitzman
\nChairperson of the Supreme Medical
\nCourt Dr. Jerzy Nosarzewski
\nChairperson of the Supreme Audit Com-
\nmittee Dr. Jaros\u0142aw Zawili\u0144ski
\n31
\nRegional and NMA news
\nInternational policy of the Polish
\nChamber of Physicians and Dentists
\nOne of the important areas of activities of
\nthe Polish Chamber of Physicians and Den-
\ntists is participating actively in international
\norganizations of physicians and dentists and
\ncollaborating with medical and dental orga-
\nnizations and chambers abroad.
\nThe Chamber is active in the following
\ninternational organizations of doctors and
\ndental 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;
\nWorld Medical Association (WMA);\u2022
\nCouncil of European Dentists (CED);\u2022
\nWorld Dental Federation (FDI);\u2022
\nEuropean Regional Organization of the\u2022
\nWorld Dental Federation (ERO\/FDI).
\nIn 2008 the Chamber applied for constitu-
\nent membership in the World Medical As-
\nsociation. The application was approved at
\nthe General Assembly in Seoul in October
\n2008 and the Chamber became an active
\nWMA member again on January 1, 2009.
\nThe Polish Chamber of Physicians and
\nDentists was one of the founding WMA
\nmember associations, though its member-
\nship ceased when the Chamber was dis-
\nsolved in 1952.
\nDr. Konstanty Radziwill, President of the
\nPolish Chamber of Physicians and Dentists,
\nis a Vice-president of the Standing Com-
\nmittee of European Doctors (CPME) and
\nwas elected to the position of the CPME
\nPresident for the years 2010 \u2013 2011.
\nSince October 2008 Dr, Romuald Kra-
\njewski,Member of the Presidium of the Su-
\npreme Medical Council, is currently serving
\nas Vice-President of the UEMS.
\nThe Polish Chamber of Physicians and
\nDentists also co-operates on regular basis
\nwith national medical chambers and medi-
\ncal organizations from many other coun-
\ntries.
\nProvided by the Polish Chamber
\nof Physicians and Dentists
\nMing-Been Lee
\nThe celebrations of Doctors\u2019 Day in Novem-
\nber 2009 marked the year end for the Taiwan
\nMedical Association. However, the commit-
\nment to end people\u2019s suffering with improved
\nquality care is our never-ending mission, par-
\nticularly during and after a disaster. In this ar-
\nticle we review three major events that demon-
\nstrateTMA\u2019s interaction with the international
\ncommunity,the pubic and our local peers.
\nTaiwan Medical Association
\nCelebrated Doctors\u2019 Day
\nThe TMA celebrated 2009 Doctors\u2019Day on
\n12 November in the presence of Dr. Dana
\nW.Hanson,President of the World Medical
\nAssociation, Dr. Masami Ishii, Vice-Chair-
\nman of the WMA, Dr. Cecil B. Wilson,
\nPresident-Elect of the American Medi-
\ncal Association, Prof. Vivienne Nathanson,
\nDirector of Professional Activities, British
\nMedical Association, and Dr. Dongchun
\nShin, Chair, Executive Committee of In-
\nternational Relations, Korean Medical As-
\nsociation. Nearly 500 senior doctors were
\nopenly acknowledged for their four to six
\ndecades-long contributions. The ceremony
\nhighlighted ten outstanding physicians re-
\nceiving the TMA Role Model Award and
\ncompliments from distinguished foreign
\nguests.
\nBefore the award giving ceremony was the
\nInternational Seminar on Health for All:
\nProblems and Solutions, chaired by TMA
\nPresident Dr. Ming-Been Lee. Focusing on
\nhealth insurance and the physician-patient
\nrelationship,the seminar invited abovemen-
\ntioned international speakers and welcomed
\nbroad participation from all over the coun-
\ntry, including TMA\u2019s boards of directors
\nand supervisors, international affairs com-
\nmittee, heads of regional branches and pro-
\nfessional medical societies to share and ex-
\nchange views. Dr. Hanson, Dr. Ishii and Dr.
\nShin provided overviews of the healthcare
\nsystems in Canada, Japan and South Korea,
\nrespectively. Dr. Wilson, drawing on the ex-
\nperience of AMA,provided in-depth analy-
\nsis on health policy making in the United
\nStates, while Prof. Nathanson elaborated on
\nthe experience of the doctor-patient rela-
\ntionship in the United Kingdom. The cel-
\nebrations were honored by President Ma
\nYing-jeou\u2019s attendance in the afternoon.
\nPost-conference programmes for our guests
\nbegan with the Bureau of National Health
\nInsurance inTaipei,where the General Man-
\nager Shou-Hsia Cheng received the visitors
\nwith his vivid illustration on the operation
\nof NHI in Taiwan. The group also visited
\nthe Buddhist Tzu Chi Hospital in Hualien
\non the east coast and learned about their
\nworldwide humanitarian work. The tour ex-
\nMessages from Taiwan Medical Association
\n32
\nThe Israeli Medical Association (IMA)
\nis an independent professional organiza-
\ntion representing Israeli physicians. The
\nIMA was established in 1912, and includes
\namong its members over 90% of the medi-
\ncal personnel working in Israel\u2019s health
\nfunds, hospitals, state institutions and pri-
\nvate clinics. The IMA is responsible for
\nestablishing professional norms and ensur-
\ning high standards of medicine in Israel
\nand is involved in shaping national health
\npolicy, influencing the legislative process
\nand presenting the achievements of Israeli
\nmedicine to the global healthcare commu-
\nnity. The IMA is similarly responsible for
\noverseeing physicians\u2019 working conditions
\nand for formulating and clarifying rules of
\nmedical ethics.
\nRegional and NMA news
\ntended to the south, cordially accompanied
\nby TMA\u2019s member organizations Tainan and
\nKaohsiung Medical Associations.
\nIt is worth noting that prior to the Doctors\u2019
\nDay programs, the TMA had arranged for
\nour guests to deliver speeches to the partici-
\npants of the 5th Global Forum for Health
\nLeaders during 9th and 10th November.
\nThe Forum was organized by Taiwan Joint
\nCommission on Hospital Accreditation and
\nsponsored by the Department of Health.
\nFive honorable speakers from overseas ex-
\npressed their compliments at Doctor\u2019s Day
\nCelebrations.
\nDisaster Management
\nOn 8th August this year, southern Taiwan
\nwas devastated by super-typhoon Morakot.
\nLarge-scale mudflows and landslides brought
\nthe death toll to 634. The TMA took im-
\nmediate action by setting up a disaster relief
\nworking group to support the government\u2019s
\ndisaster management efforts. All physicians
\nwere summoned to cooperate with local
\nhealth authorities and provide medical ser-
\nvices. Members of TMA were highly appre-
\nciated for their voluntary services, donations
\nand sponsorship of affected areas.
\nDuring post disaster reconstruction and
\nrehabilitation, the TMA places priority on
\nconsolidating resources and providing spe-
\ncialty care, adequate health information and
\neducation, as well as financial, pharmaceuti-
\ncal and psychological support. To this end,
\nthe TMA appealed to professional associa-
\ntions of physicians,lawyers,accountants and
\narchitects to participate in helping alleviate
\nvictims\u2019 trauma. In the meantime, heartfelt
\ncondolences from national medical associa-
\ntions in other countries were received with
\ngratitude.
\nAlthough almost 100 hospitals and clin-
\nics in the typhoon-hit areas suffered from
\nvarious degrees of damages, they resumed
\nservices without delay to ensure proper care
\nfor people in need. TMA President Dr.
\nMing-Been Lee, deeply concerned about
\nlocal TMA members as well as the victims,
\ntraveled to the sites in November and De-
\ncember to console victims while urging the
\nmedical community to continue services
\nand focus on rehabilitation.
\nThe TMA delegation, led by President Dr.
\nMing-Been Lee, visited indigenous people
\nin Taitung, an area hit severely by Typhoon
\nMorakot and short of medical resources.
\nMajor Projects Granted From
\nDepartment of Health
\nProfessional Autonomy
\nFor two consecutive years the TMA re-
\nceived the Bureau of National Health In-
\nsurance delegation programme of Profes-
\nsional Autonomy Affairs under the Primary
\nCare Global Budget System. Professional
\nautonomy and point-value management
\nin the primary care community have re-
\nsulted in a better healthcare environment.
\nAchievements of the programme include:
\n1) enhanced quality of care; 2) health facili-
\nties at the primary level received counseling;
\n3) response to complaints from patients;
\n4) participation in the planning of primary
\ncare global budget payment system; 5) plan-
\nning of and capacity building for personnel
\nin the review panel; and 6) improved medi-
\ncal service review practice.
\nContinuing Medical
\nEducation Accreditation
\nThe TMA also participated in the 2008 De-
\npartment of Health (DOH) Accreditation
\nProgramme of Continuing Medical Edu-
\ncation (CME) in Medical Ethics, Medical
\nRegulation and Medical Quality. By the
\nend of 2008, we received 2,330 cases and
\nour high quality accreditation plans were
\nsatisfactory to the DOH, course organizers
\nand physicians. We helped physicians ob-
\ntain necessary points to renew their licenses.
\nAn accredited administrative platform was
\nestablished to analyze and review all CME
\ncourses, and organize academic conferences
\nwith partner institutions to improve both
\nteaching and learning.
\nIn addition,we continued to act as the agen-
\ncy to accredit CME courses. We completed
\naccreditation of CME courses, academic
\nmeetings and international symposium or-
\nganized by medical schools, associations,
\nsocieties,teaching hospitals and other agen-
\ncies. Individual physicians\u2019 application for
\nCME points were processed and accepted.
\nA special team was assigned as a liaison to
\nassist CME course providers and physicians
\non the recipient side.
\nMing-Been Lee, MD,
\nPresident of the Taiwan Medical Association
\nThe Israeli Medical Association
\n33
\nRegional and NMA news
\nOne of the major activities undertaken by
\nthe IMA in recent years was a lengthy ar-
\nbitration process designed to raise physi-
\ncians\u2019 salaries and implement reforms to
\ntheir working conditions. In recognition
\nof the serious legal, ethical and financial
\ncosts of striking, the IMA agreed in July
\n2000, on behalf of all publicly employed
\nphysicians, to give up the right to strike for
\nten years in exchange for this mandatory
\narbitration. The arbitration process only
\nbegan in 2005, and in 2008 it was decided
\nthat doctors would receive a salary increase
\nof approximately 23.5%; however, no real
\nreforms on issues such as manpower and
\ncontinuing medical education were real-
\nized.
\nAnother recent and ongoing project initi-
\nated by the IMA relates to the increas-
\ningly troublesome phenomenon of violence
\nagainst physicians. The IMA approached
\nthis problem on several fronts. For instance,
\nthe IMA has proposed several bills in Par-
\nliament to prevent violence against medical
\npersonnel, such as one bill intensifying the
\npunishment for those who attack medical
\npersonnel and another allowing doctors to
\nrefuse to treat previously violent patients,
\nexcept in emergency situations.
\nThe IMA also appealed to the Supreme
\nCourt to obligate the Ministry of Health to
\nimplement an emergency plan as well as to
\nimplement the permanent directives from
\na report previously issued by the Director
\nGeneral. The Supreme Court criticized the
\nMinistry of Health for not implementing
\nits own plan. Immediately following this
\ncriticism, the Ministry of Health budgeted
\n2 million NIS to reduce violence against
\nphysicians and Clalit Health fund, the larg-
\nest Health fund in Israel, budgeted 2.5 mil-
\nlion NIS for the same purpose.
\nIn addition to the legal measures imple-
\nmented, the IMA manages an emergency
\nhotline for doctors who have been victims
\nof violence,providing immediate advice and
\nreferrals. The IMA also contracts with a
\nprofessional security company that accom-
\npanies doctors who have been attacked and
\nappear to be in danger, and provides profes-
\nsional advice. In conjunction with a profes-
\nsional media company, the IMA produced
\na video clip on the topic of violence against
\nphysicians that was broadcast on Israeli
\ncable television.
\nFinally, the IMA partnered the pilot proj-
\nect, \u201cHospitals without Violence\u201d at Wolf-
\nson Hospital and advanced a pilot of mobile
\nemergency buttons in the operating room of
\nSheba Medical Center. The IMA also initi-
\nated a forum of all the bodies representing
\nworkers in the health sector to contend to-
\ngether and to pressure decision makers to
\ndeal with the problem of violence.
\nAnother topic which the IMA chose to ad-
\ndress this year is that of physicians\u2019 health.
\nViewing the health of physicians as a pre-
\nrequisite to the proper care of patients, the
\nIMA set up a hotline that provides confi-
\ndential referrals to doctors seeking medical
\nhelp in various fields. The IMA is also pre-
\nparing information booklets for employers
\nand physicians discussing issues related to
\nphysician health and raising practical sug-
\ngestions such as: healthy food and exercise,
\nimmunizations and periodic checkups, naps
\nduring rotations, and making the workplace
\n\u201cbreastfeeding friendly\u201d.
\nThe IMA also developed several workshops
\nfor coping strategies and burnout preven-
\ntion. A pilot workshop was held for resi-
\ndents at Soroka Hospital in Beersheva and
\nconsidered very successful.
\nThe IMA has also been working on the key
\nissue of Inequalities in Health. In Israel, as
\nin many countries around the world, health
\nservices are available and accessed different-
\nly across geographic, economic and socio-
\ndemographic lines, resulting in health dis-
\nparities. In order to combat this increasing
\nproblem, the IMA convened a committee
\nwhich discussed the problem in depth and
\nproduced a report on health inequalities in
\nIsrael. Following this, several actions were
\ntaken by the IMA including developing a
\ntraining programme to teach physicians
\nhow to treat patients who are different from
\nthemselves, a telephone survey to assess the
\nimpact of health inequalities in Israel, and
\nmeetings with government officials took
\nplace.
\nThis desire to improve the health of less for-
\ntunate populations is always at the forefront
\nof the IMA\u2019s agenda. Another example can
\nbe found in the clinic the IMA, along with
\nthe Ministry of Health, established in No-
\nvember 2008 at the Tel Aviv central bus sta-
\ntion. The purpose of the clinic is to provide
\nfor people who do not yet have legal status
\nand are therefore not receiving treatment
\nat regular health institutions; this includes
\nboth refugees and those work immigrants
\nwho do not have legal status or any sort of
\nhealth insurance. The IMA and the Min-
\nistry of Health opened the clinic, which
\nfunctions by way of donations and volunteer
\ndoctors and is intended to provide primary
\nhealth care to the refugees. The clinic was
\nestablished as a temporary measure until
\nthere is proper legislation regarding health
\ncoverage for these populations.
\nProf. Leonid Eidelman
\nPresident of Israeli Medical Association
\nLeonid Eidelman
\n34
\nRegional and NMA news
\nThe Ethiopian Medical Association was
\nfounded on July 20th 1961, when His Im-
\nperial Majesty Haile Selasie I graciously
\ngranted a Royal charter to the Association
\nand consented to be Patron of the Associa-
\ntion. Its first constitution was promulgated
\nin the same year.\u00a0 Expatriate doctors played
\na prominent role in the early history and ac-
\ncounted for the majority of its membership.
\nDr. F. Hylander, Swedish nationality, was
\nthe first president of EMA and Dr. Yo-
\nhannes Kibreth, Ethiopian, was elected as
\nthe 2nd
\npresident of EMA in 1962. The or-
\nganization became a member of the WMA
\nin 1963 and is also founding member of the
\nConfederation of African Medical Associa-
\ntions & Societies (CAMAS).
\nVision:
\nA healthy and prosperous Ethiopian com-
\nmunity with access to quality health ser-
\nvices provided by physicians who have the
\nopportunity to continuously enhance their
\nprofessional capacity, exercise their rights
\nand enjoy the benefits of their profession,
\nand practice freely in an environment that
\nrespects medical ethics.
\nMission:
\nTo ensure the rights and benefits of phy-
\nsicians through lobbying and advocacy, to
\nenhance their professional abilities through
\ncontinuous development of their medical
\nknowledge in service to their patients,and to
\nwork with the government and other part-
\nners for the improvement of quality health
\nservices to the Ethiopian community.
\nObjectives:
\n1.\t To promote the professional excellence
\nof members in preventive and curative
\nmedicine and medical research
\n2.\t To promote the science and art of medi-
\ncine and improve public health
\n3.\t To promote and maintain intellectual
\nand professional freedom
\n4.\t To provide professional and technical
\nadvice to the Ministry of Health and
\nother concerned organizations
\n5.\t To publish the Ethiopian Medical Jour-
\nnal and other professional journals as
\nthe need arises
\n6.\t To provide a forum for the exchange of
\nprofessional ideas, knowledge and expe-
\nrience among the members of EMA
\n7.\t To provide Continuing Medical Edu-
\ncation for all doctors practicing in
\n\u00adEthiopia
\nIn pursuit of the above objectives, the EMA
\nholds annual medical conferences where
\nmembers exchange ideas, knowledge and
\nexperience; publishes Ethiopian Medical
\nJournal quarterly; and provides continuing
\nmedical education to update the knowledge
\nof its members.
\nDuring the last three years, the EMA has
\nreorganized the Secretariat,increased its ca-
\npacity and worked closely with the Federal
\nMinistry of Health and International Orga-
\nnizations. Other accomplishments include:
\nIn-house capacity building\u2022
\nDevelopment of a five-year Strategic\u2022
\nPlan
\nEstablishment of four branch offices\u2022
\nDevelopment and implementation of\u2022
\nprojects
\nRevision of the Constitution of EMA\u2022
\nCollaborative activities with different\u2022
\nstakeholders
\nEssential steps towards the realization of\u2022
\nEMA\u2019s future house
\nThe projects EMA is implementing are:
\nResearch-based incentive for physicians\u2022
\nworking in remote hospitals
\nHuman resource capacity building to ac-\u2022
\ncelerate ART uptake in Ethiopia
\nSupport of routine immunization services\u2022
\nInfection prevention\u2022
\nEMA is pleased to partner with WMA,
\nother sister associations and organizations
\nin implementing projects of mutual inter-
\nest.
\nPlease visit our website: www.emaethiopia.org
\nDr. Mahdi Bekri, Executive Director of
\nEthiopian Medical Association
\nThe Ethiopian Medical Association
\nMahdi Bekri
\nEMA Executive Committee with Minister of
\nFederal Ministry of Health
\nEMA 44th
\nAnnual Conference at United Na-
\ntion Conference center – Addis Ababa, 2008
\n35
\nRegional and NMA news
\nJose Ramon Huerta Blanco
\nThe Organizaci\u00f3n M\u00e9dica Colegial of Spain
\n(OMC) (Spanish Medical Association) is
\nthe institution formed by the 52 medical
\ncolleges of Spain and is in charge of the ar-
\nrangement, regulation, control and defence
\nof the medical profession according to the
\nSpanish rules and regulations. Although
\nthe medical colleges have been regulated
\nby Law since 1898, the General Council of
\nMedical Colleges of Spain was formed in
\n1921. This is the body which groups and
\ncoordinates the provincial and autonomous
\nMedical Colleges, as public law corpora-
\ntions, that are an authority within the pro-
\nfession.
\nThe OMC activities are focused on very
\ndiverse areas, always related to the medi-
\ncal profession. Besides the habitual activi-
\nties of record and professional control as
\nwell as qualifications, the OMC promotes
\ncontinuous medical training activities for
\nwhich it has a specific Foundation. It also
\nhas a Central Medical Ethics Commission
\nwhich not only studies the cases that it re-
\nceives from the Medical Colleges, but also
\ncarries out studies and documents about the
\nposition of the medical profession in fun-
\ndamental ethical questions that concern it.
\nThus in the last months, it has updated its
\npositions on medical care at the end of life
\nand on the regulation of a conscience clause
\nfor health care professionals who don\u2019t want
\nto perform abortions.
\nThe OMC has a digital journal \u201cDoctors
\nand Patients\u201d which maintains updated in-
\nformation about questions of medical health
\ncare and social interest, but also of infor-
\nmation and interest for patients. Also the
\nOMC has approved the creation of a Social
\nCouncil to foster and to promote meetings
\nand collaboration with patients who are the
\nraison d’\u00eatre of medicine.
\nIn the last year the OMC has tightened
\nits bonds of collaboration and action with
\nthe most representative medical entities of
\nSpain: the medical trade unions, the Con-
\nference of Deans of Medical Universities,
\nthe State Council of Medical Students, the
\nFederation of Spanish Medical Scientific
\nAssociations and the National Commission
\nof Specialities in Health Sciences, integrat-
\ning with them all what is known as the Fo-
\nrum of the Medical Profession.
\nIn addition, the OMC is developing a wide
\nactivity in defence of the medical associa-
\ntion and contributing its point of view to
\nthe legal regulations. Our association un-
\nderstands that the association formula is the
\none that best guarantees the social protec-
\ntion of patient\u2019s interests, the fulfilment of
\nEthics, the control and regulation of the
\nprofession, which has been commended the
\nprotection of an important asset: health.
\nThe OMC is developing efforts and taking
\nmeasures to assure the conscience clause for
\nhealth care professionals when faced with
\nthe modification of the Law on Abortion.
\nAlso it undertakes intense actions to assure
\nthat the authority to prescribe drugs is re-
\nserved to health care professionals because
\nthe competence to prescribe is inseparably
\nlinked with the diagnosis for reasons of ef-
\nficiency, quality and safety in health care.
\nEfforts are also being made in social and
\nhealth matters of general interest, promot-
\ning numerous training and informative ac-
\ntions aimed at health care professionals and
\nthe population at large,among which can be
\nhighlighted information about Influenza A
\n(H1N1), the Effects of the Climate Change
\non Health, the Prescription and the Ration-
\nal Use of Drugs.
\nRecertification of the competences of
\nhealth care professionals and reassociation
\ndepending on the fulfilment of professional,
\npsychophysical criteria and of accredited
\nupdating of professional competence is
\nanother of the challenges that the Spanish
\nmedical organisation has to face after 2010,
\nreinforcing the corporate commitment with
\nthe patient and society and transparency to-
\nwards health care professionals and society.
\nThe Spanish medical organisation has a
\nvery extensive international collaboration.
\nIt plays an active role in the World Medical
\nAssociation, European medical organisa-
\ntions like the CEOM (European Council
\nof Medical Orders) and organisations of
\nmedical specialists (UEMS), general prac-
\ntitioners (UEMO), hospital health care
\nprofessionals (AEHM), doctors in training
\n(PWG). The cooperation with the countries
\nof Latin America organised through the
\nFIEM (Latin-American Forum of Medical
\nEntities) is of special interest, without for-
\ngetting the social and solidarity action for
\nwhich the OMC has formed a Solidarity
\nFoundation with the purpose of promot-
\ning and channelling help and cooperation
\nfor medical \u2013 health care in countries with
\nprecarious health care and vulnerable and
\nneedy populations.
\nDr. Jose Ramon Huerta Blanco,
\nInternational Relations Coordinator
\nThe Organizaci\u00f3n M\u00e9dica Colegial
\nDe Espa\u00f1a
\n36
\nRegional and NMA news
\nJorge Carlos Ja\u00f1ez
\nAs a consequence of the neoliberal policies
\nimplemented, repetitive budget cuts have
\ndamaged the social, political and institu-
\ntional situation not only in our country, but
\nin the entire Region.
\nHealth services have been deteriorating
\ngradually, the public healthcare spending
\nis decreasing in terms of the income per
\ncapita ratio, and the scarce resources had to
\nbe adapted by giving importance to treat-
\nment over prevention. At the same time,
\nnew changes have been introduced in the
\nfinancial aspect, there is a rising tendency to
\nprivatisation and the operating expenditure
\nbelongs to the user now.
\nWithin the framework of these neoliberal
\npolicies, several reasons were stated which
\nprivilege the following: expenditure is now
\nafforded by the users of the system, private
\nresources are excessively used and the public
\nservices administration is decentralised.
\nIn addition to the aforementioned, the sec-
\ntor shows an extreme sanitary anarchy, a
\nlack of coordination between the public and
\nthe private sector, which results in the dou-
\nbling and superposition of services and the
\nlow use of resources.
\nSocial Security definancing is a consequence
\nof the unreleased unemployment rate. The
\nunemployed population lost their health in-
\nsurance coverage which led to the 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 affected.
\nGiven that the infrastructure and the public
\nsector supplies are in bad condition, doctors
\nlack all kind of support before patients. The
\nlatter not only demand a medical assistance
\nthat doctors cannot provide on their own,
\nbut also take legal action against them more
\nfrequently. Thus, a patient\u2019s right before an
\nundesired treatment result was turned into
\nthe so-called \u201cmedical malpractice insur-
\nance industry\u201d.
\nIt is even worse when faced by unrestrainted
\nrelatives or the same patient, since they are
\nbecoming more and more aggressive, and
\nmay end up assaulting physically. Apart
\nfrom these unfortunate situations, the doc-
\ntor\u2019s proletarianisation must also be men-
\ntioned. It is caused by several factors:
\nProfessional Plethora which shows a doc-\u2022
\ntor to patient ratio of approximately 360.
\nIn some large places, big urban centres,
\nthe ratio is 120 inhabitants per doctor.
\nIncrease of professional medical licenses\u2022
\nup to 5 times faster than the population.
\nNo planning of geographical distribu-\u2022
\ntion.
\nHigh percentage of specialists (80%, 70%\u2022
\nout of this 80% are in the big urban cen-
\ntres).
\nAfter the proposal of the National Inte-
\ngrated Health System in 1973, which was
\nabolished,and laws 23660\/61of the Nation-
\nal Health Insurance (last essays on national
\npolicies), there was a crisis in the service
\nprovider which still continues, and signs in-
\ndicate that it will get worse.
\nThis deep crisis demands a health system
\nreform in accordance with a STATE POLI-
\nCY under consensus of all participants, bas-
\ning the system programme on the following
\nproposal:
\nGive priority to Primary Attention\u2022
\n(Mother & Child Programmes, Special
\nPlans for the needed, etc.) as a response
\nto the emergency.
\nComplement all subsectors in order to\u2022
\nshift the fragmenting system by using the
\nidle installed capacity.
\nCoverage based on an Obligatory Medi-\u2022
\ncal Insurance.
\nState administration and regulation\u2022
\nwhich comprises:
\nHigh Complexity–
\nHigh Medical Technology–
\nMedicine–
\nRegulation of the professional practice\u2022
\nwhich comprises:
\nAdaptation of programmes of study in–
\nthe Medical Schools
\nPlanning the number of students who–
\nenter Schools according to the System
\nneeds
\nPlanning access to the work source–
\nProgramming the geographical distri—
\nbution
\nProfessional certification and recertifi—
\ncation
\nProfessional Career–
\nRegulation of specialisations–
\nDr. Jorge Carlos Ja\u00f1ez,
\nPresident of Medical Confederation
\nof the Argentine Republic
\nMedical Confederation
\nof the Argentine Republic
\n37
\nClimate change
\nThe COP15 \u2013 Conference of the Parties –
\nhas been the talk of Copenhagen and the
\nrest of the World, since December last year
\nwhen the city was transformed into a giant
\nhotel with a display of leaders from all over
\nthe world. Copenhagen was meant to be
\nthe place where an agreement of tremen-
\ndous importance to our planet should be
\nrealized.
\nThe World Medical Association worked
\nhard to gain access to the COP 15 NGO
\nconference by applying for observer status
\nto the UNFCC. In the end, access was not
\ngranted and WMA had to pursue other
\nmeans of participating in the negotiations.
\nFortunately HEAL \u2013 the Health and En-
\nvironment Alliance – offered to include Dr.
\nJens Winther Jensen and CEO Bente Hyl-
\ndahl Fogh from the Danish Medical As-
\nsociation in its delegation, to represent the
\nWMA.
\nThe Health and Environment Alliance is a
\nEuropean umbrella organisation, based in
\nBrussels, working for health and the envi-
\nronment. At the COP15, HEAL had in-
\nvited a number of NGOs to join in their
\nefforts to place health on the agenda at the
\nNGO conference of the COP15.
\nThe HEAL delegation included: the
\nStanding Committee for European Doc-
\ntors (CPME), International Federation for
\nMedical Student\u2019s Associations (IMFSA),
\nEuropean Public Health Alliance, Climate
\nand Health Council, Health Care Without
\nHarm, Harvard Medical School, Medsin-
\nUK and others.
\nHEAL succeeded in public promotion of
\nits agenda during the COP15. An article
\nwas published in the NGO Newsletter on
\nclimate negotiations \u201cECO\u201d. The delega-
\ntion also posted information on the \u201cPre-
\nscription for a Healthy Planet\u201d website,
\nwhere health professionals are encouraged
\nto sign up at: www.climateandhealthcare.org.
\nFurthermore,WHO delegates attended one
\nof the HEAL side events. It was an oppor-
\ntunity for HEAL to present the views of
\nthe medical community on the importance
\nof health impacts on climate change.
\nThe HEAL delegation, as well as other del-
\negates to the NGO conference, had mas-
\nsive problems actually gaining access to the
\nconference venue,including standing in line
\noutside for about six hours in the winter
\ncold, as the number of accredited delegates
\nto the UNFCC far outweighed its capac-
\nity. In the end, the WMA delegates did not
\ngain access to the Center, but invited the
\nHEAL delegation for a debriefing at the
\nDanish Medical Association building on
\nthe last day of the official NGO conference,
\nthe 17th
\nof December 2009.
\nAt the debriefing, participants agreed that
\nthe conference was not a success, given
\nthe fact that no goal for reduction of CO2
\nemissions was reached, but valuable lessons
\nhad been learned. The International Medi-
\ncal Students\u2019Association had formed strong
\nrelations with the WHO and the impor-
\ntance of building strong alliances before ar-
\nriving at the COP was stressed many times
\nduring the meeting.The need to be very ac-
\ncurate about the cost and means of turning
\nproposals and ideas into working initiatives
\nwas also underlined. This applies to policy
\nas well. For example, when WMA recom-
\nmends in a policy declaration that the public
\nhealth systems should be strengthened, the
\nrecommendation must be accompanied by
\nconcrete, detailed initiatives if the message
\nis to be received and understood by decision
\nmakers.
\nThe recommendation from the HEAL
\ndelegation in view of the next COP16 in
\nMexico was therefore to:
\n\u201cBuild relations with key decision makers
\nwell in advance of the event, build strong
\nalliances with other health professionals
\nsuch as nurses, midwives, medical students
\nas well as journalists before the next COP
\nto ensure that the message we wish to con-
\nvey is heard, but, perhaps most importantly:
\nbe very specific about the goals we wish to
\nachieve and the cost implications.\u201d
\nSuccess or failure? The delegation was hope-
\nful that the next COP will be more effective
\ngiven that valuable work has been done to
\nform a base to take decisions and lessons
\nhave been learned by the world leaders.
\nThe challenges are still in front of us. The
\npositive relationship between reducing
\ngreen house gasses and obtaining better
\nhealth must be pursued by world leaders
\nand by doctors.
\nBente Hyldahl Fogh, Chief executive\u00a0officer,
\nDanish Medical Association,
\nChristina Lumby Rasmussen,
\nDanish Medical Association
\nCOP 15 \u2013 success or failure?
\n38
\nClimate change
\n\u201cClimate change is the greatest global health
\nthreat of the 21st
\ncentury\u201d
\nWhen the four of us arrived in Copenhagen
\nlast Saturday, mid-way through negotia-
\ntions, we were shocked to see that concepts
\nof Global Health equity were absent from
\nthe UNFCCC\u2019s text. In 1992, with the cre-
\nation of the UNFCCC, human health was
\ndescribed as one of guiding principles of the
\nframework. Nineteen years on, at the 15th
\nConference of the Parties, we see no such
\nmention of health.
\nAs medical and global health students, and
\nmembers of the International Federation of
\nMedical Students\u2019 Associations (IFMSA),
\nthis fact was of great concern to us. We are
\nconvinced that health should be placed at
\nthe centre of negotiations, providing an ef-
\nfective framework for a successful global
\ndeal. Our views were supported by three
\nother delegations (the Health & Environ-
\nment Alliance,Health Care Without Harm,
\nand the World Health Organisation), with
\nwhich we formed an unofficial coalition.
\nThe Bella centre (the chosen venue for the
\n\u2018historic\u2019 conference) was enormous, and
\nfull of negotiating teams, members of civil
\nsociety, security and UN staff, all busy try-
\ning to culminate the last year of work into
\nwhat could hopefully be a successful round
\nof negotiations. If we were to be effective,
\nwe had to be organised, and smart with the
\nfew precious days we had in Copenhagen.
\nWe set out to promote the concept of health
\nwithin the UNFCCC negotiations, and
\nbuild lasting relationships and our own ca-
\npacity for coming COPs. We did just that.
\nWe wrote letters to, and met with country
\ndelegations who were either most affected
\nby climate change, had brought their health
\nministers to the negotiations, or had already
\nincluded \u2018health\u2019 as a central theme in their
\nnational statement. We encouraged them to
\nspeak out in plenary, attend our side-events
\nand actions, and plan to put them in contact
\nwith medical students and clinicians from
\ntheir country interested in climate change.
\nThis was highly successful, and we received
\ninterviews and statements from many coun-
\ntries around the world (including the UK,
\nFrance, Ghana, Burkina Faso, Indonesia,
\nthe Maldives, and the Netherlands, among
\nothers). All the while we were feeding in-
\nformation to our fellow students in the IF-
\nMSA through blogs, videos, interviews and
\ndaily summaries.
\nOn Wednesday the 16th
\n, we staged a UN
\napproved \u2018Action\u2019 with the Health Environ-
\nment Alliance and Health Care Without
\nHarm. This involved a visit from a \u2018surprise\u2019
\ndoctor, vocally teaching a ward round of
\nmedical students about the correlations be-
\ntween climate change and health. Not only
\nhas climate change been revealed to be \u201cThe
\ngreatest global health threat of the 21st
\ncen-
\ntury\u201d(The Lancet Series), but recent studies
\nhave shown that there are co-benefits for
\nhealth associated with the mitigation of cli-
\nmate change.The doctor presented the con-
\nference with our \u201cPrescription for a Healthy
\nPlanet\u201d, imploring the health sector to par-
\nticipate in the debate. The event was held
\nwithin the Bella centre, received significant
\nmedia coverage from national and inter-
\nnational sources, and was well attended by
\nvarious health delegations, including the
\nWHO.
\nWith the conclusion of the conference, we
\nsat down and asked ourselves,\u201cWhat next?\u201d
\nNegotiations were unsuccessful, more work
\nwas needed, but we were not disheartened \u2013
\nwe were left wanting more.
\nWe had covered significant ground, estab-
\nlished links with like-minded organisations,
\nand people were starting to mention human
\nhealth when they spoke of climate change.
\nBut if we are ever to be successful, we need
\nthe international health community to ac-
\ntively engage in discussion.
\nWe require further research and data high-
\nlighting the economic benefits of health
\nand climate change mitigation. We plan to
\nconnect students with the health and envi-
\nronment ministers we met, as well as with
\nhealthcare professionals currently active in
\nthis field. Most importantly though, we will
\nlearn from this experience, further educate
\nourselves, and build capacity for COP16 in
\nMexico.
\nOne thing is certain, we will be back.
\nIFMSA Delegation to the UNFCCC COP15,
\nCopenhagen – Nick Watts (Australia), Jonny
\nCurrie (UK), Guppi Bola (UK), Mori
\nMansouri (UK), Yorgos Polychronidis (Greece)
\nWritten by Nick Watts
\n39
\nWMA news
\nOrder of Physicians of Albania (OPA)
\nRr. Dibres. Poliklinika Nr.10, Kati 3
\nTirana
\nALBANIA
\nTel\/Fax: (355) 4 2340 458
\nE-mail: albmedorder@albmail.com
\nWebsite: www.umsh.org
\nCol\u2019legi de Metges
\nC\/Verge del Pilar 5,
\nEdifici Plaza 4t. Despatx 11
\n500 Andorra La Vella
\nANDORRA
\nTel: (376) 823 525
\nFax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nOrdem dos M\u00e9dicos de Angola (OMA)
\nRua Amilcar Cabral 151-153
\nLuanda
\nANGOLA
\nTel. (244) 222 39 23 57
\nFax (221) 222 39 16 31
\nE-mail: secretariatdormed@gmail.com
\nWebsite: www.ordemmedicosangola.com
\nConfederaci\u00f3n M\u00e9dica de la Rep\u00fablica
\nArgentina
\nAv. Belgrano 1235
\nBuenos Aires 1093
\nARGENTINA
\nTel\/Fax: (54-11) 4381-1548 \/ 4384-5036
\nE-mail: comra@confederacionmedica.com.ar
\nWebsite: www.comra.health.org.ar
\nArmenian Medical Association
\nP.O. Box 143
\nYerevan 375 010
\nREPUBLIC OF ARMENIA
\nTel. (3741) 53 58 68
\nFax. (3741) 53 48 79
\nE-mail: info@armeda.am
\nWebsite: www.armeda.am
\nAustralian Medical Association
\nP.O. Box 6090
\nKingston, ACT 2604
\nAUSTRALIA
\nTel: (61-2) 6270 5460
\nFax: (61-2) 6270 5499
\nE-mail: ama@ama.com.au
\nWebsite: www.ama.com.au
\n\u00d6sterreichische Arztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O. Box 213
\n1010 Wien
\nAUSTRIA
\nTel: (43-1) 514 06 64
\nFax: (43-1) 514 06 933
\nE-mail: international@aerztekammer.at
\nm.reisinger@aerztekammer.at
\nWebsite: www.aerztekammer.at
\nAzerbaijan Medical Association
\nP.O. Box 16
\nAZE 1000, Baku
\nREPublic OF Azerbaijan
\nTel.(99 450) 328 18 88
\nFax. (99 412) 431 88 66
\nE-mail: info@azmed.az – azerma@hotmail.com
\nWebsite: www.azmed.az
\nMedical Association of the Bahamas
\nP.O. Box N-3125
\nMAB House-6th Terrace Centreville
\nNassau,
\nBahamas
\nTel.: (242) 328 1858
\nFax: (242) 328 1857
\nE-mail: medassocbah@gmail.com
\nBangladesh Medical Association
\nBMA Bhaban 5\/2 Topkhana Road
\nDhaka 1000
\nBangladesh
\nTel. (880) 2-9568714 \/ 9562527
\nFax. (880) 2 9566060 \/ 9562527
\nE-mail: bma@aitlbd.net
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4
\n1050 Bruxelles
\nBELGIUM
\nTel: (32-2) 644 12 88
\nFax: (32-2) 644 15 27
\nE-mail: absym.bvas@euronet.be
\nWebsite: www.absym-bvas.be
\nColegio M\u00e9dico de Bolivia
\nCalle Ayacucho 630
\nTarija
\nBOLIVIA
\nFax. (591) 4\u00a0666 3569
\nE-mail: colmedbol_tjo@hotmail.com
\nWebsite: www.colegiomedicodebolivia.org.bo
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 \u2013 Bairro Bela
\nVista
\nSao Paulo SP \u2013 CEP 01333-903
\nBRAZIL
\nTel. (55-11) 3178 6810
\nFax. (55-11) 3178 6830
\nE-mail: presidente@amb.org.br
\nWebsite: www.amb.org.br
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.
\n1431 Sofia
\nBULGARIA
\nTel: (359-2) 954 11 81
\nFax: (359-2) 954 11 86
\nE-mail: blsus@mail.bg
\nWebsite: www.blsbg.com
\nCanadian Medical Association
\nP.O. Box 8650
\n1867 Alta Vista Drive
\nOttawa, Ontario K1G 3Y6
\nCANADA
\nTel: (1-613) 731 8610 ext. 2236
\nFax: (1-613) 731 1779
\nE-mail: karen.clark@cma.ca
\nWebsite: www.cma.ca
\nOrdem Dos Medicos du Cabo Verde (OMCV)
\nAvenue OUA N\u00b0 6 \u2013 B.P. 421
\nAchada Santo Ant\u00f3nio
\nCiadade de Praia-Cabo Verde
\nCABO VERDE
\nTel. (238) 262 2503
\nFax (238) 262 3099
\nE-mail: omecab@cvtelecom.cv
\nWebsite: www.ordemdosmedicos.cv
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639
\nSantiago
\nCHILE
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940 \/ 6336732
\nE-mail: rdelcastillo@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nChinese Medical Association
\n42 Dongsi Xidajie
\nBeijing 100710
\nCHINA
\nTel: (86-10) 8515 8136
\nFax: (86-10) 8515 8551
\nE-mail: intl@cma.org.cn
\nWebsite: www.chinamed.com.cn
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nCOLOMBIA
\nTel.\/Fax: (57-1) 8050073
\nE-mail: federacionmedicacolombiana@
\nencolombia.com
\nWebsite: www.fmc.encolombia.com
\nOrdre des M\u00e9decins du Zaire
\nB.P. 4922
\nKinshasa \u2013 Gombe
\nDEMOCRATIC REP. OF CONGO
\nTel: (243-12) 24589
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000
\nSan Jos\u00e9
\nCOSTA RICA
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: unmedica@racsa.co.cr
\nCroatian Medical Association
\nSubiceva 9
\n10000 Zagreb
\nCROATIA
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: hlz@email.htnet.hr
\nWebsite: www.hlk.hr\/default.asp
\nColegio M\u00e9dico Cubano Libre
\nP.O. Box 141016
\nCoral Gables, FL 33114-1016
\nUNITED STATES
\n717 Ponce de Leon Boulevard
\nCoral Gables, FL 33134
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nCyprus Medical Association (CyMA)
\n14 Thasou Street
\n1087 Nicosia
\nCYPRUS
\nTel. (357) 22 33 16 87
\nFax: (357) 22 31 69 37
\nE-mail: cyma@cytanet.com.cy
\nCzech Medical Association
\nJ.E. Purkyne
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nCZECH REPUBLIC
\nTel: (420) 224 266 201-4
\nFax: (420) 224 266 212
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nDanish Medical Association
\n9 Trondhjemsgade
\n2100 Copenhagen 0
\nDenmark
\nTel: (45) 35 44 82 29
\nFax: (45) 35 44 85 05
\nE-mail: er@dadl.dk, cc: clr@dadl.dk
\nWebsite: www.laeger.dk
\nEgyptian Medical Association
\n\u00ab\u00a0Dar El Hekmah\u00a0\u00bb
\n42, Kasr El-Eini Street
\nCairo
\nEgypt
\nTel: (20-2) 3543406
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10
\nColonia Miramonte
\nSan Salvador
\nEL SALVADOR, C.A.
\nTel: (503) 260-1111, 260-1112
\nFax: (503) 260-0324
\nE-mail: comcolmed@telesal.net \/ marnuca@
\nhotmail.com
\nEstonian Medical Association (EsMA)
\nPepleri 32
\n51010 Tartu
\nESTONIA
\nTel: (372) 7 420 429
\nFax: (372) 7 420 429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nEthiopian Medical Association
\nP.O. Box 2179
\nAddis Ababa
\nETHIOPIA
\nTel: (251-1) 158174
\nFax: (251-1) 533742
\nE-mail: ema.emj@telecom.net.et \/ ema@eth.
\nhealthnet.org
\nWebsite: www.emaethiopia.org
\nFiji Medical Association
\n304 Wainamu Road
\nG.P.O. Box 1116
\nSuva
\nFIJI ISLANDS
\nTel. (679) 3315388
\nFax. (679) 3315388
\nE-mail: fma@unwired.com.fj
\nWMA Directory of Constituent Members
\n40
\nWMA news
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFINLAND
\nTel: (358-9) 393 091
\nFax: (358-9) 393 0794
\nE-mail: fma@fimnet.fi
\nWebsite: .www.medassoc.fi
\nAssociation M\u00e9dicale Fran\u00e7aise
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFRANCE
\nTel: (33) 1 53 89 32 41
\nE-mail: deletoile.sylvie@cn.medecin.fr
\nGeorgian Medical Association
\n7 Asatiani Street
\n0177 Tbilisi
\nGEORGIA
\nTel. (995 32) 398686
\nFax. (995 32) 396751 \/ 398083
\nE-mail. gma@posta.ge
\nWebsite: www.gma.ge
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nHerbert-Lewin-Platz 1
\n10623 Berlin
\nGERMANY
\nTel: (49-30) 4004 56 360
\nFax: (49-30) 4004 56 384
\nE-mail: renate.vonhoff-winter@baek.de
\nWebsite: www.bundesaerztekamemr.de
\nGhana Medical Association
\nP.O. Box 1596
\nAccra
\nGHANA
\nTel. (233-21) 670510 \/ 665458
\nFax. (233-21) 670511
\nE-mail: gma@dslghana.com
\nWebsite: www.ghanamedassn.org
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re
\nAv. du Travail #33 \u2013 Bois Verna
\nPort-au-Prince
\nHAITI, W.I.
\nTel. (509) 2244 – 32
\nFax:(509) 2244 – 50 49
\nE-mail: secretariatamh@gmail.com
\nWebsite: www.amhhaiti.net
\nHong Kong Medical Association, China
\nDuke of Windsor Building
\n5th Floor
\n15 Hennessy Road
\nHONG KONG
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.org
\nWebsite: www.hkma.org
\nAssociation of Hungarian Medical
\nSocieties (MOTESZ)
\nN\u00e1dor u. 36 – PO.Box 145
\n1051 Budapest
\nHUNGARY
\nTel: (36-1) 312 3807 \u2013 312 0066
\nFax: (36-1) 383-7918
\nE-mail: international@motesz.hu
\nWebsite: www.motesz.hu
\nIcelandic Medical Association
\nHlidasmari 8
\n200 K\u00f3pavogur
\nICELAND
\nTel: (354) 864 0478
\nFax: (354) 5 644106
\nE-mail: icemed@icemed.is
\nIndian Medical Association
\nIndraprastha Marg
\nNew Delhi 110 002
\nINDIA
\nTel: (91-11) 23370009\/23378819\/23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: imawmaga2009@gmail.com
\nWebsite: www.imanational.com
\nIndonesian Medical Association
\nJl. G.S.S.Y. Ratulangie N\u00b0 29 Menteng
\nJakarta 10350
\nINDONESIA
\nTel: (62-21) 3150679 \/ 3900277
\nFax: (62-21) 390 0473
\nE-mail: pbidi@idola.net.id
\nWebsite:www.idionline.org
\nIrish Medical Organisation
\n10 Fitzwilliam Place
\nDublin 2
\nIRELAND
\nTel: (353-1) 6767273
\nFax: (353-1) 662758
\nE-mail: imo@imo.ie
\nWebsite: www.imo.ie
\nIsrael Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, Ramat-Gan 52136
\nISRAEL
\nTel: (972-3) 610 0444
\nFax: (972-3) 575 0704
\nE-mail michelle@ima.org.il
\nWebsite: www.ima.org.il
\nOrdre National des M\u00e9decins de la C\u00f4te
\nd\u2019Ivoire (ONMCI)
\nCocody Cit\u00e9 des Arts, B\u00e2t. U1, Esc.D,
\nRdC, Porte n\u00b01
\nBP 1584
\nAbidjan 01
\nIVORY COAST
\nTel. (225) 22 48 61 53 \/22 44 30 78\/
\nTel. (225) 02 02 44 01 \/08 14 55 80
\nFax: (225) 22 44 30 78
\nE-mail: onmci@yahoo.fr
\nWebsite: www.onmci.org
\nJapan Medical Association
\n2-28-16 Honkomagome, Bunkyo-ku
\nTokyo 113-8621
\nJAPAN
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nWebsite: www.med.or.jp
\nAssociation of Medical Doctors of
\nKazakhstan
\n117\/1 Kazybek bi St.,
\nAlmaty
\nKAZAKHSTAN
\nTel. (7-327 2) 624301 \/ 2629292
\nFax. (7-327 2) 623606
\nE-mail: doktor_sadykova@mail.ru
\nKorean Medical Association
\n302-75 Ichon 1-dong, Yongsan-gu
\nSeoul 140-721
\nREP. OF KOREA
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190\/795 1345
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKuwait Medical Association
\nP.O. Box 1202
\nSafat 13013
\nKUWAIT
\nTel. (965) 5333278, 5317971
\nFax. (965) 5333276
\nE-mail: kma@kma.org.kw
\nalzeabi@hotmail.com
\nLatvian Physicians Association
\nSkolas Str. 3
\nRiga 1010
\nLatvia
\nTel: (371) 67287321 \/ 67220661
\nFax: (371) 67220657
\nE-mail: lab@arstubiedriba.lv
\nWebsite: www.arstubiedriba.lv
\nLiechtensteinische \u00c4rztekammer
\nPostfach 52
\n9490 Vaduz
\nLIECHTENSTEIN
\nTel: (423) 231 1690
\nFax. (423) 231 1691
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerzte-net.li
\nLithuanian Medical Association
\nLiubarto Str. 2
\n2004 Vilnius
\nLITHUANIA
\nTel.\/Fax. (370-5) 2731400
\nE-mail: lgs@takas.lt
\nWebsite: www.lgs.lt
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes du Grand-
\nDuch\u00e9 de Luxembourg (AMMD)
\n29, rue de Vianden
\n2680 Luxembourg
\nLUXEMBOURG
\nTel: (352) 44 40 33 1
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMacedonian Medical Association
\nDame Gruev St. 3
\nP.O. Box 174
\n91000 Skopje
\nMACEDONIA
\nTel: (389-2) 3162 577
\nFax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nSociety of Medical Doctors of Malawi (SMD)
\nPost Dot Net, PO Box 387, Crossroads
\nLilongwe Malawi
\n30330 Lilongwe
\nMALAWI
\nE-mail: dlungu@sdnp.org.mw
\nWebsite : www.smdmalawi.org
\nMalaysian Medical Association
\n4th Floor, MMA House
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nMALAYSIA
\nTel: (60-3) 4041 1375
\nFax: (60-3) 4041 8187
\nE-mail: info@mma.org.my \/ president@mma.
\norg.my
\nWebsite: www.mma.org.my
\nOrdre National des M\u00e9decins du Mali
\n(ONMM)
\nH\u00f4pital Gabriel Tour\u00e9
\nCour du Service d\u2019Hygi\u00e8ne
\nBP E 674
\nBamako
\nMALI
\nTel. (223) 223 03 20\/ 222 20 58\/
\nE-mail: cnommali@gmail.com
\nWebsite: www.keneya.net\/cnommali.com
\nMedical Association of Malta
\nThe Professional Centre
\nSliema Road, Gzira GZR 06
\nMALTA
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: martix@maltanet.net
\nWebsite: www.mam.org.mt
\nColegio Medico de Mexico (FENACOME)
\nAdolfo Prieto #812
\nCol.Del Valle
\nD. Benito Ju\u00e1rez
\nMexico 03100
\nMEXICO
\nTel. 52 55 5543 8989
\nFax. 52 55 5543 1422
\nE-mail: fenacome_relint@teyco.com.mx
\nWebsite: www.cmm-fenacome.org
\nMedical Association of Namibia
\n403 Maerua Park \u2013 POB 3369
\nWindhoek
\nNAMIBIA
\nTel. (264) 61 22 4455
\nFax. (264) 61 22 4826
\nE-mail: man.office@iway.na
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189
\nExhibition Road
\nKatmandu
\nNEPAL
\nTel. (977 1) 4225860, 4231825
\nFax. (977 1) 4225300
\nE-mail: nma@healthnet.org.np
\nRoyal Dutch Medical Association
\nP.O. Box 20051
\n3502 LB Utrecht
\nNETHERLANDS
\nTel: (31-30) 282 38 28
\nFax: (31-30) 282 33 18
\nE-mail: j.bouwman@fed.knmg.nl
\nWebsite: www.knmg.nl
\nwww.artsennet.nl
\nNew Zealand Medical Association
\nP.O. Box 156, 26 The Terrace
\nWellington 1
\nNEW ZEALAND
\nTel: (64-4) 472 4741
\nFax: (64-4) 471 0838
\nE-mail: lianne@nzma.org.nz
\n41
\nWMA news
\nWebsite: www.nzma.org.nz
\nNigerian Medical Association
\n74, Adeniyi Jones Avenue Ikeja
\nP.O. Box 1108, Marina
\nLagos
\nNIGERIA
\nTel: (234-1) 480 1569, 876 4238
\nFax: (234-1) 493 6854
\nE-mail: info@nigeriannma.org
\nWebsite: www.nigeriannma.org
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum
\n0107 Oslo
\nNORWAY
\nTel: (47) 23 10 90 00
\nFax: (47) 23 10 90 10
\nE-mail: ellen.pettersen@legeforeningen.no
\nWebsite: www.legeforeningen.no
\nAsociaci\u00f3n M\u00e9dica Nacional
\nde la Rep\u00fablica de Panam\u00e1
\nApartado Postal 2020
\nPanam\u00e1 1
\nPANAMA
\nTel: (507) 263 7622 \/263-7758
\nFax: (507) 223 1462
\nFax modem: (507) 223-5555
\nE-mail: amenalpa@cwpanama.net
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791
\nMiraflores
\nLima
\nPERU
\nTel: (51-1) 241 75 72
\nFax: (51-1) 242 3917
\nE-mail: prensanacional@cmp.org.pe
\nWebsite: www.cmp.org.pe
\nPhilippine Medical Association
\n2\/F Administration Bldg.
\nPMA Compound, North Avenue
\nQuezon City 1105
\nPHILIPPINES
\nTel: (63-2) 929-63 66
\nFax: (63-2) 929-69 51
\nE-mail: philmedas@yahoo.com
\nWebsite: www.pma.com.ph
\nPolish Chamber of Physicians and Dentists
\n(Naczelna Izba Lekarska)
\n110 Jana Sobieskiego
\n00-764 Warsaw
\nPOLAND
\nTel. (48) 22 55 91 300\/324
\nFax: (48) 22 55 91 323
\nE-mail: sekretariat@hipokrates.org
\nWebsite: www.nil.org.pl
\nOrdem dos M\u00e9dicos
\nAv. Almirante Gago Coutinho, 151
\n1749-084 Lisbon
\nPORTUGAL
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: intl@omcn.pt
\nWebsite: www.ordemdosmedicos.pt
\nRomanian Medical Association
\nStr. Ionel Perlea, nr 10,
\nSect. 1, Bucarest
\nROMANIA
\nTel: (40-21) 460 08 30
\nFax: (40-21) 312 13 57
\nE-mail: amr@itcnet.ro
\nWebsite: www.ong.ro\/ong\/amr\/
\nRussian Medical Society
\nUdaltsova Street 85
\n119607 Moscow
\nRUSSIA
\nTel.\/Fax (7-495) 734-12-12
\nTel. (7-495) 734-11-00\/(7-495)734 11 00
\nE-mail: info@russmed.ru
\nWebsite: www.russmed.ru\/eng\/who.htm
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag \u2013 National Health Services
\nApia
\nSAMOA
\nTel. (685) 778 5858
\nE-mail: vialil_lameko@yahoo.com
\nOrdre National des M\u00e9decins du S\u00e9n\u00e9gal
\n(ONMS)
\nInstitut d\u2019Hygi\u00e8ne Sociale (Polyclinique)
\nBP 27115
\nDakar
\nSENEGAL
\nTel. (221) 33 822 29 89
\nFax: (221) 33 821 11 61
\nWebsite: www.ordremedecins.sn
\nSingapore Medical Association (SiMA)
\nAlumni Medical Centre, Level 2
\n2 College Road
\nSingapore 169850
\nTel. (65) 6223 1264
\nFax. (65) 6224 7827
\nE-mail. sma@sma.org.sg
\nWebsite: www.sma.org.sg
\nSlovak Medical Association
\nCukrova 3
\n813 22 Bratislava 1
\nSLOVAK REPUBLIC
\nTel. (421) 5292 2020
\nFax. (421) 5263 5611
\nE-mail: secretarysma@ba.telecom.sk
\nWebsite: www.sls.sk
\nSlovenian Medical Association
\nKomenskega 4
\n61001 Ljubljana
\nSLOVENIA
\nTel. (386-61) 323 469
\nFax: (386-61) 301 955
\nSomali Medical Association
\n7 Corfe Close
\nHayes
\nMiddlesex UB4 0XE
\nUnited Kingdom
\nE-mail: drdalmar@yahoo.co.uk
\nThe South African Medical Association
\nP.O. Box 74789, Lynnwood Rydge
\n0040 Pretoria
\nSOUTH AFRICA
\nTel: (27-12) 481 2045
\nFax: (27-12) 481 2100
\nE-mail: sginterim@samedical.org
\nWebsite: www.samedical.org
\nConsejo General de Colegios M\u00e9dicos
\nPlaza de las Cortes 11, 4a
\nMadrid 28014
\nSPAIN
\nTel: (34-91) 431 77 80
\nFax: (34-91) 431 96 20
\nE-mail: internacional@cgcom.es
\nWebsite: www.cgcom.es
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610
\nSE – 114 86 Stockholm
\nSWEDEN
\nTel: (46-8) 790 35 01
\nFax: (46-8) 10 31 44
\nE-mail: info@slf.se
\nWebsite: www.lakarforbundet.se
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses (FMH)
\nElfenstrasse 18 \u2013 C.P. 170
\n3000 Berne 15
\nSWITZERLAND
\nTel. (41-31) 359 11 11
\nFax. (41-31) 359 11 12
\nE-mail: info@fmh.ch
\nWebsite: www.fmh.ch
\nTaiwan Medical Association
\n9F, No 29, Sec.1
\nAn-Ho Road
\nTaipei 10688
\nTaiwan
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@tma.tw
\nWebsite: www.tma.tw
\nMedical Association of Thailand
\n2 Soi Soonvijai
\nNew Petchburi Road, Huaykwang Dist.
\nBangkok 10310
\nTHAILAND
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: www.medassocthai.org
\nConseil National de l\u2019Ordre
\ndes M\u00e9decins de Tunisie
\n16, rue de Touraine
\n1002 Tunis
\nTUNISIA
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: cnom@planet.tn
\nTurkish Medical Association
\nGMK Bulvari
\n\u015eehit Dani\u015f Tunaligil Sok. N\u00b0 2 Kat 4
\nMaltepe 06570
\nAnkara
\nTURKEY
\nTel: (90-312) 231 31 79
\nFax: (90-312) 231 19 52
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.ttb.org.tr
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874
\nKampala
\nUGANDA
\nTel. (256) 41 321795
\nFax. (256) 41 345597
\nE-mail. myers28@hotmail.com
\nUkrainian Medical Association (UkMA)
\n7 Eva Totstoho Street
\nPO Box 13
\nKyiv 01601
\nUKRAINE
\nTel. (380) 50 355 24 25
\nFax: (380) 44 501 23 66
\nE-mail: sfult@ukr.net
\nWebsite: www.sfult.org.ua
\nBritish Medical Association
\nBMA House, Tavistock Square
\nLondon WC1H 9JP
\nUNITED KINGDOM
\nTel: (44-207) 387-4499
\nFax: (44- 207) 383-6400
\nWebsite: www.bma.org.uk
\nAmerican Medical Association
\n515 North State Street
\nChicago, Illinois 60654
\nUNITED STATES
\nTel: (1-312) 464 5291 \/ 464 5040
\nFax: (1-312) 464 5973
\nE.mail: ellen.waterman@ama-assn.org
\nWebsite: www.ama-assn.org
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1515
\nCP 11200 Montevideo
\nURUGUAY
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nAssociazione Medica del Vaticano
\n00120 Citt\u00e0 del Vaticano
\nVATICAN STATE
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\nE-mail: servizi.sanitari@scv.va
\nFederacion MedicaVenezolana
\nAv. Orinoco con Avenida Perija
\nUrbanizacion Las Mercedes
\nCaracas 1060 CP
\nVENEZUELA
\nWebsite: www.federacionmedicavenezolana.org
\nVietnam Medical Association (VGAMP)
\n68A Ba Trieu-Street, Hoau Kiem District
\nHanoi
\nVIETNAM
\nTel: (84) 4 943 9323
\nFax: (84) 4 943 9323
\nWebsite: www.masean.org\/vietnam
\nZimbabwe Medical Association
\nP.O. Box 3671
\nHarare
\nZIMBABWE
\nTel. (263-4) 791553
\nFax. (263-4) 791561
\nE-mail: zima@zol.co.zw
\nWebsite: www.zima.org.zw
\nWMA news
\nNo time for depression \u2013 A busy year ahead for WMA . . . . . . . . 1
\nWMA Conference in Riga. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
\nDoctors for the environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
\n\u201cPhysicians suffering from silent desperation\u201d,
\nsays WMA leader. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
\nTask-shifting or task-sharing? \u2013
\nReflections from within the European Union (EU) . . . . . . . . . . 4
\nMulti-Drug Resistant TB in prisons. . . . . . . . . . . . . . . . . . . . . . . 6
\nNeuroimaging and the birth of cognitive\u00a0neuroscience. . . . . . . . 10
\nAction alertCountry-level support needed now
\nfor the global strategy to reduce the harmful use of alcohol. . . . . . . . . 12
\nResponse of the Global Alcohol Policy Alliance to WHO\u2019s. . . . 13
\nReflections on the Standing Committee
\nof\u00a0European Doctors\u2019 (CPME). . . . . . . . . . . . . . . . . . . . . . . . . . 14
\nThe European Patients\u2019 Forum (EPF). . . . . . . . . . . . . . . . . . . . . 18
\nUEMO \u2013 A common European voice
\nfor General Practicioners\/Family Physicians. . . . . . . . . . . . . . . . 21
\nGearing up for emergencies \u2013
\na vital component to our nation\u2019s health . . . . . . . . . . . . . . . . . . 24
\nReport of the 26th
\nCMAAO Bali Congress. . . . . . . . . . . . . . . . . 25
\nWhat can medical journals do for global health? . . . . . . . . . . . . 26
\nThe right to health as a bridge to peace in the Middle East. . . . 29
\nOrganization of the Professional Self-Government
\nof Physicians and Dentists in Poland . . . . . . . . . . . . . . . . . . . . . 30
\nMessages from Taiwan Medical Association. . . . . . . . . . . . . . . . 31
\nThe Israeli Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . 32
\nThe Ethiopian Medical Association . . . . . . . . . . . . . . . . . . . . . . 34
\nThe Organizaci\u00f3n M\u00e9dica Colegial De Espa\u00f1a . . . . . . . . . . . . . 35
\nMedical Confederation of the Argentine Republic. . . . . . . . . . . 36
\nCOP 15 \u2013 success or failure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
\n\u201cClimate change is the greatest
\nglobal health threat of the 21st
\ncentury\u201d. . . . . . . . . . . . . . . . . . . . 38
\nWMA Directory of Constituent Members. . . . . . . . . . . . . . . . . 39
\nWMA General Assembly, New Delhi
\nContents<\/p>\n"},"caption":{"rendered":"

wmj25 vol. 56 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 1, February 2010 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv editorin-chief@wma.net Co-Editor Dr. Alan J. Rowe Haughley Grange, Stowmarket Suffolk IP143QT, UK Co-Editor Prof. Dr. med. Elmar […]<\/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\/wmj25.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3590"}],"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=3590"}]}}