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wmj37<\/a><\/p>\n

COUNTRY
\n\u2022 Research Ethics Committees:
\nIdentifying and Weighing Potential Benefit and Harm
\nfrom Clinical Research
\n\u2022 What is \u201cDeontological Ethics\u201d?
\nvol. 58
\nMedicalWorld
\nJournalJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 1, February 2012
\nCover picture from Belarus
\nii
\nEditor in Chief
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\nCo-Editor
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\nEthics Committee
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\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nThe current year began with remarkable problems for many phy-
\nsicians and their organizations. In Poland, the parliament tried to
\nhold physicians financially responsible for the management of non-
\ntransparent entitlements of their patients. This is interesting in a
\ncountry where the health insurance system is run by the state \u2013 the
\nentity best positioned to fix the problem in the first place. Fortu-
\nnately it appears that the actions might be reversed soon.
\nAt the end of the year in the Slovak Republic, the government put
\nthe hospitals in a state of emergency, which placed hospital physi-
\ncians under a kind of martial law, prohibiting them from going on
\nstrike. Do they really believe physicians waived all their rights upon
\nentering the profession? Of course it is easy to save money at the
\nexpense of others, especially when you can \u201cgag\u201dthem with the help
\nof the police. This is yet another bitter attempt of a government to
\ncompensate for their financial problems by taking from those who
\nserve most and work hardest.The fact that physicians in the Slovak
\nRepublic are already severely underpaid makes the situation even
\nmore deplorable.
\nBut the worst situation has been the attempt by the Turkish gov-
\nernment to dismantle physician self-governance, despite the fact
\nthat this responsibility was granted by law to the Turkish Medical
\nAssociation. Through a government order, the Turkish government
\nis attempting to take key self-regulatory functions away from the
\nTMA and empower a government-controlled organization with
\noversight of all health professionals. This is a blatant attack on civil
\nsociety and defies the principles of parliamentary democracy, in
\nwhich laws made by the parliament must not be changed by the
\nexecutive branch.
\nLetters of solidarity have come to the Turkish Medical Association,
\nsupporting them in their fight for self-governance, civil engage-
\nment, and the maintenance of basic democratic rules. The World
\nMedical Association will have a presence in Ankara and Istanbul on
\nApril 16th
\nand 17th
\nto help the Turkish Physicians regain their rights
\nof self-regulation.
\nAttacks on physician self-governance have not been limited to these
\nvery recent situations. We have seen this several times in the past
\nyears, with some efforts more successful and some less so.The com-
\nmon thread among these situations is the objective of \u201ccommand
\nand control\u201dof the profession. In most affluent societies, health care
\nis by far the largest identifiable sector of economy.To steer this sec-
\ntor holds strong appeal for all governments. Physicians, with their
\nhighly influential structures designed to maintain and develop
\nhealth care systems, are the most targeted group in this changing
\nenvironment because cutting entitlements for medical and health
\ncare is most easily accomplished when this group is disempowered.
\nAnd in the end, it matters very little whether control of the profes-
\nsion is exercised by a government body, an insurance company, or a
\nmanaged care company.
\nThe profession has a lot to lose. Being regulated by a bureaucratic
\nadministration that does not understand medicine and the work of
\nphysicians is difficult. Being regulated by an administration that is
\nnot only disconnected from medicine and care but that has only
\ncost-savings on its radar is even worse. And while these frustrations
\nand difficulties are not to be underestimated, the ultimate threat is
\nto be downgraded from a respected profession to a technical service.
\nProfessional self-governance is not merely a means for physicians
\nto exercise control to serve their own interests; it serves a critical
\npatient-centered purpose and we must make that understood to
\nall stakeholders. In health care, the objective of self-governance is
\nto provide better medical care to the patients and services to our
\npeople, to protect the dignity of patients, and to improve public
\nhealth in our communities. We must be able to demonstrate to our
\nsocieties that it is to their advantage to have physicians who can
\nfreely exercise their duties according to professional standards and
\nethical rules rather then to be under the control of a government,
\nor an insurance or a managed care company. When physicians are
\nforced to follow third party orders, the interests of the patients will
\nalways come last.
\nDr. Otmar Kloiber
\nA Difficult Start Into the Year
\nEditorial
\n2
\nGERMANYClinical Research
\n1. Introduction1
\nIdentifying, assessing, and weighing poten-
\ntial benefit and harm from clinical research
\nis one of the central though most difficult
\ntasks of any research ethics committee
\n(REC). Article 15 of the World Medi-
\ncal Association\u2019s Declaration of Helsinki
\n(Seoul 2008) explicitly states:
\n\u201cThe research protocol [of every medical
\nresearch study involving human subjects]
\nmust be submitted for consideration, com-
\nment, guidance and approval to a research
\nethics committee before the study begins.\u201d
\nAnd (according to Article 18) every study
\n\u201cmust be preceded by careful assessment
\nof predictable risks and burdens to the in-
\ndividual and communities involved in the
\nresearch in comparison with foreseeable
\nbenefits to them and other individuals or
\n1 We thank Prof. Elmar Doppelfeld for helpful
\ncomments on an earlier version of the manuscript
\ncommunities affected by the condition un-
\nder investigation.\u201d
\nIn addition, biomedical research and the
\nrole of RECs are governed at the European
\nlevel by several legally binding instruments:
\nOne is the Directive 2001\/20\/EC relating
\nto the conduct of clinical trials on medicinal
\nproducts for human use. Article 3.2 states:
\n\u2026\u201dA clinical trial may be initiated only if
\nthe Ethics Committee \u2026 comes to the con-
\nclusion that the anticipated therapeutic and
\npublic health benefits justify the risks\u201d\u2026
\nThe Council of Europe\u2019s Convention on Hu-
\nman Rights and Biomedicine [1] and its Ad-
\nditional Protocol concerning Biomedical Re-
\nsearch [2] are binding only in States where
\nthey were ratified. The Convention states:
\n\u201cResearch on a person may only be under-
\ntaken if \u2026 the risks which may be incurred
\nby that person are not disproportionate to
\nthe potential benefits of the research\u201d (ar-
\nticle 16).
\nThe Additional Protocol explicates:
\n\u201cIn addition, where the research does not
\nhave the potential to produce results of
\ndirect benefit to the health of the research
\nparticipant, such research may only be un-
\ndertaken if the research entails no more
\nthan acceptable risk and acceptable bur-
\nden for the research participant\u201d (Article
\n6.2) and \u201cResearch on a person without the
\ncapacity to consent to research may be un-
\ndertaken only if \u2026 the research entails only
\nminimal risk and minimal burden to the in-
\ndividual concerned\u201d (Article 15).
\nThe task of the \u201crisk-benefit analysis\u201d pri-
\nmarily addresses researchers and secondly
\nthe relevant REC (and later i.a. monitoring
\ncommittees, industry, politicians, regulators,
\nproviders, purchasers, guideline producers;
\n[13] and finally individual doctors and pa-
\ntients: Communicating Risks and Benefits:
\nan evidence-based users guide [6].
\nIn 2004 the German Drug Law (Medicinal
\nProducts Law, in German: Arzneimittel-
\ngesetz = AMG) incorporated the norma-
\ntive framework of the European Directive
\n2001\/20\/EG, transforming the role of Ger-
\nmany\u2019s more than 50 RECs considerably.
\nIn the case of assessing clinical trials of
\nmedicinal products they had to change
\nfrom an intra-professional advisory to an
\napproving body.The changes intensified the
\nprofessionalisation of RECs and influenced
\nthe assessment of all study types. They gave
\nRECs both a stronger position and an in-
\ncreased responsibility.
\nOver the last years the bioethical literature
\nhave been proposing different approaches to
\nrisk-benefit assessment [11]. The two best
\nknown are the component analysis [15, 16,
\n17] and the net risk test [18, 19], the latter
\nbeing further developed into a seven-step
\nframework by Rid & Wendler [12].A recent
\noverview of relevant problems and literature
\nis provided by King and Churchill [10].
\nSince 2006 we have been developing and
\ntesting an own systematic approach to the
\nHeiner Raspe
\nResearch Ethics Committees:
\nIdentifying and Weighing Potential Benefit
\nand Harm from Clinical Research
\nAngelika H\u00fcppe
\n3
\nGERMANY Clinical Research
\nethical analysis of risks and potential ben-
\nefits from clinical research [8]. A prelimi-
\nnary version was applied to study protocols
\npresented (in 2006) to the REC of our
\nmedical faculty [9]. The text below gives a
\nbrief description of the method \u2013 against
\nthe background of the normative situation
\nof our country.
\n2. Evaluating potential benefit
\nand harm: a stepwise approach2
\nStep 1: Identifying potential benefi-
\nciaries and victims of possible harm
\nPrincipal beneficiaries are a) patients or
\nhealthy volunteers (probands) as study par-
\nticipants, b) patients or healthy volunteers
\noutside the study with the same charac-
\nteristics as defined by its in- and exclusion
\ncriteria, and c) a very broad range of other
\npersons, organisations, communities, (seg-
\nments of) public health or \u201cthe\u201d economy,
\nsociety, or environment. The same distinc-
\ntions are to be used to classify potential vic-
\ntims of possible harm (\u201cmaleficiaries\u201d).
\nA study implies potential individual benefit
\nif each and every participant has a priori a
\nchance to benefit directly from the diagnos-
\ntic or therapeutic intervention under study;
\nthis is the case if the benefit can be expected
\nas an effect of the specific intervention (as
\nits cause) and not via the mere inclusion in
\nthe study (by e.g. early access to novel treat-
\nment, careful monitoring, financial rewards;
\n\u201ccollateral benefit\u201d). Participation in a well
\nplanned double-blind randomised placebo-
\ncontrolled trial (RCT) convincingly hy-
\npothesising superiority of the experimental
\ncondition satisfies the criterion.
\nA study offers group benefit if its results
\ncan be more or less directly utilised in fa-
\n2 The following focuses (paradigmatically) on clini-
\ncal evaluative studies of diagnostic and therapeu-
\ntic methods.
\nvour of patients\/probands with characteris-
\ntics identical to those of the study members
\nexposed. One or few further \u2013 replicative
\nor corroborative \u2013 studies may be necessary
\nand acceptable. The first group to benefit
\nfrom the results of a \u201cpositive\u201dRCT may be
\nthe then unblinded control group followed
\nby other prevalent or incident cases with
\nidentical characteristics. We thus referred
\nto group benefit as a form of \u201cdelayed direct
\nbenefit\u201d [8]. Note that we propose a de-
\nliberately narrow definition of group ben-
\nefit\u00a0\u2013 a category which is being discussed
\nin Germany highly controversial, especially
\nwhen loosely defined (as e.g. in Article 17.2
\nof the Oviedo Convention: \u201c\u2026 other per-
\nsons in the same age category or afflicted
\nwith the same disease or having the same
\ncondition\u201d).
\nA study is said to have external benefit (or
\nharm) if c) applies. This category includes
\na wide and heterogeneous spectrum of po-
\ntential bene- and maleficiaries: it runs from
\nless well defined future patients\/probands
\nwith similar ailments and their relatives
\nand other healthy persons to researchers,
\nproviders and purchasers and further to
\npharmaceutical companies, clinical medi-
\ncine, biomedical science,\u201cthe\u201dnational eco-
\nnomy or \u201cthe\u201d community, society or envi-
\nronment.3
\nWe therefore propose to define three types
\nof possible benefits and beneficiaries \u2013 in
\ncontrast to prominent German ethicists
\nand Members of the Parliament who cling
\nto the dichotomy individual vs. external
\nbenefit. If they accept group benefit as an
\nadditional category at all, they regard it
\nonly as another subtype of external benefit.
\nAnd external benefit is seen as insufficient
\n3 \u201cExternal benefit\u201dis an incomplete and imperfect
\ntranslation of German \u201cFremdnutzen\u201d, which
\nmeans benefit not for the study participants
\nthemselves or the respective group but for unde-
\nfined others. \u201cFremd\u201d is the (German) antonym
\nto \u201cselbst\u201d (Englisch: self) and indicates a wide
\ndistance, even an opposition between individual
\nand external benefit.
\nfor justifying the inclusion of patients into
\nstudies and totally unacceptable where a
\ntrial addresses adults being \u201cincapable of
\ncomprehending the nature, significance
\nand implications of the clinical trial and
\nof determining his\/her will in the light of
\nthese facts\u201d (\u00a7 41 (3) AMG). This position
\nstill prevents Germany from ratifying the
\nConvention on Human Rights and Bio-
\nmedicine [1] and led our country to add an
\n\u201cexplanation of vote\u201d to the Universal Dec-
\nlaration on Bioethics and Human Rights
\n[2].
\nThe position poses particular difficulties for
\nmedicine as an evidence-based pragmatic
\nscience. Medicine has to rely, for example,
\non evidence-based diagnostic strategies
\nand tests to be developed and evaluated
\nin a series of diagnostic studies, be it in
\ndecisionally capable or incapable subjects
\n(e.g. newborns, young children, demen-
\ntia patients, stroke or accident victims).
\nOne indispensable early step in the series
\nis the diagnostic accuracy study; it applies
\na new test to two groups separated on the
\noutcome of an established \u201cgold standard\u201d
\ntest: subjects definitely with vs. definitely
\nwithout the disease in question. Imagine
\nthe evaluation of a novel blood test pre-
\nsumably specific for adult Alzheimer\u2019s dis-
\nease. An early low-risk phase 2 diagnostic
\nstudy (case-referent approach) would start
\nwith advanced cases and ask whether the
\nresults of the new test differ between the
\ncases and a group of non-diseased subjects.
\nIts results are evidently of no direct benefit
\nfor any of the study participants but imply
\npotential benefit for 1. the preparation and
\nconduct of a phase 3 study (cohort type in
\nthe clinical environment followed by phase
\n4 and 5 studies4
\nand 2. \u2013 when again and
\nagain \u201cpositive\u201d \u2013 for further prevalent
\nand incident clinical cases (group benefit).
\nAn analogous example from the world of
\ntherapeutic studies is given by the strictly
\n4 A phase 4 study analyses therapeutic impact, of-
\nten in a before-after design, a phase 5 study is a
\ndiagnostic RCT.
\n4
\nGERMANYClinical Research
\nnon-interventional cohort study assessing
\nfavourable and unfavourable effects of e.g.
\na certain drug under ordinary practice con-
\nditions, another by some non-inferiority
\nRCTs. Again, one cannot expect a direct
\nbenefit for any of the study participants but
\npossible benefit for equal patients outside
\nthe study, when for instance therapeutic al-
\nternatives have to be considered.
\nWe can\u2019t discuss here in detail the ethics of
\ngroup-beneficial studies but would like to
\nstate that if patients, clinicians, purchasers,
\nlegislators and regulators demand evidence-
\nbased diagnostic testing (and treatment)
\nindependently from the patients\u2019 decisional
\ncapacity then studies such as the men-
\ntioned above have to be conducted. If this
\nis accepted it is inacceptable to outlaw such
\nstudies. We hope that our narrow defini-
\ntion of group benefit (as a third category)
\nmay help building a bridge between so far
\nincompatible positions5
\n.
\nStep 2: Realising country-
\nspecific legal norms
\nThough \u2013 at least in the European con-
\ntext\u00a0 \u2013 a further convergence of legally
\nbinding norms can be expected, there are
\nstill national peculiarities (see for instance
\nfootnote 4). Hence it is necessary to realise
\nand recognise all relevant country-specific
\nnorms and directives. Some address cer-
\ntain groups of beneficiaries, others require
\ncertain types of benefit or define upper
\nlimits for risks and burdens. All this serves
\nthe purpose of harm minimisation, an
\nethical requirement which is relevant not
\nonly when legally prescribed. It has to be
\nobserved whenever and wherever a study
\nis planned and conducted. RECs should
\npropose how to minimise study-associated
\npotential harms.
\n5 The German situation is all the more incompre-
\nhensible as the law accepts group-beneficial stud-
\nies in children (\u00a7 41 (2) AMG) but not in deci-
\nsionally incapable adults (\u00a7 41 (3)).
\nStep 3: Assessing equipoise
\nThis step involves two assessments: The
\nfirst evaluates whether any study group or
\nindividual subject is at risk of substandard
\ncare as defined by relevant clinical practice
\nguidelines (\u201cexternal equipoise\u201d).This ques-
\ntion is difficult to answer especially when
\n\u201croutine or usual care\u201d serves as a compara-
\ntor in a controlled study. Does the actual
\ncare meet relevant professional standards?
\nFor uncontrolled studies such standards
\nprovide a benchmark for the evaluation of
\nthe experimental condition (or the actual
\ncare in purely observational studies).
\nThe second assessment addresses the po-
\ntential benefit\/harm relations between
\ntwo or more arms within controlled stud-
\nies (\u201cinternal equipoise\u201d). We ask whether
\nthe different exposures imply comparable
\nrisks, potential benefits and harm-benefit
\nrelations\u00a0\u2013 in the light of the current best
\navailable evidence as critically appraised by
\nthe respective expert community.If a certain
\nclinician deliberately participates in a study
\nhe or she agrees, at least implicitly, with
\nwhat was accepted as being \u201cin equipoise\u201d.
\nConfusion sometimes arises from study
\nhypotheses which take a relevant clinical
\nbenefit already for granted and do not leave
\nroom for doubt and so far imperfect knowl-
\nedge (i.e. for further research).
\nStep 4: Identifying, measuring,
\nand assessing single potential
\nbenefits and harms
\nThe following distinctions apply to the
\nanalysis of both potential benefits and
\nharms again: we assess their type\/qual-
\nity and relevance (e.g. mortality, morbidity,
\nsymptoms, quality of life) \u2013 magnitude\/size
\n(given e.g. as high relative risk, absolute risk
\ndifference, effect size) \u2013 likelihood of their
\noccurrence (absolute risk,number needed to
\ntreat\/harm) \u2013 time of onset and duration\/
\nsustainability of any favourable or unfavour-
\nable effect (minutes to years). We propose
\nto express the degree of relevance, size, and
\nlikelihood of any benefit\/harm by means of
\nsimple trichotomous scales (at least: high \u2013
\nmedium \u2013 low6
\n). Finally, a similar rating of
\nthe certainty of each single estimate and of
\nthe aggregated benefit and harm is required
\n(based on e.g. confidence intervals of point
\nestimates). An open question addresses the
\ndegree of (un)certainty (bias potential) of
\nthe total body of evidence regarding pos-
\nsible benefits and harms: Germany\u2019s Drug
\nLaw (\u00a7 5 (2)) requires not more than \u201crea-
\nson to suspect\u201d that a certain drug is un-
\nsafe\u00a0\u2013 a standard nobody would accept for
\n\u201cproving\u201d potential benefit. In view of the
\ncentral role of RECs (to protect study par-
\nticipants) a lower standard of proof thus
\nseems acceptable when risks and burdens
\nare to be considered.
\nStep 5: Analysing, comparing, and
\nassessing summary benefits and harms
\nSummary statistics (rates, means, relative
\nrisks, effect sizes etc.) are more or less blind
\nto underlying distributions: take, for ex-
\nample, a head-to-head comparison of two
\ndrugs, novel vs. standard; assume the RCT
\nresults in equal success rates (in %).Can you
\nbe sure (without additional data and analy-
\nses?) that the benefit is equally stochastical-
\nly distributed within the two groups? Could
\nit be that the interventional product favours
\nfemales (one half of each sample) whereas
\nthe comparator favours males (the other
\nhalf)? You can\u2019t be sure, even though the re-
\nsearchers started the trial under the (in the
\nlight of all current knowledge) justifiable as-
\nsumption of stochastic effectiveness within
\nboth groups. A similar question arises when
\nstatistics for central tendencies (mean, me-
\ndian) are to be analysed (who benefits with-
\nin a sample?) and compared (equal benefi-
\nciaries across samples?). These uncertainties
\n6 Wider ranging scales may be used, e.g. for ex-
\npressing the potential frequency (fivefold between
\nvery frequent and very rare) or severity (fivefold)
\nof harms:
\n5
\nGERMANY Clinical Research
\nrequire both a close inspection of individual
\ndata and subgroup analyses.
\nOther problems are encountered where
\nmultiple and\/or complex outcome measures
\nare included such as a range of heteroge-
\nneous endpoints (e.g. clinical, laboratory,
\npatient related), health related quality of life
\nscales or\u00a0\u2013 even more opaque \u2013 quality ad-
\njusted life years (QALYs). The widely used
\ninstrument SF36, for instance, comprises 8
\ncomponents (vitality, physical functioning,
\nbodily pain etc.) each made up by more than
\none item. All separate results can be sum-
\nmarised in two measures (physical\/men-
\ntal subscale summary) and a single over-
\nall score. Thus equal sum scores may well
\nhide differences at the item, component or
\nsubscale level and\/or different mixtures of
\npositive and negative effects and thus may
\nwell have different meaning in the light
\nof different patient preferences. The use of
\nQALYs adds merely another incommen-
\nsurable dimension (lifetime) to a measure
\nalready non-transparent. Similar problems
\nresult from the use of so called composite
\nendpoints.
\nThough these considerations relate more
\nto situations where completed studies have
\nto be appraised they are not irrelevant for
\nRECs. To get an estimate of potential ben-
\nefit and harm RECs have to rely on the re-
\nsults of former evaluative (e.g. phase 1 and
\n2 drug) studies, besides case reports, lab and
\nanimal research, and preclinical human ex-
\nperiments.
\nStep 6: Weighing all
\nbenefit against harm
\nNevertheless, different approaches to the
\nassessment of \u201cnet benefit\u201d have been
\nproposed (European Medicines Agency
\n20117
\n)\u00a0\u2013 mathematical (aiming at an aggre-
\n7 EMA`s considerations refer to the evaluations of
\ncompleted studies but seem useful in our context
\nas well.
\ngate statistic expressing the balance between
\nall benefits and harm),\u201calgorithmical\u201d(aim-
\ning at a structured stepwise assessment and
\nsummary), and purely judgemental. We
\nprefer and recommend the multidimen-
\nsional judgement approach to be guided
\ninitially by the stepwise identification and
\nassessment of every potential benefit and
\nharm as mentioned above [8, 9].The judge-
\nments then have to be worked out in a thor-
\nough discussion among all REC members.
\nThough this may end up with only incon-
\nsistent \u201ccapricious\u201d results, depending on
\nnumerous situational factors, the proposal
\ntakes into account the singular nature of
\neach study, the fundamental incommen-
\nsurability of different types of benefit and
\nharm (see above) and the (to our opinion)
\nindispensable exchange of various profes-
\nsional and lay perspectives.
\nHowever, before starting any discussion,
\nit has to be made clear whether individual
\n(potential) benefit always (or only in certain
\ncases?) has to exceed harm,balance it,has to
\nbe only loosely related or may in some situ-
\nations even be sacrificed for a greater good,
\ne.g. \u201cthe anticipated significance of the me-
\ndicinal product for medical science8
\n(\u00a7 40
\n(1) 2 AMG) or public health.
\nIt is surprising that virtually every REC in
\nthe world faces the task of \u201cbalancing ben-
\nefits and risks\u201d\u00a09
\nand seems to cope with it
\nsuccessfully on an everyday basis \u2013 in the
\nabsence of any formal concept, advice and
\ntraining. We are learning by doing and
\ntraining on the job.The Guide for Research
\nEthics Committee Members designed to
\nassist RECs and based on a number of Eu-
\nropean Conventions and Protocols [3] of-
\nfers some help, for example it outlines key
\n8 In German: \u201cHeilkunde\u201d which means \u201cclinical
\nmedicine\u201d and is to be distinguished from \u201cmedi-
\ncal science\u201d.
\n9 Which is eo ipso either impossible or trivial:
\n\u201crisk\u201d refers to the probability of an unfavourable
\noutcome within a defined period of time whereas
\n\u201cbenefit\u201drefers to a factually given but further un-
\nspecified advantage.
\nquestions which RECs should consider
\nwhen reviewing a research protocol.
\nIs this an unsatisfactory situation? We think
\nit is, but at present we are unable to offer a
\nmore complete solution. Nevertheless: our
\ndescriptive and evaluative taxonomy com-
\nbined with the conceptual framework for
\ncomparing and balancing potential research
\nbenefit and harm should increase transpar-
\nency of eventual judgements and facilitate
\nthe communication between and within
\nresearch groups and RECs. It may help to
\nstandardise and harmonise ethical review,
\nadvice, and approval procedures.
\nReferences:
\n1. Council of Europe: Convention for the Protec-
\ntion of Human Rights and Dignity of the Hu-
\nman Being with regard to the Application of
\nBiology and Medicine: Convention on Human
\nRights and Biomedicine. Oviedo, 4.IV.1997
\nhttp:\/\/conventions.coe.int\/Treaty\/en\/Treaties\/
\nHtml\/164.htm (accessed February 14th
\n).
\n2. Council of Europe: Additional Protocol to the
\nConvention on Human Rights and Biomedi-
\ncine, concerning Biomedical Research. Stras-
\nbourg, 25.I.2005 http:\/\/conventions.coe.int\/
\nTreaty\/en\/Treaties\/Html\/195.htm (accessed
\nFebruary 14th
\n).
\n3. Council of Europe (2011): Steering Committee
\non Bioethics (CDBI) Guide for Research Ethics
\nCommittee Members. Strasbourg, 7th
\nFebruary
\n2011. http:\/\/www.coe.int\/t\/dg3\/healthbioethic\/
\nsource\/INF(2011)_en.pdf (accessed February
\n14th
\n).
\n4. European Communities: Directive 2001\/20\/EC
\nof the European Parliament and of the Council
\nof 4 April 2001 Official Journal of the European
\nCommunities L 121\/34. http:\/\/eur-lex.europa.
\neu\/LexUriServ\/LexUriServ.do?uri=OJ:L:200
\n1:121:0034:0044:EN:PDF (accessed February
\n14th
\n).
\n5. European Medicines Agency (EMA) 2011
\nBenefit-risk methodology project: Work pack-
\nage 2 report \u2013Applicability of current tools and
\nprocesses for regulatory benefit-risk assessment.
\nhttp:\/\/www.ema.europa.eu\/docs\/en_GB\/docu-
\nment_library\/Report\/2010\/10\/WC500097750.
\npdf (accessed February 14th
\n).
\n6. Fischhoff B, Brewer NT, Downs JS, PhD, edi-
\ntors. Communicating Risks and Benefits: An
\nEvidence-Based User\u2019s Guide. Food and Drug
\nAdministration (FDA), US Department of
\nHealth and Human Services, Silver Spring
\n6
\nBELARUSMedical Ethics
\nAugust 2011. http:\/\/www.fda.gov\/downloads\/
\nAboutFDA\/ReportsManualsForms\/Reports\/
\nUCM268069.pdf (accessed February 14th
\n).
\n7. Gesetz \u00fcber den Verkehr mit Arzneimitteln
\n(Arzneimittelgesetz – AMG): http:\/\/www.ge-
\nsetze-im-internet.de\/bundesrecht\/amg_1976\/
\ngesamt.pdf (accessed February 14th
\n).
\n8. H\u00fcppe A, Raspe H (2009) Analyse und Abw\u00e4-
\ngung von Nutzen- und Schadenpotenzialen aus
\nklinischer Forschung. In J. Boos, R. Merkel, H.
\nRaspe, B. Sch\u00f6ne-Seifert (Hrsg.) Nutzen und
\nSchaden aus klinischer Forschung am Men-
\nschen. Deutscher \u00c4rzteverlag, S. 13-52.
\n9. H\u00fcppe A, Raspe H (2011) Mehr Nutzen als
\nSchaden? Nutzen- und Schadenpotenziale
\nvon Forschungsprojekten einer medizinischen
\nFakult\u00e4t \u2013 eine empirische Analyse. Ethik Med
\n23: 107-121.
\n10. King NMP, Churchill LR (2008) Assessing and
\ncomparing potential benefits and risks of harm
\nIn: EJ Emanuel, Grady C, RA Crouch, RK Lie,
\nFG Miller, D Wendler (eds.) The Oxford text-
\nbook of clinical research ethics. Oxford Univer-
\nsity Press, 514-526.
\n11. Rid A, Wendler D. (2010) Risk-benefit assess-
\nment in medical research \u2013 critical review and
\nopen questions. Law, Probability and Risk, 9,
\n151-177.
\n12. Rid A, Wendler D. (2011) A framework for
\nrisk-benefit evaluations in biomedical research.
\nKennedy Inst Ethics J. 21:141-79.
\n13. Sawaya GF, Guirguis-Blake J, LeFevre M Har-
\nris R,Petitti D (2007) Update on the methods of
\nthe U.S.Preventive Services Task Force: estimat-
\ning certainty and magnitude of net benefit. Ann
\nIntern Med.; 147:871-875.
\n14. United Nations Educational, Scientific and
\nCultural Organization (UNESCO): Universal
\nDeclaration on Bioethics and Human Rights.
\nAdopted by acclamation on 19 October 2005
\nby the 33 rd session of the General Confer-
\nence of UNESCO. http:\/\/unesdoc.unesco.org\/
\nimages\/0014\/001461\/146180E.pdf (accessed
\nFebruary 14th
\n).
\n15. Weijer C (2001) The Ethical Analysis of Risks
\nand Potential Benefits in Human Subjects Re-
\nsearch: History, Theory and Implications for
\nU.S. Regulation. In: National Bioethics Advi-
\nsory Commission: Ethical and Policy Issues in
\nResearch Involving Human Participants. Vol. 2,
\n1-29.
\n16. Weijer C, Miller PB (2004) When are research
\nrisks reasonable in relation to anticipated ben-
\nefits? Nature Medicine, 10, 570-573.
\n17. Weijer C (2000) The Ethical Analysis of Risk.
\nJournal of Law,Medicine & Ethics,28,344-361.
\n18. Wendler D, Miller FG (2008) Risk-benefit
\nanalysis and the net risk test. In : Emanuel EJ
\net al. (Eds.) The Oxford Handbook of Clinical
\nResearch Ethics. New York: Oxford University
\nPress. p 503-526.
\n19. Wendler D, Miller FG (2007) Assessing re-
\nsearch risks systematically: the net risks test.
\nJ\u00a0Med Ethics, 33, 481-486.
\n20. World Medical Association (2008) Declaration
\nof Helsinki: Ethical Principles for Medical Re-
\nsearch Involving Human Subjects, 59th
\nWMA
\nGeneral Assembly, Seoul.
\nMD, PhD Prof. Heiner Raspe,
\nDr.\u00a0Angelika H\u00fcppe,
\nCentre for Population Medicine
\nand Health Services Research and
\nResearch Ethics Committee,
\nUniversity at Luebeck
\nRatzeburger Allee, D 23538
\nLuebeck, Germany
\nE-mail: heiner.raspe@uksh.de
\nIt is known that deontological ethics means
\na set of ethical and moral standards for
\nhealth professionals when they perform
\ntheir professional duties.These notions were
\nderived from Latin word \u201cethica\u201d, Greek
\nword \u201cethice\u201d \u2013 ethics and morality study,
\nand Greek word \u201cdeon\u201d \u2013 duty.
\nFirst records about medical ethics and
\ndeontology appeared in ancient sources:
\n\u201cThe Code of Hammurabi\u201d (Babylonian
\nlaw code, XVIII BC), \u201cOn the Physician\u201d,
\n\u201cHippocratic Oath\u201d and \u201cHippocratic Cor-
\npus\u201d (V\u2013IV BC), Indian \u201cBook of life\u201d \u2013
\n\u201cAyurveda\u201d (V\u2013IV BC). Term \u201cethics\u201d as a
\ncriterion for human morality and ethics was
\nset forward by Aristotle (384-322 BC).The
\nnotion of deontological ethics as \u201c…a study
\nof proper human conduct in order to reach
\nhis\/her goal\u201d was introduced in XVIII by
\nEnglish philosopher, jurist and priest Jer-
\nemy Bentham.
\nToday medical ethics includes the following
\naspects: scientific, which is studying ethical
\nrules of health professionals\u2019 activity, and
\npractical which is development and appli-
\nVladimir Krylov
\nAnd Still, What is \u201cDeontological Ethics\u201d?
\nPavel Mikhalevich
\n7
\nBELARUS Medical Ethics
\ncation of ethical rules in professional activ-
\nity. Being a criterion for personal qualities
\nof a health professional it studies and de-
\ntermines solution to different interpersonal
\nissues between colleagues, with patients,
\ntheir relatives, junior and senior personnel,
\nadministration.
\nThe quality of performance of deontologi-
\ncal rules by health professionals depends
\ndirectly on political, economical and social
\ncondition of the states, which influence the
\nlevel of ethical views of contemporary soci-
\nety. Currently global capitalization is hap-
\npening in the world and its peak is about
\nto reach heights. Population of economi-
\ncally developed countries is consistently
\nincreasing consumption of resources, which
\npeter out tragically fast. Unstoppable con-
\nsumption, especially when humans use for
\nthemselves much more than they create by
\ntheir labor, is per se an immoral action.This
\nattitude to life leads to tension in society,
\nwhich causes social and political tempests,
\nwhich in their turn intensify demonstration
\nof immorality.
\nThis is the picture we\u2019ve observed in recent
\ndecades in CIS countries,including Belarus.
\nCertainly, in circumstances like these the
\nprinciples of ethical life of a society change
\nand this concerns medical deontological
\nethics despite its somewhat traditional pro-
\nfessional resistance to difficulties of life in
\nsociety.
\nHippocratic Oath is rarely remembered in
\ntoday\u2019s society. Commercialization, which
\naffected all levels of social life, firmly settled
\ndown in medicine as well.Profit in this once
\ngrand and genuine area of social life pushed
\nmoral principles aside from priority posi-
\ntion, replacing them with economic effi-
\nciency of rendering medical aid, its substan-
\ntiation of application effectiveness. Material
\nsignificance began to replace not only ethic,
\nbut moral principles as well.
\nHowever the reasons of it aren\u2019t only in so-
\ncial and economical tempests of contempo-
\nrary social and political system. Disparity
\nof obeying to deontological rules is based
\nin the nature of human development. To
\nunderstand that it\u2019s necessary to remember
\nfundamental provisions of ethical notions,
\nwhich humanity created in course of many
\nthousands of years. Peculiarity of ethics as
\nthe code of human conduct in society and
\ndefinition of duty we have to each other is
\nin the fact that it wasn\u2019t created by separate
\nindividuals, but was formed by community
\nin the process of making of humanity. It is
\na reflection of our life, expectations and ac-
\ntions of every one and each of us.
\nEthics lies in the following. Development
\nof humanity happens in two ways. One of
\nthem is materialistic, the other one is ideal-
\nistic. The first one implies utilitarian, selfish
\nand pragmatic character of mutual relations
\nwhereby the mindset is formed on the basis
\nof principles of material priority in our life,
\nthe other one is altruistic, sacrificial, extra
\nterrestrial spirituality is in its basis.
\nContact of these two ways is across two no-
\ntions: morality (formal duty of every person
\nto other people) and ethics (heartfelt atti-
\ntude to the formal duty, when duty to each
\nother isn\u2019t based on principles \u201cyou do this
\nfor me and I\u2019ll do that for you\u201d but when it
\nis based on deep respect and love to people
\nwho are people just like you are). Human
\nmoral principles are secured by legislation
\n(Constitution, codes, regulations, instruc-
\ntions and others) by a certain community
\nand are binding. Ethical principles are not
\ndeclared by laws, but are determined by
\neach person\u2019s conscience, and they are dem-
\nonstrated in mercy and sacrifice towards
\nother people and it all is aimed at spiritual
\ndevelopment.
\nFailure to obey moral principles, i.e. civil
\nlaws adopted by us,is called immorality,and
\ntheir complete neglect is called degradation.
\nOn the contrary, idealistic way provides
\nfor further ethical development in order
\nto reach spirituality and holiness. When a
\nperson loses ethical criteria it brings him\/
\nher back to pragmatic way of development.
\nTherefore, materialistic (pragmatic) way of
\ndevelopment is determined by moral, im-
\nmoral and degradation criteria. And ideal-
\nistic way is determined by ethics,spirituality
\nand holiness. Based on humanity develop-
\nment it is clear that humans make a way
\nfrom primitiveness to high ethical stan-
\ndards.
\nThe basis for these ethical rules is Moses\u2019
\nDecalog.His first three commandments be-
\ncame the grounds for formation of idealistic
\nway of development by humanity, and oth-
\ners \u2013 of pragmatic. On the border between
\nthem there are so called good people. They
\nfollow moral principles, they don\u2019t violate
\nthem, and to a certain extent they are self-
\nless and they tend to respect others. This
\ncondition is the basis for transition to ideal-
\nistic way. At the same time it is necessary to
\nclearly understand, that the way of develop-
\nment isn\u2019t chosen for a certain person but
\nthe person chooses it himself or herself.
\nNumerous studies showed that even in
\nmore simple biological life two thirds of so-
\nciety show characteristics of selfishness and
\none third sacrifice themselves to secure life.
\nThe same way in human society, two thirds
\nof people follow pragmatic (naturalistic)
\nway of life (development), and idealistic is
\nfollowed only by one third. That said most
\nof \u201cidealists\u201dare in the zone of ethical crite-
\nria because it is extremely difficult to reach
\nspirituality and holiness.Therefore they may
\nperiodically stray away from moral stands to
\nelements of pragmatic or utilitarian ambi-
\ntions. However mobilization of efforts in
\ndevelopment of altruism and mercy give
\nthem opportunity to harden at this ethical
\nlevel.
\nIt should be noted that there\u2019s a belief that
\nthe mentioned ratio 66.6 percent and 33.3%
\npercent reflect biblical thought. In the Bi-
\nble number 666 is mentioned as the devil\u2019s
\nnumber. And it is logical to match it with
\nthe rating 66.6 percent, which reflects self-
\nish attitude to life with utilitarian and mer-
\n8
\nBELARUSMedical Ethics
\ncenary interests. Lucifer is considered to be
\nthe prince of this world. On the contrary in
\nthe Bible there\u2019s crucifixion of 33 years old
\nJesus Christ, symbolizing sacrifice for the
\nsake of others and characterizing idealistic
\nand altruistic attitude to life.
\nTherefore the majority of the population
\nprefers utilitarian needs as the basis of their
\nlife interests, and these needs mainly de-
\ntermine the way of interpersonal relations.
\nSacrifice for the sake of others, selfless serv-
\ning to interests of other people are more rare
\nevents in our real life.
\nThis proportion is destroyed when the ma-
\njority of people abandon moral stands. Im-
\nmorality is a serious evidence of disease of
\nsociety; it draws the people who are near
\ninto greedy rush of chasing after additional
\nprofit.When that happens it\u2019s impossible to
\ntalk about mercy or require from the per-
\nson who hasn\u2019t grown to follow moral, not
\nto mention ethical criteria, to be an altruist,
\nto be selfless and sacrificial. These qualities
\nshould mature in a person, they don\u2019t just
\ncome from somewhere but they are the re-
\nsult of persistent seeking in everyday life for
\nbeautiful and genuine things which are love
\nand mercy.
\nIt is impossible to deny that many people
\ngo into medicine because of their calling,
\nat the heart\u2019s dictation or because of intu-
\nition, so they are prone to mercy, serving
\nothers, sharing their pain and sufferings.
\nHowever the experience has shown that
\namong health professionals there are lots of
\nthose who either lost these genuine qualities
\nor they have never had them and got into
\nmedicine accidentally or on opportunistic
\ngrounds.
\nWhat can you require from them? Can you
\nrequire that they act genuinely and merci-
\nfully? They know how to do that in their
\nminds but not in their souls. That is why
\nthey will adapt to these requirements, re-
\nmaining self-centered in their souls,and not
\nbeing able to share the sufferings of their
\npatients. Among them there can be spec-
\ntacular professionals, who really do good for
\nthe patient but remain cold-hearted in their
\nactions.
\nSo here in this surrounding of health pro-
\nfessionals,who live on the grounds of unsta-
\nble moral criteria, where there are no moral
\nprinciples in life, deontological problems
\narise. And furthermore it is necessary to
\nclearly understand that it is connected with
\nweak moral basis of an individual.
\nIt\u2019s been known for a long time, and that is
\nwhy at the beginning of making of nation-
\nality the rules of work for health profession-
\nals already existed and they governed their
\nattitude towards patient despite absence of
\nmorality. Even Ibn Sina required treating
\npatients in a special way: \u201cYou should know
\nthat every individual has special character,
\nnative personally to him\/her.It is very rarely
\nor never for someone to have the same char-
\nacter as somebody else\u2019s\u201d. In ancient Indian
\ntreatise the doctor told his disciples: \u201cNow
\nyou should leave your passions, rage, greed,
\nfoulness, vanity, pride, jealousy, rudeness,
\nfooling, falseness, laziness and any wrong
\nbehavior. From now on you will have your
\nhair and nails close-cut, you will wear red
\nclothes and live pure life\u201d
\nHowever health professionals by no means
\nalways obey to moral requirements, not to
\nmention ethical aspect, that it why in prac-
\ntice the main rule was formed: do no harm!
\nGradually in different countries very similar
\nlegislation was formed which was aimed at
\nregulation of work of health professionals,
\nwhich should stop ethical violations and er-
\nrors in treatment of patients.
\nHowever in healthcare professionals\u2019 activ-
\nity there may be not only errors but medical
\noffence as well.That is why abiding to moral
\nand ethical standards by health profession-
\nals means not only fulfilling one\u2019s duties but
\nalso being held liable for failure to fulfill or
\nnon-professional performance of one\u2019s du-
\nties.
\nDepending on the degree of seriousness
\nof committed offence health professional
\nis subject to administrative punishment
\n(admonition, severe admonition, transfer
\nto a less paid job, and etc.) or is subject
\nto punishment in accordance with appli-
\ncable legislation. Thus work with patients
\napart from accurate fulfillment of duties by
\nhealth professionals assumes abiding to the
\nprinciples of medical deontology and legal
\nliability.
\nWhen mutual relationships were capital-
\nized the concept of moral was substantially
\nchanged not to mention ethical grounds of
\nmedical treatment. It deprived of halo all
\nsorts of activities which before that were
\nconsidered honorable and were treated with
\nreverence. Doctors, lawyers, priests, poets,
\nscientists became paid salaried employees,
\nwhich lead to decrease in the level of cri-
\nteria of moral responsibility among them.
\nYet many famous doctors in the world have
\nurged and urge today not to turn people\u2019s
\ndiseases into means of gaining profit.
\nThere is not doubt that the main deonto-
\nlogical and standard work offences in the
\nfield of medicine are driven by weak morals.
\nPatients\u2019 sufferings form even deeper feel-
\nings of compassion and mercy only in deep-
\nly ethic employees. In these events patient
\nsay: \u201cdoctor, medical assistant or nurse with
\na God-given talent\u201d. In case of immoral
\nview of life someone else\u2019s sufferings don\u2019t
\naffect the soul of a medical employee, and
\nthis leads to an even bigger obduracy.This is
\nthe trouble of many employees. And it\u2019s im-
\npossible to change that with orders. That\u2019s
\nwhere delicate work with them is needed,
\nthe work aimed at upbringing ethical stan-
\ndards.
\nWork of a health professional is hard work.
\nThe main problem is connected with con-
\nsiderable psycho emotional load. It is es-
\npecially hard on responsible employees in
\nconnection with demonstrating by them the
\nfeelings of compassion and mercy. In this
\nsituation ethical upbringing and support of
\n9
\nRegional and NMA newsCOLOMBIA
\na health professional can not only preserve
\nhis or her psycho emotional status but also
\nincrease his or her spiritual qualities.
\nThat is why it is important for the state
\nto take care of social conditions and psy-
\nchological climate of medical personnel.
\nSupport for health professionals may be
\nin attention to them from administration,
\nrestriction from unneeded administra-
\ntive tasks, the feeling of care and delicacy
\nwhich will correspond to moral and maybe
\neven ethical criteria of the manager. Work
\nwith personnel not only concerning profes-
\nsional issues but also studying the basics of
\nmedical ethics can bring up good results in
\ntreating patients and upbringing spiritual
\nqualities specifically in every individual em-
\nployee.
\nIt is a difficult task, which can\u2019t be done by
\nmeans of administrative actions only. Of
\ncourse testing for compliance to working
\nwith patients could be introduced but it is
\nnot possible because it is very hard to orga-
\nnize it and there may be serious shortage in
\nhealth professionals. At the same time team
\nstrategy has never lead people to ethics and
\nmoral standards as our life shows it\u2019s very
\nhard for it to contain either.
\nWe need a structural element which in its
\nnature would be to a much lesser extent
\nconnected with administration. We have a
\nnonprofit volunteer organization like that.
\nIt is Belarusian Association of Doctors. In
\nit the work is based on volunteer principle
\nof assisting each other within the frame-
\nwork of legislation of the state. Special role
\nhas Ethical Commission of the Association,
\nthe aim of which is to support and pro-
\ntect honor, dignity and professionalism of
\nhealth professionals. The basis of work of
\nthis Commission must be moral and ethical
\nprinciples.
\nBelarusian Association of Doctors, remain-
\ning an open nonprofit organization, has to
\nkeep to priority membership of best spe-
\ncialists, employees who adhere to moral and
\nethic criteria. The main direction of it work
\nmust be ensuring rights, honor and dignity
\nprotection of its members in the framework
\nof legislation and ethical rules, support of
\nimprovement of their professional level,
\nhelp to the population concerning issues of
\nmutual relationships between patient and
\nhealth professional.
\nCoordination of work with the Health
\nMinistry is necessary. For that it is reason-
\nable to conclude an official agreement with
\nit concerning format of joint venture stat-
\ning clear dividing functions of work with
\nhealth professionals in the form of mutual
\nassistance and support to determine the
\nstructure of contact mechanism and the
\nrules of its operation. For the purposes of
\nAssociation popularization it is advisable
\nto prepare the organization brochure stat-
\ning rights, obligations and main directions
\nof its activity.
\nMD, Prof. Vladimir Krylov
\nMD, Pavel Mikhalevich
\nAccording to recent press releases, in 2012
\nthe General System of Social Security
\nin Health (SGSSS) in Colombia will re-
\nceive nearly $43\u2019000.000\u2019000.000 COP
\n(US $22,052,000,000). In January 2011,
\nthe Congress of the Republic of Colom-
\nbia passed Law 1438 on Health and So-
\ncial Security. Under the aegis of this law,
\nthe Colombian government presented the
\nnew POS or Benefits Plan that takes ef-
\nfect as of 2012 and about which President
\nSantos stated: \u201cThis benefit plan will be uni-
\nversal, fair, inclusive and comprehensive and
\nwill not exclude any illnesses, meaning that
\nall Colombians will receive care for all types of
\nmedical conditions since the system that exists
\ntoday does not provide care for certain types of
\nillnesses\u201d. Thus, in his own words, the Presi-
\ndent recognized the inequity of the current
\nSGSSS.
\nNonethless, and despite the Benefits Plan,
\nthat inequity will continue as long as profit-
\nbased financial intermediaries continue to
\nmanage the private EPS (Health Promot-
\ning Entities), which over the past 18 years
\nhave failed in their mission and are unnec-
\nessary for the operation of the system.Three
\nexamples that clearly demonstrate this fail-
\nure are:
\n\u2022 The government handed over
\n$1\u2019000.000\u2019000.000 COP (US
\n$513,000,000) to a section of the pub-
\nlic hospital network to save them from
\nbankruptcy due to money owed them by
\nthe EPS;
\n\u2022 The government promised but did not
\ndeliver $120.000\u2019000.000 COP (US
\n$62,000,000) to the national EPS
\n(Health Promoting Entities) under theSergio Isaza
\nIs the Colombian Health System
\nEquitable?
\n10
\nMedical Education CZECH REPUBLIC
\nThe unbelievable progress in new technolog-
\nical developments represents an important
\nfactor in medical education at all levels.Med-
\nical students and young doctors are naturally
\namazed by these new technologies. This,
\nhowever, may contribute to a certain ten-
\ndency to dehumanise medicine. The condicio
\nsine qua non for a good medical educator is to
\nprotect the humanitarian character of medi-
\ncine. The physician must remain a doctor of
\nmedicine and not an engineer of medicine.
\nPersonalised care should remain the basis of
\nthe patient-to-doctor relationship. In other
\nwords, these new techniques, however es-
\nsential they may be for the patient, must not
\ndistract physicians from this basic obligation,
\nwhich is expected by their patients.
\nThe doctor-to-patient attitude is also
\nchanging in the sense that patients are be-
\ncoming more and more informed and re-
\nquire more solid information about diseases,
\ndiagnostics and therapeutic measures.These
\npatients\u2019 needs must be taken into account
\nin medical education at all levels.
\nReforming pre-graduate medical educa-
\ntion is a continuous process. These reforms Jaroslav Blahos
\nThe Education of Medicine in the
\nCzech Republic
\nSubsidized Regime (CAPRECOM) and
\ndirectly paid some hospitals in the pub-
\nlic network part of what the EPS owed
\nthem, for fear that the money would dis-
\nappear,as had already happened.Thus,the
\nDepartment of Health will hand over the
\nmoney directly to the hospitals through a
\nmandated trustee;
\n\u2022 Since the start of Law 100, social security
\nin health care for the Colombian Con-
\ngress, national military forces, Ecopetrol,
\nand the public school teachers is provided
\nthrough a special regime that works di-
\nrectly, without discriminatory plans and
\nwithout using the EPS as an intermedi-
\nary.
\nWith the eruption of the bankruptcy scan-
\ndal of the SGSSS,it came to light that many
\nprivate EPS were misappropriating a large
\npart of the health funding to increase their
\nrevenues and using these funds for profit-
\nmaking activities other than health care
\n(private building projects, luxury hotels, golf
\ncourses, sports teams, capital export and in-
\nvestment, support for political campaigns,
\netc.).Furthermore,the public EPS under the
\nSubsidized Regime has been used to sup-
\nport political campaigns for local politicians.
\nDespite all this, the government persists in
\nmaintaining the intermediary system.
\nIn terms of the medical profession, article
\n105 of Law 1438 defines medical autonomy
\nas \u201cthe guarantee that a health professional
\nmay freely issue his professional opinion
\nin regard to the quality care and treatment
\nof his patients,applying the standards,prin-
\nciples and values that govern the practice
\nof his profession, and the right to give his
\nopinion on medical conditions and their
\nrespective treatments\u201d. By definition,
\ntherefore, medical professional autonomy
\nimplies the capacity to act and resolve med-
\nical problems based on scientific knowl-
\nedge and is not in any way limited solely
\nto stating an opinion. Clearly, the medical
\nprofessional autonomy of Colombian doc-
\ntors has disappeared by operation of the law
\nand therefore,the very decisions and actions
\nof the medical profession have also become
\nsubject to the whim of the financial entities
\nof the SGSSS.
\nColombian doctors have advocated for the
\nneed to change the Health System and to
\nstructure it in order to guarantee the pa-
\ntient the Fundamental Right to Heath. The
\ncurrent system is designed on the basis of
\neconomic production and profit-seeking
\nprivate financial intermediation. As long
\nas this structure continues, the intention of
\nLaw 1438 to develop a basic health care sys-
\ntem will only result in another failure.
\nGiven that this deficient structure under-
\nmines the development of proper training,
\nskills and professional education, we sup-
\nport work stability without intermediaries
\nand continuing education for members of
\nthe system to provide comprehensive and
\nquality care and ensure the security of pa-
\ntients.
\nLet us remember: the \u201cBenefit Plan\u201d is not
\nthe health care system; it is only one of its
\ncomponents. The equity of the system is
\nensured by the structure of the system to-
\ngether with all of its components.
\nDr. Sergio Isaza,
\nPresident, FMC (Federacion
\nMedica Colombiana)
\n11
\nMedical EducationUZBEKISTAN
\ninclude organisational as well as structural
\nchanges. In some of the medical schools in
\nthe Czech Republic, a new curriculum sys-
\ntem has been introduced to combine the ba-
\nsic and clinical sciences. This system seems
\nvery logical yet requires very detailed coor-
\ndination of teachers and departments. It is
\nuncertain whether this integrated system
\nleads to better results than the \u201cclassical\u201d
\nsystem,which was based on a separation be-
\ntween the basic sciences, taught in the first
\ntwo years, and the clinical sciences, which
\nwere taught afterwards.
\nHowever, new educational methods and
\ntechniques, like the use of telemedicine
\nand the Internet, may shed a new light on
\nand broaden educational horizons. What-
\never system is used, new knowledge will
\nhave to be incorporated in the curriculum,
\nsuch as new systems based on evidence,
\nnew methods of medical statistics, socio-
\neconomic factors, legal aspects of medical
\npractice and a basic knowledge of health-
\ncare systems in other countries.
\nAn integral part of pre-graduate education
\nshould be research that will ensure that
\nthe student is acquainted with this kind of
\nemerging medical work and learns to deal
\nwith medical literature, publication tech-
\nniques and related issues.
\nContinuing Medical Education (CME)-
\nlife-long learning-is mandatory in the
\nCzech Republic. This is understandable
\ngiven that 50% of medical science and tech-
\nnology changes every five to seven years. As
\nmentioned above,CME includes both parts
\nof medicine, from knowledge, techniques
\nand skill to ethical and personal attitudes.
\nA\u00a0 30-year-old specialist without CME is
\nno specialist at 50.
\nCME in the Czech Republic is managed
\nand supervised by the Medical Associa-
\ntion, the Medical Chamber, the Ministry
\nof Health and the Institute for Postgradu-
\nate Medicine Education. The system of
\ncredit points has been taken as a model for
\nassessment. The CME in the future will
\nhave to reflect the enormous explosion of
\nknowledge. It will not be easy to find the
\nmost suitable method to educate physi-
\ncians, as it will have to enable them to gain,
\nretain and use new knowledge rapidly. The
\ncourses led by teachers will be comple-
\nmentary to Internet education, rather than
\nthe other way around. The same will prob-
\nably happen with seminars, symposia and
\ncongresses. The era of telemedicine is ap-
\nproaching, with all its unforeseeable tech-
\nnical advances. A good doctor, however,
\nmust always find adequate time to main-
\ntain a personal, friendly and relaxed atti-
\ntude towards his patient.
\nThe next WMA Council will meet in
\nPrague, April 26\u201328, 2012. One of the top-
\nics proposed by the CzMA will be to co-
\nordinate the activities of The World Health
\nProfessions Alliance (www.whpa.org) in the
\nCzech Republic, namely targeting tobacco
\nsmoking, the need for a holistic approach
\nto health care, and the social determinants
\nof health and other cultural, environmental
\nand economic factors, with special attention
\nto the elderly.
\nProfessor Jaroslav Blahos,
\nPresident Czech Medical Association
\nformer President World Medical
\nAssociation (WMA)
\nIn modern society physicians\u2019 skills upgrading
\nthrough continuous education has become es-
\nsential. Consequently, it is a topical issue for
\npublic health service in the whole world. We
\nanalyse the situation in professional skills im-
\nprovement and describe the latest developments
\nin Uzbekistan where for the first time the mod-
\nern form of distance learning for physicians has
\nbeen introduced.
\nIntroduction. Acquisition of medical
\nknowledge and professional development
\nshould be an ongoing process with any prac-
\ntising physician and done through continu-
\nous medical education (CME). Alongside
\nwith improvement of professional skills and
\nself-education of physicians CME includes
\nraising of patients\u2019 health awareness [1, 3].
\nFast changes in medical practice demand
\nfrom physicians a constant improvement of
\ntheir professional skills. Some North Amer-
\nican research has revealed the expressed in-
\nverse relationship between the medical expe-
\nrience and the level of knowledge, as well as
\nthe diagnostic and the medical skills. Physi-
\ncians possess the best clinical skills right af-
\nter the internship [5, 6]. Attending courses
\non improvement of professional skills have
\nproved to be relatively ineffective and ac-
\ntually does not prevent gradual decrease in
\nprofessional qualification of physicians [7].
\nIn the developed countries paid short-term
\ncourses within the framework of the sys-
\ntem for continuous medical education are
\noffered to physicians for training them to
\npass examinations required for granting
\na license. A widespread form of improv-
\ning physicians\u2019 skills with subsequent li-
\ncensing is training by using the so-called
\ntranscription programmes which are pub-
\nlished in journals of various medical as-
\nContinuous Medical Education: Physicians\u2019 Professional Skills
\nImprovement by Distance Learning
\n12
\nMedical Education UZBEKISTAN
\nsociations, accredited for CME. The given
\nprogrammes are a kind of distance learning
\n[4] described, for example, in the Journal
\nof the American Academy of Dermato-
\nlogy. In Uzbekistan improvement of profes-
\nsional skills of medical workers is possible
\nin two ways \u2013 by means of direct training
\n(through educational programmes), and in-
\ndirect training (no educational programmes
\ninvolved as a rule).
\nDirect training includes a programme for
\ngeneral and thematic improvement of pro-
\nfessional skills (upgrading). The indirect
\nway embraces the following forms: on-the-
\njob training; distance learning; self-educa-
\ntion; exchange of experience; participation
\nin seminars, congresses and conferences;
\ncourses on the development of information
\ntechnology [2].
\nDistance learning as an indirect form of
\nprofessional skills upgrading is based on
\ninformation-communication technologies,
\napplied for in-service training in various
\nforms (case studies, on-line asynchronous
\nand synchronous media, etc.). Distance
\nlearning can be carried out as an indepen-
\ndent form of improving professional skills
\naccording to the respective programme or
\nbringing it closer to the customary face-to-
\nface learning. Duration of a course and its
\nstructure depend on the programme and the
\nrespective tutor; the course duration might
\nexceed the academic term. Acquiring of
\nnew knowledge is monitored by TashIUV,
\nTashFarMI and a certificate is issued after a
\nsuccessful completion of the distance learn-
\ning course; a sample of it in [2].
\nDistance learning of physicians is a per-
\nspective method for professional training
\nand improving professional skills in medi-
\ncine [3]. Participants in CME and distance
\nlearning are practicing physicians as this
\nmethod features a number of advantages,
\ne.g. they needn\u2019t leave their families and
\nhome, their medical institutions and pa-
\ntients [8].
\nResearch objective: Study effective and
\napproved methods of post-degree medical
\neducation in the developed countries of the
\nworld and introduce them in Uzbekistan.
\nMaterials and methods: More than 70\u00a0000
\nphysicians work in the Republic of Uzbeki-
\nstan. Every five years each of them has to
\nparticipate in a qualification upgrading
\ncourse,covering 288 hours,and be conferred
\na respective sertificate. Implementation of
\nResolution of the Cabinet of Ministers of
\nthe Republic of Uzbekistan No 319 \u201cOn
\nImprovement of the Retraining System
\nand Professional Skills of Medical Doctors
\nin the Republic of Uzbekistan\u201d of 18 De-
\ncember, 2009, is assigned to the Tashkent
\nInstitute of Qualification Improvement of
\nPhysicians.
\nAnalysing the reasons for physicians in Uz-
\nbekistan neglecting the traditional methods
\nfor upgrading professional skills the follow-
\ning factors can be singled out: unwillingness
\nto leave the family and home, as well as the
\nmedical institutions and patients, shifting
\nthe workload to the colleagues, the travel
\nexpenses, accommodation and sustenance
\ncosts in another city.
\nTo introduce modern training methods in
\n2010 an agreement was made for physicians
\nbecoming readers of the periodic journal
\n\u201cBulletin of the Medical Association of
\nUzbekistan\u201d; the certificate form has been
\napproved as well.
\nThe Medical Association of Uzbekistan
\ntogether with the Tashkent Institute of
\nQualification Improvement of Physicians
\ndevelop curricula of distance learning. In
\n2010\u20132011 in the \u201cBulletin of the Medi-
\ncal Association of Uzbekistan\u201d nine cur-
\nricula on the following themes have been
\npublished: the public health situation in
\nUzbekistan; stenocardia; current problems
\nin oncology; valueology, the study on the
\nformation of a healthy person; discirculato-
\nry venous encephalopathy: diagnostics and
\ntreatment problems; dysphagy; changes in
\nthe organism and uncomfortable sensations
\nof the woman during pregnancy; modern
\napproach to food for children in the first
\nyear of life; the basic directions for improv-
\ning the outpatient clinic performance in
\nthe Republic of Uzbekistan. The curricula
\nare developed taking into account the latest
\nachievements in medicine and targeted at
\nspecialists in various fields.
\nResults and analysis. Each curriculum
\ncontains in paper format 16\u201320 tests of
\nAbdulla Khudaybergenov Zokhid Abdurakhimov
\n13
\nGEORGIA Palliative Care
\ndifferent complexity and three choice
\nanswers for the task. After completion
\nof the tests they are sent to the \u201cBulletin
\nof Medical Association of Uzbekistan\u201d
\nwithin 6 months after the publication of
\nthe respective Bulletin edition. In case
\ncorrect answers exceed 60% a certificate
\non distance learning (18 hours course) is
\nconferred.
\nIn 2010 the certificate was conferred to 140
\nphysicians, in 2011 \u2013 to 112 physicians for
\ndoing the tests published in three issues
\nof the Bulletin. In total in 2010\u20132011 the
\nMedical Association of Uzbekistan received
\n302 completed tests, 252 physicians re-
\nceived the certificate, it making 83 % of all
\nthe submitted tests.
\nThus, the physicians\u2019professional skills have
\nbeen improved without leaving home and
\ninterest in the \u201cBulletin of Medical Asso-
\nciation of Uzbekistan\u201d has been growing as
\nits circulation increased twice in 2011.
\nConclusions. In the present-day situation
\nwe should develop effective methods of
\npostgraduate education that have already
\nbeen approved in the developed countries
\nof the world.
\nImprovement of professional skills through
\ndistance learning allows knowledge upgrad-
\ning and retraining of physicians without leav-
\ning their medical institutions and patients,as
\nwell as saves the incurred expenses of travel,
\naccommodation and sustenance costs.
\nReferences
\n1. Order of the Ministry of Health of the Repub-
\nlic of Uzbekistan No 505 \u201cOn Improvement of
\nthe Retraining System and Professional Skills of
\nMedical Doctors in the Republic of Uzbekistan\u201d
\nof 14 November, 2006 .
\n2. Resolution of the Cabinet of Ministers of the
\nRepublic of Uzbekistan No 319 \u201cOn Improve-
\nment of the Retraining System and Professional
\nSkills of Medical Doctors in the Republic of Uz-
\nbekistan\u201d of 18 December, 2009.
\n3. Tselujko VJ. The form of postgraduate medi-
\ncal education \u2013 distance learning via journal is
\nsomething new. Liki Ukraini 2010; 5 (141): 6\u20137.
\n4. Korotkov Y, Stuleva T. About certification and
\nlicensing abroad. Physician. 1995; 4: 2\u20133.
\n5. Evans CE,Haynes RB,Gilbert JR et al.An edu-
\ncational package on hypertension for primary
\ncare physicians: Older physicians benefit most.
\nCan Med Assoc J. 1984; 130: 719.
\n6. McCauley RG, Paul WM, Morrison GH et al.
\nResults of 5 years of peer assessment of physi-
\ncian\u2019s office practices by the College of Physi-
\ncians and Surgeons of Ontario. Can Med Assoc
\nJ. 1990; 84:162.
\n7. Davis DA, Thomson MA, Oxman AD, Haynes
\nRB.Changing physician performance.A system-
\natic review of the effect of continuing medical
\neducation strategies. JAMA. 1995; 274: 700-705.
\n8. Grant J. The Flexible Use of Distance Learning
\nin a Professional Context: the Medical Experi-
\nence. In:Distance Education Futures, ed. Ted
\nNunan, 1993, pp.\u00a0309-329.
\nDr. Abdulla Khudaybergenov,
\nDr. Zokhid Abdurakhimov,
\nMedical Association of Uzbekistan
\nGeorgian Experience in Palliative Care Development \u2013
\nFrom Pilot Programs to International Collaboration
\nTamar Lobzhanidze Gia Lobzhanidze Zaza Khachiperadze Dimitri Kordzaia
\nApproximately 42,000 deaths are registered
\nannually in Georgia, which has a population
\nof 4.5 million. Based on international data,
\napprox. 60% of these terminal patients (or
\n25,000) require palliative care and pain relief.
\nGiven that at least two family members are
\ninvolved in caring for each terminal patient,
\npalliative care services can significantly im-
\npact approximately 75,000 people each year,
\nincluding both patients and caregivers\u00a0 [1].
\nDuring recent years in Georgia, through
\ncollaboration between Governmental In-
\nstitutions and NGOs (including Interna-
\ntional Organizations), the basis for the de-
\nvelopment of Palliative Care as an integral
\n14
\nPalliative Care GEORGIA
\npart of the National Healthcare System
\nwas created. All activities were performed
\nin accordance with WHO experts\u2019 recom-
\nmendations for the integrated develop-
\nment of \u201cEducation\u201d, \u201cDrug Availability\u201d
\nand \u201cServices Implementation\u201d under the
\nunited umbrella of \u201cGovernmental Policy\u201d
\n(Figure\u00a01).
\nIn the period between 2002 and 2011 the
\nfollowing results were achieved:
\n\u2022 Establishment of Palliative Care educa-
\ntional materials in the Georgian language;
\n\u2022 Creation of Palliative Care educational
\nprograms and their implementation
\nin Medical Universities and Nursing
\nSchools;
\n\u2022 Preparation and implementation of Pal-
\nliative Care CME accredited programs;
\n\u2022 Training of medical professionals expe-
\nrienced in Palliative Care, including two
\ninternational fellows (experts);
\n\u2022 Preparation of Video\/TV and printed
\nmaterials for public education and aware-
\nness;
\n\u2022 Improvement of legislative\/normative
\nstandards regulating Palliative Care and
\nDrug Availability, and promotion of the
\nincorporation of Palliative Care in the
\nNational Healthcare system;
\n\u2022 Organization of hospices (in-patients
\nunits for Palliative care) and their finan-
\ncial support from the governmental bud-
\nget;
\n\u2022 Organization of Home-Based Palliative
\nCare Teams and their financial support
\nfrom the governmental budget;
\nIn 2009-2010 under the leadership of the
\nGeorgian National Association for Pallia-
\ntive Care, a group of authors developed the
\nGeorgian National Program for Palliative
\nCare [2].The Program was approved by the
\nGeorgian Parliament\u2019s Healthcare and So-
\ncial Issues Committee in July 2010.
\nDespite of the fact that current palliative
\ncare services cover less than 15 % of the
\nneeds of the population, and geriatric and
\npediatric palliative care are still absent (Fig-
\nure 2), given the relatively short history of
\nits development, the Georgian experience is
\nevaluated by international experts as one of
\nthe most successful Palliative Care models
\namong post-Soviet countries.
\nTo share Georgia\u2019s knowledge and expe-
\nrience in Palliative Care, site trainings of
\nforeign healthcare professionals in Geor-
\ngia\u2019s capitol, Tbilisi, began in 2011. The
\nfirst request for cooperation was received
\nfrom the former Soviet countries of Ta-
\njikistan and Kyrgyzstan.The trainings were
\nconducted by the support of Open Society
\nFoundations (OSFs) \u2013 the New York office
\n(Ms.\u00a0 Mary Callaway) and the Open So-
\nciety Georgia Foundation (Irma Khabazi,
\nNino Kiknadze) \u2013 and the Soros founda-
\ntions in Tajikistan (Nigora Abidjanova)
\nand in Kyrgyzstan (Aibek Mukambetov).
\nThe Palliative Care Service of the National
\nCancer Center (PCSNCC), which in-
\ncludes an in-patient unit with 15 hospital
\nbeds, home-based Palliative Care services,
\nand consulting services, was selected as the
\nsite for the international training programs.
\nPCSNCC provides emotional support to
\npatients and family members, guides and
\nadvises them during cancer treatments,
\nand continues to support them after treat-
\nment. PCSNCC also provides home care
\nservices in Tbilisi, as well as Kutaisi, Telavi
\nand Zugdidi. All physicians of the PC-
\nSNCC are well-trained to identify and re-
\nS
\ni
\nt
\nu
\na
\nt
\ni
\no
\nn
\nO
\nu
\nt
\nc
\no
\nm
\ne
\ns
\nPolicy
\nEducation
\nDrug
\nAvailability
\nImplementation
\nFigure 1.
\nPalliative
\nCare
\nPediatric Geriatric
\nCancer AIDS TBNeurology
\n< 15%\nFigure 2.\n15\nPalliative CareGEORGIA\nlieve physical and psychological symptoms\nof disease, and provide psychological and\nspiritual support.\nPCSNCC collaborates with numerous\nnational and international organizations\nworking in the fields of practice, education\nand research related to palliative care and\nclinical oncology. It is also the clinical af-\nfiliate of the Iv. Javakhishvili Tbilisi State\nUniversity (TSU), actively working with\nmedical students, nursing students, resi-\ndents, and general practitioners. Since 2011,\nthe PCSNCC has been accredited as a Pal-\nliative Care and Oncology integrated centre\n(ESMO designated centre).\nPCSNCC cooperates closely with the Palli-\native Care National Coordinator\u2019s Office of\nthe Parliament of Georgia in advocating for\nthe development of a national strategic plan\nfor palliative care throughout the country,\naccording the above-mentioned Georgian\nNational Program for Palliative Care [2].\nAn educational\/training program for\nhealthcare professionals from Middle Asia\nwas led by Georgian Academy of Pallia-\ntive Care \u2013 Educational Training Resource\nCentre (GAPC). GAPC was branched\nfrom the Georgian National Association for\nPalliative Care (GNAPC) for better coor-\ndination of educational\/training programs\nand research activities in different fields of\npalliative care on the national and\/or inter-\nnational levels.\nThe two-week pilot programs (bedside\ntraining courses) were conducted for four\ncolleagues from Tajikistan in July 2011 and\ntwo colleagues from Kyrgyzstan in Au-\ngust 2011. These programs included the\nkey topics in Palliative Care: essence of\npain, evaluation of pain in advanced can-\ncer patients, pain management by opioids\nadministration, evaluation and manage-\nment of delirium, nausea, vomiting, ascities,\nbreathlessness, etc. All participants worked\nwith experienced medical staff under the\nsupervision of Dr. Rukhadze \u2013 the head of\nPCSNCC and founder of GAPC, who at-\ntended three years of specialty training at\nthe Institute of Palliative Medicine & San\nDiego Hospice (California, USA). After\nsuccessfully passing exams at the end of the\ntraining courses, participants received cer-\ntificates confirming their skills and knowl-\nedge. The trainings were considered a suc-\ncess and at the end of 2011, it was decided\nthat the project would be continued in 2012\nand include 18\u201320 participants from Mid-\ndle Asian Countries.\nAs illustrated in the model provided by\nJ.\u00a0Stjernsward (Figure\u00a03), we can offer fully\nsufficient education and training programs\nin Palliative Care for GPs and Oncologists\nfrom post-Soviet countries. At the same\ntime we are realizing that the optimal ap-\nproach to training in Palliative Care is\nshould occur across the broad spectrum of\nstakeholders.\nReferences:\n1. Jan Stjernsward. Georgia National Palliative\nCare Programm, Report, 2005\n2. http:\/\/www.parliament.ge\/files\/619_8111_\n336972_Paliativi-Eng.pdf\n3. Georgian National Program for Palliative Care\n(Action Plan \u2013 2011-2015), 2010\nhttp:\/\/www.parliament.ge\/files\/janmrteloba\/\npaliatiuri\/pc-nat-2011-2015-en.pdf\n4. Jan Stjernsward: Ind.J.PallCare, 2005, Decem-\nber 2005 ,11,2: 52-58, and June 2005\nMD, PhD Tamar Rukhadze, Georgian\nNational Association for Palliative Care ;\nMD, PhD Gia Lobjanidze, President\nof Georgian Medical Association;\nMD Zaza Khachiperadze,\nGeorgian Medical Association;\nMD, PhD Dimitri Kordzaia, Georgian\nNational Association for Palliative Care;\nTbilisi, Georgia\nPC specialists (experts)\nOncologists\nGPs\nSociety\nFigure 3. The Community Approach-Necessary to Achieve Palliative Care for All\n16\nBELGIUMEvidence Based Medicine\nWhen Claude Bernard and others intro-\nduced experimental medicine, they did not\nfundamentally upset the knowledge of the\ntime from one day to the other; neither did\nthey reform the way to take care of patients.\nWhat they brought in is a method which\nallowed reaching a better level of certainty\nin the matter of knowledge and,above all,to\nget the information in a faster way. But the\nacquisition of knowledge was still based on\nformer data, since they were verified by ex-\nperimentation. A huge step had been taken,\nthough, and progress was on its way.\nExperimental research allows going further\nand deeper into the understanding of pro-\ncesses, finding remedies which have a more\nand more accurate effect on them while re-\nstraining their consequences on vital phe-\nnomena which are not concerned (side ef-\nfects). The action on identified risk factors\nhas been clearly evidenced.\nYet, our societies have added other require-\nments to efficiency: security, which is very\nlegitimate, and one more which we have to\ndeal\u00a0with: the relationship between the cost\nof treatment and the expected benefit for a\ngroup of patients (the individual patient has\nnever been taken into account).\nFrom this point of view, researchers have\nbeen lead to ask themselves two questions:\n\u2022 Does the correction of one factor really\nhave the expected effect on, on one hand,\nreducing the risk and, on the second\nhand, the chances to survive?\n\u2022 Doesn\u2019t a preventive or curative treatment\nof a given pathology cause more dreadful\ncomplications?\nLarge studies have been launched. The re-\nsulting knowledge has been summarized\nand EBM arose from it. The promoters of\nthat synthesis imagined they would come\nup with a helping tool for medical deci-\nsions. Collective experience adds itself as\na tool to personal experience and medi-\ncal experimentation. The instigators of the\nproject never imagined that they brought in\na change of paradigm for financiers. Since\nthe very beginning, physicians have always\ntaken their decisions in a state of uncertain-\nty. EBM was meant to reduce the degree of\nuncertainty.Besides,its developers have also\nestablished levels of evidence according to\nthe degree of certainty.\nNow one could believe, though, that what\nbears the EBM trademark is secure, the\nonly medication to be authorized for pre-\nscription and that what doesn\u2019t belong to\nEBM is definitely discarded. Those who\nprescribe non-EBM medications should\nthus be strongly disapproved.\nSuch a dualistic attitude is not acceptable\nfor a scientific mind. The highest degree of\nevidence in EBM is meta-analysis. By col-\nligating all the studies that were undertaken\non a given subject, it really does have the\nbenefit of reducing uncertainty, but with-\nout granting the degree of evidence. In the\nMiddle-Ages, three hear-says were consid-\nered an evidence. Will we now admit that\nthree studies amount to evidence?\nThe questions these studies try to answer are\ndifferent most of the time.The conditions of\nthe studies, the surveyed patients and, most\nof all, the results are not homogeneous.\nHow is it possible to make certainties when,\nmost of the times, they rely on facts that\nstand no comparison?\nThe resulting agreements have two short-\nages:\n\u2022 Sometimes they do not stand for any-\nbody\u2019s opinion but are the mean of dif-\nferent opinions.\n\u2022 They are an instant picture of a constantly\nevolving knowledge on a given subject.\nThey can become obsolete as soon as they\nare established.\nAs for experts\u2019recommendations,EBM itself\nplaces them at the lowest level of the scale.\nThey can be useful but only if there exist no\nmore evidential elements. Yet, it is on the\nbase of experts\u2019 opinions that the authorities\nproduce guidelines for prescription which\nhave nothing to do with a help for making\ndecisions but are imposed like some sort of\nrevelation which,when not followed,exposes\na practitioner to disciplinary measures. The\nChurch itself has no longer such power.\nConclusions\u00a0:\nIt is obvious that EBM reduces uncertain-\nty and provides a helping tool for making\nmedical decisions. But it is absolutely not\na revolution which implies to sweep away\nindividual experience, which remains an\nimportant element of the decisional process.\nEBM has not yet proven that individual\nexperience and experimental medicine are\ntools that belong to the past.\nEBM is based on statistics.These are estab-\nlished by discarding bad cases like multiple\nRoland Lemye\nEBM (Evidence Based Medicine), not an Absolute\nReference but a Help for Making Decisions\n17\nAntimicrobial ResistanceSWEDEN\nRecently I met my president-colleagues\nfrom the other Nordic medical associations.\nWe meet twice a year to discuss current is-\nsues relating to political and professional\ndevelopments in the Nordic countries. It is\nstaggering to realize how dependent we are\non international cooperation when it comes\nto issues such as the spread of infections,\npharmaceutical chemicals in the environ-\nment, and political trends. In our informa-\ntion-intense societies, healthcare trends are\nrapidly moving across borders and will be\nobserved and also used by our governments.\nIt is therefore essential to share experiences\nwith colleagues across borders.\nOne such issue we discussed is antimicro-\nbial resistance, which is climbing on the\nEU-agenda. Antimicrobial resistant bacte-\nria does not respect borders between profes-\nsions nor does it recognize national borders.\nIn Sweden there is a network called Strama\n(the Swedish strategic programme against\nantimicrobial resistance), which coordinates\nactivities across sectors to maintain antibi-\notics as a strong tool both for humans and\nanimals.\nIn November 2011 the EU-commission\nrevealed an action plan for antimicrobial\nresistance with 12 actions for the next five\nyears. A basic requirement for preventing\nantimicrobial resistance is monitoring and\nsurveillance of the use of antibiotics in hu-\nman and animal medicine. Since Denmark\nholds the Presidency of the Council of the\nEuropean Union during the first half of\n2012, they will prepare a common strat-\negy on preventing antimicrobial resistance.\nThere will be a conference the 14-15 of\nMarch in Copenhagen on the issue, with\nthe hope that conclusions from the confer-\nence will be adopted by the Council of the\nEuropean Union.\nThe Danish Medical Association, which\nis working closely with the Danish Vet-\nerinary Association, would like to see two\nmain conclusions from the conference. The\nfirst one is that all antibiotics used should\nbe prescribed by a doctor or a veterinarian.\nThe second one is that neither doctors nor\nveterinarians should be allowed to sell an-\ntibiotics, as this ability creates the wrong\nincentive. They would also like to share the\nScandinavian model on combating antimi-\ncrobial resistance with other EU-countries.\nSince about two-thirds of the antibiotics in\nDenmark are used in the agricultural sector,\nstrong cooperation with the veterinarians is\ncrucial.\nAntimicrobial resistance is a growing health\nproblem. The EU-commission states that\nabout 25,000 patients die per year in the\nEU from infections caused by drug resis-\ntant bacteria. We need to create awareness\namong patients and doctors about the risk\nof using antibiotics and the actions that\nmust be taken. Doctors and veterinarians\nmust show professionalism and present a\ncommon strategy for the use of antibiot-\nics\u00a0\u2013 a strategy that should include ethical\nconsiderations.\nIf doctors and veterinarians fail to lead the\ndevelopment in the right direction on issues\nsuch as antimicrobial resistance, pharma-\nceutical chemicals in the environment, and\nthe health effects of climate change, we face\nan overwhelming risk of losing our best\ntools for treatment as well as the trust of the\ngeneral public.\nDr. Marie Wedin,\nThe Swedish Medical Association\nMarie Wedin\nCombating Antimicrobial Resistance\npathologies, which means most of the cases\ngeneral practitioners see every day. Statistics\nappeal to populations, GPs to individuals.\nWhile EBM does give some answers, these\nare two few compared to the infinite field\nof questions. A physician has to help a pa-\ntient even if EBM provides no answer. A\nphysician has to keep on looking for solu-\ntions if a patient has been treated according\nto EBM and the treatment failed. EBM is\nalways outdated when it comes to medical\nfield knowledge. Until now, EBM has failed\nto obtain a better care for all risk popula-\ntions like diabetics, people with overweight,\nhigh blood pressure, hypercholesterolemia\netc, which grow exponentially and are un-\ndertreated.\nEBM has diverted from its purpose of being\na help for making decisions and became a\nrationing and control instrument.\nEBM\u2019s greatest achievement has been to\nhelp governments control their expenses.\nEBM has in no way fought against \u201c\u00a0magic\nthinking\u00a0 \u201c. Some social insurances, while\nadvocating prescriptions submitted to\nEBM, do not mind refunding homeopathic\nprescriptions which have never been vali-\ndated by EBM.\nDr. Roland Lemye,\ndes Syndicats Medicaux\nPresident Association Belge\n18\nPublic Health\nPublic health strives to put into place con-\nditions in which people can live healthy\nand productive lives. The cornerstones of\nthese efforts are disease\/injury prevention\nand health promotion and protection. In-\ndeed, the steps necessary for people and\ntheir communities to be healthy, productive,\nand resilient starts long before they require\nmedical treatment. Public health begins\nin the places where people live, learn, and\nwork; in other words, in their families and\ncommunities. It takes into account that the\nhealth of a population is influenced by more\nthan the health care system. The structural\nand social determinants of health encom-\npass a wide range of factors,including polit-\nical, social, economic, physical and techni-\ncal environments, personal health practices,\nindividual capacity, coping skills, human\nbiology, genetics, early childhood develop-\nment, life circumstances, income, education,\ngender and ethnicity. Public health seeks to\nmitigate preventable disease burdens along\nwith their associated financial and social\ncosts.\nThe World Federation of Public Health\nAssociations (WFPHA) is the global civil\nsociety organization representing the inter-\nests of the world\u2019s public health community.\nCreated in 1967, the WFPHA currently\ncounts as a member of over 60 national and\nregional public health associations, as well\nas regional associations of schools of public\nhealth and several academic, health-orient-\ned institutions\/organizations that share the\nFederation\u2019s mission and values (the right\nto health for all; social justice; diversity and\ninclusion, partnership and ethical conduct).\nCumulatively, the WFPHA represents a\nvoluntary membership community of over\n250,000 public health professionals, re-\nsearchers and practitioners. The WFPHA\nadvocates for a strong civil society voice,\nthe active participation of national public\nhealth associations, allied groups in national\nand global discussions and decision-shaping\naround public health policy and practice.\nOver the past 44 years, the WFPHA has\nplayed a leadership role in global public\nhealth. In terms of global health advocacy,\nthe Federation has produced over 40 reso-\nlutions, declarations and position papers.\nThese policy statements cover a variety of\ntopics, including the relationship between\nclimate change and environmental health,\nconflict\/peace and health, globalized trade\nand public health, as well as tobacco con-\ntrol, health systems sustainability, univer-\nsal and equitable access to primary health\ncare services, health human resources, and\nthe prevention of infectious and non-com-\nmunicable diseases. In 2010, the WFPHA\npassed an innovative resolution calling for\na comprehensive and equitable approach to\nthe health of people incarcerated in prisons\nand other detention centers. The Federa-\ntion has used these position statements to\neducate and advocate for stronger, more\neffective public health policies and strate-\ngies at the global level, through the World\nHealth Organization and other multilateral\norganizations. Many WFPHA member as-\nsociations have used these positions as in-\nstruments to support public health policy\nadvocacy efforts in their own countries.\nThey have also formed the evidence base\nfor presentations and statements by WF-\nPHA representatives at international and\nnational conferences.\nIn recent years, the Federation has focused\nits advocacy on health equity. At its trien-\nnial World Congress on Public Health held\nin 2009 in Istanbul (Turkey), the WFPHA\nhighlighted its commitment to the issue of\nHealth as a Human Right for All. Through\nthe Istanbul Declaration, the Federation re-\naffirmed the definition of health as a pub-\nlic good and the principles of solidarity,\nsustainability, morality, justice, equity, fair-\nness and tolerance as fundamental under-\npinnings of all public health policies and\npractices. Global health equity is the theme\nof the Federation\u2019s 13th\nWorld Congress\nThe World Federation of Public Health Association\nRepresenting the Global Civil Society Voice for Public Health and Health Equity\nJames Chauvin Laetitia Rispel Deborah Klein Walker Bettina Borisch\n19\nPublic Health\non Public Health, which takes place April\n23\u201327, 2012 in Addis Ababa (Ethiopia),\nhosted by the Ethiopian Public Health As-\nsociation.\nThe Federation has helped to build the ca-\npacity of national and regional public health\nassociations around the world. Over the\npast 25 years, through the efforts of several\nWFPHA member associations, such as the\nCanadian Public Health Association, the\nEuropean Public Health Association and\nthe American Public Health Association,\nthe organizational and programmatic ca-\npacity of new and emerging public health\nassociations in low- and middle-income\ncountries and countries in political transi-\ntion have been strengthened. Over the past\nquarter century, over 30 national public\nhealth associations have been created and\nbecome active members of the WFPHA\nand, in turn, have acted as mentors to other\nemerging national PHAs. This growing\nnumber of public health associations has\nenhanced the Federation\u2019s effectiveness as a\nglobal health advocate.\nOne of the more recent testaments to the\ngrowing importance of the public health\nmovement was the establishment in August\n2011 of the African Federation of Public\nHealth Associations, through the combined\nefforts of over two dozen national PHAs\non the African continent. The WFPHA\ncollaborates closely with the AFPHA, as it\ndoes with the European Public Health As-\nsociation and the emerging networks of na-\ntional PHAs in the Asia Pacific region and\nLatin America, to advance action on prior-\nity global public health issues and build a\nstrong collective civil society voice for pub-\nlic health.\nThe policy influence and public health pro-\ngramming impact of national public health\nassociations is impressive. Several PHAs\nhave played leadership roles in tobacco con-\ntrol by influencing the decisions of national\ngovernments to ratify and apply locally the\nFramework Convention on Tobacco Con-\ntrol (FCTC), which was the world\u2019s first\npublic health treaty. Others have focused\ntheir efforts on public health education and\ntraining, the expansion and quality of access\nto public health services, such as immuni-\nzation, water supply sanitation, maternal-\nnewborn and child health services, the pre-\nvention and control of both infectious and\nnon-communicable diseases, the prevention\nand treatment of HIV and AIDS, and ac-\ncess to essential medicines. Some of the\nPHAs have become strong advocates for a\nsocial determinants approach to achieving\nhealth and health equity.\nThe WFPHA looks forward to contribut-\ning, in an effective and productive manner,\nto achieving health equity for all. Over the\nnext few years, the Federation will review\nand refine its organizational strategic plan\nto advance public health practice,education,\ntraining and research and help facilitate and\nsupport efforts to improve the organization-\nal and programmatic capacity of national\nPHAs. The WFPHA intends to expand\nand strengthen its partnerships with orga-\nnizations such as the World Medical As-\nsociation and other civil society movements\nthat share our values. It will also enhance\nits advocacy capacity to shape global public\nhealth policies and strategies through more\npro-active participation in future World\nHealth Assemblies, the development and\ndissemination of bold position statements\non issues that affect the public\u2019s health and\nvisibility through participation in global\nand regional conferences and events.\nIn partnership with other global federations\nand associations and in support of a strong\nleadership role for the World Health Or-\nganization, the World Federation of Public\nHealth Associations will continue to make\nits mark helping put into place the condi-\ntions and opportunities for people and their\ncommunities to be healthy, productive and\nresilient.\nJames Chauvin,\nDirector of Policy\/Canadian Public\nHealth Association and Vice-President\n& President-Elect\/World Federation of\nPublic Health Associations (WFPHA)\nLaetitia Rispel,\nDean\/Witwatersrand University School\nof Public Health (South Africa) and\nmember of WFPHA Executive Board and\nGlobal Health Equity Working Group\nDeborah Klein Walker,\nVice-President and Senior Fellow\/\nAbt Associates (USA) and member of\nWFPHA Advisory Board and Global\nHealth Equity Working Group\nBettina Borisch,\nProfessor, Department of Social\nMedicine\/University of Geneva and\nHead of the WFPHA Geneva Office\nand member of WFPHA Global\nHealth Equity Working Group\nUlrich Laaser,\nProfessor, School of Public Health\/\nUniversity of Bielefeld (Germany)\nand WFPHA President\nUlrich Laaser\n20\nRegional and NMA news\nThe global context\nFor any professional association working in\nthe medical field, it is very important to be\nglobally present and make sure that the in-\nterests of the profession, and in particular\nthe interests of the public, are well repre-\nsented, promoted and defended at an inter-\nnational level.\nThe reason that associations and institu-\ntions federate locally, nationally, regionally\nand internationally is that they believe that\njoining forces with like-minded associations\nat each level gives them a better chance of\nachieving their goals. It means they can dis-\ncuss, debate, sometimes dispute, and gener-\nally arrive at some kind of compromise to\nmove forward.\nFor our colleagues, it is sometimes difficult to\nunderstandthereasonsbehindtheexistenceof\ncertain international organizations and what\nthey do beyond that which a regional,national\nor even local organization can achieve.\nDentistry and dental medicine have always\nbeen one of the best organized professions\naround the world at the national level.\nWorld Dental Federation (FDI) was set up\nover 110 years ago as a forum for dentists\nglobally to share views and experiences to-\ngether.\nIts continued existence today implicitly\nrecognizes that the profession needs an in-\nternational voice to defend its positions and\npromote its views. Let me give you three\nexamples:\n1) A focus on prevention\nAs we all know, teeth have a vital function\nin the human body: healthy teeth are a vital\npart of human health. Caring for teeth and\noral health is essential for a healthy popu-\nlation. Tooth decay and periodontal (bone\nand gum) disease currently affect 90% of\npeople around the world.\nWith limited funds available for restorative\ncare in many countries, an essential part of\nFDI\u2019s work is to raise awareness of the im-\nportance of oral health and focus its proj-\nects and activities on prevention strategies.\nThis, for example, is the key message of the\nlandmark Global Caries Initiative, GCI for\nshort.\nThe GCI vision is to improve oral health\nthrough the implementation of a new para-\ndigm for managing dental caries and their\nconsequences\u00a0\u2013 a paradigm that is based on\nour current knowledge of the disease pro-\ncess and its prevention, so as to deliver op-\ntimal oral and thus general health and well\nbeing to all peoples. In practice, the goal is\nto achieve a paradigm shift from the restor-\native to the preventive model of oral care.\nFDI launched the GCI in 2009, with some\nvery concrete priorities and actions:\n\u2022 Eradicate very early childhood caries in\nchildren 0\u20133 years of age by 2020\n\u2022 Carry out primary and secondary preven-\ntion and health promotion activities\n\u2022 Achieve consensus on terminology\nFDI was joined in its efforts by founding\npartners Colgate, GlaxoSmithKline, Proc-\ntor and Gamble Oral health, Unilever and\nWrigley. The aim was to establish a broad\nalliance of key influencers and decision-\nmakers from research, education, clinical\npractice, public health, government and\nindustry, partnering in a common goal: to\nto achieve the 2020 goal by effecting funda-\nmental change in health systems and indi-\nvidual behaviour.\nThe GCI\u2019s first task was to design and de-\nvelop a prevention-oriented caries classifi-\ncation and management system (CCMS),\nthereby laying the foundation for the pre-\nventive model of caries management. It is\nnow in the process of developing an over-\narching Global Oral Health Improvement\nMatrix (GOHIM) to integrate oral health\ninto health, thereby establishing a collab-\norative, prevention-oriented model of oral\nhealth care. It is precisely this preventive\nmodel of care that FDI is advocating, along\nwith professional partners, within the con-\ntext of the global fight against noncommu-\nnicable diseases.\n2) Oral health and noncommunicable\ndiseases (NCDs)\nIt is now time to admit that viewing oral\nhealth as somehow separate from general\nhealth is truly obsolete, and nowhere is the\nindisputable relationship between the two\nbetter illustrated than in the area of NCDs,\nor chronic diseases as they are sometimes\nknown.\nNCDs, which include cardiovascular disease,\ncancer,chronic respiratory disease and diabe-\ntes, among others, are responsible for 60% of\ndeaths worldwide: in 2008,36 million people\ndied from NCDs, around 80% of them in\nlow to medium income countries.\nOrlando Monteiro da Silva\nA Globalized World\u00a0\u2013 and a Unified Global\nApproach for Health Professions\n21\nRegional and NMA news\nWith this in mind,FDI undertook a project\nto develop a practical tool to help in the fight\nagainst NCDs, the NCD toolkit. It carried\nout the work on behalf of the WHPA World\nHealth Professions Alliance-representing\nwell over 20 million health professionals\nworldwide, including dentists, physicians,\nphysical therapists, pharmacists and nurses\nThe Toolkit was funded by the International\nFederation of Pharmaceutical Manufactur-\ners and Associations.\nThe Toolkit focuses on common risk fac-\ntors-poor diet, physical inactivity, smoking\nand alcohol abuse-and includes a \u2018Health\nImprovement Card\u2019 for the individual to\nassess personal risk, in consultation with a\nhealth professional. The Toolkit also con-\ntains support materials for the health pro-\nfessional as well as for the patient, together\nwith advice on how to reduce or eliminate\ncertain risk behaviours.\nNaturally, some people have asked why FDI\nand \u2018dentistry\u2019 agreed to lead the WHPA\nproject: after all, oral diseases do not ac-\ncount for high death rates. There are two\nmain reasons:\n\u2022 Neglected NCDs such as tooth decay and\nperiodontal disease affect more than 90%\nof the world\u2019s population and have an\nenormous impact on health;\n\u2022 There is increasing association and sci-\nentific evidence between the presence of\noral conditions (especially periodontal\ndisease) and systemic diseases, including\ncardiovascular and cerebrovascular dis-\neases, adverse pregnancy outcomes, dia-\nbetes mellitus, pulmonary infections and\ndifferent forms of cancer.\nFurthermore, it is my view that that the\ndental profession, and dental medicine in\ngeneral, should have a much broader am-\nbition. Within the medical sphere, the\nvarious fields of education, prevention,\ndiagnosis, treatment and rehabilitation are\nbecoming increasingly interrelated. Equal-\nly, relations between dental medicine and\nmedicine in general, as well as other fields\nsuch as nutrition, psychology and sociol-\nogy, are growing.\nIndeed, dental practitioners are in a unique\nposition when it comes to detecting risk\nfactors. They are one of the few medical\nprofessions to see patients who are not ac-\ntually ill but just there for a check-up. Fur-\nthermore, many behaviours are immediately\nvisible during the course of a dental check-\nup, so dentists are well positioned to initiate\ndiscussion on risks.\nFDI\u2019s next move will be to field test the\nWHPA Toolkit in one or two key develop-\ning countries to assess how well it integrates\ninto health strategy and its methods of use\nby health professionals.\nOn a wider level, FDI is now looking to\nestablish the Global Oral Health Partner-\nship (GOHP). This is envisaged as a multi-\nstakeholder partnership to address the\nNCD burden with a special responsibility\nfor oral diseases: dental caries, periodontal\ndisease and oral cancer.The GOHP\u2019s objec-\ntive is to provide strategic leadership to co-\nordinate and synergize policy, strategy and\nprogrammes within a common stakeholder\nframework. This will enable the implemen-\ntation of a model of oral health care based\non health promotion,disease prevention and\npreventive disease management worldwide.\n3) Oral health and development\nThe major contribution to the NCD Toolkit\nand the associated WHPA NCD campaign\nproject allowed FDI-along with a number\nof other agencies and groupings working in\nthe field of oral health-to achieve an impor-\ntant goal: to have oral disease specifically\nreferenced in the Political Declaration of\nthe United Nations Summit on NCDs held\nin New York in September 2011.\nIn practical terms, Summit Declarations\ncontain principles to guide development\nstrategy and projects. Having oral health\nmentioned within the context of NCDs\nand primary health care means that dental\nmedicine is now officially linked with gen-\neral health policy.\nThis is certainly what many developing\ncountries would wish for. This was clearly\nillustrated by an event I attended during\nthe course of the Summit entitled \u2018Putting\nthe teeth into NCDs\u2019 and by the Republic\nof Tanzania. It highlighted the importance\nof oral health in health strategy. In fact, one\nspeaker, Helen Clark, Administrator of the\nUnited Nations Development Programme\n(UNDP), called oral diseases \u201cobstacles to\ndevelopment\u201d.\nI am gratified to see how FDI is so much in\ntune with concepts of development: it is in-\ndeed time to face the fact that viewing oral\nhealth as somehow separate from general\nhealth is truly obsolete.\nAnd also obsolete is approaching health\nwithout a political and public understand-\ning of health inequities and social determi-\nnants of health: it is necessary to take ac-\ntion simultaneously on the broader factors\nthat influence people\u2019s health behaviour;\nthe conditions in which they are born, grow,\nlive, work and age; and the influence of so-\nciety.\nTogether with its coalition members,\nWHPA is in a unique position to raise\nawareness on this approach at a global level,\nin light of the scope of the recent WHO\nWorld Conference on Social Determinants\nof Health in Rio de Janeiro.\nConclusion\nWe at FDI have recently intensified our\ndialog, with the aim of encouraging gov-\nernments to prioritize and promote oral\nhealth and consider it as a citizens\u2019 right.\nIt is essential that we continue to stress the\nfundamental point: \u201cGood oral health is a\nprimary factor in general health\u201d.\nOrlando Monteiro da Silva,\nFDI President\nE-mail: orlando@orlandomonteirodasilva.com\n22\nRegional and NMA news THAILAND\nStanding and domestic Activities\n\u2022 Continuous Medical Education and re-\nsearch promotion.\n\u2022 Provision of scholarships for postgraduate\nstudy and research in Japan in collabora-\ntion with the Takeda Science Foundation.\n\u2022 Provision of the Research Grants to\nmember.\n\u2022 Lecture tours on Special topics: Con-\ntinuous Medical Education and Medical\nEthics.\n\u2022 Monthly Publication of the Journal of\nMedical Association of Thailand.\n\u2022 Launching of E-Journal to Members and\npublic.\n\u2022 Supply Accommodation for members at\nthe club house.\n\u2022 Provide consultative support for members\nwith professional legal problems.\n\u2022 Organize charity golf tournament for the\nfund raising.\n\u2022 Organize Post congress tours to study\nHealth Care abroad.\n\u2022 Performing Medical Advocacy through\nsocial Medias: Radio, Television and\nNewspaper.\nInternational Activities: Participation at\nthe International congresses and medi-\ncal association meetings as invited and as a\nmember\u00a0 \u2013 WMA; CMAAO; MASEAN;\nNational Medical Associations in Asia, Aus-\ntralia,Europe,North and South America etc.\nSpecial Events.\n\u2022 Hosting the 1st International Summit\non Tobacco Control in Asia and Oceania\nRegion on February\n\u2022 25,2010 at Rose Garden Riverside Hotel,\nSampran, Thailand resulting in Sampran\nDeclaration.\n\u2022 At the WMA Congress and General\nAssembly 2010 in Vancouver, Canada,\nDr.\u00a0 Wonchat Subhachaturas, the Presi-\ndent Elect of the MAT, was elected at the\nGeneral Assembly to be the 61st Presi-\ndent of the World Medical Association\nfor period of 2010\u20132011,the ninth from\nAsia and the first from Thailand\n\u2022 Organizing the 90th\nAnniversary Cel-\nebration of the MAT on September,\n27\u201330, 2011.\n\u2022 Exchange visit with the Chinese Medi-\ncal Association on August 4\u20138, 2011 in\nBeijing.\n\u2022 Promotion of community Tobacco Ces-\nsation Programs through the Thai Health\nAlliance Against Tobacco Network\n(THPAAT)\n\u2022 Setting up health and rehabilitation visit-\ning teams for the flood victims in collabo-\nration with the Thai Health Professionals\nagainst Tobacco (THPAAT).\n\u2022 Organizing the robes presentation to the\npriests at the temple with donation.\nContact Persons of the Current Executive\nBoard of the MAT: President: Dr.\u00a0 Won-\nchat Subhachaturas; President Elect: As-\nsoc.\u00a0 Prof.\u00a0 Dr.\u00a0 Prasert Sarnvivad; Vice\nPresident: Prof.\u00a0 Dr.\u00a0 Teerachai Chantraro-\njanasiri; Secretary General: Prof.\u00a0Dr.\u00a0Sara-\nnatra Waikakul; Treasurer: Group Captain\nDr.\u00a0Paisal Chantarapitak; International Re-\nlations: Lt.General Dr.\u00a0Nopadol Wora-urai;\nCEO: Prof.\u00a0Dr.\u00a0Somsri Pausawasdi\nThe Medical Association of Thailand\ncommitted itself to host the 2012 Gen-\neral Assembly of the World Medical As-\nsociation during October 10\u201313, 2012 in\nBangkok.\nThe Medical Association\nof Thailand\nFlood in Thailand 2011\nThe flood in Thailand this year, 2011 was the heaviest and the worst in the history of the\ncountry. Twenty- six provinces out of seventy-seven were affected mostly in the north\nand the central basin with the loss of 540 lives mostly from land slide, drowning and\nelectric shock. More than 2 millions of the population have been the victims of the flood\nand more than 300,000 people were evacuated from their home places to the higher\nevacuation grounds. The estimated loss of the country could reach 1,000 billion Baht\n(31\u00a0Baht = 1US$) in total. However, with the superb collaboration of the governmental\nand nongovernmental health organizations and institutions and massive health volun-\nteers, no epidemics were detected so far.\nWonchat Subhachaturas\n23\nRegional and NMA newsNEW ZEALAND\nThe New Zealand Medical Association\n(NZMA) is the largest medical professional\norganisation in New Zealand. We are pan-\nprofessional, representing doctors from all\ndisciplines within medicine and at every\nstage of their career. The pan-professional\nfocus differentiates our organisation from\nthe other medical bodies in the country and\ngives us the mandate to advocate on issues\nthat influence the medical profession as a\nwhole.\nIt was with significant pride that the\nNZMA celebrated its 125-year anniversary\nin 2011. NZMA Chair Dr. Paul Ockelford,\nspeaking at a function late last year which\nshowcased and celebrated 125 years of the\nNZMA, said that the Association had a\nlong and proud history but continued to be\nproactive by anticipating emerging health\nsector issues impacting on doctors and pa-\ntients.\nHe referred to the Role of the Doctor\nConsensus Statement, recently published\nin the New Zealand Medical Journal, as\nan example of the NZMA taking a lead-\nership role. The NZMA hosted medical\nleaders from throughout New Zealand at a\ntwo-day seminar to develop the statement,\nwhich highlights the key skills and personal\nattributes required by doctors to ensure pa-\ntient care is not compromised in a health\nsector undergoing significant change. It re-\nflects the greater role of the patient in mak-\ning decisions about their health care and\nalso considers the role of the doctor within\nthe wider healthcare team.\u00a0 The statement\nreinforces the role and the responsibility of\ndoctors as leaders in the healthcare team,\nand as public health advocates. The state-\nment, endorsed by the medical colleges, will\nserve as the foundation for ongoing discus-\nsions with government and the wider health\nsector to deliver optimal healthcare to New\nZealanders.\nThe NZMA\u2019s direction is driven by our\nmission statement: to provide leadership of\nthe medical profession; to promote profes-\nsional unity and values, and the health of\nall New Zealanders. We have developed a\nstrategic plan for the next five years which\nwill build on these principles and shape the\nAssociation\u2019s future work.The six priorities\nin the plan provide a strategic focus to ad-\nvance the health of New Zealanders and\nleadership of the profession in the context\nof a rapidly changing health sector. Key\nthemes include improving the health sta-\ntus and health outcomes of all New Zea-\nlanders; proactively advocating on behalf\nof the profession; being one profession\nwith one vision and one voice; targeting\nboth national and global health issues; be-\ning responsive to concerns raised by mem-\nbers and championing quality in health\npolicy and systems.\nThe NZMA is highly respected for its\nknowledge, reasoned commentary and\nrobust evidence based positions. It has\na strategic programme of advocacy with\npoliticians and officials at the highest lev-\nels of government and works consistently\nto maintain strong relationships within the\nhealth sector and other government agen-\ncies, including the Ministry of Health,\nAccident Compensation Corporation, De-\npartment of Labour, and Ministry of Social\nDevelopment.The Association is influential\nin shaping health policy and it has a grow-\ning membership which reflects increasing\nrecognition among doctors that a strong,\nunified voice for the profession is essential,\nespecially in a time of rapid health sector\nchanges.\nThe NZMA also advocates on a wide range\nof issues, with the medical workforce and\nhealth equity being two major areas of ac-\ntivity.\nMedical workforce\nAt the forefront of NZMA advocacy is the\nmedical workforce. New Zealand is fac-\ning shortages of doctors (and other health\nprofessionals), and there are challenges in\nrecruiting and retaining staff. The com-\npetitive global health market means many\nlocal graduates choose to work in other\ncountries often for higher salaries. New\nZealand has an over-reliance on overseas\ntrained doctors\u00a0 \u2013 around 45 percent of\ndoctors working in New Zealand did not\ntrain here. After years of little progress,\nwith governments not even acknowledging\na problem existed, we are beginning to see\nreal progress.\nHealth Workforce New Zealand (HWNZ)\nhas been formed to lead and coordinate the\nplanning and development of our country\u2019s\nhealth workforce to achieve a self-sufficient,\nfit for purpose workforce that meets the\nhealthcare needs of New Zealanders. This\nnew agency has implemented a number of\ninitiatives, including: increases in medi-\ncal student numbers, a voluntary bonding\nPaul Ockelford\nCelebrating 125 Year Anniversary\u00a0\u2013\nNZMA Challenges and Opportunities\n24\nPrior to independence, the Primary Health\nCare (PHC) System in Estonia was based\non the Soviet Semashko model. Prima-\nry care services were mainly provided in\npolyclinics at first-level patient contact.\nPolyclinics were staffed by clinicians, gyne-\ncologists, surgeons, pediatricians and other\nspecialists. There was no specialist training\nin family medicine, thus the specialty did\nnot exist.The health centers were owned by\nmunicipalities [1, 2].\nFollowing independence, PHC reforms\nwere introduced in 1991.The reforms aimed\nto develop a family medicine-centered PHC\nsystem and to establish family medicine as\na medical specialty and academic discipline.\nIn 1993, Estonia was the first post-Soviet\ncountry to designate family medicine as a\nmedical specialty. New postgraduate train-\ning programs were introduced, including a\nthree-year residency program for new grad-\nuates and an in-service retraining program\nRegional and NMA news ESTONIA\nscheme and interest free loans for medical\nstudents who stay in New Zealand. The\nNZMA is generally supportive of HWNZ\u2019s\ngoals and has forged a good working rela-\ntionship with the organisation. We are\nnevertheless concerned about some of the\ninitiatives, particularly those that have been\nundertaken with little wider policy analysis\nand without adequate consultation with\ndoctors and medical students. The NZMA\nwill continue to voice these concerns to\nHWNZ and work with the organisation to\nprovide input into its projects.\nHigh quality training for our doctors is an-\nother issue crucial for NZMA\u2019s workforce\nadvocacy. Many of our doctors in training\nmembers are concerned there is excessive\nemphasis on service delivery at the expense\nof training. Ensuring that trainee doc-\ntors have sufficient learning time, mentor-\ning and supervision is essential to effective\nhealth workforce development.\nNew Zealand\u2019s medical workforce has\nmany challenges\u00a0 \u2013 an increasing demand\nfor health services, especially in light of\nour ageing population, the ageing doctor\nworkforce which is not being adequately\nreplenished, doctor dissatisfaction and\nmorale, doctors leaving New Zealand for\noverseas and optimal scopes of practice.\nWell-informed and determined advocacy\ncan make a discernable difference towards\nimproving these and other workforce is-\nsues.\nHealth equity\nThe NZMA has taken a leadership role in\nraising awareness of health inequity and\nthe correlation between social factors and\nhealth outcomes. In our Health Equity\nPosition Statement we have recommended\na whole of government, inter-agency ap-\nproach to address the social determinants of\nhealth (such as housing, education and em-\nployment) to help bridge health inequities.\nThe NZMA has urged the Government to\ninvest more in preventive care, particularly\nin early childhood, and supports invest-\nment into disorders such as Rheumatic\nFever that disproportionately affect Maori\nand Pacific communities. There appears to\nbe a growing willingness from throughout\nthe political spectrum to address health\ninequity and certainly increased recogni-\ntion of the key actions required such as a\nminimum income for healthy living and in-\nvesting in housing and education to achieve\nhealth outcomes.\n2012\nCommemorating 125 years of the NZMA\nhas provided a platform to celebrate the As-\nsociation\u2019s achievements and reflect on the\nmajor milestones. It has also been an op-\nportunity for the NZMA Board to consider\nand evaluate the NZMA\u2019s future direction.\nThe NZMA is anticipating another active\nyear advocating on a range of issues facing\nthe healthcare sector. These include pro-\nposed changes to medicines management,\nenhancing clinical leadership and gover-\nnance, delivering electronic health records\nfor all New Zealanders, and the passage\ninto law of the Medicines Amendment Bill\nwhich seeks to align the prescribing frame-\nwork for health professionals. The NZMA\nis concerned that there has been a shift\nin the general approach to change in the\nhealth sector with less being debated at a\npolicy level and more being introduced in\nan experimental way. Challenges therefore\nlie ahead but also opportunities, as we strive\nto attain a health system which maintains\nNew Zealand as a world leader in quality\nhealthcare delivery.\nDr. Paul Ockelford, Chairman,\nNew Zealand Medical Association\nDevelopment of Family Medicine in Estonia\u00a0\u2013 from\nNothing to Modern Specialty\nKatrin Martinson\n25\nRegional and NMA newsESTONIA\nfor specialists who were working in PHC.\nCourses were formed on voluntary bases\nmainly by clinicians and district pediatri-\ncians.\nIn 1997, significant health reforms were\nintroduced in primary health care, which\nrequired citizens to register with the list of\nfamily doctors (FDs). The economic sta-\ntus changed for family doctors and they\nbecame independent contractors. As in-\ndependent contractors, family doctors had\nto establish contracts with the Estonian\nHealth Insurance Fund (EHIF) to pro-\nvide primary health care services to their\nregistered populations and be remunerated\nby according to a new mixed payment sys-\ntem comprising basic payment for practice\nand capitation payment (now 79.9% from\nincome), and fee-for-service (now 18.2%\nfrom income)\u00a0[5].\nIn 2006 a pay-for-performance (P4P) sys-\ntem was introduced by initiating incentives\nto promote clinical quality in family medi-\ncine. The system was developed in collabo-\nration with the Estonian Society of Family\nDoctors (ESFD) and EHIF. The system\u2019s\ndevelopment remains an ongoing process.\nWhile physician participation in the pro-\ngram is voluntary, in 2011, 95% of family\ndoctors were participating in clinical quality\nassessment (EHIF 2011).\nThe clinical quality assessment system con-\nsists of three parts:\n1. Prevention (vaccinations and follow-up\nof preschool age children, prevention\nof cardiovascular diseases at the age of\n40\u201360)\n2. Management of chronic diseases (type 2\ndiabetes, arterial hypertension, myocar-\ndial infarction and hypothyreosis)\n3. Professional competence and CME\n(recertification and competence of the\nfamily doctors and nurses), follow-up\nfor pregnancies, gynecological and sur-\ngical activities.\nWhen family doctors meet 80% or more\nof the criteria, they are paid on the basis of\nP4P.The P4P maximum level is 1,2% of the\nfamily doctor\u2019s income.\nIn 2009, ESFD defined standards for good\npractice, publishing the Quality Guide for\nEstonian Family Doctor Practices (photo\nadded). The manual describes how best to\norganize work in a family medicine practice.\nThe book was published in the Estonian\nand Russian language and is also translated\nand digitally available in English.\nContents of manual:\n1. Availability of family doctors and ac-\ncess to the practice (Standards: access to\npractice, patient information)\n2. Organisation of the practice (Standards:\nworking order of the practice, managing\nmedical information, work-rooms and\naccess to them, medical accessories and\ndevices, clinical supporting processes).\n3. Quality of the treatment\/therapy (Stan-\ndards: promoting health and preventing\ndiseases, diagnosing and solving indi-\nvidual health problems, consistency of\nmedical care, cooperation with the pa-\ntient, safety and quality, education and\ntraining)\n4. Practice as an educational\/scientific\nbase (Standards \u2013 practice as an educa-\ntional base, practice as a base for scien-\ntific work)\nPicture 1. The Quality Guide for Estonian\nFamily Doctor Practices\nAppendices to the document are the ques-\ntionnaire for patients feedback and a table\nof indicators.\nEret Jaanson Ruth Kalda Anneli R\u00e4tsep Madis Tiik\n26\nRegional and NMA news ESTONIA\nOn the basis of The Quality Guide for Es-\ntonian Family Doctor Practices, the devel-\nopment of a practice accreditation system\nwas launched. The ESFD uses an intranet\nSVOOG as a tool for digital practice ac-\ncreditation assessment. Family doctors\ncomplete the table regarding quality indica-\ntors for the practice and receive a score from\nA (maximum) to C (minimum).This is vol-\nuntary and open only to doctors who are\nmembers of ESFD. (Of 805 Estonian fam-\nily doctors, 787 are the members of ESFD).\nIn the first year (2009\/2010) 79 practices\nperformed this self-analysis. The number\nrose to 109 in 2010\/2011.The total number\nof family practices in Estonia is 468.\nThe board of ESFD has decided to audit\nthe best practices (A-level) through site vis-\nits to these practices by volunteer auditors.\nThe auditing protocol was agreed by both\nsides (the auditor and the practice represen-\ntative).\nAs our system is unique \u2013 bottom to top or-\nganized, voluntary, without any P4P quality\nincentives \u2013 the only motivation for par-\nticipants is recognition and positive pub-\nlic attention. In 2011, the President of the\nEstonian Republic Toomas, Henrik Ilves,\nspecifically acknowledged the A- level prac-\ntices. ESFD also provided a beautiful pen-\nnant (Picture\u00a02), designed by textile artist,\nEne Pars.\nESFD is also very proud of our digital dis-\ntance learning environment for family doc-\ntors. Our SVOOG (intranet) system now\nincludes approximately 400 different lec-\ntures. Learner can listen to the online lec-\nture, view slides, and answer the questions\nabout the issue. SVOOG also assists fam-\nily doctors in meeting continuous medical\neducation requirements, through links to\ndifferent educational centers\u2019 homepages\nand the possibility of collecting educational\npoints for recertification. As mentioned\nabove, SVOOG also facilitates practice ac-\ncreditation.\nAnother very important development\nin Estonian health care is a nationwide\ne-health system. The idea of national\ne-health information system (EHR)\nemerged in 2002, with the purpose of de-\nveloping a nationwide database of different\nmedical documents in digital format to fa-\ncilitate the exchange of health information.\nBeginning on January 1, 2009, care provid-\ners have been obliged to forward medical\ndata to the health information system.\nPatients have the right to set restrictions\nregarding access to their data. Patient take\nfull responsibility for consequences that\nmay occur from banning access to their\nmedical data [3].\nAlso part of the e-health system is the\ne-prescription program, launched on Janu-\nary 1,2010.Within a year more than 80% of\nprescriptions were made digital. Both doc-\ntors and patients have been satisfied with\nthe development.\nThe Estonian e-health system is unique. It\nencompasses the whole country, registers\nvirtually all residents\u2019 medical history from\nbirth to death, and is based on a compre-\nhensive state-developed basic IT infrastruc-\nture [4].\nThe biggest problems are the lack of doctors\nand nurses in primary care (and in special-\nist care as well), and trained staff leaving for\nEurope to earn larger salaries. The system\nfor temporary substitution in time of vaca-\ntion or illness of regular staff is underdevel-\noped. In addition, payment for primary care\nis unbalanced in comparison with specialist\ncare.\nIn conclusion, a lot has happened within 20\nyears of family medicine in Estonia. Start-\ning from scratch, there are now 486 family\nmedicine practices, led by 805 family doc-\ntors. Family medicine, as the widest medical\nspecialty, has became the most logical and\nwell-functioning base for Estonian health\ncare.\nReferences\n1. Lember M. A policy of introducing a new con-\ntract and funding system of general practice in\nEstonia. Int J Health Plann Manage 2002; 17:\n41\u201353.\n2. Lember M. Re-evaluation of general practice\/\nfamily medicine in Estonian health care system.\nEur J Gen Pract 1996; 2:72-74.\n3. Tiik, Madis (2010). Rules and access rights of\nthe Estonian integrated e-Health system. Medi-\ncal and Care Compunetics 6 (245 - 256). IOS\nPress.\n4. Tiik, M., Ross, P. (2010). Patient opportunities\nin the Estonian Electronic Health Record Sys-\ntem. Medical and Care Compunetics 6 (171 -\n177).IOS Press.\n5. Ruth Kalda, Euract Newsletter, nov. 2010,vol 1,\nissue 1.\nKatrin Martinson,\nEret Jaanson,\nRuth Kalda,\nAnneli R\u00e4tsep,\nMadis Tiik,\nEstonian Society of Family Doctors\nPicture\u00a02. The ESFD award for A-level\npractices\n27\nRegional and NMA newsTURKEY\nThe Turkish Medical Association was con-\nstituted by Law No. 6023, enacted in 1953.\nThe managing and auditing bodies of the\nAssociation are elected by its members\n(medical doctors) under the supervision of\na judge. The mission of the Association is\nto ensure that the profession of medicine is\npractised so as to promote the benefit of the\npublic in general as well as individuals, and\nto protect the rights of physicians. How-\never, recent arrangements by the Govern-\nment are but negative interventions both to\nthe autonomy of the profession and to the\nduties of the Association in this regard.\nGovernment Decree no. 663, in Force of\nLaw on the Organization and Duties of the\nMinistry of Health and its Associated Or-\nganizations, reorganizes the field of health\nin a way that creates many legal and social\nproblems. In fact, under the present Con-\nstitution, the authority to introduce pri-\nmary legislative arrangements rests with the\nTurkish Grand National Assembly as the\nlegislative body of the Republic. However,\nby means of an authorization act,the Coun-\ncil of Ministers was equipped with authori-\nties that should actually belong to the leg-\nislature. Consequently, new arrangements\nwere unconstitutionally introduced in some\ndomains where the Council of Ministers\nis normally denied the authority establish\nrules or codes.\nNow we want to share with you the nature of\nthese arrangements that destroy the univer-\nsal values of the profession and require your\nsupport and solidarity to find a solution.\n1. A new board, the \u201cBoard for Health\nProfessions\u201d which was previously non-\nexistent was recently formed and equipped\nwith authority pertaining to a large spec-\ntrum of health affairs, including physicians\nthemselves and their work.\nThe Board comprises 14 members desig-\nnated by the Government plus one mem-\nber from the Turkish Medical Association\nwhich, according to its laws of constitution,\nis supposed to form and express opinions\nregarding the profession.\u00a0 Hence the Board\nis composed of members whose profession-\nal and scientific freedom and autonomy is\nhighly questionable.\nDuties assigned to the Board are as follows:\n\u2022 Providing opinions on such matters as\neducational curricula and training in\nhealth; identification of professional areas\nand branches and planning for the em-\nployment of health workforce,\n\u2022 Establishing ethical codes and principles\nin health profession,\n\u2022 Deciding on procedures to be followed\nin such issues as testing professional\ncompetencies of health workers, training\nof health workers in ethics and patient\nrights, as well as content and duration of\ntrainings,\n\u2022 Deciding on bans to practising the pro-\nfession on grounds of health problems,\nand\n\u2022 Deciding on temporary or permanent ex-\nclusion from the profession.\nAs such, the Board assumes the authorities\nof medical schools,the Turkish Medical As-\nsociation,and even the legislative body itself\nby introducing new offences and penalties.\nThere are over 30 health professions in\nTurkey and both the respective functions\nof these professions and the conditions of\nrecruitment are prescribed by law. There are\nnearly one hundred fields of specialization\nand sub-specialization solely in the field of\nmedicine.\u00a0 Thus, the members of the Board\nappointed by the Minister will exercise au-\nthority concerning fields in which they may\nhave no competence.\nThe Board will be in charge of assessing\ncompetence in all health professions, set-\nting codes of professional ethics, handing\ndown decisions for exclusion from the pro-\nfession,measuring professional competence,\nand developing curricula! In short we face\na situation not compatible with any demo-\ncratic society.\nMeanwhile, for 58 years, the Turkish Medi-\ncal Association has been setting the rules of\nprofessional deontology, investigating and\napplying sanctions for practices not in line\nwith deontology, and organizing trainings\nto support advancements in the profession.\nThe latest arrangement by the Government\nvirtually eliminates the established duties\nand authorities of the Turkish Medical As-\nsociation and other professional associa-\ntions and undermines the autonomy of the\nprofession and its guarantees by delegating\nfull authority to a board whose members are\nto be appointed by the Ministry of Health.\n2. The expression \u201censuring that medical\nprofession is practised and promoted in\nline with public and individual well-being\nEri\u015f Bilalo\u011flu\nTurkish Medical Association (TTB)\n28\nRegional and NMA news TURKEY\nand benefit\u201d in Article 1 of the Constitut-\ning Law of the Turkish Medical Associa-\ntion has been deleted from the text.\nThis amendment is tantamount to exclud-\ning from the mandate of a professional as-\nsociation the task of practising and pro-\nmoting medicine for public and individual\nwell-being and benefit.\nThe new arrangements taken as a whole de-\nprive the medical profession of the means to\nbe managed and supervised autonomously\nby its own professionals within the frame-\nwork of values specific to the profession\nitself. They also completely disregard the\nprinciple of exemption from the control of\nany Governmental office or agency, which\nis a precondition for being a constituent\nmember of the World Medical Association.\nAs the Turkish Medical Association, we\nurge all Medical Associations to support us\nin the fight against this unacceptable action\ntaken by the Government. We request that\nyou use your strong and important influence\nto assist us in this regard.The Turkish Med-\nical Association kindly asks for the solidar-\nity of your Medical Association in stating\nits position on this issue.\nIn defence of universal values of\nthe profession of medicine and\nrights of the physician is Turkey\nWhile the TTB was founded back in 1953\nwith its present name, its background dates\nback to Etibba Chambers of 1929. Its his-\ntory runs parallel to the history of the Re-\npublic of Turkey founded in 1923 and the\ndevelopment of democracy.\nThe TTB was originally a professional orga-\nnization with compulsory membership for\nall physicians. However, after the military\ncoup of 12 September 1980, which violent-\nly eliminated democratic organization and\nintroduced constitutional arrangements for\npreventing the flourishing of democracy,the\nrequirement for compulsory membership\nwas lifted, except in the case of freelance\ndoctors. Turkey started with 700 physicians\nin 1923, reaching over 7,000 in 1953, and at\npresent has over 120,000 physicians.\nThe first president of TTB was also the\nhead of the World Medical Association in\n1957-58.The 11th\nWorld Medical Congress\nwas held in \u0130stanbul in October 1957 and\nthe \u201cAttitude of Doctors in Conflict Situa-\ntions\u201d was adopted at that meeting.\nThe TTB has 65 local chambers throughout\nthe country and their executives are elected\nevery two years. The TTB is engaged in all\nproblems in the field of medicine and car-\nries out its activities with its members work-\ning on voluntary basis. Under the umbrella\nof TTB, students of medicine, general prac-\ntitioners and associations of specialists are\norganized as autonomous bodies. The TTB\nis in close contact with the European Union\nof Medical Specialists (UEMS). The fol-\nlowing are among specific activities that the\nTTB is engaged in:\n\u2022 Organizing Workshops for developing\nprofessional ethics (1998) and ethical\nguidelines\n\u2022 dealing with disciplinary actions relating\nto the profession\n\u2022 developing and presenting draft legisla-\ntion about the rights of physicians, cases\nof malpractice, and medical practices\n\u2022 supporting and participating in such pro-\ncesses as planning for the health work-\nforce, training and education in medicine,\nlife-long professional development, cred-\niting and National Medical Education\nAccreditation\n\u2022 developing and annually publishing\nguides for medical examination fees\n\u2022 delivering health services in emergencies\n\u2022 conducting work in such areas as the\nrights of patients, women\u2019s issues, and fe-\nmale physicians\n\u2022 categorization of medical services\n\u2022 drawing attention to problems and issues\nsuch as public health, abuse of children\nand elderly people, and the health status\nof persons in prisons\n\u2022 protesting against human rights viola-\ntions, smoking, and nuclear plants and\nhydraulic power plants that harm envi-\nronmental health\n\u2022 standing against wars and defending\npeace in all circumstances.\nOf the above activities, the personal rights\nof employed physicians and medical educa-\ntion\/training enjoy special priority and im-\nportance.\n\u2022 During its more recent history follow-\ning 1980, the TTB became the focal\npoint in defending the personal rights of\nemployed physicians. Particularly after\n2003, its struggle against the dominant\nattitude, \u201cknowing the price but not the\nvalue of everything\u201d, devaluation of the\nwork of the physician, and countrywide\npractices of sub-contracting and lack of\nsecure employment were recognized even\nin the official statements of the Minis-\ntry of Health as \u201cTTB\u2019s intensive and\nnoisy opposition\u201d. In addition to present-\ning draft laws and opinions on personal\nrights and benefits for the health work-\nforce and associated initiatives, the TTB\nalso organizes demonstrations and other\nactions including temporarily stopping\nwork.\n\u2022 Due to top-to-down approaches imposed\nby the Government,Turkey is among the\nleaders in the number of new schools of\nmedicine opened. In 2006 there were 50\nmedical schools. There are 83 today. In\n2011, approximately 9,000 new students\nenrolled in these schools. A large pro-\nportion of these newly enrolled students\neventually graduate. However, despite the\nfull commitment of the academic staffs,\nthese schools were launched without con-\nsideration of the necessary infrastructure\nand standards, leading to the problem of\npoorly qualified graduates.\nThe TTB also has a legal affairs board com-\nposed of professional lawyers. This body\nmanages a large work burden, since the\n29\nRegional and NMA newsTURKEY\ngovernment\u2019s arbitrary acts outside of the\nlegal framework are rather frequent. Publi-\ncations of the Association are prepared by\neditorial boards composed of persons work-\ning voluntarily, and include \u201cContinuous\nEducation in Medicine\u201d targeting primary\nlevel health services; \u201cOccupational Health\nand Safety Journal\u201dtargeting those engaged\nin this area; the periodical \u201cCommunity and\nPhysician\u201d that contains articles in medi-\ncine and politics; and the bulletin \u201cWorld\nof Medicine\u201d providing information about\ncentrally organized activities and other is-\nsues and events of interest.\nUnfortunately, the TTB has had signifi-\ncant experience in very difficult and un-\ndesirable issues. Mushrooming events of\ntorture, cruel and degrading treatment and\nhuman rights violations-particularly after\nthe military coup of 1980-bought to the\nforefront the unity of medical profession-\nals in terms of spotting and reporting such\ncases and the actions required by medical\nethics in the face of such events. It is based\non this experience that the TTB was able\nto significantly contribute to the Guide-\nbook to the Istanbul Protocol on the Ef-\nfective Investigation and Documentation\nof Cases of Torture and other Cruel, In-\nhuman and Degrading Treatment or Pun-\nishment, which was also approved by the\nUnited Nations.\nThe Board Members of the TTB have\nbeen charged and prosecuted twice, in\n1985 and again in the 2000s, with the ob-\njective of their removal from positions to\nwhich they were elected. In the first case,\nit was for TTB\u2019s objection to capital pun-\nishment on the ground of professional\nethics and its insistence that physicians\nbe excluded from executions although it\nwas legally obligatory. The second case was\nTTB\u2019s stance on the attitude of physicians\nin regard to widespread hunger strikes go-\ning on in prisons at that time. In both cases\nand beyond, in defense of the right to life\nand health, the TTB insistently stood for\npeaceful and democratic solutions to en-\nvironments of conflict and associated as-\nsaults and killings.\nIn short, the TTB promotes and defends\nthe universal values of the profession of\nmedicine in Turkey and stands for the\nrights of physicians on the basis of profes-\nsional values and the right to health. The\nTTB is committed to protecting the pro-\nfession from established government poli-\ncies that create dilemmas regarding both\nphysicians\u2019 and patients\u2019 rights. The TTB\nevaluates its responsibilities in the context\nof the overall situation in any given peri-\nod-in Turkey or in the world-to develop\nsuggestions about health policies and de-\ntermine its stance with regard to the right\nto health. The TTB is the representative of\nan approach that refutes negative medical\npractices of the past and strives to maintain\nand promote its accumulated knowledge\nand experience by upholding the principles\nof public health.\nTurkey is endowed with a strong legacy\nin the medical profession. The history of\nthe young Turkish Republic has witnessed\nstrenuous efforts of physicians in diverse\nareas and particularly in combating conta-\ngious diseases. However, in spite popular\nsupport and prestige, physicians and the\nTTB wrestle with many difficulties, mostly\ncreated by the government. In this context,\ntwo periods deserve special mention. The\nfirst was the practice and discourse of the\nmilitary junta following the coup of 12 Sep-\ntember 1980 and the second is the period\nthat began in 2003 and continues today.\nPressure on and harassment of physicians in\nthe present period of civilian Government\nhave assumed dimensions one might ex-\npect to see in satire magazines. For example,\nregulations and instructions determine even\nthe door and window measurements and\nheights of stairs in facilities where physi-\ncians receive their patients. At present, the\npolicy pursued by the Government aims\nat creating disrespect for the profession of\nmedicine and physicians. This policy is ac-\ncompanied statistics, such as one of every\nthree patients visit the emergency service\nwhen at a hospital, and \u201cefficiency\u201d is de-\nfined as a physician examining over 100\npatients a day. The rights of patients are re-\nduced to ordinary consumer rights in terms\nof satisfaction, while the demand for health\nservices is transformed into \u201ccustomer de-\nmand\u201d. Further provoked by irresponsible\nand hostile discourse by politicians, this sit-\nuation instigated physical violence against\nphysicians. In the face of this threat, the\nTTB created a \u201cGroup for Zero Tolerance\nto Violence\u201d to combat violence targeting\nhealth workers. The Ministry of Health, on\nthe other hand,just ignored a parliamentary\ninvestigation proposal on this issue lodged\nby some deputies.\nThe stance of the TTB vis \u00e1 vis govern-\nment policies and practices is subject to\ndefamation by describing it as \u201craising op-\nposition\u201d, \u201cengaging in politics\u201d, or \u201cacting\nwith ideological motives\u201d. Another policy\nbeing pursued is geared toward ending\nTTB\u2019s connection with and representation\nbefore the Government, and the Ministry\nof Health in particular. There are initia-\ntives to position the TTB as a hierarchical\nsubordinate of the Ministry. And finally,\nthere is the Government Decree in Force\nof Law on which the WMA circulated its\nletter dated 11 January 2011 informing its\nmembers.\nWe should be proud that in the face of all\ndifficulties, Turkey still has physicians\ndedicated to their profession and there is\nthe turkish medical association!\nDr. Eri\u015f Bilalo\u011flu\nPresident of Turkish Medical Association\n30\nSERBIARegional and NMA news\nThe Serbian Medical Chamber is an inde-\npendent, professional, self-governing and\nself-financing organization of Serbian medi-\ncal doctors based on mandatory membership.\nFounded according to the Law on Health\nCare Professionals Chambers, the Serbian\nMedical Chamber was created to improve\nthe medical profession\u2019s working conditions,\nprotect its professional interests, and actively\nparticipate in developing and managing the\nhealthcare interests of citizens,particularly in\nattaining their healthcare protection rights.\nThe Republic of Serbia assigned to the\nSerbian Medical Chamber the following\nauthorities:\n\u2022 To adopt the Code of Professional Ethics\n\u2022 To register medical doctors and to keep\nan index of all members\n\u2022 To issue, renew and revoke medical li-\ncenses and to keep records on them\n\u2022 To mediate disputes among its members\nor between its members and patients\n\u2022 To organize the Courts of Honor for in-\nvestigation of alleged breaches of profes-\nsional duties and to apply penalties, main-\ntaining a separate index on these issues\n\u2022 To issue the official records, certificates\nand confirmations from the directories\n\u2022 To establish membership and license fees\n\u2022 To issue identification cards and license\nnumbers to its members\nAt the same time, the Serbian Medical\nChamber represents and protects the pro-\nfessional interests of its members, and pro-\nmotes and defends the reputation of the\nprofession and health care services provided\naccording to the Code of Professional Eth-\nics. It responds to illegitimate and unfound-\ned public statements in media for the sake\nof protection of its members.\nThe Serbian Medical Chamber was origi-\nnally founded in 1901 and remained active\nuntil 1945, when it was\ncancelled by the Com-\nmunist Decree. Its work\nwas restored in Decem-\nber 2006. The Serbian\nMedical Chamber has\nexercised its given au-\nthority and has become\none of the most impor-\ntant stakeholders in the\nhealth care system of\nSerbia. There are approx-\nimately 30,500 medical\nlicenses issued in Serbia,\ntoday, which are required\nfor medical doctors to practice.\nThe Main Working Principles of the Ser-\nbian Medical Chamber are:\n\u2022 Serbian medical chamber indepen-\ndence. The Serbian Medical Chamber is\nself-governing professional organization\nthat is financially autonomous, since it\nis financed by membership fees and not\nfrom the state budget of the Republic of\nSerbia\n\u2022 Legality of the assigned authorities.\nAmong the most important authorities\nassigned by the State are licensing and re-\nlicensing of medical doctors\n\u2022 Protection of the medical profession,\nand promotion of the honor and repu-\ntation of medical doctors and medical\nprofession.\n\u2022 Absolute equality of private and public\npractice.\n\u2022 Decentralization and regional organi-\nzation of the serbian medical chamber.\n\u2022 Transparency.\nThe Serbian Medical Chamber Mission:\nAs a specialized organization, the Serbian\nMedical Chamber protects the medical\nprofession, the honor and reputation of\nphysicians, and the overall health profession\nand, at the same time, actively works to re-\ninforce public and individual patient trust in\nmedical doctors.\nThe Serbian Medical Chamber Vision:\nThe Serbian Medical\nChamber strives to be an\nimportant factor in medical\nproblem resolution and to\ninfluence the outline, scope\nand contents of all medical-\nly-related laws, including\nthe Medical Law itself.\nBased on the professional\npotential of its members\nand its professional bod-\nies, the Serbian Medical\nChamber has the vision to\nmove from the margins of\nthe Serbian health care system (where it cur-\nrently stands despite of all its efforts), and to\nactively participate in core dialogue and de-\ncision-making within the health care system\nof Serbia. We can. We know how. We will.\nWe are responsible and we act exclusively\naccording to the law.\nSerbian Medical Chamber Plan for the\nFollowing Period\n1. Developing a strategic and sustainable\nfive year business plan\n2. Improving the Serbian Medical Cham-\nber IT system in terms of communica-\ntions networking\n3. Expanding its assigned public authority\nin the area of medical expert supervision\n4. Introducing clinical protocols as a man-\ndatory segment of the Serbian Health\nCare System\n5. Outlining the national strategy for\nminimizing professional and medical\nmistakes\n6. Introducing clinical audit and peer re-\nview as part of the licensing process\n7. Outlining the national anti-corruption\nstrategy\nDr. Tatjana Radosavljevic,\nGeneral Manager, Lekarska Komora Srbije\nTatjana Radosavljevic\nSerbian Medical Chamber\n31\nCYPRUS Regional and NMA news\nThe Cyprus Medical Association was estab-\nlished in 1967 and represents all practicing\nphysicians in Cyprus. The main aims of the\nAssociation are to unite all members of the\nmedical profession who are practicing in\nCyprus and to safeguard their interests. Ac-\ncording to the Cypriot Law, membership to\nthe CyMA is compulsory to all physicians\nthat are practising in Cyprus. Furthermore,\nthe CyMA provides advice and assistance\nto its members in their mutual relations,\nand in their relations with the State or other\nauthorities and organisations. In addition,\nthe CyMA cooperates with other national\nand international bodies in order to foster\nits aims.\nThe Cyprus Medical Association is not only\na professional body but also acts in various\nways for the benefit of patients and the pub-\nlic in general. Objectives of the Association\ninclude protecting medical ethics; devel-\noping the health care system so that every\npatient enjoys the right to adequate treat-\nment; offering its members professional\ntraining and advancement opportunities;\nintroducing new legislation and regulations\ngoverning health issues; and managing the\nmembers\u2019 pension fund and life insurance\nschemes.\nThe Association\nadministers its\nauthority through\nfive regional\nmedical associa-\ntions: 1) Nicosia-\nKyrenia, 2) Fama-\ngusta, 3) Larnaca,\n4)\u00a0 Limassol and\n5)\u00a0Paphos.\nThe Cyprus Med-\nical Association\nhas an administrative board of 24 members.\nIt meets once a month and appoints its nine\nsub-committees. These sub-committees\nare the Ethics Committee, the Continu-\ning Medical Education Committee, the\nBioethics Committee, the Scientific Com-\nmittee, the Law and Regulations Com-\nmittee, the Pension Fund Committee, the\nCommunication Committee, the National\nHealth Insurance Scheme Committee and\nthe International and European Affairs\nCommittee.\nAccording to the new General Charter of\nthe CyMA, its administrative board has\nbeen constituted as follows:\n1. The Presidents of each regional Medical\nAssociation (Nicosia-Kyrenia, Fama-\ngusta, Larnaca, Limassol and Paphos.)\n2. Representatives of each Regional Asso-\nciation according to the number of its\nmembers (Nicosia-Kyrenia = 5, Limas-\nsol = 4, Famagusta = 2, Larnaca = 2, and\nPaphos = 2) and\n3. Four members elected from the General\nAssembly of the CyMA\nIn total, the CyMA has 2584 active mem-\nbers, of which 36% are women and 64% are\nmen.\nCurrently, the Cyprus Medical Association\nparticipate in various regional, European\nand international medical bodies such as:\n\u2022 The Standing Committee of European\nDoctors (CPME)\n\u2022 The European Union of Medical Special-\nists (UEMS)\n\u2022 The European Forum of Medical Asso-\nciations (EFMA)\n\u2022 The World Health Organization (WHO)\n\u2022 European Accreditation Council for\nContinuing Medical Education (EAC-\nCME)\n\u2022 Conference Europeene des Ordres de\nMedecins (CEOM)\n\u2022 GIPEF\u00a0\u2013 Regional Medical Association\nof Mediterranean countries\n\u2022 Conferenza degli Ordini dei Medici Euro\nMediterranei (COMEM)\n\u2022 World Medical Association (WMA)\n\u2022 Commonwealth Medical Association\n(CMA)\n\u2022 Balkan Medical Association (BMA)\nAmong other events, for 2012 the Cyprus\nMedical Association will host the annual\nmeetings of the CPME and the UEMS in\nthe second half of the year.\nTwo other Medical Associations are ac-\ntive in Cyprus, besides CyMA. The first\none is the Cyprus Government Physicians\nUnion, whose members are also members\nof CyMA. The second one is the Turkish\nCypriot Medical Association, which is reg-\nistered under the illegal regime in the oc-\ncupied northern part of Cyprus and thus\nhas no legal validity. Moreover a number of\nTurkish Cypriot physician that are practic-\ning in the north are also members of the\nCyMA.\nDr. Andreas Demetriou,\nPresident of the CyMA,\nDr. Alkis Papadouris,\nSecretary of the CyMA\nAndreas Demetriou\nCyprus Medical Association (CyMA)\nA Glance to the Past, the Present and the Future\nAlkis Papadouris\n32\nTAIWANRegional and NMA news\nHumanity, professional innovation, and\nmedical quality are the three core values that\nguided the work of Taiwan Medical Asso-\nciation (TMA) in 2011. Some noteworthy\nactivities in the past year include: promoting\nmedical malpractice civil liability, establish-\nment of a Medical Specialty Think Tank,\nrevising the standards of medical establish-\nments, promoting safety medical practice,\norganizing long-term care training course,\nreviewing clinic-based global budgeting,\nimproving patient-centered care at the pri-\nmary level, advocating holistic care to ensure\nsafety and quality, and hosting the 27th\nCon-\nfederation of Medical Associations in Asia\nand Oceania (CMAAO) Congress and 47th\nCouncil Meeting.Key agenda items for 2012\ninclude international participation, the na-\ntional health insurance program,medical ser-\nvices audit, medical care act reform, continu-\ning medical education and member welfare.\nInternational participation and exchange\nThe TMA encourages and recommends\nthat physicians and experts attend inter-\nnational professional meetings. In addi-\ntion, the TMA sends goodwill delega-\ntions to visit national medical associations\nor medical societies around the world in\norder to strengthen ties and facilitate\nprofessional exchange on various issues,\nsuch as medical administration, drug ad-\nministration, the healthcare environment\nand other health affairs. In particular, the\nTMA hopes to play an active role in the\noperation, document revision and activi-\nties of the World Medical Association. By\nclose interaction and participation with\ninternational non-governmental organiza-\ntions, the TMA enhances its capacity and\nperformance.\nNational health insurance\nBeing a key stakeholder in the health care\nsystem, the TMA studies policies and op-\nerations related to the National Health In-\nsurance (NHI) financial system. By ensur-\ning full understanding of the systems, the\nTMA is able to provide solutions to achieve\nfair resource allocation. At the same time,\nthe TMA maintains regular communica-\ntions with the Bureau of National Health\nInsurance (BNHI) to improve people\u2019s\nhealth and to assist members in carrying\nout projects commissioned by the Bureau.\nThe TMA also monitors development of\npilot projects under the NHI and provides\nsuggestions. Of course, establishing a com-\nprehensive global budget implementation\nmethodology is also a continuous effort of\nthe TMA.\nClinic-based medical service audit\nThe TMA has been commissioned by the\nBNHI to design and implement a mecha-\nnism that performs clinic-based medical\nservice auditing. This mechanism aims to\nincrease efficiency, and ensure regulatory\ncompliance and effective management.\nCoping with the global budget system\nThe TMA stresses the importance of self-\nmanagement by the medical community\nand the existence of a fair and objective\naudit mechanism in the global budget sys-\ntem. To this end, the TMA will participate\nin setting reasonable practice guidelines.\nWhile the global budget payment system\nincorporates external auditing, it is the re-\nsponsibility of the TMA to take part in the\nnegotiation process and uphold the inde-\npendence and dignity of the medical com-\nmunity.\nMedical Care Act revision\nTo address the increasingly complex issues\ninvolving medical malpractice, the TMA\nhas been working since last year to revise\nthe Medical Care Act to specify crimi-\nnal malpractice and its consequences. The\nTMA will continue promoting the revision\nin 2012 by approaching government agen-\ncies for better understanding, mobilizing its\nmembers to lobby for consent, and submis-\nsion of the draft to parliament for endorse-\nment.\nViolence in the healthcare setting\nTo prevent violent episodes in healthcare\nfacilities, the TMA requests medical soci-\neties to collect information and investigate\nthe causes of such occurrences. The TMA\nalso demands that local chapters protect\nphysicians\u2019 rights when they are threatened\nor injured, and requires that they follow up\nexisting cases.Furthermore,for the safety of\npatients and medical staffs, the TMA ap-\nMission 2012\u00a0\u2013 Taiwan Medical Association\nMing-Been Lee\n33\nFRANCE Regional and NMA news\npeals to the authorities to increase punish-\nments for these offenses and will formulate\na standard operating procedure dealing with\nworkplace violence.\nImproved continuing medical educa-\ntion for higher quality medical care\nThe TMA coordinates among professional\ngroups to organize continuing medical\neducation (CME) for general practitioners.\nCME comes in multiple formats, includ-\ning the Taiwan Medical Journal and TMA\u2019s\nonline program. Course announcements\nare updated on a regular basis on the TMA\nhomepage. The TMA, along with local and\nregional academic institutions, offers video\nconferences to provide CME for members\nin the remote areas.\nMember benefit program development\nTo improve member benefits,the TMA will\noffer favorable options for its members by\nhaving several insurance companies design\npolicies that meet members\u2019 needs, specifi-\ncally malpractice insurance. In the public\nsphere, the TMA will also appeal to the\ngovernment to reaffirm the contribution of\nphysicians and pass legislation protecting\nphysicians\u2019 welfare.\nDr. Ming-Been Lee, President\nof TMA and CMAAO.\nFrance has been represented at the WMA\nby the French Medical Association (AMF),\nof which the French Medical Council\n(CNOM) is a member.The year 2012 is im-\nportant for French representation since the\nFrench Medical Council and the French\nMedical Association have decided to submit\nto the WMA the French Medical Council\u2019s\napplication for membership.\nThe French Medical Council, an indepen-\ndent and autonomous institution, recog-\nnized to be of public utility by the French\nlegislation, manages the recognition of the\nprofessional qualifications, the registration\nto the Register of the Order, the authori-\nzation to practice and the discipline of the\nprofession. The French Medical Council\u2019s\nopinion is regularly sought before any draft-\ning of a law in the field of public health in\nFrance.\nAt the international level,the French Medi-\ncal Council has a permanent office in Brus-\nsels in order to be as close as possible to\nthe European legislature. It also serves as\nthe Secretariat of the European Council of\nMedical Orders (CEOM), chaired by the\nBelgian Medical Council, in close coopera-\ntion with all the other Orders. The CEOM\nadopted on June 10, 2011 the European\nCharter of Medical Ethics.\nThe French Medical Council also provides\nthe Secretariat for the Conference of the\nFrancophone Medical Councils (CFOM),\nchaired by the Gabonese Medical Order;\nThe CFOM brings together many Euro-\npean and African francophone states.\nAs we are facing the revision of several Eu-\nropean Directives (notably in 2012, the re-\nvision of the Directive on the recognition of\nprofessional qualifications, but also the Di-\nrective on protection of personal data) and\nFrench bioethics laws, we understand that\ndeontology can differ, depending on the\nlegislation in force in each country, but we\nremain convinced that there is a single and\nuniversal ethic since Hippocrates.\nThis ethic must be fully respected by any\ndoctor, whatever the country of practice. It\nis essential that each government respect\nthe independence of the physicians and\ncomply with this right to ethic.\nThis, is one the principal reasons why we\nwish to strengthen our presence in the\nWMA in collaboration with the French\nMedical Association, indispensable partner.\nFor more information:\nwww.conseil-national.medecin.fr,\nwww.assmed.fr\u00a0, www.ceom-ecmo.eu.\nDr. Xavier DEAU,\nCNOM Vice-president,\nAMF Secretary General,\nCFOM Secretary General\nFrench Medical Association (AMF)\nXavier Deau\n34\nRegional and NMA news KAZAHSTAN\nALTYN DARIGER is the highest public\nrecognition award for physicians\u2019 contribu-\ntion to the development of national public\nhealth, selfless work in protecting people\u2019s\nhealth and an active involvement in social\nactivities,established by the National Medi-\ncal Association (NMA) of the Republic of\nKazakhstan.\nALTYN DARIGER, translated from the\nKazakh language,means a golden physician,\nimplying the high evaluation of the physi-\ncian\u2019s merits.\nThe Association established ALTYN\nDARIGER in 2009, the year when the\nAssociation of Doctors and Pharmacists\nof Kazakhstan celebrated its 20th\nanniver-\nsary and, accompanied by re-registration,\nit was renamed as the National Medical\nAssociation. We have always focused on\nmoral encouragement. I believe that many\npeople will share my opinion that we all\nfeel gratified if our work has been appre-\nciated and when putting one\u2019s heart and\nsoul into the work it is rewarded not only\nfinancially, but also morally in the form of\nletters of appreciation, badges, medals and\ntitles.\nThe members of the Association are award-\ned not only letters of appreciation, but also\nbadges of several categories: the ALTYN\nDARIGER badge,the NMA golden badge,\nthe NMA diamond badge, as well as the\ntitle of Honorary Member of the National\nMedical Association.For organizations pro-\nviding a high quality health care, the merit\naward Public Recognition of High Quality\nHealth Care has been established. More-\nover, people and organizations involved\nin charity work, aiding patients, clinics or\ndoing philanthropy work are awarded the\ntitle Mayirim that means mercy. To com-\nmemorate our colleagues who died, provid-\ning medical assistance to people during the\nGreat Patriotic War, as well as in peacetime,\nin 2000 in the 28 Panfilov Heroes Memo-\nrial Park in Almaty a memorial stone was\nerected and trees planted in the avenue Ave\nVitae.\nDoctors of the South-Kazakhstan region\nfollowed suit and in 2010 in Turkistan city\na memorial was unveiled and an avenue\nset up, financed by medical professionals\nand supported by H. Yasavi International\nKazakh-Turkish University. L. T. Tashimov,\nPresident of the University, already at the\n2010 commencement ceremony conferred\ndiplomas to young doctors at this sacred\nplace.\nWhy is the place sacred? In 2008 in\nTurkistan city three doctors died, try-\ning to save the life of a young woman.\nStruggling for her life and attempting to\nstop the bleeding, they were infected by\na deadly contagious disease. All of them\nwere awarded posthumously the honor-\nary title together with five other doctors\nof Kazakhstan. Besides, according to the\nResolution of the Central Council of the\nNational Medical Association the ALTYN\nDARIGER badge shall be awarded to doc-\ntors of other countries for great contribu-\ntion to the health protection system of\nour country. Members of WMA, WHO\nand other international organizations have\npromoted the development of our organi-\nzation and Kazakhstan, and the following\ndistinguished persons have been awarded\nthe ALTYN DARIGER:\n\u2022 Dr. Joe Asvall, former Director General,\nWHO EUROPE\n\u2022 Dr. Allan Rowe, WHO EUROPE\n\u2022 Dr. Rene Salzberg\/European Forum of\nMedical Association and WHO\n\u2022 Dr. Yoram Blachar, President, Israel\nMedical Association\n\u2022 Dr. Andrey Kehayov, SEEMF President,\nBulgaria.\nNMA has over 60 branches (regional and\nspecialty-specified), Individuals, various of-\nficial institutions and public organizations\nmay apply for membership. To become a\ncandidate member to our Organization at\nleast five-year experience is required, and\nwhat is most important \u2013 the candidate\nshould meet the requirements set for the\nhigh rank of ALTYN DARIGER.\nThe NMA golden badge and the NMA\ndiamond badge were established in honour\nof the 15th\nanniversary of our Organization.\nALTYN DARIGER is awarded twice a\nyear \u2013 during the NMA General Assembly\nheld on the eve of the Medical Workers\nDay and when celebrating independence\nof the Republic of Kazakhstan. Each As-\nsociation branch may nominate only one\ncandidate for ALTYN DARIGER, there-\nfore the candidates undergo a rigorous se-\nlection.\nDr. Aizhan Sadykova\nPresident of National Medical Association\nof the Republic of Kazahstan\nAward for Physicians in The Republic of Kazahstan\nAizhan Sadykova\n35\nNEPAL Regional and NMA news\nEstablished on March 4th\n, 1951, the Ne-\npal Medical Association is the largest and\noldest professional organization of medical\ndoctors in Nepal.The goals of the NMA are\nincreased coordination, efficiency improve-\nments and advocacy related to the needs\nand deeds of our medical doctors. The as-\nsociation has been regularly publishing an\nindexed medical journal and organizing\nscientific workshops, seminars and confer-\nences to keep our medical professionals\nfully up-to-date with the advances in medi-\ncal science. Basic health care has been en-\nshrined as a fundamental right under the\nInterim Constitution of Nepal. With this\nimportant recognition in the Constitution\npaving the way, we are working closely with\nour government to provide basic health ser-\nvices to the people of Nepal.\nThe NMA has granted affiliation under our\nconstitution to 25 specialty societies work-\ning in Nepal. All of these societies are in-\nvolved in professional and academic activi-\nties and include the Society of Surgeons of\nNepal, the Society of Internal Medicine of\nNepal, the Nepal Orthopedic Association\nand many others.The NMA, itself, operates\n14 zonal branches spread across Nepal and\nhas a total of 4,171 life members, to date.\nThe NMA is an affiliate of the World Med-\nical Association, the Indian Medical Asso-\nciation and the Confederation of Medical\nAssociations in Asia and Oceana.\nAims and Objectives\n\u2022 Maintain a Code of Conduct to protect\nthe medical profession.\n\u2022 Facilitate the formulation of health poli-\ncies with the government.\n\u2022 Protect and advocate for human rights\nand medical ethics.\n\u2022 Encourage its members to maintain the\nhighest professional standards.\nTo achieve these objectives,the NMA is spe-\ncifically focused on the following categories\nProfessional Activities:\nRights, Regulations, Ethics, and Advocacy\nof Medical Professionals.\nAcademic Activities\nThe NMA has published a peer reviewed\nmedical Journal since 1963 and an indexed\nin PubMed\/MedLine since 2005.\nContinuing Medical Education (CME)\nProgrammes conducted include:\n\u2022 National Consultative Meeting on Un-\ndergraduate vs. Postgraduate\u2019s Seats: Ra-\ntionale, Challenges and Future Prospec-\ntive in Nepal (June 28, 2009)\n\u2022 Review of Kidney Transplantation Chal-\nlenges, Recent Trends and Future Per-\nspectives in Nepal (Sep 21, 2009)\n\u2022 Malaria Diagnosis & Treatment Guide-\nline of Nepal (November 1\u20133, 2010)\n\u2022 Various other CME programmes\nCME Programmes Proposed:\n\u2022 Capacity building for Nepal Medical As-\nsociation members\n\u2022 Training for Medical Journal Editors,\nAuthor and Peer Reviewer\n\u2022 One-day workshop to implement the\nHealth Professional Protection Act in\nMedical Institutions.\n\u2022 One-day medical conference entitled\n\u201cThe Importance of District Coverage\nand Primary Health Care Services\u201d\n\u2022 A medical wastes management workshop\nInstitutional Activities\n1. NMA has actively participated in and\nchaired the Professionals\u2019 Alliance for\nPeace and Democracy in the country\n2. NMA has a small guest house with 12\nbeds available only to NMA Life Mem-\nbers who are visiting.\n3. NMA has some scholarship programs\nfor undergraduate and post graduate\nmedical students.\n4. NMA has some provisions to provide\nscholarships for the children of de-\nceased Life Members.\n5. NMA has plan to a construct a new\nbuilding for official as well as commer-\ncial purposes.\n6. Submission of a proposal on \u201cDigitali-\nzation of the Journal of Nepal Medical\nAssociation\u201d.\nThe present day world, especially in under-\ndeveloped countries like ours, is experienc-\ning a difficult phase of uncertainty. Perform-\ning our respective duties efficiently, honestly\nand sincerely in such an insecure atmosphere\nof instability and mismanagement is some-\nwhat risky. As a result, the working situation\nis deteriorating in the field of health services.\nThe proposed forum seeks to address the ob-\nstacles a doctor in a developing country is\nencountering. With the cooperation of the\nMinistry of Health, our population and dif-\nferent health agencies like the WHO, the\nNepal Medical Association is working to-\nwards better health for our people and a bet-\nter working environment for medical profes-\nsionals in our country.\nDr. Bhupendra Kumar Basnet,\nGeneral Secretary, Nepal Medical Association\nBhupendra Kumar Basnet\nNepal Medical Association\n36\nRegional and NMA news\nA lunch debate held at the European Par-\nliament in Brussels EPF, CPME, PGEU\nand EFPIA brought together perspectives\nof patients, doctors, community phar-\nmacists and the research-based pharma-\nceutical industry presenting examples of\nbest practices on adherence to therapies\nand demonstrating how a coordinated,\nmulti-stakeholder and patient-centred ap-\nproach\u00a0 \u2013 involving patients, their carers\/\nfamilies, health professionals, industry, and\nthe public, is a key factorin improving pa-\ntient safety and the quality of healthcare\ntailored to patients\u2019 needs.\nHosting MEPs Linda McAvan (S&D),\nChristoferFjellner (PPE) and CristianS-\nilviuBusoi (ALDE) opened the event by\nemphasising the vital importance of adher-\nence to therapies \u201cIn the EU alone 194,500\ndeaths each year are due to misdose of and non-\nadherence to prescribed medication. Poor ad-\nherence carries a huge cost, both in terms of pa-\ntient safety and quality of life. It also presents\na serious problem for health systems, both in\nterms of inferior health outcomes, unnecessary\ntreatments and hospitalisations\u201d said Linda\nMcAvan. \u201cThe World Health Organization\nhas stressed that increasing the effectiveness of\nadherence interventions may have a far greater\nimpact on the health of the population than any\nimprovement in specific medical treatments\u201d\nadded ChristoferFjellner.\n\u201cWhen long-term medication is prescribed,\n50% of patients fail to adhere to the prescribed\nregimen\u201d said Prof. PrzemyslawKardas from\nthe Medical University of Lodz, Poland,\nwho gave an overview of facts and figures\non non-adherence. \u201cAdherence-enhancing in-\nterventions should be adopted as a routine part\nof normal care, and provided to every patient\u201d.\nThe patients\u2019 perspective was presented by\nChristos Sotirelis, who said: \u201cAdherence sup-\nport and concordance are key components of\ngood quality care. We believe that concordance\nin healthcare decision-making will lead to\nhigher adherence by the patient. Health pro-\nfessionals should engage with patients as equal\npartners in the prescribing process, really lis-\ntening to and taking account of their views.\nWe need to empower patients and educate\nhealth professionals in order to create such an\nenvironment and promote meaningful dia-\nlogue.\u201d\n\u201cDoctors believe that much can be done from\nthe communication point of view in order to\nimprove medical adherence. eHealth tools could\nbe used on a more regular basis in order to fa-\ncilitate easy and fast communication, particu-\nlarly between doctors and pharmacists, under\nthe condition that data protection and privacy\nis safeguarded\u201d added Dr.Lemye,Vice-Pres-\nident of CPME, who presented the role of\ndoctors in a health care team with patients\nand pharmacists.\nRaj Patel from the National Pharmacy\nAssociation of UK, member of PGEU, il-\nlustrated how pharmacists in the UK con-\ntribute to a better medicines management\nthrough the Medicines Use Review service.\n\u201cPharmacists\u00b4 interventions to improve adher-\nence \u2013 such as medicine use reviews\u00a0\u2013 have been\nshown to be effective, both in terms of patient\noutcomes and cost efficiency.The need for new\napproaches to counselling patients on medicine\nuse will only grow as our population ages, and\nmore of our fellow citizens take a number of\ndifferent medicines at the same time. But to re-\nally make an impact we need to develop such\ninitiatives on a large scale. Partnership with\npatients and other health professionals is cru-\ncial for this. The opportunities are there \u2013 we\ncannot afford to miss them\u201d said John Chave\u00a0\u2013\nSecretary General, PGEU.\nSpeaking at the conference today Mr\nRichard Bergstr\u00f6m\u00a0\u2013 Director General of\nEFPIA-explained how the pharmaceuti-\ncal industry can contribute: \u201cEFPIA and its\nmember companies are committed to improve\nadherence to therapies. This will contribute to\nbetter health outcomes and support sustain-\nable healthcare systems in times of economic\nconstraints. EFPIA wishes to encourage more\ndata gathering and evaluation, encourage\nbest-practice sharing and involve all relevant\nstakeholders. A medicine that is sold but not\ntaken is a waste for everyone \u2013 only cost and\nno benefit\u201d.\nFinally, in his closing speech, MEP\nCristianSilviuBu\u015foiadded: \u201cThere is still a\nlack of coordination between health profes-\nsionals, patients and the industry.The Steering\nGroup of the European Innovation Partner-\nship on Active and Healthy Ageing, which is a\npilot flagship initiative within the EU \u201cInno-\nvation Union\u201d has recognised the importance of\naddressing treatment adherence and polyphar-\nmacy. The Partnership will be an excellent op-\nportunity to explore potential innovative solu-\ntions that can support individual patients and\ncarers, improve data sharing and communica-\ntion between health professionals, and improve\nthe integration of care\u201d.\nEPF, CPME, PGEU and EFPIA called for\na concrete EU-level action on adherence,\nfor example through:\n\u2022 Prioritising adherence and concordance\nin the future EU Health Programme,\nin the Steering Group of the Euro-\npean Innovation Partnership on Active\nand Healthy Ageing and the Research\nFramework Programmes\n\u2022 Setting up information and awareness\ncampaigns targeted to patients and the\npublic,as part of an EU strategy for health\nliteracy and information to patients\n\u2022 Using the Structural Funds to implemen-\ntadherence intervention\nEU Umbrella Organizations Call for\na Concrete EU-level Actionfor Better\nAdherence to Therapies\n37\nOrder of Physicians of Albania (OPA)\nRr. Dibres. Poliklinika Nr.10, Kati 3\nTirana\nALBANIA\nDr. Din Abazaj, President\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\nDr. Manuel Gonz\u00e1lez Belmonte,\nPresidente\nTel: (376) 823 525\nFax: (376) 860 793\nE-mail: coma@andorra.ad\nWebsite: www.col-legidemetges.ad\nOrdem dos M\u00e9dicos de Angola\n(OMA)\nRua Amilcar Cabral 151-153\nLuanda\nANGOLA\nDr. Carlos Alberto Pinto de Sousa,\nPresident\nTel. (244) 222 39 23 57\nFax (244) 222 39 16 31\nE-mail: secretariatdormed@gmail.com\nWebsite: www.ordemmedicosangola.\ncom\nConfederaci\u00f3n M\u00e9dica de la Rep\u00fablica\nArgentina\nAv. Belgrano 1235\nBuenos Aires 1093\nARGENTINA\nDr. Jorge C. Ja\u00f1ez, Presidente\nTel\/Fax: (54-11) 4381-1548 \/ 4384-\n5036\nE-mail: comra@confederacionmedica.\ncom.ar\nWebsite: www.comra.health.org.ar\nAustralian Medical Association\nP.O. Box 6090\nKingston, ACT 2604\nAUSTRALIA\nDr. Steve Hambleton, President\nTel: (61-2) 6270 5460\nFax: (61-2) 6270 5499\nE-mail: ama@ama.com.au\nWebsite: www.ama.com.au\nOsterreichische Arztekammer\n(Austrian Medical Chamber)\nWeihburggasse 10-12 - P.O. Box 213\n1010 Wien\nAUSTRIA\nDr. Walter Dorner, President\nTel: (43-1) 514 06 64\nFax: (43-1) 514 06 933\nE-mail: international@aerztekammer.at\nWebsite: www.aerztekammer.at\nArmenian Medical Association\nP.O. Box 143\nYerevan 375 010\nREPUBLIC OF ARMENIA\nDr. Parounak Zelvian, President\nTel: (3741) 53 58 68\nFax: (3741) 53 48 79\nE-mail: info@armeda.am\nWebsite: www.armeda.amt\nAzerbaijan Medical Association\nP.O. Box 16\nAZE 1000\nBaku\nREPUBLIC OF AZERBAIJAN\nDr. Nariman Safarli, President\nTel: (99 450) 328 18 88\nFax: (99 412) 510 76 01\nE-mail. info@azmed.az\nWebsite: www.azmed.az\nMedical Association of the Bahamas\nP.O. Box N-3125\nMAB House\u00a0- 6th\nTerrace Centreville\nNassau\nBAHAMAS\nDr.Timothy Barrett, President\nTel. (242) 328-1858\nFax. (242) 328-1857\nE-mail: medassocbah@gmail.com\nBangladesh Medical Association\nBMA Bhaban 15\/2 Topkhana Road\nDhaka 1000\nBANGLADESH\nProf. Mahmud Hasan, President\nTel: (880) 2-9568714 \/ 9562527\nFax: (880) 2 9566060 \/ 9562527\nE-mail: info@bma.org.bd\nWebsite: www.bma.org.bd\nAssociation Belge des Syndicats\nM\u00e9dicaux\nChauss\u00e9e de Boondael 6, bte 4\n1050 Bruxelles\nBELGIUM\nDr. Roland Lemye, Pr\u00e9sident\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\nTel: (591) 6 227 256\nFax: (591) 6 122 750\nE-mail: secretario@\ncolegiomedicodebolivia.org.bo\nWebsite: colegiomedicodebolivia.org.bo\nAssocia\u00e7ao M\u00e9dica Brasileira\nR. Sao Carlos do Pinhal 324 - Bairro\nBela Vista\nSao Paulo SP - CEP 01333-903\nBRAZIL\nDr. Florentino de Ara\u00fajo Cardoso\nFilho, President\nTel. (55-11) 3178 6810\nFax. (55-11) 3178 6830\nE-mail: rinternacional@amb.org.br\nWebsite: www.amb.org.br\nBulgarian Medical Association\n15, Acad. Ivan Geshov Blvd.\n1431 Sofia\nBULGARIA\nDr. Cvetan Raychinov, President\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\nDr. Jeffrey Turnbull, President\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\n(OMCV)\nAvenue OUA N\u00b0 6 - B.P. 421\nAchada Santo Ant\u00f3nio\nCiadade de Praia-Cabo Verde\nCAPE VERDE\nDr. Luis de Sousa Nobre Leite,\nPresident\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\nDr. Pablo Rodr\u00edguez, Presidente\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\nDr. CHEN Zhu, President\nE-mail: intl@cma.org.cn\nFederaci\u00f3n M\u00e9dica Colombiana\nCarrera 7 N\u00b0 82-66, Oficinas 218\/219\nSantaf\u00e9 de Bogot\u00e1, D.E.\nCOLOMBIA\nDr. Sergio Isaza Villa, Presidente\nTel.\/Fax: (57-1) 8050073\nE-mail: federacionmedicacolombiana@\nencolombia.com\nWebsite: www.encolombia.com\nConseil National de l\u2019Ordre des\nM\u00e9decins du\u00a0RDC\nB.P. 4922\nKinshasa, Gombe\nCONGO, DEMOCRATIC\nREPUBLIC\nDr. Antoine Mbutuku Mbambili,\nPresident\nTel: (243-12) 24589\nFax: (243) 8846574\nE-mail : cnomrdcongo@gmail.com\nWMA Directory of Constituent Members\n38\nUni\u00f3n M\u00e9dica Nacional\nApartado 5920-1000\nSan Jos\u00e9\nCOSTA RICA\nDr. Jos\u00e9 Federico Rojas Montero,\nPresident\nTel: (506) 290-5490\nFax: (506) 231 7373\nE-mail: junta@unionmedica.com\nOrdre National des M\u00e9decins de la\nC\u00f4te d\u2019Ivoire\nCocody Cite des Arts,\nB\u00e2timent U1, Escalier D, RDC,\nPorte n\u00b01, BP 1584\n01 Abidjan\nC\u00d4TE D\u2019IVOIRE\nDr. Florent Pierre Aka Kroo,\nPresident\nTel: (225) 22486153\/22443078\/\n02024401\/08145580\nFax: (225) 22 44 30 78\nE-mail: onmci@yahoo.fr\nWebsite: www.onmci.org\nCroatian Medical Association\nSubiceva 9\n10000 Zagreb\nCROATIA\nDr. \u017deljko Metelko,\nPresident\nTel: (385-1) 46 93 300\nFax: (385-1) 46 55 066\nE-mail: tajnistvo@hlz.hr\nWebsite: www.hlk.hr\nColegio M\u00e9dico Cubano Libre\n717 Ponce de Leon Boulevard\nP.O. Box 141016\nCoral Gables, FL 33114-1016\nCUBA\nDr. Enrique Huertas,\nPresidente\nTel: (1-305) 446 9902\/445 1429\nFax: (1-305) 4459310\nE-mail: info@sirspeedy5551.com\nCyprus Medical Association (CyMA)\n14 Thasou Street\n1087 Nicosia\nCYPRUS\nDr. Andreas Demetriou,\nPresident\nTel. (357) 22 33 16 87\nFax: (357) 22 31 69 37\nE-mail: cyma@cytanet.com.cy\nCzech Medical Association\nSokolsk\u00e1 31 - P.O. Box 88\n120 26 Prague 2\nCZECH REPUBLIC\nProf. Jaroslav Blahos, President\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\nDENMARK\nDr.Mads Koch Hansen, President\nTel: (45) 35 44 82 29\nFax: (45) 35 44 85 05\nE-mail: er@dadl.dk\nWebsite: www.laeger.dk\nEgyptian Medical Association\nDar El Hekmah\n42 Kasr El-Eini Street, Cairo\nEGYPT, ARAB REPUBLIC\nProf. Ibrahim Badran\nTel: (20-2) 27 94 09 91\nFax: (20-2) 27 95 78 17\nE-mail : ganzory@tedata.net.eg\nColegio M\u00e9dico de El Salvador\nFinal Pasaje N\u00b0 10, Colonia Miramonte\nSan Salvador\nEL SALVADOR\nDr. Rodolfo Alfredo Caniz\u00e1lez Ch\u00e1vez,\nPresident\nE-mail: marnuca@hotmail.com\njuntadirectiva@colegiomedico.org.sv\nWebsite: colegiomedico.org.sv\nEstonian Medical Association\nPepleri 32\n51010 Tartu\nESTONIA\nDr. Andres Kork, President\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\nDr. Fuad Temam, President\nTel: (251-1) 158174\nFax: (251-1) 533742\nE-mail: ema.emj@ethionet.et\nema@eth.healthnet.org\nFiji Medical Association\n304 Wainamu Road\nG.P.O. Box 1116\nSuva\nFIJI\nDr. Ifereimi Waqainabete,\nPresident\nTel: (679) 3315388\nFax: (679) 3315388\nE-mail: fma@unwired.com.fj\nFinnish Medical Association\nP.O. Box 49\n00501 Helsinki\nFINLAND\nDr.Timo Kaukonen,\nPresident\nTel: (358-9) 393 091\nFax: (358-9) 393 0794\nE-mail: riikka.rahkonen@fimnet.fi\nfma@laakariliitto.fi\nWebsite: www.medassoc.fi\nAssociation M\u00e9dicale Fran\u00e7aise\n180, Blvd. Haussmann\n75389 Paris Cedex 08\nFRANCE\nDr. Elie Chow-Chine,\nPresident\nTel: (33) 2 99 38 55 88\nFax. (33) 2 99 38 15 57\nE-mail: deletoile.sylvie@cn.medecin.fr\nWebsite: www.assmed.fr\nGeorgian Medical Association\n7 Asatiani Street\n0177 Tbilisi\nGEORGIA\nProf. Gia Lobzhanidze,\nPresident\nTel. (995 32) 398686\nFax. (995 32) 396751 \/ 398083\nE-mail. georgianmedicalassociation@\ngmail.com\nWebsite: www.gma.ge\nBundes\u00e4rztekammer\n(German Medical Association)\nHerbert-Lewin-Platz 1\n10623 Berlin\nGERMANY\nDr. Frank Ulrich Montgomery,\nPresident\nTel: (49-30) 4004 56 360\nFax: (49-30) 4004 56 384\nE-mail: international@baek.de\nWebsite: www.baek.de\nGhana Medical Association\nP.O. Box 1596\nAccra\nGHANA\nDr. Kwabena Opoku-Adusei,\nPresident\nTel. (233-21) 670510 \/ 665458\nFax. (233-21) 670511\nE-mail: gma@dslghana.com\nWebsite: www.ghanamedassn.org\nAssociation M\u00e9dicale Haitienne\n1\u00e8re Av. du Travail #33 - Bois Verna\nPort-au-Prince\nHAITI\nDr. Claude Surena,\nPresident\nTel. (509) 2244 - 32\nFax:(509) 2244 - 50 49\nE-mail: secretariatamh@gmail.com\nWebsite: www.amhhaiti.net\nHong Kong Medical Association,\nChina\nDuke of Windsor Social Service\nBuilding\n5th\nFloor, 15 Hennessy Road\nHONG KONG\nDr. Gabriel K. Choi,\nPresident\nTel: (852) 2527-8285\nFax: (852) 2865-0943\nE-mail: hkma@hkma.orgoui\nWebsite: www.hkma.org\nAssociation of Hungarian Medical\nSociety (MOTESZ)\nP.O. Box 200\nH-1364 Budapest\nHUNGARY\nDr.Tibor Ertl,\nPresident\nTel: (36-1) 312 2389 - 311 6687\nFax: (36-1) 383-7918\nE-mail: nagy.dora@motesz.hu\nWebsite: www.motesz.hu\nIcelandic Medical Association\nHlidasmari 8, 200 K\u00f3pavogur\nICELAND\nDr. Birna Jonsdottir,\nPresident\nTel: (354) 864 0478\nFax: (354) 5 644106\nE-mail: icemed@icemed.is\nWebsite: www.icemed.is\n39\nIndian Medical Association\nIndraprastha Marg\n110 002 New Delhi\nINDIA\nDr. G. K. Ramachandrappa,\nNational President\nTel: (91-11)\n23370009\/23378819\/23378680\nFax: (91-11) 23379178\/23379470\nE-mail: imawmaga2009@gmail.com\nWebsite: www.imanational.com\nIndonesian Medical Association\nJl. Samratulangi No. 29\n10350 Jakarta\nINDONESIA\nDr. Prijo Sidipratomo, President\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\n2 Dublin\nIRELAND\nDr. Ronan Boland, President\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\n52136 Ramat-Gan\nISRAEL\nDr. Leonid Eidelman, President\nTel: (972-3) 610 0444\nFax: (972-3) 575 0704\nE-mail: michelle@ima.org\nWebsite: www.ima.org.il\nJapan Medical Association\n2-28-16 Honkomagome\n113-8621 Bunkyo-ku\nTokyo\nJAPAN\nDr. K. Haranaka,\nPresident\nTel: (81-3) 3946 2121\/3942 6489\nFax: (81-3) 3946 6295\nE-mail: jmaintl@po.med.or.jp\nWebsite: www.med.or.jp\/english\nNational Medical Association\nof the Republic of Kazakhstan\n117\/1 Kazybek bi St.\nAlmaty\nKAZAKHSTAN\nDr. Aizhan Sadykova, President\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\n140-721 Yongsan-gu\nSeoul\nKOREA, REPUBLIC\nDr. Man Ho Kyung, President\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\nDr. Abdul-Aziz Al-Enezi, President\nTel. (965) 5333278, 5317971\nFax. (965) 5333276\nE-mail. kma@kma.org.kw \/\nalzeabi@hotmail.com\nLatvian Medical Association\nSkolas Str. 3\nRiga 1010\nLATVIA\nDr. Peteris Apinis, President\nTel: (371) 67287321 \/ 67220661\nFax: (371) 67220657\nE-mail: lma@arstubiedriba.lv\nWebsite: www.arstubiedriba.lv\nLiechtensteinische \u00c4rztekammer\nPostfach 52, 9490 Vaduz\nLIECHTENSTEIN\nDr. Remo Schneider, Secretary LAV\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\nDr. Liutauras Labanauskas, President\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\nDr. Jean Uhrig, Pr\u00e9sident\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, FYR\nProf. Dr. Jovan Tofoski, President\nTel: (389-2) 3162 577\/7027 9630\nFax: (389-91) 232577\nE-mail: mld@unet.com.mk\nWebsite: www.mld.org.mk\nSociety of Medical Doctors of Malawi\n(SMD)\nPost Dot Net, PO Box 387, Crossroads\nLilongwe Malawi\n30330 Lilongwe\nMALAWI\nDr. Douglas Komani Lungu, President\nE-mail: dlungu@sdnp.org.mw\nWebsite : www.smdmalawi.org\nMalaysian Medical Association\n4th\nFloor, MMA House,\n124, Jalan Pahang\n53000 Kuala Lumpur\nMALAYSIA\nDr. Mary Suma Cardosa,\nPresident\nTel: (60-3) 4041 1375\nFax: (60-3) 4041 8187\nE-mail: info@mma.org.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, Bamako\nMALI\nProf. Alhousse\u00efni AG Mohamed,\nPresident\nTel. (223) 223 03 20\/ 222 20 58\/\nE-mail: cnommali@gmail.com\nWebsite: www.keneya.net\/\ncnommali.com\nMedical Association of Malta\nThe Professional Centre\nSliema Road, Gzira GZR 06\nMALTA\nDr. Steven Fava, President\nTel: (356) 21312888\nFax: (356) 21331713\nE-mail: martix@maltanet.net\nWebsite: www.mam.org.mt\nColegio Medico de Mexico\nAdolfo Prieto #812\nCol. Del Valle\nD. Benito Ju\u00e1rez\nMexico 03100\nMEXICO\nDr. Ram\u00f3n Murrieta Gonz\u00e1lez,\nPresidente\nE-mail: colegiomedicomexico.\nfederacion@gmail.com\nWebsite: www.colegiomedicodemexico.\norg\nAssocia\u00e7\u00e3o M\u00e9dica de Mo\u00e7ambique\nAvenida Salvador Allende, n\u00b0 560\n1 andar, Maputo\nMOZAMBIQUE\nDr. Rosel Salomao, President\nTel: (258) 843 050 610\nFax: (258) 213 248 34\nE-mail: associacaomedicamz\n@gmail.com\nMedical Association of Namibia\n403 Maerua Park\u00a0- POB 3369,\nWindhoek\nNAMIBIA\nDr. Reinhardt Sieberhagen,\nPresident\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\nDr. Kiran Prasad Shrestha,\nPresident\nTel. (977 1) 4225860, 4231825\nFax. (977 1) 4225300\nE-mail: mail@nma.org.np\nWebsite: www.nma.org.np\n40\nRoyal Dutch Medical Association\nP.O. Box 20051\n3502 LB, Utrecht\nNETHERLANDS\nProf. A.C.Nieuwenhuijzen Kruseman,\nPresident\nTel: (31-30) 282 32 67\nFax: (31-30) 282 33 18\nE-mail: j.bouwman@fed.knmg.nl\nWebsite: www.knmg.nl\nNew Zealand Medical Association\nP.O. Box 156, 26 h e Terrace\nWellington 1\nNEW ZEALAND\nDr. Paul Ockelford, Chairman\nTel: (64-4) 472 4741\nFax: (64-4) 471 0838\nE-mail: nzma@nzma.org.nz\nWebsite: www.nzma.org.nz\nNigerian Medical Association\nNational Secretariat\n8 Benghazi Street, Off Addis Ababa\nCrescent\nWuse Zone 4, FCT, PO Box 8829\nWuse\nAbuja\nNIGERIA\nDr. Prosper Ikechukwu Igboeli,\nPresident\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\nDr.Torunn Janbu, President\nTel: (47) 23 10 90 00\nFax: (47) 23 10 90 10\nE-mail: ellen.pettersen\n@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\nDr. Rub\u00e8n Chavarria,\nPresident\nTel: (507) 263 7622 \/263-7758\nFax: (507) 223 1462\nE-mail: amenalpa@cwpanama.net\nColegio M\u00e9dico del Per\u00fa\nMalec\u00f3n Armend\u00e1riz N\u00b0 791\nMiral ores\nLima\nPERU\nDr. Julio Castro G\u00f3mez,\nPresident\nTel: (51-1) 213 1400\nFax: (51-1) 213 1412\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\nDr. Oscar D.Tinio, President\nTel: (63-2) 929 63 66\nFax: (63-2) 929 69 51\nE-mail: philmedas@yahoo.com\nWebsite: philippinemedicalassociation.\norg\nPolish Chamber of Physicians and\nDentists\n(Naczelna Izba Lekarska)\n110 Jana Sobieskiego, 00-764 Warsaw\nPOLAND\nDr. Konstanty Radziwill,\nPresident\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 (Portugal)\nAv. Almirante Gago Coutinho, 151\n1749-084 Lisbon\nPORTUGAL\nDr. Jos\u00e9 Manuel Silva,\nPresident\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, Sect. 1\nBucarest\nROMANIA\nProf. Dr. C. Ionescu-Tirgoviste,\nPresident\nTel: (40-21) 460 08 30\nFax: (40-21) 312 13 57\nE-mail: amr@itcnet.ro\nWebsite: www.ong.ro\nRussian Medical Society\nUdaltsova Street 85\n119607 Moscow\nRUSSIA\nDr. Sergey Bagnenko,\nPresident\nTel: (7-495) 734 12 12\nFax: (7-495) 734 11 00\nE-mail. info@russmed.ru\nWebsite: www.russmed.ru\/eng\/who.\nhtm\nSamoa Medical Association\nTupua Tamasese Meaole Hospital\nPrivate Bag\u00a0- National Health Services,\nApia\nSAMOA\nDr. Viali Lameko,\nPresident\nTel. (685) 778 5858\nE-mail: viali1_lameko@yahoo.com\nOrdre National des M\u00e9decins du\nS\u00e9n\u00e9gal\nInstitut d\u2019Hygi\u00e8ne Sociale\n(Polyclinique)\nBP 27115\nDakar\nSENEGAL\nProf. Lamine Sow,\nPresident\nTel. (221) 33 822 29 89\nFax: (221) 33 821 11 61\nE-mail: lamsow@orange.sn\nWebsite: www.ordremedecins.sn\nLekarska Komora Srbije\n(Serbian Medical Chamber)\nSerbian Medical Chamber\nKraljice Natalije 1-3\nBelgrade\nSERBIA\nDr.Tatjana Radosavljevic, General\nManager\nE-mail: lekarskakomorasrbije@gmail.\ncom\nSingapore Medical Association\nAlumni Medical Centre, Level 2\n2 College Road 169850\nSINGAPORE\nDr. Chong Yeh Woei, President\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\nProf. Peter Kri\u0161t\u00fafek, President\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\nProf. Dr. Pavel Poredos, President\nTel. (386-61) 323 469\nFax: (386-61) 301 955\nE-mail: matija.cevc@trnovo.kclj.si\nSomali Medical Association\n7 Corfe Close, Hayes\nMiddlesex UB4 0XE, United Kingdom\nSOMALIA\nDr. Abdirisak Dalmar, Chairman\nE-mail: drdalmar@yahoo.co.uk\nThe South African Medical Association\nP.O. Box 74789, Lynnwood Rydge\n0040 Pretoria\nSOUTH AFRICA\nDr. Ed J. Coetzee, President\nTel: (27-12) 481 2036\nFax: (27-12) 481 2100\nE-mail: GM@samedical.org\nWebsite: www.samedical.org\nConsejo de M\u00e9dicos de Espa\u00f1a\nPlaza de las Cortes 11, 4a\nMadrid 28014\nSPAIN\nDr. Juan Jos\u00e9 Rodriguez-Sendin,\nPresidente\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) P.O. Box 5610\nSE - 114 86 Stockholm\nSWEDEN\nDr. Marie Wedin,\nPresident\nTel: (46-8) 790 35 01\nFax: (46-8) 10 31 44\nE-mail: info@slf.se\nWebsite: www.slf.se\nF\u00e9d\u00e9ration des M\u00e9decins Suisses\n(FMH)\nElfenstrasse 18\u00a0- C.P. 170\n3000 Berne 15\nSWITZERLAND\nDr. Jacques de Haller,\nPr\u00e9sident\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\n10688 Taipei\nTAIWAN\nDr. Ming-Been Lee,\nPresident\nTel: (886-2) 2752-7286\nFax: (886-2) 2771-8392\nE-mail: intl@tma.tw\nWebsite: http:\/\/www.tma.tw\/EN_tma\nMedical Association of Tanzania\nP.O. Box 701\n255 Dar es Salam\nTANZANIA\nDr. Namala Nkopi,\nPresident\nE-mail: kajuna2010@gmail.com\nWebsite: www.\nmat-tz.org\nMedical Association of Thailand\n2 Soi Soonvijai\nNew Petchburi Road, Huaykwang Dist.\nBangkok 10310\nTHAILAND\nPol.Lt.Gen.Dr.Jongjate Aojanpong,\nPresident\nTel: (66-2) 314 4333\/318-8170\nFax: (66-2) 314 6305\nE-mail: math@loxinfo.co.th\nWebsite: www.mat.or.th\nTrinidad and Tobago Medical\nAssociation\nThe Medical House, #1 Sixth Avenue\nOrchard Gardens\nChaguanas\nTRINIDAD AND TOBAGO\nTel: (868) 671-5160\nFax: (868) 671-7378\ne-mail: medassocS@tntmedical.com\nWebsite: www.tntmedical.com\nConseil National de l\u2019Ordre\ndes M\u00e9decins de Tunisie\n16, rue de Touraine\n1002 Tunis\nTUNISIA\nDr. Mohamed N\u00e9jib Chaabouni,\nPresident\nTel: (216-71) 792 736\/799 041\nFax: (216-71) 788 729\nE-mail: cnom@planet.tn\nWebsite: www.ordre-medecins.org.tn\nTurkish Medical Association\nGMK Bulvari, Sehit Danis Tunaligil\nSok. N\u00b0 2 Kat 4\nMaltepe 06570\nAnkara\nTURKEY\nDr. Eris Bilaloglu,\nPresident\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\nDr. M. Mungherera,\nPresident\nTel. +256 772 434 652\nFax. (256) 41 345 597\nE-mail. mmungherera@yahoo.co.uk\nUkrainian Medical Association\n7 Eva Totstoho Street\nPO Box 13\nKyiv 01601\nUKRAINE\nDr. Oleg Musii,\nPresident\nTel: (380) 50 355 24 25\nFax: (380) 44 501 23 66\nE-mail: sfult@ukr.net\nBritish Medical Association\nBMA House,Tavistock Square\nLondon WC1H 9JP\nUNITED KINGDOM\nMr.Tony Bourne,\nSecretary General\nTel: (44-207) 387-4499\nFax: (44-207) 383-6400\nE-mail: vnathanson@bma.org.uk\nWebsite: www.bma.org.uk\nAmerican Medical Association\n515 North State Street\nChicago, Illinois 60654\nUNITED STATES\nDr. Peter W. Carmel, President\nTel: (1-312) 464 5291 \/ 464 5040\nFax: (1-312) 464 2450\nE.mail: ellen.waterman@ama-assn.org\nWebsite: www.ama-assn.org\nSindicato M\u00e9dico del Uruguay\nBulevar Artigas 1515\nCP 11200 Montevideo\nURUGUAY\nDr. Martin Rebella, President\nTel: (598-2) 401 47 01\nFax: (598-2) 409 16 03\nE-mail: secretaria@smu.org.uy\nWebsite: www.smu.org.uy\nMedical Association of Uzbekistan\nStr. Parkenentskay 51\nTashkent City\nUZBEKISTAN\nProf. Abdulla Khudaybergenov\nE-mail: info@avuz.uz\nWebsite: www.avuz.uz\nAssociazione Medica del Vaticano\nStato della Citta del Vaticano\n00120 Citt\u00e0 del Vaticano\nVATICAN STATE\nProf. Renato Buzzonetti, President\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\nDr. Douglas Leon Natera, President\nE-mail: sgeneral@saludfmv.org\nWebsite: www.\nfederacionmedicavenezolana.org\nVietnam Medical Association\n68A Ba Trieu-Street\nHoau Kiem District\nHanoi\nVIETNAM\nDr.Tran Huu Thang, Secretary General\nTel: (84) 4 943 9323\nFax: (84) 4 943 9323\nE-mail: vgamp@hn.vnn.vn\nZimbabwe Medical Association\nP.O. Box 3671\nHarare\nZIMBABWE\nDr. Billy Rigawa, President\nTel. (263-4) 791553\nFax. (263-4) 791561\nE-mail: zima@zol.co.zw\nwww.zima.org.zw\niv\nContents\nEditorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1\nResearch Ethics Committees: Identifying and\nWeighing Potential Benefit and Harm from\nClinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2\nAnd Still, What is \u201cDeontological Ethics\u201d? . . . . . . . . . . . . 6\nIs the Colombian Health System Equitable? . . . . . . . . . . . 9\nThe Education of Medicine in the Czech Republic . . . . . . 10\nContinuous Medical Education: Physicians\u2019 Professional\nSkills Improvement by Distance Learning . . . . . . . . . . . . . 11\nGeorgian Experience in Palliative Care Development \u2013\nFrom Pilot Programs to International Collaboration . . . . . 13\nEBM (Evidence Based Medicine), not an Absolute\nReference but a Help for Making Decisions . . . . . . . . . . . 16\nCombating Antimicrobial Resistance . . . . . . . . . . . . . . . . . 17\nThe World Federation of Public Health Association . . . . . 18\nA Globalized World\u00a0\u2013 and a Unified Global Approach\nfor Health Professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20\nThe Medical Association of Thailand . . . . . . . . . . . . . . . . . 22\nCelebrating 125 Year Anniversary\u00a0\u2013 NZMA Challenges\nand Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23\nDevelopment of Family Medicine in Estonia\u00a0\u2013 from\nNothing to Modern Specialty . . . . . . . . . . . . . . . . . . . . . . . 24\nTurkish Medical Association (TTB) . . . . . . . . . . . . . . . . . 27\nSerbian Medical Chamber . . . . . . . . . . . . . . . . . . . . . . . . . 30\nCyprus Medical Association (CyMA) . . . . . . . . . . . . . . . . 31\nMission 2012\u00a0\u2013 Taiwan Medical Association . . . . . . . . . . . 32\nFrench Medical Association (AMF) . . . . . . . . . . . . . . . . . 33\nAward for Physicians in The Republic\nof Kazahstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34\nNepal Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . 35\nEU Umbrella Organizations Call for a Concrete\nEU-level Actionfor Better Adherence to Therapies . . . . . . 36\nWMA Directory of Constituent Members . . . . . . . . . . . . 37\n\n<\/p>\n"},"caption":{"rendered":"

wmj37 COUNTRY \u2022 Research Ethics Committees: Identifying and Weighing Potential Benefit and Harm from Clinical Research \u2022 What is \u201cDeontological Ethics\u201d? vol. 58 MedicalWorld JournalJournal Official Journal of the World Medical Association, INC G20438 Nr. 1, February 2012 Cover picture from Belarus ii Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj37.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3629"}],"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=3629"}]}}