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wmj201303<\/a><\/p>\n

COUNTRY
\n\u2022 The Future of Global Health
\n\u2022 Physicians in Turkey
\nvol. 59
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 3, June 2013
\nEditor in Chief
\nDr. P\u0113teris Apinis
\nLatvian Medical Association
\nSkolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv
\neditorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld
\nDeutscher \u00c4rzte-Verlag
\nDieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nVelta Poz\u0146aka
\nwmj-editor@wma.net
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher
\n\u201cMedic\u012bnas apg\u0101ds\u201d,
\nPresident Dr. Maija \u0160etlere,
\nKatr\u012bnas iela 2, Riga, Latvia
\nCover painting:
\nDoctor examines a patient.The reign of
\nCharles\u00a0VIII. Engraving (France, 19th
\ncentury)
\nfrom the stock of Pauls Stradins Museum
\nfor History of Medicine in Riga.
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\nGOMES DO AMARAL
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\nBMA House,Tavistock Square
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\nUnited Kingdom
\nDr. Guy DUMONT
\nWMA Chairperson of the Associate
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\n29874
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\nUganda
\nDr. Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
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\nP.O. Box 49
\n00501 Helsinki
\nFinland
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\nWMA Treasurer
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\nWMA Chairperson of Council
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\nWMA Secretary General
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\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal \u2013 especially those in authored contributions \u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n81
\nInstead of Editorial
\nJune is graduation month and approximately 700,000 young doctors
\nthroughout the world will receive diplomas. These medical degrees
\nmay be quite variable. In some countries non-traditional practitio-
\nners, local medical specialists and dentists are counted as doctors,
\nwhereas in others, physicians must undergo six years of rigorous
\nmedical education before they get medical doctorates. Nonetheless,
\nthey will all join the pool of doctors in the world and will become
\nserious players in the medical field within ten years.
\nMost of these doctors will greet the turn of the next century. In 2100
\nlife expectancy is expected to be much longer than it is today.Continu-
\ning population growth will add further stress to the healthcare system,
\nthough eventually continued population growth will not be sustainable.
\nThe number of old people, many of whom will have chronic ill-
\nnesses, will grow exponentially and the burden to society will be
\ntremendous. Most countries will be unable to support all the re-
\ntirees, so the retirement age will increase faster than the lifespan.
\nDoctors who graduate this year will probably have to work until
\nthey are 80 to 85 years old. Just a century ago, no one thought that
\nit would be normal to be working at age 70, as is common today.
\nDuring these years, medicine will change so dramatically that much of
\nwhat graduating students have learned in medical school will be obsolete.
\nThe rate of change is increasing, and there are projections that in the
\n21st
\ncentury the philosophy of medicine will change completely every
\n20\u00a0years.In the beginning of the 20th
\ncentury a sick patient was commit-
\nted to bed rest and fed a calorie-diet rich.In the beginning of the 21st
\ncen-
\ntury,the same sick patient is mobilized and the calories may be restricted.
\nIf aging genes or cancer-predisposing genes are discovered in the
\nnext 20 years, medicine will go in a completely new direction. The
\nmost important questions in medical ethics will be related to busi-
\nness issues\u00a0\u2013 expensive medications, gene therapy and cell trans-
\nplantation will not be accessible to everyone.While it might be pos-
\nsible to extend life indefinitely, this will no be available to everyone.
\nWelcome,young doctors,to the medical profession.Welcome to the
\nWorld Medical Association.
\nEditor in Chief, WMJ
\nDr. P\u0113teris Apinis
\nOn May 30, in the third and final reading the Latvian Parlia-
\nment unanimously adopted amendments to the law \u201cProtection
\nof the Rights of the Child\u201d which among other things contain the
\nfollowing:\u201dPhysical abuse is intentional application of force that
\nthreatens the health or life of a child in contacts with the child,
\nincluding deliberate exposure of a child to the effects of harmful
\nfactors, including tobacco smoke.\u201d
\nLatvia has become the first country in the world where smoking in the
\npresence of a child regardless of the environment, a street or a private
\napartment,is a violation of the law and will be considered a criminal act.
\nIn Europe, 700 000 people every year die of direct effects of smok-
\ning, but tens of millions of smokers die prematurely of cardiovas-
\ncular diseases, cancer or lung diseases. More than 60% of smokers
\nin Europe acquired the habit because their parents were smokers,
\nsmoked in the presence of children and left the cigarettes unattend-
\ned. Moreover, when smoking in the presence of their children, par-
\nents send an implied message that smoking is not to be condemned
\nas mom or dad does it.
\nRecent studies reveal that the foetus can become addicted to nico-
\ntine if a pregnant woman smokes or has to breathe in tobacco smoke
\nregularly.
\nUnfortunately, children are dependent on their parents or other
\nadults and do not have sufficient information and life experience to
\nassess the dangers of smoking. Similarly, disabled people and those
\nwho do not possess decision making capacity should be protected
\nfrom smoking in their presence.
\nThe Ministry of Health of Latvia together with the Latvian Medi-
\ncal Association put forward further legislative proposals to reduce
\nsmoking,especially among children and youth.Currently the Latvian
\nParliament is reviewing amendments to the law \u201cOn Restrictions Re-
\ngarding Sale, Advertising and Use of Tobacco Products\u201d. Latvia aims
\nat legislation providing that any non-smoker has the human right
\nto breathe clean air instead of smokers having the right to smoke.
\nHence, the next amendment to the Law will stipulate that in Latvia
\nsmoking in the presence of other people (on the street,in a park,pub-
\nlic places, private territories) is permissible only after receiving their
\nconsent. In Latvia smoking is already prohibited in cafes, restaurants,
\nclubs,sports stadiums and halls,workplaces and public premises.Now
\nbalconies, terraces, staircase and many other places where smoking
\ncan inconvenience other people will be added to the list.
\nLatvia supports designing plain cigarette packets like in Australia,
\nnamely, 100% of the packet\u2019s design informs about the harmful ef-
\nfects of cigarettes.However,understanding the different experiences
\nof European countries,Latvia\u2019s proposal is a draft law providing that
\n75% of the packet\u2019s design carries information on the dangers of
\nsmoking, and calls on all European countries follow suit. Latvia\u2019s
\nproposition: Smoke free Latvia in 2020, smoke free Europe in 2025.
\nDr. Ingrida Circene,
\nMinister of Health of Latvia
\nDr. P\u0113teris Apinis,
\nPresident of Latvian Medical Association
\n82
\nAUSTRALIAGlobal Health
\nThe future of global health depends far more
\non fundamental ecological and social determi-
\nnants than on progress for health technologies,
\nwhether surgical, pharmacological or immu-
\nnological. There is a growing gap between the
\noptimism in official forecasts of development
\nand global health and the trend of the most
\nimportant health determinants. Without fun-
\ndamental change to these, in turn requiring
\na global shift in culture and measurements of
\nprogress, the prospects for global health look
\nbleak. \u201cPeak health\u201d in the past has generally
\nreferred to humans in their prime of fitness; in
\nthe future it may be seen to refer to the time
\nwhen global life expectancy reached its maxi-
\nmum. That time may be within a decade \u2013
\nbut, if we can change sufficient practices, then
\nwe might still improve global health through
\nthis century.
\n\u201cThe prospect for the human race is sombre be-
\nyond all precedent. Mankind is faced with a
\nclear-cut alternative: either we shall all per-
\nish, or we shall have to acquire some slight
\ndegree of common sense. A great deal of new
\npolitical thinking will be necessary if utter
\ndisaster is to be averted.\u201d Bertrand Russell,
\n1945 [1].
\nIntroduction
\nIt is a truism within public health circles,
\nin contrast to much of the common un-
\nderstanding of health, that underlying
\n\u201cdeterminants\u201d are more important than
\nhealth technologies in explaining phenom-
\nena such as life expectancy. For example,
\nmortality from infectious diseases such
\nas tuberculosis decreased, decades before
\nantibiotics, in industrialising countries of
\nEurope from the second half of the 19th
\ncentury. This has been widely credited to
\nimprovements in housing and nutrition
\n[2]. More recently, however, there has been
\nincreased appreciation that some medical
\nfactors, especially smallpox vaccination,
\nalso contributed to better health outcomes
\n[3,\u00a05].
\nIn the 18th
\ncentury, in the UK, civil society
\nalso generated an expanded number of hos-
\npitals, a trend which abated in the early 19th
\ncentury, when life expectancy declined in
\nEngland, the leading industrialised country
\nin the world,during a time when an extreme
\nform of capitalism often called laissez faire
\ndominated [5]. In this period, before wide-
\nspread labour organisation, inequalities and
\nsqualor increased along with industrialisa-
\ntion. In Glasgow, faith in market forces also
\ncontributed to a decline in state-supported
\nsmallpox vaccinations from about 1820
\n[4,\u00a06]. Ironically, this was just as Glasgow
\nwas becoming known as the \u201csecond city of
\nthe British empire\u201d.
\nThe surge of technical developments in re-
\ncent centuries is very impressive; from elec-
\ntricity to satellites and the internet. Most
\nof them have health applications. Tech-
\nnologies specific to health have also been
\nrevolutionised, and the ambition of human
\nhealth interventions has greatly expanded.
\nA global highly organised campaign led to
\nthe eradication of smallpox, and insecticides
\nand good public health have greatly reduced
\nthe burden of malaria [7]. For patients with
\nfunds, organ transplants are routinely avail-
\nable in some countries, if needed. The list
\nof such medical contributions to improved
\nhealth is very long,and their cumulative im-
\npact is a powerful reason for the general be-
\nlief that technology is now more important
\nthan deeper health determinants \u2013 and will
\ncontinue to do so.
\nHowever, while antibiotics have been dis-
\ncovered, synthesised and used in great
\nquantities, resistance to them is also in-
\ncreasing. Increased resistance to insecticides
\nalso looms.Optimism for important vaccine
\nbreakthroughs, from malaria to dengue, far
\nexceeds reality, though some progress has
\nbeen made, such as with a partly effective
\ndefence against rotavirus [8].
\nBut problems far worse than antibiotic
\nand insecticide resistance shadow future
\nglobal health. Especially fundamental are
\necological and social determinants, the se-
\nverity of which underpin the growing gap
\nThe Future of Global Health.
\nReasons for Alarm and a Call for Action
\nC. D. Butler P. Weinstein
\n83
\nAUSTRALIA Global Health
\nbetween the optimism in official forecasts
\nof development and global health and our
\nconcern.
\nBecause of these determinants, an increas-
\ning number of scientific papers declare
\nopenly that civilisation is at risk [9\u201312].This
\narticle focuses on these underlying ecologi-
\ncal and economic determinants, and then
\nlinks them to future health prospects.
\nWe assert that, without fundamental re-
\nform, associated with a shift in global cul-
\nture and measurements of genuine progress,
\nthe prospects for global health look bleak.
\n\u201cPeak health\u201d in the past has generally re-
\nferred to humans in their prime of fitness;
\nin the future it may be seen to refer to the
\ntime when global life expectancy reached
\nits maximum [13].That time may be within
\na decade \u2013 but, if we can change sufficient
\npractices,then we might still improve global
\nhealth through this century.
\nHubris, Economics
\nand Recession
\nMuch of southern Europe is in severe re-
\ncession, and unemployment also remains
\nhigh in the U.S. Tent cities sheltering the
\nhomeless have appeared in the most mili-
\ntarily powerful nation on Earth [14].These
\nare the modern equivalent of \u201cHoover-
\nvilles\u201d \u2013 shanty towns common in the
\n1930s, named after U.S. President Herbert
\nHoover, who was in power on Black Friday,
\nOctober 29, 1929, at the onset the Great
\nDepression.
\nThere are disturbing similarities between
\nthe 1930s and the present time, and we
\nshould not forget that earlier decades saw
\nthe nurturing of fascism in Europe and cul-
\nminated in an even bloodier conflict than
\nthe \u201cWar to End Wars\u201d. Perhaps the most
\nimportant similarity between the time
\nleading to the Great Depression and our
\nown is the economic and cultural hubris of
\nthose in power [15]. The U.S. stock market
\nboom of the 1920s was considered by the
\nherd of bankers, investors and politicians
\nin control at that time to be never-ending.
\nSceptics who recalled the long history of
\nbooms and busts, the best known of which
\nmay be the Tulip Mania of 1636\u201337 [16].
\nwere disregarded in what became a stam-
\npede to lock in profits, and then a rout, as
\npeople were left holding near-worthless
\nbulbs, when they had formerly possessed
\na house.
\nFor a while, the series of global catastro-
\nphes and tragedies that unfolded between
\n1914 and 1945 \u2013 two World Wars and the
\nGreat Depression \u2013 seemed to offer hope
\nof a new, fairer world order [17]. Interna-
\ntional idealism was evident at high levels,
\nfostering the birth of the United Nations
\ninstitutions and declarations, including
\nfor Universal Human Rights, a new ideal
\nfor which former U.S. First Lady, Eleanor
\nRoosevelt, had been instrumental [18].
\nPost war U.S. President Harry Truman,
\nwho had ordered the atomic attacks on
\nJapan, quickly became troubled by the aw-
\nful potential of nuclear weapons and took
\nsteps to reduce their control by the U.S.
\nmilitary.. Truman is said to have recoiled
\nfrom their further use, argued by some to
\nbe justified by the Korean War [19]. Yet,
\nwithin another few years the U.S. adminis-
\ntration was openly contemplating the con-
\nventional use of tactical nuclear weapons
\n(including in limited wars) and the Cold
\nWar was heating up [19].
\nAbout this time, the Canadian-born econo-
\nmist JK Galbraith was warning of the likeli-
\nhood of future speculative financial bubbles:
\nNo one can doubt that the American people
\nremain susceptible to the speculative mood\u2013to
\nthe conviction that enterprise can be attended
\nby unlimited rewards in which they, individu-
\nally, were meant to share. A rising market can
\nstill bring the reality of riches. This, in turn,
\ncan draw more and more people to participate.
\nThe government preventatives and controls are
\nready. In the hands of determined government,
\ntheir efficacy cannot be doubted. There are,
\nhowever, a hundred reasons why a government
\nwill determine not to use them [20].
\nGalbraith wrote this in 1955. Although
\nnumerous economic bubbles burst in the
\nfollowing decades [20], the next great
\nglobal economic crash was delayed until
\n2008, more than fifty years later. This pre-
\ncipitated today\u2019s Great Recession, which
\nto date has persisted for five years, with
\nno end yet in view. Soon after the crash,
\nEnglish Queen Elizabeth II visited the
\nLondon School of Economics, where she
\nasked why so few experts had predicted
\nthis second great financial crash it. A re-
\nsponse stated in part:
\n\u201cFinancial wizards\u201d managed to convince
\nthemselves and the world\u2019s politicians that they
\nhad found clever ways to spread risk through-
\nout financial markets \u2013 whereas \u201cit is difficult
\nto recall a greater example of wishful thinking
\ncombined with hubris\u201d [21].
\nDevelopmental and
\nEnvironmental Hubris and
\nthe 2015 Hunger Targets
\nEven less well-recognised than the risks of
\neconomic hubris, civilisation today faces
\ndangers grounded in the interaction of
\nplanetary environmental and social factors
\n[22\u201324]. Nevertheless, living conditions,
\nand life expectancy for the more privileged
\nglobal middle class or \u201csecond claste\u201d [17]
\nmay be protected for some decades, even if
\nthese trends remain unaltered.
\nThere are many components to this risk (see
\nbox), and many ways that these dimensions
\ncan be described. Importantly, the risks to
\nglobal health extend far beyond climate
\nchange [25]. Above all, it is their systemic
\nnature which is the most troubling. For ex-
\nample, an important response to the grow-
\ning scarcity of cheap oil has been to convert
\nfood crops to ethanol and biodiesel. Almost
\n84
\n40% of the U.S. maize crop (and over 16%
\nof the global crop) is now used for ethanol
\n[26,\u00a0 27]. A non-trivial fraction of other
\nfoodcrops are also used for fuel, from palm
\noil to sugar cane and cassava.This diversion
\nof food to fuel adds appreciably to global
\nfood prices, and Jos\u00e9 de Silva, the newly
\nappointed head of the FAO, has recently
\ncalled on the US to lower the percent-
\nage of maize diverted to ethanol, so as to
\nlower global food prices [28]. The diversion
\nof food to fuel also threatens biofdiversity
\n(because of the associated replacement of
\nnative forest with monoculture, for example
\noil palm), and as we shall see below a loss of
\nbiodiversity in itself poses serious threats to
\nhuman health.
\nOnly a few of these elements can be dis-
\ncussed in any detail in this article. Funda-
\nmental to most analyses, however, is the
\nprinciple common to all currently dominant
\neconomic systems, whether based on redis-
\ntribution (i.e. leftist or socialist) or market
\nforces (i.e. rightist), which is the failure to
\nproperly account for two forms of hazards.
\nThese hazards are the depletion of natural
\nresources (both non-renewable and renew-
\nable) and the accumulation of waste. The
\nfailure to measure either harm is especially
\npronounced when the damage accrues to
\npeople who are far away,whether in physical
\ndistance, culture, or time, including future
\ngenerations.
\nDepletion of non-renewable natural re-
\nsources, such as oil and other fossil fuels
\nimpacts directly on global health. The ris-
\ning cost of energy not only lifts the price
\nof food, but also makes it harder and more
\ncostly for civilisation to develop the infra-
\nstructure which may one day free us from
\ndependency on these dangerous and pol-
\nluting fuels. Depletion of renewable natu-
\nral resources, especially biodiversity and
\nintact forests is also problematic. We are
\ndependent on healthy, sustainable ecosys-
\ntems for food, water, fibre, and fuel. While
\nprovisioning ecosystem services (such as
\nfor food and fuel) continue to increase, this
\nis at the expense of regulating ecosystem
\nservices [29], which are vital for a stable
\nclimate, for adequate fresh water, and to
\nreduce runaway growth of unwanted spe-
\ncies population increases, such as jellyfish
\nswarms [30].
\nIt is also becoming increasingly clear that
\nindirect effects of biodiversity decline in-
\nclude epidemics of emerging infectious
\ndiseases: When biodiversity is lost, the
\nlikelihood is increased of disease vectors be-
\ncoming increasingly prevalent [31\u201333].
\nThe second problem \u2013 the failure to account
\nfor waste \u2013 may result from the long evo-
\nlutionary human experience as \u201cpatch dis-
\nturbers\u201d [34]. For millennia, humans were
\nmigratory,and our numbers small compared
\nto the resources and landscape. Our species
\ncould disrupt its local environment and
\nthen move on. Even after the development
\nof settlements, local pollution was generally
\nmanageable; most wastes were organic, and
\nquickly broke down \u2013 though the failure to
\nsafely dispose of human faeces and in some
\ncases urine did contribute to various infec-
\ntious diseases, including cholera, hookworm
\nand schistosomiasis. The close proximity of
\nhumans and animals living together also re-
\nsulted in a number of \u2018host jumping\u2019 events,
\nwherein animal pathogens crossed into hu-
\nman populations.
\nEconomic systems are fundamental, be-
\ncause they supply incentives, operant at
\nmultiple levels, including global in the form
\nof price signals, to act in ways that either
\nhinder or facilitate the sustainability of ci-
\nvilisation and thus the chance of reasonable
\nglobal health. Today, most financial incen-
\ntives operate to deliver short-term benefit
\nfor those who are privileged, but to pile on
\ndisadvantage and risk to those who are al-
\nready poor and vulnerable.
\nThe complacency and misunderstanding
\nwhich are generating these risks is re-
\nMajor under-appreciated risks
\nand solutions to global health
\n– A global lack of leadership, bolstered
\nby a retreat from aspirations of global
\ncivilisation by the first and second
\n\u201cclastes\u201d.
\n– Climate change, especially its impact on
\nfood security, migration and conflict.
\n– Rising energy costs.
\n– Impending phosphate scarcity.
\n– Limits to yield growth of major crops
\nin Europe, the U.S., China, and India.
\n– Biodiversity loss.
\n– Diminishing returns to increasing
\ncomplexity.
\n– Youth bulges and the risk of con-
\nflict and declining governance on the
\n\u201cfront-line\u201d.
\n– The awakening of \u201csleeping\u201d infectious
\ndisease pandemics in the threatened
\nnew milieu of chaos.
\nPotential solutions
\n– New technologies, especially solar,
\nwhich make fossil fuel uncompetitive.
\n– Revived global leadership, especially a
\nre-awakening of aspirations for educa-
\ntion and health for all.
\n– Improved human rights, especially for
\nwomen.
\n– Better treatment of parasitic and other
\nneglected diseases.
\n– Less wastage of food, pre and post-
\nharvest.
\n– Greater care to recycle phosphate and
\nreduce its waste.
\n– The ascendancy of ecological economic
\nsystems.
\nAUSTRALIAGlobal Health
\n85
\nvealed by global attitudes towards hunger
\ntargets. At the time of the World Food
\nSummit in 1996, great progress had been
\nmade in reducing the fraction of the world
\npopulation classed as chronically under-
\nnourished. The proportion of hungry peo-
\nple globally almost halved between 1970
\nand 1996, due to the success of the Green
\nRevolution (see Figure). At that summit,
\nit was announced that the hunger target
\nfor 2015 would be to reduce the number
\nof people classed as chronically hungry in
\n1990 (850 million) by half (to 425 mil-
\nlion) [35]. This number represents 6% of
\nan estimated global population of 7.2 bil-
\nlion in 2015.This promise will not be kept;
\nits failure cannot principally be attributed
\nto climate change, though that is now of
\ngrowing importance.
\nFull discussion of this little-noticed failure
\nto reduce global hunger are complex and
\nis not possible here. One factor includes
\nthe intransigence of Catholic teachings on
\ncontraception; a ruling whose power seems
\ninversely proportional to the distance from
\nRome. Slowing population growth enhanc-
\nes economic growth, and makes the prob-
\nlem of food distribution easier [37].
\nMany commentators on the political Left,
\ncertainly since Karl Marx (a trenchant critic
\nof Malthus) [38] have argued that the prob-
\nlem with food-poverty is primarily one of
\ndistribution, rather than supply. However,
\nthe decline in hunger between 1970 and
\n1996 coincided with a large increase in per
\nperson food supply, especially of grain [39].
\nIn recent years, total food supply, when ad-
\njusted for biofuels (food which cannot be
\neaten), has been either static or in decline
\n[36]. Irrespective of the wishes of idealists,
\nworld hunger is unlikely to be substantially
\nsolved by redistribution, though reduced
\nfood waste in low-income countries, espe-
\ncially India, could surely reduce rural hun-
\nger.
\nThe 2015 hunger targets could have been
\non track (and could still be reached, even
\nstarting from today) by sufficient redis-
\ntribution of food and the other resources
\nneeded to enable secure food entitlement
\n[40]. However, to argue that the failure of
\nthe hunger goals lies primarily in the fail-
\nure of redistribution is very unrealistic. It
\nis also very unlikely that the framers of the
\n1996 World Food Summit goals thought
\nthat their target could be thus achieved
\nby redistribution. Rather, they most likely
\nbelieved that the progress made between
\n1970 and 1996, in greatly expanding food
\nsupply per person, could simply continue.
\nBut the chance of such additional food was
\nin reality no more likely at possibility had
\nno more credibility than that stocks would
\nkeep rising, predictions made by econom-
\nic pundits at the height of stock market
\nbooms.
\nThis statement may sound too harsh,but not
\nto those who signed or studied the World
\nScientists Warming to Humanity, now two
\ndecades old [41]. Signatories included more
\nhalf of the Nobel Prize laureates for natural
\nscience then alive.The list included Norman
\nBorlaug, who had been awarded the Peace
\nPrize in 1970, for his work in developing
\nthe Green Revolution. The collective state-
\nment warned:
\nWe the undersigned, senior members of the
\nworld\u2019s scientific community, hereby warn all
\nhumanity of what lies ahead. A great change in
\nour stewardship of the earth and the life on it is
\nrequired, if vast human misery is to be avoided
\nand our global home on this planet is not to be
\nirretrievably mutilated.
\nThe reasons for the failure of the 1996
\nand 2000 food targets (for 2015) lie far
\nmore with wishful thinking and a failure
\nto understand limits to growth than with a
\nfailure of redistribution. The success in re-
\nducing hunger in the heyday of the Green
\nRevolution was not primarily because of
\nredistribution, but because food supply per
\nperson expanded dramatically in that pe-
\nriod.
\nProbably the single most important reason
\nfor the failure to reach the 2015 hunger
\ngoals is that the crop and technological
\nimprovement which led to the enormous
\n1970 1980 1990 2000 2010 2020
\n30
\n25
\n20
\n15
\n10
\n5
\n0
\nWorld Food Summit target
\nPercenthungry
\nGlobal financial crisis
\nMDG
\ntarget
\nGreen revolution
\nfailed trend
\nFigure. From 1960 until about 1996 great progress was made in reducing global hunger. A
\nfailure to understand the reality of limits to growth led to wildly optimistic targets for
\n2015. Raw data FAO, to 2011. FAO data in 2012 revised these data, making the target
\nlook less out of reach [36].
\nAUSTRALIA Global Health
\n86
\nincrease in yield facilitated by the Green
\nRevolution (albeit dependent on energy-
\nintensive fertilisers, pesticides and water)
\nhad largely been achieved by about 1990.
\nYields continued to increase, but at di-
\nminishing rates. In some cases, including
\nrice in China, wheat in India, and irrigated
\nmaize in the U.S, they have entirely flat-
\ntened [42]. Indeed, Borlaug broadly fore-
\ncast these developments in his Nobel Peace
\nPrize acceptance speech, in 1970, in which
\nhe also called for the kerbing of population
\ngrowth [43].
\nSince about 1990 considerable effort has
\ngone into trying to replicate the Green
\nRevolution\u2019s success, using genetically mod-
\nified crops. The effort in promoting GMOs
\nhas not been well spent [44]. Much this
\nresearch has been to improve weed control
\nthrough the development of crops such as
\ncanola and corn modified to be resistant to
\nthe herbicide glyphosate. But, as predicted
\nat least as early as 1996 [45], selection pres-
\nsure has driven the evolution of glyphosate
\nresistant weeds [46].
\nSome work has attempted to develop ge-
\nnetically modified crops for use in the Third
\nWorld that are resistant to drought and dis-
\nease; however, the results have so far fallen
\nfar short of their promise. At the same time,
\ncomplex factors have prevented the Green
\nRevolution from penetrating far into Africa
\n[47]. The Millennium Development Goal
\n(MDG) for hunger, set in 2000, was slightly
\nless ambitious than the 1996 target [48].
\nNeither has much progress been made to-
\nwards it.Furthermore,since the onset of the
\nGreat Recession, little noticed by wealthy
\npopulations, famines have returned to the
\nAfrican countryside, to Somalia, Sudan
\nand Niger. At least some of the causation
\nfor the famine in the Horn of Africa is due
\nto human-induced climate change [49,\u00a050].
\nThere is also increasing recognition that the
\nchronic food insecurity in Niger is related
\nto that nation\u2019s high population growth.
\nHalf of the people in Niger are aged under
\n15\u00a0[51].
\nEconomics, Energy
\nand Recessions
\nOur dominant economic systems, whether
\ncapitalist or communist, evolved and be-
\ncame dominant in the last two centuries, at
\na time when global resources were abundant
\nand generally increasing, even on a per-
\nperson basis. The price of energy was his-
\ntorically low in most of this period, as was
\nthe price of food [52]. Despite the warning
\nof one of the most eminent fathers of eco-
\nnomic theory, John Stuart Mill [53],\u201csteady
\nstate\u201d systems, which preferred qualitative
\nto quantitative growth were scorned.
\nThe discipline Mill helped establish, most
\ncommonly called ecological economics
\n[54,\u00a0 55], remains as marginalised today
\n[56]. as the analysis of the rare critics who
\n(correctly) questioned the wisdom of mak-
\ning \u201csub-prime\u201dloans to impoverished U.S.
\nhouse buyers in 2007. This is the case even
\nthough a major component of the seem-
\ningly intractable global recession is the
\npersistently high price of energy. Despite
\nclaims disputing the reality of \u201cpeak oil\u201d
\n[57]. energy prices remain very high glob-
\nally, even during the current deep recession
\n[58]. The former U.K. chief scientist, Sir
\nDavid King, recently co-authored a paper
\nin Nature which pointed out that consum-
\ners in the European Union and the U.S.
\neach spend $1 billion dollars per day im-
\nporting energy, greatly reducing the money
\ncirculating in the local economy. These
\nfunds could stimulate domestic employ-
\nment [59].
\nOptimists have predicted that the discov-
\nery of large supplies of shale gas and new
\ntechnologies that allow increased recovery
\nof \u201ctight\u201d oil mean that a new global en-
\nergy glut is unfolding with a consequent
\nimpending price drop. Others dispute this,
\nincluding the Post Carbon Institute [60].
\nA major report underlying this optimism
\n[57]. completely ignored the concept of
\n\u201cnet energy\u201d, or \u201cenergy return on energy
\ninvestment\u201d [61]. One way to conceptual-
\nise this is by thinking of stocks and flows.
\nThe total stock of fossil fuel has expanded,
\nbut the rate at which it can be withdrawn
\nhas altered little, so that total annual supply
\nremains constrained. A medical analogy is
\nthe birth of twins. A uterus may have two
\nfetuses, but they can only be delivered one
\nat a time, even by Caesarean.
\nA major reason for this is that much \u201cun-
\nconventional oil\u201d is extremely energy-in-
\ntensive to extract, such as the Canadian tar
\nsands. At least a fifth of the energy con-
\ntained in these fields is required to extract
\nthe remaining energy, giving an energy
\nreturn, at the best case, of 4:1[61]. Off-
\nshore wells from Brazil are so remote that
\nhelicopters must be refuelled in mid-air in
\norder for drillers to reach their platforms
\n[58]. These discoveries and new technolo-
\ngies may mean that the world oil produc-
\ntion experiences a \u201cbumpy plateau\u201d rather
\nthan a sharp peak, and it seems also likely
\nto delay really steep price rises (e.g. above
\n$200\/barrel), partly because high prices
\ngenerate a deepened recession, temporarily
\nlowering demand [61].
\nA sustained decline in the price of liq-
\nuid fossil fuels appears unlikely. But even
\nif fossil fuel prices fall substantially, relief
\nto the global economy is likely to be only
\ntemporary, unless that energy bonus can be
\nused to build the technological and energy
\nrevolution that is so badly needed, which
\ncan wean civilisation from \u201cEarth poisons\u201d
\nsuch as coal and radioactivity. But without
\ngreatly improved leadership, humanity is
\nlikely to squander that chance. High energy
\nprices may in fact be the best way to drive
\nthe creation of new technologies (such as
\nnew-generation photovoltaic), because the
\nconstrained supply acts as a de facto carbon
\nprice, applicable globally except in those
\nfew countries which export abundant oil,
\nand which continue to heavily subsidise the
\nprice of fuel, often at the same time creating
\nhigh traffic density and localised air pollu-
\ntion.
\nAUSTRALIAGlobal Health
\n87
\nMoving from Social to Eco-
\nSocial Health Determinants
\nRecently there has been a welcome revival
\nof interest in the \u201csocial determinants\u201d of
\nhealth. In short, this thinking points out the
\nimpossibility of good health when people
\nare poor, either materially or relatively. In-
\nequality appears to be an important health
\ndeterminant, perhaps rivalling undernutri-
\ntion in some societies. The core solution to
\ninadequate social determinants is either to
\nredistribute the existing \u201ccake\u201d or to bake a
\nbigger cake, perhaps preferentially distrib-
\nuting the increment to those who are only
\nreceiving crumbs.
\nHowever laudable these approaches are,
\nthey do not contribute sufficiently to solv-
\ning the problem of limits to growth. The
\ncase of energy and food has been extensively
\ndiscussed above.While redistribution of ex-
\nisting energy supplies would alleviate fuel
\npoverty for many, it would neither lower the
\nprice of electricity nor increase the supply of
\noil.The same analysis applies for phosphate,
\nan essential element which must be mined
\nor recycled and which like oil is declining in
\nquality and quantity [62].
\nTherefore, there needs to be commensurate
\nawareness of the environmental health de-
\nterminants, including ecological ones.These
\nmay be renewable \u2013 such as fish stocks, bio-
\ndiversity and fresh water \u2013 or non-renew-
\nable, such as fossil fuels, phosphate and ar-
\nable land.
\nAlso necessary is a greater recognition of
\nthe links between social and environmen-
\ntal factors,such as between conflict,migra-
\ntion and resource scarcity. The co-mingled
\ncausation of many eco-social phenomena
\nis contested, sometimes bitterly. For ex-
\nample, the Rwandan genocide of 1994\u2013
\ntogether with many other conflicts in
\nAfrica and elsewhere \u2013 are often analysed
\nas purely social events rather than inter-
\nactions between ecological events. This is
\nespecially true for resource scarcity, most
\noften of land and social factors. An excel-
\nlent rare exception was published in the
\nJournal of Economic Behaviour and Organi-
\nzation [63].
\nMost wars concern the struggle for re-
\nsources, but this purpose is often disguised.
\nThe invasion of Iraq in 2003 had much to
\ndo with the struggle to control that nation\u2019s
\noil supplies. Rupert Murdoch forecast that
\noil would fall to $20 per barrel [64]. How-
\never, the link to oil was vigorously denied
\nby the leaders of the U.S., U.K. and Aus-
\ntralia.
\nA more recent example is the displacement
\nof about 400,000 people in the northeaster
\nIndian state of Assam in 2012 [65]. This is
\ngenerally characterised as a clash between
\nMuslims and the indigenous people, the
\nBodo, who are largely Christian or animist.
\nDepending on their bias, pundits discuss
\ndifferent events as triggering factors. How-
\never, too few analysts, including academics,
\nconsider that the problem is one of insuffi-
\ncient land and other resources for the wants
\nand needs of the population. True, some
\npeople in such areas could voluntarily live in
\nmore extreme poverty,thus enabling a high-
\ner population density. But that strategy be-
\ncomes self-defeating, because such poverty
\nleads to increased weakness and vulnerabil-
\nity, creating the potential for displacement
\nby more powerful groups or populations. In
\npractice, each of the main groups in Assam
\nhas sought to increase its living standard by
\nmeans such as improved technology, better
\nfertiliser, remittances and also by utilising
\nall available resources, including fertile land.
\nThis competition creates dry tinder, requir-
\ning only a small spark for violence to catch
\nfire.
\nAn increasing number of social scientists
\nrecognise the links between earth system
\nlimits (including planetary boundaries)
\nand human well-being [66,\u00a0 67]. At the
\nsame time, a slowly increasing number of
\nhealth workers also recognise these links
\n[22,\u00a024,\u00a068,\u00a069].
\nMigration
\nMigration, including the seeking of politi-
\ncal asylum,has recently been most frequent-
\nly characterised as having an \u201ceconomic\u201d
\ncausation, that is, purely social; in the sense
\nthat the economic problem could be solved
\nby enough social cleverness. However, eco-
\nnomic factors are associated with elements
\nthat are both material (food, shelter) as well
\nas social (freedom of association and speech,
\npsychological security).
\nDespite growing understanding of the in-
\nteractions,wealthy populations are reluctant
\nto accept this argument. In countries such
\nas Australia the fiction of purely econom-
\nic refugees is used widely in the media to
\nreduce feelings of guilt and responsibility,
\nincluding about climate change, with its
\nspectre of rising sea levels and other con-
\ntributory drivers of migration.
\nAustralia, a signatory to the refugee con-
\nvention, does eventually settle \u2013 usually after
\nyears of confinement \u2013 most people who
\nseek asylum and who are able to reach an
\nAustralian territory. However, the entre-
\npreneurs who are paid by asylum seekers to
\nbring them to Australia (a lawful act) are
\nuniversally vilified as \u201cpeople smugglers\u201d.
\nWould a sympathetic German helping
\nsomeone escape from Auschwitz to Swit-
\nzerland be denigrated this way?
\nHealth
\nWe have written here much more about
\nthe determinants of health than health it-
\nself. Clinicians are familiar with the art
\nand science of diagnosis and treatment, but
\nrarely consider why their patients may suf-
\nfer a chronic disease or engage in such risk-
\ntaking behaviour as smoking. If clinicians
\ndo start to ponder this, then they venture
\ninto public health territory, a field in which
\npractitioners routinely consider population-
\nscale factors that influence health, such as
\ncalorie intake and cigarette advertising. In
\nAUSTRALIA Global Health
\n88
\nthis paper we have only sketched the nu-
\nmerous links between the planetary envi-
\nronmental determinants mentioned and
\nhealth.
\nThe most important mechanism is unlikely
\nto be a sudden ecological catastrophe that
\nends food production, though an intensi-
\nfied loss of pollinators, vital for food, is oc-
\ncurring [70]. More plausibly, as limits to
\ngrowth tighten, competition among people
\nand between human groups will increase,
\nleading to intensified regional scarcity, con-
\nflict and misery.
\nA recent spate of self-immolations in Bul-
\ngaria has been driven by poverty and in-
\nequality. Conflict over resources in Chech-
\nnya can have ramifications in Boston.Rising
\nprices of food and oil in Egypt threaten to
\ndeepen unrest there. Globalisation links di-
\nverse populations via trade; but unless the
\nwealth it creates is shared equitably \u2013 at
\nleast to a minimum standard, then resent-
\nment and occasional terror will also be ex-
\nchanged [71].
\nClimate change is expected to impact on
\nhuman health in numerous ways, classified
\nby Butler and Harley as primary, secondary
\nand tertiary [25,\u00a072]. In brief, these include
\ndirect (\u201cprimary\u201d) effects (such as from
\nheatwaves or extreme weather events),
\nless direct \u201csecondary\u201deffects such as from
\nchanges in insect vector populations or the
\nrate of growth of parasites within vectors
\nin warmer environments, and \u201ctertiary\u201d
\neffects. These occur when climate change
\nacts as a \u201crisk multiplier\u201d for events such as
\nconflict, famine and large-scale migration.
\nSome analysts think that the Syrian con-
\nflict has been worsened by climate change
\n[73].
\nEven without conflict, rising food prices
\nincrease the risk of undernutrition and
\n(perhaps paradoxically) also of obesity, as
\npopulations strive to conserve calories at
\nthe expense of micronutrients. Chronic
\nunder- or unemployment can be devas-
\ntating for self-esteem and mental health.
\nResultant poverty can stress families and
\nreduce the intergenerational transmission
\nof love and nurturing that is essential for
\npopulation health to flourish. Although
\nwe have not argued that health care is the
\nmajor health determinant, it is a factor.
\nRecessions make it harder for the poor to
\npay for health care. In many locations ill-
\nnesses are an important cause of impov-
\nerishment.
\nFrom Describing the
\nProblem to Outlining
\nthe Solution
\nThese problems may seem intractable but
\nsolutions exist. The mainstream approach
\nhas two main prongs. The first strategy is
\nto deny the existence of any fundamental
\nproblem, such as a limit to growth or con-
\nsumption, and trust that ingenuity, invest-
\nment and market forces will find a solution.
\nThis approach has had isolated success,
\nmost notably the \u201cGreen Revolution\u201d de-
\nscribed above. Today, civilization is like a
\nman falling to Earth without a parachute,
\nregarding his velocity as the chief indicator
\nof progress.
\nThe second strategy is scarcely discussed.
\nThat is to fortify the walls, moats and elec-
\ntronic surveillance mechanism that sepa-
\nrate and try to protect wealthy populations
\nfrom the masses. This approach can be seen
\nat the border between Europe and North
\nAfrica, the U.S. and Mexico, and Australia
\nand Asia. It also is evolving between India
\nand Bangladesh, which can now be called
\nthe world\u2019s \u201cbiggest human cage\u201d, due to
\nthe fence that India has been constructing
\nalong most of its border.
\nNeither of these solutions is tenable over the
\nlong run. The solution instead must lie in
\nan intellectual and social revolution which
\noverturns our dominant ways of thought.
\nWe must collectively develop the new ways
\nof thinking called for by such visionaries
\nsuch as Bertrand Russell, Albert Einstein
\nand Martin Luther King.
\nSome of these visionaries have worked in
\nhealth, including Albert Schweitzer, Ren\u00e9
\nDubos and Frank Fenner. Health organ-
\nisations including The International Phy-
\nsicians for the Prevention of Nuclear War
\n(IPPNW), Physicians for Social Responsi-
\nbility (PSR) and the International Society
\nof Doctors for the Environment (ISDE)
\nexist,and collectively can work to reduce the
\nthreats we face. Perhaps the leading medical
\naid group, M\u00e9decins Sans Fronti\u00e8res, will
\nalso take a more active role in calling for
\nimproved health determinants.
\nAnother, alternate, solution has emerged:
\nthe accelerating power of the internet. An
\nexample of how it can be used as a force
\nfor change is the use of low-cost mobile
\nphones for internet access in Kenya, which
\ncould provide a model for other African
\ncountries [74]. Many traditional authori-
\nties lament the demise of print media, but
\nsome optimists think that the rise of social
\nelectronic media may be more democratiz-
\ning than newspapers have been in recent
\nyears,controlled by oligarchs such as Rupert
\nMurdoch.
\nAcademics can contribute by greater recog-
\nnition of the dangers that exist and by writ-
\ning about solutions. A recent special issue
\nin The Lancet was devoted to human popu-
\nlation numbers and health [75]. Melinda
\nGates has also recently spoken of the need
\nto slow global population growth [76,\u00a077].
\nA meeting to commemorate the 350th
\nan-
\nniversary of the Royal Society accepted the
\nperil we face is real, and warned of the risk
\nof pessimism as a response [68]. The Royal
\nSociety report People and Planet will also
\nserve to relegitimise discussion of family
\nplanning and limits to growth [51].
\nThe fact that such reports are seen as
\ngroundbreaking shows how far we have to
\ncome.These themes were widely recognised
\nAUSTRALIAGlobal Health
\n89
\nin the 1970s, a decade which experienced
\nthe first Earth Summit in Stockholm, pub-
\nlication of the report to the Club of Rome
\ncalled The Limits to Growth [78] and the
\ncoining of the phrase \u201cdevelopment is the
\nbest contraceptive\u201d [79]. It still is.
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\nC. D. Butler
\nFaculty of Health, University of Canberra,
\nBruce, ACT 2601, Australia
\nE-mail: colin.butler@canberra.edu.au
\nP. Weinstein
\nBarbara Hardy Institute,
\nUniversity of South Australia,
\nAdelaide, SA, Australia
\nThe 66th
\nsession of the World Health As-
\nsembly (WHA) took place in Geneva from
\n20\u201328 May. It was attended by many rep-
\nresentatives from the World Medical As-
\nsociation.
\nIn the days leading up to the Assembly, the
\nWMA had joined organisations from the
\nSafeguarding Health in Conflict Coalition
\nin sending a letter to Dr. Margaret Chan,
\nDirector General of the World Health Or-
\nganisation, urging her to use her opening
\naddress to the Assembly to condemn the
\ncontinuing violence against health person-
\nnel in Syria.
\nSo when the Assembly was opened on the
\nMonday by Dr. Chan, the WMA leaders
\nwelcomed her words condemning violence
\nagainst health personnel.
\nDirector General\u2019s
\nOpening Address
\nDr. Chan declared: \u2018WHO is aware of re-
\nports of assaults on health personnel and
\nhealth care facilities in conflict situations.
\nWe condemn these acts in the strongest
\npossible terms. Conflict situations sharply
\nincrease the need for health care. I cannot
\nemphasize this point enough. The safety of
\nfacilities and of health care workers must be
\nsacrosanct.\u2019
\nIn other issues referred to in her address
\nDr.\u00a0 Chan spoke about two new diseases
\ncurrently facing the world, human infec-
\ntions with a novel coronavirus and the first-
\never human infections with the H7N9 avian
\ninfluenza virus. \u2018These two new diseases re-
\nmind us that the threat from emerging and
\nepidemic-prone diseases is ever-present\u2019,
\nshe said.
\nShe went on to talk about the place of
\nhealth in the post-2015 development
\nagenda and the need to ensure that health
\noccupied a high place on the new develop-
\nment agenda.
\nWorld Health Assembly Week
\n91
\nWMA news
\n\u2018Investing in the health of people is a smart
\nstrategy for poverty alleviation. This calls
\nfor inclusion of non-communicable dis-
\neases and for continued efforts to reach the
\nhealth-related MDGs after 2015.\u2019
\nShe talked of the success in treatments for
\nHIV and encouraging progress on tubercu-
\nlosis and malaria. The past two decades had
\nseen dramatic improvements in health in
\nthe world\u2019s poorest countries, but she added
\nthat WHO would never be on speaking
\nterms with the tobacco industry. However,
\nshe did not exclude cooperation with other
\nindustries that had a role to play in reducing
\nthe risks for NCDs.
\nJunior Doctors Network
\nThe WMA leaders who travelled to Ge-
\nneva for the Assembly began by attending
\na highly successful meeting held by the As-
\nsociation\u2019s Junior Doctors Network. This
\ndiscussed the issues likely to be raised at the
\nAssembly as well as the various projects be-
\ning pursued by the JDN, including a white
\npaper on physicians\u2019 wellbeing, a policy pa-
\nper on the ethical aspects of global health
\neducation and an environmental scan of
\npost-graduate medical education examining
\nconditions for junior doctors in training in
\ncountries around the world.
\nWHPA Luncheon
\nOn the first day of the Assembly, the World
\nHealth Professions Alliance held a lun-
\ncheon at which it issued a major new state-
\nment on collaborative practice.
\nThe global bodies for the five leading health
\nprofessions, representing more than 26 mil-
\nlion health professionals worldwide, called
\nfor a new emphasis on collaborative prac-
\ntice.They said that health professions work-
\ning together around the world can lead to
\nimproved health services and a more effec-
\ntive use of resources.
\nThe Alliance,bringing together the Interna-
\ntional Council of Nurses, the International
\nPharmaceutical Federation, the World
\nConfederation for Physical Therapy, the
\nWorld Dental Federation and the World
\nMedical Association, informed that health
\nservice users around the world can experi-
\nence duplication, gaps and discontinuity in
\nthe health system. Yet, effective collabora-
\ntion between different professions and ser-
\nvice can prevent this and lead to improved
\naccess to services, more user involvement in
\ndecision-making, more responsive services,
\nbetter use of resources, reduced incidence of
\ndisability and increased job satisfaction of
\nhealth professionals.
\nWHPA called on governments to fund
\nstructures which supported interprofes-
\nsional collaborative practice (ICP). The
\nstructures of health systems around the
\nworld should enable ICP, educational sys-
\ntems should promote shared learning, and
\nhealth professionals needed to respect each
\nother\u2019s expertise.
\nDr. Cecil Wilson, President of the WMA,
\nunderlined that once the individual contri-
\nbutions of all professionals are recognised,
\nthere is more likely to be appropriate refer-
\nral and a good matching of competencies to
\na person\u2019s needs. \u2018High quality patient care
\nis most likely to be achieved when health
\nprofessionals work together as a team. In
\nan increasingly complex and fast-moving
\nmedical world, it is safer and more efficient
\nwhen health professionals collaborate to the
\nfull extent of their training and experience.\u2019
\nRosemary Bryant, President of the Interna-
\ntional Council of Nurses, said: \u2018Health pro-
\nfessionals strive to deliver high quality ser-
\nvices within their scope of practice and with
\nrespect for the expertise of other members
\nof the team. This is a challenge that health
\nprofessions can address positively together
\nand with other agencies.\u2019
\nMichel Buchmann, President of the Inter-
\nnational Pharmaceutical Federation, said:
\n\u2018Evidence shows that effective interpro-
\nfessional collaborative practice leads to a
\ncomprehensive, coordinated and safe health
\nsystem that better meets the needs of people
\nand their communities.\u2019
\nMarilyn Moffat, President of the World
\nConfederation for Physical Therapy, stated:
\n\u2018Effective interprofessional collaborative
\npractice brings benefits in every area of
\nhealth services \u2013 from health promotion,
\nthrough injury prevention to condition
\nmanagement. Working together, profes-
\nsionals can effectively address pressing
\nsocietal health needs such as the growing
\nburden of non-communicable diseases and
\ntheir risk factors.\u2019
\nOrlando Monteiro da Silva, President of
\nthe World Dental Federation, assured: \u2018The
\nWorld Health Professions Alliance will
\npromote interprofessional collaborative
\npractice through advocacy, by example and
\nby promoting educational, legislative and
\nhealth system changes that bring about and
\nstrengthen interprofessional collaborative
\npartnerships.\u2019
\nWMA Luncheon
\nSeminar
\nThe following day the WMA held its an-
\nnual luncheon seminar on the theme \u2018Influ-
\nenza: We can do better!\u2019
\nDr. Cecil Wilson highlighted the unaccept-
\nably low level of immunization rates among
\nhealth care professionals. He said that sea-
\nsonal flu might seem a harmless infection
\nthat people got every year and then got over
\nit within a week or so. But, in fact, it was a
\nsignificant global health threat that was fre-
\nquently overlooked.
\n\u2018Flu is harmless only at first glance. Ac-
\ncording to the World Health Organization,
\ninfluenza outbreaks cause about 250,000 to
\n500,000 deaths per year globally. The US
\nCenters for Disease Control and Prevention
\n92
\nWMA news
\n(CDC) estimate that an average season of
\ninfluenza results in tens of thousands of
\ndeaths and as many as 200,000 hospitaliza-
\ntions due to influenza-related causes in the
\nUS alone.\u2019
\nDr. Wilson stressed that the risk of com-
\nplications associated with influenza is the
\nhighest among older persons, young chil-
\ndren, patients with underlying medical
\nconditions and pregnant women. These are
\nthe populations that frequently are around
\nhealth professionals by virtue of attending
\nclinics, hospitals and doctors\u2019 offices.\u00a0
\nHe added: \u2018Therefore, healthcare profes-
\nsionals play an important role in both trans-
\nmitting and preventing the virus. The good
\nnews is that a safe and affordable vaccine
\nis available against influenza. But the bad
\nnews remains that healthcare professionals\u2019
\nimmunization rates are unacceptably low,
\neven in developed countries.\u2019
\nAccording to the CDC, the healthcare
\nworkers\u2019 vaccination coverage used to be
\naround 40 per cent in the US.However,that
\nchanged in 2010 when the Veterans Health
\nAdministration healthcare facilities vacci-
\nnated 64 per cent of employees through the
\nsystem-wide \u201cInfection: Don\u2019t Pass It On\u201d
\ncampaign.\u00a0
\n\u2018We have peer-reviewed evidence that as
\nthe percentage of immunized healthcare
\nprofessionals goes up, healthcare-associated
\ninfluenza goes down. We also know that
\neducational campaigns in immunization
\nwork.\u2019\u00a0
\nDr.Wilson said that with the support of the
\nInternational Federation of Pharmaceutical
\nManufacturers and Associations the WMA
\nhad launched a global campaign to promote
\ninfluenza immunization among physicians
\nas a means of protecting their health and
\nthe health of their patients. Before launch-
\ning the campaign, the WMA had surveyed
\nits member associations, representing 102
\ncountries worldwide, and all the respon-
\ndents had stressed the need for more infor-
\nmation and global advocacy on the need for
\nimmunization of healthcare professionals.
\nSeventy seven per cent of respondents had
\nasked for toolkits with facts and figures as
\nthe most useful advocacy material, followed
\nby web-based resources and draft letters to
\ngovernments.\u00a0
\nHe said that getting a flu shot is a rou-
\ntine task that every healthcare professional
\nshould be performing every year. Physician
\nvaccination practice also has the extra ben-
\nefit of encouraging patients to follow their
\ndoctors\u2019 lead, as physicians are the best role
\nmodels for healthy behaviours.
\n\u2018Immunizing physicians against influenza
\nrepresents a standard of quality care. We, as
\nan organization speaking on behalf of more
\nthan 9 million physicians globally, are say-
\ning today that we can do better!\u2019
\nThe first guest speaker introduced by Dr.
\nWilson was Dr. Ingrida Circene, Minister
\nfor Health of the Republic of Latvia. The
\ntitle of her speech was \u2018 Influenza: The poli-
\ncies on immunization and health systems\u2019
\nrole in ensuring health workers vaccination\u2019.
\nShe said that illness from influenza result-
\ned in hospitalisations and deaths, mainly
\namong high risk groups. There were three
\nto five million cases worldwide of severe ill-
\nness. But among healthy adults, influenza
\nvaccine could prevent between 70 to 90 per
\ncent of influenza-specific illness. Among
\nthe elderly, the vaccine reduced severe ill-
\nness and complications by up to 60 per cent
\nand deaths by 80 per cent.
\nDr. Circene continued about the situation
\nin Latvia and the legislation requiring mon-
\nitoring, investigation and response plans.
\nReferring to influenza prevention among
\nhealth care professionals, she said that
\nmonitoring was not carried out, awareness
\nwas low and there was low immunization
\ntake up as a result of poor communication
\nglobally.
\nShe concluded by saying that wider, care-
\nfully planned and well communicated im-
\nmunization campaigns at a national level
\nwould promote vaccination.
\nThe final guest speaker was Dr. Cornelia
\nBetsch, a psychologist from the University
\nof Erfurt in Germany. She began her ad-
\ndress starkly: \u2018Imagine you visit your doctor
\nwith your new-born child or grandchild and
\nthe doctor can\u2019t stop sneezing and coughing
\nduring the whole consultation. Imagine a
\nfriend with cancer who has to go to hospital
\nto undergo the next chemotherapy. And the
\nnurse,just after she took blood samples,gets
\ndiagnosed with influenza. Imagine that you
\nare unsure if you should get the flu shot and
\nso you ask your doctor if she is vaccinated
\nagainst influenza. And she says \u2018no\u2019.
\n\u2018These are situations that many people have
\nto face because vaccination rates are low
\namong health care workers.\u2019
\nDr. Betsch asked why many health care
\nworkers refused vaccination? She remind-
\ned that a 2009 overview study summarized
\nthe most important reasons. \u2018Isn\u2019t it sur-
\nprising to learn that across a large number
\nof studies HCWs\u2019 most important reason
\nagainst vaccination was their fear of side
\neffects?\u2019
\nShe said that the other reasons included low
\nperceptions of risk of infection and a lack of
\nconcern, potentially because they believed
\nthat the risk to transmit influenza to their
\npatients was low. But this was wrong.
\nDr. Betsch shared her belief that the more
\npeople get immunized in society, the more
\ndifficult it gets for a disease to spread.People
\nwho are too young or ill to get vaccinated
\nwill be protected by a firewall of immunized
\nindividuals around them. With a sufficient
\nnumber of people immunized, diseases can
\nbe eradicated.
\nShe said that in the Global Vaccine Action
\nPlan, which was endorsed during the last
\n93
\nHealth Profession
\nWorld Health Assembly, immunization is
\nrecognized as a core component of the hu-
\nman right to health. Mandating vaccination
\nwould be like forcing people to drink clean
\nwater. Thus, if we do not want to mandate
\nvaccination, health care workers need to be
\nbetter educated. They need to know where
\nthere is a risk and where there isn\u2019t. They
\nneed to know that they can infect their pa-
\ntients and their families. They need to be
\naware that they are role models and highly
\ntrustworthy sources of information for their
\npatients.
\nSide Events
\nPalliative care was among the side events
\njointly supported by the WMA during the
\nweek of the World Health Assembly. The
\nmeeting was sponsored by the permanent
\nmissions to the UN of Panama, Uganda
\nand the United States, and organised by the
\nWMA together with the African Palliative
\nCare Association,
\nAsociacion Latino Americana de Cuidados
\nPaliativos, Hospice Africa Uganda, Human
\nRights Watch,International Association for
\nHospice and Palliative Care, Kenya Hos-
\npice and Palliative Care Association, Open
\nSociety Foundations and the Union for In-
\nternational Cancer Control.
\nAmong the speakers was Dr. Mary Car-
\ndosa, a Malaysian consultant anaesthesiolo-
\ngist and pain specialist and Immediate Past
\nPresident of the Malaysian Medical Asso-
\nciation. She spoke about the prejudice and
\nfears of healthcare professionals about us-
\ning morphine to relieve pain which she said
\nwere causing millions of patients to suffer
\nunnecessarily.
\nShe stressed that tens\u00a0of millions of people
\naround the world suffer from significant
\npain and other debilitating symptoms re-
\nlated to illnesses such as cancer, advanced
\ndiabetes, heart disease, other non-commu-
\nnicable diseases and HIV and TB.\u00a0
\n\u2018These patients require palliative care, a
\nhealth service that can restore or maintain
\ntheir quality of life and allows them to live
\nwith dignity.\u00a0Despite this great need, pal-
\nliative care services remain sparse in much
\nof the world,\u2019 Dr. Cardosa told the meet-
\ning.
\nDr. Cardosa went on: \u2018Apart from having
\nnational policies on pain and palliative care,
\nefforts must include education of the public
\nand of healthcare professionals in order to
\novercome barriers to effective pain manage-
\nment and palliative care.\u00a0
\nAmong the big challenges are the prejudices
\nand fears of healthcare professionals regard-
\ning the use of morphine which is the main-
\nstay of pain relief in patients with acute pain
\nas well as those with advanced cancer and
\nother painful conditions.\u00a0
\nMorphine provides cheap and effective
\nanalgesia to such patients, but is often
\nnot accessible because of legal barriers or,
\nworse still, because of healthcare profes-
\nsionals\u2019 fear of addiction and side effects
\nas well as lack of knowledge on the ap-
\npropriate prescription of morphine and
\nmorphine-like substances for pain relief in
\nthese patients.\u2019
\nDr. Cardosa told that the\u00a0Worldwide Pal-
\nliative Care Alliance estimates that about
\none hundred countries worldwide do not
\nhave any palliative care services available,
\nwhile in another 74 countries such ser-
\nvices are limited to isolated locations and
\nreach only a small proportion of patients
\nin need.
\nShe said the Executive Board of the World
\nHealth Organization (WHO) and the
\nWorld Health Assembly (WHA) are ex-
\npected to discuss palliative care needs and
\nbarriers next year.The present WMA meet-
\ning, organised with other bodies, including
\nthe Human Rights Watch and the African
\nPalliative Care Association, was designed
\nto discuss successful palliative care models
\nfrom different world regions and exchange
\nviews on how a potential WHA resolution
\ncould most effectively promote palliative
\ncare.\u00a0
\nDr. Cardosa suggested that building a glob-
\nal coalition for palliative care was a means to
\nending unnecessary suffering from treatable
\nsymptoms for the millions affected, espe-
\ncially those in the countries where palliative
\ncare services were not readily available.
\nMr. Nigel Duncan,
\nPublic Relations Consultant,
\nWMA
\nThe politicians of the European Member
\nStates spend a lot of time and resources
\non health services, planning, controlling
\nthe medical profession and revising in-
\nfrastructure, issueing laws and regulations
\ninstead of trusting doctors to continue
\ndeveloping the services patients need.
\nFor example, on the European level there
\nhas for years been a lot of work on cross
\nborder health care, and then it turns out
\nthat only about 1% of medical services
\nactually are cross border. Patients like to
\nbe treated near to where they live. I am
\nnot saying that cross border health care
\nshouldn\u2019t have been looked at, and CPME
\ncertainly has been an active stakeholder,
\nbut wouldn\u2019t it have been more beneficial
\nfor all that effort to be put into coming
\nHow Much Independence is Necessary?
\n94
\nHealth Profession
\nto grips with the financial world and the
\nbanks?
\nThe medical profession is in my opinion
\nto be trusted. There are fewer bad apples
\nto be found in medicine than in any other
\nfield that I know. The patients know this
\ntoo. Therefore there is a relationship be-
\ntween doctors and patients unlike any
\nother. At present, trust in the Icelandic
\nParliament is less than 10% and no one
\ntrusts the banks!
\nThere are not many professions that have
\na background of 10\u201315 years of study and
\nspecialist training as we have and there-
\nfore it is not surprising that doctors prefer
\nto have a say in the structure and running
\nof their own work. Our closest ally is the
\npatient and to my mind it is the right of
\neach patient to have a well trained doctor in
\ntimes of illness.
\nIn many countries the relationship be-
\ntween doctors and politicians is based on
\ntrust. On the other hand there are visible
\ntrends in some of our countries for the
\npoliticians to think they know better. I re-
\nalised this rather late in my professional
\nlife, after having spent time myself as a
\npolitician.
\nWhat is Professional Autonomy?
\nA multitude of terms is used to discuss
\nprofessional autonomy, all of which con-
\ntribute to the description of the framework
\nof doctors\u00b4professional practice. These de-
\nrive from a wide range of sources: national
\nand EU laws, ethics codes, regulations of
\nprofessional bodies, societal expectations
\nand medico-technical requirements. While
\nsome concepts can be seen to overlap in
\nmeaning, others can also be considered as a
\nbalance to each other.
\nProfessional autonomy is applicable both
\nto the medical profession as a whole and
\nto each professional individually. In both
\nconcepts, the right of autonomy implies a
\nfreedom to practice without interference
\n(be it administrative, political or other)
\ncounterbalanced by the obligation and re-
\nsponsibility for those actions. With relation
\nto the profession as a whole, professional
\nautonomoy is closely linked to the concept
\nof \u201cliberal professions\u201d. This concept is also
\nacknowledged at EU level, e.g. in the Pro-
\nfessional Qualifications Directive 2005\/36\/
\nEC. On an individual basis, professional
\nautonomy is closely linked to clinical inde-
\npendence.
\nAs a principle, the compliance with
\nclinical guidelines is seen as one of the
\nfundamentals of high quality medi-
\ncal practice; CPME policies uphold this
\nprinciple continuously. They enshrine an
\nevidence-base for effective and efficient
\nclinical treatment decisions and provide
\na reference point for demonstrating the
\ndecision-making process both to patients
\nand peers. However, in certain situations a
\nguideline\u00b4s application would not help to
\nachieve the best possible outcome for that
\nspecific patient. It is in these situations
\nthat the concept of clinical independence
\nbecomes a tool to comply to comply with
\nthe objective of delivering the best possi-
\nble care for the individual patient. Clinical
\nindependence is therefore directly linked
\nwith professional autonomy insofar as this
\n\u201c dictates that a doctor shall deviate from
\na a guideline whenever she\/he feels that
\nis in the best medical interest of the pa-
\ntient\u201d. Professional autonomy is however
\nnecessarily counterbalanced by the need to
\nensure accountability for a decision. Pro-
\nfessional responsibility brings professional
\nautonomy to an equilibrium. This respon-
\nsibility is not only relevant in terms of its
\nrelation to guidelines, but in particular as a
\ntool of accountability to patients. In addi-
\ntion to this, it also is relevant in relation to
\naccountability towards peers, professional
\nbodies and in a further step towards the
\nlegal framework of professional practice,
\nas regards professional liability.
\nProfessional responsibility therefore acts as
\nas safeguard for the exercise of professional
\nautonomy. As such it is important to ensure
\na coherent and sound framework for its ex-
\nercise.
\nThe Framework
\nThe framework therefore must ensure that
\nautonomy and responsibility are in bal-
\nance. In a CPME position paper of No-
\nvember 2009, it is stated that \u201c professional
\nautonomy, properly defined and used, can
\nhelp to preserve a balance between needs,
\ndemands and responsibilities of the par-
\nties involved with a priority for patients
\nneeds\u201d.
\nTo achieve the best possible coherence for
\nthis framework, self-regulation is a pre-
\nferred policy tool. With the EU compe-
\ntences on the organisation of healthcare,
\nincluding the organisation of the profes-
\nsion\u2019s practice, limited by the Article 168
\nTFEU, the principle of subsidiarity applies
\nto give Member States the power to al-
\nlocate self-regulatory competences to the
\nprofessions.
\nAcross the various Member States, the
\ndegree of self-regulatory competence var-
\nies, as does the legal context the profession
\nKatrin Fjeldsted
\n95
\nHealth Profession
\nmay act in. In some cases self-regulation is
\ncomplemented by significant governmen-
\ntal regulation to create a situation of co-
\nregulation.
\nFor CPME the safeguarding of profession-
\nal autonomy and the self-regulation of the
\nprofession are two sides of the same coin.
\nIn the 2009 position paper it is recalled that
\n\u201crules drawn up by the medical profession
\nand instruments to enforce their application
\nhave always served to ensure medical care of
\nthe highest possible professional and ethi-
\ncal standards.\u201dIt is this objective that shows
\nthat essentially professional autonomy is
\nnot primarily a professional privilege, but
\nrather a patient right.
\nAs can be seen, the patient and the pos-
\nsibility to make a decision in a patient\u00b4s
\nbest interest is the ultimate consequence of
\nprofessional autonomy and therefore sub-
\nstantiates the need to safeguard the prin-
\nciple.
\nWorking With Patients
\nIf departing from the point of view of the
\npatient, the right to high quality health-
\ncare, as enshrined in national and Europe-
\nan laws, is dependent on the best possible
\nquality of medical training and practice, an
\nobjective which lies at the core of CPME\u2019s
\nmission. In order to achieve this, the prin-
\nciple of professional autonomy is essential.
\nThe element of trust in the patient-doctor
\nrelationship is directly related to profes-
\nsional autonomy: If professional autonomy
\nin making clinical decisions is undermined
\nand quality healthcare outcomes are not
\nachieved, trust diminishes. Conversely the
\nexercise of clinical independence also pre-
\nnecessitates a degree of trust between pa-
\ntient and doctor.
\nA trustful patient-doctor relationship is
\ntherefore one of the pillars of professional
\nautonomy. The importance of reciprocal
\ntrust and committment to the patient-
\ndoctor relationship, the shared interest
\nand value of safeguarding the relation-
\nship is recognised by both patients and
\ndoctors. Indeed in the Joint Principles
\nCPME adopted in 2008 with the Euro-
\npean Patients\u00b4 Forum (EPF), both par-
\nties highlight patient empowerment and
\nprofessional autonomy as key areas for
\ncooperation by declaring: \u201c..information
\nto patients, medical ethics, Information
\nCommunication Technology and health,
\ncontinuous professional development,
\npatient\u00b4s empowerment and physician\u00b4s
\nautonomy (are) identified by both EPF
\nand CPME as significant areas where our
\njoint work at EU level could make an im-
\npact\u201d.
\nThe commitment to cooperation between
\npatients and doctors also reflects the chang-
\ning environment of the patient-doctor re-
\nlations. This relationship is very much a
\ndynamic one and the changing role particu-
\nlarly of the patient entails also a changing
\nenvironment for the delivery of healthcare,
\nIn order to indeed achieve a model of pa-
\ntient-centered healthcare, professional au-
\ntonomy is a vital tool to ensure quality of
\ncare for each patient.
\nRecent years have seen the parallel devel-
\nopments of increased patient empowerment
\nand health literacy. This is in part due to a
\nmore active participation of patients in the
\nmanagement of their condition, especially
\nin the case of chronic diseases. CPME is
\nvery supportive of the empowerment of pa-
\ntients, as enshrined in the Joint Principles
\nadopted with the European Patients\u2019 Fo-
\nrum. It must therefore be made clear that
\nclinical independence is a complementary
\nrather than contradictory tool in achieving
\nthe best patient care.
\nTechnology
\nThe rapid developments in health technol-
\nogy contribute significantly to the changing
\nenvironment of professional practice.
\nDevelopments in pharmaceutical care, both
\nas regards organisation of care and scientific
\nprogress resulting in technological innova-
\ntions, offer many examples of situations in
\nwhich professional autonomy is challenged,
\nThe issue of decision-making on generic
\nsubstitution has been debated for some
\ntime: in 2000 CPME recommended that
\n\u201cprescribing doctors must have the right
\nnot to allow pharmacists to dispense a dif-
\nferent generic from that prescribed, or a
\ngeneric instead of a branded pharmaceuti-
\ncal prescribed, where they judge it in their
\npatients\u00b4 interests to do so \u201c. The more re-
\ncent discussion on biosimilars has included
\nsimilar questions.
\nThe increased use of telemedicine and
\neHealth technologies has changed the
\nclinical decision-making process and con-
\nsequently redefined the context of pro-
\nfessional autonomy. CPME is closely in-
\nvolved in EU-level policy initiatives and
\nprojects on eHealth and telemedicine
\ntechnologies, in recognition of their vast
\npotential to improving access to an deliv-
\nery of care. One of CPME\u00b4s priority prin-
\nciples in eHealth is however safeguarding
\nthe trust and confidentiality of the patient-
\ndoctor relationship regardless of the medi-
\num through which healthcare is delivered.
\nAs stated in the \u201c CPME guidelines for
\ntelemedicine\u201d, adopted in 2002: \u201cThe use
\nof telemedicine must not adversely affect
\nthe individual patient-doctor relationship
\nwhich, as in all fields of medicine, must be
\nbased on mutual respect, the independence
\nof judgement of the doctor, autonomy of
\nthe patient and professional confidential-
\nity\u201d. Therefore innovative eHealth tech-
\nnologies should only be used if these prin-
\nciples are respected. An even more recent
\ntechnological development is the creation
\nof computer-programmes which assis
\nclinical decision-making. Their potential
\nimpact on clinical independence is vast,
\na discussion on the status of professional
\nautonomy and professional responsibility
\nin light of such technologies therefore of
\nsignificant interest.
\n96
\nHealth Profession
\nChanges in healthcare systems as such also
\nhave significant implications for profes-
\nsional autonomy. The organisation, regula-
\ntion and training of the health workforce
\nis subject to constant policy changes in all
\nMember States. These changes are driven
\nas a response to budgetary pressures, short-
\nages and changing requirements as to the
\nskills and knowledge of professionals as
\nwell as new systemic models of care, the
\ndefintion of the different healthcare pro-
\nfessions\u2019 tasks, the influence of other ac-
\ntors, such as payers and administrators.
\nThe process for clinical decision-making
\nand therefore also the status of clinical
\nindependence and professional respon-
\nsibility is often affected. One example is
\ntask-shifting, especially when motivated
\nby reasons other than improving quality of
\ncare. In its policy on task-shifting adoped
\nin 2010, CPME recommends that \u201c In
\norder to guarantee the safety of patients,
\n(task -shifting) should always take place
\nunder the condition that the responsibil-
\nity for diagnosis and therapeutic decisions
\ncannot be divided and remains with a doc-
\ntor, even if (s)he has shifted a task as de-
\nscribed above\u201d.
\nThe Budget
\nCost-effectiveness drives are one of the
\nmost direct challenges to professional au-
\ntonomy. CPME fully recognises the need
\nto respect budgetary restraints and take
\ninto account not only the effectiveness but
\nalso the efficiency of treatments and has
\nacknowledged this repeatedly. However,
\nthe patient\u00b4s best interest must be the main
\ncriterion for the decision taken, be it policy
\nor treatment related. Challenging or disin-
\ncentivising the exercise of professional au-
\ntonomy as cost-containment policy must
\ntherefore be opposed. Examples for such
\naction can be found i.a.in the incentivising
\nof generic prescriptions through financial
\nrewards to doctor; this was discussed by
\nCPME in 2006 on the basis of a case in
\nthe Netherlands.
\nPatient Mobility
\nPatient mobility has now been codified in
\nthe Directive 2011\/24\/EY on the appli-
\ncation of patients\u00b4 rights in cross-border
\nhealthcare. This legislation also addresses
\nthe importance of transparent safety and
\nquality standards to ensure access for
\nwell-informed patient decisions. CPME
\nvery much welcomed the clarification of
\npatients\u00b4rights in accessing healthcare ser-
\nvices outside their home Member State and
\nrepeatedly highlighted the need to establish
\n\u201ca clear framework of safe, high quality and
\nefficient heathcare throughout the EU-
\nwhich will be beneficial both to patients
\nand to physicians\u201d. The need to be able to
\ndemonstrate and be accountable for qual-
\nity, must however not be seen as eliminating
\nprofessional autonomy, neither at an organ-
\nisational nor individual level.
\nGovernment Regulation
\nLastly trends in government regulation can
\nundermine the basis for professional au-
\ntonomy by challenging the self-regulaton
\nof the profession.This may be motivated by
\npoitical preference for centralised regulation
\nor taken with a view ot cost-containment.
\nIn many Member States developments can
\nbe observed in which the legislative frame-
\nwork shift decision-making competences
\nfrom professional bodies to the government
\nthus eradicating the substance of autono-
\nmy. CPME has lent support to number of
\nmembers which have faced challenges by
\ntheir governments and confirmed its belief
\nof the importance of professional autonomy
\nalso at organisational level for the best in-
\nterest of the patient.
\nThe Future
\nThe future holds new technologies for cer-
\ntain. The financial crisis has reinforced and
\nrenewed pressure for cost containment in
\nhealth workforce and services in general.
\nWe must always bear in mind that the pa-
\ntient-doctor relationship must be central
\nto the introduction of new technologies.
\nThere are also some moves towards stan-
\ndardisation at EU level and the possible
\nincrease in cross-border healthcare makes
\ndemands on greater harmonisation of
\nclinical practice and may seek to constrain
\nprofessional autonomy.
\nConclusions
\nProfessional autonomy both at organisa-
\ntional and individual level is a vital tool for
\nthe achievement of high quality health-
\ncare and as such a patient right. So as to
\nretain its place in medical practice, pro-
\nfessional autonomy msut strike a balance
\nbetween safeguarding its core values, such
\nas the observance of ethical codes and the
\ntrustful patient-doctor relationship, and
\nthe evolving environment of professional
\npractice and healthcare systems.This could
\ninclude better communication of the regu-
\nlatory framework, in which professional
\nautonomy is exercised, in order to provide
\nbetter information to patients and other
\nstakeholders. It must also include a con-
\ntinuous review of professional guidelines
\nto safeguard an adequate response to the
\nchanging environment of healthcare deliv-
\nery and scientific progress.The existing and
\nnew challenges arising from governmental
\nregulation, but also societal and commer-
\ncial developments must be addressed sus-
\ntainably. Support should be lent to those
\nwhose governance model is challenged to
\nthe detriment of professional autonomy
\nand thus patient care.
\nKatrin Fjeldsted,
\nPresident of CPME
\n97
\nPrison Health
\nIn a previous publication1
\n, various actions
\nhave been suggested for the physician to
\nimplement during this quality time with the
\nhunger strikers. The initial encounter with
\nthe hunger striker, for the history and exam,
\nand initial evaluation, is the starting point.
\nIt is essential that the physician conveys
\nfrom the start that he is not there as a prison
\nofficial to try to convince them to stop their
\nprotest. He is there as their physician, to see
\nto their health, to answer any questions they
\nmay have, to explain how fasting and me-
\ntabolism work, but above all he is there to
\nlisten and maintain a constant line of com-
\nmunication with them. The physician has
\nto convey genuine concern for health, and
\nfor providing professional care.This in most
\ncases should counterbalance any qualms or
\nlegitimate fears the hunger striker may have
\nabout the doctor\u2019s role.
\nWithout respect for the dignity of the pa-
\ntient,any medical practice is severely handi-
\ncapped. In the case of a hunger strike, the
\nphysician should see to it that the patient
\nis not placed automatically in a bleak or
\n1 Allen S., Reyes H. Clinical and Operational Issues
\nin the Medical Management of Hunger Strikers. In:
\nInterrogations, Forced Feedings, and the Role of
\nHealth Professionals; ed. Ryan Goodman and
\nMindy Roseman, Harvard University Press, Feb-
\nruary 2009.
\ndemeaning environment by the authority
\nwanting to punish him. This is an aspect
\noften neglected by doctors. If there is to
\nbe communication, and this is the key to a
\npositive way forward, the patient has to be
\ntreated with respect. At the very least, the
\nphysician should clearly demarcate himself
\nfrom any abusive attitude by the custodial
\nstaff and hierarchy. This is particularly im-
\nportant in settings where torture is occur-
\nring or is likely to occur.
\nThe physician has to ensure his own clini-
\ncal independence and autonomy. He has to
\nfirmly establish, with the custodial hierar-
\nchy, that he must have a free hand in deal-
\ning with all matters relating to health,in the
\nbroad sense of the term,as well as any medi-
\ncal interventions. If he is to try to influence
\nthe hunger strike so that extreme situations
\nare not reached, he cannot be taking orders
\nthat go against medical common sense, let
\nalone medical ethics.
\nThis is easier said than done in many con-
\ntexts. It is beyond the scope of this paper
\nto examine the issue of \u201cdoctors, serving the
\nstate first and their patients second\u201d, as this
\neasily spills over into \u201ccultural\u201d, \u201ctraditional\u201d
\nand \u201cpolitical\u201ddiscussions.The status quo of
\nhunger strikes and forced feeding will likely
\ncontinue unless there are deliberate steps to
\nensure respect of medical ethics2
\n. National
\nmedical associations need to provide sup-
\nport for physicians confronted with such
\nethical dilemmas, and if necessary appeal to
\nsupra-national entities such as the WMA
\nfor guidance.
\nDuring the initial history, often a key mo-
\nment for establishing the role he wants to
\nplay, the physician must ensure confidenti-
\nality, as in any doctor-patient relationship.
\nThis means there should be no presence
\nof a guard during the discussion in private
\nbetween the hunger striker and the doctor.
\nThis is easier said than done, and in recent
\nsituations, this was out of the question from
\nthe start because of \u201cSOPs\u201d not allowing
\nsuch privacy. This has to be accepted. If
\nsecurity is a non-negotiable concern, then
\na guard should be at the very least out of
\nearshot, so that privacy of exchanges be-
\ntween the hunger striker and the doctor
\nare guaranteed. If there are microphones
\nor other devices to monitor conversations,
\nthe physician should be transparent and tell
\nthe hunger striker that he, the doctor, is not
\nin a position to impose their removal. Such
\ncommunication can be achieved, if there is
\na common language, if necessary by scrib-
\nbling on a pad.
\nOnce this trust has been, however pre-
\ncariously, established, it is then up to the
\nphysician to use the four weeks ahead of
\nthem to asses the seriousness of the situ-
\nation. How resolute exactly is the hunger
\nstriker? How determined is he to push his
\nprotest through? Can he accept a compro-
\nmise solution that would allow the fasting
\nto stop? What is behind the protest? Is
\n2 Annas, G.\u00a0 J. \u2018Dual Use,\u2019 Prison Physicians, Re-
\nsearch, and Guant\u00e1namo\u201d;, American Vertigo:,
\nCase Western Reserve J. International Law 2011;
\n43: 631-650.
\nPhysicians and Hunger Strikes in Prison: Confrontation,
\nManipulation, Medicalization and Medical Ethics (part 3) (part 1, 2 vol. 59 N 1, 2)
\nHern\u00e1n Reyes George J. AnnasScott Allen
\n98
\nPrison Health
\nthere some misunderstanding that could
\nbe easily corrected so as to defuse the situ-
\nation? Is there peer pressure from other
\nprisoners? \u2026Or from within the group
\nof hunger strikers themselves when it is a
\ncollective action?
\nDuring these first few weeks, a physician
\ndedicated to his task should have sufficient
\ntime to determine whether the hunger
\nstriker is alone in his decision, or whether
\nhe is under pressure. For public consump-
\ntion the solution the hunger striker wants
\nto find may be a political statement, often
\na realistically impossible proposal\u2026 How-
\never, and this is what the physician should
\nbe able to pin down, the hunger striker will
\noften be prepared to accept a fall back po-
\nsition, accepting much less than initially
\nasked for. If he somehow, however indi-
\nrectly, admits he does not really \u201cwant to
\ndie\u201dthen the door is open for the physician
\nfinding a solution. What solution, depends
\non a multitude of factors. It may be to con-
\nvince the hunger striker to lower the bar
\nof contention so that a compromise can
\nbe reached with the hierarchy. It may be
\nto persuade the hunger striker to take vi-
\ntamins and perhaps other nutrients, so as
\nto allow plenty of time for negotiations. In
\nextreme cases, which are rare, the hunger
\nstriker may agree to receive artificial feed-
\ning \u2013 thus allowing him not to lose face
\n(by quitting the hunger strike) while get-
\nting him out of danger while a solution
\nis found. If the patient is under pressure,
\nmoral or potentially physical from his
\npeers, the physician may simply arrange for
\nthe hunger striker to being transferred to
\nthe sick bay, where (voluntary) \u201ctherapeutic
\nfeeding\u201d may be undertaken. In most cas-
\nes, this feeding will simply mean that the
\nhunger striker quietly starts to eat again.
\nIn a collective hunger strike, the situation
\nmay be more complex, a small number of
\n\u201chard liners\u201d, or sometimes even just one
\nleader, making it impossible for any other
\nhunger striker to get out of line. The group
\nmay adopt an intransigent position \u2013 and
\nthe individual hunger striker may not be
\nin a position to back out individually, even
\nthough he would like to.The key here is for
\nthe physician first to get to talk to each hun-
\nger striker individually.If the relationship of
\ntrust has been attained, some at least of the
\ngroup will admit in confidence that they do
\nnot want to \u201cgo all the way\u201d. If the physi-
\ncian can get to know this, it is most of the
\ntime half the battle won. The next step will
\nbe to separate the hunger strikers from one
\nanother.This does not mean isolating them,
\nputting them in solitary confinement, let
\nalone punishing them actively or worse hu-
\nmiliating them (as has been the case these
\nrecent years in a well-known hunger strike.)
\nOnce the peer pressure relieved, the road to
\nreconciliation is open.
\nPerhaps even more important, the physi-
\ncian has to strive to avoid the development
\nof a clash between the custodial or judicial
\nauthorities and himself or his medical su-
\nperiors. This will be over untoward medical
\nintervention, and ultimately about force-
\nfeeding. In the first stage of a hunger strike,
\nhe has to calm things down so that there is
\nno \u201chasty\u201d decision to force a naso-gastric
\ntube down the hunger striker\u2019s throat when
\nthere is absolutely no need for any medi-
\ncal intervention.The hunger strikers should
\nbe informed, officially, or perhaps \u201cless of-
\nficially\u201d in some contexts, that the doctor is
\nnot going to force a naso-gastric tube into
\ntheir throat. The physician should persuade
\nthe authorities that there is no risk before
\nat least four weeks of total fasting. If the
\nsituation is one of non-total fasting, this
\nlimit can be pushed back even further. He
\nhas to convince the non-medical authori-
\nties, sometimes \u201citching for a fight\u201d with
\nthe \u201chostage takers\u201d, that he will do his best
\nto reach a way out well before that limit is
\nreached. It may be at this stage counter-
\nproductive for the physician to brandish
\nhis ethical banner and declare that he will
\nrefuse to force-feed whatever the authori-
\nties decide. The physician knows his duty,
\nand when the moment comes, he will know
\nwhat to do, In the meantime, the point is
\nnot to push the \u201ctrigger-happy\u201d custodial\/
\njudicial authorities to pull the force-feeding
\ntrigger. An open clash is also to be avoided
\nat all times.
\nAll the high publicity hunger strikes in the
\nrecent years have been very badly managed
\nin this respect.Physicians have found them-
\nselves to be the instruments of the high-
\nspirited and interventionist non-medical
\nauthorities. Some physicians, not having a
\nsolid ethical education, have simply \u201cobeyed
\norders\u201d. Others, thinking to help the situ-
\nation, have loudly protested and clashed
\nopenly with the non-medical authorities,
\nwhich has poisoned the general atmosphere
\nand often provoked a crack-down, with
\nsubsequent orders being given to force-feed,
\nwhen there was no medical need whatso-
\never, thus dashing any hopes for a compro-
\nmise.
\nThe first month of a hunger strike elimi-
\nnates all the \u201cfood refusers\u201d, and becomes
\npremium time for the physician to genu-
\ninely play his role and to try to preserve life
\nand dignity, and find the best solution for
\ncompromise. He has to have the trust of the
\nhunger strikers, and also that of the custo-
\ndial authority. He has to persuade the latter
\nnot to be hasty, and above all not to make
\ndecisions that are unwarranted, unsound
\nand unethical. Prison Governors have been
\nknown to up the ante by taking decisions, or
\nimplementing new constraints that make it
\nmuch more difficult for a prisoner to reflect
\nand stop fasting, by withholding medical
\ncare for example. There have been concrete
\ncases of physicians themselves knowingly
\ngiving out false \u201cmedical\u201d information, so
\nas to frighten prisoners into stopping their
\nfast. In one specific case, a medical officer
\nof a prison in the Middle East \u201clet it be
\nknown\u201d that going on hunger strike \u201ccaused
\nimpotency in the young male, which could
\nbe long-lasting.\u201dThis was obviously deceit-
\nful information, and the use of medical au-
\nthority in such a way obviously undermines
\nany trust with the prisoners, already so dif-
\nficult to obtain.
\n99
\nPrison Health
\nThe physician has to stretch out a hand to
\nthe hunger striker, to allow him to confide
\nin the doctor, and in the majority of cases
\nfind a way out of what should never become
\nan inextricable situation.
\nIn the very rare event of a hunger strike in a
\nBobby Sands-type situation, where intran-
\nsigence on both sides is impossible to break,
\nthe physician must know when to back off
\nhimself. As clearly stated and explained in
\n\u201cMalta 2006\u201d and its comprehensive back-
\nground paper, it is never ethically acceptable
\nto force-feed anyone. The physician should
\nnever lend himself and his medical skills to
\nsuch abusive practice. In the specific case of
\nGuant\u00e1namo Bay, Navy reservist physicians
\nwere \u201cvetted\u201d before being sent to the Base.
\nAny doctor strongly against force-feeding
\nwas not sent there1
\n.
\nConclusions: Medical Ethics
\nIn managing hunger strikes,no one seems to
\nrealise exactly how counter-productive the
\nconfrontation between the custodial\/judi-
\ncial authorities and the medical doctors can
\nbe towards the goal of resolving the hunger
\nstrike. By shining the spotlight of public-
\nity on this clash between professionals, both
\nsides are helping to paint the hunger striker
\ninto a corner. They also prevent the physi-
\ncian from playing a crucial role during the
\nfirst weeks of the strike, when there is time
\nand no danger.The hunger striker thus finds
\nhimself in the limelight, which may \u201cforce
\nhis hand\u201d. The hubbub around his case, the
\nfact that his \u201cdetermination\u201d becomes com-
\nmon knowledge, the fact he is placed on the
\npedestal of \u201cheroism\u201d or \u201cmartyrdom,\u201d may
\nwell end up pushing him into actually want-
\ning to become one.
\nManagement of fasting, possibly taken to
\nits extreme limits, will seem to involve a
\nconflict between the duty of health profes-
\nsionals to preserve life and the right of the
\n1 Okie S. op. cit.
\npatient to make an informed refusal of a
\nmedical intervention2
\n. The main point we
\nhave tried to make here is that there has
\nbeen far too much focus on the \u201cEndgame\u201d3
\n,
\nand \u201csaving lives\u201d, when in the vast major-
\nity of cases, hunger strikers do not intend
\nto get that far and most often need only to
\nobtain some of their goals. Time is wasted,
\nand, worse, radical positions are taken and
\nhunger strikers can be thus \u201cpainted into
\ncorners\u201d when it becomes extremely diffi-
\ncult to get out of.That there are many weeks
\nbefore a situation warranting any medical
\nintervention will arise, is just not grasped by
\nmost physicians, let alone the non-medical
\nauthorities.
\nThe Declaration of Malta does not cat-
\negorically forbid resuscitation. There may
\nbe room for some legitimate debate in indi-
\nvidual cases when the health of the hunger
\nstriker is so critical that death is imminent,
\nand the individual\u2019s real intentions are not
\nclear.But this is a decision for the physician,
\nnot the prison officials. Policies, however, of
\nforce-feedings of groups of hunger strikers
\nen masse before clinically indicated for rea-
\nsons of intimidation or punishment, as have
\nbeen reported at Guant\u00e1namo, is without
\nquestion in violation of basic human rights,
\nincluding the provisions against cruel and
\ninhuman treatment in the Geneva Conven-
\ntions.
\nThe use of emergency restraint chairs for
\nforce-feeding can never be ethically, legally,
\nor medically justified. A patient who must
\nbe forcibly restrained in such a device to be
\nfed is certainly strong enough to be in little
\nor no health danger from continuing a fast.
\nThe primary justification for the use of this
\ndevice for force-feeding would seem to be
\nfor punishment, control and humiliation
\nrather than for legitimate medical care.
\n2 Allen S., Reyes H., op. cit.
\n3 Doctors attack US over Guant\u00e1namo; BBC NEWS;
\nhttp:\/\/news.bbc.co.uk\/go\/pr\/fr\/-\/2\/hi\/americas
\n\/4790742.stm, accessed March 2012.
\nThe main conclusion is that medical ethics
\nis consistent with a type of ethical pragma-
\ntism in dealing with the vast majority of
\nhunger strikers.This means doctors treating
\neach one as a patient and finding a way to
\nestablish at least a minimum of trust in the
\ncontext of what will always be a difficult and
\nconfining the doctor-patient relationship.
\nTo this end, we have drawn up here a series
\nof practical recommendations which would
\nmost certainly \u201ccalm things down\u201d and en-
\ncourage an ethical, pragmatic and humane
\nway to defuse the vast majority of difficult
\nhunger strikes. The WMA \u201cMalta 2006\u201d is
\nvery clear in its prohibition of any form of
\nforce-feeding of a competent patient, but it
\ngives generous leeway for the bedside clini-
\ncian, and only that physician, to address the
\nsituation and take the final best decisions
\nfor the patient.
\nFinally, in the specific case, again of Guan-
\nt\u00e1namo Bay, President Barack Obama\u2019s
\nExecutive Order (EO) of March 7, 2011,
\nunfortunately makes it at least likely that
\nthe detention facility there will remain
\nopen indefinitely. The EO ignores the
\nwhole hunger strike issue and the ongo-
\ning force-feedings of at least some pris-
\noners. Solutions and approaches based on
\nthe patient trust in the military clinicians
\nare by now impossible because of the past
\npractices. For the reasons stated, the issue
\nis not, at the present time, how to end the
\non-going force-feeding, but rather how
\nour suggestions and observations could
\nbe useful to prevent another Guant\u00e1namo
\nforce-feeding scenario in the future, there
\nor elsewhere.
\nRecommendations
\n\u2192 Conform to established medical ethics
\nThe WMA\u2019s Declaration of Tokyo very
\nclearly anticipates the exact scenario of
\nhunger strikes undertaken at places like
\nGuantanamo Bay, and the declaration rep-
\nresents the established ethical guidelines for
\n100
\nPrison Health
\nphysicians. The use of torture during inter-
\nrogations, or in cases where the very con-
\nditions of confinement constitute a form
\nof torture, were envisaged when writing
\nup \u201cTokyo\u201d, as a central and direct cause
\nfor the initiation of the hunger strikes. As
\nmentioned, it was this that ultimately led
\nthe WMA to specifically condemn force-
\nfeeding itself. In 2006 in an editorial ex-
\nplaining the AMA\u2019s endorsement of the
\nWMA\u2019s Declaration of Tokyo, Duane M.
\nCady, MD, chair of the AMA\u2019s Board of
\nTrustees quoted from the WMA itself \u201c\u2026
\nwhere a prisoner refuses nourishment and
\nis considered by the physician as capable of
\nforming an unimpaired and rational judg-
\nment concerning the consequences of such
\na voluntary refusal of nourishment, he shall
\nnot be fed artificially.\u201d1
\nIn addition, efforts to circumvent medi-
\ncal ethics by pre-deployment screening of
\nhealth professionals to exclude those who
\nmight object to the policy of force-feeding
\nat Gtmo does not excuse ethical misconduct
\nby either the health professionals or the de-
\ntaining authority.2
\nPhysicians deployed to provide detainee
\nand prisoner care should be appropriately
\ntrained in the ethical management of hun-
\nger strikes,as well as international standards
\nof medical care for detainees and prisoners.
\nCredentialing for work in detention facili-
\nties should emphasize and address humane
\ntreatment and familiarity with the accepted
\nstandards of care in prison and detention
\nfacilities.
\n\u2192 Don\u2019t undermine detainee trust in physi-
\ncians
\nThe foundation of effective medical prac-
\ntice is trust between the doctor and the
\n1 O\u2019Reilly, Kevin B. Physicians Speak out on Prisoner
\nForce-feeding http:\/\/www.ama-assn.org\/amed-
\nnews\/2006\/04\/03\/prsc0403.htm; April 3, 2006.,
\nlast accessed March 2012.
\n2 Okie S, op. cit.
\npatient. This is especially true in the sce-
\nnario of hunger strikes where the doctor\u2019s
\nability to engage with the patient to find an
\nacceptable resolution to the hunger strike
\nis entirely dependent on the patient\u2019s abil-
\nity to trust the physician. For that reason,
\npractices that may undermine the trust be-
\ntween the patient and the physician must
\nbe eliminated. These include the practice
\nof assigning some health professionals
\nto support the interrogation procedures.
\nThese health professionals quite obviously
\ndid not act in the detainee\u2019s interest (that
\nwasn\u2019t their assignment), and their pres-
\nence in support of interrogation clearly
\nundermined any detainee\u2019s trust in the cli-
\nnicians working outside of the interroga-
\ntion setting. In a 2005 Memo, DoD Assis-
\ntant Secretary for Health Affairs William
\nWinkenwerder established differential
\nethical duties for \u201cclinical\u201d, as opposed to
\n\u201cnon-clinical\u201d, medical personnel. This
\ngoes against the very essence of medical
\nethics: a physician is a physician is a physi-
\ncian! In addition, the use of medical per-
\nsonnel or even psychologists for activities
\nsuch as identifying psychological vulner-
\nabilities so as to advise interrogators, con-
\nstitutes a serious breach of medical ethics.3
\nMoreover, failures of health professionals
\nto document and report evidence of abuse
\nand torture undoubtedly undermined the
\ntrust between the detainee and the health
\nprofessionals.4
\nTrust between health pro-
\nfessionals and patients in custodial settings
\nis unavoidably challenging from the outset.
\nEffective correctional health professionals
\novercome structural barriers to trust slowly
\nby developing trust with the patient over
\ntime largely by the integrity of their ac-
\ntions in treating the patient. Policies that
\nask health professionals to undermine
\n3 http:\/\/www1.umn.edu\/humanrts\/OathBetrayed\/
\nWinkenwerder%206-3-2005.pdf
\n4 Iacopino, V., Xenakis, S. Neglect of Medi-
\ncal Evidence of Torture in Guant\u00e1namo Bay: a
\ncase series.In: PLoS Medicine. 8(4): e1001027.
\ndoi:10.1371\/journal.pmed.1001027. Available at:
\nhttp:\/\/www.plosmedicine.org\/article\/info%
\n3Adoi%2F10.1371%2Fjournal.pmed.1001027
\ntheir own credibility and integrity must be
\navoided. Making physicians force-feed de-
\ntainees destroys any possible trust between
\nthe doctor and the patient.
\n\u2192 Respect clinician autonomy (clinical deci-
\nsions to be made by clinicians)
\nKey clinical interventions such as whether
\nor not to use forced naso-gastric feeding
\nmust be left exclusively to the treating cli-
\nnician. While there will unavoidably be a
\nrole for non-medical chain of command
\nand courts, the clinical approach must be
\ndetermined by the treating clinician within
\nthe frame of accepted ethics and clinical
\npractice.
\n\u2192 Minimize coercive practices that infringe
\non patient autonomy
\nFrom a psychological perspective, it is im-
\nportant to understand the act of a hunger
\nstrike as an act by the patient to assert his
\nor her autonomy over the basic act of eat-
\ning. This is not only an act of autonomy as
\nan ethical issue, but as a practical issue. The
\nreason food refusal is often chosen as the
\nact of assertion of autonomy is that often all
\nother areas of autonomy have been removed
\nas options. In the case of Guantanamo, the
\ndevelopment of widespread hunger strikes
\ncannot be separated from the authorization
\nand widespread application of practices that
\ninfringed on the autonomy of the prisoners
\nand have now been recognized as ill-treat-
\nment and torture.
\n\u2192 Develop alternative means of addressing
\ngrievances
\n\u201cIndefinite detention\u201d as applied in Guan-
\nt\u00e1namo Bay is the major grievance, and as
\nhas been stated, one of major reasons the
\ninternees initiated hunger strikes there \u2013 a
\nsituation that hopefully will not be repeated
\nin most hunger strike cases. Fundamental-
\nly, the act of hunger striking is a form of
\nstating a grievance. It is more likely to be
\nemployed as a means of stating a grievance
\n101
\nPrison Health
\nwhen alternatives to resolution of griev-
\nances are not available. Here it should be
\nnoted that the custodial authorities hold \u201call
\nof the cards,\u201d so to speak. The non-medical
\nofficials have the power and authority to ne-
\ngotiate, address and where possible resolve
\nall prisoner grievances (and do not require a
\nmedical intervention to do so).
\n\u2192 Individualize care
\nDevelop emphasis on individualized reso-
\nlution of the hunger strike before clinical
\ndeterioration occurs. The rapport estab-
\nlished between the bedside clinician and
\nthe hunger striker can be a crucial element
\nstarting to resolve the conflict and develop-
\ning a dialogue between the authorities and
\nthe prisoner- patients.
\n\u2192 De-medicalize the early stage
\nHunger strikes are predicated on the as-
\nsumption that the assertion of autonomy by
\nthe detainee will result in a response from
\nthe authority. In societies where it is known
\nthat the authority will not intervene, hun-
\nger strikes are rare to non-existent. One
\nway to reduce incentive to a hunger strike
\nis to avoid intervening too early.The earliest
\nhours and days of a hunger strike pose little
\nor no health risk in the patient without sig-
\nnificant underlying health problems.In fact,
\nfrom a clinical perspective, there is little or
\nno justification to monitor or intervene in
\nany way during the first 72 hours of a hun-
\nger strike. Accordingly, in the case of the
\nU.S., its Department of Defense Standard
\nOperating Procedures should be redrafted
\nto emphasize clinically appropriate care.
\nHealth professionals must not be exploited
\nto assert control over the patient even for
\nnational or prison security purposes.
\n\u2192 Reduce peer pressure
\nIn settings such as Guantanamo, the po-
\ntential for a prisoner to undertake a hunger
\nstrike as a result of peer pressure from other
\nprisoners is a genuine concern. Ideally, peer
\npressure must be reduced or eliminated.Re-
\nmoval or transfer of the prisoner to a health
\nsetting may provide some mitigation of peer
\npressure issues. Allowing access to family
\nand community supports would, of course,
\nbe another.
\n\u2192 Don\u2019t punish or further limit other areas of
\nautonomy
\nEfforts by the detaining authority to limit
\nand control other areas of personal au-
\ntonomy make it all the more likely that the
\ndetainee will use food refusal as a means of
\nasserting some autonomy and as a form of
\ngrievance. In this equation, the detaining
\nauthority actually has almost all the control
\nover the other areas of autonomy and must
\nnot lose sight of that fact. Such broad con-
\ntrol provides options for creating alternative
\npaths for the detainee to food refusal. Ac-
\ncordingly, routine use of the restraint chair
\ncannot be justified and must be discontin-
\nued.
\n\u2192 Improve conditions of confinement
\nConditions of confinement are often a lead-
\ning cause for grievance. Indefinite detention
\nand prolonged social isolation often are the
\ndrivers of the kind of desperation that pro-
\nduces hunger strikes.
\n\u2192 Employ outside expert clinicians
\nNo matter how good the facility medical
\nstaff is at establishing trust with the de-
\ntainee, access to a doctor who can offer im-
\npartial and independent expert advice to the
\npatient is essential in developing options for
\nresolving a hunger strike. There should be
\nno prison in the world that does not permit
\na prisoner to be seen and examined by an
\noutside medical consultant at their request
\nor the request of their family.
\n\u2192 Involve family, clergy, and community
\nOutside community supports can be effec-
\ntive in providing support needed to achieve
\na successful resolution of a hunger strike. In
\naddition to dissipating a sense of isolation
\nand entrenched conflict, community and
\nfamily influences can counter-balance peer
\npressure from fellow detainees.
\n\u2192 Develop honest informed consent proce-
\ndures and advance directives
\nIt is essential for the clinician to know the
\nintentions of the hunger striker. To formal-
\nize it early on in a written declaration, how-
\never, may be the start of painting him into
\na corner. More important is the reverse of
\nthe coin, which leaves the final decision in
\nthe hands of the bedside clinician, who is to
\nact ethically (and not follow any diktat from
\nJudges, prison authorities or any others) but
\nalso take into account the situation he has
\nassessed in his bedside care of the patient.
\nKnowing this, and it is carefully spelled out
\nin \u201cMalta 2006\u201d, the clinician can devote all
\nhis time and efforts to find the proper, in-
\ndividual, ethical solution best suited to the
\npatient, including death.
\nDr. Hern\u00e1n Reyes,
\nMD, Medical coordinator for the
\nInternational Committee of the Red Cross,
\nspecializing in medical and ethical aspects
\nof Human Rights, Prison Health, and in
\nthe field of MDR TB in prisons. Observer
\nfor the ICRC on issues of medical ethics.
\nProf. George J. Annas,
\nChair of the Department of Health
\nLaw, Bioethics & Human Rights of
\nBoston University School of Public
\nHealth; Prof. Boston University School
\nof Medicine, and School of Law.
\nScott A. Allen, MD, FACP, School of
\nMedicine,University of California, Riverside
\nE-mail: manzikert@gmail.com
\n102
\nGERMANYHealth Profession
\nGenerally one does not like to talk about
\naddictive diseases and in particular if it con-
\ncerns physicians. The Intervention Program
\nof the Hamburg State Chamber of Physi-
\ncians breaks this taboo and assists physi-
\ncians with addictions in therapy, organi-
\nzation of the doctor\u2019s office and postcare.
\nAddiction to alcohol is still underestimated
\nin our society as a whole.
\nThe percentage of apparent addiction to
\nalcohol in the general population ranges \u2013
\ndepending on the source \u2013 between 3 to 5%,
\ni.e. 2.5 to 5 million people in Germany. As-
\nsuming the frequency of addiction among
\ndoctors to be the same as in the total popu-
\nlation these are small figures. We have 15
\nthousand members in the Hamburg State
\nChamber. If you estimate that 2% suffer
\nfrom addiction the Intervention Program
\nshould be offered to 300 Doctors. We treat
\nabout 10 doctors a year.
\nAlthough we started the Program 20 years
\nago and have gained some experience we
\nare still at the beginning. All over the pe-
\nriod the main slogan of the Program has
\nbeen: \u201cSupport rather than punishment\u201d
\nand it still sails under this flag. Let us now
\nexamine the specific conditions that could
\nbe the cause of physicians\u2019addictive diseases
\nand the specific problems existing before
\nintervention.
\n1. Among the causes are
\n\u2022 unfavorable work conditions
\n– great demands from hierarchical struc-
\ntures
\n– irregular and too long working hours
\n– unfavorable working contents
\n– high emotional stress due to frequent
\ninvolvement in patients\u2019 fates
\n– pharmacological practice as a catalyst
\nfor addicted behavior
\nThe usage and availability of drugs act in
\nsynergy with the professional everyday life
\nand the doctor\u2019s supposedly precise knowl-
\nedge about the risks often lead to a faulty
\nestimation in the \u201cself-experiment\u201dor \u201cuse \u201c.
\n2. Among the problems prior to the treat-
\nment are
\n– the idealized self-image of the doctor.
\nBasically the doctor has to be an invul-
\nnerable helper who himself does not
\nbecome sick. Hence, the doctor never
\nloses his self-control, and he excludes
\nall possibilities of doubt in every situ-
\nation about the fact that his consump-
\ntion of addictive substances is no longer
\nmanageable by himself. Moreover, the
\neffect of the substance increases the
\ninability to think critically. The high
\ndoctor\u2019s ideal contrasts with the real
\nmedical personality, which is exhaust-
\nible.The so far unselfish helper requires
\nhelp for himself;
\n\u2022 the fear of the consequences of the addic-
\ntive disease\u2019s disclosure. This fear has two
\ncomponents:
\n– the immediately felt distress because
\nof the possible loss of the professional
\nexistence (by revoking of the license or
\nother arrangement by the authority);
\n– the shame and fear of stigmatizing
\nin the personal and professional sur-
\nroundings;
\n\u2022 another disadvantageous effect for the
\naffected person: the repression of the
\nproblem by his surroundings. We often
\nfind an extensive and misunderstood col-
\nleagueship of medical and also paramedi-
\ncal employees concerning not only the
\nlegally established addictive drugs, which
\nare tolerated up to a certain threshold val-
\nue, but also with drugs and opiate abuses.
\nIt is often accompanied by a like-minded
\nprivate-familial tolerance. Ignoring the
\naddicted colleague\u2019s weakness and grow-
\ning illness leads to co-dependency and for
\nthe addicted to a chronic disease.
\nWhat makes physicians so vulnerable? We
\nshould be aware that many factors work to-
\ngether.
\n1. Hierarchy-pressure
\n2. Extended working time
\n3. Fatal destinies of patients, they have to
\ncope with
\n4. Easy access to substances
\n5. Professional experience that leads to the
\nmisapprehension that he could control
\nthe risk he takes by consuming addictive
\nsubstances.
\nThe Intervention Program is mostly initi-
\nated in the following way. First of all the
\nChamber is informed about the suspicion
\nof an existing addictive disease. Different
\nsources are considered.
\nWe get information from
\n1. affected physicians,
\n2. their patients,
\n3. their partners or spouses,
\n4. their colleagues \u2013 usually rather late be-
\ncause of co-dependency,
\n5. pharmacies, telling us about suspicious
\nprescriptions,
\n6. media as we saw it at the beginning,
\nIntervention Program for Addictive Diseases.
\nHamburg State Chamber of Physicians
\nKlaus Beelmann
\n103
\nGERMANY Health Profession
\n7. the court about criminal cases \u2013 this in-
\nformation is regulated by law and is re-
\nceived if matters of professionalism are
\ntouched upon;
\n8. anonymous advice.
\nThe physician is directly confronted with the
\nfact if the suspicion is serious enough and if it
\nseems to be proven that the physician suffers
\nfrom an addictive disease. If the addiction is
\nnot obvious and the physician agrees with
\nthe evaluation, it is possible to discuss the
\ndifferent necessary rehabilitation measures.
\nThe Chamber itself becomes a kind of
\nEmergency Room. It offers
\n\u2022 First examination
\n\u2022 Crisis intervention
\n\u2022 Possibility to change the treatment
\n\u2022 Accompaniment of the cured \u201cpatient
\ndoctor\u201d.
\nThe path from the willingness to change
\nis exhausting and usually needs a clinical
\nhospitalization (initial) therapy to show the
\ndrastic results.The regeneration and conser-
\nvation of the doctor\u2019s health and the protec-
\ntion of the patient\u2019s interests are essential.
\nIn the beginning we often have to face con-
\nflicts and resistance against the diagnosis.
\nIt is not so easy to verify the suspicion of an
\nexisting addictive disease We start by refer-
\nring the member to a specialist for further
\nexamination. If the physician does not agree,
\nthe Chamber informs him that the docu-
\nments are to be forwarded to the competent
\nsupervising authority. There is also informa-
\ntion included if the physician does not take
\npart in the agreed plans for the protection of
\nhis medical activity without drugs.
\nReporting on the addicted Chamber mem-
\nber to the authority is mandatory, even if
\nthe Chamber member is cooperative. So
\ntransparency and compliance are essential
\nfor the Program.
\nAccording to the agreement with the su-
\npervising authority the implementation of
\nthe Intervention Program is approved and
\njudicial steps regarding the revoking of the
\nlicense to practice are not initiated in case of
\npositive improvement. This creates a stable
\nbase for the attempt of co-operative rein-
\ntegration of addicted doctors into the daily
\nmedical routine. Informing of the authori-
\nties does not cause any disadvantage for the
\ndoctor who trustfully contacts the Chamber.
\nThe conversation with the affected doctor
\ntakes place immediately after informing the
\nChamber, possibly also on the ground,e.g.in
\nthe doctor\u2019s practice. Usually the physi-
\ncian is in a desolate, often also in an in-
\ntoxicated condition. Often the employees
\nof the Chamber face reactions of protective
\nbehavior and denial. In spite of the initial
\naggression we mostly succeed in clarifying
\nthe purposes and contents of the Program,
\nsuch as help and necessary support. It also
\nincludes providing room for cooperation
\nand maneuver to be used constructively for
\ndecontamination and rehabilitation.If there
\nis no cooperation in the cases of clear addic-
\ntive diseases, the physician is informed that
\nthe existing documents are to be forwarded
\nto the competent supervising authority
\nwithin the next day. Notwithstanding the
\npartly emotional and aggressive atmosphere
\nit is nearly always possible to reach coopera-
\ntion with the addicted person at the begin-
\nning of such an intervention.
\nIn case of doubt concerning the existence of
\nan addictive disease an examination is car-
\nried out by a doctor experienced in rehab
\nmedicine, if necessary with a recommenda-
\ntion for a therapy.
\nSo the Intervention Program consists of
\nthree major steps.The first step: clarification,
\nstarting with a conversation with the doctor
\nconcerned, usually an examination by an ex-
\npert. The second: usually in-patient therapy
\nfor two months. The third: the follow-up
\nprogram running for two years, including
\n\u2022 curricular post care \u2013 usually offered by
\nthe clinic
\n\u2022 psychotherapy
\n\u2022 participation in self-help-groups
\n\u2022 laboratory tests
\n\u2022 meetings at the Chamber with physicians
\nIf the addictive disease is not to be doubted,
\na stationary withdrawal therapy paying at-
\ntention to the person\u2019s habits will usually
\nfollow. It takes about 6 to 8 weeks aver-
\nage. The problems that often appear in the
\nclinic involve the acceptance of the patient\u2019s
\nrole by the addicted physician, the capac-
\nity to understand and emotionally accept
\nthe disease and the relapse management.
\nThe Chamber of Physicians helps with the
\nchoice of an adequate institution, finding
\nreplacement in the affected physician\u2019s prac-
\ntice and also with the clarification of costs
\nto make the therapy in the clinic possible.
\nAfter the decision on treatment is made the
\nIntervention Program is carried out based on
\na yearlong support. If a relapse occurs within
\nthe period, the time line of the curriculum is
\nadapted accordingly and the need of another
\nstationary therapy will be evaluated.
\nThe postcare follow-up program \u2013 as men-
\ntioned above \u2013 is laid down in a \u201cvolunteer\u2019s
\nagreement\u201d. It begins after the discharge on
\nthe basis of the agreement reached with the
\naddicted person. This usually contains five
\nitems and initially covers a period of two
\nyears:
\n1. Implementation of a monthly examina-
\ntion including the psychopathological
\nresults and objective lab parameters. We
\ntry to arrange an alternative regular con-
\ntrol in case the clinic offers no curricular
\npostcare.
\n2. Weekly sessions of psychotherapy on
\nwhich the Chamber is only informed
\nin case of missing appointments (in re-
\nspect of secrecy obligations).
\n3. Regular visits of self-help groups (e.g.
\nAlcoholics Anonymous) once a week.
\n4. Random abstinence controls by the
\nChamber (hair-\/blood\/urine and field
\nsobriety tests). The frequency differs in
\nrelation to the type of test and the rec-
\nommendation of the involved expert. So
\n104
\nHealth Profession TURKEY
\nit could be three times a week for breath
\ntests or once in a half year for hair analy-
\nsis. To obtain valid results the Chamber
\narranges these controls which are per-
\nformed under the supervision of the lo-
\ncal forensic institute.
\n5. A fixed appointment as a follow-up in
\nthe Chamber to discuss the situation
\nand the results once a month to com-
\nplete the Program.For this interview we
\nclaim a monthly record of the proceed-
\nings.
\nThe Chamber of Physicians is committed
\nto the fact that participation in a structured
\ntreatment is to be a success. It is important
\nto involve the addicted person in therapy
\nand at the same time to protect his patients
\nin the phase of the disease against possible
\nnegative consequences of the treatment.The
\nrate of effective abstinence throughout the
\nProgram is about 70\u201380%, the dropout is
\n10%.
\nThe legal framework for the Intervention
\nProgram in Germany is as follows \u2013 the
\nChamber of Physicians is supported by
\nthe local Ministry of Health that provides
\nour members with the license to practice
\nmedicine. As a result of a long persuading
\nprocess our Ministry of Health supports the
\nProgram explicitly.
\nUsually untreated addiction leads immedi-
\nately to the loss of license. Due to the Inter-
\nvention Program there is a chance offered to
\ncontinue working after the treatment.
\nIn general our addicted doctors have a lot of
\nemotional stress. The practice is usually in
\na deplorable economic state. Therefore it is
\nvery important to clarify the financial situ-
\nation first. The decontamination and with-
\ndrawal is financed by the health insurance
\nand in Hamburg the retirement fund joined
\nin to bear the costs for the weaning.
\nSo what is the key message? Looking closer
\ninstead of looking away is in the interests of
\nthe concerned, both: doctors and patients.
\nTo conclude we want to encourage to act
\nwhen people may have an addiction. In this
\nsituation we are a partner of the patients
\nand a partner of the doctor as a patient to
\nsupport his successful restart.
\nDr. Klaus Beelmann,
\n\u00c4rztekammer Hamburg
\nE-mail: klaus.beelmann@aekhh.de
\nThe Greatest Motivation: Assurance of Practicing the Profession
\nwith Dignity. Motivational State of Physicians in Turkey
\nFeride Aksu Tanik Eri\u015f Bilalo\u011flu Ziynet \u00d6z\u00e7elik U\u011fur Okman
\nThis article will try to illustrate the motiva-
\ntional state of physicians inTurkey based on the
\nwell known Guidelines \u201cIncentives for Health
\nProfessionals\u201d.
\nThe main data sources are three separate web
\nbased researches carried out by the Turkish
\nMedical Association.
\nThe fixed income of physicians is below the pov-
\nerty line. Physicians are not happy with Pay
\nfor Performance. They are not able to use their
\nrights to rest sufficiently. Their reasonable fi-
\nnancial expectations focus on providing them-
\nselves with modest human life.
\nThe health care environment starts to destroy
\nthe autonomy of physicians and the professional
\nvalues alienate from the practice of medicine.
\nIn the last decade not a single law has been ad-
\nopted to ensure professional autonomy.
\nPhysicians consider the managerial structure
\nof their work places as a stress factor. They are
\nworking long hours. Physicians demand secure
\nwork and secure future.
\nThere is not an effective, participative man-
\nagement of occupational health and safety. The
\nviolent atmosphere of health care in Turkey
\ntremendously demotivates physicians and other
\nhealth care staff.
\n105
\nHealth ProfessionTURKEY
\nThe status of the Association concerning its
\nfreedom is reflected in the ILO reports and
\nunfortunately it is in the black list. There is
\nno paid leave for Continuous Medical Educa-
\ntion.
\nPhysicians\u2019 sense of belonging has weakened
\nand the expectation of future decrease. Phy-
\nsicians in Turkey as honorable members of a
\nprofession dedicated to the good of society do
\nnot want to be actors in a commercialized
\nhealth care.
\nIntroduction
\nWhat motivates a health care worker or a
\nphysician? What ensures that physicians
\nperform at their best all the time? What
\nis the driving force of physician\u2019s efforts
\nfor the wellbeing of the individual and so-
\nciety? What should it be? Have the moti-
\nvating factors for physicians been the same
\nsince the past up to nowadays? How can we
\nachieve and maintain motivation?
\nDoes the quality of health care differ ac-
\ncording to the motivating factors? What
\nis it especially under the hegemony of the
\npharmaceutical industry? If everything is a
\ncommodity, can we expect from physicians
\nto work only for the wellbeing of the indi-
\nvidual and society? What physicians\u2019 mo-
\ntivation do people expect to provide good
\nhealth care? Which motivating factor is the
\nmost reassuring for the patient who is ex-
\npecting a qualified health care? Is it making
\nmore money or the value associated with
\nhealth and physicians and the privilege this
\nvalue provides?
\nThe health of individuals and society is
\nsomething very special. In the capitalist and
\nneoliberal world and in the era of trivializa-
\ntion and commodification of health, how
\ncan we talk about a trustable health care?
\nTurkey is a laboratory\u2026The annual number
\nof admissions increased fourfold in the ten
\nyear period 2002\u20132012. What is the moti-
\nvating power behind this increase? What
\nis the main reason of this \u201csuccess\u201d in the
\nera of increased violence against physicians,
\nincluding killing? Is this a real success in
\nterms of a qualified health care?
\nMaybe the reader could find these questions
\nunnecessary, confusing, meaningless.
\nWe will try to illustrate the motivational
\nstate of physicians in Turkey based on the
\nwell known Guidelines \u201cIncentives for
\nHealth Professionals\u201d [1]. By closing our
\neyes to the recent health care, we hope for
\nthe situation described in the guidelines,
\nknowing that such a World is possible.
\nMethod
\nThis article is based on the data of three
\nseparate web based researches carried out by
\nthe Turkish Medical Association (TMA) in
\n2007\u20132008, 2009 and 2010.
\nThe first research was carried out by the
\nTMA Ethics Committee and evaluated
\nthe attitude of the physicians towards Pay
\nfor Performance (PFP). The Questionnaire
\nwas on the website in 2007\/2008 for seven
\nmonths. Random sampling method was
\nused. The total number of participants was
\nTable 1: Types of incentives
\nFinancial incentives Non-financial incentives
\nTerms and conditions
\nof employment
\n\u2022 Salary\/wage
\n\u2022 Pension
\n\u2022 Insurance (e.g. health)
\n\u2022 Allowances (e.g. hous-
\ning, clothing, child
\ncare, transportation,
\nparking)
\n\u2022 Paid leave
\nPerformance payments
\n\u2022 Achievement of per-
\nformance targets
\n\u2022 Length of service
\n\u2022 Location or type of
\nwork (eg. remote loca-
\ntions)
\nPositive work environment
\n\u2022 Work autonomy and clarity of roles and responsibilities
\n\u2022 Sufficient resources
\n\u2022 Recognition of work and achievement
\n\u2022 Supportive management and peer structures
\n\u2022 Manageable workload and effective workload management
\n\u2022 Effective management of occupational health and safety
\nrisks including a safe and clean workplace
\n\u2022 Effective employee representation and communication
\n\u2022 Enforced equal opportunity policy
\n\u2022 Maternity\/paternity leave
\n\u2022 Sustainable employment
\nSupport for career and professional development
\n\u2022 Effective supervision
\n\u2022 Coaching and mentoring structures
\n\u2022 Access to\/support for training and education
\n\u2022 Sabbatical and study leave. Access to services such as
\n\u2022 Health
\n\u2022 Childcare and schools
\n\u2022 Recreational facilities
\n\u2022 Housing
\n\u2022 Transport
\nIntrinsic rewards
\n\u2022 Job satisfaction
\n\u2022 Personal achievement
\n\u2022 Commitment to shared values
\n\u2022 Respect of colleagues and community
\n\u2022 Membership of team, belonging
\n106
\n1567. Due to missing data 98 respondents
\nwere excluded, 1469 respondents were eval-
\nuated and reported on [2].
\nThe second research focused on the working
\nconditions of physicians and their approach
\nto insecure modes of working.This crosssec-
\ntional study was carried out in 2009 when
\nthe government was preparing new legisla-
\ntion on the working conditions of physi-
\ncians.2224 physicians participated,16 of the
\nrespondents were excluded due to repetitive
\nentries. The answers of 2208 physicians
\nwere used [3].
\nThe third research had the title \u201cConsen-
\nsus on the working conditions, workload
\nand labor force of physicians, 2010\u201d. 4354
\nphysicians participated in this web based re-
\nsearch. The report was based on the entries
\nof 2316 physicians since they had filled in
\nall the compulsory items for the evaluation.
\nThis corresponds to 2.6% of the physicians.
\nFactors Affecting the
\nMotivation of Physicians
\nAccording to the Guidelines \u201cIncentives
\nfor Health Professionals\u201d the incentives are
\nclassified into two main groups: financial
\nand non-financial incentives [1].
\nIncentive mechanisms as a whole have a mul-
\ntidimensional content and structure. One of
\nthe most important features of this approach
\nis the combination of financial and non-
\nfinancial incentives. Literature on the ap-
\nplication of incentive schemes in health care
\nacknowledges that financial incentives alone
\nare not sufficient to retain and motivate staff.
\nResearch has confirmed that non-financial
\nincentives play an equally crucial role.
\nWhile the importance and potential of
\nnon-financial incentives is widely recog-
\nnized, it is important to note that there are
\nlimitations to what can be achieved with
\nnon-financial incentives alone.
\nEffective incentive schemes share the fol-
\nlowing characteristics: they have clear ob-
\njectives, are realistic and deliverable, reflect
\nhealth professionals\u2019 needs and preferences,
\nare well designed, strategic and fit-for-pur-
\npose, are contextually appropriate, are fair,
\nequitable and transparent, are measurable
\nand incorporate financial and non-financial
\nelements.
\nResults
\n1. Financial Incentives
\nSalary\/wage
\nIn general, salaries are low for all kind of
\npersonnel. In 2011 the minimum net wage
\nwas \u20ac 291.73. For a family of four the food
\npoverty line was \u20ac 365.03, while the poverty
\nline was \u20ac 1189.06 [5].
\nIn 2011 the fixed income for physicians
\nworking in the public sector was \u20ac 803
\nfor specialists and \u20ac 643 for GPs. The
\nfixed income is the salary which will af-
\nfect what they receive after retirement and
\nis guaranteed to be paid every month. In
\naddition to the fixed income physicians
\nget PFP which is variable, not guaranteed.
\nThe fixed income of physicians is below
\nthe poverty line. The expectations of phy-
\nsicians are very clear concerning their sal-
\naries. 94.8% of the physicians request an
\nincome that does not require doing extra
\njob, 99.3% expect that their salary should
\naffect what they receive after retirement.
\n97.6% claim that the unpredictable, vari-
\nable income policies affect their future
\nplans negatively [3].
\nPhysicians demand 6000 Turkish Lira
\nwhich makes \u20ac 2921.56 per month if it
\ndoes affect what they receive after retire-
\nment.But they demand 10 600 Turkish Lira
\nwhich makes \u20ac 5161.42 per month if it does
\nnot affect what they receive after retirement
\n[4]. It shows that the financial expectations
\nof the physicians are not very high, they are
\nreasonable in order to provide themselves
\nwith modest human life.
\nPension
\nNowadays a retired physician would get
\n1600 Turkish Lira or \u20ac 779.08 per month
\nin Turkey. This level of income is below
\nthe poverty line. Under this condition a
\nphysician cannot live modest human life
\nand cannot survive without doing anoth-
\ner job. For that reason 67% of the GPs,
\n77% of the specialists stated that under
\nthese conditions they do not want to re-
\ntire [4].
\nPaid leave
\nThe right to rest is of vital importance in or-
\nder to prepare for another productive work-
\ning day. Only 27% of the physicians admit-
\nted that they can afford spare time to spend
\nwith their families. Physicians are not able
\nto use their right to rest sufficiently. Only
\n19% of the physicians stated that they can
\nafford a break from work. The majority of
\nthe physicians could not use the one month
\nvacation time [4].
\nPerformance payments
\nPFP started in 2004 in public hospitals and
\nin 2011 in university clinics in Turkey [6,7].
\nPFP is not an incentive, it is rather a princi-
\npal way of payment in Turkey. It is paid for
\nthe active working days only. Illness, preg-
\nnancy, holiday leaves are not paid, it does
\nnot affect what they receive after retirement
\nand related social rights.
\n90.1% of the physicians find the criteria of
\nPFP insufficient. 64.6% consider that PFP
\nincreases the cost of health care and 83.3%
\nthink that PFP damages the work environ-
\nment [3]. 54.9% of the physicians believe
\nthat PFP destroys their relationships with
\ntheir colleagues, 56.1% \u2013 that professional
\nsolidarity has been damaged. 52.7% stated
\nHealth Profession TURKEY
\n107
\nthat the doctor \u2013 patient relationship was
\nnegatively affected [2].
\nSince PFP is based on individual evalua-
\ntions it has a negative effect on team work
\nand the quality of care and makes physi-
\ncians compete with one another [8].
\nEducational activities are very badly affect-
\ned by PFP. The training time has been re-
\nduced \u2013 70.9% of the physicians underlined
\nthe time decrease for skills training,66.6%\u00a0\u2013
\nfor bedside training, 69.6% \u2013 for theoretical
\ntraining of RA\u2019s and 64.4% \u2013 the time for
\nContinuous Medical Education (CME)[2].
\nThus, preconditions for professional devel-
\nopment are not met in Turkey.
\nAccording to the report of the Turkish Sur-
\ngery Association in specialty training the
\nbalance between educational activities and
\nhealth care is destroyed. Training hospitals
\nhave lost their educational functions. The
\nnumber of clinical meetings, seminars and
\ncase discussions has decreased. In order
\nto use time efficiently operations are per-
\nformed by specialists [9].
\n2. Non-financial Incentives
\nWork autonomy
\nIn Turkey the Social Security Institution
\nintervenes seriously in professional au-
\ntonomy of physicians through changes in
\nregulations on reimbursement of health
\ncare services. The reimbursement rules af-
\nfect the PFP rules.The reimbursement rules
\nindirectly determine in what way physicians
\nwill carry out their professional activities. In
\nthe determination of reimbursement rules
\nno participative mechanism is involved ei-
\nther in the form of specialty associations or
\nthe Turkish Medical Association. Therefore
\nhealth care environment starts to destroy
\nthe autonomy of physicians and the values
\nof profession alienate from the practice of
\nmedicine.
\nJob security
\nJob security is vital for professional auton-
\nomy and elimination of job security makes
\nphysicians open to the influence of political
\nauthority. In the last decade two approaches
\nwere used systematically eliminating the job
\nsecurity of the health care workers. Legisla-
\ntion was amended in the following way:
\n\u2022 secure employment was replaced with
\ncontract based, insecure modes of em-
\nployment, such as subcontracting [10,
\n11], contract based working [12,13,14];
\n\u2022 limitations to the freedom of physicians\u2019
\nwork in terms of fields and places; limit-
\ning the number of physicians in private
\nhospitals [15], promoting the opening of
\nprivate clinics [16], compulsory service
\n[17], obstructing the independent self-
\nemployment [18], work bans [19, 20, 21],
\nlicence auctions [22], free trade zones for
\nhealth [23, 24].
\nIn the last decade no single legislation has
\nbeen adopted to ensure professional au-
\ntonomy. On the contrary, the public and
\nprivate health care institutions have been
\nreorganized according to the expectations
\nof the sector.
\nThe report of the UK House of Commons
\nreveals that in the Queen Alexandra hospi-
\ntal 700 health workers, including the physi-
\ncians,were fired in order to overcome the fi-
\nnancial difficulties [25].We can assume that
\nthe health workers in Turkey will be forced
\nto work longer, harder under the threat of
\nunemployment.
\nAccess to literature and new technologies
\nIt is hard to believe that 71% of the GPs,
\n54% of the specialists, 20% of the RAs do
\nnot have access to literature in their work
\nplaces. 95% of the physicians stated that
\nthey are under stress trying to keep their
\nknowledge up to date and 91% of the phy-
\nsicians are under stress caused by access to
\nnew technologies [4].
\nSupportive management
\nSupportive management is one of the criti-
\ncal elements in motivation. 45% of the GPs,
\n30% of the specialists and 37% of the RAs
\nadmitted that they do not have supportive
\nmanagement in their workplaces [4]. 92%
\nof the physicians evaluated the managerial
\nstructure of their work places as a stress fac-
\ntor. On the other hand, 41% of the physi-
\ncians experienced oppression, even violence
\nfrom their managers [4].
\nManageable workload and effective work-
\nload management
\nAccording to the laws in Turkey the
\nworking time is 40 hours per week in the
\npublic, 45 hours in the private sector. But
\nthere is not an upper limit of the work-
\ning hours. Physicians are working for long
\nhours.
\nFigure 1 shows the working hours of phy-
\nsicians. Most of the physicians are work-
\ning more than 40 hours per week. Nearly
\none third of the RAs admitted that they
\nwork more than 95 hours per week [4].
\nThey stated that they work nonstop 33
\nhours which is a threat to public health.
\nRAs demand limitation of working hours
\nto 56 hours per week and 220 hours per
\nmonth and leave of absence after the night
\nduties [26].
\n51% of the physicians have compulsory du-
\nties. In addition to the compulsory duties
\nphysicians have on-call duties \u2013 26% of the
\nphysicians in the public sector and 41% in
\nthe private sector [4].
\nPhysicians demand secure work and secure
\nfuture. 90% of the physicians demand the
\nright to strike and collective bargaining
\nagreements. As concerns contract based
\nwork, 71.2% consider that it decreases con-
\ntrol over work, 72% \u2013 that it does not im-
\nprove productivity, 79.3% \u2013 that it leads to
\njob insecurity [3].
\nHealth ProfessionTURKEY
\n108
\nEffective management of occupational
\nhealth and safety risks
\nThere is not an effective, participative man-
\nagement of occupational health and safety.
\nThe most important issue is violence against
\nhealth care personnel and physicians. 28%
\nof the physicians are exposed to violence
\nfrom other health care staff, 36% \u2013 from
\ntheir colleagues, 41% \u2013 from their manag-
\ners, 66% \u2013 from their patients [4]. The vio-
\nlent atmosphere of health care in Turkey
\nhas tremendously demotivated physicians
\nand other health care staff. Unfortunately,
\none surgeon was stabbed to death in 2011.
\nPhysicians\u2019 suicides have not been the sub-
\nject of scientific research yet, but it cannot
\nbe ignored. In Erzurum in 14 months three
\nyoung physicians committed suicide. The
\nTMA committee has prepared a prelimi-
\nnary report:
\n\u201cIt is hard to establish a connection between
\ndeaths but there is an increase of depression,
\npsychological disorders, physical problems due to
\nvery heavy work load and even the substance use.
\nThere is a social pressure on physicians. Compul-
\nsory service creates broken families. Physicians
\nhave worries about future. These cases cannot be
\ndefined as individual cases\u201d\u00a0[26].
\nEffective employee representation and
\ncommunication
\nThe status of freedom of the Association is
\nreflected in the ILO reports and unfortu-
\nnately it is in the black list. Only the trade
\nunions close to the government are sup-
\nported,while being a member of other trade
\nunions is a serious risk.The long detentions
\nin prison and penalties have been reflected
\nin the European Commission Progress Re-
\nport on Turkey in 2012 [27].
\nMaternity\/paternity leave
\nWomen physicians have 4 months of paid
\nleave after delivery. But PFP is cut dur-
\ning this period. Since the fixed income
\nis around the poverty line physicians are
\nhaving difficulties in using maternity
\nleaves.
\nWomen physicians have a nursing leave for
\none year.They are relieved of shift work and
\nduties during this period, but they face dif-
\nficulties in the unions of private hospitals
\nand public hospitals in terms of restrictive
\ninterventions.There are not enough well or-
\nganized nursery and day care units for the
\nchildren of health care workers.
\nAccess to\/support for training and educa-
\ntion
\nThere is no paid leave for CME activities.
\n95% of the GPs, 68% of the RAs and 33%
\nof the specialists state that they cannot af-
\nford time for CME [4]. The total time de-
\nvoted to CME is extremely negligible \u2013 24
\nhours by the GPs, 36 hours by the special-
\nists and 31 hours by the RAs per year [4].
\n75% of the GPs, 65% of the specialists and
\n66% of the RAs stated that their managers
\nare not aware of the importance of CME
\nand educational activities are not paid for
\n[4]. 75% of the GPs, 64% of the special-
\nists and 74% of the RAs stated that their
\nrequests for further training resulted in
\ncuts from their earnings [4]. This is limit-
\ning the participation of physicians in the
\nCME activities. On the other hand, since
\nparticipation in the educational activities is
\nnot supported financially, physicians might
\nhave unethical financial relationships with
\npharmaceutical firms.
\nIntrinsic rewards
\nIn the WHO report \u201cSuccessful health sys-
\ntem reforms: the case of Turkey\u201d, the dis-
\ncontent of the health professionals has been
\nhighlighted: \u201cThe SABIM telephone hot-
\nlines have significantly empowered patients
\nand resulted in a considerable change in the
\npower relationship between doctors and pa-
\ntients. This led to discontent among health
\nprofessionals.\u201d [28] The investigations trig-
\ngered by SABIM became another form of
\nviolence against physicians and resulted in
\nsuicide of one young RA in 2012.
\nConclusion
\nIn addition to the health policies of the last
\n30 years, the last decade created a wreck of
\nhealth professionals and physicians. Physi-
\ncians\u2019 sense of belonging has weakened and
\nthe expectation of future decreased.This sit-
\nuation has been reflected even in the publi-
\n5% 9%
\n31%
\n2%
\n2%
\n8%
\n3%
\n5%
\n14%
\n6%
\n11%
\n12%
\n10%
\n16%
\n15%
\n26%
\n25%
\n7%
\n31%
\n19%
\n10%17% 12%
\n4%
\n0%
\n20%
\n40%
\n60%
\n80%
\n100%
\nGeneral practitioner Specialists Resident
\nLess than 40 hours
\n41\u201345
\n46\u201355
\n56\u201365
\n66\u201375
\n76\u201385
\n86\u201395
\nMore than 95 hours
\nDistribution in specialty status, %
\nFigure. Weekly working hours including duty and overtime. Consensus on the working condi-
\ntions, workload and labor force of physicians, 2010
\nHealth Profession TURKEY
\n109
\ncations of the Ministry of Health. The gov-
\nernment has lost physicians.This is tangible
\nand visible. The profession is falling into an
\nordinary status. This needs serious, radical,
\nsincere precautions and interventions [26].
\nPhysicians in Turkey as honorable members
\nof a profession which is dedicated to society,
\ndo not want to be an actor in a commercial-
\nized health care.
\nWe would like to conclude with a quotation
\nfrom what Dr. Otmar Kloiber, Secretary
\nGeneral of the World Medical Association,
\nhas said in relation to the Turkish govern-
\nment\u2019s attack to dismantle physician self-
\ngovernance.
\n\u201c\u2026The profession has a lot to lose. Being
\nregulated by a bureaucratic administration
\nthat does not understand medicine and
\nthe work of physicians is difficult. Being
\nregulated by an administration that is not
\nonly disconnected from medicine and care
\nbut that has only cost-savings on its radar
\nis even worse. And while these frustrations
\nand difficulties are not to be underestimat-
\ned, the ultimate threat is to be downgraded
\nfrom a respected profession to a technical
\nservice.
\nProfessional self-governance is not merely a
\nmeans for physicians to exercise control to
\nserve their own interests; it serves a criti-
\ncal patient-centered purpose and we must
\nmake that understood to all stakeholders. In
\nhealth care, the objective of self-governance
\nis to provide better medical care to the pa-
\ntients and services to our people, to protect
\nthe dignity of patients, and to improve pub-
\nlic health in our communities. We must be
\nable to demonstrate to our societies that it
\nis to their advantage to have physicians who
\ncan freely exercise their duties according
\nto professional standards and ethical rules
\nrather than to be under the control of a
\ngovernment, or an insurance or a managed
\ncare company. When physicians are forced
\nto follow third party orders, the interests of
\nthe patients will always come last\u201d [29].
\nReferences
\n1. International Council of Nurses, International
\nPharmaceutical Federation, World Dental Fed-
\neration, World Medical Association, Interna-
\ntional Hospital Federation, World Confedera-
\ntion for Physical Therapy, Guidelines: Incentives
\nfor Health Professionals: 2008.
\n2. Turkish Medical Association Ethics Commit-
\ntee. Physicians evaluations about Pay for Perfor-
\nmance 2009. http:\/\/www.ttb.org.tr\/kutuphane\/
\nperformansadayaliodeme.pdf
\n3. Turkish Medical Association. Physicians evalu-
\nations about working conditions and the law
\nof full time working. 2009 http:\/\/www.ttb.org.
\ntr\/c_rapor\/2008-2010\/2008-2010.pdf
\n4. 4. Turkish Medical Association. Consensus on
\nthe working conditions, workload and labor
\nforce of physicians. 2010 http:\/\/www.ttb.org.tr\/
\nkutuphane\/OG2010.pdf
\n5. http:\/\/www.turkis.org.tr\/?wapp=52521E5F-
\nFCA5-4BDD-940D-A284DA6F151D
\n6. 5027 Financial Year of 2004 Budget Act. Offi-
\ncial Journal 28.12.2003, No 25330
\n7. 5947 Amending the Law on Full\u2013time Work-
\ning of University and Healthcare Staff and Some
\nOther Laws. Official Journal 2010, No 27478
\n8. Rosenthal MB, Fernandopulle R, Song HR,
\nLandon B. Paying for quality: providers\u2019 incen-
\ntives for quality improvement. Health Aff (Mill-
\nwood) 2004; 23: 127-41.
\n9. Terzi, C., A\u011falar, F. Workshop on Pay for Per-
\nformance in Surgery, Turkish Surgery Associa-
\ntion. 2010
\n10. Amending the Law On Employ Contract
\nHealthcare Employee Whereas Finding a Per-
\nsonel is Demanding and Some Other Laws. Of-
\nficial Journal 24.7.2003, No 25178
\n11. 6428 Amending the Law on Renovate and Ser-
\nvice Procurement by Public Private Partnership
\nModel by the Ministry of Health and Some
\nOther Laws. Adopted on 21.02.2013
\n12. 5258 General Practitioner Act. Official Journal
\n9.12.2004, No 25665
\n13. 5413 Amending the Law On Employ Con-
\ntract Healthcare Employee Whereas Find-
\ning a Personel is Demanding and Some Other
\nLaws, Fundamental Law of Sanitary Service
\nand Amending the Law On Organization and
\nDuties of Ministry of Health and Some Other
\nLaws. Official Journal 01.11. 2005, No 25983
\n14. 6354 Amending the Executive Order on Minis-
\ntry of Health and its Subsidiaries\u2019 Organization
\nand Duties and Some Other Executive Orders
\nOfficial Journal 12.07.2012, No 28352
\n15. Amending the By-law on Private Hospitals By-
\nlaw. Official Journal 13.04.2003, No 25078
\n16. Amending the By-law on Private Hospitals
\nand Some Other By-laws. Official Journal
\n21.10.2006, No 26326
\n17. Fundamental Law of Health Services, Dam-
\nages and Labor Rules of Healthcare Employee
\nAct, Goverment Officer Act and Amending the
\nLaw on Organization and Duties of Ministry of
\nHealth. Official Journal 5.7.2005, No 25866
\n18. Amending the Private Hospitals and Private
\nHealthcare Institute By-laws. Official Journal
\n15.02.2008, 3.8.2010- 25.09.2010, 6.1.2011-
\n7.4.2011, 3.8.2011 and 6.10.2011, Circular
\nnumber: 2011\/55
\n19. Amending the Law on Full-time Work of Uni-
\nversity and Healthcare Practitioner and Some
\nOther Laws. Official Journal 30.01.2010, No
\n27478
\n20. Sentence of Turkish Constitutional Court
\nE.2010\/29, K.2010\/90 of 16.07.2010. Official
\nJournal 04.12.2010, No 27775
\n21. 650 Executive Order on Organization and
\nDuties of Ministry of Justice. Official Journal
\n26.08.2011, No 28037
\n22. 663 Executive Order on Ministry of Health and
\nits Subsidiaries\u2019 Organization and Duties. Offi-
\ncial Journal 02.11.2011, No 28103
\n23. Uzay N, T\u0131ra\u015f H. Economic results of Free
\nTrade Zones: Kayseri Free Trade Zone. Journal
\nof Erciyes University Social Sciences Institute.
\n2009:26:1: 247-277
\n24. Kocaman \u00c7B. Evaluation of macroeconomic
\nresults of Free Trade Zones: Case of Turkey,
\nA\u00dcHFD. 2007: 56: 3 :99-135
\n25. House of Commons. 2011: 22
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\nsicians. 2012 http:\/\/www.ttb.org.tr\/kutuphane\/
\nhekimsorunlari.pdf
\n27. European Commission. Turkey 2012 Progress
\nReport
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\nCase of Turkey. 2012
\n29. Kloiber O. A difficult start into the year. World
\nMedical Journal. 2012, 58\/1
\nMD Feride Aksu Tanik,
\nthe member of Advisory Board of
\nTurkish Medical Association
\nMD, Eri\u015f Bilalo\u011flu,
\nthe member of Advisory Board of
\nTurkish Medical Association
\nZiynet \u00d6z\u00e7elik,
\nlawyer, Legal Advisor of Turkish
\nMedical Association
\nU\u011fur Okman,
\ncity planner, IT Specialist of
\nTurkish Medical Association
\nHealth ProfessionTURKEY
\n110
\nBOSNIA and HERZEGOVINAMedical Publications
\nIntroduction
\nScientific publishing is the end product of
\nthe scientific work. The number of publica-
\ntions and their citations are measures of sci-
\nentific success, while unpublished research-
\ners are invisible to the scientific community
\nand as such are non-existent. Researchers in
\ntheir work rely on precedents, so the use of
\nworks of other authors is the verification of
\ntheir contribution to the growing knowl-
\nedge of mankind. If the author published
\nan article in a scientific journal, this article
\nshould not be published in any other jour-
\nnal, with little or no modification without
\nquoting parts of the first article [1,2,3,4,5].
\nWhy do scientists publish? Apart from the
\nalready mentioned, there stand out three
\nmain reasons [1]:
\n\u2022 Profit, money incentives, grants;
\n\u2022 Personal promotion, fame, recognition of
\nsociety;
\n\u2022 Quest for sponsors.
\nAccording to K. Gowrinath [3], plagiarism
\nis one of the ways of scientific misconduct,
\nbesides there is also data fabrication, falsifi-
\ncation, and specifying nonexistent references
\nor literature references. Plagiarism is defined
\nas \u201cintentional or unintentional use of other
\npeople\u2019s thoughts, words, or ideas as their
\nown without clear attribution to their source\u201c.
\nStealing someone else\u2019s intellectual work and
\nits appropriation is cheating of the public.
\nViolation of copyright occurs when the
\nauthor of a new article, with or without
\nmentioning of the author whose work has
\nbeen used, is using parts of previously pub-
\nlished articles, including tables and figures.
\nIn accordance with the principles of good
\nscientific practice (GSP) and Good Labora-
\ntory Practices (GLP) scientific institutions
\nand universities should have a center for
\nmonitoring, security, promotion and devel-
\nopment of quality research. Setting rules
\nand abiding by the rules of good scientific
\npractice are obligations of each research
\ninstitution, university and each individual
\nresearcher, regardless of the field of science
\nthat is being investigated. In this way, inter-
\nnal quality control ensures that the research
\ninstitution, such as a university, is respon-
\nsible for creating an environment that will
\npromote standards of achievement, intellec-
\ntual honesty and legality.
\nCommon reasons of intellectual dishonesty
\nare as follows:
\n\u2022 Persisting \u201cpublish or perish\u201d mantra;
\n\u2022 The personal ambitions of poorly edu-
\ncated individuals;
\n\u2022 Vanity;
\n\u2022 Financial pressure.
\nTherefore, all the reasons could be classified
\ninto two categories: a) human nature (the
\ndesire for status, power and glory without
\nthe ability to perform the research in a
\nproper way), or b) a feverish competition
\namong researchers, under the pressure for
\nbetter results and lack of proper supervi-
\nsion at the workplace (\u201cpublish or perish\u201d
\nculture).
\nAs mentioned above, the worst forms of
\nscientific misconduct and intellectual dis-
\nhonesty are:
\n\u2022 Falsification of information obtained;
\n\u2022 Fabrication of data;
\n\u2022 Plagiarism of ideas and words (stealing
\nother people\u2019s ideas, data, texts).
\nAlthough the truth should be the goal of sci-
\nentific research,it is not a guideline for all sci-
\nentists.The best way to reach the truth in the
\nstudy and to avoid methodological and ethical
\nmistakes is a constant application of scientific
\nmethods and ethical standards in research.
\nPlagiarism \u2013 Terms
\nand Definitions
\nThe term \u201cplagiarism\u201d originates from the
\nLatin word plagium which means \u201cto kid-
\nnap a man\u201d.Literally it means \u201cstealing,tak-
\ning someone else\u2019s work and presenting that
\nmaterial as the work of someone else\u201d[1, 2].
\nPlagiarism of words and ideas can be un-
\nintended and deliberate. It is \u201cthe tendency
\nof literary theft and illegal appropriation
\nof spiritual ownership of other people\u201d, or
\ngenerally \u201cpresenting someone else\u2019s work as
\nown\u201d. According to Miguel Roig (St. John\u2019s
\nUniversity, USA), \u201cPlagiarism can take
\nmany forms,from the presentation of some-
\none else\u2019s work as the own work of the au-
\nthor, to copying or paraphrasing substantial
\nparts of another\u2019s work without attributing
\nthe results to a survey conducted by others\u201d
\n[1]. In all its parts, plagiarism includes un-
\nethical behavior and it is unacceptable.
\nAccording to the World Association of
\nMedical Editors (WAME), plagiarism is
\nrepetition of 6 consecutive words, or over-
\nlapping of 7\u201311 words in a set of 30 words.
\nAlthough variously defined, plagiarism is
\nbasically a method that is intended to mis-
\nlead the readers about one\u2019s own scientific
\ncontribution [1].
\nPlagiarism in Scientific Publishing
\nIzet Masic
\n111
\nBOSNIA and HERZEGOVINA Medical Publications
\nTypes of Plagiarism
\nThere are distinguished different forms
\nof plagiarism. The most common ones are
\ngiven below [1]:
\n1. Plagiarism of ideas: the inclusion of
\nothers\u2019 ideas, methods and results in
\none\u2019s own work without acknowledging
\nthe original author.
\n2. Text plagiarism: copying materials from
\nother researchers and its inclusion in the
\nown work without any acknowledgment
\nor quotation. Inclusions comprise:
\na. Not quoting the sources: the inclu-
\nsion of the text, or any material by
\nother authors without accurate cit-
\ning of the sources.
\nb. Para plagiarism: inclusion of the text
\nof other authors with minor changes
\nor additions to someone else\u2019s text
\nwithout recognizing the source text.
\nc. Pure copying: not using quotation
\nmarks when the exact wording is
\ncopied from other authors, even if
\nthe source is indicated.
\nd. Incorrect paraphrasing: the text of
\nother authors is used with small
\nchanges, but using the same word
\nor sentence structure, even if the
\nsource is indicated.
\ne. Violation of copyright: exact copy-
\ning of others\u2019 words is a violation of
\ncopyright.
\n3. Self-plagiarism
\na. Duplicate publication: publishing
\nthe same article with similar con-
\ntent to that which has already been
\npublished.
\nb. \u201cSalami\u201d publication: publishing
\nseveral papers based on the results
\nof one study. However, the num-
\nber of papers that can be published
\nbased on the results of a study has
\nnot yet been fixed.
\nc. Recycling texts: publication of the
\nsame paper in different journals or
\nin different languages.
\nAdverse effects of plagiarism include un-
\nnecessary utilization of space in journals,
\nspending time of reviewers and editors, the
\nrisk of professional liability and infringe-
\nment of copyright, inflating the importance
\nof research subject and awarding lies.Today
\nthe availability of abundant materials of the
\nsame or similar subject through a simple
\ninternet search results in an increase in the
\nincidence of plagiarism. At the same time
\nthe internet makes the detection of plagia-
\nrism easier with the help of detection soft-
\nware [3].
\nPlagiarism Prevention
\nAccording to M. Roig [4], since 2005 un-
\ntil today the number of published articles
\ncontaining the word \u201cplagiarism\u201d is higher
\nthan in all the years up to 2004. The author
\nalso argues that plagiarism is manifested in
\nvarious forms and describes self-plagiarism
\nand its other forms.
\nThere is no general regulation of control
\nfor scientific research and intellectual hon-
\nesty of researchers that would be absolutely
\napplicable in all situations and in all re-
\nsearch institutions. In the case of substan-
\ntial plagiarism (copying more than 25% of
\nthe published sources), the redundant text
\nshould be withdrawn from the publication
\nand measures should be taken to inform the
\nrespective institutions. If plagiarism is de-
\ntected only after publication, editors should
\nwithdraw the article and inform readers
\nabout the abuse.
\nAccording to the Office of Research Integ-
\nrity USA (ORI), plagiarism is on the top of
\nthe list of the three largest research fraud of-
\nfenses. In Bosnia and Herzegovina, plagia-
\nrism is not yet listed in the law as a criminal
\noffense and therefore appropriate penalty
\nfor plagiarism is not defined.
\nThe ethical aspect of publishing is especially
\nimportant for small and developing coun-
\ntries. The participation of scientists from
\nBosnia and Herzegovina in the global sci-
\nentific communication implies the obliga-
\ntion of accepting international standards for
\nciting the sources used.
\nThe authors should:
\n\u2022 Always follow the proper rules of citation
\nreferences, acknowledging that the ideas
\nwere heard at conferences and in formal
\nor informal discussion;
\n\u2022 References must contain full bibliograph-
\nic information;
\n\u2022 Each source cited in the text must be
\nlisted in the bibliography;
\n\u2022 Quotation marks should be used if more
\nthan 6 consecutive words are copied;
\n\u2022 Obtain permission of other authors\/pub-
\nlishers for reproduction of protected fig-
\nures or text.
\nK. Gowrinath [3] recommends the follow-
\ning steps to prevent plagiarism:
\n\u2022 All data that have already been published
\nby other researchers should be quoted
\nwith appropriate references and all the
\nsources of information used in the prepa-
\nration of the document should be recog-
\nnized in the appropriate format;
\n\u2022 Provide footnotes and use inverted com-
\nmas whenever necessary;
\n\u2022 Written approval of other authors should
\nbe obtained prior to the incorporation of
\ntheir figures or tables in the article.
\nSpecific form of plagiarism is self-pla-
\ngiarism. Scientists need to take into ac-
\ncount this form of plagiarism, because at
\nthe moment there is an attitude that their
\nown words can be used without fear of
\nplagiarism. If an author cites his\/ her own
\narticle that has already been published,
\nthen this should be listed as a quote and
\ncite the source in which the article is pub-
\nlished.
\nConclusion
\nScience should not be exempt from dis-
\nclosure and sanctioning of plagiarism. In
\nthe struggle against intellectual dishonesty,
\neducation on ethics in science has a signifi-
\n112
\nHealth Care and Pharmaceutical Industry BELGIUM
\ncant place. General understanding of ethics
\nin scientific research and in all its stages had
\nto be acquired during undergraduate studies
\nand is to be improved further in later years.
\nThe ethical aspect of publishing industry is
\nas important, particularly in small and de-
\nveloping economies, because the publisher
\nhas an educational role in the development
\nof the scientific community that wants to
\nenjoy it.
\nReferences
\n1. Masic I. Plagiarism in Scientific Publishing.
\nActa Inform Med. 2012 Dec); 20(4): 208-
\n213.\u00a0doi:10.5455\/aim.2012.20.208-213\u00a0
\n2. Masic I. Ethical Aspects and Dilemmas of Pre-
\nparing, Writing and Publishing of the Scientific
\nPapers in the Biomedical Journals. Acta Inform
\nMed. 2012 Sep; 20(3): 141-148.\u00a0 doi:10.5455\/
\naim.2012.20.141-148\u00a0
\n3. Gowrinath K. Plagiarism in Scientific Research.
\nNMJ. 2012; 1(2): 49-51.\u00a0
\n4. Roig M. Avoiding unethical writing practic-
\nes.\u00a0Food and Chemical Toxicology. 2012; 50(10):
\n3385-3387. (doi: 10.1016\/j.fct.2012.06.043)
\n5. The insider\u2019s guide to plagiarism. Nature Medi-
\ncine. 2009; 15: 707. doi:10.1038\/nm0709-707
\nhttp:\/\/www.nature.com\/nm\/journal\/v15\/n7\/
\nfull\/nm0709-707.html
\nDr. Izet Masic,
\nBosnia and Herzegovina
\nLike every industry, pharmaceutical indus-
\ntry develops a product, medication in this
\ncase, which purpose is to draw the best pos-
\nsible benefit.
\nTo do that, it aims for the highest possible
\nprices in accordance with the purchasing
\npower in each country it targets.
\nAs much as possible, pharmaceutical indus-
\ntry avoids the reentry of a medication from
\na country where it has a low price to another
\nwhere its price is high.
\nPharmaceutical industry attempts to extend
\nthe duration of patents by introducing ga-
\nlenic or chemical improvements of some-
\ntimes low usefulness.
\nIt tries to increase demand by raising the
\nconscience of a need or by creating a need
\nwhere there is none.
\nTo achieve that, it works on:
\n\u2022 General public by publishing something
\nwhich is not always an advertisement but
\nis related to information;
\n\u2022 The prescribing practitioner.
\nAnd, indeed, what makes pharmaceutical
\nindustry different from other industries,
\nis the fact that it is not the customer who
\npays or chooses his product (at least for pre-
\nscribed medications). That is why pharma-
\nceutical industry creates a relationship with
\nthe prescribers.
\nPharmaceutical industry needs doctors who
\nwill prescribe its products.
\nTherefore, a doctor must be well informed
\nabout a pathology. That is why pharmaceu-
\ntical industry spends substantial money in
\ncontinuous medical education of doctors.
\nIt also makes tremendous efforts to inform
\nabout its products.
\nOn the other hand, competition between
\nfirms which develop related medications for
\nthe same pathologies and the ineluctable
\ndeadline of the end of patent protection
\nincite the firms to develop a high research
\nactivity because innovation only allows
\ngrowth and durability.
\nThe firms need the cooperation of doc-
\ntors to do that. The use of new molecules
\ncannot, actually, happen without periods
\nof trial combined with an intense moni-
\ntoring of the patients who undergo these
\ntests.
\nThe policy of pharmaceutical industry
\nis not guilty in itself. Search for profit
\nis the driving force of progress and pro-
\nvides us, doctors, in therapeutic means
\nwhich allow us to relieve or heal our
\npatients more often than before. What
\nother product could be more useful to
\nmankind?
\nThat remains true as long as these thera-
\npeutic means are used advisedly in the pa-
\ntients\u2019 only interest and in complete trans-
\nparency towards them.
\nYet, the boom of expenses in the field of
\nmedications, the accidents, sometimes
\ncaused by an excessive use, too much pro-
\nmotion from the firms, the taboo on their
\nunwanted side-effects and the bad results of
\nresearch have led to mistrust from general
\npublic towards the industry as well as to-
\nwards the prescribers.
\nCooperation Between Medical Profession
\nand Pharmaceutical Industry
\nRoland Lemye
\n113
\nHealth Care and Pharmaceutical IndustryBELGIUM
\nHow was it possible to come as far as sus-
\npecting WHO to have been swindled or
\nbribed by pharmaceutical industry about
\nthe risk of a H1N1 pandemic and the ne-
\ncessity to vaccinate the world\u2019s population?
\nThe reason is quite simple: in public view,
\npharmaceutical industry seemed to have
\nunlimited abilities and doctors were entirely
\ncompliant to its messages.
\nHow many abuses made this possible?
\nThe most visible part was conviviality, fes-
\ntive invitations, presents, which amount
\ngrew exponentially because they found
\nplace in a climate of competition.
\nDoctors did not feel like they were being
\nbought without being aware of it, since
\nthey cared most for the content of com-
\nmunications from those who had made up
\nthe atmosphere of conviviality.
\nSo it was about time to restore a climate of
\ncredibility for both parts.
\nSpeaking for medical ethics, medical or-
\nganizations have defined, in statements,
\nwhat was acceptable and what was not in
\nthe context of relationship between prac-
\ntitioners and industry.
\nThe Standing Committee of European
\nDoctors (SCED) has taken it further
\nby negotiating a charter with the Euro-
\npean Pharmaceutical industry (EFPIA).
\nIts advantage is, as long as it is signed
\nby all parties, to impose on doctors as
\nwell as on firms. Many countries have
\ndone the same or even preceded these
\nmeasures.
\nIt must be said that the pharmaceutical
\nindustry has hesitated for a long time be-
\nfore it decided to commit itself but finally
\ndid so when it was confronted to two un-
\navoidable outcomes of its policy:
\n\u2022 The exponential cost of conviviality and
\n\u2022 The receding decision-making power of
\ndoctors to the benefit of pharmacists.
\nFor all that, all problems are not solved yet
\neven if progress is evident.
\nThe problem which is currently focused on
\nis that of transparency and conflict of inter-
\nest.
\nEverybody knows now how tobacco indus-
\ntry has fought against medical efforts to
\neradicate that plague, by corrupting famous
\nscientists so that they wrote articles which
\nminimized or denied some of tobacco\u2019s
\nharmful effects. That strategy was particu-
\nlarly used against the idea of passive smok-
\ning in public places.
\nMethods used by pharmaceutical industry
\nare not always very different.
\nA spokesman, chosen by the firm (prefer-
\nably a pacesetter in his field) makes a sci-
\nentific speech, using the firm\u2019s slides, to a
\npublic invited by the firm itself.
\nIndustry sponsors medical reviews which
\nare sent for free to the practitioners, in
\nwhich professors claim the benefits of a
\ngiven product.
\nConflicts of interests are obvious in this
\ncase, but what about those who exist in
\ndecision-making instances (Drug Agen-
\ncies, Repayment Commissions, and so on)?
\nIt appears clearly that a doctor who has
\ntaken part in clinical tests about a given
\nmedication can only be influenced by his
\nknowledge of the medication itself, which
\nhe gained during the tests (is that a bad
\nthing?), but also by the fact that he is often
\noffered clinical tests and that he does not
\nwant to lose that source of income.
\nIf doctors who have that knowledge were
\nby-passed, would a medication be consid-
\nered with more impartiality by people who
\ndo not know it?
\nConflict of interest can also occur in the
\nopposite way. Is the person in charge of ex-
\npenses more neutral, who has to decide over
\nthe conditions of repayment of a medica-
\ntion which is useful but expensive?
\nThe problem is complex but must be solved.
\nThe Platform on Ethics & Transparency,
\nwhich has recently published a\u00a0list of guid-
\ning principles promoting good governance
\nin pharmaceutical sector, is dedicated to
\nthat.
\nThe intention is that the patient, finally, re-
\nceives the most appropriate treatment with
\nrelevant information that goes with it.
\nIn order to achieve that, all parties must es-
\ntablish relationships based on mutual trust
\nand transparency.
\nTransparency implies that all parties reveal
\nall their relationships and potential conflicts
\nof interests. As for companies, they must
\nprovide complete information, particularly
\nto the competent authorities.
\nBy introducing all partnerships, not only
\nindustry and practitioners but also patients\u2019
\nassociations, caregivers, consumer associa-
\ntions, society, hospitals and competent au-
\nthorities of all levels into debates, the Plat-
\nform on Ethics & Transparency\u00a0has given
\nthe discussion a new dimension which al-
\nlows hope in a better future.
\nDr. Roland Lemye,
\nPresident of Association Belge
\ndes Syndicats M\u00e9dicaux
\n114
\nMedical Education
\nMedical education has evolved beyond
\nthe traditional didactic way of teaching.
\nDr.\u00a0William Osler put into practice a learn-
\ning process that extended beyond the class-
\nroom and to the patient\u2019s bedside. From
\nthe first day of medical school, students are
\nquickly exposed to the experiential concept
\nof \u201csee one, do one, teach one,\u201d and all can
\nagree that a considerable amount of learn-
\ning in medicine happens through observa-
\ntion. Nonetheless, we need to be innovative
\nin changing the way we learn and teach as
\nthe quantity of material has significantly in-
\ncreased in recent decades.
\nWill sitting through numerous lectures
\nthroughout medical training and attending
\nscientific meetings implicitly make one an
\nexpert in designing lectures? Will it enable
\nfuture physicians tooptimize the transfer of
\nknowledge, and will it aid in understanding
\nthe true meaning of Bloom\u2019s Taxonomy and
\nfundamental theorists of pedagogy and an-
\ndragogysuchasBeinstein,Freire,orKnowles?
\nWhat are the principles of medical educa-
\ntion in relation to learning and teaching?
\nMany efforts have been made to advance
\nresidency education such as the develop-
\nment of the CanMEDS roles which are
\nmeant to promote \u201cbetter standards, better
\nphysicians, better care.\u201dThese were formally
\nadopted by the Royal College of Physicians
\nand Surgeons of Canada in 1996 and are
\nin place to help guide educators to better
\ndefine the competencies of well-rounded
\nphysicians should possess at the end of his
\ntraining. The CanMEDS Scholar role en-
\ncompasses the role of physician as a teacher.
\nAdditionally, the imperative to teach oth-
\ners is intrinsic to most descriptions of the
\nconstituents of professionalism in medicine.
\nPhysicians must not only be lifelong learn-
\ners, but also lifelong educators; however,
\nthere is a paucity of formal training prepar-
\ning them for either role. A greater emphasis
\nshould be placed on the manner and context
\nin which these competencies are attained
\nwithin atraining program to ensure resi-
\ndents and trainers are adequately equipped
\nwith the fundamentals of education in order
\nto properly acquire them.
\nPhysicians are trained as medical profes-
\nsionals and generally do not receive formal
\npedagogy training. There is a gap in the
\nmedical community between knowledge
\nand understanding contemporary, effective
\nstrategies of delivering the material.The ed-
\nucator is a facilitator of learning; they need
\nto have some understanding of how people
\nlearn as wellas how to teach. As an effect,
\nthe trainer does not drive the curriculum,
\nbut facilitates it for proficient and efficient
\nlearning.
\nCommunicating the science can be very dif-
\nficult in a multifaceted and humanistic field
\nsuch as medicine where a plethora of factors
\ncontinuously shape the psychology of edu-
\ncation. Basic principles of education should
\nbe further explored, integrated, and rein-
\nforced within post graduate medical educa-
\ntion. Furthermore, in order to see a change
\nin its culture,a stress on faculty development
\nis vital and an auditing of the education and
\nteaching should be imperative, particularly
\nin the delivery of material.A high-ranking
\nmeasurable is the transfer of knowledge and
\nskills to equip physicians with a certain ca-
\npacity for critical thinking. Consequently,
\nlearners would be given a greater sense ovf
\ninquiring about the material being deliv-
\nered, especially with the relevance of their
\nsocio-political context.
\nThere is a call for a culture of continuous
\nquality improvement in medical education.
\nThis would allow physicians to not only
\nidentify weaknesses and strengths in their
\nscholars, but to guide them on how to act in
\nresponse. Increasing awareness forthe im-
\nportance and need of adult education must
\nbe a priority among stakeholders as it has a
\ndirect impact on patient care. Globally and
\nin itself, medical educationis a fragmented
\nsystem with a lack of commitment to excel-
\nlence from many political leaders. Recogni-
\ntion from the latter for the aforementioned
\ncompetencies could translate into higher
\nstandards in medical education with the
\naim of increasing the quality assurance and
\npreventing harm to patients.
\nThe World Medical Association encour-
\nages the highest possible standards not
\nonly in medical ethics, but also in medical
\neducation by way of \u201chelping physicians to
\ncontinuously improve their knowledge and
\nskills.\u201dThrough its declarations, resolutions,
\nand statements, the World Medical As-
\nsociation and their partners and alliances,
\nhave the potential to positively impact how
\nmedical competencies are being transferred.
\nMedical education is an ongoing and dy-
\nnamic process. In modern medicine, it is es-
\nsential that efforts are made to provide both
\njunior physicians and senior faculty with the
\nskills to evolve into educationalists.
\nJean-Marc Bourque,
\nDeputy Chair of the Junior Doctors Network
\nA Call for Quality Improvement
\nin Medical Education
\nJean-Marc Bourque
\n115
\nHealthy Ageing
\nIntroduction
\nThe Standing Committee of European
\nDoctors (CPME) represents national med-
\nical associations across Europe. CPME is
\ncommitted to contributing the medical pro-
\nfession\u2019s point of view to EU and European
\npolicy-making through pro-active coopera-
\ntion on a wide range of health and health-
\ncare related issues.
\n\u2022 CPME believes the best possible quality
\nof health and access to healthcare should
\nbe a reality for everyone. To achieve this,
\nCPME promotes the highest level of
\nmedical training and practice, the safe
\nmobility of physicians and patients, law-
\nful and supportive working conditions for
\nphysicians and the provision of evidence-
\nbased, ethical and equitable healthcare
\nservices. CPME offers support to those
\nworking towards these objectives when-
\never needed.
\n\u2022 CPME sees the patient-doctor rela-
\ntionship as fundamental in achieving
\nthese objectives and are committed
\nto ensuring its trust and confidential-
\nity are protected while the relationship
\nevolves \u00a0with healthcare systems.\u00a0Patient
\nsafety and quality of care are central to
\nour policies.
\n\u2022 CPME strongly advocates a \u2018health in
\nall policies\u2019 approach to encourage cross-
\nsectoral awareness for and action on the
\ndeterminants of health, to prevent dis-
\nease and promote good health across
\nsociety.
\nCPME\u2019s policies are shaped through the
\nexpertise provided by our membership of
\nnational medical associations, representing
\nphysicians across all medical specialties all
\nover Europe and creating a dialogue be-
\ntween the national and European dimen-
\nsions of health and healthcare.
\nCPME\u2019s involvement in healthy ageing
\ngoes back to the 1960s with policies ad-
\ndressing demographic change and the el-
\nderly including recommendations on health
\ncare for the ageing population. In 2010 a
\nstatement on Mental health in older peo-
\nple\/healthy ageing was adopted (CPME
\n2010\/105), in 2011, a statement regarding
\nthe European Innovation Partnership on
\nActive and Healthy Ageing (EIPAHA)
\n(CPME 2011\/066). The latter, EIPAHA is
\ncoordinated by the European Commission,
\nwhich gives high priority to initiatives in
\nthis area. Three European Commissioners
\nstrongly support EIPAHA which aims to
\nadd two extra healthy life years to citizens
\nby 2020 and adopted in this sense a Stra-
\ntegic Implementation Plan in November
\n2010. Within the implementation plan,
\nCPME committed itself to Prevention,
\nearly Diagnosis of Functional and cognitive
\ndecline.
\nDoctor\u2019s role in Healthy
\nAgeing
\nThe role of doctors in healthy ageing is to
\ntackle both the physical and cognitive com-
\nponents of frailty\/functional decline, to
\ncontribute to raising awareness within the
\nmedical profession as well as partner with
\npatients and citizens and their social di-
\nmension for a life-long approach to health.
\nThis includes maintaining functional ca-
\npacity, participation and social inclusion,
\nindependent living and caring environment
\nas well as a healthy work environment and
\nleadership.
\nHealthy ageing will be one of the most
\nimportant topics for European doctors
\nin the coming decade(s) with a specific
\nfocus on maintaining, restoring and im-
\nproving the functional capacity of patients
\nand citizens. Hence, the role of doctors
\ncan be seen in two components. One is
\nthe physical component in which expert
\nknowledge is needed on physical fitness,
\non nutrition and on chronic conditions
\nmanagement including polypharmacy and
\novermedication followed by functional
\ncapacity assessment and evaluation. Im-
\nportant to mention here, is to concentrate
\nnot only on the disabilities of patients but
\nabove all on the existing abilities. (ability
\nvs. disability). Wrong judgments in this
\narea can easily lead to social exclusion of
\npeople. Next is the psychological compo-
\nnent in which expert knowledge on social
\nand psychological well-being is needed,
\nincluding knowledge on a healthy lifestyle.
\nPatients and citizens should be engaged in
\nmeaningful activities and get physical sup-
\nport and easy transportation when neces-
\nsary.
\nVery important is the need for a health lit-
\neracy program in which dissemination of
\nknowledge is channelled into the capillaries
\nof the population through doctors and oth-
\ner stakeholders, also through educational
\nprogrammes, e-learning modules, web
\nHealthy Ageing.
\nA Socio-Medical Perspective
\nThe role of European doctors
\nJacques van der Vliet
\n116
\nHealthy Ageing
\nbased applications, all of which must be
\nfocused on the caregiving network and the
\npatients and the public.
\nImportant Elements
\nof Healthy Ageing
\nMaintaining functional capacity can be
\nachieved through healthy eating and physi-
\ncal activity also including a healthy work
\nenvironment and lifestyle, a proper work-
\nlife balance and smoking cessation. Avoid-
\nance of drugs and controlled drinking are
\nalso part of this topic. Avoidance of drugs,
\nalcohol and smoking cessation have the
\nmost significant impact when introduced at
\nan early stage of one\u2019s life. Healthy child-
\nhood habits will bring health profits 40
\nyears later. Finally, coping skills and resil-
\nience to live with daily pressure and stress
\nare needed as well as one must furthermore
\nrespect heterogeneity, autonomy and differ-
\nences in people.
\nFunctional capacity assessment and evalu-
\nation can be reached through use of tools
\nthat measure subjectively and objectively a
\nperson\u2019s functional condition. In the objec-
\ntive tool a doctor looks at personal and so-
\ncial functioning and at adaptation to physi-
\ncal demands. This leads to an outcome in
\nwhich the result is either normal, limited or
\nlimited to a certain extent. The Workability
\nIndex is a subjective judgment by an indi-
\nvidual (see figure). As the figure above illus-
\ntrates, the subjective judgement engages the
\nindividual in a progressive follow-up ob-
\ntained from answering a set of 10 questions
\nthat, dependent on the score, indicate either
\nthe need to intervene and redress functional
\ncapacity or assures the individual of his\/her
\nfunctional capacity. The functional capacity
\nstatus may be observed through yearly eval-
\nuations done by the occupational physician
\nat the workplace.
\nParticipation and social inclusion can be
\nrealised through staying active in society,
\neither in work or in a social environment.
\nOne should be well protected from get-
\nting in an isolated position or facing the
\nloneliness which can be a threat for many
\npeople in the later stage of their lives. The
\nposition of family, relatives, social workers
\nor even neighbours is of key importance.
\nPeople are entitled to a meaningful place in
\nsociety and most people want to continue
\nto contribute having a lifetime of knowl-
\nedge and experience. One must keep older
\npeople stimulated and engaged through
\nemployment or through learning and pro-
\nmote fiscal benefits and cheap transporta-
\ntion to prolonge flexibility. A basic idea of
\nhow to extend the social residency of the
\nelderly is through increasing their literacy
\nin technologies (computer skills, special
\nphones with bigger screens or buttons and
\nphone applications for caregivers) Further-
\nmore courses and social clubs for the older
\nmembers of society could include musical
\nand artistic activities.
\nIndependent living and caring environ-
\nment is implemented by promoting in-
\ndependence and offer support where nec-
\nessary. One should stay in his\/her own
\nenvironment as long as possible and create
\na network of formal and informal carers,
\nsuch as family, social workers, GPs. Physi-
\ncal support (like vacuuming the house or
\ndoing repairwork and or cooking meals)
\nwill help people stay in their original set-
\nting. Also organising shopping services
\nwith transportation and support can be of
\nimmense help.
\nGood Working conditions are important
\nsince demographics show that in an ageing
\npopulation people will have to work lon-
\nger. Evidence shows that work is good for
\nyour (mental) health, provided that proper
\nworking conditions are in place. A healthy
\nworking environment is implemented
\nthrough a stimulating and inspiring lead-
\nerships or management style. There is a
\nneed for a special focus on senior employ-
\nees, providing them with a stable psycho-
\nsocial environment and good working
\natmosphere including clear communica-
\ntion and clarity about goals and objectives,
\nchanges and results in the organisation.
\nTraining on IT and increasing the tech-
\nnological literacy, as mentioned previously,
\ncould aid not only in making the older
\nemployee stay integrated in the team but
\nalso giving them a constant intellectual
\nstimulus. Human resources management
\nmust be active, enabling senior employees
\nto use their potential to the full and con-
\ntribute to their ability including perma-
\nnent education.(and task shifting) Skills
\nand experience should be passed on to the
\nnext generation with seniors as coaches or
\nmentors.
\nLikeable Organisations
\nIn order to optimize the working environ-
\nment for individual employees, employers
\nshould promote likeable organisations. David
\nKerpen, CEO of two companies (Likeable
\nLocal and Likeable Media) and author of two
\nbooks, (Likeable Social Media and Likeable
\nBusiness), describes a likeable organisation
\nWorkability Index
\nSubjective
\njudgment by
\nindividual
\n10 questions
\naddressing
\npresent and
\nfuture health
\nsituation
\nScore leads to
\nassurance intervention
\nYearly
\nevaluation
\nto measure
\ntrend
\n117
\nHealthy Ageing
\nin 11 elements in a triangle (see figure). Key
\nelements would include:
\n\u2022 Listening: \u201cWhen people talk, listen
\ncompletely. Most people don\u2019t listen\u201d, Er-
\nnest Hemingway;
\n\u2022 Storytelling: \u201cStorytelling is the most
\npowerful way to put ideas into the world
\ntoday\u201d,Robert McKee and \u201cif you tell me,
\nit is an essay, if you show me, it is a story\u201d,
\nBarbara Greene;
\n\u2022 Authenticity: \u201cI had no idea that being
\nyour authentic self could make me as rich
\nas I\u2019ve become, if I had, I\u2019d have done it a
\nlot earlier\u201d, Oprah Winfrey;
\n\u2022 Transparancy: \u201c As a small businessper-
\nson you have no greater leverage than the
\ntruth\u201d, John Whittier;
\n\u2022 Teamplaying:\u201d individuals play the game,
\nbut teams beat the odds\u201d, SEAL team
\nsaying;
\n\u2022 Responsiveness: \u201cLife is 10% what hap-
\npens to you, and 90% how you react to
\nit\u201d Charles Swindell and \u201cyour most un-
\nhappy customers are your greatest source
\nof learning\u201d, Bill Gates
\n\u2022 Adaptibility: \u201cWhen you\u2019re finished
\nchanging, you are finished\u201d; humility and
\nwillingness to adapt mark a great leader,
\nBen Franklin
\n\u2022 Passion: \u201cThe only way to do great work is
\nto love the work you do\u201d, Steve Jobs
\n\u2022 Surprise and delight: \u201c A true leader
\nalways keeps an element of surprise
\nup his sleeve, which others cannot
\ngrasp but which keeps his public
\nexcited and breathless\u201d Charles de
\nGaulle; likeable leaders underpromise
\nand overdeliver.
\n\u2022 Simplicity: \u201c Less isn\u2019t more, just enough
\nis more\u201d Milton Glaser
\n\u2022 Gratefulness: I would maintain that
\nthanks are the highest form of thought,
\nand that gratitude is happiness doubled
\nby wonder\u201d Gilbert Chesterton
\n\u2022 The Golden Rule: \u201cAbove anything else,
\ntreat others as you \u2018d like to be treated\u201d
\nSource: David Kerpen. Likeable social media
\nand likeable business. http:\/\/www.likeable-
\nbook.com\/
\nBlue Zones
\nMaintaining functional capacity, social in-
\nclusion and a stimulating working environ-
\nment are crucial to healthy ageing,acknowl-
\nedging the potential of the older person.
\nResearch has shown that where all these
\nelements are in place, people live longer and
\nhappier.
\nHealthy Ageing
\nBlue zones (adapted from Dan Buettner,
\nUSA):
\n\u2022 Still at work
\n\u2022 Physical activity
\n\u2022 Healthy nutrition
\n\u2022 Participation and social inclusion
\n\u2022 Porpose in life
\n\u2022 It starts with goed genes of course
\nFor example, Dan Buettner, a journalist\/
\nresearcher from the USA and connected
\nto the National Geographic Journal de-
\nscribes 5 areas in the world where people
\nreach-on average- a higher age. What do
\nall these people have in common? Firstly,
\nit starts with good genes, of course. Then,
\nthey are still at work most of the time.
\nThirdly, they are engaged in some kind of
\nphysical activity. They eat healthily. Never
\ncease being well integrated with a group.
\nThey participate one way or another in so-
\ncial activities. Last but not least, they have
\na very well \u2013marked purpose in life (a rea-
\nson to get up in the morning; In Japan: iki-
\ngai). What we also see here is that a basic
\nthought is to avoid the disease instead of
\ncuring it. Moreover, in our society we see
\nthat people tend to be preoccupied about
\na lot of issues, very often worrying solely
\nabout themselves. Let us find out what we
\ncan do for someone else who might be in
\nneed. This could mean looking at our clos-
\nest environment including family, friends,
\nand neighbours. A small piece of advice
\ncould be to try a change in attitude by be-
\ning kind to other people and smile at one\u2019s
\nneighbour. People in most societies work
\nGRATEFULNESS
\nADAPTABILITY
\nAUTHENTICITY
\n&TRANSPARENCY
\nSIMPLICITY
\nSUPRISE
\n&DELIGHT
\nRESPONSIVENESS
\nLISTENING STORYTELLING PASSION
\nTEAM
\nPLAYING
\nHelthy
\nworkplaces are
\nlikeable
\norganisations
\nFigure. Adapted from David Kerpen. Likeable social media and likeable business. http:\/\/
\nwww.likeablebook.com\/
\n118
\nSpeaking Books
\nBackground
\nThe Health Extension Program (HEP) is
\nan important institutional framework de-
\nveloped to achieve the goals of the Health
\nSector Development Program (HSDP) at
\ncommunity level [1]. It aims to improve
\naccess and equity of services by provid-
\ning health interventions at kebeles and the
\nhousehold level, with a focus on sustained
\npreventive health actions and increased
\nawareness [2] by covering all rural kebeles
\nwith the HEP. The HEP focuses on four
\nkey areas: (1) Hygiene and Environmen-
\ntal Sanitation, (2) Disease Prevention and
\nControl,(3) Family Health Services,and (4)
\nHealth Education. These packages address
\nproper and safe water\/waste management
\nand disposal systems; HIV\/AIDS, malaria
\nor tuberculosis prevention and control; first
\naid; maternal and child health, family plan-
\nning and reproductive health.The Speaking
\nBook is used as an additional health promo-
\ntion tool particularly for community health
\npromoters with low levels of literacy and for
\nhealth extension workers (HEW) to use
\nfor existing projects related to community-
\nbased maternal, newborn, child and family
\nhealth. As such, the research study has the
\nfollowing objectives:
\n\u2022 Assess use and effectiveness of MNCH
\nSpeaking Book in selected kebeles by
\nHEWs and HDA.
\n\u2022 Understand care-takers\u2019perception of the
\nSpeaking Book and the potential impact
\nof this initiative on caretakers\u2019 knowledge
\nand practice.
\n\u2022 Assess effectiveness of Speaking Books as
\na health promotion tool in general and for
\nfuture initiatives.
\nSpeaking Books
\nThe first Speaking Book in Ethiopia was
\ndeveloped in 2010 by the Federal Minis-
\ntry of Health (FMoH) in partnership with
\nUnited Nations International Children
\nFund (UNICEF), the Integrated Fam-
\nily Health Program (IFHP), and the Last
\nTen Kilometers \/JSI. The Speaking Book
\nis an educational tool containing 16 key
\nmessages on community based maternal
\nand new born health presented through
\ntext, pictures, and a recorded soundtrack in
\nAmharic.
\nHealth extension workers (HEWs) and the
\nhealth development army (HDA) utilize
\nthe books as a supplement to the Family
\nHealth Card during interactions with the
\ncommunity (mothers, fathers, grandparents,
\naunts, care-takers and others) regarding
\nRapid Qualitative Assessment of Maternal and Newborn
\nHealth Care (MNHC) Speaking Book in Two Districts
\nin the Amhara Region, Ethiopia
\ntowards retirement as a purpose in life, for
\npeople in blue zones the word pension of-
\nten does not exist in their language.
\nIn conclusion 11 steps towards healthy
\nageing are worth mentioning.
\nHere they come:
\n\u2022 \u201ctake the stairs,
\n\u2022 drink more water,
\n\u2022 eat a big breakfast,
\n\u2022 snack on fruit,
\n\u2022 have a cup of coffee every now and then,
\n\u2022 breathe more deeply,
\n\u2022 exercise your eyes,
\n\u2022 stretch regularly,
\n\u2022 take a walk after lunch,
\n\u2022 take a powernap,
\n\u2022 be more optimistic \u2026\u2026\u2026and
\n\u2022 smile at your neighbour\u201d
\nReferences
\n1. CPME Statement on the European Innovation
\nPartnership Ageing Healthy Ageing,April 2011.
\nCPME 2011\/066
\n2. CPME Statement on Mental Health in
\nthe Older People, November 2010. CPME
\n2010\/105
\n3. Dan Buettner, Blue zones. http:\/\/www.bluez-
\nones.com\/about\/dan-buettner\/
\n4. David Kerpen, Likeable social media and like-
\nable business, New York Times best selling
\nauthor, 2013. http:\/\/www.davekerpen.com\/
\nbooks
\nJacques van der Vliet,
\n(with the kind support
\nof Anamaria Corca (CPME)
\nand Olga Rostkowska, (EMSA))
\n119
\nSpeaking Books
\nantenatal care, safe delivery, postnatal and new-born care (includ-
\ning early and exclusive lactating), recognition of danger signs, care-
\nseeking and immunization.
\nProcess
\nThe aim of the study was to assess the effectiveness, acceptability
\nand relevance of the Speaking Book as a health promotion tool. As
\nthe use of Speaking Books as a communication tool is still in the de-
\nvelopment phase in this region,the pool of potential participants for
\nthis study was too small to fill both the intervention and the control
\ngroup. However, the study can be valuable by providing:
\n\u2022 Information on who is being served by this program.
\n\u2022 Information that suggests whether anticipated changes are oc-
\ncurring.
\n\u2022 Information on whether anticipated changes are occurring in
\nsome subgroups and not others [3].
\nA total number of 1500 Speaking Books were distributed to the
\nAmhara region during March, 2012. The field research was con-
\nducted between May and July 2012. Structured interviews, focus
\ngroup discussions (FDGs) and observations (use of book during
\nhome visits, outreach and at health posts) in the woredas of Dem-
\nbia (North Gondar) and Dembecha (W\/Gojjan) were conducted
\nto provide qualitative reports on the appropriateness, contribution,
\nand challenges of the Speaking Books. Interview participants in-
\ncluded:
\n\u2022 18 health extension workers (HEWs),
\n\u2022 29 health development army members (HDA),
\n\u2022 27 care-takers (10 breast feeding mothers and 17 pregnant wo-
\nmen),
\n\u2022 4 focus group discussions with 21 pregnant and 15 lactating
\nmothers.
\nTranscripts were prepared for analysis through: (1) transcription
\nfrom voice recorder to paper, (2) translation from Amharic to Eng-
\nlish, and (3) manual test analysis.
\nFindings
\nIn some locations, it was found that both HEWs and HDAs were
\nusing the Speaking Book as a job aid on daily basis in health
\nposts, for home visits and during outreach programs. It was also
\nfound that HDAs were using Speaking Books once a week during
\nhome visits, local meetings, market days and local holidays. The
\nbook was also used for health promotion during local gatherings
\nincluding coffee ceremonies, pregnant women\u2019s conferences and
\nin churches.
\n120
\nSpeaking Books
\nHEWs and HDA made the following ob-
\nservations:
\n\u2022 The book was a good communication
\ntool to strengthen messages of the Family
\nHealth Card.
\n\u2022 The book helped HDA and HEWs gain
\ncommunity acceptance.
\n\u2022 The book enabled health workers to pro-
\nvide essential MNCH information in an
\norganized, structured and creative format
\nsuitable for small groups.
\n\u2022 The book assisted and simplified health
\neducation efforts of health workers and
\nmade more efficient use of health workers
\ntime and energy.
\n\u2022 The intended audiences trust the mes-
\nsages and consider the Speaking Book
\ninformation as \u2018expert advice or as a pro-
\nfessional delivering the message\u2019.
\n\u2022 Mothers claimed to learn new informa-
\ntion including the importance of avoiding
\nharmful traditional practices and impor-
\ntance of calling HEWs to attend delivery.
\n\u2022 The book is a good communication tool
\nfor the illiterate \u2013 the majority of the in-
\ntended audience.
\nThe following are key takeaways from inter-
\nviews with health workers:
\n\u2022 Showing pictures followed by hearing
\nsound messages was an effective way to
\ndeliver the message.
\n\u2022 Speaking Books were useful during con-
\nferences for pregnant women, home-vis-
\nits, outreach programs, and at church.
\n\u2022 It is worth noting that the number of new
\nattendees in antenatal care in April and
\nMay 2012 were double that of February
\nand March, 2012.
\nInterviews with care-takers revealed that:
\n\u2022 The Speaking Book is a good tool to de-
\nliver full information.
\n\u2022 The voice was clear and understandable
\nand was the most informative aspect of
\nthe Speaking Book.
\n\u2022 They trust the messages from the Speak-
\ning Book.
\n\u2022 They appreciated the commitment of the
\nresponsible parties for the provision of
\nSpeaking Book and hoped such programs
\nwill continue.
\n\u2022 Women showed interest in having fre-
\nquent and repeated learning through the
\nSpeaking Book and preferred to have
\navailable at least one book at household
\nor community level during their pregnan-
\ncy and lactation period.
\nFocus groups with pregnant\/lactating
\nmothers, none of whom could read or write,
\nrevealed that:
\n\u2022 All FGD participants claimed to learn
\nsomething new. Information found to be
\nparticularly useful included: importance
\nof antenatal care visits; danger signs dur-
\ning pregnancy and labor; birth prepara-
\ntion; attending a health facility; delivery;
\nnew born colostrum feeding; breast feed-
\ning; not washing a new born before 24
\nhours post-delivery; and feeding of infant
\nafter 6 months.
\n\u2022 Participants claimed the book provided
\nthe opportunity to ask HDA questions
\nduring book use for additional informa-
\ntion (i.e. availability of delivery service in
\nthe health posts; stretcher to carry labor-
\ning women from home to health post;
\nsolution to those infant with throat and
\ntooth problem if it is not extracted or cut;
\nand type of complementary food they
\nneed to give to their children, etc.).
\n\u2022 The voice was the most informative as-
\npect of the book and the pictures were
\nalso found to be clear and understand-
\nable.
\nThere were very few challenges or obstacles
\nin using the Speaking Books. Some chal-
\nlenges that were identified included failing
\nbattery\/replacing the battery, un-adjustable
\nvolume and protecting the book from wa-
\nter\/rain damage.
\nRecommendations
\nDue to the limited availability, rotating
\nSpeaking Books between HEWs and HDA
\nwould result in more efficient use and in-
\ncreased exposure in the community. As
\nsuggested by pregnant and lactating moth-
\ners and HDA\/HEWs, it would be highly
\nbeneficial to create Speaking Books to cover
\nother health areas such as: malaria, sanita-
\ntion, and hygiene. Speaking Books can be
\nused in someone\u2019s home, in community and
\nsocial gathering forums, church programs,
\ndevelopment forums and even during in-
\nformal meetings. Clear training by instruc-
\ntors should be provided on how to replace
\nthe battery of the Speaking Book. Alter-
\nnatively, instructions to replace the battery
\ncould be added to the Speaking Book in a
\npicture format. Adding adjustable volume
\nto the Speaking Books would make it use-
\nful to distribute to larger groups or in larger
\nvenues. Finally, advocacy for resource mo-
\nbilization at federal and regional levels is
\nneeded to provide communities with effec-
\ntive health promotional tools.
\nInvestigators:
\nEndale Engida,Tesfaye Simireta.
\nAdvisors:
\nLuwei Pearson, Shalini Rozario
\nReferences
\n1. FMOH, HSDP IV document, Ethiopia, 2012
\n2. FMOH. Health Extension Implementation
\nManual, Ethiopia. 2005
\n3. Kristin Anderson Moore, Ph.D. QUASI-EX-
\nPERIMENTAL EVALUATIONS Part 6 in a
\nSeries on Practical Evaluation Methods, Publi-
\ncation #2008-04
\nBrian M. Julius
\nE-mail: bj@speakingbooks.com
\nIII
\nTURKEY
\n4 June 2013
\nI am writing to you on behalf of the World
\nMedical Association (WMA), the global
\nfederation of National Medical Associa-
\ntions representing millions of physicians
\nworldwide. Acting on behalf of patients
\nand physicians, the WMA endeavours to
\nachieve the highest possible standards of
\nmedical care, ethics, education and health-
\nrelated human rights for all people. As such,
\nthe WMA plays a key role in promoting
\ngood practice, medical ethics and medical
\naccountability internationally. The Associa-
\ntion supports doctors at risk worldwide.
\nThe purpose of this letter relates to the
\ncurrent demonstrationsthatstarted peace-
\nfully in Gezi Public Park in Taksim
\nSquare-\u0130stanbul on 27 May. The Turkish
\nMedical Association (TMA) has draw-
\nnour attention to alarming violence with
\nexcessive force used against protestors.
\nTMA reports hundreds of cases of injury
\nand detention following police confron-
\ntations with protestors in Ankara as well
\nas in other provinces including Adana,
\nEski\u015fehir and Gaziantep. According to
\nour sources, the majority of the injuries
\nwere caused by the use of water cannon
\nand tear gas.
\nThe WMA condemns strongly crowd con-
\ntrol or riot prevention technology \u2013 such as
\ntear gar and water cannon \u2013 that is misused,
\nincluding to perpetrate human rights abuses
\nor that is used in a manner out of propor-
\ntion with the need, or against populations
\nwith particular vulnerabilities.
\nWe therefore call on you to immediately end
\nthe excessive use of force against peaceful
\nprotestors and to ensure the right to free-
\ndom of expression and assembly. We also
\nurge initiation of an independent and im-
\npartial investigation into the excessive use
\nof force and bringing to justice law enforce-
\nment officials found to have ill-treated dem-
\nonstrators or other members of the public.
\nI thank you for your attention.
\nDr. Cecil Wilson, President
\nWorld Medical Association
\nLetters to Prime Minister of Turkey
\nRecepTayyip Erdo\u011fan
\n11 June 2013
\nI am writing to you on behalf of the World
\nMedical Association (WMA), the global
\nfederation of National Medical Associa-
\ntions representing millions of physicians
\nworldwide.
\nWe sent you last week a letter expressing
\nour deep concerns on the use of excessive
\nforce against protestors in Ankara as well
\nas in other provinces including Adana,
\nEski\u015fehir and Gaziantep.
\nThe Turkish Medical Association, one of
\nWMA members, reported cases of violence
\nthese last days that were directed at health-
\ncare workers and medical students taking
\ncare of wounded people in houses, restau-
\nrants, and mosques that were converted
\ninto temporary infirmaries. Mobile clinics
\nwere disrupted and 13 doctors and students
\nwere detained in Ankara.
\nThe WMA notes with serious concern
\nthat health-care services are threatened,
\nviolating the principle of medical neu-
\ntrality. According to this principle \u2013 de-
\nriving from international human rights
\nlaw, medical ethics and humanitarian
\nlaw\u00a0 \u2013 health professionals must be al-
\nlowed to care for the sick and wounded,
\nregardless of their political affiliations.
\nAll parties must refrain from attacking
\nand misusing medical facilities, transport,
\nand personnel.
\nWe therefore urge you to ensure that medi-
\ncal neutrality is fully respected and that all
\nhealth personal is protected regardless of
\nwhom they help.
\nFurthermore, we reiterate our call to imme-
\ndiately end the excessive use of force against
\npeaceful protestors and to ensure the right
\nto freedom of expression and assembly.
\nI thank you for your attention.
\nDr. Cecil Wilson, President
\nWorld Medical Association
\nContents
\nInstead of Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
\nThe Future of Global Health . . . . . . . . . . . . . . . . . . . . . . . 82
\nWorld Health Assembly Week . . . . . . . . . . . . . . . . . . . . . . 90
\nHow Much Independence is Necessary? . . . . . . . . . . . . . . 93
\nPhysicians and Hunger Strikes in Prison: Confrontation,
\nManipulation, Medicalization and Medical Ethics . . . . . . . . . 97
\nIntervention Program for Addictive Diseases.
\nHamburg State Chamber of Physicians . . . . . . . . . . . . . . . 102
\nThe Greatest Motivation: Assurance of Practicing
\nthe Profession with Dignity. Motivational State
\nof Physicians in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
\nPlagiarism in Scientific Publishing . . . . . . . . . . . . . . . . . . . 110
\nCooperation Between Medical Profession
\nand Pharmaceutical Industry . . . . . . . . . . . . . . . . . . . . . . . 112
\nA Call for Quality Improvement in Medical Education . . . 114
\nHealthy Ageing. A Socio-Medical Perspective . . . . . . . . . 115
\nRapid Qualitative Assessment of Maternal and Newborn
\nHealth Care (MNHC) Speaking Book in Two Districts
\nin the Amhara Region, Ethiopia . . . . . . . . . . . . . . . . . . . . 118
\nLetters to Prime Minister Erdo\u011fan . . . . . . . . . . . . . . . . . . III
\nSince May 31st
\n2013 the peaceful and legitimate demonstrations
\nare tried to be suppressed by the police.The police forces are using
\nchemical gases savagely on the unprotected civil masses.
\nBefore complete blockage of health assistance to the injured peo-
\nple and the preclusion of the functioning of health services by the
\npolice attacks, that took place once more again on the night of
\nJune 15th
\n, Turkish Medical Association was started a web based
\nsurvey in order to disclose the dangerous health effects of these
\ngases targeted at defenceless people and in one week period, over
\n11 thousand of people declared that they have been effected by
\nthe gas.
\n65% of the repliers were between 20\u201329 years of age and profes-
\nsional protecting mask usage was only 13%. The total duration of
\nexposure was evaluated among 11.164 replies. 53% declared that
\nthey have exposed to the chemical gases 1\u20138 hours where 11%
\nexposed more than 20 hours. Exposing the chemical gases more
\nthan one day increases the prevalence of the systemic symptoms,
\nespecially cardiovascular symptoms.These data shows the dimen-
\nsions of the problem.
\nBefore the 15th
\nof June disaster the total number of injuries were
\n788 (7%). These data shows that the gas bombs were targeted the
\npeople. Many of them were the injuries of head, face, eyes, thorax
\nand abdomen which could be fatal. 20% of the injuries were open
\nsores and fractures.
\nOnly 5% of the people were admitted to hospitals. The tagging of
\nthe people who are admitting to the hospitals is preventing people
\nfrom going to the hospitals in order to ask medical assistance.Min-
\nistry of Health opened an investigation about Istanbul Chamber of
\nMedicine which is organizing the volunteer physicians\u2019 work. In
\nIstanbul one physician an done medical student handcuffed and
\ndetained.There are many other information about the detaining of
\nhealth care staff.These data shows the witch-hunt in Turkey.
\nTurkish Medical Association making calls to the government to
\nact responsibly and stop the barbaric violence immediately. As
\nTurkish Medical Association it is our responsibility to inform the
\ninternational community. We urgently call the international com-
\nmunity to act against brutal suppression of democratic demands.
\nTurkish Medical Association
\nUrgent Call FromTurkish Medical Association<\/p>\n"},"caption":{"rendered":"

wmj201303 COUNTRY \u2022 The Future of Global Health \u2022 Physicians in Turkey vol. 59 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 3, June 2013 Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@arstubiedriba.lv editorin-chief@wma.net Co-Editor Prof. Dr. med. Elmar […]<\/p>\n"},"alt_text":"","media_type":"file","mime_type":"application\/pdf","media_details":{},"post":727,"source_url":"https:\/\/www.wma.net\/wp-content\/uploads\/2016\/11\/wmj201303.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3650"}],"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=3650"}]}}