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wmj201401<\/a><\/p>\n

COUNTRY
\n\u2022 Reconstruction of the Radiation Emergency
\nMedical System in Japan
\n\u2022 On the Road to Tobacco-Free Finland
\nvol. 60
\nMedicalWorld
\nJournal
\nOfficial Journal of the World Medical Association, INC
\nG20438
\nNr. 1, February 2014
\nCover picture from JAPAN
\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: \u201cThe Passing Year\u201d.
\nA Japanese Painting (hemp paper, Iwaenogu)
\n50F (116.7 x 90.9cm) by Dr.Takakazu Kato.
\nThe most renowned Japanese flower is the cherry
\nblossom,which first blooms in the beginning of
\nMarch until the end of May.Cherry blossoms in
\nfull bloom are magnificent,but they are just as
\nexquisite before they fall.In autumn,they turn a
\nbeautiful deep red and to the Japanese,the cherry
\ntrees are an endearing source of delight throughout
\nthe four seasons.When the leaves turn color and
\nfall,they symbolize the pathos of a passing year.
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\nWorld Medical Association Officers, Chairpersons and Officials
\nOfficial Journal of the World Medical Association
\nOpinions expressed in this journal\u00a0\u2013 especially those in authored contributions\u00a0\u2013 do not necessarily reflect WMA policy or positions
\nwww.wma.net
\n1
\nLet me begin by congratulating you all on
\nyour achievements and successes this year.
\nMy special thanks to the Secretariat for
\nall the ways they continue to support the
\nWMA.
\nAs we move into the New Year, as physi-
\ncians, we must continue to play our role in
\nadvocating for the right to health for the
\ncommunities we serve and especially the
\nmost disadvantaged. Regardless where we
\nlive, there are those among us who do not
\nhave access to quality health and health
\ncare. We have a responsibility to play the
\nadvocacy roles required to ensure that our
\nhealth systems are strengthened enough to
\nachieve universal health coverage. An im-
\nportant area for advocacy is the conditions
\nunder which people are born, grow up, live and work also known
\nas the Social Determinants of Health.
\nThe basic principles underlying medical ethics continue to be com-
\npassion, competence and professional autonomy. Every physician
\ntherefore must become involved in advocating for quality medical
\neducation, the highest possible ethical standards and evidence based
\ncare. As we end the New Year, our hearts go out to those physicians
\nworking in countries like Syria,Somalia,Israel,Palestine,Turkey and
\nothers who struggle to ensure access to healthcare in such difficult
\ncircumstances, at times risking their lives and those of their families.
\nIn this regard, the WMA is partnering
\nwith others in the Health Care in Danger
\nProject of the International Committee
\nof the Red Cross (ICRC)\u2019s to advocate for
\nprotection of health facilities and health
\nworkers in areas of armed conflict and
\nother emergencies.
\nAs physicians and NMAs, we must be-
\ncome part of this community of concern.
\nWe must ensure we adhere to our ethi-
\ncal principles, document and report inci-
\ndents, support our colleagues whose lives
\nare threatened and to work with others
\nin ensuring that health facilities, ambu-
\nlances and health workers are protected
\nin cases of armed conflict and other
\nemergencies.
\nThe WMA will continue to play its role of advocating for the right
\nof physicians to exercise their professional autonomy and the right
\nto provide the quality of health care that their patients and com-
\nmunities require.
\nFinally, as we end the year, I wish you and your families an enjoy-
\nable holiday season and a new year 2014 full of good health and
\nsuccess.
\nDr. Margaret Mungherera
\nPresident, World Medical Association
\nNew Year Message from the President, World Medical Association
\nMargaret Mungherera
\n2
\nThe radiation emergency medical system in
\nJapan ceased to function as a result of the
\naccident at the Fukushima Daiichi Nuclear
\nPower Plant, which has commonly become
\nknown as the \u201cFukushima Accident.\u201d In this
\npaper, we review the reconstruction processes
\nof the radiation emergency medical system
\nin order of events and examine the ongoing
\nchallenges to overcoming deficiencies and re-
\ninforcing the system by reviewing relevant
\nliterature, including the official documents of
\nthe investigation committees of the National
\nDiet of Japan, the Japanese government,
\nand the Tokyo Electric Power Company, as
\nwell as technical papers written by the doc-
\ntors involved in radiation emergency medical
\nactivities in Fukushima. Our review has re-
\nvealed that the reconstruction was achieved in
\n6 stages from March 11 to July 1, 2011: [1]
\nRe-establishment of an off-site center (March
\n13), [2] Re-establishment of a secondary ra-
\ndiation emergency hospital (March 14), [3]
\nReconstruction of the initial response system
\nfor radiation emergency care (April 2), [4]
\nReinforcement of the off-site center and sta-
\ntioning of disaster medical advisors at the
\noff-site center (April 4), [5] Reinforcement
\nof the medical care system and an increase in
\nthe number of hospitals for non-contaminated
\npatients (From April 2 to June\u00a023), and [6]
\nEnhancement of the medical care system in
\nthe Fukushima Nuclear Power Plant and the
\nconstruction of a new medical care system, in-
\nvolving both industrial medicine and emer-
\ngency medicine (July 1). Medical resources
\nsuch as voluntary efforts, academic societies, a
\nlocal community medical system and univer-
\nsity hospitals involved in medical care activi-
\nties on 6 stages originally had not planned. In
\nthe future, radiation emergency medical sys-
\ntems should be evaluated with these 6 stages
\nas a basis, in order to reinforce and enrich both
\nthe existing and backup systems so that mini-
\nmal harm will come to nuclear power plant
\nworkers or evacuees and that they will receive
\nproper care. This will involve creating a net-
\nwork of medical resources becoming involved
\nacross the country.
\nIntroduction
\nThe nuclear disaster measures in Japan have
\nbeen developed by the prefectures with nu-
\nclear power plants, based on lessons learnt
\nfrom nuclear power plant accidents in the
\npast, including Three Mile Island (1979),
\nChernobyl (1984), and the JCO Co., Ltd.
\naccident (Ibaraki, Japan: 1999) [1]. In those
\nprefectures, the government funded the
\nconstruction of an off-site center for deci-
\nsion-making and coordination relating to
\nradiation emergency medical responses to
\nbe built around nuclear power plants. The
\nradiation emergency medical system estab-
\nlished by the prefectures consisted of 3\u00a0lev-
\nels of hospital care: initial, secondary, and
\ntertiary radiation emergency hospitals. The
\nprefectures designated the initial and sec-
\nondary radiation emergency hospitals,while
\nthe government designated the National
\nInstitute of Radiological Sciences (NIRS)
\nand Hiroshima University as the tertiary
\nradiation emergency hospitals.
\nIn Fukushima Prefecture, the off-site center
\nwas located about 5\u00a0km from the Fukushima
\nDaiichi Nuclear Power Plant (hereafter re-
\nferred to as FNPP1). Five initial radiation
\nemergency hospitals (Fukushima Prefec-
\ntural Ono Hospital, Futaba Kosei Hospital,
\nImamura Hospital, Fukushima Rosai Hos-
\npital, and Minamisoma City General Hos-
\npital) and 1 secondary radiation emergency
\nhospital (Fukushima Medical University
\nHospital) had also been designated (Fig-
\nure\u00a01).
\nAfter the nuclear accident at FNPP1,which
\noccurred as a result of the Great East Japan
\nEarthquake on March 11, 2011, the off-site
\ncenter and the radiation emergency hospi-
\ntals in Fukushima became non-functional.
\nEmergency Medical System JAPAN
\nReconstruction of the Radiation Emergency Medical System from
\nthe Acute to the Sub-acute Phases After the Fukushima Nuclear
\nPower Plant Crisis
\nMayo Ojino Masami Ishii
\n3
\nJAPAN Emergency Medical System
\nThe earthquake caused an emergency shut-
\ndown of the reactors and a loss of the exter-
\nnal power supply, the tsunami caused sev-
\neral of the reactors to lose all AC power,and
\nthe water injection system for emergency
\ncore cooling failed. Hydrogen explosions
\noccurred at Unit 1 on March 12 and at Unit
\n3 on March 14, and radioactive materials
\nwere subsequently released into the envi-
\nronment.This accident later became known
\nas the \u201cFukushima Accident.\u201d
\nResidents who lived within a 20 km ra-
\ndius of the power plant had to be evacu-
\nated, and residents within a 20\u201330 km
\nradius had to stay indoors on March 15.
\nDue to the earthquake damage, limited
\nsatellite connection was the only means
\nof communication left for FNPP1\u2019s off-
\nsite center, and information such as the
\nplant\u2019s situation or radiation levels (eg.,
\nSPEEDI), could not be obtained. Disap-
\npointingly, there was very little scope for
\nassembling relevant organizations such as
\nnational and local governments and plant
\noperators, meaning that it was extremely
\ndifficult to examine the radiation protec-
\ntion that was available for residents or the
\ntransportation system that was in place for
\nradiation-contaminated patients [2]. At
\n5:44 on March 12, the off-site center had
\nto be evacuated because everything within
\na 10 km radius from FNPP1 was desig-
\nnated an evacuation zone by government
\norder. The facility that was previously des-
\nignated as an alternate location was un-
\nsuitable because the radiation level in the
\narea was increasing. Moreover, there was
\ninsufficient space available, as the facil-
\nity was already used for disaster manage-
\nment for earthquakes and tsunamis [13].
\nAt 18:25 on the same day, 3 out of 5 of
\nthe initial hospitals also had to be evacu-
\nated when the evacuation zone expanded
\nto a 20 km radius from the plant, again
\nby government order. The inpatient ward
\nof the Minamisoma City General Hos-
\npital was also closed because the hospital
\nwas located within the designated indoor-
\nsheltering zone [3]. The\u00a0Fukushima Acci-
\ndent Hospital and the Fukushima Medi-
\ncal University Hospital are located outside
\nthe 30 km zone, but the earthquake dam-
\naged their essential utilities, leading to a
\nmarked functional decline\u00a0 [3]. The mal-
\nfunctioned medical systems were recon-
\nstructed in order to respond to the much-
\nneeded medical care for the plant workers
\nwho were attempting to contain the acci-
\ndent, as well as about 78,000 residents and
\n850 inpatients.
\nIn this paper, we have systematically clas-
\nsified the reconstruction of the radiation
\nemergency medical system in Fukushima in
\norder of events and examined the problems
\nand the future challenges.
\nResults
\nWe have classified the reconstruction of the
\nradiation emergency medical system in Fu-
\nkushima into the following 6 stages.
\nStage 1: Re-establishment of an off-site
\ncenter (March 13).
\nStage 2: Re-establishment of a second-
\nary radiation emergency hospital
\n(March 14).
\nStage 3: Reconstruction of the initial re-
\nsponse system for radiation emer-
\ngency care (April 2).
\nStage 4: Reinforcement of the off-site
\ncenter, and stationing of disaster
\nmedical advisors at the off-site
\ncenter (April 4).
\nStage 5: Reinforcement of the medical
\ncare system, and an increase in the
\nnumber of hospitals for non-con-
\ntaminated patients (from April 2
\nto June 23).
\nStage 6: Enhancement of medical care
\nsystem at the Fukushima Nuclear
\nPower Plant, and the construc-
\ntion of a new medical care sys-
\ntem, involving both industrial
\nmedicine and emergency medi-
\ncine (July 1).
\nFigure 1. Location of nuclear power plants and Radiation Emergency Hospitals in
\nFukushima (Figure 1 was created by the authors using Google maps)
\n10km20km30km50km
\nFukushima Medical University Hospital
\n4
\nStage 1: Re-establishment of an off-site
\ncenter (March 13)
\nOn March 13, the Fukushima Prefecture
\nRadiation Emergency Medical Coordina-
\ntion Council was established in the Fuku-
\nshima Prefectural Government Building
\n[3]. This council was voluntarily organized
\nby members of NIRS team, physicians from
\nthe Fukushima Medical University Hospi-
\ntal, and prefectural government officers to
\nsubstitute the radiation emergency medi-
\ncal system, as the off-site center\u2019s function
\nhad failed. The members of the council had
\nknowledge and skills relating to radiation
\nemergency medicine, as well as personal
\nnetworks through the radiation emergency
\nmedical training that had previously been
\nconducted by the government. This council
\nserved in the decision-making regarding
\nthe radiation emergency medical system,
\nsuch as transportation of contaminated pa-
\ntients, the screening of contamination, and
\ndecontamination work, and coordinated
\nthese tasks.
\nStage 2: Re-Establishmentofasecondary
\nradiation emergency hospital (March\u00a014)
\nOn March 14, the Fukushima Medical
\nUniversity Hospital (FMUH), a designated
\nsecondary radiation emergency hospital lo-
\ncated 57 km from FNPP1 (Figure 2) started
\naccepting radiation emergency patients. It
\ntakes 2.5 hours by car or 15 minutes by he-
\nlicopter to travel from FNPP1 to FMUH.
\nAlthough there were other hospitals nearer
\nto FNPP1, they were not equipped to pro-
\nvide radiation emergency care.
\nAt 11:00 on the same day, a hydrogen ex-
\nplosion occurred in Unit 3 of FNPP1, in-
\njuring 11 people [4], and FMUH accepted
\n4 of them. While 1 out of these 4 patients
\nwas transported directly to FMUH, the
\nremaining 3 patients were brought into
\nthe FMUH about 20 hours after the ex-
\nplosion [3] because their injuries were ini-
\ntially thought only to be minor trauma. On
\nMarch 16, a worker suspected of having
\ntrauma to the right of his chest was trans-
\nported to FMUH by a Japan Self-Defense
\nForce (SDF) helicopter [3]. He had more
\nthan 10,000 cpm of contamination on his
\nhead [3]. On March 24, 3 workers who
\nwere laying cables on the first floor and the
\nfirst basement level of the turbine building
\nof Unit 3 submerged their feet in the con-
\ntaminated water, resulting in external ex-
\nposure of over 170 mSv [2].They also were
\naccepted at FMUH. At this point, the ini-
\ntial radiation emergency care system near
\nFNPP1, which was supposed to provide
\nunsophisticated decontamination and first
\naid, was extremely weak. Medical treat-
\nment for radiation for the evacuated resi-
\ndents was supposed to be provided mainly
\nby the local hospitals and clinics; however,
\nmany medical teams from various orga-
\nnizations across the country were provid-
\ning the care. Disaster Medical Assistance
\nTeam (DMAT) members, dispatched by
\nthe national government, essentially pro-
\nvides medical assistance for natural disas-
\nters, and specializes in providing emer-
\ngency care in affected areas [15]; it was
\nnot intended to address a nuclear disaster.
\nThe available information on the status of
\nFNPP1 and radiation were sketchy, and
\nexperts disagreed in their opinions. The
\nevacuees who had been forced to flee from
\ntheir homes with nothing but the clothes
\nthey wore were concerned about their
\nlives at shelters, and the impact of radia-
\ntion exposure on their health [16]. The Ja-
\npan Medical Association also dispatched
\nmedical assistance teams (called JMAT) to
\nthe disaster area and supported community
\nhealth with the help of local medical as-
\nsociations [5; 6].
\nStage 3: Reconstruction of the initial ra-
\ndiation emergency care system (April 2)
\nOn April 2, a facility for initial radiation
\nemergency medicine was established in
\nJ-Village [7]. J-Village is a sports train-
\ning center in Naraha Town, located 20 km
\nfrom FNPP1 (about 40 minutes by car)
\n(Figure 3). It was used by workers from
\nTokyo Electric Power Co. (TEPCO; the
\ncompany that owns and operates FNPP1)
\nand other companies engaged in control-
\nling the accident as a place to assemble,
\nput on protective clothing, and for moni-
\ntoring radiation levels. The SDF and fire
\ndepartments also used J-Village as a front-
\nline base. Emergency physicians were also
\navailable here: they would accompany the
\nemergency firefighting support team to the
\naccident site to provide health manage-
\nment, medical care, and radiation protec-
\ntion, including the administration of stable
\niodine tablets [8].
\nOn March 24, at J-Village, an emergency
\nphysician dispatched from a fire depart-
\nment examined the aforementioned 3
\nworkers who had their feet submerged in
\nthe contaminated water during the cable-
\nlaying work [2], and ordered them to be
\ntransported to FMUH [8]. This incident
\nserved as the turning point in the rebuild-
\ning of the area\u2019s radiation emergency medi-
\ncal system. The local headquarters of the
\nGovernment Nuclear Emergency Response
\nasked the Japanese Association for Acute
\nMedicine (JAAM) to dispatch emergency
\nphysicians, and the reconstruction of the
\nradiation emergency medicinal system for
\nFukushima, including J-Village, became
\nfully operational [8].This is when the initial
\nand secondary levels of radiation emergency
\ncare system regained their function (Fig-
\nure\u00a02).
\nStage 4: Reinforcement of the off-site
\ncenter, and the stationing of disaster med-
\nical advisors at the off-site center (April 4)
\nThe Government Nuclear Emergency Re-
\nsponse\u2019s local headquarters also requested
\nthat JAAM dispatch disaster medical ad-
\nvisors to the medical team at the FNPP1\u2019s
\noff-site center in order to supplement its
\ninsufficient manpower: this dispatch began
\non April 4 [8]. Disaster medical advisors
\nselected by JAAM were specialists in emer-
\ngency and disaster medicine with excellent
\ncoordination capabilities, the ability to co-
\nEmergency Medical System JAPAN
\n5
\noperate, and leadership skills [8]. Their role
\nincluded giving proper advice to the head
\nof the medical team regarding emergency
\nand overall disaster medicine, formulating
\nresponse plans for cases where there were
\nmultiple patients with injuries and\/or high-
\ndose radiation exposure, and ensuring effec-
\ntiveness in the patient response, including
\nthe status of medical facilities and patient
\ntransport [8].
\nStage 5: Reinforcement of the medical
\ncare system, and an increase in the num-
\nber of hospitals for non-contaminated pa-
\ntients (from April 2 to June 23)
\nEmergency hospitals in Fukushima pre-
\nfecture could not accept trauma patients
\nfrom FNPP1, because of these patients
\nmight have contamination [3). From April
\n2 to June 23, a total of 8 hospitals were
\nprepared to provide general medical care
\nfor non-contaminated patients. Specifi-
\ncally, on April 2 [7), Ohta General Hospi-
\ntal and Aizu Chuo Hospital were added to
\nthe list of hospitals able to accept patients.
\nFukushima Rosai Hospital, Iwaki Kyoritsu
\nGeneral Hospital, Mito Medical Center,
\nand Ibaraki Prefectural Central Hospital
\n(secondary radiation emergency hospitals in
\nIbaraki Prefecture) were also added to this
\nlist on April 22 [9], and Tohoku University
\nHospital and Sendai Medical Center (sec-
\nondary radiation emergency hospitals in
\nMiyagi Prefecture) were added on June 23
\n[10] (Figure 3).
\nAt this point in the reconstruction process,
\npatients with high-dose exposure or heavy
\ncontamination were transported to the
\ndesignated radiation emergency hospital
\n(FMUH, NIRS, or Hiroshima University),
\nwhereas patients in a severe condition with
\nmoderate,minor,or no exposure were trans-
\nported to other hospitals [11]*
\n.
\n* External full-body exposure of at least 1 Gy (with
\nprodromal symptoms such as vomiting) is consid-
\nered high-dose exposure; heavy contamination is
\n100,000 cpm or higher.
\nFigure 2. The Radiation Emergency Medical System in Japan rebuilt after the Fuku-
\nshima Accident
\nFigure 3. Locations of the Fukushima Daiichi Nuclear Power Plant, J-Village and
\nhospitals (Figure 3 was created by the authors using Google maps.)
\n10km
\n20km
\n30km
\n50km
\nJAPAN Emergency Medical System
\n6
\nStage 6: Enhancement of the medical
\ncare system within the Fukushima Nucle-
\nar Power Plant, and the construction of a
\nnew medical care system, involving both
\nindustrial medicine and emergency medi-
\ncine (July 1)
\nFrom May 29 onward, physicians who had
\nbeen dispatched from Fukushima Rosai
\nHospital and the University of Occupa-
\ntional and Environmental Health were
\npermanently stationed 24 hours a day at
\nthe Critical Based Isolated Building within
\nthe plant to provide initial care and health
\nconsultations for injured workers [12]. In
\naddition, the medical facility \u201c5\/6ER\u201d was
\nestablished in the service building, located
\nbetween Units 5 and 6[12], and physicians
\nwith a good knowledge of radiation medi-
\ncine were stationed around the clock in or-
\nder to strengthen the emergency medical
\ncare. On July 1, TEPCO organized an in-
\nplant emergency medical system network
\nfor FNPP1 to enhance preventive medi-
\ncine, industrial medicine, and emergency
\nmedicine within the plant facility.
\nDiscussion
\nThe world has experienced nuclear di-
\nsasters several times, including the Three
\nMile Island (1979), Chernobyl (1984),
\nand JCO (1999). Japan has learned lessons
\nfrom these past nuclear crises and devel-
\noped plans that incorporated international
\ntrends [1]. Nonetheless, a drastic review of
\nthe Emergency Preparedness Guide has not
\nbeen carried out, because of the blief that
\na Chernobyl type nuclear accident could
\nnot occur in Japan [2]. Furthermore, the
\ngeneral disaster management training for
\nnuclear disasters, which is annually con-
\nducted by the national government, did
\nnot take into account severe accidents or
\ncompound disaster, and in a sense existed
\nmerely as titular training [2]. In other
\nwords, the national preparation for a nucle-
\nar disaster never went beyond the \u201cformu-
\nlation of plans\u201d or the \u201cexecution of plans.\u201d
\nWe believe that the biggest problem with
\nthe radiation emergency medical system in
\nJapan lies in the vulnerability of the back-
\nup system when the system that had been
\nplanned proved dysfunctional. On this oc-
\ncasion, it took 3 weeks to compensate for
\nthe failed radiation emergency medical
\nsystem (Stage 1 to 3) and almost 4 months
\nto reinforce the system (Stage 4 to 6).None
\nof these stages was planned ahead; they
\nwere created in accordance with the needs
\nof the accident sites. This suggests that the
\n6 stages revealed here can serve as a prac-
\ntical and effective backup system, as they
\nwere obtained from real experience. The
\nFukushima Accident, as a compound di-
\nsaster involving a natural disaster, a nuclear
\ndisaster, and a mass evacuation, surpassed
\nthe level of disaster that any previous plans
\nhad anticipated.
\nImmediately after the accident (March
\n13 and 14: Stage1 and 2), the voluntary
\nefforts of willing doctors contributed the
\nmost to the reconstruction of the radia-
\ntion emergency medical system in the
\narea. For example, the doctors who vol-
\nuntarily gathered launched an organiza-
\ntion at the Fukushima Prefecture Jichi
\nKaikan building to serve as a substitute
\noff-site center with regard to medical
\nprovision in the affected areas. These
\ndoctors had knowledge of and skills in
\nemergency radiation care and personal
\nnetworks of colleagues: this allowed
\nsmooth communication and prompt re-
\nsponses in the decision-making process
\nat sites [3].Various medical teams across
\nthe country also gathered to assist with
\nthe care and health management of the
\nevacuees. JMA dispatched JMAT teams
\nto shelters and other places to provide
\nmedical care and health management
\nwith the help of local medical associa-
\ntions [17]. JMA also created a map of ra-
\ndiation levels in the air and posted it on
\nthe website [18; 19]. Fulfilling this social
\nmission required not only collaboration
\nwithin JMA and its affiliated medical
\nassociations, but also collaboration with
\nvarious medical organizations and dif-
\nferent professions [6].By nature, doctors
\nare guaranteed their right to freely exer-
\ncise own professional judgment [20]. We
\nwould suggest that the ability of doctors
\nin the field to think for themselves cre-
\nated resilience in overcoming many dif-
\nficulties that they faced.
\nIn the aftermath of the Fukushima Ac-
\ncident, many suffered injuries as well as
\nradiation contamination, and required
\nemergency care. From March 11 through
\nDecember 16, 2011, there were 118 cases
\nof injuries, 44 cases of heat illnesses, 5 cas-
\nes of acute coronary syndrome or arrhyth-
\nmia, and 2 cases of cerebral strokes among
\nthe plant workers alone [11].
\nJapanese Association for Acute Medicine
\n( JAAM) dispatched doctors to the facil-
\nity for initial radiation medicine ( J-Vil-
\nlage) and the off-site center (April 2 and
\n4: Stage3 and 4). In particular, disaster
\nmedical advisors enhanced the quality of
\nmedical care that was provided by mak-
\ning full use of the limited transportation
\nmeans and selecting appropriate care fa-
\ncilities based on the urgency and sever-
\nity of a patient\u2019s needs [11]. Neither the
\nbasic disaster management plan nor the
\nnuclear emergency guidelines established
\nby the nation stipulated the involvement
\nof academic societies [23; 24]. In the fu-
\nture, it will be essential to clearly estab-
\nlish the position of disaster medical ad-
\nvisors in response plans in advance. The
\ninvolvement of academic societies will
\nalso be indispensable in establishing dis-
\npatch systems and in fostering and train-
\ning advisors.
\nFrom April 2 to June 23 (Stage 5), the
\nradiation emergency system cooperated
\nwith local community medical system. In
\nthis accident, emergency care, including
\ndecontamination management and sim-
\nple decontamination, were much needed,
\nwhile professional medical treatment for
\nsevere exposure that requires tertiary ra-
\nEmergency Medical System JAPAN
\n7
\ndiation emergency hospitals was in less
\ndemand. The designated initial and sec-
\nondary radiation emergency hospitals
\nwere unable to respond to patients who
\nrequired emergency radiation care. The
\nlink between initial, secondary, and tertiary
\ncare was severed, leaving only 2 tertiary
\nhospitals a long distance away: the Na-
\ntional Institute of Radiological Sciences
\nin Chiba Prefecture (approx. 215 km by
\nair) and Hiroshima University Hospital
\nin Hiroshima Prefecture (approx. 840 km
\nby air).Tertiary radiation emergency hos-
\npitals were supposed to treat the patients
\nin need of emergency radiation care if the
\ninitial or secondary radiation emergency
\nhospitals were incapable of treating them
\n[21].The means of transporting patients to
\na tertiary radiation emergency hospital, the
\nlast safety net, were very limited. Seeking
\nand securing means of transport took time,
\nand so did the actual transport. Therefore,
\nprompt treatment was not easily available
\nfor patients in need of emergency care.
\nWe submit that tertiary radiation emer-
\ngency hospitals alone were insufficient as a
\nbackup for initial and secondary radiation
\nemergency hospitals. We propose moving
\nbeyond the conventional continuity con-
\ncept of initial, secondary, and tertiary care,
\nand encourage the establishment of a na-
\ntional network that involves local clinics
\nand hospitals for emergency care, as well as
\nthe Disaster Base Hospitals.
\nOn July 1(Stage 6), the in-plant medical
\nsystem was enriched from both the \u201cpre-
\nventative\u201d viewpoint of industrial medicine
\nand the \u201ctreatment\u201d viewpoint of emer-
\ngency medicine. According to the medi-
\ncal records of the FNPP1\u2019s workers from
\nMarch 2011 to June 2012 [22], the number
\nof cases was highest in the month of the
\naccident (March 2011), with 67 patients.
\nThe number decreased from June 2011 (45
\npatients). This underlines the importance
\nof stationing both industrial physicians
\nand emergency physicians through an or-
\nganized dispatch of manpower in collabo-
\nration with university hospitals.
\nVarious medical resources such as vol-
\nuntary efforts, academic societies, a local
\ncommunity medical system and university
\nhospitals provided as much support as pos-
\nsible under extremely limited circumstanc-
\nes. They originally had not planned to in-
\nvolving in radiation emergency medicine.
\nThe radiation emergency medical system
\nshould be reevaluated and further enriched
\nfor the future by incorporating the per-
\nspectives of these 6 stages, so that nuclear
\npower plant workers and evacuees who re-
\nquire emergency radiation care may suffer
\nminimal harm and receive proper care. In
\nthe future, radiation emergency medical
\nsystems should be evaluated with these 6
\nstages as a basis, in order to reinforce and
\nenrich both the existing and backup sys-
\ntems so that minimal harm will come to
\nnuclear power plant workers or evacuees
\nand that they will receive proper care. This
\nwill involve creating a network of medi-
\ncal resources becoming involved across the
\ncountry.
\nConclusions
\nThe conventional radiation emergency
\nmedical system of Japan was proved insuf-
\nficient after the Fukushima Accident, and
\nthe vulnerability of the backup system in
\nthe plan that existed previously became
\nevident at a time of major disaster. In this
\npaper,we have systematically classified the
\nactual reconstruction process into 6 stag-
\nes. These 6 stages were not the result of
\nestablished procedures by planning ahead;
\nthey were born from the actual experience
\nand have substantial significance.We con-
\nclude that the radiation emergency medi-
\ncal system should be reevaluated for the
\nfuture, and further enriched by incorpo-
\nrating the perspectives of these 6 stages,
\nin order to minimize radiation damage
\nand enable proper care for nuclear power
\nplant workers and evacuees. It\u2019s important
\nto create a network emergency medical
\nresources and organizations across the
\ncountry.
\nAcknowledgements
\nThe authors would like to express to sincere
\nthanks to Mr. Takayoshi Ozaki, Chief Senior
\nResearcher from JMARI , Mr. Kazutaka Sato,
\nResearcher from JMARI and Ms. Fumiko
\nKanekawa, translator.
\nReferences
\n1. Akashi M, Tominaga T, Goto T (2011) The ra-
\ndiation emergency medicine in Japan. Hoken no
\nKagaku. 53(12). pp.804-809.
\n2. The National Diet of Japan Fukushima Nuclear
\nAccident Independent Investigation Commis-
\nsion (2012) The official report of The Fukushima
\nNuclear Accident Independent Investigation
\nCommission.
\n3. Tanigawa K, Hosoi Y, Terasawa H, Kondo H,
\nAsari Y, Shishido H, Tase C, Tominaga T, Tat-
\nsusaki H, Iwasaki Y, Hirohashi N, Makoto A,
\nKamiya K (2011) Lessons learned from the
\nFukushima Daiichi nuclear power plant acci-
\ndent; the initial 5 days medical activities after the
\naccident.The Journal of Japanese Association for
\nAcute Medicine. 22(9), pp.782-791.
\n4. Japanese Association for Medical Management
\nof Radiation Accident (2012) Lessons Learned
\nfrom the Fukushima Daiichi Nuclear Power
\nPlant Accidnt. Iryokagakusha.
\n5. Ishii M(2011) Japan Medical Association
\nTeam\u2019s(JMATs) First Operation: Responding
\nto the Great Eastern Japan Earthquake. World
\nMedical Journal. 57(4), pp.131-140.
\n6. Ishii M, Nagata T, Aoki K (2011) Japan Medi-
\ncal Association\u2019s Action in the Great Eastern
\nJapan Earthquake. World Medical&Health
\nPolicy.
\n7. Local Nuclear Emergency Response Head-
\nquarter (2011) The response guidelines in the
\nevent of multitudinous injury victims, April 2,
\n2011.
\n8. Sakamoto T, Yamaguchi Y, Koido Y, Yokota H,
\nAruga T (2012) Emergency medical response
\nfor Fukushima nuclear power plant accident
\nby Japanese Association for Acute Medicine.
\nThe Journal of the Japan Medical Association.
\n141(1), pp.66-70.
\n9. Local Nuclear Emergency Response Head-
\nquarter (2011) The response guidelines in the
\nevent of multitudinous injury victims, April 22,
\n2011.
\n10.Local Nuclear Emergency Response Head-
\nquarter (2011) The response guidelines in the
\nevent of multitudinous injury victims, June 23,
\n2011.
\nJAPAN Emergency Medical System
\n8
\nIn 1847 the American Medical Associa-
\ntion (AMA) revolutionized medicine in
\nthe United States. Members of the newly
\nformed organization, meeting in Philadel-
\nphia as the first national professional medi-
\ncal organization in the world, dedicated
\nthemselves to establishing uniform stan-
\ndards for professional education, training
\nand conduct. They unanimously adopted
\nthe world\u2019s first national code of profession-
\nal ethics in medicine.For the more than 165
\nyears since then, the AMA\u2019s Code of Medical
\nEthics (www.ama-assn.org\/ama\/pub\/physi-
\ncian-resources\/medical-ethics\/code-medical-
\nethics.page) has been the authoritative ethics
\nguide for practicing physicians.
\nThe Code articulates the enduring values
\nof medicine as a profession. As a statement
\nof the values to which physicians commit
\nthemselves individually and collectively, the
\nCode is a touchstone for medicine as a pro-
\nfessional community. It defines medicine\u2019s
\nintegrity and the source of the profession\u2019s
\nauthority to self-regulate.
\nAt the same time, the Code of Medical Eth-
\nics is a living document, evolving as changes
\nin medicine and the delivery of health care
\nraise new questions about how the profes-
\nsion\u2019s core values apply in physicians\u2019 day-
\nto-day practice. The Code links theory and
\npractice, ethical principles and real-world
\ndilemmas in the care of patients.
\nAt the end of 2008, the AMA Council on
\nEthical and Judicial Affairs launched a multi-
\nyear project to critically review and update the
\nCode of Medical Ethics. This project represents
\nthe most thoroughgoing effort to update the
\nCode since 1957. The council hopes to com-
\nplete a draft of this work for deliberation by
\nthe AMA House of Delegates in 2014.
\nBy promoting physician professionalism
\nand accountability, the AMA\u2019s work around
\nthe Code of Medical Ethics strengthens trust
\nin the medical profession. This core com-
\nmitment to ethics is critical to the founda-
\ntion on which physicians are trained and
\nempowered to uphold the highest standards
\nin promoting health and in delivering qual-
\nity patient care.
\nUNITED STATES OF AMERICAMedical Ethics
\n11. Members of the Japanese Association for Acute
\nMedicine, Emergency, Task Force on the Fuku-
\nshima Nuclear Power Plant Accident (2012).
\nEmergency and disaster medical support for the
\nFukushima nuclear power plant accident repair
\nwork. The Journal of Japanese Association for
\nAcute Medicine. 23(3), pp.116-129.
\n12. Tokyo Electric Power Company (2012) Fuku-
\nshima Nuclear Accidents Investigation Report,
\nJune 20, 2012. http:\/\/www.tepco.co.jp\/en\/nu\/
\nfukushima-np\/interim\/index-e.html
\n13. Investigation Committee on the Accident at
\nthe Fukushima Nuclear Power Station of To-
\nkyo Electric Power Company (2011) Interim
\nReport.
\n14. Ministry of Land, Infrastructure, Transport and
\nTourism (MLIT) (2012) MLIT\u2019s activities for
\nthe Great East Japan Earthquake. https:\/\/www.
\nmlit.go.jp\/common\/000208803.pdf.
\n15. Ministry of Health, Labour and Welfare (2012)
\nJapanese DMAT\u2019s Action Guide.
\n16. Mayo O (2012) The report of Japan Medical
\nAssociation Research Institute: Reviewing ra-
\ndiation emergency medicine – The future radia-
\ntion emergency medicine from lessons learned
\nthe Fukushima Daiichi Nuclear Power Plant
\nAccident.
\n17. Ishii M(2011) Fukushima Nuclear Power Plant
\nAccidents Caused by Gigantic Earthquake and
\nTsunami-Healthcare Support for Radiation Ex-
\nposure. World Medical Journal. 57(4), pp.141-
\n144.
\n18. Ishii M (2011) Japan Medical Association
\nTeam\u2019s (JMAT) First Call to Action in the
\nGreat Eastern Japan Earthquake. Japan Medical
\nAssociation Journal. 54(3), pp.144-154.
\n19. Nagata T, Kimura Y, Ishii M (2012) Use of a ge-
\nographic information system (GIS) in the medi-
\ncal response to the Fukushima nuclear disaster
\nin Japan. Prehospital and Disaster Medicine.
\n27(2), pp.213-215.
\n20. WMA Declaration of Seoul on Professional Au-
\ntonomy and Clinical Independence.2008.http:\/\/
\nwww.wma.net\/en\/30publications\/10policies\/
\na30\/
\n21. Aoki Y(2011) Construction of radiation emer-
\ngency medical system. Journal of Clinical and
\nExperimental Medicine. 239(10), pp.973-976.
\n22. Tokyo Electric Power Company(2012) The
\nmedical records of the FNPP1\u2019s workers from
\nMarch 2011 to June 2012.
\n23. Central Disaster Prevention Council (2012).
\nThe Basic Plan for Emergency Preparedness in
\nJapan. September.2012.
\n24. Nuclear Regulation Authority (2013) The
\nEmergency Preparedness Guide in Japan. Sep-
\ntember 5, 2013.
\nMayo Ojino
\nResearcher,
\nJapan Medical Association
\nResearch Institute,
\nTokyo, Japan
\nE-mail: ojino@jmari.med.or.jp
\nMasami Ishii
\nExecutive Board Member,
\nJapan Medical Association,
\nTokyo, Japan
\nE-mail: jmaintl@po.med.or.jp
\nHistory of AMA Ethics
\nArdis Dee Hoven
\n9
\nMedical EthicsUNITED STATES OF AMERICA
\nAMA Ethics Timeline:
\n1952 to 2012
\n1952
\nThe AMA House of Delegates adopted a
\ncouncil report condemning fee splitting in
\nhealth care.
\n1954
\nAMA establishes the Committee on Geri-
\natrics to outline basic problems of aging.
\n1957
\nAfter two years of debate, the Principles
\nof Medical Ethics is revised, eliminat-
\ning regulations on specific conduct with
\nbroad, fundamental ethical principles.
\nThis change gives the Judicial Council
\nbroad rule-making authority, allowing
\nthem to issue ethical pronouncements
\nwithout securing House of Delegates ap-
\nproval.
\n1971
\nAMA adopts report to the Board of Trust-
\nees that states a need exists for more women
\nphysicians and reviews specific changes
\nnecessary to increase the number of women
\nphysicians.
\n1974
\nAMA presents recommendations to ensure
\nadequate protection of individuals used in
\nhuman experimentation.
\n1975
\nAMA adopts resolution opposing sex dis-
\ncrimination in medical institutions.
\n1976
\nAMA encourages handicapped access to
\npublic facilities.
\nAMA adopts resolution seeking an increase
\nin participation of women physicians in or-
\nganized medicine.
\n1978
\nAMA develops national policy endorsing
\nhospice care to enable the terminally ill to
\ndie in a more homelike environment.
\n1980
\nJames S. Todd, MD, eloquently defends his
\nad hoc committee\u2019s new Principles of Medi-
\ncal Ethics at the Annual Meeting of the
\nHouse of Delegates.This new version of the
\nPrinciples addressed changing ethical issues
\nin the field of medicine.
\n1982
\nAMA adopts a resolution calling for in-
\ncreased representation among women and
\nminority physicians.
\n1985
\nAMA\u2019s Judicial Council becomes the Coun-
\ncil on Ethical and Judicial Affairs.
\n1986
\nAMA passes resolution opposing acts of
\ndiscrimination against AIDS patients and
\nany legislation that would lead to such cate-
\ngorical discrimination or that would involve
\npatient-physician confidentiality.
\nAMA adopts policy prohibiting investment
\nof AMA funds in tobacco stocks and urging
\nmedical schools and parent universities to
\neliminate investments in corporations that
\nproduce or promote use of tobacco.
\n1987
\nIn School Board of Nassau County v. Gene H.
\nArline, the U.S. Supreme Court rules that
\nindividuals with infectious diseases are con-
\nsidered \u201chandicapped\u201d under anti-discrim-
\nination laws, and decisions as to whether
\nthey are \u201cotherwise qualified\u201d for employ-
\nment should be based on \u201creasonable medi-
\ncal judgments\u201dmade on a case by case basis,
\nas outlined in a friend-of-the-court brief
\nprovided by the AMA.
\n1989
\nAMA develops National HIV Policy reit-
\nerating physicians\u2019 ethical responsibilities
\nto treat HIV patients whose condition is
\nwithin the physicians\u2019 realm of compe-
\ntence.
\nAMA files brief on behalf of Cruzan fam-
\nily in U.S. Supreme Court case Cruzan
\nv. Missouri Department of Health. AMA
\nholds that the guardian has a right to re-
\nfuse medical treatment for a patient in a
\npersistent vegetative state. Court later rules
\nthat states have the right to regulate food
\nwithdrawal.
\n1990
\nAMA adopts guidelines governing gifts to
\nphysicians from industry.
\n1993
\nAMA passes resolution declaring physi-
\ncian-assisted suicide is fundamentally in-
\nconsistent with the physician\u2019s professional
\nrole.
\n1994
\nAMA drafts the Patient Protection Act.
\nElements of the act were included in ev-
\nery health system reform bill reported out
\nof committee in both the House and Sen-
\nate.
\n1995
\nThe Journal of the American Medical Associa-
\ntion (JAMA) publishes an issue examining
\nthe tobacco industry through corporate
\ndocuments of Brown and Williamson To-
\nbacco Company.
\n1996
\nAMA drafts the Patient Protection Act II
\nbill with two goals: protection for patients
\nthrough increased disclosure requirement
\nand managed care fairness; and physicians
\nneed to have defined rights and protections
\nfrom arbitrary separation from managed
\ncare plans.
\n1997
\nIn conjunction with the AMA\u2019s sesquicen-
\ntennial observance, \u201cEthics and Modern
\nMedicine,\u201d the AMA\u2019s first ethics confer-
\nence, is held in Philadelphia, the city of the
\nAMA\u2019s founding.
\nAMA renews its emphasis on medical eth-
\nics by establishing the Institute for Ethics.
\nThe Institute\u2019s mission is to provide a fo-
\nrum for the timely exploration and discus-
\nsion of the tough decisions now affecting
\n10
\nUNITED STATES OF AMERICAMedical Ethics
\nphysicians and their patients. The Institute
\nprovides practical physician outreach and
\nguidance as well as scholarly research for
\nend-of-life issues, genetics, professionalism
\nand managed care.
\n1998
\nThe AMA\u2019s Task Force on Association\/
\nCorporate Relations develops definitive
\nstandards that guide the conduct of corpo-
\nrate relationships involving the AMA and
\nproduces a report on such principles, stan-
\ndards and guidelines.
\nNamed after the co-writers of the original
\nCode of Medical Ethics, the AMA selects its
\nfirst recipient of the Isaac Hays, MD, and
\nJohn Bell, MD, Leadership in Medical
\nEthics Award.
\n1999
\nThrough an educational grant from the
\nRobert Wood Johnson Foundation, the
\nAMA Institute for Ethics\u2019 Educating Phy-
\nsicians on End-of-Life Care project provides
\ntraining to practicing physicians on the core
\nskills needed to provide quality end-of-life
\ncare.
\nThe AMA founds the Virtual Mentor, an
\nonline ethics journal. The journal is open-
\naccess and advertisement-free, and explores
\nthe ethical issues and challenges that stu-
\ndents, residents and other physicians are
\nlikely to confront in their training and daily
\npractice. For this reason, the journal is a
\nvaluable teaching resource for medical edu-
\ncators at all levels as well as for doctors and
\ndoctors-to-be.
\n2001
\nAMA revises its Principles of Medical Eth-
\nics to emphasize a physician\u2019s responsibility
\nto the patient as paramount during the care
\nof that patient,and a physician\u2019s responsibil-
\nity to support access to medical care for all
\npeople.
\nThe AMA Council on Ethical and Judicial
\nAffairs drafted the Declaration of Profes-
\nsional Responsibility: Medicine\u2019s Social
\nContract with Humanity. The declaration,
\nadopted by the House of Delegates at the
\n2001 Interim Meeting, serves as a reaf-
\nfirmation of professional standards by the
\nworld community of physicians.
\nThe AMA launches a new national ini-
\ntiative \u201cThe Communication of Ethical
\nGuidelines for Gifts to Physicians from In-
\ndustry\u201d as a means to urge physicians and
\nindustry representatives to adhere to AMA
\nethical guidelines regarding gifts.
\n2003
\nThe AMA House of Delegates approves
\nrecommendations from the Council on
\nEthical and Judicial Affairs, which state
\nthat cloning for biomedical research is con-
\nsistent with medical ethics.The recommen-
\ndations also include the critical importance
\nof appropriate oversight and safeguards for
\nsubjects involved in such research.
\nThe AMA\u2019s Ethics Resource Center se-
\nlects 10 U.S. and Canadian medical school
\npartners for its Strategies for Teaching and
\nEvaluating Professionalism (STEP) pro-
\ngram, which encourages the design of in-
\nnovative methods for teaching professional
\ncompetencies and for evaluating the success
\nof those methods.
\n2004
\nThe Ethical Force Program\u00ae releases \u201cEn-
\nsuring Fairness in Health Care Cover-
\nage Decisions: A Consensus Report on
\nthe Ethical Design and Administration of
\nHealth Care Benefits.\u201dThe report indicates
\nfive general criteria to be used in health care
\ncoverage decisions in addition to providing
\nmore than 70 recommendations to enable
\norganizations to fulfill these criteria.
\nThe AMA House of Delegates set new
\nethical guidelines for physicians provid-
\ning retainer services, sometimes known as
\n\u201cboutique care.\u201d The guidelines ensure that
\nphysicians who provide additional care or
\nspecial services in return for retainer fees
\ndeliver the same standard of care to all pa-
\ntients.
\n2005
\nThe AMA issues new ethical guidelines ad-
\ndressing quarantine and isolation treatment
\nto help physicians adequately balance public
\nhealth goals with the interests of individual
\npatients during epidemics.
\n2006
\nThe Ethical Force Program, led by the
\nAMA\u2019s Ethics Resource Center, releases a
\nconsensus report, \u201cImproving Communi-
\ncation\u2013Improving Care: How health care
\norganizations can ensure effective, patient-
\ncentered communication with people from
\ndiverse populations.\u201d
\n2008
\nA group convened by the AMA\u2019s Institute
\nfor Ethics publishes \u201cAfrican American
\nPhysicians and Organized Medicine, 1846-
\n1968.\u201d Appearing in the July 16 edition of
\nJAMA, the piece investigates the associa-
\ntion\u2019s relationship to and positions on race.
\nFollowing publication of the article, AMA
\nissues an apology for its historical role in
\ndiscrimination against African Americans
\nin organized medicine.
\n2009
\nAt its 2009 Interim Meeting, the AMA\u2019s
\nHouse of Delegates reaffirms policy that
\nunequivocally states that physicians \u201cmust
\noppose and must not participate in torture
\nfor any reason.\u201d
\n2011
\nAMA updates ethical guidelines on physi-
\ncian relationships with industry.
\n2012
\nAMA issues new ethical guidelines on phy-
\nsicians\u2019 responsibilities to be prudent stew-
\nards of health care resources.
\nDr. Ardis Dee Hoven,
\nPresident of American
\nMedical Association
\n11
\nMedical ProfessionLATVIA
\nSummary
\nThe Congress of Latvian Physicians and
\nthe 25th
\nanniversary of the Latvian Medi-
\ncal Association was the right moment to
\nanalyze what has been done, define the cur-
\nrent status and make conclusions regarding
\nphysicians work in Latvia on the whole, as
\nwell as the role of governmental and non-
\ngovernmental institutions, the achieve-
\nments and setting tasks and goals for the
\nfuture.
\nTo find out how doctors feel in Latvia at
\nthe current moment, their own assessment
\nof their profession and the public opinion
\nregarding doctors, the Latvian Medical As-
\nsociation commissioned the survey Medi-
\ncal Profession in Latvia Today to the public
\nopinion research centre SKDS.
\nThis survey was organized by carrying out
\ntwo questionnaires\u00a0 \u2013 one for doctors and
\nthe other for the population of Latvia. Both
\nwere carried out in August 2013.Invitations
\nto participate were sent to those physicians
\nwhose addresses were available in the data
\nbase of the Latvian Medical Association
\n(LMA). Responsiveness was high and the
\nquestionnaire was filled out by 2274 doctors
\nrepresenting various fields. Not all respon-
\ndents were members of LMA.Consequent-
\nly, it may be assumed that the results repre-
\nsent not only the opinion of the Association
\nmembers, but they might be referred to the
\nphysicians of Latvia on the whole.
\nThe questionnaire addressed to the people
\nof Latvia embraced in total 1,005 perma-
\nnent residents of Latvia aged 18 to 74 ac-
\ncording to quota sampling. The question-
\nnaire was carried out in the Internet while
\nthe respondents were selected to make a
\nnational representation as well.
\nTo formulate the goals, research themes and
\nquestions to be asked, the LMA formed a
\nworking group. Later the issues were dis-
\ncussed and supplemented by the LMA
\nBoard members. After the discussions six
\nthemes were chosen to be included:
\n\u2022 prestige of medical profession, satisfac-
\ntion with professional choices;
\n\u2022 motivation;
\n\u2022 professional burnout;
\n\u2022 habits of doctors and their attitude to
\npersonal health;
\n\u2022 the system of health care in Latvia;
\n\u2022 assessment of the activities of the LMA,
\ngovernmental and non-governmental in-
\nstitutions concerning health care.
\nThe survey results had been reported dur-
\ning 7th
\nCongress of Latvian Physicians by
\nthe sociologist Arnis Kakti\u0146\u0161. All graphs
\nand tables were published in the journal
\nLatvijas \u0100rsts (Physician of Latvia) . Now
\nhere we are going to highlight the most im-
\nportant data and outcomes. Mostly the re-
\nsearch confirmed what was already known
\nand suspected. The results could have been
\nmore optimistic, but bitter truth is better
\nthan sweet lies.
\nThe doctors assessment of the organizations
\nmakes interpreting of the data possible.The
\nsurvey covers more than one fourth of doc-
\ntors working in Latvia, so their opinion is
\nfairly comprehensive. The assessment was
\ndone using the scale from 1 to 10. The ac-
\ntivities of the LMA were evaluated as very
\ngood (9 or 10, according to the scale) by
\n20% of the respondents, while 37% admit-
\nted it was good (7 or 8), which altogether
\nmakes 57%. It is also essential that 12%
\nof the doctors have no opinion about the
\nLMA activities. To compare\u00a0\u2013 51% of the
\ndoctors have no opinion about the Latvian
\nHospital Association. Another compari-
\nson\u00a0\u2013 the Ministry of Health was evaluated
\nas very good by 2%, or good\u00a0\u2013 by 8% of the
\ndoctors.
\nAt any rate the data give evidence that the
\nTrade Union of Health and Social Care
\nEmployees, the Hospital Society and gov-
\nernmental health structures have more
\nroom for improvement than the Medical
\nAssociation.
\nUndoubtedly, the questionnaire for our col-
\nleagues contained a question on what they
\nconsider to be good points of the Latvian
\nMedical Association.And particularly posi-
\nMedical Profession in Latvia Today
\nP\u0113teris Apinis Arnis Kakti\u0146\u0161
\n12
\nMedical Profession LATVIA
\ntive is the fact that 83% of the respondents
\nevaluated the journal Latvijas \u0100rsts as very
\ngood (36%) or good (47%). This is a really
\npositive evaluation which decisively makes
\nthe Latvian Medical Association to im-
\nprove even more! Interdisciplinary confer-
\nences organized by the LMA were evalu-
\nated as very good or good by 73% of the
\nrespondents,thematic conferences\u00a0\u2013 by 68%
\nand likewise the process of certification\u00a0\u2013 by
\n53% of the respondents. In many opinions
\nthe thematic conference What do Latvian
\nChildren Eat? was the year\u2019s best.
\nMoreover, the survey revealed that doctors
\nare not informed well enough about every-
\nday work of the LMA, e.g. the concerns of
\nthe activities of Ethics Committee or Pro-
\nfessional Court
\nThe colleagues had evaluated the work of
\nthe LMA and LMA, in our turn, could
\nevaluate doctors work. The survey revealed
\nthat a doctor works average in 1.93 work
\nplaces. More work places are common for
\nmale doctors, younger people as well as ra-
\ndiologists, surgeons, neurologists. Latvian
\ndoctor\u2019s income usually is from medical
\nactivities in 1.73 work places average. The
\nremaining 0.2 work places usually are con-
\nnected with pedagogical or organizational
\nwork while a number of colleagues get in-
\ncome from business, scientific research or
\ndividends.
\nMore than 34% of the doctors work directly
\nwith patients more than 40 hours a week
\n(which means more than 8 hours in a work-
\ning day). More than 50 hours are worked
\nby 15%, while more than 60 hours\u00a0\u2013 by 7%
\nof the doctors. Please, note that these hours
\nare spent in direct contact with patients,
\nnot including the time spent on settling
\nbureaucratic formalities. In general, more
\nthan the official hours for direct contact
\nwith patients are worked by doctors in in-
\npatient clinics as well as anaesthetists, re-
\nanimatologists, specialists in obstetrics and
\ngynaecology. Bureaucratic formalities take
\nmore than 5 hours a week for 67% of the
\ndoctors, but 13% of the doctors spend on it
\n20 hours a week.
\n91% of the doctors believe that the health
\ncare system should be better financed, 88%
\nthink that the care giving system and man-
\nagement should be improved, 85% con-
\nsider that the population awareness about
\nhealth issues should be raised. Regarding
\nthe question whether health care provided
\nby government should be tied to taxes paid
\nby a respective patient, 49% answered posi-
\ntively while 29% opposed it. We can add
\nhere that 35% of the doctors admitted that
\ntheir income decreased during the last year,
\nwhile only 15% reported increase of in-
\ncome. Only 12% of the colleagues consider
\nthat their work is sufficiently rewarded fi-
\nnancially. Only 33% of respondents think
\nthat non-financial rewards like apprecia-
\ntion from patients and colleagues, prestige
\nof the profession etc. are sufficient. 80% of
\nthe colleagues are of the opinion that fi-
\nnancial reward is not sufficient while 45%
\nalso think that non-financial rewards are
\nscarce.
\nThese conditions cause the burnout syn-
\ndrome that is felt by 88% of the colleagues
\n(moreover,31% of them suffer from it often,
\nonly 8% have never felt it). Burnout can be
\ncaused by many different reasons, however,
\nthe answers provided by the doctors reveal
\nthat mostly burnout is connected with the
\nnever-ending reforms of the health care
\nsystem, permanent uncertainty about the
\nfuture, excessive bureaucracy, low salaries
\nand too much time spent at work leaving
\ntoo little for self-improvement.
\n59% of the doctors feel positive and opti-
\nmistic about their own health while only
\n55% of them feel well mentally and emo-
\ntionally. To be a good doctor while feeling
\nemotional discomfort is a difficult task. Still
\nin our survey we mostly focused on physical
\nhealth and habits that support healthy life-
\nstyle. So we recommend everyone to look
\ncloser into the graphs that show the doc-
\ntors smoking habits and what they recom-
\nmend to their patients concerning giving up
\nsmoking; the doctors sports activities, over-
\nweight,vaccinations,following one\u2019s choles-
\nterol level and blood pressure, PSA estima-
\ntion, mammography or blood in faeces in
\nconnection with their recommendations for
\npatients.
\nDespite all the above mentioned, most of
\nthe doctors still love their profession. 75%
\nof the respondents are sure that they would
\nchoose to become a doctor again if they
\ncould turn the time back,59% would choose
\nthe same speciality they are working in at
\nthe moment, 58% would prefer the work
\nplace they have now.
\nDescription of the survey
\nThe survey was carried out by the public
\nopinion research centre SKDS.
\nThe working group: Arnis Kakti\u0146\u0161, Margita
\nOtto, Andrejs Solopenko, Laila B\u012bri\u0146a, Ilze
\nGrase, Saiva Bre\u017einska and Ieva Strode.
\nDoctors questionnaire
\nTime period: 25 July, 2013 \u2013 15 August,
\n2013.
\nRespondents: Latvian doctors according to
\nthe data base supplied by the client. Valid
\nand unique e-mail addresses in the data
\nbase: 4804. Reached sampling: 2274 re-
\nspondents. Method of the questionnaire:
\nInternet questionnaire (CAWI).
\nPopulation questionnaire
\nTime period: 2 August, 2013 \u2013 7 August,
\n2013.
\nRespondents: permanent residents of Lat-
\nvia aged 18 to 74. Reached sampling: 1005
\nrespondents.
\nMethod of sampling: quota sample. The
\ndata were weighed in accordance with
\nthe Population Register of the Office of
\n13
\nMedical ProfessionLATVIA
\nCitizenship and Migration Affairs of the
\nMinistry of the Interior as of 21 January,
\n2013. Geographical coverage: the whole
\nterritory of Latvia. Method of the question-
\nnaire: Internet questionnaire (CAWI).
\nThe following graphs reveal the data ob-
\ntained according to Net Promoter assess-
\nment index that is often used by companies
\nto estimate the customer loyalty level.
\nNet Promoter system is based on the prin-
\nciple that customers can be divided into
\n3\u00a0categories:
\n\u2022 promoters (the possibility to recommend
\nthe company is 9 or 10)\u00a0\u2013 loyal and en-
\nthusiastic customers who will continue to
\nuse the company services and will recom-
\nmend them to other people;
\n\u2022 passive ones (the possibility to recom-
\nmend the company Is 7 or 8)\u00a0\u2013 satisfied
\ncustomers who could be tempted away by
\nrival companies;
\n\u2022 detractors (the possibility to recommend
\nthe company is 1 to 6)\u00a0\u2013 dissatisfied cus-
\ntomers who could damage the brand with
\ntheir negative references.
\nTo calculate Net Promoter index, the per-
\ncentage of detractors should be subtracted
\nfrom the percentage of promoters.Theoreti-
\ncally Net Promoter index could range from
\n\u2013100 (everyone is a detractor) to +100 (ev-
\neryone is a promoter).
\nSource: Fred Reichheld, Rob Markey. The Ul-
\ntimate Question 2.0: How Net Promoter Compa-
\nnies Thrive in a Customer-Driven World,
\nTo estimate the statistical measurement er-
\nror it is necessary to know the number of
\nrespondents in the corresponding group
\nand the outcome in per cent.Based on these
\ncharacteristics, the table shows limits of sta-
\ntistical measurement error in +\/\u2013 per cent
\nwith 95% probability.
\nFor example, if the survey data show that
\n55% of all respondents (the number of re-
\nspondents n=1005), taking into account the
\ninformation available about doctors and their
\nsalaries, believe that doctors work in Latvia
\nis not sufficiently rewarded financially, then
\nwe can assume with 95% probability that
\nthe statistical measurement error is within
\n+\/\u2013 3.1%. It means that 51.9 to 58.1% from
\nthe target group believe that doctors work in
\nLatvia is not sufficiently rewarded financially.
\nFigure 1. Prestige of the doctor\u2019s profession (Doctors\u2019 view)
\nPlease, estimate the prestige of the following professions in\u00a0Latvia
\ntoday
\n29
\n17
\n18
\n17
\n10
\n9
\n3
\n17
\n4
\n3
\n1
\n25
\n23
\n22
\n22
\n14
\n12
\n9
\n11
\n7
\n7
\n1
\n1
\n1
\n20
\n23
\n21
\n23
\n20
\n15
\n15
\n11
\n14
\n14
\n3
\n3
\n2
\n1
\n1
\n11
\n16
\n17
\n15
\n18
\n14
\n18
\n8
\n18
\n18
\n8
\n6
\n6
\n3
\n2
\n8
\n14
\n16
\n15
\n22
\n26
\n31
\n17
\n33
\n33
\n37
\n31
\n32
\n22
\n19
\n5
\n4
\n5
\n5
\n15
\n21
\n19
\n31
\n23
\n23
\n51
\n57
\n57
\n71
\n76
\n2
\n3
\n2
\n3
\n2
\n4
\n5
\n5
\n1
\n3
\n1
\n1
\n1
\n2
\n1
\nLawyers
\nEntrepreneurs
\nBank employees
\nArchitects
\nJudges
\nCivil servants
\nMilitary
\nPoliticians
\nDoctors
\nEngineers
\nTeachers
\nPolice
\nNurses
\nDrivers
\nShop assistants
\nVery prestigious (10) (9) (8) (7) Average (5-6) Not prestigious (1-4) No opinion
\n8.2
\n7.9
\n7.8
\n7.8
\n6.9
\n6.4
\n6.2
\n6.1
\n6.0
\n5.9
\n4.4
\n4.2
\n4.1
\n3.5
\n3.3
\n0 5 10Index*
\nBasis: all respondents, n=2274 * Index \u2013 average estimation from
\n1 (not prestigious at all) to 10 (very prestigious)
\n1. Occupational prestige, satisfaction with the chosen profession
\nFigure 2. Prestige of the doctor\u2019s profession (People\u2019s view)
\nPlease,estimate the prestig of the following professions in Latvia today
\naccording to public opinion
\nBasis: all respondents, n=1005 * Index \u2013 average estimation from
\n1 (not prestigious at all) to 10 (very prestigious)
\n25
\n14
\n15
\n15
\n14
\n16
\n8
\n13
\n6
\n17
\n3
\n2
\n2
\n1
\n1
\n20
\n16
\n15
\n15
\n12
\n13
\n11
\n8
\n9
\n7
\n3
\n2
\n3
\n2
\n1
\n17
\n21
\n19
\n17
\n20
\n17
\n16
\n12
\n11
\n7
\n5
\n5
\n4
\n3
\n2
\n12
\n14
\n17
\n17
\n17
\n13
\n16
\n10
\n14
\n6
\n10
\n12
\n8
\n5
\n3
\n13
\n17
\n20
\n21
\n22
\n18
\n26
\n24
\n29
\n16
\n35
\n36
\n35
\n27
\n22
\n9
\n9
\n10
\n12
\n12
\n17
\n19
\n28
\n25
\n41
\n40
\n41
\n45
\n58
\n68
\n3
\n8
\n4
\n3
\n3
\n5
\n6
\n5
\n6
\n5
\n3
\n3
\n2
\n4
\n3
\nLawyers
\nArchitects
\nEntrepreneurs
\nBank employees
\nDoctors
\nJudges
\nEngineers
\nCivil servants
\nMilitary
\nPoliticians
\nNurses
\nTeachers
\nPolice
\nDrivers
\nShop assistants
\nReally prestigious(10) (9) (8) (7) Average (5-6) Not prestigious (1-4) Hard to say
\n7.8
\n7.4
\n7.3
\n7.1
\n7.0
\n6.9
\n6.4
\n6.0
\n5.9
\n5.3
\n4.9
\n4.8
\n4.6
\n4.0
\n3.5
\n0 5 10Index*
\n14
\nFigure 5. Whom to trust? (People\u2019s view)
\nPlease, estimate the prestige of the following professions in the eyes of
\nLatvian society. In your opinion, what might be the trust level in the
\nfollowing professions on the whole?
\nBasis: respondents who have given
\nthe responding estimation
\nData ranked according to trust data.
\n* Index \u2013 average estimation according to scale
\nfrom 1 (cannot be trusted\/not prestigious at all)
\nto 10 (can be trusted\/really prestigious)
\n6.9
\n6.8
\n6.5
\n6.3
\n6.3
\n6.0
\n6.0
\n5.9
\n5.5
\n5.2
\n5.1
\n5.0
\n5.0
\n4.1
\n2.3
\n6.4
\n7.4
\n4.8
\n7.0
\n4.9
\n4.0
\n5.9
\n7.1
\n7.8
\n7.3
\n3.5
\n6.9
\n4.6
\n6.0
\n5.3
\n0 5 10
\nEngineers
\nArchitects
\nTeachers
\nDoctors
\nNurses
\nDrivers
\nMilitary
\nBank employees
\nLawyers
\nEntrepreneurs
\nShop assistants
\nJudges
\nPolice
\nCivil servants
\nPoliticians
\nIndex*
\nTrust Prestige
\nFigure 6. Would you advise your child to choose your own profession?
\nTaking into account everything you know about your profession and
\nyour practical experience, would you recommend your child to become a
\ndoctor?
\nBasis: all respondents, n=2274
\nDefinitely
\nwould
\nrecommend
\n12%
\nSooner would
\nrecommend
\n39%
\nSooner would
\nnot
\nrecommend
\n31%
\nDefinitely
\nrecommend
\n9%
\nNo opinion
\n9%
\nFigure 3. Prestige of the doctor\u2019s profession
\nPlease, estimate the prestige of the following professions in
\nLatvia today
\nBasis: respondents in respective groups
\n(see \u00ab\u00a0n =\u00a0\u00bb in the graph)
\n* Index \u2013 average estimation from 1 (not prestigious at all)
\nto 10 (very prestigious ). Data ranked according
\nto characteristics in doctors’group
\n7.8
\n7.3
\n7.1
\n7.4
\n6.9
\n6.0
\n5.9
\n5.3
\n7.0
\n6.4
\n4.8
\n4.6
\n4.9
\n4.0
\n3.5
\n8.2
\n7.9
\n7.8
\n7.8
\n6.9
\n6.4
\n6.2
\n6.1
\n6.0
\n5.9
\n4.4
\n4.2
\n4.1
\n3.5
\n3.3
\n0 5 10
\nLawyers
\nEntrepreneurs
\nBank employees
\nArchitects
\nJudges
\nCivil servants
\nMilitary
\nPoliticians
\nDoctors
\nEngineers
\nTeachers
\nPolice
\nNurses
\nDrivers
\nShop assistants
\nIndex*Population Doctors, n=2274
\nFigure 4. Whom to trust? (People\u2019s view)
\nIn your opinion, can representatives of the following professions
\nbe trusted?
\nBasis: all respondents, n = 1005 * Index \u2013 average estimation according to scale
\nfrom 1 (cannot be trusted) to 10 (can be trusted)
\n6
\n5
\n3
\n4
\n4
\n3
\n5
\n4
\n2
\n1
\n2
\n1
\n1
\n13
\n14
\n9
\n9
\n9
\n7
\n9
\n7
\n7
\n3
\n3
\n5
\n2
\n1
\n20
\n18
\n20
\n17
\n15
\n13
\n14
\n17
\n11
\n8
\n8
\n11
\n10
\n5
\n1
\n18
\n17
\n22
\n22
\n20
\n17
\n14
\n16
\n15
\n14
\n14
\n13
\n15
\n9
\n2
\n23
\n24
\n29
\n29
\n34
\n33
\n27
\n29
\n29
\n36
\n34
\n28
\n33
\n28
\n10
\n9
\n10
\n14
\n15
\n15
\n18
\n20
\n23
\n29
\n30
\n34
\n36
\n34
\n50
\n82
\n12
\n13
\n4
\n4
\n4
\n8
\n11
\n5
\n7
\n7
\n5
\n6
\n4
\n6
\n4
\nEngineers
\nArchitects
\nTeachers
\nDoctors
\nNurses
\nDrivers
\nMilitary
\nBank employees
\nLawyers
\nEntrepreneurs
\nShop assistants
\nJudges
\nPolice
\nCivil servants
\nPoliticians
\nCan be trusted (10) (9) (8) (7) Average (5-6) Cannot be trusted (1-4) Hard to say
\n6.9
\n6.8
\n6.5
\n6.3
\n6.3
\n6.0
\n6.0
\n5.9
\n5.5
\n5.2
\n5.1
\n5.0
\n5.0
\n4.1
\n2.3
\n0 5 10Index*
\nMedical Profession LATVIA
\n15
\nFigure 7. Satisfaction with your own choice
\nAre you sure that you
\nwould choose to become
\na doctor again if you
\ncould turn the time
\nback?
\nAre you sure that you
\nwould choose the same
\ndoctor\u2019s speciality
\nagain if you could turn
\nthe time back?
\nAre you sure that you
\nwould choose the same
\nwork place you are
\nworking in now again
\nif you could turn the
\ntime back?
\nFigure 8. Income changes over the last year
\nTaking into account all the income you get from your medical activities,
\ncan you estimate the changes during the last year?
\nBasis: all respondents, n=2274
\n\u00ab\u00a0Decreased by
\nmore than 10%\u00a0\u00bb
\n21%
\n\u00ab\u00a0Decreased by
\nup to 10%\u00a0\u00bb
\n14%
\nNot changed
\n44%
\n\u00ab\u00a0Increased by
\nup to 10%\u00a0\u00bb
\n10%
\n\u00ab\u00a0Increased by
\nmore than 10%\u00a0\u00bb
\n5%
\nHard to
\nestimate
\n6%
\nBasis: all respondents, n=2274
\nYes
\n75%
\nNo
\n10%
\nNo
\nopinion
\n15%
\nYes
\n59%
\nNo
\n8% Would not
\nbecome a
\ndoctor
\n10%
\nNo
\nopinion
\n23%
\nBasis: all respondents, n=2274
\nYes
\n58%
\nNo
\n20%
\nNo
\nopinion
\n22%
\nBasis: all respondents, n=2274
\nFigure 9. Satisfaction in doctor\u2019s work
\nIn your opinion, is your work in medical area evaluated sufficiently?
\nBasis: all respondents, n=2274
\n12
\n33
\n80
\n45
\n9
\n22
\nFinancially (salary and other income
\nrelated to professional activities)
\nNon-material (recognition by patients and
\ncolleagues, prestige of the profession etc.)
\nEvaluated sufficiently Not evaluated sufficiently
\nFigure 10. Satisfaction in doctor\u2019s work
\nPlease, identify the most rewarding moment in your doctor\u2019s job.
\nBasis: all respondents, n=2274
\n37
\n22
\n21
\n5
\n4
\n5
\n1
\n4
\n0 20 40
\nTo be a skilled practician able to
\nfind answers and state diagnoses
\nPatients’ gratitude\/
\nrelationship with patients
\nThe feeling that I can make the world
\na better place, save people’s lives, help them
\nPossibility to feel proud
\nabout being a doctor\/medic
\nPossibility to earn what I need
\nSomething else
\nThere is nothing rewarding
\nHard to say
\n2. Professional burnout
\nFigure 11. Burnout in work
\nSometimes doctors\u2019 professional activities are associated with the burn-
\nout syndrome, which means emotional and physical problems, loss of in-
\nterest concerning one\u2019s work, cynical attitude, and feeling of no personal
\nachievements. Do you ever feel like that?
\nBasis: all respondents, n=2274
\nOften
\n31%
\nSometimes
\n58%
\nNever
\n8%
\nHard to say
\n3%
\nMedical ProfessionLATVIA
\n16
\nFigure 14. Satisfaction with different aspects of life
\nHow satisfied are you in general with …
\nBasis: all respondents, n=2274
\n(10) I am absolutely satisfied (9) (8) (7) Average (5-6) (1-4) Not at all Hard to say
\n10
\n6
\n15
\n9
\n20
\n16
\n20
\n24
\n20
\n32
\n13
\n11
\n1
\n1
\nyour life outside
\nyour doctor’s job
\nyour professional life
\n6.98
\n6.60
\n0 5 10Index*
\nIndex* \u2013 average value according
\nto scale from 1 (I am not satis\ufb01ed at all)
\nto 10 (I am absolutely satis\ufb01ed)
\nHow would you evaluate in general …
\nBasis: all respondents, n=2274
\n3
\n4
\n12
\n10
\n22
\n20
\n22
\n21
\n26
\n28
\n13
\n17
\n1
\n1
\nyour state
\nof health
\nyour emotional
\nfeelings
\n6.65
\n6.42
\n(10) It is excellent (9) (8) (7) Average (5-6) (1-4) Not at all Hard to say 0 5 10Index*
\nIndex* \u2013 average value according
\nto scale from 1 (it is really bad)
\nto 10 (it is excellent)
\n3. Doctors\u2019 habits and caring for their health
\nFigure 15. Smoking
\nDo you smoke?
\nBasis: all respondents, n=2274
\nYes
\n12%
\nNo
\n87%
\nHard to
\nsay
\n1%
\nFigure 16. Overweight
\nAre you overweight?
\nBasis: all respondents, n=2274
\nYes
\n46%
\nNo
\n50%
\nHard to say
\n4%
\nFigure 12. Burnout intensity
\nPlease, using the 7 point scale, estimate the level of your professional
\nburnout
\n8 9
\n12
\n18 18
\n15
\n10
\n5
\n5
\n0
\n5
\n10
\n15
\n20
\n25
\nNo feeling
\nof \u00ab\u00a0burn-out\u00a0\u00bb
\n1
\nI do not feel
\nbothered by it
\n2 3 4 5 6 7
\nIt is so serious
\nthat I am considering
\nthe possibility
\nto leave medical
\nprofession
\nHard to say
\nBasis: all respondents, n=2274
\nFigure 13. Burnout causes
\nPlease, evaluate the importance of the following factors that might
\nenhance your feeling of burnout, according to the 7 point scale.
\nBasis: respondentis that feel \u201dburn-out\u201d, n=2009
\n52
\n39
\n31
\n24
\n30
\n18
\n18
\n18
\n10
\n10
\n7
\n6
\n7
\n3
\n13
\n13
\n16
\n15
\n12
\n14
\n14
\n13
\n11
\n10
\n5
\n7
\n6
\n3
\n11
\n11
\n16
\n14
\n10
\n15
\n13
\n12
\n13
\n15
\n8
\n8
\n7
\n4
\n7
\n10
\n13
\n14
\n9
\n15
\n15
\n11
\n16
\n14
\n11
\n9
\n8
\n8
\n6
\n10
\n10
\n12
\n7
\n15
\n13
\n12
\n17
\n15
\n13
\n13
\n13
\n13
\n5
\n11
\n7
\n11
\n11
\n12
\n14
\n15
\n18
\n17
\n22
\n21
\n21
\n26
\n5
\n5
\n5
\n9
\n17
\n10
\n11
\n17
\n13
\n16
\n32
\n35
\n37
\n41
\n1
\n1
\n1
\n1
\n4
\n1
\n2
\n3
\n2
\n3
\n2
\n1
\n2
\n2
\nNever-ending reforms of the health
\ncare system\/continuously unclear future
\nToo many bureaucratic
\nduties and procedures
\nNot sufficient income\/salary
\nToo much time spent at work
\nProblems in taking sick leave
\nto become completely healthy
\nNot enough time and energy to improve
\nprofessional knowledge and qualifications
\nThere is no possibility to ensure
\nthat patients get quality service
\nFeeling like a tiny gerar
\nwheel in a huge system
\nToo many heavy and complicated cases
\nLack of professional satisfaction
\nIncreasing computerization of practice
\nFeeling of loneliness, there is nobody
\nto change professional advice with
\nProblems in co-operating
\nwith authorities\/employer
\nProblems in co-operating with
\ncolleagues and other employees
\n7 – really important 6 5 4 3 2 1- not important at all Hard to say
\nMedical Profession LATVIA
\n17
\nFigure 17. Going in for sports
\nHow many hours a week do you spend on physical activities\/sports,
\nintensive enough to make you sweat?
\nBasis: all respondents, n=2274
\n10
\n15 13
\n9
\n7
\n10
\n3
\n10
\n22
\n67
\n57
\n42
\n29
\n20
\n13
\n0
\n20
\n40
\n60
\n80
\n1 h and less 1.1\u20132 h 2.1\u20133 h 3.1\u20134 h 4.1\u20135 h 5.1\u201310 h More than
\n10 h
\nI don’t do any
\nsports
\nHard to say
\nCumulative
\nFigure 18. Cholesterol index
\nDo you know what your cholesterol index is\/do you follow your level of
\ncholesterol?
\nBasis: all respondents, n=2274
\nYes
\n62%
\nNo
\n37%
\nHard to say
\n1%
\nYes
\n38%
\nNo
\n57%
\nHard to say
\n5%
\nBasis: all respondents, n=1005
\nDoctors\u2019 answers People\u2019s answers
\nFigure 19. Blood pressure
\nDo you know what your blood pressure is\/do you follow your blood pres-
\nsure?
\nBasis: all respondents, n=2274 Basis: all respondents, n=1005
\nDoctors\u2019 answers People\u2019s answers
\nYes
\n84%
\nNo
\n15%
\nHard to say
\n1%
\nYes
\n66%
\nNo
\n31%
\nHard to say
\n3%
\nFigure 20. Vaccination (Doctors\u2019 answers)
\nHave you been vaccinated against the following infections?
\n18
\n36
\n38
\n77
\n79
\n63
\n60
\n23
\n3
\n1
\n1
\n1
\nDiphteria
\nTick-borne encephalitis
\nHepatitis
\nInfluenza (last 3 years)
\nNo Yes Hard to say
\nBasis: all respondents, n=2274
\nDo you recommend your patients vaccination against the following
\ninfections?
\nNot recommend I recommend Hard to say
\nBasis: respondents contacting patients, n=2161
\n19
\n20
\n32
\n45
\n70
\n69
\n49
\n32
\n11
\n11
\n19
\n22
\nTick-borne encephalitis
\nDiphteria
\nHepatitis
\nInfluenza (last 3 years)
\n(People\u2019s answers)
\nThere are different opinions about vaccination against infections.
\nPlease, identify the infections everybody should be vaccinated
\nagainst:
\n66
\n64
\n60
\n19
\n7
\n9
\n0 20 40 60 80 100
\nHepatitis
\nDiphteria
\nTick-borne encephalitis
\nInfluenza
\nNeither of the mentioned
\nHard to say
\nBasis: all respondents, n=1005
\nMedical ProfessionLATVIA
\n18
\nFigure 23. Attitude towards clinical guidelines
\nDoctors differ in their attitude towards evidence based medicine. Part
\nbelieves in accurate following the guidelines, performing the indicated
\nactivities, the sequence of their application and the tactics in the treat-
\nment. Others consider that such guidelines cannot substitute the doctors\u2019
\nexperience, intuition and individual approach to each patient. Where
\nwill you place yourself in the 7 point scale?
\nBasis: all respondents, n=2274
\n3
\n11 11
\n23
\n19
\n13
\n16
\n5
\n0
\n20
\n1- Guidelines 2 3 4 5 6 7 – Experience Hard to say
\nIn my opinion, practical usage of clinical
\nguidelines in practice is limited,
\nso I usually act by my experience
\nI usually follow clinical guidelines exactly
\n25% 48%
\nFigure 24. Passive euthanasia
\nIn case, you would get into a situation when you are unconscious and
\ncannot make any decisions, and your life would be maintained in termi-
\nnal condition without any medical solutions to improve the situation,
\nwould you wish to have passive euthanasia performed??
\nMay be
\npermissible
\n48%
\nMust not be
\npermissible
\n16%
\nHard to say
\n36%
\nBasis: all respondents, n=2274
\nIn case, you would get into a situation when you are unconscious and
\ncannot make any decisions, and your life would be maintained in termi-
\nnal condition without any maedical solutions to improve the situation,
\nwould you wish to have passive euthanasia performed?
\nBasis: respondent of respective groups, (see \u00ab\u00a0n=\u00a0\u00bb in the graph)
\n54
\n84
\n11
\n33
\n13
\n1
\n58
\n8
\n33
\n15
\n30
\n59
\nALL RESPONDENTS, n=2274
\nATTITUDE TOWARDS PASSIVE EUTHANASIA
\nMay be permissible, n=1082
\nMust not be permissible, n=362
\nHard to say, n=830
\nWould wish Would not wish Hard to say
\nFigure 21. Early diagnosis of oncologic diseases
\n(Doctors\u2019 answers)
\nHave you had prostata specific antigen (PSA) timely determined
\naccording to guidelines? Have you had mammography done timely
\naccording to guidelines? Have you had hemoplus in faeces timely
\ndetermined according to guidelines?
\n61
\n70
\n19
\n34
\n28
\n78
\n5 2 3
\n0
\n25
\n50
\n75
\n100
\nMale, 50+, n=261 Female, 50+, n=913 Respondents, 50+, n=1174
\nHard to say No Yes
\nBasis: respondents at least 50 years of age, (see \u00ab\u00a0n=\u00a0\u00bb in the graph)
\nFigure 22. Recommendations for patients
\nDoctors\u2019 attitude to their patients can be different. Some of them give
\nadvice on healthy lifestyle while others do it rarely or never. Do you
\nrecommend your patients the following actions?
\nBasis: all respondents, n=2161
\n66
\n53
\n48
\n48
\n28
\n38
\n40
\n40
\n5
\n6
\n10
\n9
\n1
\n3
\n2
\n2
\nTo give up smoking \u2013 for
\nsmoking patients
\nTo take care about their
\nemotional well-being
\nTo lose weight \u2013 for
\noverweight patients
\nTo practise sports regularly
\nI often recommend
\nI don’t recommend
\nI sometimes recommend
\nHard to say
\nMedical Profession LATVIA
\n19
\nFigure 26. Core values of health care system
\nWhich two of the mentioned values should be the most important in
\nLatvian medical care system, in your opinion?
\nBasis: respondents of respective groups, (see \u00ab\u00a0n=\u00a0\u00bb in the graph)
\n57
\n50
\n31
\n18
\n5
\n56
\n62
\n38
\n18
\n4
\n0 20 40 60 80
\nDoctors, n=2274 Population, n=1005
\nHolistic approach \u2013
\nthe patient is examined as a whole,
\nnot only particular illnesses are cured
\nEquality of chances \u2013
\ntimely and equal availability of health care
\nservices not dependidng on patient’s income,
\nstate and location
\nReal effectiveness \u2013
\nfast and effective treatment
\nEfficiency of costs \u2013
\nmedical decisions based on costs efficiency
\ncriteria, avoiding extra and overlapping costs etc.
\nHard to say
\n5. Evaluation of the performance of the Latvian Medical Association
\nFigure 28. Evaluation of the Association\u2019s performance
\nHow do you evaluate activities of the following institutions?
\n20
\n3
\n4
\n7
\n4
\n2
\n37
\n12
\n13
\n17
\n16
\n8
\n30
\n35
\n46
\n54
\n57
\n78
\n12
\n51
\n37
\n22
\n22
\n12
\nLatvian Medical Association
\nLatvian Hospital Association
\nTrade Union of Latvian Health and Social Workers
\nHealth Inspection
\nNational Health Service
\nMinistry of Health
\nExcellent (9\u201310) Good (7\u20138) Average and poor (1\u20136) Hard to say
\n\u201310
\n\u201332
\n\u201342
\n\u201347
\n\u201353
\n\u201376
\n\u2013100 \u201380 \u201360 \u201340 \u201320 0
\nEvaluation index*
\nBasis: all respondents, n=2274 Evaluation index* \u2013 (excellent (9\u201310)) \u2013 (average and poor (1\u20136))
\nFigure 27. Health care system in the future
\nThinking about future development of health care in Latvia which two
\ntheses do you agree with?
\nBasis: all respondents, n=2274
\n91
\n88
\n85
\n77
\n67
\n57
\n50
\n32
\n7
\n10
\n13
\n19
\n28
\n30
\n39
\n58
\n1
\n1
\n0,5
\n1
\n2
\n3
\n4
\n4
\n1
\n2
\n1
\n3
\n3
\n10
\n6
\n6
\nHealth care system needs more funding
\nManagement and organisation
\nof health care should be improved
\nPeople’s knowlwdge about
\nhealth should be improved
\nHealth care system should improve
\nquality of people’s survival
\nHealth care system should
\nprovide more prevention
\nPublic resources should be involved into
\ndoctos’professional development
\nHealth care system should be more
\nindividualised concerning each patient
\nHealth care system should
\nbe more innovation oriented
\nI agree completely I agree partly I don’t agree Hard to say
\n4. Health care system in Latvia
\nFigure 25. Available services and tax payment
\nIn your opinion, should the health care paid by the state
\nbe connected with the taxes paid by respective patients?
\nBasis: all respondents, n=2274
\nYes
\n49%
\nNo
\n29%
\nHard to say
\n22%
\nMedical ProfessionLATVIA
\n20
\nFigure 31. Contacts with patients
\nOn average for how many hours a week do you contact your patients directly?
\nBasis: all respondents, n=2274
\n5 5 5
\n9 11 10 14 10 8
\n4 4
\n7 5
\n1
\n94
\n88
\n83
\n78
\n69
\n58
\n48
\n34
\n24
\n15
\n11
\n0
\n20
\n40
\n60
\n80
\n100
\nLess
\nthan10
\n11\u201315 16\u201320 21\u201325 26\u201330 31\u201335 36\u201340 41\u201345 46\u201350 51\u201355 56\u201360 More
\nthan 60
\nNo direct
\ncontacts
\nCumulative %
\nMore than 40 hours per week are usually worked by doctors in hospitals,
\nas well as anesthesiologists, reanimatologists, specialists in obstetrics and gynecology
\nIn how many work places do you currently get income from medical
\nactivities?
\n51
\n29
\n11
\n4 1 0.4 3
\n96
\n46
\n17
\n5
\n0
\n20
\n40
\n60
\n80
\n100
\n1 2 3 4 5\u20137 I am not working
\nat the moment
\nI cannot say
\nCumulative %
\nBasis: all respondents, n=2274
\nEarnings of a Latvian doctor from medical practice come average from 1.73 work places
\nFigure 30. Number of work places
\nHow many paid work places do you currently have?
\n42
\n31
\n15
\n5 3 0.4 2
\n97
\n55
\n24
\n8
\n0
\n20
\n40
\n60
\n80
\n100
\n1 2 3 4 5\u20138 I am not working
\nat the moment
\nI cannot say
\nCumulative %
\nBasis: all respondents, n=2274
\nA Latvian doctor works average in 1.93 work places. Several work places are
\ncommon for men, doctors of younger age group, as well as radiologists, surgeons, neurologists
\nFigure 29. Evaluation of the Association\u2019s performance
\nPlease, evaluate the following events and activities organized by the Latvian Medical Association:
\n42
\n35
\n10
\n6
\n21
\n31
\n33
\n14
\n10
\n32
\n14
\n13
\n14
\n13
\n30
\n13
\n19
\n62
\n71
\n17
\nInterdisciplinary conferences by LMA
\nSpecialized conferences by LMA
\nWork done by Ethics commission of LMA
\nWork done by Occupational court of LMA
\nThe process of certification and work
\ndone by the Certification Council of LMA
\n28
\n22
\n\u20134
\n\u20137
\n\u201310
\n\u201320 0 20 40
\nBasis: all respondents, n=2274 Evaluation index* \u2013 (excellent (9\u201310)) \u2013 (average and poor (1\u20136))
\nEvaluation index*
\nExcellent (9\u201310) Good (7\u20138) Average and poor (1\u20136) Hard to say
\n6. Statistics on the doctors-respondents
\nMedical Profession LATVIA
\n21
\nFigure 34. Statistics on the doctors-respondents
\nIn what medical area do you work?
\n0.4
\n16
\n4
\n13
\n22
\n33
\n43
\nHard to say
\nOther area
\nRehabilitation
\nDiagnostics
\nPrimary care
\nStationary care
\nAmbulatory care
\nBasis: all respondents, n=2274
\nDoctor\u2019s speciality
\n23
\n15
\n12
\n11
\n7
\n5
\n5
\n5
\n4
\n4
\n3
\n3
\n3
\n3
\n2
\n2
\n2
\n16
\n0.04
\nFamily doctor (GP)
\nInternist
\nPediatrician
\nDentist
\nOccupational doctor
\nAlcohol narcotic and psychoactive
\nsubstances checking doctor
\nSurgeon
\nGynaecologist, birth specialist
\nAnaesthetic, reanimatologist
\nCardiologist
\nNeurologist
\nPsychiatrist
\nRadiologist diagnostic
\nHealth care management doctor
\nOphtalmologist
\nOtolaryngologist
\nPsychotherapist
\nOther
\nNot stated
\nBasis: all respondents, n=2274
\nHow many patients do you contact on average per week?
\nHard
\nto say
\n3
\n7 7 8 9 6
\n4 6 3
\n8 5
\n20
\n76
\n73
\n66
\n59
\n51
\n42
\n36
\n32
\n26 23
\n15
\n0
\n20
\n40
\n60
\n80
\n100
\n1\u201310 11\u201320 21\u201330 31\u201340 41\u201350 51\u201360 61\u201370 71\u201380 81\u201390 91\u2013100 101
\nand
\nmore
\nNo
\ncontacts
\nBasis: all respondents, n=2274
\nCumulative %
\nFigure 32. Time spent on bureaucratic and administrative work
\nHow many hours on average do you spend filling out documents and
\nreports and doing administrative work?
\n18 19
\n11
\n10
\n6 3
\n33
\n67
\n50
\n31
\n20
\n10
\n0
\n20
\n40
\n60
\n80
\n100
\nLess than 5 h
\n(incl.)
\n5.1\u201310 h 10.1\u201315 h 15.1\u201320 h 20.1\u201330 h More than 30 h Hard to say
\nCumulative %
\nBasis: all respondents, n=2274
\nFigure 33. Total length of service
\nFor how many years have you been in a medical profession?
\nBasis: all respondents, n=2274
\n12
\n24
\n34
\n23
\n7
\n0.4
\n100
\n88
\n64
\n31
\n0
\n20
\n40
\n60
\n80
\n100
\n1\u201310 years 11\u201320 years 21\u201330 years 31\u201340 years 41 years and more Hard to say
\nCumulative %
\nMedical ProfessionLATVIA
\n22
\nFigure 38. Statistics on the people-respondents
\nHow many medical institutions did you visit as a patient
\nlast year at least once?
\nHow many doctors did you visit last year (including family doctors,
\ndentists etc.)?
\nBasis: all respondents, n=1005
\n18
\n21
\n18
\n8
\n6
\n4
\n1
\n16
\n9
\n0
\n10
\n20
\n1 2 3 4 5 6\u20139 10 and more None Hard to say
\n12
\n18
\n16
\n11
\n9 9
\n4
\n14
\n8
\n0
\n10
\n20
\n1 2 3 4 5 6\u20139 10 and more None Hard to say
\nBasis: all respondents, n=1005
\nFigure 37. Requirements for the doctor
\nHow important for you is that your doctor \u2026
\n79
\n69
\n58
\n49
\n42
\n15
\n3
\n-25
\n-50 0 50 100
\n0.4
\n1
\n2
\n3
\n4
\n11
\n15
\n22
\n3
\n6
\n10
\n27
\n30
\n41
\n33
\n37
\n42
\n48
\n45
\n37
\n39
\n23
\n63
\n54
\n44
\n32
\n31
\n21
\n14
\n8
\n1
\n1
\n1
\n4
\n3
\n4
\n3
\n7
\nHas good reputation
\nHas long practical working experience
\nHas enough time to talk to you
\nRegularly improves his\/her professional knowledge
\nIs healthy
\nIs possible to contact via Internet
\nHas professional certificates exposed in his\/her surgery
\nIs a university lecturer, teaches students and young doctors
\nNot important at all Sooner not important Sooner important Really important
\n12
\n17
\nHard to say
\nBasis: all respondents, n=1005 * Index scale from \u2013 100 (not important at all) up to +100 (very important)
\nIndex*
\n7. Data from the population questionnaire
\nFigure 35. Adequate remuneration for doctors
\nTaking into account everything you know about doctors and their
\nsalaries, do you think that doctors in Latvia are sufficiently financially
\nrewarded?
\nBasis: all respondents, n=1005
\nYes, they do
\n24%
\nNo, they
\ndon’t
\n55%
\nHard to say
\n21%
\nFigure 36. Ideas on doctors\u2019 remuneration
\nWhat is in your opinion an average Latvian doctors monthly earnings
\nafter taxes?
\n1
\n4
\n16
\n22
\n19
\n12
\n8
\n5 5 3
\n5
\n0
\n5
\n10
\n15
\n20
\n25
\n30
\n285
\nor less
\nFrom 286
\nto 427
\nFrom 428
\nto 569
\nFrom 570
\nto 712
\nFrom 713
\nto 854
\nFrom 855
\nto 996
\nFrom 997
\nto 1139
\nFrom 1140
\nto 1280
\nFrom 1281
\nto 1423
\nFrom 1424 Hard to say
\nThe population believes the average doctors\u2019
\nremuneration to be about EUR 800 net per month
\nEUR
\nBasis: all respondents, n=1005
\nDr. P\u0113teris Apinis, President of Latvian Medical Association
\nArnis Kakti\u0146\u0161, sociologist, executive director of the public opinion research centre SKDS
\nMedical Profession LATVIA
\n23
\nTobaccoFINLAND
\nBackground
\nTobacco use leads to high morbidity and in-
\ncreased mortality, shortening the user\u2019s life
\nexpectancy by 7\u201315 years. It accounts for
\none in 10 deaths among adults [1]. Every
\nday 80,000\u2013100,000 young people around
\nthe world become addicted to tobacco. If
\nthe current trends of tobacco use continue,
\n250 million children and young people alive
\ntoday will die from tobacco-related diseas-
\nes\u00a0[1].Tobacco remains a major health issue.
\nFinland was one of the first countries to
\nintroduce a comprehensive Tobacco Con-
\ntrol Act (TCA, adopted in 1976. came into
\nforce in 1977) [2]. The TCA restricted mar-
\nketing, banned advertising, and set an age
\nlimit to sales. It also allocated resources,
\n0.5% of tobacco tax revenue, for preven-
\ntion, monitoring and development. Smoking
\nwas prohibited in schools, public transport
\nand public indoor areas, and allowed only
\nin specially designated places. The Finnish
\nTCA was the toughest act in its time, and
\nover the decades it has been developed due
\nto improved knowledge of tobacco-induced
\nhealth hazards. Workplaces and public areas
\nare smoke-free, and environmental tobacco
\nsmoke (ETS) was classified by law as a car-
\ncinogenic substance.Overall,the Finnish ex-
\nperience demonstrates a remarkable process
\nfrom new medical knowledge to compre-
\nhensive action and public policy. Adult male
\nsmoking prevalence has decreased from 60%
\nto 21% in a few decades (Figure). This has
\nencouraged the Finnish tobacco policy mak-
\ners to adopt an ambitious goal:Tobacco-Free
\nFinland by 2040.This was set as the objective
\nin the TCA in 2010 (Table).
\nSuccesses and Challenges of
\nTobacco Control in Finland
\nThe impact of the TCA has been monitored
\nover the years and there are several achieve-
\nments that have genuinely increased health
\nat the population level. Cardiovascular mor-
\ntality was high in the 1970s when the North
\nKarelia project was launched to improve
\nhealth behaviours in the Eastern province
\nof Finland [3]. By the 1990s, male CVD
\nmortality had decreased by 68 %, with an
\nestimated 10% of which was due to declin-
\ning smoking rates [4]. Exposure to ETS was
\nshown conclusively to be a health hazard,
\nand in 1995 workplaces became smoke-free;
\ncurrently 1\u20132% of non-smokers are exposed
\nto ETS (AVTK 2012) [5]. The health ben-
\nefits deriving from smoking bans have been
\nwell documented in the UK, for instance,
\nwhere there is a marked decrease in CVD
\nmortality [6]. Tobacco use is responsive to
\nthe cost of tobacco, and the World Bank has
\nrecommended price elasticity as one of the
\nmost effective measures of prevention [7].
\nFinland used this tool successfully in the
\nearly 1980s and then again in the 2010s,
\nwhich has contributed to the declining
\nsmoking initiation rate,together with health
\neducation, cessation support and measures
\nto limit tobacco use in the public space [8].
\nOn the Road to Tobacco-Free Finland
\nKristiina Patja
\nFigure. Tobacco Control time \u2013 of Finland 1950\u20132010
\n\u201310
\n0
\n10
\n20
\n30
\n40
\n50
\n60
\n70
\n1950 1960 1970 1980 1990 2000 2010
\nchange % of GDP
\nMen
\nWomen
\nConsumption in100xtons
\nper 15-year old\/100
\nExpenditure on tobacco
\nproducts in relation to
\ndisposable income %
\nTCA 2010:
\nEndgame 2040
\nTCA 1995: Smoke-free
\nworkplaces
\nTCA 1976+1978
\n24
\nTobacco FINLAND
\nTable. Proposed actions from Framework Convention for Tobacco Control (FCTC) and how and when they have been implemented in
\nFinnish Tobacco Control Acts between 1977 and 2012. In italics the new initiatives from Tobacco Free Finland in 2013
\nFramework Convention for Tobacco Control
\n(FCTC)
\nFinnish TCA 1977\u20132012
\nNew initiatives from Tobacco Free Finland in 2013
\nTaxation and duty-free sales:
\nTax policies reducing tobacco consumption\u00a0
\nTobacco tax has increased with direct mechanism since 2009. In the 1980s tax
\nincreased nearly annually, but then the real price actually decreased due to good
\neconomic growth in the early 2000s as tobacco tax was not increased.
\nDuty-free sales are discouraged: Countries may
\nprohibit\/restrict duty-free sales and import
\nDuty-free allowed in airports and ferries, but import of snuff allowed only for
\npersonal use. Restrictions on sales in some ferries to Estonia.
\nAny sale of snuff is forbidden. Ordering snuff, e.g. via the Internet, will also
\nbe forbidden. A maximum of 30 packets, each containing 50 grams snuff, may,
\nhowever, be imported for one\u2019s own use. It will be forbidden to import snuff as a
\ngift.
\nSetting a new insurance system for covering costs of tobacco induced diseases funded by
\ninsurance payment from tobacco industry.
\nSecond-hand smoke (Article 8): Non-smokers must be protected from exposure to tobacco smoke:
\nIndoor workplaces
\nETS classified as carcinogenic substance since 1995 at work sites and smoke free
\nworkplaces since 1995, restaurants from 2007.
\nPublic transport
\nSmoking not allowed in public transport in 1977, totally smoke-free airplanes since
\n1995 and trains since 2012.
\nIndoor public places Smoke-free since 1977.
\nOther public places: schools, kindergartens,
\nlibraries a.o.
\nAll public facilities have been smoke-free since 1977. In 2010 TCA the prohibitions
\nagainst smoking were extended, outdoor (e.g. outdoor facilities used by children and
\nyoung peole) used by children and young people, the common facilities of apartment
\nhouse companies, events organised outdoors and hotel rooms.\u00a0
\nObligation to protect from second-hand smoke for the housing association or the owner of
\nthe house.
\nBanning smoking in cars, when minors in a car.
\nCommunities and other public organisations have a right to ban smoking and use of
\ntobacco products at their premises indoors and outdoors.
\nProduct regulation and ingredient disclosure (Articles 9 and 10):
\nCountries shall adopt and implement measures for
\nsuch testing, measuring and regulation
\nTCA includes guidelines for testing and measuring, currently the EU-legislation as
\nwell.
\nIngredients are to be disclosed Ingredients are partly disclosed within the EU.
\nManufacturers and importers shall disclose to
\ngovernmental authorities information on contents
\nand emission
\nIngredients are partly disclosed within the EU.
\nMeasures for public disclosure of information
\nabout toxic constituents and emissions
\nInformation available, not fully implemented with campaigns.
\nTobacco products will be classified as unusual consumer products and can be regulated
\nmore: any chemical formulation of pH or addictiveness of nicotine will be banned as well
\nas sugar.
\nNew tobacco products, tobacco and tobacco imitations offsets the import, sale or
\nother transfer is prohibited but cessation products regulated by medical agency.
\nLimiting availability of tobacco products in reducing points of sales to 500 in 2020.
\n25
\nFramework Convention for Tobacco Control
\n(FCTC)
\nFinnish TCA 1977\u20132012
\nNew initiatives from Tobacco Free Finland in 2013
\nPackaging and labelling (Article 11):\u00a0Large health warning labels are required:
\nWarnings Since 2003 text warnings; pictorial warnings the latest in 2016 with a new EU directive
\nLarge, clear, visible and legible Since 2003.
\nShould be 50% or more of the principal display
\nareas (shall not be less than 30%)
\nNot applied in the EU.
\nDeceptive labels must be prohibited False\/mislead-
\ning term, description, trademark or any other sign
\nshall be prohibited (e.g. mild, low tar, light)
\nApplied in 1977.
\nPlain packaging planning with a health warning over 90 % of the package.
\nPackages have information on the environmental hazards.
\nTobacco waste contains hazardous chemicals for environment: the manufacturer
\nresponsible for collection and disposal (compare electronic waste).
\nEducation, communication, training and public awareness (Article 12): Each party shall
\npromote and strengthen public awareness of tobacco control issues:
\nBroad access to effective and comprehensive
\neducational and public awareness programmes on
\nSince 1977 TCA separate finding from tobacco tax within TCA.
\nhealth risks of tobacco consumption;
\nSince 1977 TCA separate finding from tobacco tax within TCA and special health
\neducation, including on tobacco, for all minors at schools
\nrisks of exposure to tobacco smoke; Included in 1995 TCA.
\nrisk of addiction; Added in 2012 TCA for grounds of TCA.
\nbenefits of tobacco cessation; Since 1977 TCA, strengthened with the national current care guidelines in 2003.
\npublic access to a range of information on the
\ntobacco industry.
\nNew text added after this: Public health associations provide information on
\nTI\u00a0actions.
\nTraining or sensitization and awareness pro-
\ngrammes to various stakeholder groups on the
\nhealth, economic and environmental consequences
\nof tobacco production and consumption.
\nIn Finland,for decades there is a long tradition of the involvement of non-governmen-
\ntal organisations (NGO),like public health associations and patient organisations,in
\ntobacco control.Government funds can be applied for public health programmes and
\ncollaboration with public services.Majority of campaigns are carried out by NGOs.
\nAdvertising, promotion and sponsorship (Article 13): A comprehensive ban is required:
\nNo point of sales advertising, brands hidden at sales since 2012.
\nSellers of tobacco products must be at least 18 years of age since 2010.
\nMinimum package of measures prescribed Since 2012 TCA.
\nDirect and indirect advertising and promotion
\ncovered
\nSince 1977 direct and indirect since 1995.
\nCross-border advertising subject to ban and penalty Since 1995, joining the EU.
\nBanning movies with smoking from minors
\nTobacco dependence and cessation (Article 14):
\nDesigning and implementing effective tobacco
\ncessation programme in such establishments as
\neducational institutions, health care facilities.
\nSince 1977.
\nIncluding diagnosis and treatment of tobacco
\ndependence and counselling services on cessation
\nof tobacco use in national health and education
\nprogrammes, plans and strategies
\nFormally from the late 1990s, but initiated since the 1972 North Karelia Project.
\nNational Current Care Guideline published in 2003.
\nEstablishing tobacco cessation programmes in
\nhealth care facilities and rehabilitation centres
\nFrom the 1990s.
\nTobaccoFINLAND
\n26
\nFramework Convention for Tobacco Control
\n(FCTC)
\nFinnish TCA 1977\u20132012
\nNew initiatives from Tobacco Free Finland in 2013
\nFacilitating accessibility and affordability for
\ntreatment of tobacco dependence, including
\npharmaceutical products
\nNicotine replacement therapy over counter sales in 2005.
\nTailored cessations programs, e.g. pregnant smokers.
\nSmuggling (Article 15): Action is required to eliminate tobacco smuggling:
\nOrigin and final destination must be indicated on
\nthe packaging
\nApplied by customs and manufacturers.
\nDeveloping a practical tracking\/tracing regime. Applied by customs and manufacturers.
\nConfiscating products and proceeds of illicit trade Applied by customs.
\nMutual cooperation in anti-smuggling, law
\nenforcement and litigation efforts
\nApplied by customs and the Ministry of Internal Affairs.
\nSales to and by minors (Article 16): Prohibition of the following is required:\u00a0
\nParties shall prohibit the sale of tobacco products
\nto persons under the age set by national law or
\neighteen years of age
\nSince 1977 TCA (first 16, then 18 years in 1995).
\nParties shall prohibit or promote the prohibition of
\nthe distribution of free tobacco products
\nSince 1977 TCA.
\nCurbs on or prohibition of tobacco vending
\nmachines
\nWill be applied in 2015.
\nProhibition of sale by minors, as per national law.
\nSince 1977 TCA, even selling one cigarette or fetching a packet of cigarettes from
\na shop to a minor person should be interpreted as a tobacco selling violation, for
\nwhich the person can be fined or sentenced to prison for a maximum of six months.\u00a0
\nChallenges exist. The less-educated seg-
\nment of the population still suffers more
\nseverely from tobacco-induced health haz-
\nards. Smoking prevalence among men is
\nthree times higher in the lowest education
\ngroup compared to the highest, and the ra-
\ntio is similar for women [8]. Smoking dur-
\ning pregnancy remains common in the less
\neducated group as well, with every third
\nchild of these mothers being exposed to to-
\nbacco chemicals prenatally. And if ETS has
\nbeen defeated in the workplace, the same
\ncannot be said for the home: 17% of the
\npopulation report domestic exposure every
\nyear [8].These challenges need to be met in
\na new phase of tobacco control.
\nFrom Reduction to Endgame
\nAt the National Conference on Tobacco
\nin 2006, the Speaker of the Parliament,
\nformer Prime Minister Paavo Lipponen,
\nasked the audience what their ultimate goal
\nwas: to cut down tobacco use or end it. He
\nsuggested that Finland should aim at To-
\nbacco-Free Finland within a timeframe of
\n35 years, the goal being set for 2040. This
\nwas received with some bewilderment, but
\nsoon researchers, public health advocates
\nand health professionals organised a meet-
\ning for establishing a new network, which
\nall stakeholders could join in. By 2009, the
\nnetwork had formulated the first roadmap
\nand gave a proposal for a new TCA that
\nemphasised the need to move ahead toward
\nan eventual total prohibition of tobacco use:
\nthe endgame had begun.
\nNew alliances were formed that had new
\napproaches, such as child protection asso-
\nciations or municipalities. The Government
\nacted timely, and in 2010 the new TCA
\nwas adopted, with the aim of legislating a
\nTobacco-Free Finland in 2040. This year
\nthe network has provided a detailed, gradu-
\nated roadmap for Finland to achieve this
\ngoal. Although the term endgame did not
\nexist in Finland in 2006, in actuality it was
\nlaunched at the time.
\nThe Endgame Policy Today
\nThere are four pathways in combat-
\ning tobacco-related health harms at the
\npopulation level: preventing the initiation
\nof tobacco use, promoting and support-
\ning tobacco use cessation, protecting the
\npopulation from ETS, and the treatment of
\ntobacco induced diseases.These are all cov-
\nered in the Finnish tobacco policy (Table).
\nIn implementing the TCA, multiple part-
\nners are needed. They include tobacco-free
\ncities\/municipalities (220 out of a total of
\n300 smoke-free), smoke-free hospitals,
\nTobacco FINLAND
\n27
\nHONG KONG NMA and Regional News
\nsmoke-free schools, universities and vo-
\ncational schools, doctors against smoking,
\nhealth educators, trade unions and sports
\nassociations. Finland has adhered to most
\nof the FCTC implementation guidelines
\nand is strongly supporting the European
\nUnion in its efforts to set ambitious health
\ntargets for its tobacco policy. Unfortunately,
\nnegotiations have been influenced by the
\ntobacco industry, and Finland will have to
\nkeep to the strict aim without full support
\nfrom the EU.
\nWhat has Changed?
\nThe new Finnish approach has changed the
\ntarget from reducing to ending tobacco use
\naltogether.The language and the image have
\nboth become more positive: tobacco control
\nis an investment and a proactive measure,not
\njust a cost.We now have a clear new roadmap
\nfor the endgame, and it has already led to
\nnew alliances that deepen the engagement of
\ncivil society [9].The social climate in Finland
\nis generally rather favourable to tobacco con-
\ntrol owing to a steady process that has lasted
\nover four decades.The self-image of tobacco
\ncontrol community has reversed, which may
\nbe the key feature in the success.The tobacco
\ncontrol community has a vision of victory in
\nthe struggle to defend human life.The target
\nis simple and measurable. We do not need
\nany proof to justify our actions. We have a
\npositive message and no need to defend our
\nactions.Obviously there will be struggles,but
\nwith forty years of experience, these can be
\nsolved.One lesson has been learned: no com-
\npromises with the tobacco industry.
\nReferences
\n1. WHO Global Report. Mortality attri-
\nbutable to tobacco. 2012. http:\/\/whqlibdoc.
\nwho.int\/publications\/2012\/9789241
\n564434_eng.pdf (accessed 2.12.2013)
\n2. Leppo K. Letter from Finland. Smoking
\ncontrol policy and legislation. BMA: 11;
\n1(6109): 345\u2013347. 1978.
\n3. Puska P, Tuomilehto J, Salonen J et al.
\nEvaluation of a comprehensive community
\nprogramme for control of cardiovascular dis-
\neases in North Karelia,Finland 1972\u20131977.
\nWorld Health Organization,Regional of-
\nfice for Europe,Copenhagen 1981.
\n4. Puska P, Vartiainen E, Tuomilehto
\nJ,\u00a0 Salomaa, V, Nissinen A. Changes in
\npremature deaths in Finland: success-
\nful long-term prevention of cardiovascu-
\nlar diseases. Bull World Health Organ.
\n76(4): 419\u2013425. 1998.
\n5. Tobacco statistics Finland 2012. http:\/\/
\nwww.thl.fi\/en_US\/web\/en\/statistics\/
\ntopics\/tobacco (accessed 2.12.2013).
\n6. Lin H, Wang H, Wu W, Lang L, Wang
\nQ, Tian L. The effects of smoke-free leg-
\nislation on acute myocardial infarction:
\na systematic review and meta-analysis.
\nBMC Public Health. 13: 529. 2013
\n7. Warner K. The economics of tobacco: myths
\nand realities. Tob Control. 9(1): 78\u201389.
\n2000.
\n8. S Helakorpi, T Martelin, J Torppa,
\nK\u00a0 Patja, E Vartiainen, A Uutela. Did
\nFinland\u2019s Tobacco Control Act of 1976
\nhave an impact on ever smoking? An ex-
\namination based on male and female cohort
\ntrends. J\u00a0Epidemiol Community Health.
\n58(8): 649\u2013654. 2004.
\n9. Tobacco Free Finland \u2013 http:\/\/www.
\nsavutonsuomi.fi\/en.php (accessed 2.12.2013)
\nKristiina Patja,
\nMD PhD, Adjunct Professor
\nScientific Advisory Board
\nof Tobacco-Free Finland 2040
\nE-mail: Kristiina.patja@promedico.fi
\nFounded in 1920, the Hong Kong Medi-
\ncal Association brings together all medi-
\ncal practitioners practicing in and serv-
\ning the people of Hong Kong, with the
\nobjective to promote the welfare of the
\nmedical profession and the health of the
\npublic. With the continuous efforts of our
\ncolleagues, the Association\u2019s membership
\nhas grown steadily over the past year with
\ncurrently over 9,000 members from all
\nsectors of medical practice. We speak col-
\nlectively for our members and aim to keep
\nour members abreast of medical ethics
\nand issues around the world. \u201cTo safe-
\nguard the health of the people\u201d is the motto
\nwe proudly display in the Association\u2019s
\nemblem, and it could not be achieved in
\nvacuum. We tried as much as we could to
\nwork with the Government for the bet-
\nterment of public health. As representa-
\ntives of doctors, our supervisory role on
\nthe Government is irreplaceable. We ad-
\nThe Hong Kong Medical Association
\nThe Hong Kong Medical Association Council 2013-2014
\n28
\nNMA and Regional News HONG KONG
\nvise, and we criticize as the case demands
\nus to, and we have been unwavering in so
\ndoing.
\nThere has been a public-private imbal-
\nance in the provision of medical services
\nin Hong Kong for long. The Hong Kong
\nMedical Association tries its best to voice
\nour concern, and urges for a revamp or
\neven overhaul of the Hospital Authority of
\nHong Kong. The jump of doctors, juniors
\nand seniors, from public to private sector,
\nhas created a shortage of manpower in
\nsome public hospitals in recent years. The
\never-increasing chronic medical cases fur-
\nther expose the shortage of manpower in
\nthe specialist outpatient service. Partner-
\nship between the public and private sector
\nin the caring of these chronic cases would
\nimprove public health efficiency, and after
\nall benefit both patients and doctors. We
\nlook forward to an all-win proposal from
\nthe Government in the near future.
\nThe Hong Kong Medical Association has
\nalso established a close relation with all
\ndoctors\u2019 groups in the society, as well as
\nwith the Chinese Medical Association.
\nThe 15th
\nBeijing\/Hong Kong Medical Ex-
\nchange on \u201cRecent Advances in Cancer
\nMedicine\u201d was successfully held in Beijing
\nin 2013. Exchange visits to China were
\nalso organized for young doctors and med-
\nical students.
\nIn the support of life-
\nlong medical educa-
\ntion, we accredited
\n522 continuous medi-
\ncal education (CME)
\nevents in 2013, of
\nwhich we organized
\n345. We are the CME
\nadministrator for 1,065
\ndoctors. Thanks to our
\nCommunity Networks
\nwhich are instrumental
\nin providing members
\nwith CME lectures.
\nFor many years we organize exercise for
\nhealth training courses to teach participants
\na number of exercises for different chronic
\ndiseases for them to apply in daily practice.
\nThese are extended to various Community
\nNetworks.
\nTo help doctors face adversities in the daily
\npractice, and to go around avoidable pit-
\nfalls, the Hong Kong Medical Association
\njointly published a Clinical Risk Manage-
\nment Handbook with the Medical Protec-
\ntion Society in late 2013. A two-day train-
\ning course was organized in September the
\nsame year to help doctors become expert
\nwitness for inquiries, courts and tribunals.
\nWe have a Duty Council Member Scheme
\nto constantly answer to members\u2019 queries
\nmonth-to-month, year-to-year. Our Pa-
\ntient Complaints Mediation Committee
\nhandles cases with care, with resolution
\nbetween interested parties most of the
\ntime.
\nWe observe work-life balance as an im-
\nportant component of our lives. The Hong
\nKong Medical Association organizes a
\nnumber of social and recreational activi-
\nties for our members, from photo shooting,
\ncharity concerts to professional choir and
\norchestra performances and band shows.
\nWe also arrange countless sports events
\nincluding ball games such as football, bas-
\nketball, volleyball, badminton, tennis, table-
\ntennis, squash, bowling, snooker and golf, as
\nwell as bench pressing, power-lifting, hik-
\ning, and the annual dragon boat competi-
\ntion and Trailwalker event.
\nPatient\u2019s well-being is in the heart of our
\nmembers whose welfare is in the heart of
\nthe Hong Kong Medical Association. We
\npledge to serve both the community and
\nthe doctors, to safeguard the health of the
\npeople of Hong Kong.
\nDr. TSE Hung Hing,
\nPresident of the Hong Kong
\nMedical Association15th
\nBeijing\/Hong Kong Medical Exchange
\nThe HKMA Choir
\n29
\nNMA and Regional NewsREPUBLIC OF KOSOVO
\nOn 10 November this year,134 elected phy-
\nsicians met in Pristina to celebrate the es-
\ntablishment of the Chamber of Physicians
\nof the Republic of Kosovo. In the presence
\nof the Kosovan Minister of Health and
\ninternational guests, the delegates of the
\nchamber assembly were sworn in and a new
\nPresident elected. Up until this point there
\nhad been no representative organisation of
\nphysicians in this emerging state, which has
\nso far been recognised by 105 countries in
\nthe world since its declaration of indepen-
\ndence from Serbia in 2008. Although 90%
\nof its population is Albanian speaking,there
\nis a region in the northern part of the coun-
\ntry with a large Serbian population. At the
\nEuropean level, Serbia and Kosovo are cur-
\nrently negotiating solutions for the future of
\nthis part of Europe.
\nBefore the establishment of the Chamber
\nof Physicians, all matters concerning phy-
\nsicians and other healthcare professions in
\nKosovo had been regulated by the Ministry
\nof Health. As is common practice in many
\nstates of Central and Eastern Europe, this
\nchamber will not only be responsible for
\nrepresenting the interests of physicians, but
\nwill also take on regulatory and licensing
\ntasks.
\nThe foundation of the Chamber represent-
\ned the culmination of a process in which the
\nGerman Medical Association (GMA) has
\nbeen closely involved.
\nOver the past two years a legal framework
\nhas been established and elections to the
\nchamber assembly took place on 17 Octo-
\nber 2013, with the participation of 85% of
\nthe roughly 4,000 Kosovan physicians.
\nDuring the inaugural celebrations, elections
\nwere held for the Chamber leadership. The
\nonly female candidate of the four presiden-
\ntial candidates, neuropsychologist Dr Zyl-
\nfije Hundozi, was chosen to represent the
\nphysicians of Kosovo over the next four
\nyears.
\nInvolvement at the international and Eu-
\nropean level is of great importance to the
\nphysicians of Kosovo and their newly es-
\ntablished organisation as they do not yet
\nhave many contacts with other physicians\u2019
\norganisations abroad. A seminar was there-
\nfore organised by the German Medical As-
\nsociation following the inauguration of the
\nchamber during which examples were given
\nof international organisations of physicians\u2019
\nself-governance including the World Medi-
\ncal Association (WMA) and the Standing
\nCommittee of European Doctors (CPME).
\nDr. Otmar Kloiber, Secretary General of
\nthe World Medical Association, encour-
\naged the physicians of Kosovo to live up to
\ntheir responsibilities and speak out on be-
\nhalf of their patients, even if this may not be
\nlooked upon favourably by some politicians.
\nAlong with a delegation from the GMA,
\nrepresentatives of the medical chambers
\nof Austria, Albania, Bosnia-Herzegovina,
\nCroatia, Hungary, Macedonia (FYROM)
\nand Montenegro were guests of honour
\nin Pristina. CPME was represented at the
\nevent by its Vice-President, Dr. Istvan \u00c9ger,
\nand Secretary General, Birgit Beger.
\nThe GMA\u2019s approach throughout was to
\nassist the physicians of Kosovo at the pro-
\nfessional level independent of political is-
\nsues, helping them to establish their own
\norganisation and thereby guarantee better
\nhealth care for all patients in Kosovo, re-
\ngardless of their ethnicity. It was therefore
\na success that physicians from the Serbian
\npopulation also registered for the chamber
\nelections. In the end, four Serbian physi-
\ncians were among the elected delegates of
\nthe new Chamber.
\nWith the legal framework already in place,
\nthe inaugural event on 10 November in
\nPristina represented the beginning of the
\nwork of the Chamber of Physicians in
\nKosovo. It is now time to breathe life into
\nthe new Chamber and welcome it into the
\nEuropean and international community of
\nmedical associations.
\nDomen Podnar
\nPolicy Advisor, Department for International
\nAffairs
\nBundes\u00e4rztekammer\/German
\nMedical Association
\nOfficial Advisor to the WMA
\nCommittees for Finance and Planning
\nand Socio-Medical Affairs
\nE-mail: domen.podnar@baek.de
\nNew Chamber of Physicians Established
\nin Kosovo
\n30
\nMONTENEGRONMA and Regional News
\nMedical Chamber of Montenegro was es-
\ntablished by the Decree of the Parliament of
\nMontenegro in 1994, within Changes and
\nAmendments of the Law on Health Care,
\nand based on the initiative of the Medical
\nAssociation of Montenegro. It was estab-
\nlished as a professional organization con-
\nsisting of medical doctors and dentists, with
\nthe objective of improving professional-
\nism, maintaining medical ethics, improving
\nquality of health care and protecting profes-
\nsional interests, with rights and obligations
\nestablished in the Law on Health Care.
\nAfter long preparatory procedures, the
\nChamber was established at the Constitu-
\ntional Assembly held on June 21, 1995. Prim.
\nDr. Djoko Jocic, specialist in internal medi-
\ncine-haematologist, was elected as the first
\npresident of the Chamber in 1996, and he is
\nstill the president of the Chamber. Pursuant
\nto the Law on Health Care, the Chamber is
\nresponsible for maintain of the register, is-
\nsuing, and renewal and revoking of licenses,
\nas well as education. Current Register of the
\nChamber includes 2800 medical doctors and
\ndentist, whereof 650 are dentists. We are ex-
\npecting that the Dental Chamber will be es-
\ntablished soon,as an independent profession-
\nal institution, based on the request of Dental
\nAssociation and approval obtained from the
\nMedical Chamber and Ministry of Health.
\nMedical Chamber has its bodies (Assembly,
\nExecutive Board,Chamber\u2019s Court,prosecu-
\ntor, barristers and Supervisory Board) and
\ncommissions.President of Executive Board is
\nalso the President of the Chamber.Chamber
\nhas nine commissions, among which is the
\nCommission for International Cooperation,
\nheaded by doc. dr Olivera Miljanovi\u0107, who
\nhas been delegated to participate in meetings
\nof international medical associations.
\nPursuant to our Law and rulebooks, license
\nfor work is obtained upon graduating the
\nMedical Faculty and passing of professional
\nexam and fulfilling of other requirements
\nestablished in our rulebooks. Employment
\nrelation cannot be established without this
\nlicense. Limited validity of the license is not
\nprescribed by the Law.
\nHealth Care Law stipulates license based
\non practice that is obtained upon completed
\nspecialization and other forms of profes-
\nsional training (additional education, pub-
\nlishing of professional and scientific works,
\nprofessional publications, and periodical
\nstays in institutions in the country and
\nabroad,etc.).Number of points is prescribed
\nfor obtaining of this license, which is deter-
\nmined based on categorization of all forms
\nof professional training. This is the respon-
\nsibility of the Chamber\u2019s Commission for
\nContinuous Education. Doctor that doesn\u2019t
\nhold this license cannot be elected to profes-
\nsional and managerial positions and cannot
\nbecome member of professional. expert and
\neducational teams, and has to work under
\ncontrol of licensed doctor, regardless of his
\nspecialty.This license is valid for seven years
\nand after this period it can be extended. Li-
\ncense must be extended in order to retain all
\nthe benefits arising from it.
\nSpecial activities of the Chamber include ed-
\nucation of its members, conducted through
\norganizing of professional and educational
\nconferences and issuing of publication. Par-
\nticipation in conferences are also basis for
\nawarding points to doctors to help them meet
\nthe requirements for obtaining license based
\non practice. Chamber has a relatively good
\ncooperation with line ministry \u2013 Ministry of
\nHealth, and participates in development of
\nlaws that are of interest for profession and
\nhealth care service as a whole. Chamber has
\nstarted the initiative for establishing of pro-
\nfessional trade union of physicians and has
\nconducted all the activities for its establish-
\ning, which was done in June 2013.This is an
\nindependent professional body that will be a
\ncompetent representative of the profession
\ntogether with the Medical Chamber.
\nWe are making efforts to have greater com-
\npetencies, similar to other Chambers and to
\nhave Law on Chambers and Law on Physi-
\ncians, since the existing legal solutions pre-
\nscribe only rights of patients and our obliga-
\ntions and we want to regulate our rights with
\nthe new law. We are not satisfied with the
\ncurrent status of profession which is exposed
\nto unargumented attacks and accusations
\nby different media and non-governmental
\norganizations. Chamber doesn\u2019t tolerate
\nviolations of professional ethics and super-
\nficial and unprofessional work. However
\nthis should be proven first and then sanc-
\ntioned. Therefore, it is our priority to pro-
\ntect doctors from potential mistakes, which
\nwe are currently doing in cooperation with
\nnewly-established professional trade union
\nof physicians and we are expecting to have
\na better solution, as we didn\u2019t have support
\nof domestic insurance companies in the past.
\nPrim. dr \u0110oko Jo\u010di\u0107,
\nPresident of the Medical
\nChamber of Montenegro
\nMedical Chamber of Montenegro
\nNew Member of WMA
\n\u0110oko Jo\u010di\u0107
\n31
\nIRLAND NMA and Regional News
\nThe Irish Medical Organisation (IMO) is
\nthe representative body for all doctors in
\nIreland and is celebrating its 30th
\nanniver-
\nsary this year.The IMO was formed in 1984
\nfollowing the amalgamation of the Irish
\nMedical Association and the Irish Medical
\nUnion, to act as the national representative
\nmedical organisation linking all branches of
\nthe medical profession in Ireland.
\nThe basic objective of the IMO is to fulfil its
\nMission Statement:
\n\u201cThe role of the IMO is to represent doctors in
\nIreland and to provide them with all relevant
\nservices. It is committed to the development of
\na caring, efficient and effective Health Service.\u201d
\nThe IMO is a registered trade union in Ire-
\nland and for three decades has been work-
\ning to safeguard both the working condi-
\ntions of our doctors and the integrity of our
\nhealth services.
\nRecently we ran a successful campaign
\ncalling for an end to 24 hour shifts and
\nthe full implementation of the European
\nWorking Time Directive (EWTD). This
\nculminated in the first strike action in a
\ngeneration by our junior doctors (Non-
\nConsultant Hospital Doctors \u2013 NCHDs)
\non the 8th
\nOctober 2013. Many of our ju-
\nnior doctors were working shifts of over
\n24 hours and working weeks of up to
\n100 hours posing significant safety issues
\nto both patient and doctors. Since 2000,
\nthe IMO has been engaged with govern-
\nment bodies on the implementation of the
\nEWTD, however frustrated by continued
\nlack of progress, the IMO launched its
\n\u201c24\u00a0 No More\u201d campaign early last year.
\nThe IMO engaged with health service
\nmanagement to produce proposals to ad-
\ndress the issues, however the NCHDs were
\nnot totally satisfied that penalties would be
\nimposed on employers for non-compliance
\nand voted unanimously for strike action.
\nIn November 2013, the IMO reached a
\nsettlement agreement with the health ser-
\nvice management to achieve maximum 24
\nhour shifts and the implementation of an
\naction plan to achieve full compliance with
\nthe EWTD.
\nResources for General Practice have been
\nsuccessively cut over recent years and
\nin early November last year the IMO
\nlaunched our \u201cHelp us to Help More\u201d
\ncampaign calling on the Government to
\nincrease resources for General Practice.
\nThe IMO are also continually engaged in
\nissues concerning our Consultant members
\nand our Specialists in Public and Commu-
\nnity Health.
\nWhile the core activity of the IMO is in-
\ndustrial relations, as the leading represen-
\ntative body for the medical profession in
\nIreland, the IMO has an important role in
\nadvocacy. The IMO has been particularly
\nconcerned about growing inequalities in
\nhealth and access to health care. In recent
\nyears the IMO have published position pa-
\npers on Universal Health Coverage,Health
\nInequalities and Child Health. At our
\nAGM in April this year, the IMO will be
\ncelebrating 30 years and will be holding a
\npolicy seminar and publishing a discussion
\npaper entitled Balancing a Strong Economy
\nand an Equitable Society. The IMO will aim
\nto create debate on the future of Irish So-
\nciety as Ireland as the country returns to
\neconomic growth.
\nOver the years the IMO has been and re-
\nmains at the forefront promoting public
\nhealth policy on Obesity, Tobacco, Alco-
\nhol and Road Safety and advocating for
\nresources for the provision of public health
\nservices, including Mental Health Services,
\nElderly Care Services and Acute Hospital
\nServices.
\nThe IMO also promotes professionalism
\nand has developed a number of papers on
\nthe Role of the Doctor in Ireland.The IMO
\nrecently published papers on Social Media,
\nDoctor-Patient Confidentiality and the
\nRole of the Doctor as Advocate.
\nVanessa Hetherington,
\nAssistant Director \u2013 Policy and
\nInternational Affairs,
\nIrish Medical Organisation
\nIrish Medical Organisation Celebrates
\n30\u00a0years
\nVanessa Hetherington
\n32
\nUNITED KINGDOMMedical Ethics
\nEarly in the life of the World Medical Jour-
\nnal one of my predecessors wrote about eth-
\nics at the BMA. We have been providing
\nethics advice to doctors in the UK for the
\nbest part of a century, while campaigning
\nand advocating for legislative and regula-
\ntory change. The most recent change in our
\nactivities was nearly 30 years ago when we
\nstarted to undertake an active role in pro-
\nmoting and protecting human rights. In
\nthis article I shall look at the current areas
\nof work and how we undertake a series of
\ntasks to support members.
\nOne of the earliest ethics matters on which
\nthe BMA lobbied was on the regulation of
\nthe medical profession. In the 1840\u2019s only a
\nminority of those in the UK calling them-
\nselves medical practitioners were medically
\nqualified\u00a0 \u2013 either through an apprentice-
\nship route or via universities and the medi-
\ncal Royal College examinations. The BMA
\npublished an expose of quackery, leading
\nto the establishment of the UK\u2019s General
\nMedical Council.This body regulates medi-
\ncine, including ensuring that the universi-
\nties are training undergraduates properly.
\nFor the last 25 years it has also produced
\nan increasingly complex set of advisory
\nbooklets and other materials to help doctors
\nunderstand the expectations that the GMC
\nhas of doctors, addressing among other ar-
\neas some of the ethically complex matters
\nthat doctors see whether every day, or at
\nleast frequently.
\nThe BMA also provides advice in the form
\nof published material for doctors.Fifty years
\nago this amounted to a very slim volume
\nsetting out some of the rules, and stressing
\nthe avoidance of behaviours that might lead
\nto being erased from the medical register by
\nthe GMC. But that has now transformed
\ninto a serious text book of medical ethics
\nand medical law\u2019 \u201cMedical Ethics Today\u00a0\u2013
\nthe BMA\u2019s Handbook of Ethics and Law\u201d*.
\nThe current edition is over 900 pages, and
\ncovers all aspects of health care ethics and
\nthe relevant statute and case law (judge
\nmade law) in the UK, including identifying
\nthe differences in the four countries of the
\nUK. It is not designed to be a text that is
\nread through once, but is a reference work.
\nBMA members have free access to it on-
\nline in a fully searchable version accessed
\nthrough the BMA\u2019s on-line library.
\nThe book was written by the BMA staff
\nwho write all our ethics guidance, work
\nwith members to negotiate on legislative
\nchanges, and answer the queries that come
\nin to the Association from members facing
\ndecisions with difficult ethical aspects.They
\nare experts, but experts who can write in a
\nmanner that is academically excellent and
\nalso readable and readily intelligible.
\nGiven that the books size alone militates
\nagainst wide readership we have also pro-
\n* Medical Ethics Today; The BMA\u2019s Handbook
\nof Ethics and Law, Third Edition, BMA, Wiley-
\nBlackwell, ISBN 978-1-4443-3708-2, pub 2012
\nduced a pocket sized book,\u201cEveryday Med-
\nical Ethics and Law\u201d** which covers the ar-
\neas on which we receive the most queries. It
\nis based on the larger book,but at just under
\n300 pages is readily readable.
\nIn addition we produce guidance docu-
\nments and a series of small toolkits on
\ncommon problems such as consent and
\nconfidentiality, or for groups with a need
\nfor specific guidance such as doctors in the
\narmed forces, and doctors new to practice
\nin the UK.
\nBut how does the advice the BMA offers
\nto members come about? And how do we
\ndecide on our ethics stance on new devel-
\nopments in medical practice, before we put
\nthose into words of explanation and exposi-
\ntion?
\nThe BMA has had a committee looking at
\nmatters of medical ethics for over 100 years.
\nWhile the committee has had different it-
\nerations its current shape has been fixed for
\nnearly 25 years. The majority of members
\nare doctors (and medical students) elected
\nannually at our annual meeting. They may
\ncome from any area of medicine\u00a0\u2013 general
\nfamily practice, hospital medical specialties,
\nacademic medicine, public health, occupa-
\ntional health etc\u00a0\u2013 and bring a rich variety
\nof clinical experience to committee discus-
\nsions.In addition the BMA\u2019s ruling Council
\nappoints 8 extra members to the committee,
\nwho are not doctors but who have specific
\nexpertise in the ethics area. These may in-
\nclude philosophers, professors of medical
\nlaw, theologians, social scientists and other
\ndisciplines. All these members, and the staff
\nwho support the Association\u2019s work on eth-
\nics, then debate the issues of the day.
\nUsually committee debates start with a pa-
\nper written by the secretariat, and setting
\nout the area under consideration. These
\n** Everyday Medical Ethics and Law, BMA Eth-
\nics Department, Wiley-Blackwell, ISBN 976-1-
\n1183-8489-3, pub 2013
\nEthics at the BMA
\nVivienne Nathanson
\n33
\nMedical EthicsUNITED KINGDOM
\npapers include questions which the author
\nhas identified as ones on which we need a
\ndebate to establish a policy position, but de-
\nbate is not limited to those question-points.
\nSometimes the paper will then be rewrit-
\nten and represented, on other occasions
\nit moves more quickly to publication as a
\nposition statement, part of our evidence to
\nan enquiry or some other equivalent dis-
\nposal. As with everyone else much of our
\npublished guidance goes straight onto our
\nweb pages; we are exploring ways of making
\nsuch web based guidance more interactive.
\nIf the matter under consideration is a gov-
\nernment regulatory or legislative proposal
\nthen the staff, working with members, will
\nstart to lobby on legislative changes. In-
\ncreasingly the committee looks at matters
\nbefore the government has decided on its
\nlegislative direction and the discussions are
\nwith civil servants to attempt to influence
\nlegislation as it is being developed to ensure
\nit is ethically sound.
\nAll this sounds very dry\u00a0\u2013 the reality is far
\nfrom that. All of the staff in the depart-
\nment teach, from undergraduates through
\nto CPD, and they draw on the real cases
\nthey are presented with when answering
\nmember queries to bring the issues alive, to
\nensure they are relevant to clinicians in ac-
\ntive practice, and to help those in the audi-
\nence see how the academic material relates
\nto their working environment. The UK has
\nvery many experts on philosophy and eth-
\nics; the BMA is very unusual in bringing
\nthat academic expertise together with real
\nlife clinical examples and relevance. Frankly,
\nmembers want the clinically relevant sup-
\nport rather than ivory tower excellence. The
\nfact that our advice is\u00a0\u2013 as one of the \u201civory
\ntower\u201d experts says\u00a0\u2013 also academically ex-
\ncellent is a benefit but arguably not essential.
\nFrom time to time we analyse what the
\nmost commonly asked questions are\u00a0\u2013 it was
\nessential to know before preparing the sec-
\nond book cited above, but it also helps us in
\nconsidering whether there are other matters
\nthat would benefit from additional guidance
\nand advice. It also helps us to see if there are
\ntrends, for example in challenges, or in legal
\nuncertainty.
\nIssues under consideration at present in-
\nclude a number relating to the beginning
\nof life, including the operation of Abortion
\nlegislation, communication about death and
\nthe process of dying, including decisions to
\nterminate treatment, consent to treatment,
\nnew technologies impacting on diagnos-
\ntics, including maternal plasma testing for
\nfoetal genetic anomalies, resource alloca-
\ntion, research regulation, whistle-blowing
\n(informing on bad or dangerous working
\nconditions) and professionalism.
\nFor decades the commonest issue has been
\nconfidentiality. The law is extremely com-
\nplex\u00a0 \u2013 and there are regular changes fol-
\nlowing from new legislation. There are also
\nregular challenges as government and oth-
\ners seek to use rich medical and other health
\ncare data for management of health care,for
\nmedical research and\u00a0\u2013 from time to time\u00a0\u2013
\nfor other government purposes. Govern-
\nments often, in our experience, fail to un-
\nderstand the simple truth that people give
\nhealth care workers, and especially doctors,
\nsensitive private information to aid them
\nin their role as their health care provider.
\nWhile repeated public opinion surveys have
\nshown willingness to share genuinely ano-
\nnymised, usually aggregated, data for pur-
\nposes such as medical research (population
\nbased epidemiological research in particu-
\nlar) and better health services management,
\nit is also clear that they expect that such data
\nwill not be shared with other government
\ndepartments or commercial companies.
\nOne element of our role is ensuring that
\ngovernment understands the guardianship
\nrole we share in relation to patient data, and
\ndo not exploit this data inappropriately. It
\ncan be a very delicate line to tread when we
\nare also seeking to ensure medical research
\nhas proper access to information; more re-
\nsearch is in our interests as doctors and also
\nas patients and families of patients.
\nIn much the same way government pro-
\nposes legislative and regulatory changes
\nthat will affect medical practice. Recently
\nattempts to diminish the number of Quasi
\nAutonomous Non Governmental Organ-
\nisations (QANGO\u2019s) or \u201cArms-length bod-
\nies\u201d which regulate sensitive areas of public
\nlife have led to substantial areas of work.
\nExamples in recent months include the
\nregulation of the use of Human Tissue
\nand of Assisted Reproductive Technol-
\nogy. Our members will be affected by the
\nway in which the regulations affect their
\ndaily work, and expect us to ensure that
\nthey make ethical and legal sense as well as
\nclinical sense. So we work with government
\nand with arms-length agencies to attempt
\nto ensure that we can regulate properly,
\nkeep public confidence, maintain the high-
\nest ethical standards and do so in ways that
\nwork with rather than against good clinical
\npractices.
\nFrequently we develop short or medium
\nterm alliances with other interested groups
\nand work together to try to ensure a better
\noutcome for patients, scientists and doc-
\ntors. One example of an informal alliance
\nrelates to organ transplantation. The BMA
\nhas run a campaign for a number of years to
\nencourage the UK governments to choose
\na policy of presumed consent or opt out.
\nThis would mean that when someone died
\nin the right clinical circumstances unless
\nthey had previously registered a refusal to
\nbe a donor their organs could be retrieved
\nfor transplantation. We prefer what is often
\ncalled a soft opt out system, where organ
\nretrieval would not go ahead if the family
\nwere opposed and would be seriously dis-
\ntressed.The basis of the BMA policy is that
\nthe government would have to fund a major
\npublicity campaign over several years to give
\npeople information about opting out and
\nthe opportunity to do so.That would ensure
\nfamilies had many chances to discuss their
\nwishes, preferences and fear. While we have
\nhad a significant increase in investment in
\nthe infrastructure for organ transplantation,
\n34
\nHealthy Life Style BRAZIL
\npleasingly increasing the numbers of organs
\nretrieved, and lives saved, only the Welsh
\nAssembly Government has so far legislat-
\ned as we would want. Wales will therefore
\nbecome a within-the-UK \u201cpilot\u201d for this
\npolicy.
\nTo get this policy adopted we got together
\na coalition of many groups interested in in-
\ncreasing the number of organs donated and
\ntransplanted. Not all agreed with opt out,
\nbut there was common agreement on many
\nother areas. We all supported each other
\nas research was released or policy papers
\ndistributed, and that has in no small part
\nhelped with the attaining the high levels of
\npublic awareness that has procured the in-
\ncrease in donation achieved so far. In other
\nareas of work similar loose coalitions have
\nworked in achieving tobacco control and are
\nbeginning to work in alcohol control.
\nOne large area of work undertaken within
\nour ethics team is on human rights. This
\nstarted over 25 years ago with a report that
\nmade it clear that doctors and other health
\ncare professionals were or had recently been
\ninvolved in torture in many countries. Since
\nthen two other reports have followed. The
\nlast\u00a0\u2013 \u201cThe Medical Professional and Hu-
\nman Rights; Handbook for a changing
\nagenda\u201d* is used as a core book by many en-
\ntering the human rights arena for the first
\ntime. The book sets out traditional human
\nrights and explains what these mean, how
\ndoctors can become involved in protecting
\nor otherwise defending them, and gives ex-
\namples of abuse.
\nIn writing this the BMA was aware that
\nmany doctors, and their medical associa-
\ntions, see human rights as someone else\u2019s
\nresponsibility. The BMA has long taken the
\nview that doctors are often the people who
\nsee the evidence of abuses\u00a0\u2013 we examine the
\npatients who survive and we certify the death
\nof those who die.We can gather evidence,or
\nwe can ignore and become part of a system
\nseeking to hide the abuses it perpetrates.
\nIn addition to working with Human Rights
\nactivists, seeking to achieve a world free
\nfrom torture, we also take up individual cas-
\nes of human rights abuses. We concentrate
\nespecially on cases where there is a health
\nissue\u00a0\u2013 for example when there are reports
\nof a prisoner being denied access to health
\ncare, or with serious health problems being
\n* The medical profession and human rights; Hand-
\nbook for a changing agenda, BMA, Zed Books
\nISBN 1-85649-612-0, pub 2001
\ninadequately treated.We also act on all cases
\nwhere health care professionals are targeted,
\nespecially where that links to their provision
\nof care. Currently we, like the WMA itself,
\nare involved in trying to help the Turkish
\nMedical Association get their government
\nto understand that when doctors offer care
\nto people injured in riots or demonstra-
\ntions they do as a part of their ethical duty
\nto proffer care to all who need it, and not
\nas supporters of a particular political view.
\nDoctors, as all other citizens, will have par-
\ntisan views. But when acting as doctors we
\ndo not act in a partisan manner. And here
\nethics and human rights sit closely together.
\nFifty years ago this article would have
\nstressed trying to stop doctors from being
\nstruck off the register, and trying to help
\ndoctors understand their privileged posi-
\ntion\u00a0\u2013 and not abuse patients or indeed the
\npower that they have. Today we are acting
\nas advocates for patients, working with their
\nrepresentative groups, and ensuring that the
\npower doctors still retain is used for public
\ngood as well as benefitting individual pa-
\ntients.
\nProf. Vivienne Nathanson
\nDirector of Professional Activities
\nBritish Medical Association
\nIn the last decades men and women have
\ngained weight and the global prevalence
\nof obesity (defined as a BMI \u226530) doubled
\nbetween 1980 and 2008, to 9.8% among
\nmen and 13.8% among women \u2013 equiva-
\nlent to more than half a billion obese people
\nworldwide (205 million men and 297\u00a0mil-
\nlion women)*. Another 950 million adults
\n* Finucane MM, Stevens GA, Cowan MJ, et al.
\nNational, regional, and global trends in body-
\nmass index since 1980: systematic analysis of
\nhealth examination surveys and epidemiological
\nhave a BMI of 25 to less than 30. The
\nUnited States has had the largest absolute
\nincrease in the number of obese people
\nsince 1980, followed by China, Brazil, and
\nMexico.** Obesity and excess body weight
\nhave been associated with increased total
\nstudies with 960 country-years and 9.1 million
\nparticipants. Lancet 2011;377:557-67.
\n** Stevens GA, Singh GM, Lu Y, et al. National,
\nregional, and global trends in adult overweight
\nand obesity prevalences. Popul Health Metr
\n2012;10:22
\nmortality and increased risks of disease or
\ndeath from diabetes, coronary heart disease,
\nstroke,cancers,andchronickidneydisease,***.
\n*** Whitlock G, Lewington S, Sherliker P, et al.
\nBody-mass index and cause-specific mortality
\nin 900 000 adults: collaborative analyses of 57
\nprospective studies. Lancet 2009;373:1083-96.
\nWormser D, Kaptoge S, Di Angelantonio E, et
\nal. Separate and combined associations of body-
\nmass index and abdominal adiposity with car-
\ndiovascular disease: collaborative analysis of 58
\nprospective studies. Lancet 2011;377:1085-95.
\nRenehan AG, Tyson M, Egger M, Heller RF,
\nZwahlen M. Body-mass index and incidence of
\ncancer: a systematic review and meta-analysis
\nof prospective observational studies. Lancet
\n2008;371:569-78.
\nExcess Weight and Obesity
\n35
\nHealthy Life StyleBRAZIL
\nExcess weight is responsible for about 3.8%
\nof the global burden of disease, implicating
\nin 3.4 million annual deaths, also account-
\ning for diseases that have low mortality and
\nlong periods of disability, such as diabetes
\nand musculoskeletal diseases.
\nIn this scenario physical activity has become
\nan important way in reverse the burden of
\nweight gain. Studies of the beneficial health
\neffects of physical activity date back to the
\n1950s*\u00a0and have been replicated in large co-
\nhorts.**\u00a0Regular physical exercise improves
\nthe CV risk profile and is a robust recom-
\nmendation for primary and secondary pre-
\nvention, according to current current guide-
\nlines [1;2]. In addition, low-to-moderate
\nrunning reduces levels of the inflammatory
\nmarkers [3]. On the other hand, vigorous
\nexercise, such as marathon running, may
\nincrease the short-term risk of coronary
\nevents [4]. Coronary atherosclerosis is the
\nmain underlying cause of exercise-related
\ncoronary events not only among elderly
\npersons unaccustomed to exercise [5], but
\nalso in adult athletes including marathon
\nrunners [6;7]. Over the past decades, the
\nnumber of recreational marathon runners,
\nincluding those at older age, is constantly
\nrising.
\nIn developed countries air pollution, strictly
\nrelated to industrialization, has become
\na major public health concern in the last
\nyears, specially because of it\u2019s association
\nas a risk factor of many kind of common
\ndiseases, such as respiratory and CVD. Cu-
\ntrufello et. al. [8] in a recent review among
\npollutant exposure on healthy individuals,
\nhave noticed that, despite detrimental ef-
\nfects are still in question, the inhalation
\n* Morris JN, Heady JA, Raffle PA, Roberts CG,
\nParks JW. Coronary heart-disease and physical
\nactivity of work. Lancet 1953; 265:1053-7.
\n** Sattelmair J, Pertman J, Ding EL, Kohl HW
\nIII, Haskell W, Lee IM. Dose response between
\nphysical activity and risk of coronary heart dis-
\nease: a meta-analysis. Circulation 2011;124:789-
\n95.
\nof particulate matter (PM) is linked to an
\nincreased inflammatory status and adverse
\nmyocardial and vascular functions. Con-
\nsequently, onset of higher blood pressure
\nlevels, decreased heart rate variability and
\nmyocardial ischemia follows, contributing
\nto higher morbidity and mortality. Oxida-
\ntive stress, through endothelial dysfunc-
\ntion, seems to be one of the most important
\nmechanisms by which pollutants affect CV
\nperformance\u00a0 [9]. Despite compensatory
\nmechanisms, chronic exposure to air pollu-
\ntion still leads to decreased pulmonary and
\ncardiovascular function and increased mor-
\ntality, as it is recurrently shown on traffic
\nrelated air-pollution studies [10].
\nNotably, studies indicate that the forceful
\ninhalation, as in intense exercise, of small
\nenvironmental particles may directly or in-
\ndirectly result in vascular damage, an early
\nfeature of the atherogenic process [11; 12].
\nThe mechanisms responsible for this vas-
\ncular dysfunction remain unknown. One
\nhypothesis is that the amplification of shear
\nand oxidative stresses, present during vigor-
\nous running in air-polluted surroundings,
\npromote the activation of inflammatory and
\nthrombotic mediators as well as endothelial
\ninjury [13; 14; 15]
\nSince the Los Angeles Olympics in 1984,
\nthis issue has become a frequent global con-
\ncern, attracting inclusively media attention.
\nSeveral studies were designed to correlate
\nexposure to PM and other gases (i.e., O3,
\nCO and NOx) to its effects on athlete\u2019s per-
\nformance. This particular population may
\nhave higher risk of inhaling pollutants be-
\ncause of vigorous breathing [16]. Rundell,
\nin his 2012 review [17] on effect of air pol-
\nlution on athlete health and performance,
\nestablished that vascular dysfunction related
\nto pollution inhalation limits performance.
\nHowever, he empathically says that there
\nhas been no research into the effects of
\nlong-term exposure to air pollution on ath-
\nletic performance and a paucity of studies
\nthat describe the effects of acute exposure
\non exercise performance.
\nTo date, little is known about the genetic
\nresponses to human exercise [18]. Exercise
\ntraining induces numerous cardiovascular
\nchanges in the cellular and molecular level,
\nincluding mitochondrial synthesis [19],
\nmyocardial remodeling [20] and angiogen-
\nesis [21]. Although such adaptations and
\ntheir attendant impact on exercise capacity
\nand health outcomes have been well docu-
\nmented, the genetic mechanisms lead-
\ning to these changes remain incompletely
\nunderstood. In addition, it is important
\nto point out that genetic susceptibility is
\nlikely to play a role in response to air pol-
\nlution [22]. Hence, gene-environment in-
\nteraction studies can be a tool for explor-
\ning the mechanisms and the importance
\nof the pathway in the association between
\nexercise, air pollution and a cardiovascular
\noutcome [23].
\nAs seems above, many scientists around the
\nworld dedicated their studies to the harm-
\nful effects of pollutant inhalation restrict to
\ntheir own cities or countries, proving that
\ntraining or living close to major roads or to
\nindustrial centers may assemble CV risks
\nand reduce exercise performance. But is the
\nburden of CVD attributed to outdoor air
\npollution similar among different running
\nvolumes? Has air pollution exposure any
\nimplication on international competitions,
\nas training programs are developed in dif-
\nferent cities and countries?
\nReferences
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\nLT, Creager MA, Franklin BA, Gibbons RJ,
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\nED, Sacco RL, Spertus J, Stein JH, Taubert
\nKA; World Heart Federation and the Preven-
\ntive Cardiovascular Nurses Association. AHA\/
\nACCF Secondary prevention and risk reduc-
\ntion therapy for patients with coronary and
\nother atherosclerotic vascular disease (2011 up-
\ndate):a guideline from the American Heart As-
\nsociation and American College of Cardiology
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\ncan College of Cardiology\/American Heart
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\n3. Colbert LH, Visser M, Simonsick EM,Tracy
\nRP, Newman AB, Kritchevsky SB, Pahor
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\nJ Am Geriatr Soc 2004;52:1098-104.
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\nIM, Hennekens CH, Manson JE. Triggering
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\nJ Med 2000;343:1355-61.
\n5. Mittleman MA, Maclure M, Tofler GH,
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\ntriggering by regular exertion. N Engl J Med
\n1993;329:1677-83.
\n6. Thompson PD, Balady GJ, Chaitman BR,
\nClark LT, Levine BD, Myerburg RJ. Task
\nforce 6: coronary artery disease. J Am Coll
\nCardiol 2005;45:1348-53.
\n7. Noakes TD, Opie LH, Rose AG, Kleynhans
\nPH, Schepers NJ, Dowdeswell R. Autopsy-
\nproved coronary atherosclerosis in marathon
\nrunners. N Engl J Med 1979;301:86-9.
\n8. Cutrufello PT, Smoliga JM, Rundell KW.
\nSmall things make a big difference: par-
\nticulate matter and exercise. Sports Med
\n2012;42:1041-58.
\n9. Mills NL, Donaldson K, Hadoke PW, Boon
\nNA, MacNee W, Cassee FR, Sandstr\u00f6m T,
\nBlomberg A, Newby DE. Adverse cardiovas-
\ncular effects of air pollution. Nat Clin Pract
\nCardiovasc Med 2009;6:36-44.
\n10.Wilund KR, Tomayko EJ, Evans EM, Kim
\nK, Ishaque MR, Fernhall B. Physical activ-
\nity, coronary artery calcium, and bone mineral
\ndensity in elderly men and women: a prelimi-
\nnary investigation. Metabolism Clinical and
\nExperimental 2008;57:584-91.
\n11.Miyata R, Hiraiwa K, Cheng JC, Bai N,
\nVincent R, Francis GA, Sin DD, Van Ee-
\nden SF. Statins attenuate the development
\nof atherosclerosis and endothelial dysfunc-
\ntion induced by exposure to urban particu-
\nlate matter (PM10). Toxicol Appl Pharmacol
\n2013;272:1-11.
\n12.Brucker N, Moro AM, Char\u00e3o MF, Dur-
\ngante J, Freitas F, Baierle M, Nascimento S,
\nGauer B, Bulc\u00e3o RP, Bubols GB, Ferrari PD,
\nThiesen FV,Gioda A,Duarte MM,de Castro
\nI, Saldiva PH, Garcia SC. Biomarkers of oc-
\ncupational exposure to air pollution, inflam-
\nmation and oxidative damage in taxi drivers.
\nSci Total Environ 2013;463-464C:884-93.
\n13.Rich DQ, Kipen HM, Huang W, Wang G,
\nWang Y, Zhu P, Ohman-Strickland P, Hu M,
\nPhilipp C, Diehl SR, Lu SE, Tong J, Gong J,
\nThomas D, Zhu T, Zhang JJ. Association be-
\ntween changes in air pollution levels during
\nthe Beijing Olympics and biomarkers of in-
\nflammation and thrombosis in healthy young
\nadults. JAMA 2012;307:2068-78.
\n14.M\u00f6hlenkamp S, Lehmann N, Breuckmann F,
\nBr\u00f6cker-Preuss M, Nassenstein K, Halle M,
\nBudde T, Mann K, Barkhausen J, Heusch G,
\nJ\u00f6ckel KH, Erbel R, Marathon Study Inves-
\ntigators, Heinz Nixdorf Recall Study Investi-
\ngators. Running, the risk of coronary events:
\nprevalence and prognostic relevance of coro-
\nnary atherosclerosis in marathon runners.Eur
\nHeart J 2008;29:1903-10.
\n15.Libby P. Mechanisms of acute coronary syn-
\ndromes and their implications for therapy. N
\nEngl J Med 2013;368:2004-13.
\n16.Smith SC Jr,Benjamin EJ,Bonow RO,Braun
\nLT, Creager MA, Franklin BA, Gibbons RJ,
\nGrundy SM, Hiratzka LF, Jones DW, Lloyd-
\nJones DM, Minissian M, Mosca L, Peterson
\nED, Sacco RL, Spertus J, Stein JH, Taubert
\nKA; World Heart Federation and the Pre-
\nventive Cardiovascular Nurses Association.
\nAHA\/ACCF Secondary prevention and risk
\nreduction therapy for patients with coronary
\nand other atherosclerotic vascular disease
\n(2011 update): a guideline from the Ameri-
\ncan Heart Association and American Col-
\nlege of Cardiology Foundation. Circulation
\n2011;124:2458-73.
\n17.Rundell K.W. Effect of air pollution on ath-
\nlete health and performance. Br J Sports Med
\n2012;46:407-12.
\n18.Baggish AL, Hale A, Weiner RB, Lewis GD,
\nSystrom D, Wang F, Wang TJ, Chan SY.
\nDynamic regulation of circulating micro-
\nRNA during acute exhaustive exercise and
\nsustained aerobic exercise training. J Physiol
\n2011;589:3983-94.
\n19.Kiessling KH, Pilstrom L, Karlsson J, Piehl
\nK. Mitochondrial volume in skeletal muscle
\nfrom young and old physically untrained and
\ntrained healthy men and from alcoholics.Clin
\nSci 1973;44:547-54.
\n20.Baggish AL, Wang F, Weiner RB, Elinoff
\nJM, Tournoux F, Boland A, Picard MH,
\nHutter AM, Jr, Wood MJ. Training-specific
\nchanges in cardiac structure and function:
\na prospective and longitudinal assessment
\nof competitive athletes. J Appl Physiol
\n2008;104:1121-8.
\n21.Gute D, Fraga C, Laughlin MH, Amann
\nJF. Regional changes in capillary sup-
\nply in skeletal muscle of high-intensity
\nendurance-trained rats. J Appl Physiol
\n1996;81:619-26.
\n22.Yang IA, Fong KM, Zimmerman PV, Hol-
\ngate ST, Holloway JW. Genetic susceptibil-
\nity\u00a0to the respiratory effects of air pollution.
\nPostgrad Med J 2009;85:428-36.
\n23.Zanobetti A, Baccarelli A, Schwartz J. Gene-
\nair pollution interaction and cardiovascu-
\nlar disease: a review. Prog Cardiovasc Dis
\n2011;53:344-52.
\nProf. Carlos Vicente Serrano, JR,
\nPaulo O. Cardoso
\nDr. Paulo O. Cardoso;
\nProf. Carlos Vicente Serrano, JR,Director,
\nAtherosclerosis Clinic Unit,
\nHeart Institute;
\nSchool of Medicine,University
\nof Sao Paulo, Brazil
\nE-mail: cvserranojr@gmail.com
\n37
\nWMA Directory of Constituent Members
\nOrder of Physicians of Albania
\nRr. Dibres. Poliklinika Nr.10, Kati 3,
\nTirana
\nALBANIA
\nDr. Din ABAZAJ,
\nPresident
\nTel\/Fax: (355) 4 2340 458
\nE-mail: albmedorder@albmail.com
\nWebsite: www.umsh.org
\nCol\u2019legi de Metges
\nC\/Verge del Pilar 5, Edifici Plaza 4t.
\nDespatx 11, 500 Andorra La Vella
\nANDORRA
\nDr. Manuel Gonz\u00e1lez
\nBELMONTE, President
\nTel: (376) 823 525
\nFax: (376) 860 793
\nE-mail: coma@andorra.ad
\nWebsite: www.col-legidemetges.ad
\nOrdem dos M\u00e9dicos de Angola
\nRua Amilcar Cabral 151-153,
\nLuanda
\nANGOLA
\nDr. Carlos Alberto Pinto DE
\nSOUSA, President
\nTel. (244) 222 39 23 57
\nFax (244) 222 39 16 31
\nE-mail:
\nsecretariatdormed@gmail.com
\nWebsite:
\nwww.ordemmedicosangola.com
\nConfederaci\u00f3n M\u00e9dica de la
\nRep\u00fablica Argentina
\nAv. Belgrano 1235, Buenos Aires
\n1093
\nARGENTINA
\nDr. Jorge C. JA\u00d1EZ, President
\nTel\/Fax: (54-11) 4381-1548\/
\n4384-5036
\nE-mail: comra@
\nconfederacionmedica.com.ar
\nWebsite: www.comra.org.ar
\nArmenian Medical Association
\nP.O. Box 143, Yerevan 375 010
\nARMENIA
\nDr. Parounak ZELVIAN, President
\nTel: (3741) 53 58 68
\nFax: (3741) 53 48 79
\nE-mail: info@armeda.am
\nAustralian Medical Association
\nP.O. Box 6090, Kingston, ACT 2604
\nAUSTRALIA
\nDr. Steve HAMBLETON,
\nPresident
\nTel: (61-2) 6270 5460
\nFax: (61-2) 6270 5499
\nE-mail: ama@ama.com.au
\nWebsite: www.ama.com.au
\nOsterreichische Arztekammer
\n(Austrian Medical Chamber)
\nWeihburggasse 10-12 – P.O.
\nBox 213,
\n1010 Wien
\nAUSTRIA
\nDr. Artur WECHSELBERGER,
\nPresident
\nTel: (43 1) 514 063000
\nFax: (43 1) 514063042
\nE-mail: international@
\naerztekammer.at
\nWebsite: www.aerztekammer.at
\nAzerbaijan Medical Association
\nP.O. Box 16, AZE 1000, Baku
\nREPUBLIC OF AZERBAIJAN
\nDr. Nariman SAFARLI, President
\nTel: (99 450) 328 18 88
\nFax: (99 412) 510 76 01
\nE-mail. info@azmed.az
\nWebsite: www.azmed.az
\nMedical Association of the Bahamas
\nP.O. Box N-3125,
\nMAB House\u00a0– 6th
\nTerrace
\nCentreville,
\nNassau
\nBAHAMAS
\nDr.Timothy BARRETT, President
\nTel. (242) 328-1858
\nFax. (242) 328-1857
\nE-mail: medassocbah@gmail.com
\nBangladesh Medical Association
\nBMA Bhaban 15\/2 Topkhana Road,
\nDhaka 1000
\nBANGLADESH
\nProf. Mahmud HASAN, President
\nTel: (880) 2-9568714\/9562527
\nFax: (880) 2 9566060\/9562527
\nE-mail: info@bma.org.bd
\nWebsite: www.bma.org.bd
\nAssociation Belge des Syndicats
\nM\u00e9dicaux
\nChauss\u00e9e de Boondael 6, bte 4,
\n1050 Bruxelles
\nBELGIUM
\nDr. Roland LEMYE, Pr\u00e9sident
\nTel: (32-2) 644 12 88
\nFax: (32-2) 644 15 27
\nE-mail: info@absym-bvas.be
\nWebsite: www.absym-bvas.be
\nColegio M\u00e9dico de Bolivia
\nCalle Ballivian Nro. 1266 2do. Piso
\nMurillo
\nBOLIVIA
\nDr. Edgar Villegas GALLO,
\nPresident
\nTelfs. Fax: (591-2) 2203643 –
\n2203649 \u2013 2113252
\nE-mail: secretario@
\ncolegiomedicodebolivia.org.bo
\nWebsite: colegiomedicodebolivia.org.bo
\nAssocia\u00e7ao M\u00e9dica Brasileira
\nR. Sao Carlos do Pinhal 324 – Bairro,
\nBela Vista,
\nSao Paulo SP – CEP 01333-903
\nBRAZIL
\nDr. Florentino de Ara\u00fajo
\nCARDOSO FILHO, President
\nTel. (55-11) 3178 6810
\nFax. (55-11) 3178 6830
\nE-mail: rinternacional@amb.org.br
\nWebsite: www.amb.org.br
\nBulgarian Medical Association
\n15, Acad. Ivan Geshov Blvd.,
\n1431 Sofia
\nBULGARIA
\nDr. Cvetan RAYCHINOV, President
\nTel: (359-2) 954 11 81
\nFax: (359-2) 954 11 86
\nE-mail: blsus@mail.bg
\nWebsite: www.blsbg.com
\nOrdre National des M\u00e9decins du
\nCameroun
\nB.P. 15534
\n11111 Yaound\u00e9
\nCAMEROON
\nDr. SANDJON, Guy, President
\nE-mail: onmcam@yahoo.fr;
\nonmc.cam@gmail.com
\nWebsite: www. onmc.cm
\nCanadian Medical Association
\nP.O. Box 8650, 1867 Alta Vista
\nDrive,
\nOttawa, Ontario K1G 5W8
\nCANADA
\nDr. FRANCESCUTTI, Louis
\nHugo\u00a0, President
\nTel: (1-613) 731 8610\/2289
\nFax: (1-613) 731 1779
\nE-mail: karen.clark@cma.ca
\nWebsite: www.cma.ca
\nOrdem Dos Medicos du Cabo Verde
\nAvenue OUA N\u00b0 6 – B.P. 421
\nAchada Santo Ant\u00f3nio
\nCiadade de Praia-Cabo Verde
\nCAPE VERDE
\nDr. Luis de Sousa NOBRE LEITE,
\nPresident
\nTel. (238) 262 2503
\nFax (238) 262 3099
\nE-mail: omecab@cvtelecom.cv
\nWebsite: www.ordemdosmedicos.cv
\nColegio M\u00e9dico de Chile
\nEsmeralda 678 – Casilla 639,
\nSantiago
\nCHILE
\nDr. Enrique PARIS, Presidente
\nTel: (56-2) 4277800
\nFax: (56-2) 6330940\/6336732
\nE-mail: amisseroni@colegiomedico.cl
\nWebsite: www.colegiomedico.cl
\nChinese Medical Association
\n42 Dongsi Xidajie, Beijing 100710
\nCHINA
\nDr. Zhu CHEN, President
\nTel: 86-10-85158143
\nFax: 86-10-85158551
\nE-mail:\u00a0intl@cma.org.cn;
\nsiwen@cma.org.cn
\nWebsite: www.cma.org.cn\/ensite
\nFederaci\u00f3n M\u00e9dica Colombiana
\nCarrera 7 N\u00b0 82-66, Oficinas
\n218\/219
\nSantaf\u00e9 de Bogot\u00e1, D.E.
\nCOLOMBIA
\nDr. Sergio Isaza VILLA, President
\nTel.\/Fax: (57-1) 8050073
\nE-mail:
\nfederacionmedicacolombiana@
\nencolombia.com
\n38
\nConseil National de l\u2019Ordre des
\nM\u00e9decins du\u00a0RDC, B.P. 4922,
\nKinshasa, Gombe
\nCONGO, DEMOCRATIC
\nREPUBLIC
\nDr. Antoine MBUTUKU
\nMBAMBILI, President
\nTel: (243-12) 24589
\nFax: (243) 8846574
\nE-mail: cnomrdcongo@gmail.com
\nWebsite: www.cnom-rdc.org
\nUni\u00f3n M\u00e9dica Nacional
\nApartado 5920-1000,
\nSan Jos\u00e9
\nCOSTA RICA
\nDR. Edwin Solano ALFARO,
\nPresident
\nTel: (506) 290-5490
\nFax: (506) 231 7373
\nE-mail: junta@unionmedica.com
\nWebsite: www.unionmedica.com
\nOrdre National des M\u00e9decins
\nde la C\u00f4te d\u2019Ivoire
\nCocody Cite des Arts,
\nB\u00e2timent U1, Escalier D, RDC,
\nPorte n\u00b01, BP 1584, 01 Abidjan
\nC\u00d4TE D\u2019IVOIRE
\nDr. Florent Pierre AKA KROO,
\nPresident
\nTel: (255) 22486153\/22443078\/
\n02024401\/08145580
\nFax: (255) 22 44 30 78
\nE-mail: secretariat@medecins.ci
\nWebsite: www.medecins.ci
\nCroatian Medical Association
\nSubiceva 9, 10000 Zagreb
\nCROATIA
\nDr. Zeljko METELKO,
\nPresident
\nTel: (385-1) 46 93 300
\nFax: (385-1) 46 55 066
\nE-mail: tajnistvo@hlz.hr
\nWebsite: www.hlz.hr
\nColegio M\u00e9dico Cubano Libre
\n717 Ponce de Leon Boulevard,
\nP.O. Box 141016,
\nCoral Gables, FL 33114-1016
\nCUBA
\nDr. Enrique HUERTAS, President
\nTel: (1-305) 446 9902\/445 1429
\nFax: (1-305) 4459310
\nE-mail: info@sirspeedy5551.com
\nCyprus Medical Association
\n14 Thasou Street, 1087 Nicosia
\nCYPRUS
\nDr. Andreas DEMETRIOU,
\nPresident
\nTel. (357) 22 33 16 87
\nFax: (357) 22 31 69 37
\nE-mail: cyma@cytanet.com.cy
\nWebsite: www.cyma.org.cy
\nCzech Medical Association
\nSokolsk\u00e1 31 – P.O. Box 88
\n120 26 Prague 2
\nCZECH REPUBLIC
\nProf. Jaroslav BLAHOS, President
\nTel: (420) 224 266 201-4
\nFax: (420) 224 266 212
\nE-mail: czma@cls.cz
\nWebsite: www.cls.cz
\nDanish Medical Association
\n9 Trondhjemsgade, 2100
\nCopenhagen
\nDENMARK
\nDr.Mads Koch HANSEN, President
\nTel: (45) 35 44 82 29
\nFax: (45) 35 44 85 05
\nE-mail: er@dadl.dk
\nWebsite: www.laeger.dk
\nEgyptian Medical Association
\nDar El Hekmah
\n42 Kasr El-Eini Street, Cairo
\nEGYPT, ARAB REPUBLIC
\nProf. Ibrahim BADRAN
\nTel: (20-2) 27 94 09 91
\nFax: (20-2) 27 95 78 17
\nE-mail: ganzory@tedata.net.eg
\nColegio M\u00e9dico de El Salvador
\nFinal Pasaje N\u00b0 10, Colonia
\nMiramonte
\nSan Salvador
\nEL SALVADOR
\nDr. Milton Dagoberto Ram\u00f3n
\nBRIZUELA, President
\nE-mail: juntadirectiva@
\ncolegiomedico.org.sv
\nWebsite: colegiomedico.org.sv
\nEstonian Medical Association
\nPepleri 32, 51010 Tartu
\nESTONIA
\nDr. Andres KORK, President
\nTel: (372) 7 420 429
\nFax: (372) 7 420 429
\nE-mail: eal@arstideliit.ee
\nWebsite: www.arstideliit.ee
\nEthiopian Medical Association
\nP.O. Box 2179, Addis Ababa
\nETHIOPIA
\nDr. Fuad TEMAM,
\nPresident
\nTel: 251 115 521776\/
\n251 115 547982
\nFax: 251 115 151005
\nE-mail: info@emaethiopia.org
\nWebsite: www.emaethiopia.org
\nFiji Medical Association
\n304 Wainamu Road,G.P.O.
\nBox 1116,Suva
\nFIJI
\nDr. James Fong, President
\nTel: (679) 3315388
\nFax: (679) 3315388
\nE-mail: fma@unwired.com.fj
\nWebsite: fijimedassoc.webnode.com
\nFinnish Medical Association
\nP.O. Box 49, 00501 Helsinki
\nFINLAND
\nDr. RAJANIEMI,Tuula,
\nPresident
\nTel: (358-9) 393 091
\nFax: (358-9) 393 0794
\nE-mail:
\nsuvi.koljonen@laakariliitto.fi
\nWebsite: www.laakariliitto.fi\/en
\nConseil National de l\u2019Ordre des
\nM\u00e9decins (CNOM)
\n180, Blvd. Haussmann,
\n75389 Paris Cedex 08
\nFRANCE
\nDr. Patrick, BOUET Chair
\nTel: (33) 2 99 38 55 88
\nFax. (33) 2 99 38 15 57
\nE-mail: international@
\ncn.medecin.fr
\nWebsite:
\nwww.conseil-national.medecin.fr
\nGeorgian Medical Association
\n7 Asatiani Street, 0177 Tbilisi
\nGEORGIA
\nProf. Gia LOBZHANIDZE,
\nPresident
\nTel. (995 32) 398686
\nFax. (995 32) 396751\/398083
\nE-mail.
\ngeorgianmedicalassociation@gmail.com
\nWebsite: www.gma.ge
\nBundes\u00e4rztekammer
\n(German Medical Association)
\nPostfach 120 864
\n10598 Berlin
\nGERMANY
\nDr. Frank Ulrich MONTGOMERY,
\nPresident
\nTel: (49-30) 4004 56 360
\nFax: (49-30) 4004 56 384
\nE-mail: international@baek.de
\nWebsite: www.baek.de
\nGhana Medical Association
\nP.O. Box 1596, Accra
\nGHANA
\nDr. Kwabena OPOKU-ADUSEI,
\nPresident
\nTel. (233-21) 670510\/665458
\nFax. (233-21) 670511
\nE-mail: gma@dslghana.com
\nAssociation M\u00e9dicale Haitienne
\n1\u00e8re Av. du Travail #33 – Bois Verna
\nPort-au-Prince
\nHAITI
\nDr. Marie Ginette RIVIERE
\nLUBIN, President
\nE-mail: secretariatamh@gmail.com
\nHong Kong Medical Association,China
\nDuke of Windsor Social Service
\nBuilding
\n5th
\nFloor, 15 Hennessy Road
\nHONG KONG
\nDr.TSE Hung Hing,, President
\nTel: (852) 2527-8285
\nFax: (852) 2865-0943
\nE-mail: hkma@hkma.orgoui
\nWebsite: www.hkma.org
\nHungarian Medical Chamber
\nSzondi utca 100
\n1068 Budapest
\nHUNGARY
\nDr. Istvan, EGER President
\nTel: +36 13020065
\nFax: +36 13540463
\nE-mail: elnok@mok.hu
\nWebsite: www.mok.hu
\nIcelandic Medical Association
\nHlidasmari 8, 201 K\u00f3pavogur
\nICELAND
\nDr.Thorbj\u00f6rn J\u00d3NSSON, President
\nTel: (354) 864 0478
\nFax: (354) 5 644106
\nE-mail: lis@lis.is
\nWebsite: www.lis.is
\n39
\nIndian Medical Association
\nIndraprastha Marg,110 002 New Delhi
\nINDIA
\nDr. K. VIJAYAKUMAR,
\nNational President
\nTel: (91-11)
\n23370009\/23378819\/23378680
\nFax: (91-11) 23379178\/23379470
\nE-mail: inmedici@gmail.com
\nWebsite: www.ima-india.org
\nIndonesian Medical Association
\nJl. Samratulangi No. 29, 10350 Jakarta
\nINDONESIA
\nDr. Zaenal ABIDIN, President
\nTel: (62-21) 3150679\/3900277
\nFax: (62-21) 390 0473
\nE-mail: pbidi@idionline.org
\nWebsite: www.idionline.org
\nIrish Medical Organisation
\n10 Fitzwilliam Place, 2 Dublin
\nIRELAND
\nDr. Matthew SADLIER, President
\nTel: (353-1) 6767273
\nFax: (353-1) 662758
\nE-mail: imo@imo.ie
\nWebsite: www.imo.ie
\nIsraeli Medical Association
\n2 Twin Towers, 35 Jabotinsky St.
\nP.O. Box 3566, 52136 Ramat-Gan
\nISRAEL
\nDr. Leonid EIDELMAN, President
\nTel: (972-3) 610 0444
\nFax: (972-3) 575 0704
\nE-mail: michelle@ima.org
\nWebsite: www.ima.org.il
\nFederazione Nazionale degli Ordini
\ndei Medici
\nChirurghi e degli Odontoiatri
\nPiazza Cola di Rienzo 80\/a
\n00192 Roma
\nITALY
\nDr. Amedeo BIANCO, President
\nTel: +39 06 36203242
\nFax: +39 06 3222794
\nE-mail: estero@fnomceo.it
\nWebsite: www.fnomceo.it
\nJapan Medical Association
\n2-28-16 Honkomagome,
\n113-8621 Bunkyo-ku,Tokyo
\nJAPAN
\nDr.Yoshitake YOKOKURA,President
\nTel: (81-3) 3946 2121\/3942 6489
\nFax: (81-3) 3946 6295
\nE-mail: jmaintl@po.med.or.jp
\nWebsite: www.med.or.jp\/english
\nNational Medical Association of the
\nRepublic of Kazakhstan
\n117\/1 Kazybek bi St., Almaty
\nKAZAKHSTAN
\nDr. Aizhan SADYKOVA, President
\nTel. (7-327 2) 624301\/2629292
\nFax. (7-327 2) 623606
\nE-mail: doktor_sadykova@mail.ru
\nKorean Medical Association
\n302-75 Ichon 1-dong
\n140-721 Yongsan-gu, Seoul
\nKOREA, REPUBLIC
\nDr. Hwan Kyu ROH, President
\nTel: (82-2) 794 2474
\nFax: (82-2) 793 9190\/795 1345
\nE-mail: intl@kma.org
\nWebsite: www.kma.org
\nKuwait Medical Association
\nJabriah, Blk,\u00a0 2 Next To Blood Bank
\nKUWAIT
\nDr. Ali Zaid ALMAKAIMI,
\nPresident
\nFax: (965) 25333905\/(965) 25333276
\nTel:\u00a0 1881181 Ext: 100\/101
\nE-mail. doctorshehab@gmail.com
\nWebsite: www.kma.org.kw
\nLatvian Medical Association
\nSkolas Str. 3, Riga 1010
\nLATVIA
\nDr. Peteris APINIS, President
\nTel: (371) 67287321\/67220661
\nFax: (371) 67220657
\nE-mail: lma@arstubiedriba.lv
\nWebsite: www.arstubiedriba.lv
\nLiechtensteinische \u00c4rztekammer
\nEssanestrasse 93\u00a0
\n9492 Eschen
\nLIECHTENSTEIN
\nDr. Rainer DE MEIJER, President
\nT +(423)370 20 30\u00a0
\n20 31 F +423,370
\nE-mail: office@aerztekammer.li
\nWebsite: www.aerztekammer.li
\nLithuanian Medical Association
\nLiubarto Str. 2, 2004 Vilnius
\nLITHUANIA
\nDr. Liutauras LABANAUSKAS,
\nPresident
\nTel.\/Fax. (370-5) 2731400
\nE-mail: lgs@takas.lt
\nWebsite: www.lgs.lt
\nAssociation des M\u00e9decins et
\nM\u00e9decins Dentistes
\ndu Grand-Duch\u00e9 de Luxembourg
\n(AMMD)
\n29, rue de Vianden, 2680
\nLuxembourg
\nLUXEMBOURG
\nDr. Jean UHRIG, President
\nTel: (352) 44 40 33 1
\nFax: (352) 45 83 49
\nE-mail: secretariat@ammd.lu
\nWebsite: www.ammd.lu
\nMacedonian Medical Association
\nDame Gruev St. 3, P.O. Box 174,
\n91000 Skopje
\nMACEDONIA, FYR
\nProf. Dr. Jovan TOFOSKI,
\nPresident
\nTel: (389-2) 3162 577\/7027 9630
\nFax: (389-91) 232577
\nE-mail: mld@unet.com.mk
\nWebsite: www.mld.org.mk
\nSociety of Medical Doctors
\nof Malawi
\nPost Dot Net, 387X,
\nCrossroads
\nLilongwe
\nMALAWI
\nDr. Douglas Komani LUNGU,
\nPresident
\nE-mail: smdmalawi@gmail.com\u00a0
\nWebsite: www.smdmalawi.org
\nMalaysian Medical Association
\n4th
\nFloor, MMA House,
\n124 Jalan Pahang
\n53000 Kuala Lumpur
\nMALAYSIA
\nDr. Dato\u2019 Dr. N.K.S.Tharmaseelan,
\nPresident
\nTel: (60-3) 4041 1375
\nFax: (60-3) 4041 8187
\nE-mail: info@mma.org.my
\nWebsite: www.mma.org.my
\nOrdre National des M\u00e9decins
\ndu Mali
\nArea of the river Bamako
\nMALI
\nDr. Lassana FOFANA,
\nPresident
\nTel. (223) +223 20 22 20 58
\nE-mail: cnommali@gmail.com
\nWebsite: cnom.sante.gov.ml
\nMedical Association of Malta
\nThe Professional Centre,
\nSliema Road, Gzira GZR 06
\nMALTA
\nDr. Steven Fava, President
\nTel: (356) 21312888
\nFax: (356) 21331713
\nE-mail: martix@maltanet.net
\nWebsite: www.mam.org.mt
\nColegio Medico de Mexico
\nAdolfo Prieto #812, Col. Del Valle,
\nD. Benito Ju\u00e1rez, Mexico 03100
\nMEXICO
\nDr. Ramon MURIETTA, President
\nE-mail: colegiomedicomexico.
\nfederacion@gmail.com
\nWebsite:
\nwww.colegiomedicodemexico.org.mx
\nMedical Chamber of Montenegro
\nUl. Slobode 64\/1
\n81000 Podgorica
\nMONTENEGRO
\nDr. Djoko Jocic, President
\nE-mail: lkomcg@t-com.me
\nWebsite: www.ljekarskakomora.co.me
\nAssociacao Medica de Mocambique
\nAvenida Salvador Allende, n. 560,
\n1 andar, Maputo
\nMOZAMBIQUE
\nDr. Jorge ARROZ, President
\nTel: (258) 843 050 610
\nFax: (258) 213 248 34
\nE-mail: rsalomao@teledata.mz
\nMyanmar Medical Association
\nNo. 249,Theinbyu Road
\nMingalartaungnyunt Township,
\nYangon Region
\nMYANMAR
\nProf. Kyaw Myint Naing, President
\nTel: +95-01-380899, 388097, 394141
\nFax: +95-01-378863
\nE-mail: mmacorg@gmail.com
\nWebsite: www.mmacentral.org
\nMedical Association of Namibia
\n9 Bassingthwaighte Street
\nKlein Windhoek
\nP O Box 3369
\nWindhoek
\nNAMIBIA
\nDr. Reinhardt SIEBERHAGEN,
\nPresident
\nTel. (264) 61 22 4455
\nFax. (264) 61 22 4826
\nE-mail: man.office@iway.na
\nWebsite: www.man.com.na
\n40
\nNepal Medical Association
\nSiddhi Sadan, Post Box 189,
\nExhibition Road, Katmandu
\nNEPAL
\nDr. Anjani Kumar JHA,
\nPresident
\nTel:\u00a0+977 1 4225860\/4231825
\nFax:\u00a0+977 1 4225300
\nE-mail:\u00a0info@nma.org.np
\nWebsite: www.nma.org.np
\nRoyal Dutch Medical Association
\nP.O. Box 2005, 3502 LB, Utrecht
\nNETHERLANDS
\nDr. R.J. Van Der GAAG,
\nPresident
\nTel: (31-30) 282 32 67
\nFax: (31-30) 282 33 18
\nE-mail: info@fed.knmg.nl
\nWebsite: knmg.artsennet.nl
\nNew Zealand Medical Association
\nP.O. Box 156,\u00a0Level 13 Greenock
\nHouse, 39,The Terrace,
\nWellington 1
\nNEW ZEALAND
\nDr. Lesley CLARKE, Chief
\nExecutive Officer
\nDr. Mark PETERSON,
\nChairman
\nTel: (64-4) 472 4741
\nFax: (64-4) 471 0838
\nE-mail: nzma@nzma.org.nz
\nWebsite: www.nzma.org.nz
\nNigerian Medical Association
\n8 Benghazi Street,
\nOff Addis Ababa, Crescent,
\nWuse Zone 4,
\nFCT, PO Box 8829,
\nWuse Abuja
\nNIGERIA
\nDr. Osahon ENABULELE,
\nPresident
\nTel: (234-1) 480 1569, 876 4238
\nFax: (234-1) 493 6854
\nE-mail: nationalnma@yahoo.com
\nNorwegian Medical Association
\nP.O.Box 1152 sentrum, 0107 Oslo
\nNORWAY
\nHege GJESSING, President\u00a0
\nTel: (47) 23 10 90 00
\nFax: (47) 23 10 90 10
\nE-mail:
\nlegeforeningen@legeforeningen.no
\nWebsite: legeforeningen.no
\nAsociaci\u00f3n M\u00e9dica Nacionalde la
\nRep\u00fablica de Panam\u00e1
\nApartado Postal 2020, Panam\u00e1 1
\nPANAMA
\nDr. Alfredo MACHARAVIAYA,
\nPresident
\nTel: (507) 263 7622\/263-7758
\nFax: (507) 223 1462
\nE-mail: amenalpa@cwpanama.net
\nColegio M\u00e9dico del Per\u00fa
\nMalec\u00f3n Armend\u00e1riz N\u00b0 791,
\nMiraflores, Lima
\nPERU
\nDr. Juan VILLENA VIZCARRA ,
\nPresident
\nTel: (51-1) 213 1400
\nFax: (51-1) 213 1412
\nE-mail: clunyd@hotmail.com
\nWebsite: www.cmp.org.pe
\nPhilippine Medical Association
\nPMA Bldg.,
\nNorth Avenue, Quezon City 1105
\nPHILIPPINES
\nDr. Modesto O. LLAMAS,
\nPresident
\nTel: (63-2) 929 63 66
\nFax: (63-2) 929 69 51
\nE-mail:
\ninfo@philippinemedicalassociation.org
\nWebsite:
\nphilippinemedicalassociation.org
\nPolish Chamber of Physicians and
\nDentists
\n(Naczelna Izba Lekarska)
\n110 Jana Sobieskiego, 00-764
\nWarsaw
\nPOLAND
\nDr. Maciej HAMANKIEWICZ,
\nPresident
\nTel. (48) 22 55 91 300\/324
\nFax: (48) 22 55 91 323
\nE-mail: sekretariat@hipokrates.org
\nWebsite: www.nil.org.pl
\nOrdem dos M\u00e9dicos (Portugal)
\nAv. Almirante Gago Coutinho 151,
\n1749-084 Lisbon
\nPORTUGAL
\nDr. Jos\u00e9 Manuel SILVA, President
\nTel: (351-21) 842 71 00\/842 71 11
\nFax: (351-21) 842 71 99
\nE-mail: omcne@omcne.pt
\nWebsite: www.ordemdosmedicos.pt
\nRomanian College of Physicians
\nBulevardul Timisoara nr. 15,
\n061303 Sector 6, Bucarest
\nROMANIA
\nProf. Dr. Vasile ASTARASTOAE,
\nPresident
\nTel: (40-21) 413 88 00
\nFax: (40-21) 413 77 50
\nE-mail: office@cmr.ro
\nWebsite: www.cmr.ro
\nRussian Medical Society
\nUdaltsova Street 85,
\n119607 Moscow
\nRUSSIAN FEDERATION
\nDr. Sergey BAGNENKO,
\nPresident
\nTel: (7-495) 734 12 12
\nFax: (7-495) 734 11 00
\nE-mail. info@russmed.ru
\nWebsite:
\nwww.russmed.ru\/eng\/who.htm
\nSamoa Medical Association
\nTupua Tamasese Meaole Hospital
\nPrivate Bag\u00a0– National Health
\nServices,
\nApia
\nSAMOA
\nDr. Viali LAMEKO, President
\nTel. (685) 778 5858
\nE-mail: viali1_lameko@yahoo.com
\nOrdre National des M\u00e9decins
\ndu S\u00e9n\u00e9gal
\nInstitut d\u2019Hygi\u00e8ne Sociale
\n(Polyclinique)
\nBP 27115 Dakar
\nSENEGAL
\nDr. Sheikh A.\u00a0Bamba Diop,
\nPresident
\nTel. (221) 33 822 29 89
\nFax: (221) 33 821 11 61
\nE-mail: lamsow@orange.sn
\nWebsite: www.ordremedecins.sn
\nLekarska Komora Srbije
\n(Serbian Medical Chamber)
\nKraljice Natalije 1-3, Belgrade
\nSERBIA
\nDr.Tatjana RADOSAVLJEVIC,
\nGeneral Manager
\nE-mail:
\nlekarskakomorasrbije@gmail.com
\nWebsite: www.lks.orgs.rs
\nSingapore Medical Association
\nAlumni Medical Centre,
\nLevel 2
\n2 College Road 169850
\nSINGAPORE
\nDr. Jing Jih CHIN,
\nPresident
\nTel. (65) 6223 1264
\nFax. (65) 6224 7827
\nE-mail. sma@sma.org.sg
\nWebsite: www.sma.org.sg
\nSlovak Medical Association
\nCukrova 3, 813 22
\nBratislava 1
\nSLOVAK REPUBLIC
\nProf. Peter KRIST\u00daFEK,
\nPresident
\nTel. (421) 5292 2020
\nFax. (421) 5263 5611
\nE-mail: secretarysma@ba.telecom.sk
\nWebsite: www.sls.sk
\nSlovenian Medical Association
\nKomenskega 4,
\n61001 Ljubljana
\nSLOVENIA
\nProf. Dr. Pavel POREDOS,
\nPresident
\nTel. (386-61) 323 469
\nFax: (386-61) 301 955
\nE-mail: matija.cevc@trnovo.kclj.si
\nSomali Medical Association
\nKPP, Wadnaha Street, Hodan
\nDistrict
\nMogadishu
\nSOMALIA
\nProf. Osman Adan ABDULLE,
\nPresident
\nTel: +615-777615\/+699-999222
\nE-mail: drmumin@hotmail.com
\nThe South African Medical
\nAssociation
\nP.O. Box 74789,
\nLynnwood Rydge
\n0040 Pretoria
\nSOUTH AFRICA
\nProf. Zephne VAN DER SPUY,
\nPresident
\nTel: (27-12) 481 2037
\nFax: (27-12) 481 2100
\nE-mail: online@samedical.org
\nWebsite: www.samedical.org
\nConsejo General de Colegios
\nM\u00e9dicos de Espa\u00f1a
\nPlaza de las Cortes 11 4a,
\n28014 Madrid
\nSPAIN
\nDr. Juan Jos\u00e9 RODRIGUEZ-
\nSENDIN, President
\nTel: (34-91) 431 77 80
\nFax: (34-91) 431 96 20
\nE-mail: internacional@cgcom.es
\nWebsite: www.cgcom.es
\nSri Lanka Medical Association
\nWijerama House, 6 Wijerama
\nMawatha
\nColombo 00700
\nSRI LANKA
\nDr. Palitha Abeykoon,
\nPresident
\nTel: +94-112-693 324
\nFax: +94-112-698 802
\nE-mail:\u00a0slma@eureka.lk
\nWebsite: www.slmaonline.info
\nSudan Doctors Union
\nPost box : 1001 Khartoum
\n11111 Khartoum
\nSUDAN
\nProf. Abdalzaeem M. KABALLO,
\nPresident
\nTel: +(249-83)777617
\nFax: +(249-83)778322
\nE-mail: azimkaballo@yahoo.com
\nSwedish Medical Association
\n(Villagatan 5)
\nP.O. Box 5610,
\nSE – 114 86 Stockholm
\nSWEDEN
\nDr. Marie WEDIN,
\nPresident
\nTel: (46-8) 790 35 01
\nFax: (46-8) 10 31 44
\nE-mail: info@slf.se
\nWebsite: www.slf.se
\nF\u00e9d\u00e9ration des M\u00e9decins Suisses
\nElfenstrasse 18,
\nC.P. 170, 3000 Berne 15
\nSWITZERLAND
\nDr. Juerg SCHLUP,
\nPresident
\nTel. (41-31) 359 11 11
\nFax. (41-31) 359 11 12
\nE-mail: saqm@fmh.ch
\nWebsite: www.fmh.ch
\nTaiwan Medical Association
\n9F, No 29 Sec.1,
\nAn-Ho Road,
\n10688 Taipei
\nTAIWAN
\nDr. Ching-Chuan SU,
\nPresident
\nTel: (886-2) 2752-7286
\nFax: (886-2) 2771-8392
\nE-mail: intl@tma.tw
\nWebsite: www.tma.tw\/EN_tma
\nMedical Association of Tanzania
\nP.O. Box 701,
\n255 Dar es Salam
\nTANZANIA
\nPrimus Felician Saidia,
\nPresident
\nE-mail: kajuna2010@gmail.com
\nWebsite: www.mat-tz.org
\nMedical Association of Thailand
\n2 Soi Soonvijai, New Petchburi
\nRoad, Huaykwang Dist.,
\n10320 Bangkok
\nTHAILAND
\nDr. Wonchat SUBHACHATURAS,
\nPresident
\nTel: (66-2) 314 4333\/318-8170
\nFax: (66-2) 314 6305
\nE-mail: math@loxinfo.co.th
\nWebsite: www.mat.or.th
\nTrinidad and Tobago Medical
\nAssociation
\nThe Medical House, #1 Sixth
\nAvenue,
\nOrchard Gardens, Chaguanas
\nTRINIDAD AND TOBAGO
\nDr. Rohit DASS,
\nPresident
\nTel: (868) 671-5160
\nFax: (868) 671-7378
\nE-mail: medassocS@tntmedical.com
\nWebsite: www.tntmedical.com
\nConseil National de l\u2019Ordre des
\nM\u00e9decins de Tunisie,
\n16, rue de Touraine, 1002 Tunis
\nTUNISIA
\nDr. Mohamed N\u00e9jib
\nCHAABOUNI,
\nPresident
\nTel: (216-71) 792 736\/799 041
\nFax: (216-71) 788 729
\nE-mail: cnom@planet.tn
\nWebsite: www.ordre-medecins.org.tn
\nTurkish Medical Association
\nChi GMK Boulevard.\u00a0Danis
\nTunaligil Sok.\u00a0No: 2\/17 to 23
\nMaltepe, Ankara
\nTURKEY
\nAhmet \u00d6zdemir Aktan,
\nChairman
\nTel: (90-312) 231 31 79
\nFax: (90-312) 231 19 52
\nE-mail: Ttb@ttb.org.tr
\nWebsite: www.ttb.org.tr
\nUganda Medical Association
\nPlot 8, 41-43 circular rd.
\nP.O. Box 29874, Kampala
\nUGANDA
\nDr. Margaret MUNGHERERA,
\nPresident
\nTel. +256 772 434 652
\nFax. (256) 41 345 597
\nE-mail:
\nmmungherera@yahoo.co.uk
\nWebsite: www.uma.co.ug
\nUkrainian Medical Association
\n7 Eva Totstoho Street,
\nPO Box 13,
\n01601 Kyiv
\nUKRAINE
\nDr. Oleg MUSIJ, President (2013)
\nTel: (380) 50 355 24 25
\nFax: (380) 44 501 23 66
\nE-mail: sfult@ukr.net
\nBritish Medical Association
\nBMA House,
\nTavistock Square,
\nWC1H 9JP London
\nUNITED KINGDOM
\nProf. Vivienne NATHANSON,
\nDirector of Professional Activities
\nTel: (44-207) 387-4499
\nFax: (44-207) 383-6400
\nE-mail: vnathanson@bma.org.uk
\nWebsite: www.bma.org.uk
\nAmerican Medical Association
\n515 North State Street,
\n60654 Chicago, Illinois
\nUNITED STATES
\nDr. Ardis Dee HOVEN, President
\nTel: (1-312) 464 5291\/464 5040
\nFax: (1-312) 464 2450
\nE-mail:
\nellen.waterman@ama-assn.org
\nWebsite: www.ama-assn.org
\nSindicato M\u00e9dico del Uruguay
\nBulevar Artigas 1565\/1569,
\nCP 11200 Montevideo
\nURUGUAY
\nDr.TROSTCHANSKY
\nVASCONCELLOS, Julio, President
\nTel: (598-2) 401 47 01
\nFax: (598-2) 409 16 03
\nE-mail: secretaria@smu.org.uy
\nWebsite: www.smu.org.uy
\nMedical Association of Uzbekistan
\nStr. Parkenentskay 51,
\nTashkent City 100007
\nUZBEKISTAN
\nProf. Abdulla
\nKHUDAYBERGENOV, President
\nE-mail: info@avuz.uz
\nWebsite: www.avuz.uz
\nAssociazione Medica del Vaticano
\nStato della Citta del Vaticano,
\n00120 Citt\u00e0 del Vaticano
\nVATICAN STATE
\nProf. Renato BUZZONETTI,
\nPresident
\nTel: (39-06) 69879300
\nFax: (39-06) 69883328
\nE-mail: servizi.sanitari@scv.va
\nFederacion MedicaVenezolana
\nAv. Orinoco con Avenida Perija,
\nUrbanizacion Las Mercedes,
\n1060 CP Caracas
\nVENEZUELA, RB
\nDr.Douglas Leon NATERA,President
\nE-mail: info@saludfmv.org
\nWebsite:
\nwww.federacionmedicavenezolana.org
\nVietnam Medical Association
\n68A Ba Trieu-Street, Hoau Kiem
\nDistrict, Hanoi
\nVIETNAM
\nDr. Pham SONG, President
\nTel: (84) 4 943 9323\/943 1866
\nFax: (84) 4 943 9323
\nE-mail: vgamp@hn.vnn.vn
\nZimbabwe Medical Association
\nP.O. Box 3671, Harare
\nZIMBABWE
\nDr. Billy RIGAWA, President
\nTel. (263-4) 791553
\nFax. (263-4) 791561
\nE-mail: zima@zol.co.zw
\nWebsite: www.zima.org.zw
\nIV
\nDr. Musij, an anaesthetist and President
\nof the Ukrainian Medical Association, has
\nrepresented his country at the WMA in re-
\ncent years.
\nCommenting on his appointment,
\nDr.\u00a0Musij\u00a0said:\u00a0\u201eThe Ministry of Health of
\nUkraine faces many challenges that urgently
\nneed solving.The country has a poor economy
\nand poor health care and to tackle these the
\nMinistry has to take a number of organiza-
\ntional measures to work efficiently. Its main
\ngoal is to preserve and ensure the health of
\nthe Ukrainian nation. Despite the difficulties
\nwe face, health care reform must not stop\u201d.
\nDr. Otmar Kloiber, Secretary General of
\nthe WMA, said:\u00a0\u201eWe offer our friend and
\ncolleague\u00a0Dr. Musij our\u00a0best wishes and full
\nsupport in the difficult tasks he faces.\u00a0These
\nhave been difficult months so far and it will
\nnot be easy in the near future.\u201d
\nDr. Musij, who has studied in Poland, the
\nUSA, Finland, Austria and Germany, has
\nbeen chairman of the Kiev Medical Asso-
\nciation and Vice-President of the World
\nFederation of Ukrainian medical societies.
\nHe is a board member of the international
\nmedical organization \u2013 Southeast Euro-
\npean Medical Forum (Southeast Euro-
\npean Medical Forum, SEEMF, Bulgaria)
\nand has been involved in drafting many of
\nhis country\u2019s laws on health, professional
\nself-government and self-regulation of
\nmarkets.
\nContents
\nThe World Medical Association has offered its support to the newly
\nappointed Minister of Health in Ukraine, Dr. Oleg Musij\u00a0
\nOleg Musij
\nNew Year Message from the President, World Medical
\nAssociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
\nReconstruction of the Radiation Emergency Medical
\nSystem from the Acute to the Sub-acute Phases
\nAfter the Fukushima Nuclear Power Plant Crisis . . . . . . . 2
\nHistory of AMA Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
\nMedical Profession in Latvia Today . . . . . . . . . . . . . . . . . . 11
\nOn the Road to Tobacco-Free Finland . . . . . . . . . . . . . . . . 23
\nThe Hong Kong Medical Association . . . . . . . . . . . . . . . . 27
\nNew Chamber of Physicians Established in Kosovo . . . . . 29
\nMedical Chamber of Montenegro . . . . . . . . . . . . . . . . . . . 30
\nIrish Medical Organisation Celebrates 30\u00a0years . . . . . . . . . 31
\nEthics at the BMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
\nExcess Weight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . 34
\nWMA Directory of Constituent Members . . . . . . . . . . . . 37<\/p>\n"},"caption":{"rendered":"

wmj201401 COUNTRY \u2022 Reconstruction of the Radiation Emergency Medical System in Japan \u2022 On the Road to Tobacco-Free Finland vol. 60 MedicalWorld Journal Official Journal of the World Medical Association, INC G20438 Nr. 1, February 2014 Cover picture from JAPAN Editor in Chief Dr. P\u0113teris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone […]<\/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\/wmj201401.pdf","_links":{"self":[{"href":"https:\/\/www.wma.net\/fr\/wp-json\/wp\/v2\/media\/3662"}],"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=3662"}]}}