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wmj201503<\/a><\/p>\n

COUNTRY
\nvol. 61
\nMedicalWorld
\nJournal
\nOfficial Journal of The World Medical Association, Inc.
\nISSN 2256-0580
\nNr. 3, October 2015
\nContents
\nDoctor in the World and Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t81
\nInterview with Dr. Xavier Deau, President of the World Medical Association . . . . . . . . . . . . \t82
\nInterview with Dr. Zsuzsanna Jakab, WHO Regional Director for Europe . . . . . . . . . . . . . . . \t83
\nInterview with Dr. Jacques de Haller, Vice\u00a0President, President Elect
\n2016\u20132018 (Switzerland) of CPME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t86
\nFrom Zoonosis to Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t87
\nHealth and Asylum Seekers in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t89
\nInternational Committee of the Red Cross activities for refugees\/displaced persons
\nin the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \t98
\nSubjectivity and Narratives in Primary Care: A Person Centered Issue. . . . . . . . . . . . . . . . . . . \t106
\nThe Integration of Mental Health and Primary Care: A Person-centered Approach. . . . . . . . \t109
\nThe Road to Paris: What is at Stake for Health in COP21 Negotiations? . . . . . . . . . . . . . . . . . \t114
\nMore Good Days: Person-Centered Care at\u00a0the End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . \t119
\nBACK TO CONTENTS
\n81
\nEditorial
\nIn the modern world, pharmaceutical business is an honorary sec-
\nond runner-up among the most profiteering businesses, right after
\ntrafficking in humans and in drugs. With the recent shipping of
\nrefugees to Europe, the winner and the first runner-up have merged
\ninto one.The pharmaceutical business mostly is a quite legal, trans-
\nparent and straight one,except for counterfeit medicines which take
\nup 10\u201315% of the market. For a medical doctor, global information
\navailable in 2015 is interesting due to the following patterns:
\n(I) clinical research is becoming increasingly costly, new drugs are
\ngetting discovered less,generics are taking up higher proportion and
\neven prevail in the market. Countries and regions happen to over-
\nlook the letter and spirit of the Helsinki Declaration, particularly in
\nrespect of the work of the Ethics Committees;
\n(II) the pharmaceutical industry is losing interest in small-size mar-
\nkets, production costs are increasing due to quality control require-
\nments, whereas compensation systems in the countries fail to evolve
\ntogether with the changing market. The pharmaceutical business is
\nfacing new challenges, which are shortages of production capacities
\nand limited availability of raw materials;
\n(III) the accessibility of medicines and counterfeit drugs is becom-
\ning a global problem as a result of internet pharmacies chains, re-
\nexport with the purpose of price arbitrage and parallel import;
\n(IV) refugee crisis in Europe (also the flows of refugees in Asia,
\nAustralia,the Republic of South Africa and some countries in Latin
\nAmerica) involve uncertainties about the immigrants\u2019state of health,
\ninfectious and parasitic diseases, vaccination against dangerous dis-
\neases, e.g. poliomyelitis.With some countries failing financially (e.g.
\nGreece is unable to settle its payments for the delivered medicines
\nfor quite a while), selected segments of the drugs market start pan-
\nicking, and a tendency emerges to stock up some medicines, instead
\nof placing them on the market;
\n(V) there is not enough research as to the dosages for senior patients
\nand children: it is still believed that patients, though dissimilar as to
\nage, gender or physical capacities, should get prescribed medicines
\nin equal dosages;
\n(VI) most of clinical trials are shifted to developing countries,which
\nleads to a mistrust in the trial results in developed countries;
\n(VII) resistance to drugs is increasing, and not exclusively to anti-
\nbiotics. The body cells tend to develop biochemical dependency on
\nmedicines, and dosages need to be raised;
\n(VIII) polypragmasia as a medical problem in industrial and devel-
\noped economies.Both in Europe and America,the population in the
\nage group beyond 50 are taking more than six different drugs daily,
\nplus a number of food supplements and over-the-counter medicines.
\nFor the time being, no proper research has been done, and there is
\na lack of understanding how much food supplements and other
\nchemically active substances are being consumed along with medi-
\ncines (e.g. illegal psychoactive substances, sports drinks and powders
\netc.). Advertising promotes unreasonable consumption of medicines
\nand food supplements, especially among senior citizens;
\n(IX) biomedicines \u2013 medicines of the future \u2013 and their biological
\nequals appear in the market without adequate knowledge and un-
\nderstanding on the part of doctors and pharmacists,they are scarcely
\nused due to the high price;
\n(X) medicines launched to the market at an early stage and having
\nheightened vigilance, which have been subject to less trials and who
\nmay have more side effects, especially when taken with other medi-
\ncines. Individualised medicines are being released to the market as
\nwell;
\n(XI) non-cooperating patients. 25\u201340% of patients are non-cooper-
\nating when receiving treatment: they are neither willing nor moti-
\nvated to get well again.10\u201320% of population prefer to be treated by
\ncharlatans, healers and witchdoctors, or by psychologists or psycho-
\ntherapists without any medical education etc.. Alongside with the
\ndrugs prescribed by the doctor, nature therapy, Ayurveda medicines
\nand other chemically active substances are used;
\n(XII) medicines are continuously being discarded in open environ-
\nment and may end up into food; in most cases the non-used medi-
\ncines still do not get destroyed.
\nThis list could be compiled in a different order and complemented
\nwith other items. In global medicine, the influence of the pharma-
\nceutical industry is increasing, people are ageing, funds from gov-
\nernments or insurance are not sufficient to pay for medicines.
\nThe World Medical Association has to analyse the developments in
\nthe medicines market all over again.
\nDr. P\u0113teris Apinis
\nPresident of the Latvian Medical Association
\nEditor in Chief
\nDr. P\u0113teris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
\nPhone +371 67 220 661
\npeteris@arstubiedriba.lv, editorin-chief@wma.net
\nCo-Editor
\nProf. Dr. med. Elmar Doppelfeld, Deutscher \u00c4rzte-Verlag, Dieselstr. 2, D-50859 K\u00f6ln, Germany
\nAssistant Editor
\nMaira Sudraba, Velta Poz\u0146aka; lma@arstubiedriba.lv
\nJournal design and
\ncover design by
\nP\u0113teris Gricenko
\nLayout and Artwork
\nThe Latvian Medical Publisher, \u201cMedic\u012bnas apg\u0101ds\u201d, President Dr. Maija \u0160etlere, Skolas street 3, Riga, Latvia
\nPublisher
\nThe Latvian Medical Association, \u201cLatvijas \u0100rstu biedr\u012bba\u201d,
\nSkolas street 3, Riga, Latvia.
\nISSN: 2256-0580
\nDr. Xavier DEAU
\nWMA President
\nConseil National de l\u2019Ordre des
\nM\u00e9decins (CNOM)
\n180, Blvd. Haussmann
\n75389 Paris Cedex 08
\nFrance
\nDr. Donchun SHIN
\nWMA Chairperson of the Finance
\nand Planning Committee
\nKorean Medical Association
\n46-gil Ichon-ro
\nYongsan-gu, Seoul 140-721
\nKorea
\nProf. Dr. Frank Ulrich
\nMONTGOMERY
\nWMA Vice-Chairperson of Council
\nBundes\u00e4rztekammer
\nHerbert-Lewin-Platz 1 (Wegelystrasse)
\n10623 Berlin
\nGermany
\nDr. Margaret MUNGHERERA
\nWMA Immediate Past-President
\nUganda Medical Association
\nPlot 8, 41-43 circular rd., P.O.
\nBox 29874
\nKampala
\nUganda
\nDr. Joseph HEYMAN
\nWMA Chairperson
\nof the Associate Members
\n163 Middle Street
\nWest Newbury, Massachusetts 01985
\nUnited States
\nDr. Masami ISHII
\nWMA Treasurer
\nJapan Medical Assn
\n2-28-16 Honkomagome
\nBunkyo-ku
\nTokyo 113-8621
\nJapan
\nSir Michael MARMOT
\nWMA President-Elect
\nBritish Medical Association
\nBMA House,Tavistock Square
\nLondon WC1H 9JP
\nUnited Kingdom
\nDr. Heikki P\u00c4LVE
\nWMA Chairperson of the Medical
\nEthics Committee
\nFinnish Medical Association
\nP.O. Box 49
\n00501 Helsinki
\nFinland
\nDr. Miguel Roberto JORGE
\nWMA Chairperson of the Socio-
\nMedical Affairs Committee
\nBrazilian Medical Association
\nRua-Sao Carlos do Pinhal 324,
\nCEP-01333-903 Sao Paulo-SP
\nBrazil
\nDr. Ardis D. HOVEN
\nWMA Chairperson of Council
\nAmerican Medical Association
\nAMA Plaza, 330 N. Wabash,
\nSuite 39300
\n60611-5885 Chikago, Illinois
\nUnited States
\nDr. Otmar KLOIBER
\nSecretary General
\nWorld Medical Association
\n13 chemin du Levant
\n01212 Ferney-Voltaire
\nFrance
\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
\nDoctor in the World and Medicines
\nBACK TO CONTENTS
\n82 83
\nWMA News Public Health Care
\nQ.Global warming and emission gases are
\namong the world\u2019s most essential public
\nhealth problems. What initiatives can we
\nexpect from the WMA for the forthcom-
\ning Paris conference as to fighting global
\nwarming?
\nThe WMA will be present in Paris at the
\nCOP21, channelling the serious con-
\ncerns of physicians regarding the impact
\nof climate change on health. The health of
\nthe planet is our health. This is the mes-
\nsage that I would like to bring forward.
\nThe WMA has joined the Campaign \u201cOur
\nClimate, Our Health\u201d. It is a new campaign
\ncreated to mobilise the health profession in
\nthe lead up to the 2015 climate change ne-
\ngotiations in Paris. The Campaign is led by
\nthe World Health Organization in collabo-
\nration with the Global Climate and Health
\nAlliance. It aims to reach out to all parts of
\nthe health sector, communicating the links
\nbetween health and climate change, de-
\nmanding a stronger international deal, and
\nbuilding support around a common decla-
\nration\u00a0 \u2013 to be presented to negotiators in
\nParis this December. We will participate in
\nthe Climate and Health Summit which is
\nscheduled to take place on the 5th
\nof De-
\ncember in Paris in the framework of this
\nCampaign.
\nQ. Clean air, clean water and harmless
\nfood are the most important health pre-
\nconditions for global population. Right
\nnow, when the global oceans and seas are
\nbeing polluted with plastics and chemi-
\ncal products, it has an impact on each
\nsingle inhabitant on the Earth. We can
\neven call the polluting of the world with
\nchemicals a chemical war. What could
\nthe WMA do in order to reduce the glob-
\nal pollution with chemicals? Shouldn\u2019t
\nthe WMA take a more radical position
\nagainst the use of heavy metals (mercury,
\nbismuth), against pesticides, herbicides,
\nmineral substances and other substances
\nwhich inhibit the development of hor-
\nmonal system?
\nThe WMA\u2019s policies in the area of environ-
\nment have been developing over the last
\nyears with the expertise of its members. We
\nhave a clear position on climate change,
\nmercury products, chemicals, and more
\nrecently on air pollution. We have also set
\nup the environment caucus to promote ex-
\nchange of good practices and experiences
\nbetween the members. We could certainly
\nwork further on our policies. But most im-
\nportant, the challenge now is to make sure
\nthat our voice is finally heard, that strong
\ncommitments and actions are finally taken
\nby decision-makers. This is a matter of ur-
\ngency. Our planet is ill and we are all ac-
\ncountable. Mobilisation of all is what is
\nneeded today.
\nQ. Shouldn\u2019t the WMA develop its own
\nstrategy for fighting global warming
\nand use a variety of instruments, such as
\nstrong criticism of global polluters,or cre-
\nate a WMA award in recognition of the
\nmost successful pollution treatment and
\necological projects?
\nThe WMA has been increasingly active in
\nthe area of climate change nationally and
\nglobally through various means: the UN
\nprocess, the promotion of regular plat-
\nforms for discussion between NMAs and
\nalso through partnerships with the WHO
\nand non-governmental organisations,
\nactive in the area of health and environ-
\nment. I do not believe that another award
\nwill bring significant changes. Today we
\nneed concrete actions nationally and lo-
\ncally, we need to raise awareness amongst
\nthe health professionals, the public, the
\ndecision-makers. I\u00a0 nourish great hopes
\nthat the young generation will continue
\ncarrying that torch. As a matter of fact, the
\nJunior Doctors Network is extremely ac-
\ntive in putting health at the centre of the
\nclimate negotiations, and I am proud that
\nthe WMA embraces this new generation
\nof physicians.
\nInterview with Dr. Xavier Deau, President of the World Medical
\nAssociation
\nBy Dr. Peteris Apinis. September, 2015
\nXavier Deau
\n\u201cBetter Health for Europe: More Equitable
\nand Sustainable\u00a0\u2013 That is What We Work for\u201d
\nQ. The WHO Regional Office is a Euro-
\npean leader in public health area. Could
\nyou please update us on the progresses,
\nconcerns and main goals of the Region?
\nDuring the past few years, the WHO Eu-
\nropean Region made good progress in many
\nareas, but we must do more and we must
\ndo better.
\nOn key health indicators, such as life
\nexpectancy, Europeans are living longer
\nand the differences between countries in
\nhealth outcomes are shrinking: a clear
\nsign that inequalities are declining and
\nHealth 2020\u00a0\u2013 the WHO European pol-
\nicy framework developed and adopted by
\nall our 53 Member States\u00a0\u2013 works. How-
\never, the gap between the countries with
\nthe highest and lowest life expectancy is
\nstill 11 years.
\nThe Region is on track towards reduc-
\ning premature mortality due to decline
\nin cardio-vascular diseases (CVDs), and
\nEuropeans are reducing their health risk
\nbehaviours. But people in Europe still
\nsmoke and drink more than anywhere
\nelse in the world, and are among the most
\nobese.
\nWe are making progress in improving
\nwomen\u2019s health, but wide inequities be-
\ntween and within countries remain.The use
\nof modern, effective methods of contracep-
\ntion is alarmingly low in many countries.
\nSome countries have the highest abortion
\nrates in the world. Effective perinatal care
\nresulted in the decrease in the major killer
\nof mothers\u00a0\u2013 the severe obstetrical bleed-
\ning. Now is the time to focus on pre-exist-
\ning medical conditions\u00a0\u2013 such as diabetes,
\nobesity, CVD and mental diseases\u00a0\u2013 that
\nare exacerbated by pregnancy. More needs
\nto be done on sexual and reproductive
\nhealth and rights.
\nTransforming health services to match the
\nneeds of the 21st
\ncentury is the strategic pri-
\nority in our Region. Coordinated, integrat-
\ned health-service delivery towards people-
\ncentred care is the way forward.The Region
\nis scaling up efforts on strengthening health
\nsystems and public health capacity in order
\nto improve health outcomes in an equitable
\nmanner, ensuring financial protection, re-
\nsponsiveness and efficiency.
\nWe are addressing health-systems barriers
\nfor specific diseases and conditions, includ-
\ning communicable diseases and NCDs,
\nwhich are then translated into policy deci-
\nsions and actions. We are now broadening
\nthe focus to include environmentally sus-
\ntainable health systems.
\nAn extensive area of work in the Region
\nrelates to tackling public health emergen-
\ncies and crisis situations. Our aim is to en-
\nsure that our Member States are adequately
\nprepared to effectively detect and respond,
\nwhenever and wherever an emergency with
\nhealth consequences strikes. The recent Eb-
\nola outbreak in West Africa demonstrated
\nthat the international community is not suf-
\nficiently prepared to manage major health
\nhazards. This is a defining moment for
\nchange.We are fully committed to taking all
\nnecessary action.This is a global objective.In
\nthe Regional Office, we take an integrated,
\ngeneric, all-hazards and multisectoral ap-
\nproach to preparedness for both humanitar-
\nian and public health emergencies.
\nLet me stress: real improvements in health,
\nincluding the areas I just outlined, can be
\nachieved if we work across government. All
\nsectors, especially with those responsible for
\nsocial and fiscal policies, need to work in
\npartnership for better health for all.
\nIntersectoral action for health requires politi-
\ncal commitment.It should focus on key public
\nhealth priorities and upstream interventions
\nby addressing the determinants of health and
\nhealth equity,and strive for maximum impact
\nby creating win\u2013win partnerships.
\nDevelopment is impossible without better
\nhealth. Health is a precondition for alleviat-
\ning poverty, and an indicator and outcome
\nof progress towards a sustainable society.
\nMore decision-makers are making coherent
\nand interconnected government policies, with
\na strong intersectoral component, and using
\nHealth 2020 as the way forward. From 2010
\nto 2013, the proportion of countries with
\nnational health policies aligned with Health
\n2020 almost doubled: from 38% to 70%. And
\nthis is a great achievement so far.This progress
\ndemonstrates what we can do if we are com-
\nmitted and work together, but it also shows
\nthat we have many challenges ahead,confirm-
\ning that the key strategic directions of Health
\n2020 remain more relevant than ever before.
\nInterview with Dr. Zsuzsanna Jakab,
\nWHO Regional Director for Europe
\nBy Dr. Peteris Apinis. September, 2015
\nZsuzsanna Jakab
\nBACK TO CONTENTS
\n84 85
\nPublic Health CarePublic Health Care
\nOnly the governments that put health and
\nwell-being high on their social,economic and
\ndevelopment agenda will be able to overcome
\nthese challenges. Health is a political choice.
\nIn essence, Health 2020 supports making the
\nright political choices for health.Our key role
\nis to protect health as a universal value and
\nto promote it as a social and political goal for
\ngovernment and society as a whole.
\nThe economic case for investment in health
\nis strong. Investing in health generates cost-
\neffective health outcomes and economic,
\nsocial and environmental benefits. The
\nhealth sector\u2019s call on government to invest
\nin health will make this change happen. We
\nneed to give this message loudly.
\nFor example, current evidence suggests
\nthat investment in reproductive, maternal
\nand child health has a potential return of
\nmore than US$\u00a0 20 for every dollar spent.
\nThe argument for investing in the best-buy
\ninterventions is equally clear for addressing
\nnoncommunicable diseases (NCDs).
\nCurrent investments in health and public
\nhealth are not sufficient. We need to invest
\nmore. It is alarming to see that, between 2007
\nand 2011, the health share of public spending
\nfell in 24 countries in Europe.By tapping into
\nnew sources,improving efficiencies and giving
\nhigh priority to health, all countries can find
\nways to raise sufficient funds for health.
\nAlso, many countries are applying the life-
\ncourse approach in developing their na-
\ntional policies or improving collaboration
\nbetween sectors, which is a key strategic
\ndirection of Health 2020.
\nOn 25 September, world leaders gathered
\nat the United Nations summit to adopt the
\nAgenda for Sustainable Development, to
\nend poverty by 2030. The Agenda has uni-
\nversal goals that will apply to every nation\u00a0\u2013
\nnot just to developing countries. Among
\nthe 17 Sustainable Development Goals, the
\none for health is central. It aims to \u201censure
\nhealthy lives and promote well-being for all
\nat all ages\u201d. There is increasing acceptance
\nthat the new health goal must also aim to
\nachieve universal health coverage in every
\ncommunity, in every country of the world.
\nThe formulation of the health goal is fully
\naligned with Health 2020.
\nFocusing solely on the health goal would be
\na missed opportunity. All the Sustainable
\nDevelopment Goals will influence health,
\nbecause they all address the determinants
\nof health.The 2030 Agenda will link differ-
\nent dimensions of development\u00a0\u2013 including
\nhealth\u00a0\u2013 to the environment, to prosperity
\nand to all actions and policies that people
\nneed.
\nNow we have a historic political respon-
\nsibility to pursue the integration of health
\nand well-being into each and every goal.We
\nhave the opportunity to put into practice
\nthe whole-of-government and whole-of-
\nsociety approaches to which we subscribed
\nthrough Health 2020.
\nBetter health for Europe: more equitable
\nand sustainable\u00a0\u2013 that is what we work for.
\nQ. At present, there is an opposition to
\nvaccination in Latvia. The situation is
\npretty similar in other European coun-
\ntries. What can the WHO Regional Of-
\nfice do in order to promote immunization?
\nVaccination is one of the most cost-effective
\nhealth interventions available, saving mil-
\nlions of people from illness, disability and
\ndeath each year. Vaccines protect against
\nmore than 20 serious diseases.
\nAlthough the WHO European Region
\nhas made good progress in protecting more
\npeople, vaccine-preventable diseases still
\nchallenge Europe\u2019s public health and con-
\ntinue to burden our Member States. The
\nloss of a child from diphtheria, the deaths
\nof children from measles complications,
\nalongside thousands of cases of measles,
\nrepresent solemn reminders of unfinished
\nbusiness. Accepting the status quo is not an
\noption.
\nOur goal is to reach and maintain high levels
\nof immunization, particularly in vulnerable
\ngroups, at the appropriate ages and recom-
\nmended doses. To achieve this goal, WHO\/
\nEurope works with Member States, interna-
\ntional organizations and bilateral agencies to
\nhelp countries strengthen their programmes
\nfor the control of infectious diseases. Cur-
\nrent major initiatives include: supporting
\ncommunication capacity of national immu-
\nnization programmes; introducing new and
\nunderused vaccines; eliminating measles and
\nrubella and maintaining the poliomyelitis-
\nfree status of the European Region.
\nIn adopting the European Vaccine Action
\nPlan, our Member States committed them-
\nselves to eliminating measles and rubella by
\n2015.
\nWhile many countries are on track to do
\nthis by the end of this year, the regional
\ngoal continues to elude us,owing to the lack
\nof steadfast political commitment in some
\ncountries. We need public health leaders to
\nstand by your commitments to eliminate
\nmeasles and rubella.
\nThere is no stronger reminder of the need
\nfor vigilance than the return of polio.The re-
\nport of two cases in Ukraine, in August this
\nyear, is alarming, particularly given the large
\npockets of susceptible populations who could
\nbe exposed to this crippling, deadly disease.
\nIt is imperative that Ukraine and all Euro-
\npean countries continue to mitigate the risks
\nposed by polio by maintaining high immuni-
\nzation coverage and surveillance.
\nIn the 21st
\ncentury, every child has the right
\nto live free from vaccine-preventable dis-
\neases. Strengthening immunization is vital.
\nWHO\/Europe leads and coordinates Euro-
\npean Immunization Week (EIW). Since its
\nestablishment 10 years ago, EIW has served
\nas a flexible platform for Member States in
\nthe European Region to mobilize support for
\nimmunization. From its humble beginning
\nin 2005 with eight pilot countries, EIW ex-
\npanded each year to become a truly Region-
\nwide campaign encompassing all 53 Member
\nStates. Together with Immunization Week in
\nthe Americas,EIW was a forerunner of World
\nImmunization Week, established in 2012.
\nRegional and national partners,including the
\nUnited Nations Children\u2019s Fund (UNICEF)
\nand the European Centre for Disease Pre-
\nvention and Control (ECDC), support im-
\nplementation. EIW also benefits from high-
\nlevel support at the national level, including
\nministers, ambassadors, first ladies and other
\ndistinguished supporters. At the regional lev-
\nel, the initiative has the support of Her Royal
\nHighness Crown Princess of Denmark, who
\nis WHO\/Europe\u2019s patron. In April this year,
\nwe celebrated the tenth anniversary of the
\nEIW initiative throughout the Region.
\nThere is still a lot to be done in this area\u00a0\u2013 our
\nvision is a European Region free of vaccine-
\npreventable diseases. We need Latvia\u2019s full
\nsupport and commitment in reaching this goal.
\nQ. In the past two years, Latvia has made
\ngood progress in adopting a range of to-
\nbacco control regulatory legal acts. In
\nLatvia smoking is absolutely prohibited
\nin public facilities, premises of central and
\nlocal government institutions, work plac-
\nes, and elsewhere where it can harm other
\npeople\u2019s health. How would you evaluate
\nour achievement and how could we attain
\nthis in entire Europe?
\nYou are right: Latvia is doing well in tobac-
\nco control. The country ratified the WHO
\nFCTC in 2005 and took a number of legally
\nbinding obligations in tobacco control,from
\nsmoke-free public places, high taxes on to-
\nbacco products, banning tobacco advertis-
\ning to eliminating illicit trade in tobacco
\nproducts. Latvia is among only 33 countries
\nin the world that have sufficiently high tax
\nrates on tobacco, which are among the most
\neffective tools in reducing consumption.
\nHowever, a lot more needs to be done. Al-
\nthough the smoking among the adult popula-
\ntion has gone down in recent years, 30% of
\nLatvian adults smoke and this is slightly high-
\ner than in the WHO European Region in av-
\nerage (28%). Over 17% of female and 45% of
\nmale adult population smokes in Latvia\u00ad.
\nMore needs to be done in stopping young
\npeople to become addicted to tobacco and
\nstart the use of tobacco at an early age. Data
\non the current situation is grim: 70% of the
\nboys in Latvia initiated smoking at the age
\nof 15 years or younger (in comparison, in
\nUK and Ireland, it is around 30%); up to
\n72% of the girls in Latvia started smoking at
\nthe age of 15 years or younger (in compari-
\nson, in UK and Ireland, it is around 40%).
\nThe Region as a whole is striving towards
\nmaking tobacco a thing of the past. Last
\nweek, WHO Regional Committee for Eu-
\nrope\u00a0\u2013 Region\u2019s governing body\u00a0\u2013 adopted a
\nroadmap for tobacco control, setting an am-
\nbitious goal of full implementation of the
\nFCTC and the voluntary global target to
\nreduce tobacco use by 30% by 2025. We are
\ngrateful to Latvia for its support in adopting
\nthis roadmap and count on its support in its
\nimplementation in the coming years.
\nTobacco smoking among adults continues
\nto decline in the Region. Nevertheless, we
\nremain the region with the highest overall
\nrate of adult smoking.
\nIn the year 2000, 250 million adult people
\nin Europe smoked,in 2015,200 million and
\nit is projected that in 10 years\u2019time, in 2025,
\n180 million will continue to smoke. As of
\n2015, Europe has the highest number of its
\npeople smoking, 28%, in the world. Glob-
\nally, being born male has been the highest
\npredictor of smoking. However, European
\nwomen are smoking alarmingly more than
\nany other women around the globe.
\n19% of European adult women smoke and
\nthis number will continue to rise in the
\ncoming years while smoking among men is
\nstabilizing or going down.As a consequence
\nof women smoking like men in some coun-
\ntries, the breast cancer is not any more the
\nbiggest killer but the lung cancer is. The
\nchange in the rates of incidence and mor-
\ntality for lung cancer can be attributed to
\nsmoking prevalence amongst females.
\nAs a result of high levels of smoking, 16% of
\nEuropeans die as a result of a tobacco related
\ndisease while the global average is lower,12%.
\nAgainst this background, it is clear that Eu-
\nrope could and should do more to save health
\nand life of Europeans.We know what works;
\nwe have an international health treaty\u00a0\u2013 the
\nWHO Framework Convention on Tobacco
\nControl (FCTC), which is celebrating a de-
\ncade of action.At present,50\u00a0countries out of
\n53 in the WHO European Region have tak-
\nen the political commitment by ratifying this
\nTreaty but the actual implementation should
\nbe scaled up. Since last year, four additional
\ncountries in our Region have become parties
\nto the Protocol to Eliminate Illicit Trade in
\nTobacco Products. This is a great achieve-
\nment and we call on others to join.
\nSeveral countries in Europe are already
\nmoving towards becoming tobacco-free:
\nsuch as Ireland by 2025, Finland by 2040,
\nUK Scotland by 2034. Tobacco free coun-
\ntry is defined by less than 5% of adult
\npopulation\u00adsmokes. I am proud that our
\ncountries are taking global leadership in
\nplain packaging for tobacco products.
\nThe generation growing up now cannot
\ncomprehend that people used to smoke on
\nairplanes, buses, in restaurants or in offices.
\nThe achievements of the past 20 years show
\nthat the dream of a Europe where tobacco
\ncontrol has succeeded is not unrealistic.The
\ngains will be huge if tobacco control suc-
\nceeds, but there is hard work ahead. Gov-
\nernments must fully implement the mea-
\nsures in the WHO Framework Convention
\non Tobacco Control and work toward the
\nimplementation of a common goal: a Eu-
\nrope where tobacco is not a social norm.
\nBACK TO CONTENTS
\n86 87
\nGERMANY Infection DiseasesPublic Health Care
\nQ. Right now, there is quite an opposi-
\ntion to vaccination in Latvia. The situa-
\ntion is pretty similar in other European
\ncountries. There are excellent lecturers,
\nnice-looking books and YouTube files
\ndiscouraging people from vaccination
\nand explaining about the dangers of vac-
\ncination. What could the European phy-
\nsician do in order to present the informa-
\ntion on the need of immunization in an
\nequally attractive manner from the visual
\nand informative aspect?
\nYou are addressing a real problem in-
\ndeed. In our European countries, many
\nseem to have forgotten how life and
\ndeath was before vaccination and, disre-
\ngarding the immense progress medicine
\nhas brought to all of us, and particularly
\nto our children, they show something
\nlike a \u201cspoiled child\u201d attitude towards
\nvaccination.
\nI don\u2019t think that this is only a question of
\nnice booklets and lively internet pages\u00a0 \u2013
\nthe WHO for instance has produced an
\nabundance of both, and although it does
\noffer an important support, it is obviously
\nnot enough of what is needed. I think that
\nthe question relates much more to culture
\nand societal trends: as a reaction to the dif-
\nficulties of our industrial world and to the
\nthreats on health and the environment,
\npeople see nature, \u201cnatural\u201d medicines and
\nthe rejection of \u201cchemistry\u201d as the way to a
\n\u201csafer health\u201d.
\nSo what we have to do, as Doctors, and
\nthat\u2019s something I see as an ethical obliga-
\ntion for Doctors, is to convince, convince
\nand convince, without losing any opportu-
\nnity to discuss this with the patients, with
\nall the parents we see at our consultation.
\nWe don\u2019t have the right to give up!
\nQ.Maybe it is the time to have a single im-
\nmunization calendar in Europe?This issue
\nis becoming more and more topical due to
\nthe increasing labour mobility in Europe.
\nChildren are moving along with their par-
\nents. For example, a child is born in Lat-
\nvia, three months later it is taken to his or
\nher father to Ireland, and a year later the
\nparents come to Brussels to work there.
\nEach single country in Europe has its own
\nvaccination calendar, which is the reason
\nwhy many children do not get adequate
\nvaccination and immunization. To start
\nwith, perhaps we could declare as manda-
\ntory such vaccinations as against diphthe-
\nria, poliomyelitis, tetanus and some more
\nand these to be administered according to
\nstrictly defined time schedule all across
\nEurope, whereas the rest (rotavirus, Ger-
\nman measles, pneumococci) could be left
\nat the national level?
\nI understand the idea behind your question
\nvery well, but I am not sure I completely
\nshare your point of view.
\nWe live in a time when the European Union
\nis a concept questioned by quite a few peo-
\nple in all our countries, and it\u2019s obviously
\nnot a good time to go for mandatory uni-
\nformity; I\u2019d suggest to concentrate on the
\nresults\u00a0\u2013 request a good immunisation cov-
\nerage of the children at the end of school,
\nfor instance, and leave the \u201chow\u201d, the deci-
\nsions on the means to achieve this goal, in
\nthe hands of the Member States.
\nQ. Isn\u2019t it high time that we have a man-
\ndatory requirement to vaccinate all immi-
\ngrants from third countries, because their
\nearlier vaccination is unreliable? We are
\naware that many countries in Africa are
\nshort of vaccines, and people often have
\nfake vaccination documents.
\nI definitely think that it is an absolute ne-
\ncessity, and in fact a question of ethics and
\ndignity for all our European countries, to
\noffer proper healthcare to the refugees and
\nimmigrants now arriving in Europe.
\nI don\u2019t think though that we should make
\nany treatment mandatory in medicine, ex-
\ncept in very critical situations of health
\nemergencies, like epidemics for instance. In
\nall other circumstances, medical treatment
\n(and vaccination is one!) should be done
\nwith the consent of the patient: patients,
\nirrespective of their situation at the given
\nmoment, are partners of the health profes-
\nsionals for their own health!
\nQ. In Latvia, we conducted a survey
\namong medical doctors about vaccination.
\nThe question we asked was: do you im-
\nmunize and are you active in prescribing
\nimmunization against the flu for infants,
\npregnant women, patients with immuno-
\ndeficiency, and the answer was \u201cyes\u201d. An-
\nInterview with Dr. Jacques de Haller,
\nVice\u00a0President, President Elect 2016\u20132018
\n(Switzerland) of CPME
\nBy Dr. Peteris Apinis. September, 2015
\nJacques de Haller
\nother question was: have you immunized
\nyour own grandchildren, your daughter
\nor daughter-in-law who is expecting, in
\nmost cases the answer was \u201cno\u201d. Still an-
\nother question to doctors was: have you
\nimmunized yourself against the flu, and
\nthe answers were evasive\u00a0 \u2013 \u201ca couple of
\ntimes\u201d, \u201conce\u201d. The trust in vaccination
\nprogrammes has decreased in the doctors\u2019
\ncommunity. What can be done to recover
\nthe prestige of vaccination among medical
\nprofessionals?
\nThis is a terribly difficult question! We
\nhave the same situation in Switzerland,
\nand not only for immunization: some sur-
\ngical procedures show the same pattern, for
\ninstance.
\nI find it very positive that Doctors are in close
\ncontact with society,share its concerns,and are
\nnot isolated in an ivory tower, but at the same
\ntime Doctors should definitely remain in close
\ncontact with the academic world (permanent
\nmedical education is the point, here!), and be
\nmore willing and able to believe in what they
\nlearned. \u201cDo what I\u00a0say and not what I do\u201d is
\nnot an option for us,Doctors!
\nThe human-animal interface has devel-
\noped from ancient times till today into an
\narena with a complex pattern of interac-
\ntions, strongly affected by the constantly
\nevolving impact that humans have on
\ntheir local and global environments. Con-
\nsequently, many human pathogens have
\nevolved in the Neolithic revolution by
\ncrossing the animal-human species barrier
\nand subsequent adaptation to the newly
\ninvaded species. These include mumps
\nvirus (of the Paramyxoviridae family),
\nsmallpox virus, Corynebacterium diph-
\ntheriae, and Bordetella pertussis\u00a0 [1]. The
\nrespective animal hosts of origin of these
\npathogens, being domesticated, commen-
\nsal, or wild, have largely remained elusive.
\nWhile the phylogenetically closest spe-
\ncies of measles virus and smallpox virus
\nare rinderpest virus (infecting cattle), and
\ncamelpox or gerbilpox viruses, respec-
\ntively, it is unknown whether these animal
\nhost species were sources or recipients of
\nthese human pathogens. A recent pan-
\ndemic infectious disease outbreak fuelled
\nby a complex mix of predisposing factors
\nin our modern society was caused by the
\nemergence of HIV\/AIDS in Africa some
\n30 years ago. Today, the virus claims more
\nthan one million lives each year, with more
\nthan 20 million deadly victims in total
\nsince its emergence.
\nFortunately, the ever-increasing range of
\ninfectious diseases is largely paralleled by
\nthe implementation of an almost equally
\ncomplex mix of intervention strategies.
\nThe latter includes the coordinated and
\ntimely use of the achievements of medi-
\ncal, molecular, mathematical, social, and
\nother sciences. In the past decade, this has
\nresulted in the timely identification of the
\nSARS coronavirus, allowing concerted
\npublic health efforts to successfully control
\nthe emerging epidemic before the newly
\nintroduced pathogen could cause a full
\nblown pandemic. Although this will prove
\nmuch more difficult for more transmissible
\npathogens, as was the case for the latest
\ninfluenza pandemic of 2009, the SARS
\nepisode is unique in our recorded history.
\nAmong other most successful achieve-
\nments of modern medicine is the eradica-
\ntion of two long-time plagues: smallpox
\nand rinderpest that have devastated human
\nand animal populations for many centu-
\nries. In both cases, a combination of well
\ncoordinated mass vaccination campaigns,
\nintensive surveillance, and case contain-
\nment, successfully brought these pathogens
\nto extinction, with last identified cases in
\n1977 and 2001, respectively [2]. Stimulated
\nby these successes, concerted public health
\nefforts for the eradication of measles and
\npolio are currently ongoing, which in prin-
\nciple should be considered feasible in the
\nnear future, however, with major obstacles
\nrather being of political nature than related
\nto technical feasibility.
\nAlthough these successful eradications
\nmay represent victories over infectious
\ndiseases, the dynamic nature of infectious
\npathogens, in particular due to their epi-
\ndemiological and evolutionary flexibility
\nand adaptability, call for caution. With the
\neradication of pathogens and the waning
\nof immunity that had characterized ani-
\nmal and human populations for millennia,
\nwe are facing new challenges by creating
\nniches for colonization by related patho-
\ngens lurking in the animal world. Mon-
\nkeypox virus may be considered a loom-
\ning threat at the global human-animal
\ninterface, which one day could fully adapt
\nto more efficient human-to-human trans-
\nmission and fill the niche left empty by the
\neradicated smallpox virus. Similar threats
\nto animals and humans may come from
\nFrom Zoonosis to Pandemic
\nA.D.M.E. Osterhaus
\nBACK TO CONTENTS
\n88 89
\nRefugees and Health CareInfection Diseases GERMANY
\n\u00adanimal morbilliviruses\u00adafter the eradica-
\ntion of rinderpest or the future eradication
\nof measles [3].
\nUnexpected virus threats continue to
\nemerge, as is painfully demonstrated by the
\nincreasing number of human MERS coro-
\nnavirus (MERS-CoV) infections, partly
\ndue to increase in nosocomial transmis-
\nsion, but also because of ongoing transmis-
\nsion from dromedary camels to humans.
\nThe most prominent mode of camel-to-
\nhuman transmission is probably through
\nhuman contacts with respiratory excreta
\nalthough transmission via milk or urine
\ncannot be ruled out. An important break-
\nthrough was the identification of the re-
\nceptor of the virus in humans and animals,
\nwhich already proved helpful in identifying
\nanimal species susceptible to MERS-CoV
\ninfection and may further help in identi-
\nfying intervention strategies. An attractive
\noption would be to develop a vaccine for
\ndromedary camels and tackle the problem
\nat the source.
\nOur new era characterized by a real explo-
\nsion of novel molecular technology leads to
\nthe discovery of an avalanche of hitherto
\nunknown human and animal pathogens,
\nsome of which are candidates to fill newly
\nemerging niches at the modern human\u2013
\nanimal interface. For instance, in 2013, we
\nexamined sick harbour seals that had de-
\nveloped neurological signs. The seals were
\nsuffering from meningo-encephalitis of an
\nunknown cause. After thorough examina-
\ntion, a novel parvovirus was discovered
\nthat resembles the human B19 parvovirus
\nwhich among other manifestations has
\nbeen associated with neurological disease
\nin children. The human B19 parvovirus
\nhad also been associated with meningo-
\nencephalitis, but it was never demon-
\nstrated before that the virus can indeed
\nenter the brain tissue. By showing that
\nthe newly discovered seal B19-like parvo-
\nvirus is indeed present in brain tissue and
\ndirectly linked with neurological disease,
\nwe provide evidence that infection with
\nthis group of viruses may cause meningo-
\nencephalitis in animals and most probably
\nalso in humans F [4].
\nAnother group of infectious agents that
\ncontinues to cross animal-human species
\nbarriers consists of influenza A viruses.
\nIn the framework of several US and EU
\nfunded projects, the minimal determi-
\nnants of H5N1 transmission through air
\nwere identified: only a handful of amino
\nacid substitutions suffice for avian H5N1
\nvirus to become airborne in mammals,
\nand these are associated with three traits:
\nefficient binding to human type recep-
\ntors, increased stability of the hemag-
\nglutinin, and increased polymerase activ-
\nity in mammalian cells. In line with the
\nH5N1 research, similar experiments were
\nconducted with avian H7N9 virus, which
\nemerged in spring 2013. This virus was
\nfound to already display certain traits of
\nairborne H5N1. The wild type H7N9,
\nwithout any experimental modifications,
\nis indeed already airborne transmissible in
\nferrets, though not very efficiently\u00a0[5]. It
\nis suspected that it lacks sufficient hem-
\nagglutinin stability to be efficiently trans-
\nmissible, and needs to reduce binding to
\navian receptors.
\nIn conclusion, rather than investing in
\ntrying to influence the complex mix of
\npredisposing factors of emergence at the
\nhuman\u2013animal interface, which are largely
\nrelated to human behavioural issues, in-
\nvestment in newly emerging technologies
\nand intervention strategies may provide us
\nwith the tools to prevent or limit disasters
\ncaused by emerging infections. This will
\nnot only allow us to win major battles, but
\nalso to limit the impact of the apparently
\nnever ending war between mankind and
\nits relentlessly emerging microbial foes.
\nWe should do this in a multidisciplinary
\nOne Health approach. After all, emerg-
\ning and re-emerging infectious diseases
\nclearly demonstrate that human, animal
\nand ecosystem health are inextricably
\nlinked. It is therefore good to see that new
\nOne Health initiatives are taken, and in
\nthis context I would like to highlight the
\nnewly founded One Health Platform.This
\ninternational foundation brings together
\nkey opinion leaders of the One Health
\ntopic and provides them with a framework
\nfor information-sharing, cooperation and
\nawareness raising activities.
\nReferences
\n1.\t Wolfe ND. Origins of major human infectious
\ndiseases; Nature May 2007; 447.
\n2.\t Normile D. Rinderpest, Deadly for Cattle, Joins
\nSmallpox as a Vanquished Disease; Science Oc-
\ntober 2010; Vol 330 22.
\n3.\t de Swart R et al. Rinderpest eradication: lessons
\nfor measles eradication? j.coviro 2012.
\n4.\t Bodewes R et al. Novel B19-like parvovirus in
\nthe brain of a harbor seal; PLoS One. 2013 Nov
\n5;8(11)
\n5.\t Richard M et al. Limited airborne transmission
\nof H7N9 influenza A virus between ferrets; Na-
\nture. 2013 Sep 26;501(7468):560-3.
\nProf. A.D.M.E. Osterhaus,
\nDirector Research Centre for
\nEmerging Infections and Zoonoses
\n(RIZ), Hannover, Germany
\nE-mail: albert.osterhaus@tiho-hannover.de
\nAuthors\u2019 foreword
\nTruth is \u201cthe first casualty of war\u201d[1]. Many
\nrefugees come from war zones, and there is
\nlittle independent and even less empirical
\nresearch into the emerging refugee situation
\nin Europe. The authors strongly feel that
\navailable data should be presented without
\nbias so that readers may make their own
\njudgment.
\nFirst and foremost, the authors would like
\nto applaud the countless volunteers includ-
\ning health professionals providing assis-
\ntance to refugees across Europe and beyond.
\nMany are going above and beyond the call
\nof their professional duty to provide health-
\ncare to refugees. The main purpose of this
\narticle is to describe the current refugee cri-
\nsis. However, those providing this valuable
\nassistance should be recognized.
\nIntroduction
\nEach and every day, many individuals leave
\ntheir home countries, where instability, re-
\npression, terrorism, forced labor, poverty
\nand civil wars pose a threat to their lives and
\ntheir families. Current instability in parts of
\nthe Middle East, Northern and Sub-Saha-
\nran Africa is driving the biggest movement
\nof refugees across Europe since the Balkan
\nwars in the 1990s [2, 3, 4].
\nUnder the UN 1951 Convention and Pro-
\ntocol Relating to the Status of Refugees,
\na refugee is defined as an individual who
\n\u201c…owing to a well-founded fear of being
\npersecuted for reasons of race, religion, na-
\ntionality, membership of a particular social
\ngroup or political opinion, is outside the
\ncountry of his nationality, and is unable to,
\nor owing to such fear, is unwilling to avail
\nhimself of the protection of that coun-
\ntry\u201d\u00a0[5]. Refugee and asylum seeker are two
\ndistinct legally defined terms often used as
\nsynonyms in public and varying between
\njurisdictions [6]. This article focuses exclu-
\nsively on health and, for this reason, will
\nnot explore this legal nuance; therefore, the
\nterms are used synonymously unless other-
\nwise stated.
\nThe current crisis began in the wake of the
\nArab Spring when border crossings began to
\nrise in 2011. In addition, refugees originat-
\ning in both Northern and Sub-Saharan Af-
\nrica who had previously migrated to Libya
\nbegan to flee the unrest of the post-Qaddafi
\nera [4]. However, numbers have increased
\nsharply in 2015.The latest data, gathered in
\nSeptember 2015, indicate a total of 473,887
\nmen, women and children have arrived in
\nEurope by sea. Just under 40% were from
\nSyria, fleeing the country\u00b4s civil war and the
\nthreat posed by the self-styled Islamic State
\n(IS). In 2014, between 25-33% of those ar-
\nriving by sea were from Syria [2].
\nTurkey has an open door policy granting
\n\u201ctemporary protection status\u201d to every Syr-
\nian fleeing the conflict. Currently, Turkey
\nhosts the largest number of refugees in the
\nworld, with around 2 million people, while
\nLebanon has the highest quota of refugees
\nper inhabitant [7,8].According to UN High
\nCommission for Refugees (UNHCR), it
\nis estimated that Lebanon will have more
\nthan 1.8 million refugees and asylum seek-
\ners by the end of 2015 [9]. This condition
\nhas become a severe economic challenge for
\nthese countries\u2019 economies. Approximately
\n260,000 refugees are located in refugee
\ncamps,while the remaining live freely in the
\ncities [10]. The plight of children displaced
\nby the Syrian conflict is particularly dire;
\nMalta and Italy alone have received 10,000
\nseparated or unaccompanied children this
\nyear [11].
\nRefugees and migrants typically use one of
\nseven routes to reach Europe [7]:
\n\u2022\t Western African
\n\u2022\t Black Sea
\n\u2022\t Eastern borders
\n\u2022\t Western Mediterranean
\n\u2022\t Central Mediterranean
\n\u2022\t Eastern Mediterranean
\n\u2022\t Western Balkan
\nIn 2015, the Central Mediterranean, East-
\nern Mediterranean and Western Balkan
\nroute are most commonly used. Land bor-
\nders within the Western Balkan region were
\nthe main entry points for refugees with the
\nHungarian-Serbian border being the most
\nfrequently crossed border in the region. Mi-
\ngrants entering Europe through this route
\ninclude Western Balkan nationals and Syr-
\nians, followed by Afghans, Iraqis and Paki-
\nstanis [12]. Another highly popular route is
\nthrough Turkey, over the Eastern Aegean
\nSea to the Greek islands. Refugees from
\nSyria, Afghanistan, Iraq, Pakistan and Pal-
\nestine, amongst others, often use this route.
\nThey may arrive in Turkey by land or ferry
\nand continue on their way to Greece on car-
\ngo ships or inflatable boats [7].The number
\nof asylum seekers arriving in Greece each
\nday typically reaches around 5000, with
\npeaks of up to 10,000 [8].
\nCrossing the desert
\nFor Sub-Saharan African nationals, the
\nCentral Mediterranean route is a primary
\npoint of entry into Europe. Little data are
\navailable describing events in the Saharan
\ndesert.The United Nations Office on Drugs
\nand Crime (UNDOC) reports \u201conly\u201d 1691
\nconfirmed deaths in the desert; however,
\nit has been suggested that these numbers
\nsignificantly underestimate the number of
\nthose killed with actual numbers at least
\nthree times higher [13].
\nRefugees are not only at risk due to heat
\nstroke,thirst or starvation,but also face oth-
\ner dangers. According to UNDOC, many
\nHealth and Asylum Seekers in Europe
\nBACK TO CONTENTS
\n90 91
\nRefugees and Health CareRefugees and Health Care
\npaid a ransom. However, it is hard to verify
\nthis information. In a 2013 report, Reisen
\net al. that there have been an estimated
\n25,000-30,000 victims of Sinai trafficking
\nwith about 622 million USD in ransom
\ncollected [17]. While the Egyptian govern-
\nment\u2019s efforts have been successful in reduc-
\ning these crimes, exploitation of vulnerable
\nrefugees may have simply shifted to other
\nlawless zones.
\nCrossing the Mediterranean
\nAlmost daily, powerful photos are emerging
\nof refugees struggling to cross the Mediter-
\nranean \u2013 and in some cases, losing their lives
\nin search of a better future. In 2015, an esti-
\nmated 2,812 people have died crossing the
\nMediterranean Sea to date \u2013 an average of
\neight fatalities per day [18].The Internation-
\nal Organization for Migration estimates that
\nabout 75% of all refugee deaths worldwide
\nare occurring in the Mediterranean [19].
\nMany human smuggling networks operate
\nfrom the practically failed state of Libya,
\nsmuggling migrants mainly from Gambia,
\nSenegal, Somalia, Syria, Eritrea, Ethio-
\npia, Mali and Nigeria on wooden fishing
\nboats or inflatable boats with no naviga-
\ntion capacities and engines which often fail.
\nUsually a distress call is sent to the Italian
\nauthorities about 6-7 hours after departure
\nfrom the Libyan coast [7].
\nArriving in Europe
\nAccording to the International Organisa-
\ntion for Immigration, out of 430,000 refu-
\ngees and migrants who have reached West-
\nern Europe since the beginning of 2015,
\n390,000 have passed from Greek territory.
\nDaily, more than 4000 refugees set foot on
\nthe island of Lesbos having traveled across
\non small boats from the Turkish coast. Most
\nrefugees continue their journey via main-
\nland Greece, Macedonia, Serbia and Hun-
\ngary [20].
\nGermany and other neighboring Western
\nEuropean countries are the primary desti-
\nnations for refugees. In absolute numbers
\nGermany has admitted most refugees of all
\nEU countries, resulting in multiple health-
\ncare challenges [21].
\nHealth of refugees
\nFor most refugees, the journey to Europe is
\nfraught with a multitude of health threats,
\nalthough it is a common misconception
\nthat refugees themselves constitute a sig-
\nnificant health risk [22]. In this context,
\nit is also important to emphasize that
\nstigmatization of refugees is never justi-
\nfied and only risks creating or exacerbat-
\ning threats to health. Long and exhaust-
\ning travel under unsafe conditions and the
\ninterruption of health care can exacerbate
\nchronic diseases. Dangers specific to the
\nroutes and border-crossings pose health
\nthreats to young and healthy migrants
\nas well. People spend a long time hidden
\nin overcrowded trucks or boats. Injuries,
\nburns and dehydration are frequently oc-
\ncurring health problems. Traumatizing
\nexperiences in the country of origin or on
\nthe journey, and exposure to violence and
\nthe loss of family members, increase their
\nvulnerability to communicable and non-
\ncommunicable diseases. Children, preg-
\nnant women, elderly and immunocompro-
\nmised people are particularly susceptible to
\nhealth threats\u00a0[8].
\nFood insecurity among refugees also creates
\nmany additional potential health threats.
\nStarvation and malnutrition are a real-
\nity for many refugees [23, 24]. In addition,
\nrefugees may resort to trying to obtain food
\nwherever they can.In Germany,this has had
\ndisastrous consequences where more than
\nthirty refugees have become seriously ill and
\nat least one refugee has died after ingesting
\npoisonous mushrooms. It is believed that
\nthese mushrooms were consumed because
\nthey look similar to common edible mush-
\nroom in Syria [25, 26, 27].
\nInfectious Diseases
\nDue to poor hygiene conditions in transit
\nand in receiving facilities, diarrhea, acute re-
\nspiratory infections, skin infections, scabies
\nand head lice may occur [28, 29]. The sup-
\nply of safe water and food may be limited
\nduring the journey. Unsanitary conditions
\ncan often be found at border points and in
\nreceiving facilities, with a lack of safe drink-
\ning water, shower facilities and regular re-
\nmoval of waste. The result can be outbreaks
\nof food- and water-borne diseases such as
\nsalmonellosis, shigellosis, campylobacterio-
\nsis and hepatitis A [8].
\nCommunicable diseases are often associ-
\nated with poverty. An efficient health sys-
\ntem, good housing, hygiene, vaccinations
\nand clean water reduce the prevalence of
\ndiseases such as TB, measles, rubella, and
\nhepatitis.They still exist in the European re-
\ngion, independent of migration. The influx
\nof people from countries where infectious
\ndiseases are more prevalent can change the
\ndisease burden in Europe, although there is
\nno proven association between migration
\nand the importation of infectious diseases.
\nExperience shows that if cases of exotic in-
\nfections, such as the Ebola virus, occur in
\nEurope it affects regular travelers or health
\ncare workers rather than migrants [8].
\nOther infectious diseases such as scabies
\nhave also emerged as a public health chal-
\nlenge. In Germany, Hamburg, health au-
\nthorities declared a health emergency on
\nAugust 21st
\ndue to an outbreak of scabies
\nin an emergency shelter for newly arrived
\nasylum seekers. At the time, only topical
\nanti-scabies therapies were available within
\nGermany (Permethrin and Benzylben-
\nzoate) [30]. Ivermectin, an antifilarial on
\nWHO\u2019s list of essential medicines [31] and
\nthe de facto oral therapeutic standard for
\nscabies [32], is publicly available in France
\nbut only with indications for treatment of
\nstrongyloidiasis and elefantiasis not scabies
\n[33]. On September 2nd
\n, the Federal Minis-
\ntry of Health declared scabies a dangerous
\ndie in traffic accidents,overcrowded vehicles
\nor by simply falling off of a vehicle and be-
\ning left in the desert [13]. There are even
\nmore shocking reports of abuse, torture and
\nother crimes against refugees. Until 2013,
\nwhen the Egyptian Government reinstated
\nthe rule of law in the Sinai [14], many refu-
\ngees became victims of rape, torture \u2013 or
\neven homicide.
\nPhysicians for Human Rights-Israel report
\nthat 59% of asylum seekers treated at their
\nopen clinic report being chained and\/or
\nlocked up with 52% also reporting physical
\nabuse [15]. A CNN crew visiting the Sinai
\nreported that the morgue was packed with
\ndead corpses daily [16] with refugees being
\nabducted and tortured until their families
\nBACK TO CONTENTS
\n92 93
\nthat a person (migrant) will experience with
\ntime: \u201cfamily and friends, language, culture,
\nhomeland,loss of status,loss of contact with
\nthe ethnic group, and exposure to physical
\nrisks\u201d [46]. Reception in the intended des-
\ntination country can be very important for
\ncompletion of this grief process [46].
\nMcColl et al. defined some pre-migration
\nand post-migration adversities in the con-
\ntext of UK asylum applicants. Pre-migra-
\ntion adversities include war, imprisonment,
\ngenocide, physical or sexual violence, trau-
\nmatic bereavement, lack of healthcare, etc.,
\nwhile post-migration adversities are the
\n\u201cseven Ds\u201d: discrimination, detention, dis-
\npersal, destitution, denial of the right to
\nwork,denial of healthcare,delayed decisions
\non asylum applications [47].
\nIt is important to emphasize that the ma-
\njority of refugees and asylum seekers do not
\nsuffer from a psychiatric condition [47]. In
\nthis context, traumatic experiences should
\nbe addressed without pathologizing normal
\nhuman reactions [48].
\nA meta-analysis by Porter and Haslam found
\nthat,compared to non-refugees,refugees had
\nsomewhat poorer outcomes in psychopa-
\nthology measures. They also found that the
\nmental health outcomes are influenced by
\npostdisplacement conditions, and that refu-
\ngees who are living in institutional accom-
\nmodation, economically restricted, internally
\ndisplaced, persons who were repatriated, or
\nwhose initiating conflict was unresolved had
\nworse outcomes. Worse outcomes were also
\nfound in more educated, older, female, per-
\nsons with higher socioeconomic status and
\nrural residence before the migration [49].
\nStudies suggest that two thirds of refugees
\nexperience anxiety and\/or depression, and
\nhave a higher incidence of post traumatic
\nstress disorder, panic disorder and agora-
\nphobia, in addition to depression and anxi-
\nety [46]. Post traumatic stress disorder is
\nthe leading mental health condition among
\nrefugees and asylum seekers, probably con-
\nnected to the experiences in the country of
\norigin (persecution, conflicts, etc.) [46]. A
\nreview by Fazel et al.in 2005 found that ref-
\nugees placed in Western countries were 10
\ntimes more likely to have PTSD than the
\ngeneral population [50]. There is also a dif-
\nference between the group of migrants \u2013 for
\nexample, a Norwegian study found asylum
\nseekers to have higher rates of PTSD than
\nrefugees [51]
\nIn addition, asylum interviews are shown
\nto have a stressful effect on asylum seekers,
\nespecially when the asylum seekers were
\nalready traumatized [52]. Apart from the
\nprocedural difficulties in obtaining asylum,
\naccess to healthcare also poses a major chal-
\nlenge for many refugees.
\nUndocumented migrants, or the migrants
\nwithout legal status, face obstacles to receiv-
\ning adequate healthcare services \u2013 particu-
\nlarly mental health services \u2013 in destination
\ncountries. Many times healthcare access for
\nrefugees is limited to emergencies curbing ac-
\ncessibility to mental health services and there-
\nfore influences the overall health of refugees.
\nIt is important to protect and ensure ad-
\nequate treatment of persons who are already
\nsuffering of a severe mental disorder. This
\ngroup of refugees is particularly vulnerable
\nand can be considered neglected in complex
\nemergencies, such as conflicts [53].
\nSome countries provide mental health ser-
\nvices to the refugees who enter their borders
\n(e.g. temporary protection status in Turkey
\nincludes mental health services). However,
\nresource shortages limit these services to life-
\nthreatening emergencies in many places\u00ad.
\nWomen and LGBT Health
\nRefugee women face higher rates of ex-
\nposure to violence, sexual exploitation and
\nabuse than men [54].Risks increase on their
\njourney and can be exacerbated by lack of
\naccess to emergency sexual assault treat-
\nment and obstetrical care [55]. The stress
\nof the migratory process can also trigger or
\nintensify intimate partner violence [56, 57].
\nSexual violence, abuse, trafficking and rape
\nby smugglers, officials, policemen and male
\nrefugees are a common experience among
\nrefugee women. Some may be forced into
\nprostitution [58, 59, 60].The selling of Syr-
\nian brides has become a business in Turkey.
\nUnwanted pregnancies without access to
\nsafe abortions and venereal diseases without
\naccess to appropriate treatment may occur
\nas a result [61, 62].
\nIn July and August of 2015, 36160 Syrian
\nmales applied for asylum in the EU-28 only
\n10970 female Syrian refugees did so [63].
\nThis is in sharp contrast to the 1:1 ratio
\nworldwide. [64] It is reported that many
\nfamilies can only afford paying for one per-
\nson\u2019s trip and will send young healthy males
\nas a pilot, hoping for their female family
\nmembers to be allowed to join them later
\n[65]. However, it should not be neglected
\nfemale refugees are an even more vulnerable
\ngroup [66, 67].
\nIn Germany, emergency shelters are cur-
\nrently so overcrowded that males and fe-
\nmales share sleeping space in gyms, as well
\nas toilets and showers [66]. Even though
\nauthorities were not able to confirm, Ger-
\nman NGOs reported widespread cases of
\nrape and forced prostitution in an emer-
\ngency shelters for new arrivals in Gie\u00dfen,
\nHesse Germany [68].
\nAccording to a report from the German In-
\nstitute for Human Rights on refugees and
\ngender-specific violence,protection through
\n\u201crestraining and protection orders\u201dare avail-
\nable for refugees as well; however, refugees\u2019
\nchoice of accommodations and even move-
\nment is limited by law. In many cases, only
\nthe husband claimed reasons for asylum and
\nin that case under German law the partner\u2019s
\nasylum will depend on continued marriage.
\nLegally violent partners may be separated
\nto different accommodations even against a
\n\u00adcommunicable disease and authorized im-
\nportation of Ivermectin without prior mar-
\nketing approval [30].
\nThe prevalence of HIV is low among people
\nfrom the Middle East and Northern Africa
\n[8]. Most HIV cases in migrants are found
\nin Sub-Saharan African nationals. About
\n40% of HIV cases in Europe are migrants.
\nThere is also growing evidence that some
\nmigrant populations acquire HIV after ar-
\nriving in Europe [34]. Antiretroviral treat-
\nment can be interrupted for refugees liv-
\ning with HIV with potentially devastating
\nconsequences. In some European countries,
\nno HIV services are offered to people with
\nuncertain legal status [34].
\nThe majority of tuberculosis (TB) cases are
\ndetected in the native-born population in
\nEurope, with substantial variation across
\nEuropean countries. People with severe
\ncases of TB are often not fit for travel and
\ntherefore do not attempt the journey. TB is
\nnot easily transmissible and active disease
\noccurs only in a small proportion of those
\ninfected. However, crowded and humid
\nspaces such as those found in trucks and
\nships may facilitate the transmission of TB
\nwhen an infected person is present [8]. The
\noverall incidence is declining, while it is on
\nthe rise among migrants [34].
\nThe mass influx of refugees increases the
\nrisk of the reintroduction of vector-borne
\ndiseases such as Malaria, Leishmaniasis and
\nto the European region.Tajikistan and Tur-
\nkey are at particularly high risk at the mo-
\nment [8, 34, 35].
\nOutbreaks of measles, rubella and other
\nvaccine-preventable diseases can occur in
\nthe migrant population and spread to un-
\nvaccinated people of the receiving country.
\nThere is still a gap in vaccination coverage
\nin European countries due to refusal to
\nvaccinate. In migrants\u2019 countries of origin,
\naccess to vaccinations is often considerably
\nlower than in EU countries, creating condi-
\ntions under which outbreaks may emerge.
\nThe 2015 outbreak of measles in Berlin had
\noriginated within a group of asylum seekers
\nfrom Serbia and Bosnia and Herzegovina
\n[36, 8].
\nIn Turkey, registered refugees are provided
\ntemporary protection status and are then
\nplaced in provinces based on a national plan.
\nHowever, the rapidly increasing number of
\nrefugees has made execution of this plan dif-
\nficult and created new medical challenges.
\nAccording to an official field survey report
\nby AFAD in 2013, 26% of children in refu-
\ngee camps and 45% of children not living
\nin camps did not receive polio vaccination.
\nOne in three children in camps and 41% of
\nthe children out of the camps did not have
\nmeasles vaccination [37]. This situation in-
\ntroduced the risk of polio to a country which
\nwas polio-free for more than 15 years.There
\nhas been also a rise in other infectious dis-
\neases including measles,tuberculosis and cu-
\ntaneous leishmaniasis [38, 39].
\nMany developing countries experience a
\nhigh burden of hepatitis B cases. Incidence
\nis higher among migrants than among na-
\ntive populations in most European coun-
\ntries. Chronic infections are particularly
\nincreasing. In most cases, migrants acquired
\nthe virus in their countries of origin or from
\nmother-to-child transmission [34].
\nIn Lebanon, the sanitation conditions in
\nrefugee camps are very basic and a surge
\nof diarrheal diseases has been observed in
\n2014 by the epidemiologic surveillance unit
\nof the Lebanese Ministry of Public Health.
\nLebanon has seen an increase in the num-
\nber of reported tuberculosis, hepatitis A
\nand measles cases [40]. In addition, a vec-
\ntor borne disease, cutaneous leishmaniasis,
\nwhich was not present in Lebanon before,
\nhas made its appearance with 476 cases in
\n2014, all in Syrian Refugees.There is a con-
\ncern about the introduction of the sandfly
\nvector to Lebanon, but this has not been
\nproven with certainty yet. The community
\nphysicians have faced a major challenge in
\nmaking a timely diagnosis of Leishmaniasis,
\na condition they had not be accustomed to
\nevaluating and treating in the past[35]. Ma-
\njor education efforts for healthcare workers
\nthrough tertiary care and academic medi-
\ncal centers in Lebanon, are undertaken to
\nspread the knowledge about the disease.
\nNCDs
\nNoncommunicable diseases are a significant
\nproblem in the refugee population. Diabetes,
\ncardiovascular diseases, chronic lung diseases
\nand cancer are the most common of these.
\nThe exhausting and demanding circumstanc-
\nes of the journey often lead to exacerbations
\nof chronic diseases.A common characteristic
\nis that these conditions require regular and
\ncontinuous treatment. The supply of drugs
\nand the access to necessary procedures and
\ncare can be interrupted, resulting in poorer
\nhealth outcomes including unnecessary mor-
\nbidity and mortality [8, 41]. In the process
\nof uprooting and social marginalization, mi-
\ngrants may lose self-esteem and feel power-
\nless to manage chronic illness. The situation
\nis exacerbated by linguistic barriers and a real
\nor perceived inability to seek health care [42,
\n18]. For many refugees fleeing the Syrian
\ncivil war, access to non-communicable dis-
\nease management and prevention may have
\nbeen limited for years as the Syrian health
\ncare system has been \u201cshattered\u201d by the con-
\nflict with more than 75% of physicians hav-
\ning fled the country [43, 44]. Numerous re-
\nports have described attacks on health care
\nfacilities in clear violation of international
\nhumanitarian law [45].
\nMental Health
\nThe effect of migration on an individual
\nis pervasive \u2013 everything in person\u2019s life
\nchanges: diet, family, culture, social rela-
\ntions, status, etc [46]. Migratory experience
\nis essentially a psycho-social process of loss
\nand change, which can be labeled as a grief
\nprocess. This can be explained through a
\nmodel comprising of seven griefs of losses
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n94 95
\nConclusion
\nPeople travel with their health profiles, val-
\nues, culture and beliefs. Health workers in
\nEurope and beyond need to be aware of this
\nand have the necessary knowledge to pro-
\nvide high quality care to refugees. Recipient
\ncountries must be prepared to be responsive
\nin the event of a crisis, so as to deliver basic
\nservices to migrants in recognition to their
\nbasic human rights [28].
\nLarge numbers of people moving between
\ncountries may have implications for the
\ncharacter and distribution of a country or
\nregion\u2019s disease burden. Acute conditions,
\nmany of them infectious disease, psychiat-
\nric illness or injuries sustained fleeing their
\nhome countries might be the most obvious.
\nMany refugee lack access to mental health-
\ncare and delayed treatment for mental
\nhealth problems may worsen refugees\u2019prog-
\nnosis. Attention must be given to persons
\nwith pre-existing psychiatric disorder as
\nwell as other vulnerable groups.
\nHowever, host countries themselves are also
\nimportant factors for refugees\u2019 health. Cul-
\ntural and language barriers can in worst case
\ncause innocent, yet deadly confusion. The
\nbasic rules of hygiene and sanitation are an
\nimportant factor for today\u2019s increased life
\nexpectancy [84], ensuring these basic rules
\nfor refugees should be of immediate concern.
\nHowever, we believe that after the acute
\nphase refugees and health care systems
\nwill adapt to each other and chronic con-
\nditions will set in. The social determinants
\nof health have been shown to be crucial for
\nhealth [85] and first and second generation
\nimmigrants face many challenges, amongst
\nthem often lower wages and less education
\n[86]. While today\u2019s situation may seems to
\nbe a crisis, it should not be forgotten that
\nrefugees health challenges will not end
\nwhen an asylum decision has been made.
\nLike with any other human being, health
\nis a lifelong process even setting the course
\nfor future generations. For this reason, it is
\ncritical that governments, national medical
\nassociations and health professionals ensure
\na sustained,timely and appropriate response
\nto the health implications of refugee crises
\n[87,\u00a088]. Refugee health is public health.
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\nviolent partners wishes and women\u2019s shel-
\nters may be accessed, however, there are still
\nmany bureaucratic hurdles. In the case of
\nviolence, the Institute recommends either
\nlifting restrictions causing vulnerability for
\nvictims or introducing fast track procedures
\nfor victims to offer them different shelters
\nand making emergency accommodations
\navailable. It further recommends making
\nrefugee shelters safer places by ensuring
\nlockable rooms and sanitary facilities, in-
\nforming residents about their rights, setting
\nup women\u2019s rooms, sensitizing staff, inte-
\ngrating NGOs and ensuring there is female
\nas well as male security staff at shelters [69].
\nPregnant women in refugee or migrant
\ncommunities can have limited access to an-
\ntenatal care or safe delivery facilities [70].
\nThis can result in late diagnosis and some-
\ntimes life-threatening conditions for moth-
\ners and their babies [8].
\nIn addition, discrimination and violence
\nbased on sexual orientation and gender
\nidentity is an unfortunate reality for refu-
\ngees who identify as lesbian, gay, bisexual,
\ntransgender, queer or intersex (LGBTQI).
\nAlthough data are limited, anecdotal evi-
\ndence suggests these refugees face addition-
\nal health threats including psychological
\nsuch as \u201chumiliation\u201d [71].
\nImplications for Health
\nSystems: Examples
\nEuropean Union
\nAccording to the Fundamental rights of
\nmigrants in an irregular situation in the
\nEuropean Union \u2013 Comparative report
\nfrom 2011, in \u201c19 out of 27 EU Member
\nStates migrants in an irregular situation
\nare entitled to emergency healthcare only\u201d
\n[72]. For example, Croatia\u2019s law on asylum
\n(28th
\nmember state of the European Union)
\nstates that health care services for asylum
\nseekers include emergency medical services.
\nTurkey
\nIn Turkey, registered refugees are offered
\nfree primary healthcare services in public
\nhospitals for both emergency and elec-
\ntive procedures. Since the beginning of
\nthe Syrian conflict, 4.383.907 outpatient
\nvisits have occurred in the temporary shel-
\nters and 4.914.920 polyclinic examinations
\nwere performed in hospitals across the
\ncountry, while 389.837 of them ended up
\nwith inpatient service. 62.022 deliveries
\nand 278.035 surgeries were performed ac-
\ncording to official numbers [10]. This put
\nthe healthcare system of the country under
\nextra stress, which had already limitations
\nwith the shortage of healthcare workers
\n[73, 74].
\nLebanon
\nSince the beginning of the Syrian conflict
\nin 2011, Lebanon as one of the closest
\nbordering states has witnessed a contin-
\nued influx of refugees to reach about 1.5
\nmillion in official numbers provided by the
\nUNHCR. This has propelled the country
\ninto the pole position, having the high-
\nest refugee per capita in the world (232
\nrefugees per 1000 inhabitants).The already
\nstrained healthcare system is now stretched
\nvery thin with the healthcare needs of the
\nrefugee population [75]. The drop in vac-
\ncination rates in Syria has impacted the
\nreemergence of infectious diseases thought
\nto be close to eradication from Lebanon
\nsuch as measles [76, 43].
\nGreece
\nGreece faces an unprecedented economic
\ncrisis that has led the country to a con-
\ntinuous depression since 2010. The current
\nrefugee crisis creates therefore tremendous
\nproblems in Greece, which the Greek state
\ncannot handle by itself. As a common point
\nof entry to Europe, lack of first recep-
\ntion and accommodation infrastructure in
\nGreece may exacerbate public health issues
\nand prove hazardous to refugee populations
\nand local societies.It is a humanitarian need
\nthat healthcare services and infrastructure
\nin Greece, a country at Europe\u2019s doorstep,
\nbe financially supported by European funds
\nto ensure refugees have access to holistic
\ncare upon arrival in Europe [77].
\nGermany
\nUpon arrival, refugees receive a preliminary
\nmedical examination and are offered vacci-
\nnations according to German national rec-
\nommendations. Due to this policy and the
\nsheer number of refugees, vaccine stocks for
\nmany combination vaccines were exhausted
\nduring the summer of 2015 [78].
\nRefugees are distributed throughout Ger-
\nmany under a pre-agreed quota system [79].
\nLocal authorities are required to provide
\nfood and shelter for refugees, sometimes
\nwith a few hours of prior notice [80]. In or-
\nder to meet the need,gyms,empty school or
\nstores and tents have been set up as make-
\nshift shelters with only basic sanitary ser-
\nvices available [21].
\nOverall, under German law, refugees are
\nentitled to free healthcare for alleviating
\npain and acute disease. The only exception
\nbeing pregnant women, who are entitled to
\nthe same health care standard as all pub-
\nlicly insured women [81]. Until recently
\nrefugees had to first go to public admin-
\nistration receive a written approval before
\nhaving their doctors visit for acute disease
\ncovered. This has often been criticized as
\ndiscriminatory, especially as public officials
\nin charge of granting the visit had no for-
\nmal medical expertise [82]. Recently most
\nstates changed statutes to issue refugees
\nstandard German health insurance cards
\n[83]. They do not extend coverage, how-
\never, allow refugees to see doctors without
\nprior approval and for doctors to receive
\nreimbursement through standard health
\ninsurance processes.
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n96 97
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\nfrom: http:\/\/www.aerzteblatt.de\/nachrichten\/62227\/
\nAsylbewerber-erhalten-wohl-einfacher-Gesundheit-
\nsleistungen
\n84.\t Oeppen J, Vaupel JW, Others. Broken limits to life ex-
\npectancy. Science [Internet]. 2002;296(5570):1029\u201331.
\nAvailable from: http:\/\/truemedmd.com\/wp-content\/
\nuploads\/2013\/07\/Life_expectancy_scienceMay2002.
\npdf
\n85.\t Marmot M. Social determinants of health inequali-
\nties. Lancet [Internet]. 2005; 365(9464): 1099\u2013104.
\nAvailable from: http:\/\/dx.doi.org\/10.1016\/S0140-
\n6736(05)71146-6
\n86.\t Algan Y, Dustmann C, Glitz A, Manning A. The
\nEconomic Situation of First and Second-Generation
\nImmigrants in France, Germany and the United King-
\ndom*. Econ J Nepal [Internet]. Blackwell Publishing
\nLtd; 2010 Feb 1;120(542):F4\u201330. Available from:
\nhttp:\/\/dx.doi.org\/10.1111\/j.1468-0297.2009.02338.x
\n87.\t WMA Statement on Medical Care for Refugees, in-
\ncluding Asylum Seekers, Refused Asylum Seekers and
\nUndocumented Migrants, and Internally Displaced
\nPersons World Medical Association. [Internet]. [cit-
\ned 2015 Sep 28]. Available from: http:\/\/www.wma.
\nnet\/en\/30publications\/10policies\/m10\/index.html.
\npdf?print-media-type&footer-right=[page]\/[toPage]
\n88.\t Doctors urge government to respond to Syrian refugee
\ncrisis [Internet]. National Observer. 2015 [cited 2015
\nSep 28]. Available from: http:\/\/www.nationalobserver.
\ncom\/2015\/09\/04\/opinion\/doctors-urge-government-
\nrespond-syrian-refugee-crisis
\nIsabel Tourneur,
\nDRK Kliniken Westend, Berlin,
\nGermany;
\nMD, MPH, DTMH Xaviour\u00a0Walker,
\nJohns Hopkins Bloomberg School
\nof Public Health, USA;
\nMD, JD, MPH Elizabeth Wiley,
\nUniversity of Maryland, USA;
\nMD Caline Mattar,
\nWashington\u00a0University in St. Louis, USA;
\nMD Fehim Esen,
\nTurkish Young Doctors Association,
\nDevrek State Hospital, Turkey;
\nMD Goran Mijaljica,
\nPsychiatric\u00a0Hospital Ugljan and University
\nof Split School of Medicine, Croatia;
\nMD, MSc Kostas Roditis,
\nNational Kapodistrian University
\nof Athens, Greece;
\nMD, PhD Kostas Louis,
\n\u201cKonstantopoulio-Patision\u201d
\nGeneral Hospital, Greece;
\nMD, MSc Ahmet Murt,
\nCerrahpasa\u00a0Medical Faculty,
\nIstanbul, Turkey;
\nMD Thorsten Hornung,
\nUniversity\u00a0of Bonn, Germany
\nE-mail: Thorsten.hornung@ukb.uni-bonn.de
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n98 99
\nJORDAN, 2013-10-28,
\n\u00a9 ICRC \/ REVOL, Didier
\nMafraq Governorate. The ICRC and the
\nJordan Red Crescent Society distribute
\ndebit cards to vulnerable Syrian families liv-
\ning in host communities.
\nThe mechanism for the cash transfer is done
\nthrough ATM cards issued by a major bank.
\nThe project will last until March 2014, with
\none instalment per month. The amount
\nof cash assistance varies according to the
\nhousehold size. To help Syrians withstand
\nwinter, the amount will increase during the
\ncold season. The ICRC and Palestinian RC
\nhelped around 1000 syrian families with
\ntheir cash transfer programme.
\nAs the conflict continues unabated, Syr-
\nians are fleeing their homes every day to
\nseek refuge in Jordan. With winter ap-
\nproaching, the ICRC and the Jordan Na-
\ntional Red Crescent Society are finding
\nnew ways to help them cope with increas-
\ning needs.
\nMany Syrians who have found refuge in
\nJordan depend on aid provided by local and
\ninternational aid agencies. The vast major-
\nity of the refugees have been taken in by lo-
\ncal communities in northern areas near the
\nSyrian border. Some have not received any
\nother kind of assistance since arriving in the
\ncountry.
\n\u201cBetween 200 and 500 people are arriving
\ndaily. Most have endured a gruelling jour-
\nney across the desert,\u201d said Nana Chukhua,
\nICRC delegate in Jordan. \u201cAs soon as they
\narrive, they urgently need water, food and
\nshelter.\u201d
\n\u201cWe were forced to travel dozens of kilo-
\nmetres through the desert with scarcely any
\nfood or water,\u201d said Abu Yazan, a Syrian
\nrefugee from Homs. \u201cIt was cold, and we
\nhad to sleep on the ground.\u201d
\nThe majority have left all their belongings
\nbehind and cannot meet basic needs such as
\nfood,health care,house rent,water and elec-
\ntricity bills. Besides distributing relief items
\nto the refugees, the ICRC and the Jordan
\nNational Red Crescent Society launched a
\nprogramme in October to provide cash as-
\nsistance for 1,000 families in Mafraq gover-
\nnorate, northern Jordan, with the dual aim
\nof helping them and easing the burden on
\nlocal communities.
\n\u201cThe cash money will definitely help us
\ncover our basic needs, mainly house rent,\u201d
\nsaid Um Anwar, a 32-year-old Syrian who
\nresides in Mafraq.\u201cThe money will also help
\nme obtain treatment for my 13-year-old
\ndaughter,\u201d the mother of five added.
\nAn innovative cash transfer programme:
\nIn Jordan, the vast majority of Syrian refu-
\ngees live in host communities and often
\nhave problems meeting their basic needs.
\nTo help them with expenses not covered
\nby other relief mechanisms, the ICRC and
\nthe Jordan National Red Crescent Soci-
\nety launched a cash assistance programme
\nin October in Mafraq governorate, in the
\nnorth of the country, which will be imple-
\nmented over a period of six months.
\nAn initial group of 1,000 families have
\nstarted receiving debit cards issued by a ma-
\njor bank that will allow them to withdraw
\nmoney directly from ATM machines. The
\namount of money (from USD 70 to 310)
\nmade available to each family depends on
\nthe size of the household and will be in-
\ncreased during winter months.
\nAs the ICRC\u2019s Hekmat Sharabi puts it, this
\nprogramme \u201cis much more flexible than
\njust giving them assistance that they might
\nnot consider suitable. It preserves people\u2019s
\ndignity by giving them the opportunity to
\ndetermine on their own what they are most
\nin need of.\u201d
\nIRAQ, 2013-09-25
\n\u00a9 ICRC \/ MOHAMMAD, Flamerz
\nDohuk governorate, Qsrouk sub-district,
\nQsrouk transit camp. Distribution of ICRC
\nnon-food assistance to Syrian refugees. A
\nyoung girl carries the thermos her family
\nreceived during the distribution.
\nIn Qasrouk kits were distributed to a total
\nof 561 persons (99 families and 35 singles).
\nThe kits consisted of basic hygiene and
\nhousehold items (stove, bucket, kettle, tea
\npot, thermoses and tarpaulin).
\nIRAQ, 2015-01-16
\n\u00a9 ICRC \/ ACHKAR, Nora
\nIraqi Kurdistan, Penjwin. ICRC assistance
\noperation.
\nOn Friday 16 January, the ICRC provides
\nemergency aid to nearly 180 displaced per-
\nsons who are currently living in Penjwin, 46
\nkm from Sulaymaniyah. Penjwin lies at an
\naltitude of 1500 m, where meteorological
\nconditions are harsh in winter.
\nA similar distribution operation took place
\nin December 2014,when the ICRC provid-
\ned supplies for 660 people. The people that
\nthe ICRC is helping have fled from Nayna-
\nwa, Salah al-Din, and Diyala governorates
\nin Iraq, and from Ayn al-Arab\/Kobani.
\nRefugees and Health CareRefugees and Health Care
\nInternational Committee of the Red Cross activities for
\nrefugees\/displaced persons in the Middle East
\nBACK TO CONTENTS
\n100 101
\nJORDAN, 2013-10-29
\n\u00a9 ICRC \/ REVOL, Didier
\nRuwaishid area, assembly point in Bustana.
\nThe ICRC distributes blankets, jerrycans
\nand hygiene items.
\nThe ICRC has, since July 2013, equipped
\nthree asssembly points and two transit sites
\nin the area with water tanks and drinking-
\nwater coolers, sanitation facilities and waste
\ncontainers; it has also ensured temporary
\naccommodation for refugees fleeing Syria
\nAs the conflict continues unabated, Syrians
\nare fleeing their homes every day to seek
\nrefuge in Jordan. With winter approach-
\ning, the ICRC and the Jordan National Red
\nCrescent Society are finding new ways to
\nhelp them cope with increasing needs.
\nMany Syrians who have found refuge in
\nJordan depend on aid provided by local and
\ninternational aid agencies. The vast major-
\nity of the refugees have been taken in by lo-
\ncal communities in northern areas near the
\nSyrian border. Some have not received any
\nother kind of assistance since arriving in the
\ncountry.
\n\u00abBetween 200 and 500 people are arriving
\ndaily. Most have endured a gruelling jour-
\nney across the desert,\u00bb said Nana Chukhua,
\nICRC delegate in Jordan. \u00abAs soon as they
\narrive, they urgently need water, food and
\nshelter.\u00bb
\n\u00abWe were forced to travel dozens of kilo-
\nmetres through the desert with scarcely any
\nfood or water,\u00bb said Abu Yazan, a Syrian
\nrefugee from Homs. \u00abIt was cold, and we
\nhad to sleep on the ground.\u00bb
\nThe majority have left all their belongings
\nbehind and cannot meet basic needs such as
\nfood,health care,house rent,water and elec-
\ntricity bills. Besides distributing relief items
\nto the refugees, the ICRC and the Jordan
\nNational Red Crescent Society launched a
\nprogramme in October to provide cash as-
\nsistance for 1,000 families in Mafraq gover-
\nnorate, northern Jordan, with the dual aim
\nof helping them and easing the burden on
\nlocal communities.
\nJORDAN, 2013-10-30
\n\u00a9 ICRC \/ REVOL, Didier
\nGrowing numbers of families in search of
\na safe haven are embarking on a danger-
\nous journey across Syria to border areas
\nin eastern Jordan. Between 200 and 500
\npeople arrive every day in this remote des-
\nert area.
\nRefugees, iamong them the elderly and the
\nvery young, walk long distances, mostly at
\nnight, to cross the border.
\nBecause of the intensity of the fighting on
\nthe Syrian side, the usual entry points in
\neastern Jordan are now harder to reach for
\nthe refugees. The refugees are gathered by
\nthe Jordan Armed Forces, first at assembly
\npoints and then at transit sites.
\nAs the conflict continues unabated, Syrians
\nare fleeing their homes every day to seek
\nrefuge in Jordan. With winter approach-
\ning, the ICRC and the Jordan National Red
\nCrescent Society are finding new ways to
\nhelp them cope with increasing needs.
\nMany Syrians who have found refuge in
\nJordan depend on aid provided by local and
\ninternational aid agencies. The vast major-
\nity of the refugees have been taken in by lo-
\ncal communities in northern areas near the
\nSyrian border. Some have not received any
\nother kind of assistance since arriving in the
\ncountry.
\n\u00abBetween 200 and 500 people are arriving
\ndaily. Most have endured a gruelling jour-
\nney across the desert,\u00bb said Nana Chukhua,
\nICRC delegate in Jordan. \u00abAs soon as they
\narrive, they urgently need water, food and
\nshelter.\u00bb
\n\u00abWe were forced to travel dozens of kilo-
\nmetres through the desert with scarcely any
\nfood or water,\u00bb said Abu Yazan, a Syrian
\nrefugee from Homs. \u00abIt was cold, and we
\nhad to sleep on the ground.\u00bb
\nThe majority have left all their belongings
\nbehind and cannot meet basic needs such as
\nfood,health care,house rent,water and elec-
\ntricity bills. Besides distributing relief items
\nto the refugees, the ICRC and the Jordan
\nNational Red Crescent Society launched a
\nprogramme in October to provide cash as-
\nsistance for 1,000 families in Mafraq gover-
\nnorate, northern Jordan, with the dual aim
\nof helping them and easing the burden on
\nlocal communities.
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n102 103
\nJORDAN, 2013-10-30
\n\u00a9 ICRC \/ REVOL, Didier
\nRuwaished area, assembly point in Bustana.
\nICRC trucks regularly deliver blankets, jer-
\nrycans and hygiene items to refugees fleeing
\nSyria; twice a day, a local NGO distributes
\nmeals paid for by the ICRC.
\nThe ICRC has, since July 2013, equipped
\nthree asssembly points and two transit sites
\nin the area with water tanks and drinking-
\nwater coolers, sanitation facilities and waste
\ncontainers; it has also ensured temporary
\naccommodation for refugees fleeing Syria.
\nAs the conflict continues unabated, Syrians
\nare fleeing their homes every day to seek
\nrefuge in Jordan. With winter approach-
\ning, the ICRC and the Jordan National Red
\nCrescent Society are finding new ways to
\nhelp them cope with increasing needs.
\nMany Syrians who have found refuge in
\nJordan depend on aid provided by local and
\ninternational aid agencies. The vast major-
\nity of the refugees have been taken in by lo-
\ncal communities in northern areas near the
\nSyrian border. Some have not received any
\nother kind of assistance since arriving in the
\ncountry.
\n\u00abBetween 200 and 500 people are arriving
\ndaily. Most have endured a gruelling jour-
\nney across the desert,\u00bb said Nana Chukhua,
\nICRC delegate in Jordan. \u00abAs soon as they
\narrive, they urgently need water, food and
\nshelter.\u00bb
\n\u00abWe were forced to travel dozens of kilo-
\nmetres through the desert with scarcely any
\nfood or water,\u00bb said Abu Yazan, a Syrian
\nrefugee from Homs. \u00abIt was cold, and we
\nhad to sleep on the ground.\u00bb
\nThe majority have left all their belongings
\nbehind and cannot meet basic needs such as
\nfood,health care,house rent,water and elec-
\ntricity bills. Besides distributing relief items
\nto the refugees, the ICRC and the Jordan
\nNational Red Crescent Society launched a
\nprogramme in October to provide cash as-
\nsistance for 1,000 families in Mafraq gover-
\nnorate, northern Jordan, with the dual aim
\nof helping them and easing the burden on
\nlocal communities.
\nLEBANON, 2013-08-05
\n\u00a9 ICRC \/ SPAULL, John
\nBekaa Valley, close to the Syrian border,
\nnear Bar Elias.Tal Sarhoun informal Syrian
\nrefugee settlement. Children huddle around
\na flimsy tent.
\nSeveral makeshift settlements of this sort
\nhost hundreds of families, especially in the
\nBekaa region.
\nThe ICRC is working to help family mem-
\nbers separated by the conflict from their
\nloved ones to reestablish links. It has also
\nreminded the Lebanese government of its
\nresponsibility to ensure respect for the prin-
\nciple of non-refoulement.
\nLEBANON, 2013-08-05
\n\u00a9 ICRC \/ SPAULL, John
\nBekaa Valley, close to the Syrian border,
\nnear Bar Elias.Tal Sarhoun informal Syrian
\nrefugee settlement.
\nThis informal refugee settlement hosts
\naround 500 families. Having fled their
\nhomes, taking little of their belongings with
\nthem, the refugees need essential assistance,
\nranging from shelter, to food, water, hygiene
\nitems and sleeping material.
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n104 105
\nLEBANON, 2012-10-09, \u00a9 ICRC \/ PARRISH, Paula
\nTripoli. ICRC nurses visits a Syrian wounded.
\nSYRIA, 2012-06-22, \u00a9 ICRC \/ GARCIA VILANOVA, Ricardo
\nHoms governorate, Qussayr. A doctor takes care of a child in a
\nfield hospital.
\nSYRIA, 2012-08-24, \u00a9 ICRC \/ GARCIA VILANOVA, Ricardo
\nAleppo. A wounded man is tended to.
\nSYRIA, 2013-03-18
\n\u00a9 ICRC \/ s.n.
\nBetween Aleppo and Manbij. An ICRC
\nconvoy on its way to deliver medical sup-
\nplies to Manbij an opposition held area.
\nSyria: Heavy fighting in Aleppo plagues
\nlives of hundreds of thousands
\nDamascus\/Geneva (ICRC) – Humanitari-
\nan needs in Aleppo are enormous,according
\nto personnel from the International Com-
\nmittee of the Red Cross (ICRC) who have
\njust concluded a five-day visit to Aleppo
\ngovernorate together with the Syrian Arab
\nRed Crescent.
\nDuring the visit, they gauged the humani-
\ntarian situation and delivered much-needed
\nmedical assistance.
\n\u00abThere are tens of thousands of displaced
\npeople in the governorate with no income
\nand no savings who depend on assistance
\nto survive,\u00bb said Marianne Gasser, head of
\nthe ICRC delegation in Syria, upon her re-
\nturn from the governorate. \u00abApart from the
\npressing humanitarian needs, several roads,
\nhospitals, schools, other public facilities and
\nworld heritage sites have been damaged.
\nEssential public services such as the distri-
\nbution of power and water have also been
\ndisrupted as a result of the heavy fighting
\nthat has plagued the governorate over the
\npast nine months.\u00bb
\nThe ICRC has been unable to return to
\nAleppo since July of last year because of
\nthe ongoing fierce fighting. However, the
\nSyrian Arab Red Crescent never stopped
\ndelivering food and household essentials,
\nwith ICRC support. In addition, the ICRC
\nensured that potable water was available
\nto the population. \u00abOur trip to Aleppo is
\nan important step forward. It is a good ex-
\nample of how continuous dialogue with all
\nparties concerned yields results, and makes
\nit possible to reach people in need, includ-
\ning in opposition-controlled areas,\u00bb added
\nMs Gasser.
\nTogether with the Syrian Arab Red Cres-
\ncent, the ICRC visited a number of differ-
\nent areas in the governorate, including op-
\nposition-held territory in the eastern parts
\nof Aleppo city such as Bustan Al-Qasr and
\nMasaken Hanano, and Manbij in Rural
\nAleppo. \u00abDuring these visits, we assessed
\nhumanitarian needs and spoke to people
\nsuffering the effects of the violence to better
\nunderstand their needs as well as the situa-
\ntion,\u00bb said Ms Gasser.
\nWorking with the Syrian Arab Red Cres-
\ncent and the local water boards, ICRC wa-
\nter engineers surveyed the effect the fight-
\ning has had on the supply of clean drinking
\nwater in the city of Aleppo and surrounding
\nrural areas. \u00abWe are planning to go forward
\nwith a number of upgrades and to provide
\nsupport that will help the Aleppo water
\nboard solve some of the problems it is fac-
\ning,\u00bb said Antonio Bolinches, an ICRC
\nwater engineer who participated in the visit.
\nICRC health personnel also visited the
\ngovernorate and checked on a number of
\nhealth-care facilities, where they provided
\nmuch-needed medical supplies and drugs
\nfor chronic diseases.
\nThe Syrian Arab Red Crescent branch in
\nAleppo was highly involved in the activities
\ncarried out during the visit. \u00abThese young
\nvolunteers are doing tremendous work on
\nthe ground,\u00bb said Ms Gasser. \u00abI was moved
\nby their dedication and commitment to
\nhelping everyone in need \u2013 irrespective of
\nwhere they are.\u00bb
\nSYRIA, 2012-07-08, \u00a9 ICRC \/ GARCIA VILANOVA, Ricardo
\nHoms governorate, Qussayr. A wounded man is tended to at a
\nhospital.
\nSYRIA, 2013-04, \u00a9 ICRC \/ CARRIN, Jeroen
\nZabdani. Ambulance damaged.
\nSYRIA, 2014-02, \u00a9 ICRC \/ KAS BARSOUM, Jack
\nAleppo, Internally Displaced People Centre.The black buildings,
\nwhich are used by the internally displaced persons.
\nRefugees and Health CareRefugees and Health Care
\nBACK TO CONTENTS
\n106 107
\nFRANCEFRANCE Person Centered MedicinePerson Centered Medicine
\nIt has been extensively shown that mental
\nhealth problems or symptoms are frequently
\nbrought up in the context of primary care
\neither as the main reason to consult or as a
\nconcomitant symptom. It is at the heart of
\nthe WHO WONCA report \u201cIntegrating
\nmental health into primary care\u201d[1] and also
\nextensively demonstrated by several well-
\ndesigned studies more or less in line with the
\nAlma Ata declaration on primary health care
\n(see for example) [2,3].Hence,it can no lon-
\nger be disputed that primary care is the best
\nsetting to ensure that people get the mental
\nhealth care they need, not only because \u201cit
\nis accessible, affordable, acceptable and cost
\neffective\u201d but also because while promoting
\n\u201cearly diagnosis, respect of human rights and
\nsocial integration\u201d,\u201cprimary care also helps to
\nensure that all people are treated in a holistic
\nmanner, addressing both their physical and
\nmental health needs\u201d[1].To the point that \u2013
\neven if there is still a lack of evidence*\u00a0\u2013 this
\n*\u2002 Mainly because there is a lack of criteria and met-
\nrics to evaluate these aspects
\nholistic ambition is fulfilled in this perspec-
\ntive, many countries have tried more or less
\nsuccessfully to restructure their organization
\nbased on these principles including practical,
\nrather than conceptual, adaptations to their
\ncultural and socio economic context.In many
\ncases their main objective is to find the most
\ncost effective and sustainable way to diagnose
\na nosographic mental disorder using brief
\nevidence based screening for such conditions
\n[4].In this type of adaptation \u201cholism\u201dis lim-
\nited to the integration of a somatic and men-
\ntal disorder centered appraisal of the health
\nstatus without real consideration of the per-
\nson as a whole including his values, expec-
\ntations and subjective aspects. An apparent
\nunanimity on benchmarked principles hides
\na profound heterogeneity of their definitions
\nand, not surprisingly, a strong implicit ten-
\ndency to maintain the health organizations
\nin their usual biomedical type of approach to
\nphysical and mental health: a disorder cen-
\ntered approach. Various indicators, and par-
\nticularly criticisms and complaints coming
\nfrom users and stakeholders, show that this
\nperspective is far from satisfactory.
\nTowards a Person
\nCentered Perspective
\nOne of the main problems health profes-
\nsionals have to face when dealing with
\nmental health or psychological issues is the
\nfact that \u2013 maybe more than other medi-
\ncal disciplines \u2013 Psychiatry and Mental
\nHealth are exposed to the negative effects
\nof a disorder centered approach. Because of
\nthe many competing theories about the very
\nnature of one\u2019s mental life a disorder cen-
\ntered approach risks neglecting many of the
\nnon-objective aspects of the person\u2019s mental
\nhealth,including key aspects such as subjec-
\ntivity and psychodynamic dimensions. The
\nimplicit or explicit tendency is to mimic the
\nparadigm based on the biomedical classifi-
\ncations in other medical disciplines.
\nThe first stake of a person-centered per-
\nspective is to fight against this abusive re-
\nductionism that leaves us \u201cwith half a sci-
\nence\u201d\u00a0[5] and landmarks not well adapted
\nto clinical practice [6]. The objective of this
\npaper is to briefly consider and discuss the
\nprocess allowing a professional to access
\nsubjective and psychodynamic dimensions
\nof the patient\u2019s health status and consider
\nhow this process could be integrated into
\nprimary care.
\nIn this perspective, the modernity and
\noriginality of Person Centered Medicine
\n(PCM) resides in the fact that it does not
\nsatisfy itself with asserting its principles
\nbut strives to define conditions for effective
\nimplementation of this ambition in each
\nmedical situation. What counts the most
\nhere is to meet real patients\u2019 needs and not
\nthose of more or less paradigmatic entities
\ndefined by each medical speciality which
\ntrigger the reductionist approach imposed
\nby the research methodology in a \u201cclassical\u201d
\nEvidence-Based Medicine approach.
\nThree conditions must be met to reach this
\ngoal [7,8]:
\n\u2022\t To take into account the whole being of the
\npatient (I am myself and my context) [9].
\n\u2022\t To consider the diagnosis and therapeu-
\ntic choices as a joint process involving the
\nperson of the patient, the persons of the
\ncarers (family and caregivers in general),
\nand the person of the clinician.
\n\u2022\t To consider as essential the subjective as-
\npects of the person\u2019s health situation, and
\nnot only the objective aspects of the ill-
\nness.
\nThis last condition is the focus of this brief
\npaper, starting with the idea that, in addi-
\ntion to the attention paid to the medico-
\nbiological aspects of the person\u2019s health
\nstatus, a person centred assessment needs to
\ngive enough consideration to the patient\u2019s
\nsubjective feelings. Whether or not we sus-
\npect a psychic or psychosomatic causality to
\nthe disorder that a patient brings to us, it is
\nessential to keep in perspective the factors
\ninvolved in the patient\u2019s health situation.
\n\u201cBeyond reasserting this principle, we need
\nto utterly enhance the methodology for ac-
\ncessing these subjective dimensions among
\ndifferent partners involved in the diagnos-
\ntic process and the therapeutic relation-
\nship\u201d[10]. For the professionals, the only
\nway to access these subjective dimensions is
\nthrough what the patient (and or his carers)
\nsays in words or shows in acting, as long as
\nthese words or acts can trigger in the pro-
\nfessionals enough empathy to approach the
\npatient\u2019s subjective feelings to which these
\nexpressions are related.
\nAt first considered as the professional\u2019s
\nability to listen sympathetically to the
\ncomments of the patient and to integrate
\nhis wishes and needs, the notion of em-
\npathy has gradually widened to include
\nrepresentations that the physician (or the
\nhealth professional) makes of the clinical
\nsituation in which the person in need of
\ncare is involved. In short, these are repre-
\nsentations that the professional makes of
\nthe health situation of the person suffer-
\ning through his\/her (the professional) own
\nempathy, triggered by the words and the
\nacts of the patients and their caregivers.
\nThis mechanism is well described by the
\nconcept of \u201cmetaphorizing-empathy\u201d pro-
\nposed by Lebovici [12] from his work with
\nbabies and their mothers. It is also close
\nto the notion of \u201cnarrative empathy\u201d pro-
\nposed by Jacques Hochmann [13] based
\non his work with autistic children and on
\nthe philosophical ideas brought by Paul
\nRicoeur, a famous French phenomenolo-
\ngist, in his book \u201cTime and Narrative\u201d[14].
\nIt is also consistent with Kleinman\u2019s as-
\nsumptions [15] on illness narratives. This
\nimportant development in PCM marked
\nthe full recognition of the role of the phy-
\nsician\u2019s subjectivity as a diagnostic and
\ntreatment tool in the physician-patient
\nrelationship.
\nTo approach the subjectivity of the person (in
\nboth its conscious and unconscious aspects)
\n[10] the physician has to use his personal
\ncommitment in the relation with the patient
\nand his use of his metaphorizing empathy.
\nThis perspective is very consistent with the
\nreality of medical practice that, in one form
\nor another, must deal with this vital dimen-
\nsion in every patient.Moreover,by establish-
\ning the subjectivity of the physician as a tool
\nfor understanding the patient and his disor-
\nder, the subjective involvement of the pro-
\nfessional regains positive status which was
\nlost with the progress of objective technical
\nmedicine. In this perspective the subjectivity
\nof the professional can be properly included
\nin practice and training if enough space is
\ngiven to work it through. Rather than train-
\ning the professionals to fight against their
\nsubjective movements or to deny it and to
\nprevent them from getting closer to the
\npatient\u2019s personal needs, Person Centered
\nMedicine (PCM) proposes to train them to
\nuse these subjective movements as their best
\ntool to access the patient\u2019s subjectivity.Thus,
\nPCM acknowledges relevance for clinical
\npractice of the clinician\u2019s congruence in the
\nrelationship, (i.e. his or her access to experi-
\nences arising in resonance with the patient).
\nA required condition is, for professionals, to
\nbe trained to work it through properly, and
\ndevelop enough reflexive capacities. This
\nwould enable them to take subjectivity and
\nintersubjectivity as one of the bricks of the
\ntherapeutic relationship, i.e. the interactive
\nconstruction they should build with the pa-
\ntient and for him or her, involving all those
\nwho are contributing to their health care and
\nhealth status [10]. The teamwork and peer
\nsupervision are crucial to enhance and sus-
\ntain this interactive process.
\nWhat about subjectivity and
\nnarrative in primary care?
\nObviously, subjectivity is of crucial impor-
\ntance in primary care, not only because a
\nprimary care visit usually is the first contact
\nwith health professionals but also because it
\nis the first step in a process transforming a
\nsuffering or a distress into a medical disease
\nor disorder. In this complex process con-
\ntributing eventually to the transformation
\nof \u201cpain into suffering\u201d [16]*, the proximity
\nof primary care with the person\u2019s every day
\nlife can obviously be a major asset to take
\ninto account the subjective feelings induced
\nby his\/her health experience and status, and
\npotentially their subjective determinants. It
\nis generally considered and well document-
\ned that this asset contributes to the acces-
\nsibility of care and their cost effectiveness
\nin most medical conditions. However, there
\nare emerging concerns that this asset could
\nbecome an obstacle to care when proximal
\nrelations do not help the patient to address
\nthe subjective aspects of his health in rela-
\ntion or not with his\/her somatic condition.
\nSchematically, three reasons can transform
\nprimary cares proximity and generality into
\nan obstacle for such subjective appraisal:
\n\u2022\t The patient\u2019s fear to disclose a stigmatiz-
\ning situation to a health professional in-
\ntegrated in his every day life
\n\u2022\t His difficulty to recognize subjective as-
\npects and psychological distress related
\nto health questions (physical, mental or
\nboth) due to the health problem itself,
\neither when this difficulty is one of the
\nsymptoms of this condition (Alexithymia
\nas symptom of various health disorders**)
\nor when the pervasiveness of the somatic
\nissues tends to mask the psychosocial as-
\npects of the disease
\n\u2022\t In these various situations,the lack of time
\nand expertise of primary care\u2019s profession-
\nals to recognize and overcome adequately
\nsuch obstacles in clinical situations
\n*\u2002 For Paul Ricoeur, there is a crucial difference
\nbetween Pain and Suffering. In Pain, physical or
\npsychical, painful experience suppresses all psychical
\nrepresentations and reduces communication with
\nothers, whereas in Suffering, the painful experience
\ntriggers psychical representations and the need to
\ncommunicate with others [17].
\n**\u2002 It can be related to various health issues or dis-
\norders: suffering Adolescents [18], Psychosomatic
\nconditions [19] , Personality disorders [20], or other
\nmedical of psychiatric illnesses [21].
\nSubjectivity and Narratives in Primary Care:
\nA Person Centered Issue
\nMichel Botbol
\nBACK TO CONTENTS
\n108 109
\nPerson Centered MedicineUNITED STATES OF AMERICAFRANCEPerson Centered Medicine
\nIn a person-centered perspective, these
\nobstacles should be addressed in the
\nsituations in which they occur. While
\nin many cases, this could be achieved
\nthrough the better promotion of person-
\ncentered medicine principles (given that
\nperson-centeredness in medicine is not
\nonly an ethical stance but also a techni-
\ncal advancement), we have to study more
\nclosely if the current \u201cWHO service or-
\nganization pyramid for an optimal mix of
\nservices for mental health\u201d [1:16] is suf-
\nficiently adapted to tackle the problem
\nraised by the integration of the subjective
\naspects of health into health care. To do
\nso, there is an urgent need to elaborate rel-
\nevant metrics to evaluate more thoroughly
\nhow this issue is tackled in the currently
\nrecommended health service models. My
\nhypothesis is that, if we want to address
\nseriously the problem raised by the inte-
\ngration of subjective dimensions into pri-
\nmary health care, we may have to consider
\namending this optimal model to make
\nsure that renouncing the integration of
\nsubjective aspects of health into primary
\ncare will not be the price to pay to the cost
\neffectiveness, affordability and transpar-
\nency claimed by the model.
\nConclusion
\nPCM has brought back the person of the
\npatient at the centre of medicine, allowing
\nintegrating the subjective dimensions of
\nthe patient\u2019s mental health into the health
\ncares from where they have been generally
\nexcluded by the disease-centered approach.
\nBecause it involves the personal commit-
\nment of the health professional and his
\nempathic capacities the approach of this
\ndimension needs time and specific training.
\nAs first interface between the patients and
\nthe health system, primary care is of cru-
\ncial importance for the implementation of
\nperson-centered principles into the health
\nsystem. It is the reason why, after being the
\nfocus of the International College for Per-
\nson Centered Medicine (ICPCM) last Ge-
\nneva Conference, it is going to be the topic
\nof the 2015 ICPCM International Con-
\ngress in London.The usefulness of the opti-
\nmal use of primary care is well documented
\nfor its cost effectiveness and affordability; in
\ncontrast, however, more studies are needed
\nto better know the conditions that primary
\ncares have to meet to be person-centered,
\nespecially when it comes to integrating sub-
\njective aspects of health. This paper claims
\nthat, besides the well-demonstrated useful-
\nness of the primary care oriented model,
\nthere is still a long way to go to ensure that
\nthis subjective dimension will not be lost in
\nprimary care.
\nReferences
\n1.\t WHO and Wonca (2008) Integrating mental
\nhealth into primary care: a global perspective.
\nWHO Library.
\n2.\t Berkel H, Henderson J, Henke N, et al. Mental
\nhealth promotion and prevention strategies for
\ncoping with anxiety, depression, and stress relat-
\ned disorders in Europe (2001- 2003). Research
\nreport 1001. Bremerhaven: Federal Institute for
\nOccupational Safety and Health 2004
\n3.\t Hickie I. Can we reduce the burden of depres-
\nsion? The Australian experience with beyond
\nblue: the national depression initiative. Austral-
\nian Psychiatry 2004: 12, 38-46
\n4.\t Spitzer RL, Williams JB, Kroenke K, Linzer M,
\nde Gruy FV 3rd, Hahn SR, Brody D, Johnson
\nJG. Utility of a new procedure for diagnosing
\nmental disorders in primary care: The PRIME-
\nMD 1000 study. JAMA 1994; 272: 1749-1756
\n5.\t Strauss JS. Diagnosis and reality: A noun is a
\nterrible thing to waste. Psychopathology, Spe-
\ncial Issue on Philosophical and Methodological
\nFoundations of Psychiatric Diagnosis 2005; 38:
\n189-191
\n6.\t Mises R, Quemada N, Botbol M, Burstejn C,
\nGarrabe J, Golse B, Jeammet P, Plantade A,
\nPortelli C, Thevenot JP. French classification for
\nChild and Adolescent mental disorders. Psycho-
\npathology 2002; 2: 3
\n7.\t Mezzich JE, Salloum I, Cloninger R et al. Per-
\nson-centered integrative diagnosis: conceptual
\nbases and structural model. Canadian Journal of
\nPsychiatry 2010; 55: 701-708
\n8.\t Botbol M. Du manifeste au subjectif: ce qu\u2019est
\nla m\u00e9decine de la personne [From objectivity to
\nsubjectivity: What is Person Centered Medi-
\ncine] In SD Kipman (ed.) Manifeste pour la
\nm\u00e9decine de la personne [Manifesto for Person
\nCentered Medicine]. Paris, Dunod, 2012
\n9.\t La\u00edn-Entralgo P. El Diagn\u00a9stico M\u00e9dico: His-
\ntoria y Teor\u00eda [The medical diagnostic: history
\nand theory]. Salvat, Barcelona, 1982
\n10.\tBotbol M, Lecic-Tosevski D. Person-Centered
\nMedicine and Subjectivity. In: Jeffrey HD Cor-
\nnelius-White, Renate Motschnig- Pitrik, Mi-
\nchael Lux (eds) Interdisciplinary Applications of
\nthe Person-Centered Approach. Springer, New
\nYork, 2013
\n11.\tBotbol M, Lecic-Tosevski D. Subjectivity Inter-
\nsubjectivity and Psychological Functioning, In
\nPerson Centered Psychiatry. Springer, Heidel-
\nberg, in press, 2015
\n12.\tLebovici S. L\u2019arbre de vie \u2013 \u00e9l\u00e9ments de la psy-
\nchopathologie du b\u00e9b\u00e9 [The tree of life \u2013 Princi-
\nples of infant psychopathology]. Eres, Toulouse,
\n1999
\n13.\tHochmann J. Une histoire de l\u2019empathie [A his-
\ntory of empathy]. Odile Jacob, Paris, 2012
\n14.\tRicoeur P. Temps et r\u00e9cit [Time and narrative].
\nLe Seuil, Paris,1983
\n15.\tKleinman A.The Illness Narratives. Basic Book,
\nNew York, 1988
\n16.\tRicoeur P. La souffrance n\u2019est pas la douleur
\n[Suffering is not Pain]. Psychiatrie Fran\u00e7aise,
\nJuin 1992
\n17.\tBotbol M, Hagmann V. Douleur ou souffrance?
\nA propos du point de vue de Paul Ricoeur. [Suf-
\nfering or Pain\u00a0 ? on Paul Ricoeur perspective]
\nNervure 2005; 17: 2
\n18.\tLoas G. L\u2019Alexithymie [Alexithymia]. Annales
\nmedico-psychologiques 2010; 168: 712-715
\n19.\tSifneos PE.The prevalence of Alexithymic char-
\nacteristics in psychosomatic patients. Psycho-
\ntherapy and Psychosomatics 1973; 22: 255-26
\n20.\tFeldman-Hall O, Dalgleish T, Mobbs D. Alex-
\nithymia decreases altruism in real social deci-
\nsions. Cortex 2012; 49: 899-90
\n21.\tTaylor GJ, Bagby MR, Parker JDA. Disorders of
\nAffect Regulation: Alexithymia in Medical and
\nPsychiatric Illness. Cambridge University Press,
\n1999
\nProf. Michel Botbol,
\nProfessor of Child and Adolescent Psychiatry
\nat University of Western Brittany,
\nChief of the Child and Adolescent
\nDepartment of Brest University Hospital
\nMember of the Board of the International
\nCollege for Person Centered Medicine
\nChair of the Psychoanalysis in
\nPsychiatry WPA Section
\nE-mail: botbolmichel@orange.fr
\nIntroduction
\nAncient as well as modern concepts of
\n\u201chealth\u201d have highlighted the holistic un-
\nderstanding (emphasizing the importance
\nof the whole and the interdependence of its
\nparts) in medicine. Ancient Chinese medi-
\ncine used diagnostic indicators in a holistic
\nframework to provide an understanding of
\nthe disease process. The Indian medicine
\nAyurveda (or the knowledge of living),
\nviewed health as harmony between body,
\nmind and spirit. Ancient Greek philoso-
\nphers affirmed that \u201cif the whole is not well,
\nit is impossible for the part to be well\u201d [1, 2].
\nA modern articulation of this understand-
\ning is expressed in the World Health Or-
\nganization (WHO) constitution published
\nin 1946 which defined health as \u201ca state of
\ncomplete physical, emotional, and social well-
\nbeing and not merely the absence of disease or
\ninfirmity.\u201d\u00a0[3]
\nThe extraordinary advances in medicine
\npost World War II, with its emphasis on
\nspecialized care, resulted in the provision
\nof medical care unimaginable only a few
\ndecades ago, especially for complex and ad-
\nvanced medical-surgical problems.This em-
\nphasis and the current progress has changed
\nour expectations of medicine and has in-
\ncreased hope in prolonging life and improv-
\ning the quality of life for people suffering
\nfrom these ailments, an obvious example
\nbeing the field of organ transplantation. On
\nthe other hand, the focus on disease special-
\nization has led to an unfortunate shift in
\nthe practice of medicine away from a view
\nof health as an interdependent whole with
\nartificially parceling out care, resulting in
\nfragmentation, incoordination, and in some
\ninstances decreased access to care.
\nFurthermore, the worldwide increased
\nprevalence of non-communicable chronic
\ndiseases, the interconnectedness and ex-
\nceptional burden of chronic diseases and
\nmental health conditions, along with the
\nkey role of behavioral determinant of health
\nstrongly demand models of care that ad-
\ndress the totality of health with emphasis
\non disease prevention and health restora-
\ntion. In this paper, we will review the ra-
\ntional for integrating mental health within
\nprimary care along with reported positive
\nexperiences in the field. We will also discuss
\nthe Person-centered Integrative Diagnosis
\n(PID) model, an emerging person- and pa-
\ntient-centered approach to care anchored in
\nperson-centered medicine.The PID consid-
\ners the person-in-context as the center and
\ngoal of interventions and care [4, 5].
\nWhy Integrate Mental Health
\nCare and Primary Care
\nThe need for integrated care is almost uni-
\nversally appreciated and it has risen from
\nthe recognition that specialized care often
\nleads to fragmentation of care, inadequacy
\nof addressing comorbid problems, limits ac-
\ncess to care and largely neglects preventive
\nefforts. In contrast to disease focused spe-
\ncialized and fragmented system approach
\nwith clear barriers to care, integrated care
\nis the systematic coordination of care for
\nphysical and mental disorders. It allows for
\nthe provision of adequate care for the whole
\nperson (addressing any presenting health-
\nrelated problems) facilitating a holistic ap-
\nproach to care.
\nMultiple lines of evidence point to the rel-
\nevance of this model for addressing mental
\nand physical disorders.There is a high prev-
\nalence of mental disorders among people
\npresenting to primary care settings. Like-
\nwise, people with mental disorders have
\nhigh rates of physical disorders.
\nMedical comorbidity is the most significant
\ncause of mortality in people with mental
\ndisorders, and these disorders are less likely
\nto receive adequate attention in non-inte-
\ngrated care systems. Patients with chronic
\nmental disorders such as major depression,
\nbipolar disorder, schizophrenia, alcoholism
\nand other substance use disorders have high
\nrates of physical disorders such as diabetes,
\ncardiovascular, chronic respiratory diseases,
\nhuman- immune deficiency virus (HIV) in-
\nIhsan M. Salloum
\nThe Integration of Mental Health and
\nPrimary Care: A Person-centered Approach
\nLadan Khazai
\nBACK TO CONTENTS
\n110 111
\nPerson Centered MedicinePerson Centered Medicine UNITED STATES OF AMERICAUNITED STATES OF AMERICA
\nthe availability of unified support systems
\nsuch as shared medical information and
\nreferral systems, the degree of shared goals
\nand vision among the health care teams and
\nthe degree of shared financing streams.
\nHealth services have been graded on a con-
\ntinuum of integration of care, from low to
\nfully integrated systems, based on the level
\nof collaboration between the various disci-
\nplines of health care providers. The lower
\nthe level of care, the less being able to ad-
\ndress more complex conditions. Level one
\nidentifies a low level of integration with
\nminimal collaboration between health pro-
\nfessionals. Level two identifies basic col-
\nlaboration and loosely coordinated care,
\nwith periodic communications between
\nhealth providers in separate systems of care
\nand separate locations. Level three refers
\nto closer collaboration among health pro-
\nviders who still are part of different teams
\nbut share the same facility (co-located).The
\nco-location facilitates more frequent com-
\nmunications,including occasional meetings.
\nLevel four identifies close collaboration in
\na setting where there is partial integration
\nbetween mental health and other medical
\ncare. Providers are co-located at the same
\nsites and share other functions such as the
\nmedical information system or scheduling.
\nThere is more formal collaborative work
\nand meetings that may involve coordinated
\ntreatment plans for certain cases. The most
\nintegrated level is level five. There is close
\ncollaboration in this fully integrated model
\nwhere health professionals operate as part
\nof the same team, with shared vision, and
\nusing the same supportive system. There is
\nregular and systematic team meetings and
\ntreatment planning with similar emphasis
\nand expectations on prevention and treat-
\nment.
\nThe Four Quadrant Model is a conceptual
\npopulation-based planning model for in-
\ntegrated care developed under the auspices
\nof the National Council for Community
\nBehavioral Healthcare (NCCBH) [29].
\nHealth risk and complexity are considered
\nin each quadrant and used as a guide for in-
\nterventions and levels of services to meet the
\nindividual patient\u2019s need. Quadrants range
\nfrom low risk\/low complexity (quadrant I)
\nto high risk\/high complexity (quadrant IV)
\non both mental health\/substance abuse and
\nphysical health. Quadrant II indicates high
\nrisk\/complexity on mental health\/substance
\nabuse and low to moderate risk\/complexity
\non physical health; quadrant III indicates
\nlow to moderate risk\/complexity on men-
\ntal health substance abuse and high risk\/
\ncomplexity on physical health. The Care
\nModel is another conceptual model de-
\nveloped for improving care for chronic ill-
\nnesses by refocusing the emphasis from an
\nillness-centered reactive model to a health-
\ncentered preventative model. It addresses
\nkey features for enhancing care at multiple
\nlevels including community, organization,
\npractice and patient levels [29].
\nModels have been advanced for linking inte-
\ngrated care to the processes of care through
\nsystematic screening and identification of
\nmental and behavioral disorders. This pro-
\nvides targeted linkage to appropriate inter-
\nventions within an integrated primary care
\nproviders with the goals to enhance access
\nto care, reduce stigma, and enhance engage-
\nment and adherence to care [30].
\nAn example of systematic screening and
\nbrief intervention highly relevant to prima-
\nry care is the Screening, Brief Interventions,
\nReferral and Treatment (SBIRT) program
\nfor unhealthy alcohol use [31]. The SBIRT
\nis an evidence-based practice aimed at iden-
\ntifying, reducing and preventing problemat-
\nic alcohol use. The SBIRT has three major
\ncomponents: Screening, using highly effi-
\ncient and practical standardized screening
\ntools such as the CAGE questionnaire, the
\nAlcohol Use Identification test (AUDIT)
\nor the three questions AUDIT-C [32\u201334].
\nBrief Intervention, providing feedback and
\nadvice for patients with unhealthy alcohol
\nuse. Referral to Treatment, for either brief
\ntherapy or for additional more intensive
\ntreatment. Similarly, interventions for the
\nhighly prevalent depression in primary care
\nhave been developed and extensively tested
\n[35]. Community friendly interventions
\nthat could be incorporated into integrated
\nprimary care programs for serious mental
\ndisorders are less developed. Two examples
\nof integrated counseling interventions for
\nbipolar disorder with comorbid alcohol or
\nsubstance use that are designed to be simple
\nand easily adaptable to community settings
\ninclude a group therapy format [36] and
\nan individual counseling approach [37].
\nThese interventions utilize integrated dis-
\nease management and educational strate-
\ngies along with motivational enhancement
\napproaches that are practical and easily ap-
\nplicable in community settings.
\nThe Person-centered Integrative
\nDiagnosis (PID) Model
\nThe Person-centered Integrative Diagno-
\nsis model (PID) may provide a conceptual
\napproach to integrative care. The emerging
\nPID model aims at putting into practice the
\nvision of Person-centered Medicine affirm-
\ning the whole person of the patient in con-
\ntext as the center of clinical care and health
\npromotion at the individual and community
\nlevels [4,5].The PID motto of \u201cpersons car-
\ning for persons\u201d recognizes that the person
\nof the patient and the person of the health
\nproviders are in a respectful and empower-
\ning partnership. The PID considers the to-
\ntality of the person\u2019s health, including both
\nill health and positive aspects of health with
\nprimary emphasis on prevention and health
\nrestoration. It is based on a holistic, contex-
\ntual and humanistic approach to care em-
\nphasizing recovery and wellbeing. It views
\nthe process of care as a partnership (equali-
\ntarian) approach, including the patient,
\nfamily, care givers and other stakehold-
\ners and the health professionals forming a
\nhealth support network.
\nThe PID scheme could be easily incorporat-
\ned into other models of integrated care, and
\nit provides a comprehensive and dynamic
\nfection, Hepatitis, sexually transmitted dis-
\neases (STD), tuberculosis (TB) and trauma
\nwith excess mortality. Factors that increase
\nrisk for physical disorders in mental dis-
\norders include high rates of smoking, sub-
\nstance abuse, and obesity [6]. Studies have
\nshown that those with serious mental illness
\nhave 25 years less life expectancy compared
\nto the general population [7]. They are over
\nthree times more likely to die from cardiac
\ndiseases and over six times more likely to
\ndie from respiratory ailments. These pa-
\ntients often suffer from multi-comorbid
\nproblems. For example, patients with bipo-
\nlar disorder have high rates of cardiovascu-
\nlar and respiratory diseases, in addition to
\nsubstance use disorders which increase their
\nrisk for chronic infectious diseases such as
\nviral hepatitis and HIV infection [8, 9].
\nThree or more chronic comorbid conditions
\nwere found, on the average, among people
\nwith bipolar disorder [10]. Additional co-
\nmorbidity increases the risk for mortality.In
\na study of mortality among Medicaid ben-
\neficiaries, while the most common causes
\nof death were attributed to heart disease
\nand cancer, death by injury was found to
\nbe twice as likely among the mentally ill
\ncompared to the general population. Those
\nwith mental illness and comorbid substance
\nabuse were 6-8 times more likely to die of
\ninjury,primarily poisoning,than their coun-
\nterparts treated for medical conditions only
\n[11]. While that study did not look at the
\ntrajectory of care for those patients, limited
\naccess to appropriate care may have been a
\nkey contributing factor for those with excess
\nmortality. Integrated care will substantially
\nfacilitates access to care for patients with
\nsevere mental disorders.
\nThe need for integrated care stems from an
\neven more fundamental reason for a holistic
\nview of health. Studies have long reported
\nthat psychosocial determinants generate
\nthe majority of health care visits [12]. Psy-
\nchosocial distress or depressive disorders
\noften are expressed as physical distress seen
\nby primary care physicians. Likewise, de-
\npression may develop as a consequence of
\nchronic physical disorder such as diabetes or
\ncardiovascular disorder [13]. Furthermore,
\nbehavioral and life style factors are overrep-
\nresented among the preventable risk factor
\nfor developing chronic diseases. The World
\nHealth Alliance (World Medical Asso-
\nciation, International Council of Nurses,
\nWorld Dental Federation, and Internation-
\nal Pharmaceutical Federation) has recently
\nidentified through a Health Improvement
\nCard a number of key risk factors to pre-
\nvent chronic diseases. Among these are diet,
\nexercise, avoidance of alcohol and other
\nhazardous drugs, stress-control, adequate
\nrest and sleep, and participation in social
\nand creative activities [14]. Addressing be-
\nhavioral health problems in primary care is
\nessential because of the prevalence of these
\nproblems in primary care setting with re-
\nported prevalence of smoking at 20%, obe-
\nsity at 30% and sedentary lifestyle at 50%.
\nChronic conditions that require a behav-
\nioral health component in a standard care
\nprotocol include asthma, diabetes, cardio-
\nvascular disease, irritable bowel syndrome,
\nobesity and substance abuse. Alcohol abuse
\nis linked to over 60 medical disorders [15].
\nPrimary care practices are de facto where
\nthe overwhelming majority of patients with
\nmental health problems receive care [16].
\nThere is mounting empirical evidence dem-
\nonstrating that integrated care improves
\naccess to both mental health and physical
\nhealth services, decrease stigma of receiving
\nmental health care, improves outcome and
\nreduces health care costs [17\u201325].
\nThe importance of integrating mental
\nhealth into general health and public health
\npractice has been recognized as a way for
\npromoting mental health [26]. Integration
\nof mental health and substance use disor-
\nders treatment in primary care has been also
\nsupported by legislative acts, such as the Pa-
\ntient Protection and Affordable Care Act of
\n2014 in the United States of America and
\nhave been highlighted by the US Surgeon
\nGeneral and the Institute of Medicine re-
\nports [27, 28].
\nLevels and Models of
\nIntegrated Care
\nIntegration may need to be addressed at
\nmultiple levels. At the systems\u2019 level, major
\nfactors such as financing of care and facili-
\ntating access to care need to be addressed
\nto facilitate integration. At the providers\u2019
\nlevel\u00ad, training and commitment are es-
\nsential. For example, integrating mental
\nhealth and substance abuse treatment into
\nprimary care there is a need for a three-
\nway enhancement of training. Medical care
\nproviders need to have enhanced training in
\nmental health and substance abuse recogni-
\ntion and need for intervention. Likewise,
\nmental health and substance abuse provid-
\ners need to have enhanced training in the
\nrecognition and need for intervention for
\nmedical, mental health or substance abuse
\nproblems. At the interventions\u2019 level there
\nis a need to identify, select, and develop in-
\ntegrated pharmacological or psychosocial
\ninterventions that are most appropriate for
\nthe patient. Repeated studies have high-
\nlighted the superiority of integrated inter-
\nventions, tailored to the patient\u2019s comorbid
\nconditions, compared to interventions that
\nare condition specific. These studies high-
\nlight the importance of addressing the dy-
\nnamic interplay between comorbid condi-
\ntions and their reciprocal negative impacts
\non the overall outcome. Patients\u2019 factors
\nis another crucial factor for integration of
\ncare, especially with the increased patient\u2019s
\nawareness and participatory, protagonist
\nrole in the process of care. This involves
\nenhanced patients\u2019 recognition of interrela-
\ntionship of health problems and enhanced
\ncommitment to wellness maintenance and
\nhealth restoration [5, 8].
\nIntegration of care between different service
\nproviders is facilitated by addressing a num-
\nber of features. These include the level of
\ncommunication between the services, their
\nphysical proximity (co-located or not), their
\naccessibility to patients in terms of distance
\nand time for the appointment, the availabil-
\nity of expertise and cross-trained personnel,
\nBACK TO CONTENTS
\n112 113
\nPerson Centered Medicine Person Centered MedicineUNITED STATES OF AMERICAUNITED STATES OF AMERICA
\n20.\tLemmens LC, Molema CC, Versnel N, Baan
\nCA, de Bruin SR. Integrated care programs for
\npatients with psychological comorbidity: A sys-
\ntematic review and meta-analysis. J Psychosom
\nRes, 2015.
\n21.\tOuwens M, Wollersheim H, Hermens R, Huls-
\ncher M, Grol R. Integrated care programmes for
\nchronically ill patients: a review of systematic re-
\nviews. International journal for quality in health
\ncare, 2005;17(2):141-6.
\n22.\tKilbourne AM, Greenwald DE, Bauer MS,
\nCharns MP, Yano EM. Mental health provider
\nperspectives regarding integrated medical care
\nfor patients with serious mental illness. Adm
\nPolicy Ment Health, 2012;39(6):448-57.
\n23.\tLawrence D, Kisely S. Inequalities in healthcare
\nprovision for people with severe mental illness. J
\nPsychopharmacol, 2010;24(4 Suppl):61-8.
\n24.\tWittwer SD. The patient experience with the
\nmental health system: a focus on integrated
\ncare solutions. J Manag Care Pharm, 2006;12(2
\nSuppl):21-3.
\n25.\tAHRQ. Integration of Mental Health\/Sub-
\nstance Abuse and Primary Care. Structured Ab-
\nstract. Rockville, MD.: Agency for Healthcare
\nResearch and Quality, October 2008.
\n26.\tHerman H, Saxena S, Moodie R. Promoting
\nmental health: concepts, emerging evidence,
\npractice. WHO, 2005.
\n27.\tMental Health: A Report of the Surgeon Gen-
\neral (1999) Office of the Surgeon General of the
\nUnited States.
\n28.\tReport TIoM. Building a Better Delivery Sys-
\ntem: A New Engineering\/Health Care Partner-
\nship (2005). Washington, DC.
\n29.\tNASMHPD. Integrating Behavioral Health
\nand Primary Care Services: Opportunities and
\nChallenges for State Mental Health Authorities.
\nAlexandria VA: National Association of State
\nMental Health Program Directors. Medical
\nDirectors Council January, 2005 Contract No.:
\nEleventh
\n30.\tButler M, Kane RL, McAlpine D, Kathol RG,
\nFu SS, Hagedorn H, et al. Integration of mental
\nhealth\/substance abuse and primary care. 2008.
\n31.\tMadras BK,Compton WM,Avula D,Stegbauer
\nT, Stein JB, Clark HW. Screening, brief inter-
\nventions,referral to treatment (SBIRT) for illicit
\ndrug and alcohol use at multiple healthcare sites:
\ncomparison at intake and 6 months later. Drug
\nAlcohol Depend, 2009;99(1-3):280-95.
\n32.\tBohn MJ, Babor TF, Kranzler HR. The Alco-
\nhol Use Disorders Identification Test (AUDIT):
\nvalidation of a screening instrument for use in
\nmedical settings. Journal of studies on alcohol,
\n1995;56(4):423-32.
\n33.\tEwing JA. Detecting alcoholism: The cage ques-
\ntionnaire. JAMA, 1984;252(14):1905-7.
\n34.\tBush K, Kivlahan DR, McDonell MB, Fihn
\nSD, Bradley KA.The audit alcohol consumption
\nquestions (audit-c): An effective brief screen-
\ning test for problem drinking. Ambulatory Care
\nQuality Improvement Project.. Archives of In-
\nternal Medicine, 1998;158(16):1789-95.
\n35.\tdeGruy FV. Treatment of depression in primary
\ncare. Ann Fam Med, 2015;13(1):3-5.
\n36.\tWeiss RD, Griffin ML, Kolodziej ME, Green-
\nfield SF, Najavits LM, Daley DC, et al. A ran-
\ndomized trial of integrated group therapy versus
\ngroup drug counseling for patients with bipolar
\ndisorder and substance dependence. American
\nJournal of Psychiatry, 2007;164(1):100-7.
\n37.\tSalloum IM, Douaihy AB, Daley DC, Kelly
\nTM, Cornelius JR, Kirisci L. Integrated individ-
\nual therapy for bipolar disorder and alcoholism:
\nresults from a randomized pilot study. Bipolar
\nDisorders, 2009;11:74-5.
\n38.\tSalloum IM, Mezzich JE. Person-centered di-
\nagnosis. Int J Integr Care, 2010;10 Suppl:e027.
\n39.\tSalloum IM,Mezzich JE.Outlining the bases of
\nperson-centred integrative diagnosis. Journal of
\nevaluation in clinical practice 2011;17(2):354-6.
\n40.\tMezzich JE, Snaedal J, van Weel C, Botbol M,
\nSalloum I. Introduction to person-centred med-
\nicine: from concepts to practice. Journal of Eval-
\nuation in Clinical Practice, 2011;17(2):330-2.
\nIhsan M. Salloum, MD,
\nMPHProfessor of Psychiatry
\nUniversity of Miami, Miller
\nSchool of Medicine
\nExecutive Board Member, International
\nCollege of Person-centered Medicine;
\nChair, Section on Classification, Diagnostic
\nAssessment and Nomenclature,
\nWorld Psychiatric Association
\nLadan Khazai, MD, Master of Public
\nHealth Graduate Candidate, 2016;
\nDepartment of Public Health
\nSciences, Research Assistant,
\nDepartment of Psychiatry and
\nBehavioral Sciences,
\nUniversity of Miami, Miller
\nSchool of Medicine
\nCorresponding address:
\nIhsan\u00a0M.\u00a0Salloum, MD, MPH
\n1120 NW 14th
\nStreet, suite 1449,
\nMiami, Florida 33136, USA.
\nE-mail: isalloum@med.miami.edu
\nassessment of the health status of the person
\npresenting for care. The PID is a multilevel
\napproach to assessing the health status. The
\nfirst level includes the assessment of health.
\nThis includes the assessment of ill health,
\nsuch as any physical or mental disorders
\nalong with assessment of functional abili-
\nties. This level also includes the assessment
\nof positive aspects of health and wellbeing.
\nPositive aspects of health and wellbeing are
\nkey to the recovery, health restoration and
\nhealth preservation efforts.The second level
\nin the PID is the assessment of contributors
\nto the health status. These contributors are
\nconsidered on a bio-psycho-social continu-
\num. Contributors to health are divided into
\nhealth promoters and health risks.The PID
\nhas incorporated the health contributors
\nincluded in the Health Improvement Card
\ndeveloped by the World Health Professions
\nAlliance [14]. Health promoters include
\ndiet, physical activity, creative activity, social
\ninvolvement,and other.Health risks include
\noverweight, elevated lipid, elevated glucose,
\nhigh blood pressure, alcohol and tabacco
\nuse, family history, early trauma, significant
\nstress, and other. The third level of the PID
\nis the experience of health which includes
\nthe experience of wellbieng and the experi-
\nence of ill health. This provides assessment
\nof personal and cultural identity, suffering,
\nmeaning of illness and expectations for the
\nhealth care encounter.These subjective con-
\ntributions to the process of diagnosis and
\ncare provide idiographic narrative crucial
\nfor the processes of empowerment, engage-
\nment, partnership and recovery [38\u201340].
\nFuture Directions
\nIntegration of care has become a pressing
\nprerogative to provide an adequate response
\nto the growing pandemic of chronic diseas-
\nes and to the increase of the aging world-
\npopulation with substantial rise of the bur-
\nden of comorbid chronic conditions. The
\nintegration of mental health into primary
\ncare and general health responds to the
\nconsiderable evidence of the strong impact
\nof mental and behavioral health on physical
\nhealth, and also to the need for adequately
\naddressing ill physical health in people with
\nmental health problems. The dictate that
\n\u201cthere is no health without mental health\u201d and
\nthe goal of eliminating disparities in health
\ncare are best served by integration of care.
\nRefocusing medicine from an essentially
\ndisease-centered, \u201creactive\u201d attitude to an
\napproach focusing on disease prevention
\nand health restoration with emphasis on
\nenhancing wellbeing and healthy living also
\ncalls for integration of care.
\nThe Person-centered Integrative Diagnosis
\napproach, embodying the vision of Person-
\ncentered Medicine as expressed to a large
\nextent in the various Geneva Declarations
\nand proceedings of the International Col-
\nlege of Person-centered Medicine (ICP-
\nCM), provides an overarching conceptual
\nframework for integrated care converging
\non the person in context as the center and
\ngoal of care and public health.
\nReferences
\n1.\t Christodoulou GN. (1987) Psychosomatic med-
\nicine. New York Plenum Press, NY
\n2.\t Plato. Harmidis Dialogue. 156 E. Athens: Papy-
\nros editions, 1975.
\n3.\t WHO. WHO Constitution. World Health Or-
\nganization, 1946.
\n4.\t Mezzich JE, Salloum IM, Cloninger CR, Salva-
\ndor-Carulla L, Kirmayer LJ, Banzato CEM, et
\nal. Person-centred integrative diagnosis: concep-
\ntual bases and structural model. Canadian Jour-
\nnal of Psychiatry, 2010;55(11):701-8.
\n5.\t Salloum IM, Mezzich JE. Conceptual appraisal
\nof the Person-centered Integrative Diagnosis
\nModel. International Journal of Person Cen-
\ntered Medicine, 2011;1(1):39-42.
\n6.\t De Hert M, Correll CU, Bobes J, Cetkovich-
\nBakmas M, Cohen D, Asai I, et al. Physical
\nillness in patients with severe mental disorders.
\nI. prevalence, impact of medications and dis-
\nparities in health care. World Psychiatry: official
\njournal of the World Psychiatric Association,
\n2011;10:52-77.
\n7.\t Parks J,Svendsen D,Singer P,Foti ME.Morbid-
\nity and Mortality in People with Serious Mental
\nIllness. Alexandria, VA: National Association of
\nState Mental Health Program Directors, 2006.
\n8.\t Salloum IM, Williams L, Douaihy A. Diagnos-
\ntic and Treatment Considerations: Bipolar Pa-
\ntients with Comorbid Substance Use Disorders.
\nPsychiatric Annals, 2008; 38(11):716-23.
\n9.\t Prieto ML, McElroy SL, Hayes SN, Sutor
\nB, Kung S, Bobo WV, et al. Association be-
\ntween history of psychosis and cardiovascular
\ndisease in bipolar disorder. Bipolar Disorder,
\n2015;17(5):518-27.
\n10.\tCarney CP, Jones LE. Medical comorbidity in
\nwomen and men with bipolar disorders: a pop-
\nulation-based controlled study. Psychosom Med,
\n2006;68(5):684-91.
\n11.\tDickey B, Dembling B, Azeni H, Normand
\nS-LT. Externally caused deaths for adults with
\nsubstance use and mental disorders. Journal
\nof Behavioral Health Services & Research,
\n2004;31(1):75-85.
\n12.\tShapiro S, Skinner EA, Kramer M, Steinwachs
\nDM, Regier DA. Measuring need for mental
\nhealth services in a general population. Med
\nCare, 1985;23(9):1033-43.
\n13.\tDucat L, Rubenstein A, Philipson LH, An-
\nderson BJ. A review of the mental health is-
\nsues of diabetes conference. Diabetes Care,
\n2015;38(2):333-8.
\n14.\tSeyer J. Development of the Health Improve-
\nment Card developed by the World Health Pro-
\nfessions Alliance. (2012) In: Medicine ICoPC
\n(ed.) The 5th Geneva Conference on Person-
\ncentered Medicine. Geneva, Switzerland,.
\n15.\tGoldberg D.Psychiatry and primary care.World
\npsychiatry: official journal of the World Psychi-
\natric Association, 2003;2(3):153-7.
\n16.\tRegier DA, Narrow WE, Rae DS, Mandersc-
\nheid RW, Locke BZ, Goodwin FK.The de facto
\nUS mental and addictive disorders service sys-
\ntem. Epidemiologic catchment area prospective
\n1-year prevalence rates of disorders and services.
\nArch Gen Psychiatry, 1993;50(2):85-94.
\n17.\tWoltmann E, Grogan-Kaylor A, Perron B,
\nGeorges H, Kilbourne AM, Bauer MS. Com-
\nparative effectiveness of collaborative chronic
\ncare models for mental health conditions across
\nprimary,specialty,and behavioral health care set-
\ntings: systematic review and meta-analysis. Am J
\nPsychiatry, 2012;169(8):790-804.
\n18.\tKilbourne AM, Pirraglia PA, Lai Z, Bauer MS,
\nCharns MP, Greenwald D, et al. Quality of gen-
\neral medical care among patients with serious
\nmental illness: does colocation of services mat-
\nter? Psychiatr Serv, 2011;62(8):922-8.
\n19.\tDruss BG, von Esenwein SA, Compton MT,
\nRask KJ,Zhao L,Parker RM.A randomized tri-
\nal of medical care management for community
\nmental health settings: the Primary Care Access,
\nReferral, and Evaluation (PCARE) study. Am J
\nPsychiatry, 2010;167(2):151-9.
\nBACK TO CONTENTS
\n114 115
\nClimate ChangeClimate Change
\nClimate change is considered one of the
\ngreatest threats and\/or opportunities for
\n(human) health [1, 2, 11, 13]. Although
\nthe relationship between climate change
\nand health is complex, concrete examples
\ninclude extreme heat and weather events
\n[46], poor air quality exacerbating pulmo-
\nnary disease [47, 48], increased water-borne
\nand vector-borne infectious disease out-
\nbreaks and food insecurity and malnutrition
\ncaused by drought and crop failure.
\nDespite widespread recognition of the
\nnumerous health implications of climate
\nchange, evidence suggests that climate
\nchange continues relatively unabated [15].
\nIn this context, there is an imperative for
\nhealth professionals to be involved in the
\ndiscussion and act on this issue which
\nthreatens to undermine public health ef-
\nforts worldwide [2, 34, 35]. This paper
\nprovides a brief introduction to the United
\nNations Framework on Climate Change
\n(UNFCCC), current climate change ne-
\ngotiations and health sector engagement in
\nglobal efforts to tackle climate change.
\nI.The Climate-Health Nexus
\nBroad scientific evidence shows that climate
\nchange has and will continue to have pro-
\nfound health implications [2, 4], primar-
\nily driven by carbon and other greenhouse
\ngas emissions [16]. The effects of climate
\nchange on health are diverse and complex;
\nsome directly attributable to rising tem-
\nperatures and changes in precipitation pat-
\nterns, others are mediated through social
\nand ecological changes such as population
\ndisplacement, vector migration, conflict and
\nagricultural failure [7, 8, 14].
\nIn 2014, the Intergovernmental Panel on
\nClimate Change (IPCC) highlighted some
\nof the most significant threats to human
\nhealth posed by climate change including
\nbut not limited to:
\n\u2022\t Spread of infectious diseases including ma-
\nlaria,dengue fever,and water-borne diseases;
\n\u2022\t Increased frequency and severity of natu-
\nral disasters and flooding;
\n\u2022\t Worsening food insecurity;
\n\u2022\t Increased migration and conflict; and
\n\u2022\t More than 7 million deaths annually at-
\ntributable to rising temperatures and air
\npollution [2].
\nThe Road to Paris: What is at Stake for
\nHealth in COP21 Negotiations?
\nMediating factors
\nSocial infrastructureEnvironmental
\nconditions
\nCLIMATE CHANGE
\n\u2022 Precipitation
\n\u2022 Heat
\n\u2022 Floods
\n\u2022 Storms
\nHEALTH IMPACT
\n\u2022 Undernutrition
\n\u2022 Drowning
\n\u2022 Heart disease
\n\u2022 Malaria
\nPublic health capability
\nand adaptation
\n\u2022 Warning systems
\n\u2022 Socioeconomic status
\n\u2022 Health and nutrition status
\n\u2022 Primary health care
\n\u2022 Geography
\n\u2022 Baseline weather
\n\u2022 Soil\/dust
\n\u2022 Vegetation
\n\u2022 Baseline air\/water
\nquality
\n\u2022 Food production distribution
\n\u2022 Mental stress
\nVia economic and social disruption
\nMediated through natural systems:
\n\u2022 Allergens
\n\u2022 Disease vectors
\n\u2022 Increase water\/air pollution
\nIndirect exposures
\nDirect exposures
\n\u2022 Flood damage
\n\u2022 Storm vulnerability
\n\u2022 Health stress
\nFigure 1.\u2002\u0007Diagram of the three exposure pathways through which climate change affects health [3]
\nClimate change has been recognized as one
\nof the many social determinants of health
\n[5, 6]. Not surprisingly, health implications
\nof climate change are inequitably distribut-
\ned worldwide, excessively affecting popula-
\ntions in low-and-middle income countries
\nand vulnerable populations around the
\nglobe [10, 18, 19, 49, 54].
\nSynergistic adaptation and mitigation
\nstrategies are widely viewed as necessary
\nto address climate change broadly and,
\nmore specifically, the resulting health ef-
\nfects. Mitigation strategies seek to prevent
\nor otherwise avert climate change, while
\nadaptation implies modifying systems in
\nresponse to the effects of climate change
\n[38]. Health impacts of climate change are
\nindeed mediated through the environmen-
\ntal conditions, the social infrastructure and
\nthe public health adaptation [3, 49]. As a
\nresult, mitigation and adaptation strate-
\ngies demand a multisectorial approach
\nwhich includes the health sector [9, 10, 12,
\n32,\u00a033].
\nII.The Road to Paris\/COP21
\nAdopted as part of the Rio Convention at
\nthe Rio Earth Summit in 1992, UNFCCC
\nentered into force in 1994 and now includes
\n196 parties [37]. Each year, the Conference
\nof Parties (COP) is convened to review
\nUNFCCC progress.
\nIn December 2014, COP20 was held in
\nLima,Peru,and resulted in the Lima call for
\nclimate action [20], a precursor to this year\u2019s
\nmuch anticipated COP21 negotiations.The
\nLima call for climate action represented the
\nfirst time parties revived the health effects
\nfrom Art. 1 of the Convention [37] and
\nrecognized the need to further assess the
\nhealth co-benefits of climate change miti-
\ngation.
\nA new ambitious agreement on climate
\nchange is anticipated this December at
\nCOP21 (\u201c2015 Paris Climate Conference\u201d)
\nFigure 2.\u2002\u0007Diagram of the Road to Paris
\nWorld Conference Center Bonn (ADP 2.9, June 2015)
\nBACK TO CONTENTS
\n116 117
\nClimate Change Climate Change
\n[50] and is expected to be an important step
\nin addressing this huge challenge for hu-
\nmanity. This agreement is meant to succeed
\nto the Kyoto Protocol [51, 52] in setting
\nvery ambitious long-term goals for address-
\ning climate change. High profile targets
\nmay include limiting global mean tempera-
\nture increase and carbon emissions. Current
\nlong term goals under discussion are: a max-
\nimum of a two degree temperature increase
\nand carbon neutrality by 2050.
\nSince 2011, the Ad Hoc Working Group
\non the Durban Platform for Enhanced Ac-
\ntion (ADP) has been meeting regularly to
\ndiscuss the post 2020 agreement as well as
\nthe pre-2020 ambitions needed to reach
\nthe long term goal(s). The mandate of the
\nADP is set to conclude in December 2015;
\nthus, several ADP meetings are scheduled
\nin 2015.
\nThe first ADP meeting of the year (ADP
\n2.8) took place in Geneva in February, 2015
\nwhere an early draft of the party-led negoti-
\nating text was created, the so-called Geneva
\nNegotiating Text [21]. This text, essentially
\na compilation of all possible components
\nparties would want to see in an agreement,
\nwas the first time that health co-benefits
\nwere recognized with preamble language
\ninitially tabled by Switzerland. At the con-
\nclusion of ADP 2.8, all parties agreed that
\nthis text would need to be streamlined in
\nthe months to come.
\nIn June 2015, ADP 2.9 convened at the
\nUNFCCC Headquarters in Bonn, Ger-
\nmany. Although ADP 2.9 was a much an-
\nticipated opportunity to refine the 90-page
\nGeneva Negotiating Text, little significant
\nprogress was made to streamline the docu-
\nment.Parties met and started the streamlin-
\ning process but only managed to reduce the
\nnegotiating text to 85 pages [22]; however,
\nprogress was made in defining the way for-
\nward and the Co-Chairs of the ADP will
\nproduce a tool which will facilitate the work
\nat the next session at the end of the month
\nof July [23, 24].
\nDespite the lackluster progress at ADP 2.9,
\nG7 leaders concurrently announced a com-
\nmitment to \u201c…a protocol, another legal in-
\nstrument or an agreed outcome with legal
\nforce\u201d under the UNFCCC in Paris includ-
\ning an explicit political commitment to the
\n\u201cglobal goal to hold the increase in global
\naverage temperature below 2\u00b0C\u201d [25,\u00a0 26].
\nHowever, this commitment was not reflect-
\ned in concurrent negotiations at ADP 2.9
\nin Bonn.
\nIn 2013, parties adopted a new approach
\nto climate change negotiations which in-
\ncludes submission of Intended Nationally
\nDetermined Contributions (INDCs) , or
\npost-2020 climate commitments and plans.
\nINDCs are expected to be submitted by
\nall countries and are intended to shape the
\nanticipated COP21 framework.In anticipa-
\ntion of COP21 and a new comprehensive
\ninternational climate agreement, parties
\nwill continue to unveil their INDCs in the
\nmonths to come [17]. At COP20, parties
\nagreed that INDCs would focus on reduc-
\ning emissions, although little additional
\nINDC guidance for parties was agreed
\nupon [53]. The next INDC deadline is cur-
\nrently 1 October 2015 with a synthesis re-
\nport from the Secretariat anticipated by 1
\nNovember 2015.
\nIII. Health Professionals and
\nClimate Change Negotiations
\nHealth is included in the first article of the
\nUNFCCC as an requiring action: \u201cAdverse
\neffects of climate change\u201d means changes in
\nthe physical environment or biota resulting
\nfrom climate change which have signifi-
\ncant deleterious effects on the composition,
\nresilience or productivity of natural and
\nmanaged ecosystems or on the operation
\nof socio-economic systems or on human
\nhealth and welfare.\u201d[37] The grave and om-
\nnipresent threat of climate change demands
\ncoordinated multisectoral action [27] and
\nthe health sector has the potential to unite
\nactors behind a shared well understood and
\ntangible common cause [2].
\nYet, the climate-health connection has not
\nbeen consistently recognized in UN process-
\nes including development of the post-2015
\ndevelopment agenda [38], and the health
\nsector\u00a0 \u2013 and physicians more specifically\u00a0 \u2013
\nhave only distantly been involved in climate
\nchange negotiations. In the current stream-
\nlined and consolidated Geneva Negotiating
\nText, health is highlighted only in the pre-
\namble: \u201cRecognizing that actions to address
\nclimate change simultaneously contribute to
\nthe attainment of the highest possible level
\nof health and that climate change policies
\nand health policies should be mutually sup-
\nportive.\u201d [21] It is, however, generally recog-
\nnized that health sector interventions both
\nmitigation and adaptation and that financial
\nresources will be flowing through climate
\ndedicated funds to the health sector. At a
\nminimum, given the relationship between
\nclimate change and health, the health sector
\nwill need to be ready to anticipate the effects
\nof climate change on the natural history of
\ndisease, distribution of illness and severity
\nof disease burden for vulnerable populations
\n[2]. It will be important to mitigate these ef-
\nfects while also working to change the fac-
\ntors leading to worse health outcomes and
\nsupporting smart public policy decisions to
\nimprove population health. Health care pro-
\nviders are uniquely positioned to assume a
\nleadership role through both education and
\nadvocacy to advance mitigation and adapta-
\ntion [14, 29, 30, 31].
\nIt is critical, however, that the health sec-
\ntor engages in development of the global
\nframework for climate change action\u00a0 \u2013
\nnamely, the anticipated COP21 agreement.
\nAs recommended by the recent Lancet
\nCommission report, this agreement should,
\nat a minimum, provide clear support and
\ndirection for countries transitioning to a
\nlow-carbon economy, a strong predictable
\ncarbon pricing mechanism and ensuring ac-
\ncess to renewable energy [2].
\nSpecific advocacy targets for health profes-
\nsionals and organizations could include [2]:
\n\u2022\t Urging negotiators and national policy-
\nmakers (both within and beyond Minis-
\ntries of Health) to ensure urgent, ambi-
\ntious binding action on climate change as
\nreflected in both national level commit-
\nments (INDCs) and the COP21 Paris
\nagreement;
\n\u2022\t Leveraging media to communicate the
\nhealth risks of climate change and health
\nco-benefits of mitigation and adaptation
\nas well as the need for emergent action;
\n\u2022\t Investing in climate-health research to
\nmore clearly define and measure the
\nhealth co-benefits of adaptation and mit-
\nigation; and
\n\u2022\t Supporting integration of climate change
\neducation into health professions curri-
\ncula.
\nOver the last several years, several interna-
\ntional health and health professions orga-
\nnizations [61] including the World Health
\nOrganization (WHO) [62],World Medical
\nAssociation (WMA) [34-36, 60], Global
\nClimate & Health Alliance (GCHA) [31]
\nand International Federation of Medical
\nStudents\u2019 Associations (IFMSA) [57-9]
\nhave been engaging in UNFCCC processes
\nand negotiations.
\nHowever, the urgency and severity of the
\nthreat to health from climate change de-
\nmands further action and participation by
\nhealth professionals and organizations on a
\nlocal, national and global scale.
\nThere are a growing number of successful
\nexamples of health professional advocacy
\nfor policy change that recognizes the health
\nco-benefits of climate change mitigation
\nand adaptation. The divestment movement
\nhas been rapidly growing within the last
\nfew years and seeks to support the transi-
\ntion to a low-carbon economy through
\n\u201cdisruptive innovation\u201d [55]. Divestment is
\ngenerally defined to include the withdrawal
\nof all existing investments in fossil fuels and
\na commitment not to make any new in-
\nvestments. In some cases, divestment may
\nbe coupled with investment in renewable
\nenergy or similar more socially responsible
\nindustries. In 2014, the British Medical As-
\nsociation (BMA) passed a motion to divest
\nfrom the fossil fuel industry [40, 41, 13, 45].
\nOther national medical associations, aca-
\ndemic institutions and other organizations
\nare increasingly considering and adopt-
\ning similar divestment policies [42-44].
\nSimilarly, Health Care Without Harm,
\nan international coalition of hospitals and
\nhealth care systems, professions and other
\norganizations, has developed and executed
\nnumerous successful local, national and in-
\nternational advocacy campaigns around en-
\nvironmental health and justice\u00a0\u2013 including
\nclimate change [56].
\nIV. Conclusion
\nUnchecked climate change will inevitably
\nhave grave negative implications for health;
\nconversely, addressing climate change
\nthrough mitigation and adaptation presents
\nan extraordinary opportunity to protect
\nglobal health [2]. Without concerted global
\naction, climate change will continue to have
\nprofound negative effects, both directly and
\nindirectly, on the patients and communi-
\nties health professionals serve\u00a0\u2013 and global
\npopulation health more broadly. Many
\nhealth sector interventions addressing cli-
\nmate change are no-regret policies which
\neven without accounting for the benefits for
\nclimate change are valuable for the health
\nof population [2]: health professionals have
\na role to play in illustrating that to policy-
\nmakers.
\nIn this context, the medical community has
\na professional obligation to engage in an ef-
\nfective multisectoral global response to cli-
\nmate change and to ensure a strong climate
\nchange agreement [34, 35]. The urgency
\naround this action and engagement by
\nhealth professionals could not be stronger
\nin the coming months as ADP\/COP21 ne-
\ngotiations proceed down the \u201croad to Paris\u201d.
\nKeep up with upcoming COP21 negotiations
\nand the road to Paris on Twitter by following
\n@medwma and #COP21, #ADP2015, #Cli-
\nmateHealth.
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Global Air Quality and Health Co-benefits of Mitigating Near-Term Climate Change through Methane and Black Carbon Emission Controls<\/a><\/p><\/blockquote>\n