WMJ 06 2013

COUNTRY
• Communication of Results and Incidental Findings in
Medical Research
• Working for Health Equity: The Role of Health
Professionals
vol. 59
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 6, December 2013
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201
Medical Research
Elmar Doppelfeld1
The principle of free and informed consent –
codified, perhaps for the first time ever, as
early as December 29, 1900 [Minister der
geistlichen Unterrichts- und Medizinal-
Angelegenheiten 1900] by a decree of the
Prussian Minister of Education – is con-
sidered an essential prerequisite for the
involvement of human subjects in medi-
cal research. Since World War II, numer-
ous sets of rules – including both legally
binding and so-called “soft law” instru-
ments intended to serve as recommenda-
tions – have established legal and ethical
principles that need to be observed to
ensure that “free and informed consent” is
obtained. One of them is to provide full
and frank information to the potential re-
search participant, or “a proper instruction
regarding potential adverse effects that
might result from the intervention”, to put
it in the words of the aforementioned de-
1 Based on a lecture given at the IMAGEN Meet-
ing of the Ethics Council and Workshop “Inciden-
tal Findings and Disclosure of Information in the
Context of Research”, September 20, 2010 – Berlin.
cree. Thus, the principle of informing par-
ticipants before the commencement of a
research project is well-established and no
longer contested.
Less clear, however, is the extent to which
a person who participated in a research
project is to be informed about the results.
Should, or may, the participant be informed
at all? Should the information be restrict-
ed to “health-related” findings obtained
in the course of the project? Who defines
what “health-related” means? These ques-
tions are all the more important as research
projects in all disciplines produce findings
that are difficult to interpret – if they can be
interpreted at all. But does this entitle the
researcher or the physician-researcher to
withhold such findings (even if they cannot
be interpreted) from the person concerned?
After all,an increasing number of incidental
findings2
can be related to the choice of the
research methodology. They, too, raise the
question of the research participant’s right to
know and not to know. Can, or may, the de-
cision regarding disclosure of information
about such findings be left to the good will
or the discretion of the physician-researcher
or other researchers?
The right to know and not to know can
be associated with the right to informa-
tional selfdetermination. Hence, it needs
to be established whether the respect for
the dignity of the research participant calls
for this right to be respected. To this end,
the present Chapter will examine the legal
standards for the protection of that dignity,
particularly the instruments of the Council
of Europe.
2 “The term ‘incidental finding’ refers to the unex-
pected discovery of an abnormality for which there
was no recognizable prior evidence and that was not
specifically looked for.” [Heinemann et al. 2007].
Interest in the results
of medical research
The vast majority of people who agree to
participate in a medical research project do
not do so to serve as a mere “source of data”.
The decision to be part of a research study
may be motivated by various interests – in-
terests, which may also give rise to the de-
sire to know the results.
For instance, participants who are patients
may hope to learn more about the current
status of diagnostics and therapy for their
disease, or they may desire to contribute to
improvements in these areas. This motiva-
tion may be coupled with the need to gain
knowledge about the overall results of this
disease-specific research and, as the case
may be, also about the status of their own
disease. It must be borne in mind, however,
that a patient may also refuse to be informed
about the possibly advanced stage of their
disease. Furthermore, unexpected findings
may occur during the diagnostic process,
which the patient may or may not want
to know about. Healthy volunteers may be
guided by the idea of making a contribu-
tion to research in general, without expect-
ing any personal benefit; there might still be
some advantage for them. Furthermore, it
should be recognised that patients and test
persons (healthy volunteers) alike may also
have a legitimate interest when it comes to
the future use of findings that have been ob-
tained with their participation. It may not
be acceptable to everybody that “their find-
ings” might be used in follow-up studies in
areas they do not approve of.
In the context of research projects, we can
systematically distinguish between expected
or preferred findings and unexpected find-
ings with respect to the applied method,
disease status or evidence of a previously
Communication of Results and Incidental Findings in Medical
Research – A European Perspective1
202
GERMANYMedical Research
undiagnosed disease, as well as limitations
or new possibilities for therapy.To complete
this attempt at classification,we need to add
findings discovered in the course of a re-
search project involving healthy volunteers
that are not related to the aims of the study.
Communication of results
to research participants
When considering how to deal with the
findings obtained, respect for the dignity of
the persons concerned and for their right
to informational self-determination should
be given priority. The idea that – from an
“ethical” or “medical” perspective – it is un-
acceptable to inform people about negative
findings (especially when they cannot be in-
terpreted) is quite common and understand-
able. Others argue that unexpected findings
pointing to a potential disease should be
communicated to a person even against his
or her will, so that appropriate measures can
be taken to preserve that person’s health if
necessary. Such considerations, reasonable
though they may seem, find their limits in
provisions that, in respect for human dig-
nity, have been established to protect the
“right to know”and the “right not to know”.
These provisions, which have only been in-
troduced in the past few years, do not dif-
ferentiate between different categories of
findings, as mentioned in the classification
proposal above. A systematic distinction is
made between rules with a general scope
that also extend to medicine and medical
research and provisions that, in the form of
legal or quasi-legal instruments (“soft law”),
pertain specifically to these areas.
General provisions
One example of a legal instrument with a
general scope is the German Federal Data
Protection Act (Bundesdatenschutzgesetz).
This Act stipulates the obligation to inform
individuals about recorded data relating to
them (Section 34). This obligation is ex-
pressly linked to the person concerned in
making a request to be informed about the
data. If no such request is put forward, there
is no obligation to inform.At the same time,
this right granted by Section 34 may not be
excluded or restricted by a legal transaction
(Section 6), such as an agreement between
the researcher and the research participant.
The cited provisions – which also apply to
medical research without restriction – bind
the owner of the data, whether they are a
medical researcher or a member of any oth-
er scientific discipline, to provide informa-
tion on request. The waiver of this right to
information, which can be found in many
contracts with research participants, con-
flicts with the cited Section 6, and should
therefore be considered invalid.
Specific provisions
The current version of the Declaration
of Helsinki [World Medical Association
2008] clearly states that “patients” entered
into a study are entitled to be informed
about the outcome of the study (Paragraph
No. 33). The guidelines issued by CIOMS
[Council for International Organizations of
Medical Sciences 2002] stipulate that the
research protocol (Appendix 1, Item  34)
must include “plans to inform subjects
about the results of the study”. Hence, it
can be acknowledged that two prominent
and widely accepted instruments of “soft
law” postulate an obligation to inform re-
search participants about research findings.
In particular, the definition established
in the Declaration of Helsinki, which has
been developed by the medical profession as
a statement of ethical principles for medical
research, could help to point the way ahead
when conflicts arise between the legal obli-
gation to inform and “ethical/medical con-
cerns”against the disclosure of information.
Besides,it remains unclear why the Helsinki
Declaration only affirms the patient’s right
to information, without explicitly including
other test persons (healthy volunteers) as
well. The CIOMS guidelines use the neu-
tral term “subjects”, without differentiating
between the two groups.
On the European level, the primary rule
governing the handling of data from medi-
cine and research in the context discussed
here is Article 101
3 of the Oviedo Con-
vention [Council of Europe 1997], which
30 members of the Council of Europe have
ratified to date.
According to Article 10, “everyone is en-
titled to know any information collected
about his or her health. However the wishes
of individuals not to be so informed shall be
observed.” Article 10 further provides that
“in exceptional cases, restrictions may be
placed by law” on the exercise of the afore-
mentioned rights “in the interests of the
patients”. It should be noted that this provi-
sion, besides establishing the right to obtain
exhaustive information on all recorded data,
explicitly codifies the right not to know.
No such explicit stipulation is contained in
either of the other aforementioned docu-
ments. In general, the right not to know is
considered as an element of informational
self-determination, requiring no specific
wording. Article 10 of the Oviedo Conven-
tion provides that in exceptional cases, both
rights may be restricted for the benefit of
the patient, namely on a legal basis. Article
10 grants rights to the persons concerned,
without naming those who must comply
with them. This suggests that anyone who
disposes of the collected information  –
whether a medical researcher or a member
of any other scientific discipline – must ful-
1 “Private life and right to information:
a. Everyone has the right to respect for private
life in relation to information about his or her
health.
b. Everyone is entitled to know any information
collected about his or her health. However,
the wishes of individuals not to be so in-
formed shall be observed.
c. In exceptional cases, restrictions may be
placed by law on the exercise of the rights
contained in paragraph 2 in the interests of
the patient.” (Convention on Human Rights
and Biomedicine, Article 10).
203
GERMANY Medical Research
fil the obligation to provide information on
the one hand,and to respect the right not to
know on the other.Thus,anyone who deems
it necessary to deviate from this principle
should (even if there may be good reasons in
individual cases) first make sure that there is
a legal basis for doing so. It should also be
borne in mind that the Oviedo Convention
only allows for such deviations if they are in
the interests of the patient.
The Additional Protocol to the Oviedo
Convention on “Biomedical Research”
[Council of Europe 2005], is  – like the
Convention itself – an instrument of Inter-
national Law, and hence legally binding in
countries that have ratified it. With regard
to the right to information, the Protocol
specifies the framework conditions laid
down in Article 10 by adding more detailed
provisions. The Chapter on information
for research participants  – which makes
no distinction between patients and other
test persons (healthy volunteers) – explicitly
states that it must be made comprehensible
to participants how they can get access to
information that is relevant to them, as well
as to the overall research project results (Ar-
ticle 13.2).The ethics committee must veri-
fy that this requirement has been met when
evaluating the research project in question.
The Appendix to the Research Protocol
(“Information to be given to the ethics
committee”) specifies the details of this re-
quirement by referring to the relevance of
the generated information to the present
or future health of the research participants
and their family members.
The Additional Protocol on Biomedical Re-
search emphasises the research participant’s
right to be informed in three articles cov-
ering different areas. To begin with, Article
26 of the Protocol reaffirms the right of re-
search participants “to know any informa-
tion collected on their health in conformity
with Article 10 of the Convention.”The text
refers to “research participants”, i.e. no dis-
tinction is made between patients and test
persons (healthy volunteers). Since refer-
ence is made to Article 10, the right not to
know is secured, too. Data collected in the
course of the project that are not health-
related shall be made accessible to the per-
son concerned, in accordance with national
law.The main objective here is to guarantee
the rights of Third Parties to the results ob-
tained. Article 27 regulates the handling of
information on research results that are of
relevance to the present or future health or
quality of life of research participants. Such
information is to be offered to the person
concerned within a framework of health
care or counselling; confidentiality and the
right not to know are to be respected.
The obligation to offer the information
to research participants is not limited to a
particular profession. Physician-researchers
and researchers from other disciplines are
equally bound to make this offer; only the
disclosure itself shall take place within a
framework of health counselling. Since ref-
erence is made to Article 10 of the Con-
vention, it is made clear that in the context
of information disclosure also, the right to
know and the right not to know may only
be restricted under the provisions contained
therein.
Finally, the conclusions of the research
project must be made available to the par-
ticipants  – again, no distinction is made
between patients and test persons (healthy
volunteers) – on request (Article 28 of the
Protocol). Further, Article 28 refers to the
obligations to submit a report to the ethics
committee on completion of the research,
and to take measures to make the results
public.
Conclusions
The provisions which have been addressed –
whether they are legally binding or “soft
law” instruments, and whether they are
based on data protection law or have been
specifically established for the areas of
medicine and medical research – allow for
the statement that everybody has the right
to be informed about any data collected on
his or her health. To this end, the legal in-
struments of the Council of Europe provide
detailed guidelines pertaining to medical
research. The authors deemed it necessary
to adopt detailed regulations in order to
guarantee right to informational self-deter-
mination and to avoid the possibility that
researchers circumvent this right by making
decisions that may well be morally justifi-
able in certain cases, but which may also be
somewhat arbitrary in nature. Information
on collected data relating to health and to
the conclusions of a research project is to
be provided to the persons concerned on
request.
The obligation to offer information to the
research participant only applies in the case
of findings of relevance to the health of the
person concerned. The research protocols,
which are submitted to the ethics commit-
tee for evaluation, must specify how the
process of disclosure will be managed.
When a research participant requests to be
informed, he or she exercises his/her right
to know.The exercise of this right cannot be
restricted or invalidated by means of a waiv-
er signed by the participant – at least not
under German data protection law. Here,
the right not to know comes into play: It
must be respected, even in the case of find-
ings and research outcomes that are of rele-
vance to the health of the person concerned.
From the author’s point of view, the cre-
ators of these different provisions have set
clear standards to substantiate the right to
informational self-determination, which is
associated with the autonomy of the person.
A responsible person must be able to decide
for himself/herself what he or she does or
does not want to know, since it is this per-
son who has to live with the consequences
of, for instance, a disease in an advanced
stage that might have been successfully
treated if information – which the person
refused to obtain – had been given. A re-
204
sponsible person must also decide whether
he or she wants to let the matter rest when
a research project produces findings that are
difficult or nearly impossible to interpret, or
whether he or she desires further clarifica-
tion. It is the responsible person who bears
the risk of a potentially adverse progression
of the condition,not the researcher by with-
holding this information and of acting con-
trary to law.
Of course, these clear provisions  – which
do not yet provide for any exceptions in
the case of incidental findings or inex-
plicable findings  – give rise to the ques-
tion of morally acceptable conduct in the
physician-researcher. Some rules could be
found in “Codes of Deontology” of physi-
cians (in Germany: “Berufsordnungen der
Landesärztekammern”). It must be noted,
however, that the right to know and the
right not to know are regulated by law and
cannot be modified or invalidated by any
code of deontology. With the exception of
the German “Berufsordnung”, such codes of
deontology are not legally binding in any
European State. Hence, they do not really
provide a solution to the moral dilemma
of either burdening a person by informing
them about findings which may be irrel-
evant after all, or – if the right not to know
is invoked – of leaving this person with the
risk of a looming disease. But again: This
risk is borne by the responsible person alone.
To conclude, a few remarks are warranted
concerning incidental findings, which occur
more and more frequently in research proj-
ects in many areas. Such findings are not
given any special status in the provisions
discussed above – they are to be treated in
the same way as any other “health-related
information”, and the right to know or not
to know is to be respected. Sometimes it
is argued that incidental findings only oc-
cur when certain parameters apply to the
research project, e.g. the use of imaging
techniques, and that it is impossible to draw
conclusions about their medical relevance.
In the author’s opinion, which is substan-
tiated by the cited provisions, the person
concerned must be informed in such cases,
at least on request. He or she may then
decide whether they want to let the mat-
ter rest, or whether they prefer to watch
for further developments related to these
findings – for instance in the context of a
long-term observation, which is sometimes
desired by researchers. However, the re-
searcher may not make this decision tacitly
or on the participant’s behalf. As regards
the requirement that findings which can-
not be interpreted with the methods used
in the research project should be clarified
by means of appropriate medical diagnos-
tics, this is often objected to on the grounds
that it would involve excessive costs and
administrative effort. However, cost and
effort should be considered and budgeted
for when such projects are being planned –
after all, we are talking about the weal and
woe of the research participants. The mea-
sures envisaged for a medical clarification
of incidental findings must be documented
in the research protocol, which is submit-
ted to the ethics committee. It is sometimes
argued that, in the context of the research
situation discussed here, the doctor and the
research participant are not engaged in a
typical physician/patient relationship, and
that hence there is no obligation to perform
further medical diagnostics. Whether this
splitting of roles between physicians and
physician-researchers is consistent with
the requirement contained in Item No. 4 of
the Declaration of Helsinki, “The health of
my patient will be my first consideration”,
is something that everybody must judge
for themselves. However, the instruments
of the Council of Europe do not allow for
such splitting. They refer exclusively to the
“researcher”, who has both rights and du-
ties, or, in more neutral terms, to actions,
measures etc. to be taken.
References
1. Minister der geistlichen Unterrichts- und
Medizinal-Angelegenheiten, Anweisung an die
Vorsteher der Kliniken, Polikliniken und sonsti-
gen Krankenanstalten. Zentralblatt für die gesa-
mte Unterrichts-Verwaltung in Preußen (1900),
188–189
2. Heinemann T, Hoppe C, Listl S, Spickhoff A,
Elger CE, Incidental findings in neuroimaging:
Ethical problems and solutions. Dtsch Arztebl
(2007), 104, A1982–7
3. Bundesdatenschutzgesetz in der Fassung der
Bekanntmachung vom 14. Januar 2003 (BGBl. I
4. S. 66), das zuletzt durch Artikel 1 des Gesetzes
vom 14.August 2009 (BGBl.I S.2814) geändert
worden ist
5. World Medical Association (2008) Dec-
laration of Helsinki: Ethical Principles for
Medical Research Involving Human Sub-
jects. Adopted by the 18th
WMA General
Assembly, Helsinki, Finland, June 1964, and
amended by the 59th
WMA General Assem-
bly, Seoul, October 2008. https://www.wma.net/
en/30publications/10policies/b3/index.html
(26.03.13)
6. Council for International Organizations of
Medical Sciences (2002) International Ethical
Guidelines for Biomedical Research Involving
Human Subjects, Geneva
7. Council of Europe (1997) Convention for the
protection of human rights and dignity of the
human being with regard to the application of
biology and medicine: Convention on human
rights and biomedicine. European Treaty Series
No. 164. Oviedo
8. Council of Europe (2005) Additional protocol
to the convention on human rights and biomed-
icine, concerning biomedical research. European
Treaty Series No. 195. Strasbourg
Prof. Elmar Doppelfeld, MD
Chair of the Working Group
“Biomedical Research”, Committee on
Bioethics (DH-BIO),Chair (2005–2007)
of the “Steering Committee
on Bioethics (CDBI)”
Council of Europe
Chair (1994–2012) of the Permanent
Working Party of Research Ethics
Committees in Germany
E-mail: elmar-doppelfeld@t-online.de
In: Lanzerath D et al. (eds) Incidental Findings. Scien-
tific, Legal and Ethical Issues. Köln: Deutscher Ärzte-
Verlag, 2014: 53–58.
GERMANYMedical Research
205
Foreword
The Merseyside Fire and Rescue Service
made a lasting impression. When conduct-
ing the Marmot Review of Health Inequal-
ities, published as Fair Society Healthy Lives,
we partnered with the North West Region
of England. On one of our visits to Liver-
pool, we were hosted by the fire fighters.
Their compelling story was of going outside
their core professional practice of fighting
fires to preventing them, which entailed
engaging with the local community. They
then became involved in looking at quality
of housing, and at smoking, which are fire
risks, to more general issues that benefit the
community, including activities for young-
sters and older people.
“If the fire fighters can do it, why not the
doctors?”was a question I posed to the Brit-
ish Medical Association, during my time as
President. Doctors are involved in treating
illness but most accept they have an im-
portant role in prevention. If illness arises
from the conditions in which people are
born, grow, live, work, and age – the social
determinants of health – should the doctors
not get involved in the causes of illness and,
indeed, the causes of the causes. The BMA
picked up the challenge and produced a
report on what doctors could do about the
social determinants of health. But why stop
at doctors? Other health professionals have
key roles to play on improving the condi-
tions of people’s lives and hence could have
profound effects on health inequalities.This
report builds on the BMA’s report and the
inspiring work of health professionals.
Fair Society Healthy Lives laid out the evi-
dence and made recommendations of what
should be done on the social determinants
of health in order to reduce health inequali-
ties. Many of the recommendations were
aimed at sectors other than health. But the
medical and health professions are well
placed to take action on the social deter-
minants of health – they are trusted, expert,
committed, and great powerful advocates.
One response to the evidence on social de-
terminants of health is weary reluctance –
it is simply all too difficult. The response
we have had from colleagues who helped
us with this report has been far from that.
Nineteen organisations have contributed,
including medical Royal Colleges, nurses,
midwives, medical students, and several al-
lied health professions. We appear to have
struck a chord. And it is hugely encourag-
ing.
The response can be summarised as: not
only should we be taking action but there
Health Equity
Sir Michael Marmot
Matilda Allen, Jessica Allen,
Sue Hogarth with Michael Marmot
Statements for action were written by the
following:
– Nurses by the Royal College of Nursing;
– Social workers and social care by the Social
Work & Health Inequalities Network;
– Clinical Commissioning Groups by the
Royal College of GPs;
– General practitioners by the Royal Col-
lege of GPs;
– Paediatricians by the Royal College of
Paediatrics & Child Health;
– Midwives by the Royal College of Mid-
wives;
– Obstetricians and gynaecologists by the
Royal College of Obstetricians and Gyn-
aecologists;
– Hospital doctors by the Royal College of
Physicians;
– Psychiatrists by the Royal College of Psy-
chiatrists;
– Dentists and the oral health team by
the Faculty of Dental Surgery, Royal
College of Surgeons of England; Den-
tal Faculty, Royal College of Surgeons
of Edinburgh; Dental Faculty, Royal
College of Physicians and Surgeons of
Glasgow; Faculty of General Dental
Practice, Royal College of Surgeons of
England; Dental Schools Council; Brit-
ish Association for the Study of Com-
munity Dentistry;
– Medical students by Medsin
– Allied health professionals by the Allied
Health Professions Federation with sec-
tions on: Music therapists by the British
Association of Music Therapy, Dieticians
by the British Dietetic Association, Oc-
cupational therapists by the College of
Occupational Therapists, Physiothera-
pists by the Chartered Society of Phys-
iotherapy, Paramedics by the College of
Paramedics, Radiographers by the Soci-
ety and College of Radiographers,Speech
and language therapists by the Royal Col-
lege of Speech and Language,Therapists.
Working for Health Equity:The Role of Health Professionals
206
Health Equity
is ample evidence that we can. This report
shows the evidence base for actions,the case
studies present examples of organisations
with effective strategies, and the statements
for action put forward practical actions.
The report and statements make clear that
action on the social determinants of health
should be a core part of health profession-
als’ business, as it improves clinical out-
comes, and saves money and time in the
longer term. But, most persuasively, tak-
ing action to reduce health inequalities is
a matter of social justice. The enthusiastic
response from medical and health profes-
sionals to the challenges of a fairer distri-
bution of health contributes to what I have
described as my evidence-based optimism:
we are making progress in a good cause.
Join us.
Professor Sir Michael Marmot
Director of the UCL Institute
of Health Equity
Executive Summary
Those in the health sector regularly bear
witness to, and must deal with, the effects of
the social determinants of health on people.
This report will demonstrate that the health
care system and those working within it
have an important and often under-utilised
role in reducing health inequalities through
action on the social determinants of health.
The health workforce are, after all, well
placed to initiate and develop services that
take into account, and attempt to improve,
the wider social context for patients and
staff.
This report launches a new programme
of activities to tackle health inequalities
through action by health professionals on
the social determinants of health. It draws
on many examples of inspiring and excel-
lent practice which demonstrate what can
be done. The report describes areas where
greater action is necessary and possible and
makes some practical suggestions about
how to take forward action on the social
determinants of health.
The report contains recommendations and
analysis in six core areas, described below. It
also contains nineteen Statements for Ac-
tion about actions health professionals can
take to tackle the social determinants of
health through their practitioner role.These
have been written by Royal Colleges and
other representative organisations, and set
out, for each profession, a rationale for ac-
tion, practical guidance on what activities to
engage in, and relevant case studies and fur-
ther reading. Working with the authors of
these statements, and other organisations,
the Institute of Health Equity (IHE) will
support and encourage health profession-
als to take greater action to tackle health
inequalities.
The report also sets out a series of com-
mitments made specifically for this report
and future work programme, from twenty
relevant organisations. These cover each
of the six priority areas in this report, and
display an impressive ambition to take
forward action on the social determinants
of health. Organisations have committed
to work in partnership to implement the
recommendations of this report by pro-
ducing educational materials, developing
new research and publications, setting up
networks, embedding the social determi-
nants of health in current work and dis-
seminating information to health profes-
sionals. These commitments are described
throughout the document at the ends of
chapters, and a full list can be found on
the IHE website (1). They will form the
basis for an on-going programme of work
led by IHE in partnership with Royal Col-
leges, the Academy of Medical Royal Col-
leges (AoMRC), the British Medical As-
sociation (BMA), the Canadian Medical
Association (CMA), the World Medical
Association (WMA), and other organisa-
tions and institutions. These commitments
will extend and develop over time, but are
included in the full report in their current
form in order to give an indication of fu-
ture steps. As we continue the programme
of work over the next few years, these will
be developed, tested and implemented fur-
ther.
Background
Evidence presented in the Marmot Review
2010 (2), and many other evidence-based
analyses of health inequalities (3–6) show
a clear social gradient in health outcomes,
which closely relates to social and economic
factors: the conditions of daily life. Most of
the factors influencing health lie outside the
immediate reach and traditional remit of
the health system – early-years experiences,
education, working life, income and living
and environmental conditions. The recom-
mendations of the Marmot Review were
therefore mainly focussed on actions which
could be taken outside the health care sys-
tem to reduce health inequalities. This re-
port now focuses on actions and strategies
that can be developed within the health care
system, and particularly the health work-
force, where there is great scope. It builds
on and learns from other recent initiatives
(7–9).
While inequities in access and care within
the NHS do exist, they do not account for
a large proportion of health inequality, par-
ticularly when compared to the powerful
influence of social and economic factors on
health (10–12). This report demonstrates
that there is much that the health system
can do to influence these wider social and
economic factors,beyond ensuring equity of
access and treatment.Those working within
the health system have an important, albeit
often under-utilised, role in reducing health
207
Health Equity
inequalities through action on the social
and economic factors: the social determi-
nants of health. Tackling health inequity is
a matter of social justice; it is also essential
in order to provide the best care possible.
Preventive measures that improve the con-
ditions in which people live can lengthen
people’s lives and years spent in good health,
improve services and save money (2).
The report is based on literature, case stud-
ies, and other evidence about how health
professionals and organisations can influ-
ence social determinants and tackle health
inequalities in a systematic and effective
way. Many relevant organisations have had
direct input into the report, and this input
forms much of the basis for the analysis and
recommendations. We organise this analy-
sis into six areas in which actions will be
particularly effective: education and train-
ing, working with individuals, action by
NHS organisations, working in partnership,
workforce as advocates, and opportunities
and challenges within the health system.
These are described briefly below and in
greater detail in the main report, where they
are also accompanied by case studies, rec-
ommendations and commitments.
Part A. Ways for health professionals
to take action on health inequalities
1 Workforce education and training
In order for the health workforce to suc-
cessfully tackle health inequalities and take
action on the social determinants of health,
the right education and training are essen-
tial. Good education on the social determi-
nants of health will not only inform but also
empower the health workforce to take ac-
tion. Changes should take place within un-
dergraduate education, postgraduate educa-
tion, Continued Professional Development,
and other forms of training.
There are two important actions in this
area. Firstly, professionals should be taught
about the nature of the social determi-
nants of health, and what actions by those
within, and outside, the health system have
been successful in tackling them. Educa-
tion should include information about the
graded distribution of health outcomes,
how social and economic conditions can
help to explain these unequal outcomes,
and what practical actions can be undertak-
en by health professionals to decrease these
inequalities. This teaching should take the
form of dedicated compulsory and assessed
modules, and should be included in other
specialised courses, for instance a course on
cardiovascular disease should include infor-
mation on the social determinants of that
disease (13).
This first area can then be supplemented
by a second action, the teaching of skills:
that is, how to reduce inequalities within
professional practice areas. Some necessary
skills are more general and have broad ap-
plication – for example, skills of commu-
nication, partnership and advocacy are all
essential for tackling health inequalities.
There are also specific strategies which
have been shown to be effective, for exam-
ple, taking a social history and making pa-
tient referrals to external support services.
Teaching skills in these specific practice-
based areas should be a core element of all
health courses.
Seeing the effects of social and economic
inequalities will ground and ‘realise’ the
knowledge described above. For this reason,
student placements are central to learning.
They should take place in a range of non-
clinical settings, for example with social
services or with a debt advice service, and
should be designed to expose students to
disadvantaged areas and needs.It is also im-
portant that access to health professions is
made more equal.
Within England, action across the areas
discussed above is the responsibility of
Health Education England, Local Edu-
cation and Training Boards, the General
Medical Council,medical schools,NHS or-
ganisations, and professionals and students
in advocacy roles. IHE will work with these
organisations to embed the recommenda-
tions below.
Key recommendations:
Workforce Education and Training
Knowledge
A greater focus on information about
the social determinants of health, and
information on what works to tackle
health inequities, should be included as
a mandatory, assessed element of under-
graduate and postgraduate education.
Skills
Communication, partnership and advo-
cacy skills are all general areas that will
help professionals to tackle the social de-
terminants of health. Thereare also spe-
cific practice-based skills, such as taking
a social history and referring patients to
non-medical services, which should be
embedded in teaching in undergraduate
and postgraduate courses.
Placements
Student placements in a range of health
and nonhealth organisations, particular-
ly in deprived areas,should be a core part
of every course.This will help to improve
students’ knowledge and skills related to
the social determinants of health.
Continued Professional Development
Both knowledge about the social de-
terminants of health and skills to tackle
these should be taught and reinforced as
a compulsory element of CPD.
Access
Universities should take steps to ensure
that students from all socio-economic
backgrounds have fair access to health
care careers.
208
2 Working with individuals and commu-
nities
The Marmot Review showed that if the
conditions in which people are born, grow,
live, work, and age are favourable, and dis-
tributed more equitably, people would have
more control over their lives in ways that
will influence their own health and health
behaviours, and those of their families. In-
dividual health professionals can tackle the
social determinants of health by helping to
create the conditions in which their patients
can have control over their lives.
It is important that health professionals
build relationships of trust and respect with
their patients.This is good for the patient as
control and reducing stress can have direct
effects on health (14).It can also improve the
uptake of public health messages and other
strategies to reduce inequalities. Greater
communication and better relationships can
also enhance practitioners’ knowledge and
understanding of their patients and the lo-
cal community, thereby improving the care
that they are able to offer. Techniques such
as motivational interviewing, a method that
increases communication and collaboration
between patients and providers, can help to
build these relationships on an individual
level. On a community level, professionals
should be promoting and engaging in col-
laboration and communication with the lo-
cal population.
In taking action to reduce inequalities,
health professionals can focus on two key
activities: gaining information, and pro-
viding information. Gaining information
about patients is important in order to un-
derstand how social and economic factors
are impacting on a patient’s health.Taking a
social history can enhance a medical history
and enable professionals to provide the best
care possible. This type of information is
also essential on an aggregate basis, as it can
help to influence and inform local commis-
sioning and provision, both of health care
and of other services within the community.
Longitudinal social data can also enable
organisations to measure progress and the
effectiveness of interventions against health
equity indicators.
Giving information that can help to im-
prove the social determinants of health
mainly consists of referring patients to non-
medical services.These should cover a broad
range of sectors and issues, beyond lifestyle
and disease management programmes. For
example,referral to Legal Aid,Relate,CAB,
employment programmes or housing ad-
vice services can help patients to tackle the
sources of ill health. By connecting patients
to professional advice about state benefits,
health professionals can ease patient anxiety
and stress (15) and improve the context in
which they live. Other referrals can help to
tackle other social determinants of health.
Such activity may reduce the number of
consultations with and prescriptions from
GPs (16). Referral of this type is particu-
larly successful where the services are read-
ily accessible or medical and non-medical
services are co-located – for example, where
Citizens Advice Bureaux are situated in GP
surgeries.
There will be two types of changes needed:
those requiring increased resources of time
and money, and those that can be accom-
modated within existing structures and
constraints. In the first case, professionals
should be advocating for change and help-
ing to build an evidence base to support
the case. However, some changes can and
should be made within existing structures
and constraints.
3 NHS organisations
In addition to actions taken to improve
the health and wellbeing of their patients,
NHS organisations have a responsibility
to ensure that health inequities among
their employed staff are also tackled. The
NHS is the largest employer in the coun-
try with 1.4 million staff (17), plus staff
employed in non-NHS commissioned
services. Health professionals have oppor-
tunities in their roles as managers, com-
missioners and employers to ensure that
workforce health and wellbeing are central
to their activities.
Firstly, NHS organisations should be places
of good quality work. Evidence has consis-
tently shown that employment is better for
mental and physical health than unemploy-
ment. However, this only applies to good
quality work (2).Good quality work is char-
acterised by a living wage, having control
over work, being respected and rewarded,
being provided with good quality in-work
Key recommendations:
Fiorking with Individuals and Commu-
nities
Relationships
Health professionals should build rela-
tionships of trust and respect with their
patients. They should promote collabo-
ration and communication with local
communities to strengthen these rela-
tionships.
Gathering information
Health professionals should be taking a
social history of their patients as well as
medical information. This should then
be used in two ways: to enable the prac-
titioner to provide the best care for that
patient, including referral where neces-
sary; and at aggregate level to help or-
ganisations understand their local popu-
lation and plan services and care.
Providing information
Health professionals should refer their
patients to a range of services – medi-
cal, social services, other agencies and
organisations, so that the root causes of
ill health are tackled as well as theback-
grounds have fair access to health care
careers.
Health Equity
209
services such as occupational health servic-
es, and with adequate support to return to
work after absence.
The importance of these areas was recog-
nised by Carol Black’s review of the UK’s
working age population (18), and was ap-
plied to NHS workplaces in the Boorman
Review (19). Managers should be ensuring
that all staff, including contracted staff, are
provided with good quality work in line
with the recommendations of the Boorman
Review. IHE have produced a strategy for
Barts and the London Trust which set out
how to implement the recommendations
of the Boorman Review and the Marmot
Review (22). Implementing these strate-
gies across the workforce is likely to reduce
inequalities as there is a gradient in quality
of work: those from lower socio-economic
groups currently tend to experience worse
quality work.
NHS organisations, and therefore their
staff, have considerable influence through
their sizeable purchasing power, both as
employers and contractors of staff and as
commissioners of services. One literature
review found that the health sector often
accounts for 15–20% of a local commu-
nity’s employment and income (20). This
gives health organisations significant power
to affect the health and wellbeing of their
local population. Public bodies also have
a legal duty to consider how procurement
might improve the economic, social and
environmental wellbeing of their area (21).
Employment should be designed to be par-
ticularly beneficial for those from lower
socio-economic groups, as this will reduce
inequalities. In addition to providing a good
quality place of work, this can be achieved
by ensuring that there is security and flex-
ibility of employment and retirement age,
and that jobs are suitable for lone parents,
carers and people with mental and physical
health problems (22).
This report outlines many actions that can
be taken by individual health professionals.
They can start to take most of these actions
straight away. However, in order for action
to be comprehensive, systematic and sus-
tained, these actions must be supported at
every level. For this reason, managers and
leaders should ensure that strategies on or-
ganisational health inequalities that incor-
porate the areas in this report are in place,
with dedicated leads and budgets. They
should be auditing proposed actions, moni-
toring progress and sharing good practice.
4 Working in Partnership
In order to take effective action to reduce
inequalities, working in partnership is es-
sential. Evidence shows that effective ac-
tion often depends on how things are de-
livered, as much as what is delivered (2). A
key element of this is collaborative, coop-
erative work that is either delivered jointly
by more than one sector, or draws on in-
formation and expertise from other sectors.
Since many of the causes of ill health lie
in social and economic conditions, actions
to improve health must be taken collab-
oratively by a range of agencies that have
the potential to affect social and economic
conditions.
Many health professionals work extensively
and successfully with other health care staff.
These partnerships within the health system
often extend across primary, secondary and
tertiary care; between nurses, psychiatrists,
doctors, surgeons and more; and are a core
part of day-to-day business for practising
professionals. Partnerships should occur be-
tween different organisations, for example
hospitals and community health services,
and different professionals in the same or-
ganisation.They can help to improve patient
experience and practitioner knowledge, and
reduce inequalities in outcomes.
However, perhaps more importantly, part-
nerships between health and non-health
professionals and organisations should be
established, supported and extended. Inte-
grated work should be broad, and include
partnerships with local government, other
public sector partners, the police and fire
service, charities and other third sector or-
ganisations, private companies and places of
work, and schools (2). There is a legal duty
on Clinical Commissioning Groups and the
NHS Commissioning Board to integrate
services where this would reduce inequali-
ties (23), and other professionals should
work to support and extend this. Infor-
mation-gathering and monitoring systems
should be collaborative where possible.Joint
planning, commissioning and delivery are
particularly important for effective partner-
ships.Collaborative local strategies can pro-
vide effective ways of reaching shared goals
and providing excellent services, as well as
reducing inequalities, although partnerships
must be carefully designed and assessed in
order to ensure effectiveness (24).
Early years and childcare health are impor-
tant examples of the value and necessity of
Key recommendations:
NHS Organisations
Health professionals should utilise their
roles as managers and employers to en-
sure that:
• Staff have good quality work, which
increases control, respects and rewards
effort, and provides services such as
occupational health.
• Their purchasing power, in employ-
ment and commissioning, is used to
the advantage of the local population,
using employment to improve health
and reduce inequalities in the local
area.
• Strategies on health inequalities are
given status at all levels of the organ-
isation, so the culture of the institu-
tion is one of equality and fairness,
and the strategies outlined elsewhere
in this document are introduced and
supported.
Health Equity
210
partnership working. In order to tackle the
root causes of ill health effectively, action
early on in life is essential. This can change
the conditions in which children are born
and grow, and the care and opportunities
that are made available to them. In order to
take action in this area, partnerships should
be established between Children’s Centres,
schools,social care,health visitors,midwives
and other health professionals. When these
different sectors communicate effectively,
deliver joint programmes and tackle indi-
vidual problems in a collaborative way, out-
comes tend to improve (25).
Since the passage of the Health and Social
Care Act 2012, a new form of partnership
has been established – Clinical Commis-
sioning Groups (CCGs). These are locally
based consortia, made up of GP practices,
which will commission care for the local
community (26). The doctors and nurses
who sit on CCGs have three important
ways to tackle health inequalities: through
their actions as health professionals; in
their role on the CCGs, which includes
making commissioning decisions; and in
the way they use the CCG as a local ad-
vocacy and community asset. If CCGs and
professionals are aware of and responsive
to the social determinants of health in
their local area, they will be able to tackle
health inequalities while delivering clinical
services.
5 Workforce as advocates
Every health professional has the potential
to act as a powerful advocate for individu-
als, communities, the health workforce, and
the general population. Since many of the
factors that affect health lie outside the
health sector − in early-years experiences,
education, working life, income and living
and environmental conditions − health pro-
fessionals may need to use their positions
both as experts in health and as trusted,
respected professionals to encourage or in-
stigate change in other areas. The medical
Royal Colleges have a clear advocacy func-
tion, and regularly petition government for
policy changes on behalf of their members
and their patients. However, advocacy is
also powerful and important for health stu-
dents, qualified professionals, CCGs, NHS
organisations and other professional bodies
such as unions.
Acting as an advocate for individual pa-
tients and their families is often particu-
larly helpful to improve the conditions in
which people live. Professionals can use
their understanding of the factors that are
influencing a patient’s health, and act as
advocate in order to help these patients to
access services both within and outside the
health service. In a similar way, advocacy
on behalf of communities is also impor-
tant.
The actions proposed in this report will be
most effective where they are adopted wide-
ly and supported at all levels – from central
to local and individual arenas. This will en-
sure that strategies are in place to instigate
change, to regulate action, to measure and
reward progress, and to learn from oth-
ers. This will require, in some cases, action
that is beyond the remit of the individual
professional. In these cases, professionals
should use their position to advocate for the
changes that are necessary,both within their
Key recommendations:
Working in Partnership
Within health sector
Partnerships within the health sector
should be consistent, broad and focussed
on the social determinants of health.
With external bodies
Partnerships between the health sector
and other agencies are essential – they
should be maintained, enhanced, and
supported by joint commissioning, data-
sharing and joint delivery. They must,
however, be well designed and assessed
for impact.
Clinical Commissioning Groups
CCGs should make tackling health in-
equalities a priority area, and should
measure their progress against this aim.
They can do this via their role as com-
missioners, in partnership (particularly
with Health and Wellbeing Boards), and
as a local community employer and ad-
vocate.
Key recommendations:
Workforce as advocates
For individuals
Individual health professionals and
health care organisations should, where
appropriate, act as advocates for indi-
vidual patients and their families.
For changes to local policies
Individual health professionals and
health care organisations such as lo-
cal NHS Trusts should act as advocates
for their local community, seeking to
improve the social and economic con-
ditions and reduce inequalities in their
local area.
For changes to the health profession In-
dividual health professionals, students,
health care organisations such as NHS
Trusts and pro- fessional bodies such as
medical Royal Colleges and the BMA
should advocate for a greater focus on
the social determinants of health in
practice and education.
For national policy change
Individual health professionals, students
and professional bodies such as medi-
cal Royal Colleges should advocate for
policy changes that would improve the
social and economic conditions in which
people live, and particularly those that
would reduce inequalities in these con-
ditions.They should target this advocacy
at central government, and bodies such
as the NHS Commissioning Board.
Health Equity
211
organisation, and within other local bodies
or central systems. For example, changes to
education, as outlined above, will need the
support and backing of health students and
professionals.
Health professionals have great author-
ity and expertise, and should also be us-
ing this to advocate for policies that will
reduce health inequalities and against
policies that will widen them. This should
be targeted at central government depart-
ments as they consider policy change, but
also towards newly formed bodies such as
the NHS Commissioning Board, which are
currently considering what to prioritise and
what strategies to adopt. With concerted
pressure from health professionals and the
bodies that represent them, we have a great
opportunity to ensure that tackling health
inequalities is a central concern across the
policy spectrum, and that all bodies con-
sider the health equity impact of new and
existing policies.
6 The health system – challenges and op-
portunities
The Health and Social Care Act of April
2012 has led to significant changes in
structure, provision, incentives, regulation,
commissioning and monitoring within the
health system (23). While the changes are
challenging and disruptive, there are also
new opportunities to tackle health in-
equalities and to embed an approach based
on the social determinants of health across
the new system.The new legal duties in the
Health and Social Care Act can act as an
important lever in encouraging action. In
exercising their functions, the NHS Com-
missioning Board and Clinical Commis-
sioning Groups must have regard to the
need to reduce inequalities, both in terms
of access and health outcomes of patients.
They must also secure integrated provision
of services, both within the health system
and beyond it, where this would reduce
inequalities in access or outcomes. In ad-
dition, there are duties on the Secretary
of State, Monitor and NHS Foundation
Trusts, all of whom must integrate these
duties into their plans and report progress
on them annually (23). The Equality Act
2010 states that public sector bodies “must,
when making decisions of a strategic na-
ture about how to exercise its functions,
have due regard to the desirability of ex-
ercising them in a way that is designed to
reduce the inequalities of outcome which
result from socio-economic disadvantage.”
(27). These duties mean that work by the
NHS workforce to tackle health inequali-
ties should be integrated into organisa-
tional strategies and plans, as well as being
incentivised and monitored. Unfortunately,
other mechanisms may make this harder.
For example, the Quality Outcomes
Framework is a powerful incentive sys-
tem but tends to measure certain outputs
rather than patient outcomes, weakening
its potential to reduce health inequalities.
On the other hand, the Public Health
Outcomes Framework includes important
social determinants of health indicators,
but is not linked to financial incentives
or requirements, decreasing its potential
to leverage change and increase impact.
There are other mechanisms which may
provide opportunities or challenges: the
NHS Commissioning Board and the NHS
mandate, the NHS constitution, funding
and allocation arrangements, monitoring
and data-sharing procedures, and various
mechanisms that impact on health edu-
cation. This chapter in the full report sets
out some initial conclusions from a work-
ing paper, which is available on the IHE
website (1). IHE will be developing this
analysis as part of the ‘Working for Health
Equity’ programme.
Part B. Professions:
Statements for action
The analysis set out in this report has been
largely welcomed by health professionals
and their representative organisations. But
there is a need for health professionals to
have brief, practical guidance for tackling
health inequalities through the social de-
terminants of health. To inform this report
we asked Royal Colleges and other organ-
isations to provide statements for action, to
give practical accessible guides for particu-
lar professionals to develop and use in their
roles. The result of an enthusiastic response,
nineteen statements for action by different
organisations are set out in the main report.
These statements also include a rationale
for action, case studies and further read-
ing. During the implementation phase of
our programme of work, we will be working
with various organisations to drive uptake
of these practical actions.
There are statements for each of the follow-
ing professional groups:
• Nurses
• Social workers and social care
• Clinical Commissioning Groups
• General practitioners
• Paediatricians
• Midwives
• Obstetricians and gynaecologists
• Hospital doctors
• Dentists and oral health teams
• Psychiatrists
• Medical students
• Allied health professionals
• Music therapists
• Dieticians
• Occupational therapists
• Physiotherapists
• Speech and language therapists
• Paramedics
• Radiographers
Commitments and next steps
This report also sets out a series of commit-
ments by the health workforce and other
organisations to embed and develop action
on the social determinants of health. These
form the basis of an on-going programme
of work led by IHE in partnership with
Royal Colleges, the Academy of Medi-
cal Royal Colleges, and the British Medi-
cal Association among other organisations
Health Equity
212
and institutions. The current commitments
are placed throughout the document at the
ends of chapters. These commitments will
be added to over time. Please see the IHE
website for an up-to-date list of commit-
ments (1).
IHE will lead a programme of work to dis-
seminate the messages in this report, en-
courage their practical application across
the workforce, and to extend the evidence
base. We have been sent many examples
of excellent practice already taking place,
and the ‘Working for Health Equity’ pro-
gramme will be focussed on increasing the
systematic and sustained implementation of
this activity across the health system. This
will be undertaken in partnership with or-
ganisations that have already been involved
in the project by writing statements for ac-
tion and commitments. IHE also welcomes
other organisations to join the programme
and share their experience, working togeth-
er to achieve greater health equity through
actions by health professionals and related
organisations.
References
Denoted by (n) in the text
1. Institute of Health Equity. Working for
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2. Marmot M. Fair society, healthy lives : the
Marmot review ; strategic review of health
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3. Commission on the Social Determinants of
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4. Institute of Health Equity. Interim second
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health divide in the WHO European Region.
Institute of Health Equity; 2012 Sep.
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16. Abbott S, Davidson L. Easing the burden on
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Review of the ehalth of Britain’s working age
population. 2008 Mar 17.
19. Boorman S. NHS Health and Well-being –
Final Report. 2009.
20. Doeksen GA, Johnson T, Willoughby C.
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health sector on a local economy: A brief
literature review and procedures to measure
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Available from URL: http://www.legislation.
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ukpga/2012/7/pdfs/ukpga_20120007_en.pdf
24. Audit Commission. Governing Partnerships.
London: Audit Commission; 2005.
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Morris M, O’Donnell L, et al. Scoping review 1:
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through effective practise in integrating early
years services. 2008 Available from URL: http://
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children.pdf
26. Department of Health. The functions of clinical
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[Date accessed: 2013 Jan 8] Available from
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Abbreviations
AoMRC — Academy of Medical Royal Colleges
BMA — British Medical Association
CAB — Citizens Advice Bureau
CCG — Clinical Commissioning Group
CMA — Canadian Medical Association
CPD — Continued Professional Development
GP — General Practitioner
IHE — UCL Institute of Health Equity
NHS — National Health Service
WMA — World Medical Association
www.instituteofhealthequity.org
Health Equity
213
Introduction
Great East Japan Earthquake:
14:46 March 11, 2011
When I returned to my hospital in Iwaki,
Fukushima, there was a thunderous roar
coming up from below, after which I was
assailed by violent shaking like I had never
experienced before. The reinforced concrete
building creaked as it shook widely with the
enormous waves of energy propagating re-
peatedly up from the bottom of the earth.
A tsunami warning was then issued, after
which a giant tsunami carrying a tremen-
dous amount of energy transmitted through
the ocean water bore down upon one sea-
side community to the next, from the To-
hoku Pacific coast to Ibaraki and Chiba
prefectures.
Making matters worse following this nat-
ural disaster of a scale seen once in a thou-
sand years, the Fukushima Daiichi Nucle-
ar Power Plant owned by Tokyo Electric
Power Company (TEPCO) experienced
a melt-through and explosions starting
the following day, March 12. This devel-
opment robbed 140,000 people from the
surrounding communities of their places
to live and was a man-made disaster that
struck the sharpest fear into many Japa-
nese, including those in the Tokyo metro-
politan area.
The disaster victims as well as we who were
taking action onsite faced an overwhelm-
ing dearth of information that is supposed
to be provided by the government during
an emergency. The hunger I felt with all
my heart while leading all the support
efforts that I could, including the Japan
Medical Association Team (JMAT), as a
disaster victim on the one hand and as the
Japan Medical Association (JMA) officer
in charge of disasters in the face of this
situation is still engraved in my body and
soul.
Events Before the Great
East Japan Earthquake
Tokaimura nuclear accident:
10:35 Thursday, September 30, 1999
The Tokaimura nuclear accident, in which
large amounts of neutron radiation and
gamma rays as well as fission products were
released for about 20 hours with the reac-
tor in criticality, began when alarms were
sounded in a conversion test building at the
facility operated by JCO in the town of To-
kaimura.
Residents who passed nearby the accident
site on the Joban railway line and the Joban
Expressway made inquire with medical in-
stitutions in the city of Iwaki. I received lots
of information and many questions at that
time, as I had been the director in charge
of emergency and disaster medicine at the
Iwaki Medical Association since April
1998.
I immediately reported the situation to
then-director of the Health Center, Shogo
Asahina, and made an urgent request. As a
result, a radiation dose measurement service
using a handheld Geiger counter was hast-
ily arranged and provided from the follow-
ing day at the Iwaki Health Center to resi-
dents who requested it. A total of over 800
people came for the service, 10% of them
residents from northern Ibaraki.
Although this was an inadequate response,
there is no boundary to actions that can be
taken for the peace of mind and safety of
residents in a radiation disaster. This event
made it clear that building disaster preven-
tion schemes based on this truth is funda-
mental.
This had become my basic stance as some-
one who participates every year in emergen-
cy drills for the group of TEPCO nuclear
power plants in Fukushima. It also became
the basis for a request I made at a later date
for the stockpiling, above and beyond the
national regulations, of our own iodine
preparation for all Iwaki residents in case of
a nuclear accident in the city. This stockpile
was created before the TEPCO Fukushima
nuclear accident, put in place at the city’s
health center, and distributed to residents
after the accident.
9.11 Terrorist Attacks in NY and
WMA 2002 General Assembly
in Washington
In April 2000 I was elected president of
the Iwaki Medical Association and at the
same time continued to be in charge of
emergency and disaster medical responses
as vice-president of the Fukushima Medi-
cal Association, a position to which I had
been appointed [1].The large-scale terrorist
Great East Japan Earthquake
Before and After
Masami Ishii
DisasterJAPAN
214
JAPANDisaster
attacks on the World Trade Center build-
ings in New York and other targets on the
morning of September 11, 2001 was an
event that once again seared into the breasts
of relevant parties worldwide the impor-
tance of disaster preparedness against both
natural and man-made disasters.
The Scientific Session Program at the Gen-
eral Assembly of the World Medical As-
sociation (WMA) held in Washington DC
from October 2–6, 2002 took up a wide va-
riety of subjects including preparedness to
large-scale disasters, infectious disease, and
terrorism under the central theme of “Re-
sponding to the Growing Threat of Terror-
ism and Biological Weapons”in light of the
horrific tragedy of the previous year’s inter-
national terrorist attacks.
I voluntarily attended the assembly as
an associate member of the WMA and
was deeply impressed by the stance of the
American Medical Association and inter-
ested parties who disclosed extremely prag-
matic and full contents. I returned to Japan
with many documents and a desire to es-
tablish the foundation of disaster medicine
in Japan.
On the way home, my suitcase had been
prized open during the flight from New
York and my commemorative WMA’s con-
gress bag with all the documents related to
disaster medicine had been stolen. Luckily,
my wife Atsuko’s suitcase was fine, and it
contained a second set, as she had listened
to all the lectures with me.
As I was filing a claim at Narita Airport,
I realized that the WMA bag and all the
documents had been distributed for free at
the meeting venue. So, I ended up filing a
claim only for the suitcase whose lock no
longer shut. But this incident taught me
the important lesson that truly important
things are priceless and the importance of
backups-things that we have to consider
when thinking about life and disaster medi-
cine.
Agreement regarding Medical
Relief during a Disaster:
January 2004
On January 5, 2004, Fukushima Prefec-
ture and the Fukushima Medical Asso-
ciation signed an Agreement regarding
Medical Relief during a Disaster based on
repeated discussions on regional disaster
prevention planning for Fukushima pre-
fecture during disaster prevention meet-
ings held at the prefectural government
office [2].
The Fukushima Medical Association is
positioned as a designated local public in-
stitution under laws such as the Basic Act
on Disaster Control Measures (1961) and
what is called the Civil Protection Law
(Act concerning the Measures for Protec-
tion of the People in Armed Attack Situ-
ations, etc.; enacted in 2004 and amended
in 2008).
In settling the negotiations, the Medical
Association inserted a clause indicating that
while it would take responsibility for medi-
cal relief planning and medical relief teams,
on the flip side, the Prefecture would grant
retrospective approval after the dispatch of
medical relief teams deemed necessary by
the Medical Association when faced with
circumstances in which emergency action is
unavoidable.
This clause ensures that the government
accepts our decisions and actions based on
physicians’ professional autonomy as stated
in the WMA Declaration of Seoul on Pro-
fessional Autonomy and Clinical Indepen-
dence [3].
In addition, the agreement stipulates that
the Prefecture shall bear expenses for medi-
cal team formation, participation in drills,
and for actual deployment, settlement of
actual costs such as medical supplies car-
ried, and financial aid if by any chance team
members are injured, contract a disease, or
die during medical relief efforts.
This arrangement is grounded in the basic
concept that team members act as quasi
public servants throughout all medical re-
lief efforts. Moreover, a provision has been
included indicating the entire agreement
shall be reviewed every year, thereby pre-
venting the agreement from becoming a
dead letter.
Even before the agreement was signed with
the Prefecture, I was an active participant
in prefectural emergency drills conducted
at Fukushima Airport in disaster scenarios,
based on a disaster prevention agreement
made directly between the airport and the
Fukushima Medical Association.
The annual emergency drill was usually
planned for early dawn on a weekday so
as to not affect aircraft operations. To en-
sure that I made it on time from Iwaki,
I would take two days to participate,
staying at the nearby Bobata hot springs
the day before. It was by some curious
chance, in relation to radiation exposure
medicine, that the inn I usually stayed at
on those occasions was well know for its
radon hot springs.
In Fukushima prefecture, the majority of
hydro-, thermal, and nuclear power gen-
eration since the Meiji Restoration (1868)
has been conducted under the control of
TEPCO and supplied roughly a third of
power consumed by the Tokyo metropoli-
tan area.
Additionally,TEPCO also controls the wa-
ter rights to Lake Inawashiro in the center
of the prefecture, creating a special environ-
ment in which the prefectural government
conducts river administration while the
entire water system is under the control of
TEPCO.
In other words, the entire prefecture is like
a giant backyard for the Tokyo metropolitan
area. Within the prefecture, the Hamadori
region in particular functioned as one of
the world’s leading nuclear energy stations,
215
JAPAN Disaster
having a total of 10 power-generating facili-
ties: 6 reactors at TEPCO’s Daiichi Nuclear
Power Plant and 4 reactors at its Daini
Nuclear Power Plant. After I took charge
of emergency and disaster medicine at the
Fukushima Medical Association, I had a
place prepared for myself in a corner of the
prefectural government’s medical team sta-
tioned at the Fukushima Prefecture Offsite
Center in Okuma Town and participated in
annual emergency drills.
M6.9 earthquake off the Sanriku Coast:
6:39 November 15, 2005
At 6:46 a tsunami advisory was issued for
central part of Hokkaido’s Pacific coast
and the Pacific coast of the Tohoku region
(Iwate,Miyagi,and Fukushima prefectures).
Tremors from 3 to 1 on the Japanese earth-
quake intensity scale of 1 to 7 were observed
from Hokkaido to the Kanto region and the
largest tsunami, at 0.5 meters, struck the
city of Ofunato at 7:35.
This apparently harmless earthquake
happened to occur on a morning for
which a nuclear disaster prevention drill
had been planned at Fukushima’s of Off-
site Center.
Since April 2002, I have participated every
time in the prefectural government’s medi-
cal team during drills at the Offsite Center.
On this day I had left Iwaki early and was
heading to the center, but arrived a little
late because of traffic congestion.
Meanwhile, the Offsite Center was wait-
ing for reserve firefighters, fire corps vol-
unteers and police officers, who had gone
to inspect the coast and estuary barrages
when the tsunami advisory was lifted at
8:38. I remember that the drill started
about an hour late – a little after 9:00 – as
a result.
The drill itself proceeded smoothly, but
conversation in the center turned to con-
cern that it would likely be hard to re-
spond, including the securing of person-
nel, in the event of a combined disaster
in which a nuclear accident occurred at
the same time as an earthquake-induced
tsunami. Nevertheless, after complet-
ing the planned drill, this concern was
not brought up in successive discussion.
Consequentially, and unfortunately, the
real meaning of this experience was not
realized until after experiencing the Great
East Japan Earthquake.
1st
WMA Asian-Pacific Regional Confer-
ence: September 2006
In April 2006, I was elected as an execu-
tive board member of the JMA and here
too took over emergency and disaster work,
where it became one of my heavy duties to
be involved in disaster responses for all of
Japan.
Since then I promoted the dispatch and
putting into practice of information by
both national agencies and prefectural
medical associations so that the idea be-
hind of the above-mentioned Agreement
Regarding Medical Relief During a Disas-
ter signed between Fukushima Prefecture
and the Fukushima Medical Association
could be shared by all prefectural medi-
cal associations as a basic principle of the
JMA.
At the same time, I repeatedly talked with
the WMA as the JMA’s international af-
fairs representative and as the secretary
general of the Confederation of Medi-
cal Associations of Asia and Oceania
(CMAAO), which brought into shape the
idea of holding a regional conference of
the WMA.
The 1st
WMA Asian-Pacific Regional
Conference, held at the Hotel Chinzanso
in Tokyo on September 10–11, addressed
the two topics of earthquake and tsunami
countermeasures and infectious disease un-
der the theme of disaster preparedness and
response.
The conference also discussed, under the
title, “State of the Profession,” means of
increasing the autonomy of physicians and
medical association activities, rooted in pro-
fessional autonomy.
Other subjects also have significance today,
but we narrowed the focus on earthquake
and tsunami and looked at responses to the
2004 Indian Ocean earthquake and tsuna-
mi,which had earlier struck Indonesia.Dis-
cussion started with an unavoidable mecha-
nism of the high earthquake and tsunami
risk throughout the entire Asia and Oceania
region, and widened to future preparedness
and possible responses [4].
JMAT creation proposal:
March 2010
Right away I asked that the JMA’s Commit-
tee on Emergency and Disaster Medicine
be composed not only of block representa-
tives of prefectural medical associations and
physicians who are specialists in emergency
and disaster medicine, but also include the
director of the Self-Defense Forces Central
Hospital as well as observer participation by
the Guidance of Medical Service Division
in the Health Policy Bureau of the Ministry
of Health, Labour and Welfare (MHLW),
the Fire and Disaster Management Agen-
cy of the Ministry of Internal Affairs and
Communications, and the Japan Coast
Guard, plus the participation of Dr.  Ma-
koto Akashi, the Executive Director of the
National Institute of Radiological Sciences
in order to respond to all conceivable situ-
ations.
The committee as well as a subcommittee
organized under Dr. Toshio Ido ( Immidi-
ate Past president of Okayama Medical
Association) added ex-post verification of
experiences during the Great Hanshin-
Awaji Earthquake of 1995, the Mid Ni-
igata Prefecture Earthquake of 2004, the
Noto Hanto Earthquake of 2007, and the
Niigataken Chuetsu-oki Earthquake of
2007.
216
This resulted in the committee proposing,
on March 10, 2010 – one year before the
Great East Japan Earthquake – the creation
of the JMAT. A press conference was held
the same day and the JMAT creation an-
nounced. The nationwide announcement
of JMAT creation appeared on the JMA’s
newsletter the following day, by strange co-
incidence March 11 [5].
Response to the Great
East Japan Earthquake
Support through cooperation in and
outside Japan
The purpose of JMAT operations was to
provide health support for the approxi-
mately 400,000 people who survived in a
150-km sphere in addition to the nearly
20,000 lives lost in the enormous damage of
the Great East Japan Earthquake.
I will avoid saying much about this here,
as details have been published in the Ja-
pan Medical Association Journal and else-
where [6, 7, 8, 9, 10].
However, the transport of medical supplies
to the afflicted areas, which came about
through the US military, the Japan Self-
Defense Forces, and the good will of many
people, was the pioneering figure of the
US’s Operation Tomodachi [11].
The JMA set up a disaster response head-
quarters on March 11, the first day of the
Great East Japan Earthquake, and made a
collective effort to respond around the clock
with nearly 200 people, from officers to of-
fice staff.
The JMA aimed to create a system for
JMAT operations that could meet chang-
ing needs by acting as a coordinator be-
tween prefectural medical associations af-
flicted by the disaster and those dispatching
teams. As much as ¥1.9 billion (approx.
USD 20million as of April 2013) donated
mainly by sympathizers in medical associa-
tions around the country was delivered im-
mediately to afflicted medical institutions
through medical associations in the affected
areas.
Moreover, in addition to receiving reim-
bursement from the government for actual
expenses of operations conducted under the
umbrella of the JMAT and compensation
as the an activity of quasi public servants,
with the consent of the MHLW, the JMA
started up its own accident insurance and
established an insurance system in all op-
erations.
The JMA negotiated with the National
Police Agency and obtained emergency ve-
hicle stickers that enabled teams to travel to
the affected areas.
The JMA also made it possible for teams
going on-site during the early phase to get
free tickets on Japan Airlines and All Nip-
pon Airways flights and to receive priority
supplies of gasoline. Further, the JMA re-
quested the Ministry of Land, Infrastruc-
ture, Transport and Tourism to reopen
expressways running through the affected
areas.
The JMA received support and assistance
from many and a wide variety of people and
organizations in and outside Japan, such as
donations from outside Japan, including
from the Taiwan Medical Association, and
the stationing of Dr. Maya Arii of the Har-
vard Humanitarian Initiative at the JMA’s
office. And the various problems occurring
before our eyes were dealt with, from health
support for evacuation shelters to coopera-
tion in dispatching autopsy teams, support
in establishing temporary clinics, and sup-
port in reconstructing afflicted medical in-
stitutions.
Thanks to the well-intentioned efforts of
medical personnel from throughout the
country, JMAT operations reached a total
of 1,398 teams on which 6,054 people par-
ticipated, including 2,145 physicians, by the
end of operations on July 15, 2011.
Since then,the JMA has continued to be in-
volved in support efforts, given the situation
on the ground in the afflicted areas, which
have not been able to recover completely
from the tremendous damage. Thirty-four
medical-related groups (18 organizations)
as well as government-affiliated agencies
launched the Survivors Health Support Li-
aison Council, for which the JMA serves as
secretariat.
Efforts were switched over to JMAT II
operations, which carry on medical sup-
port activities that are broader than disas-
ter support. As of February 4, 2013, a total
of 763 teams with 2,475 people, including
1,730 physicians, have been dispatched
and are carrying on operations even now
(Figs. 1, 2).
Efforts for better information sharing
The Japan Medical Association Research
Institute, which is the JMA’s think tank,
also responded to the Great East Japan
Earthquake with concerted efforts. These
included field investigations in areas dam-
aged by the tsunami, collection of data re-
lating to JMAT operations, and consider-
ation of the problem of compensation for
loss relating to the nuclear accident [12, 13,
14, 15].
In order to prepare for potential complex
disasters close to home, the JMA held, one
year after the earthquake, a training course
on JMAT activities in disaster medicine
[16] (which will be certified for the JMA’s
continuing medical education credit) on
March 10,2012 and a symposium on health
policy “Disaster Medicine and Medical As-
sociations” the following day [17]. Since
then, content has been added and enriched
and made available on the JMA’s website
and other sources.
JAPANDisaster
217
Based on reflections after the disaster of
personnel in charge of information, it was
agreed that combining multiple informa-
tion media was realistic, as there is no
single medium that can definitively cover
many different events, and within that the
need to share information became a com-
mon view.
That is why in 2012 the Liaison Council of
Prefectural Medical Associations on Disas-
ter Medicine conducted an emergency com-
munications demonstration that attempted
to link clinical records and evacuation shel-
ter information during a disaster via cloud
computing, assuming disaster scenarios
such as an earthquake directly beneath the
Tokyo Metropolitan area.
The demonstration used the Wideband In-
terNetworking engineering test and Dem-
onstration Satellite (WINDS) called “KI-
ZUNA” operated by the Japan Aerospace
Exploration Agency (JAXA), with which
Iwate Prefecture had past results, and also
included simultaneous Internet transmis-
sion to prefectural medical associations.
Based on the demonstration’s good results,
the JMA and JAXA signed an agreement
on demonstration experiments using the
satellite KIZUNA in disaster medical ac-
tivities and held a press conference at the
same time on January 30, 2013.
After the Great East
Japan Earthquake
The problem of radiation exposure and ra-
dioactive contamination
According to Dr. Jose Luiz Gomes do
Amaral, president of the WMA in 2012, it
is difficult to avoid the fact that disasters of
a certain level take on the aspect of a com-
plex disaster in developed societies. It is also
a fact that there is no place on Earth that
could be called safe with absolute certain-
ty [17]. The problem of radiation exposure
and radioactive contamination resulting
JMAT: 1,398 teams;
JMAT II: 763 teams;
5 additional teams sent to
multiple prefectures.
Top: JMAT
Bottom: JMAT II
Iwate
461 teams
558 teams
Miyagi
645 teams
82 teams
fukushima
275 teams
123 teams
Ibaraki
12 teams
Figure 1. JMAT and JMAT II dispatches (updated as of February 4, 2013)
8.8% (534) 5.5% (135)
0.2% (6)
18.8% (1,139) 20.0% (494)
7.6% (458)
69.9% (1,730)
29.3% (1,775)
35.4% (2,145)
Physicians Nurses Pharmacists Coordinators Medical technologists and others
100%
80%
60%
40%
20%
0%
JMAT JMAT II
4.4% (110)
Figure 2. Breakdown by occupation of JMAT and JMAT II participants in the Great
EastJapanEarthquake(updatedasofFebruary4,2013).(Numbersofpeoplearerepre-
sented in parenthesis)
JAPAN Disaster
218
from the Fukushima Daiichi Nuclear Pow-
er Plant accident following the Great East
Japan Earthquake, in particular, emerged at
an unprecedented scale. What is more, the
spread of contamination brought about a
major problem greatly exceeding the con-
ventional administrative framework and
predictions and raised widespread anxiety
that still has not been brought under con-
trol.
Considering the truth of responses that
were actually made, although a disaster
response headquarters was set up in the
Fukushima Prefecture government office
during the Great East Japan Earthquake,
the prefectural government was utterly
negative regarding medical association par-
ticipation and the building of a cooperative
relationship. This is extremely difficult to
comprehend, given the point of the already
signed Agreement regarding Medical Re-
lief during a Disaster and considering the
lives and health support for citizens of the
prefecture.
On October 22, 2008, the national govern-
ment under the Taro Aso Administration
conducted a nuclear disaster prevention
drill with the scenario that the emergency
cooling system failed after the usual reactor
cooling system had failed at the Fukushima
Daiichi Nuclear Power Plant, releasing ra-
dioactive material offsite.
On October 20 and 21, 2010, during the
Naoto Kan Administration, disaster pre-
vention drills were conducted with a similar
scenario at the Hamaoka Nuclear Power
Station. Ahead of the later, a comprehen-
sive disaster prevention drill for the Iwaki
region was held in the city of Iwaki in Au-
gust 2010 with the scenario of a large tsu-
nami triggered by a M7.7 earthquake (in-
tensity 6 lower on the Japanese scale) off
the Fukushima coast. Assuming that these
kinds of drills were not made use of at all in
the actual Great East Japan Earthquake of
March 11, 2011, there is a need to create a
system for improving skills through effec-
tive drills and ex-post verification, beyond
the framework of routine work by the gov-
ernment alone.
International Physicians for the Preven-
tion of Nuclear War World Congress: Au-
gust 2012
On August 26, 2012, the International
Physicians for the Prevention of Nuclear
War (IPPNW) held its 20th
World Con-
gress at the International Conference
Center Hiroshima. I was invited to the
congress and gave a lecture on “JMAT
Operations in Response to the Great East
Japan Earthquake and the Fukushima Nu-
clear Accident.
”This was an opportunity to present the pic-
ture that JMAT activities were the realiza-
tion of a vision to provide continuous sup-
port from the acute phase,when teams work
in cooperation with the Disaster Medical
Assistance Team (DMAT), until medi-
cal care in the afflicted areas has recovered,
and convey the fact that the nationwide call
for support activities for medical care at
first-aid stations for evacuees and for local
medical institutions turned into an opera-
tion that was Japan’s largest medical support
effort.
Additionally, I reported on activities on
the ground in the disaster-stricken area of
Fukushima Daiichi Nuclear Power Plant
accident, including original information
gathering and disclosure. While there was
a tumultuous atmosphere at the venue just
at that time, with remarks flying about from
an anti-nuclear movement, the program
was run with a clear division between de-
termined opposition to nuclear weapons,
which are an inhumane use of nuclear
power, and discussion of the peaceful use of
nuclear power.
I stressed that my report was based on ex-
periences on the ground and also that we
physicians, who practice the peaceful use of
nuclear power in clinical care, always strive
in future to minimize the risks while maxi-
mizing the benefits to patients of radiodi-
agnosis and during treatment. While there
were opinions that completely deny the
application of nuclear power and calls for
practical information disclosure on the Fu-
kushima Daiichi Nuclear Power Plant ac-
cident, those kinds of remarks disappeared
as the presentation proceeded.
Conclusions
Need for comprehensive health policy and
health support
My heart truly aches at the fact that today,
nearly two years since the Great East Japan
Earthquake, the communities destroyed by
the earthquake and tsunami have not been
restored, let alone revived. Still more, the
district where the nuclear power plant is lo-
cated and nearby areas from which whole
communities were forced to evacuate due
to the nuclear accident in Fukushima pre-
fecture and the subsequent radioactive con-
tamination, have only called for decontami-
nation; the disposal of rubble has hardly
even begun, to say nothing of the building
of new communities. In such a situation,
only the delay in responding to the people
of the areas that accepted nuclear power
plants in compliance with national policy
stands out.
Nuclear power stations, regardless of
whether they decommission their reactors
or continue operations,need integrated pol-
icy making covering everything from fuel
refinement through use to final disposal, a
scientific basis to underpin those policies,
and policy agreement that will carry them
out.Considering the Fukushima nuclear ac-
cident,which saw explosions and resulted in
a major disaster even though the plant was
under an emergency shutdown, work pro-
cesses that are assured to be safe and health
support for the workers engaged in that
work will most likely be necessities for more
than a few decades.
JAPANDisaster
219
Further, there is a pressing need for com-
prehensive policy and health support for
evacuees from radioactive contamination
in addition to health support for evacuees
from natural disaster.
Above all, active national involvement is
expected in the creation of a long-term sup-
port system for young people  – especially
children – with the elimination of trivial-
ized frameworks that are limited to Fuku-
shima prefecture and the inclusion of evac-
uees who have scattered around the country
and residents of areas with relatively high
radioactive contamination that spread from
the Tohoku to the Kanto region.I also think
that cordial and considerate accountability
must continue to be fulfilled for the many
members of the general public that cannot
get rid of growing anxiety caused by looking
at the current situation.
Peaceful use of nuclear power
On my way back from the UNESCO 8th
International Conference on Bioethics
Education held in Tiberias, Israel on Sep-
tember 2-5, 2012, I had the opportunity to
stop by the Israel Academy of Sciences and
Humanities and stand face-to-face with
the statue of Einstein in the garden. When
looking back at the footsteps of Einstein,
I am certain that humanity,which obtained
new knowledge and a source of energy in
the 20th
Century, has an obligation and a
role to raise its voice in strong opposition
to the misuse of science that harmed so
many people with atomic bombs and has
an adverse effects on the global environ-
ment.
On the other hand, however, I reaffirmed
my belief that Japan, precisely because it
suffered the crippling damage of atomic
bombs and experienced the Fukushima
nuclear accident, should not abandon its
world-leading role in contributing to the
field of ensuring the peaceful use and safety
of nuclear power based on humanity’s wis-
dom. I believe that because human civili-
zation, which established cultural life us-
ing Prometheus’ fire, set sail over the open
seas, made possible safe transport through
the skies, and even bent its steps into outer
space,accomplished today’s development by
sincerely facing unforeseen accidents at ev-
ery point in time and being cautious about
the abuse of new technologies and power.
Lastly, I offer heartfelt condolences for the
people who lost their lives in the Great
East Japan Earthquake and my sympathies
to the survivors. I should also like to ex-
press my respect and appreciation to all the
medical personnel who were engaged in-
tently in medical operations in the afflicted
areas.
References
1. Ishii M. Emergency Medicine in Fukushima
Prefecture. Journal of the Fukushima Medical
Association. 2003;65(8) (in Japanese)
2. Ishii M. Regarding “the Agreement Regarding
Medical Relief During a Disaster”. Journal of
the Fukushima Medical Association. 2004;66(3)
(in Japanese)
3. World Medical Association. WMA Declaration
of Seoul on Professional Autonomy and Clinical
Independence. 2008. https://www.wma.net/
en/30publications/10policies/a30/index.html
4. JMAJ. 2007;50(1). http://www.med.or.jp/
english/journal/pdf/jmaj/v50no01.pdf
5. JMA Committee on Emergency and Disaster
Medicine Report (March 10, 2010) http://www.
med.or.jp/shirokuma/no1258.html (in Japanese)
6. Ishii M. Japan Medical Association Team’s
(JMAT)FirstCalltoActionintheGreatEastern
Japan Earthquake. JMAJ.2011;54(3):144-
154. http://www.med.or.jp/english/journal/
pdf/2011_03/144_154.pdf
7. Ishii M. Activities of the Japan Medical
Association Team in response to the Great
East Japan Earthquake. JMAJ.2012;55(5):362-
367. http://www.med.or.jp/english/journal/
pdf/2012_05/362_367.pdf
8. Ishii M, Nagata T. The Japan Medical
Association’s disaster preparedness: lessons
from the Great Eastern Japan Earthquake and
tsunami. Disaster Med Public Health Prep.
2013. (accepted)
9. Nagata T, Halamka J, Himeno S, Himeno A,
Kennochi H, Hashizume M. Using a Cloud-
based Electronic Health Record During
Disaster Response: A Case Study in Fukushima,
March 2011. Prehosp Disaster Med. 2013 Apr
26:1-5.
10. NagataT,Kimura Y,Ishii M.Use of a geographic
information system (GIS) in the medical
response to the Fukushima nuclear disaster in
Japan. Prehosp Disaster Med. 2012 Apr; 27(2):
213-215.
11. JMAT Kaku Funto Seri. Seiron. Oct. 2011.
http://www.tottori.med.or.jp/secure/2960/
seiron2011.10.pdf (in Japanese)
12.Sameshima N. Japan Medical Association
Research Institute (JMARI) Working
Paper No. 253:Research into the Effects on
and Responses by Hospitals and Clinics in
Schedule Power Outages and Electricity
Supply and Demand Measures Associated
with the Great East Japan Earthquake.2012.
http://www.jmari.med.or.jp/research/summ_
wr.php?no=475 (in Japanese)
13. Deguchi M. JMARI Working Paper No.
254: The Role of Medical Associations in
JMAT Operations During the Great East
Japan Earthquake and Future Issues.2012.
http://www.jmari.med.or.jp/research/summ_
wr.php?no=476 (in Japanese)
14. JMARI. JMARI Working Paper No. 257:
Research into Compensation for Loss in the
Fukushima Nuclear Disaster and the State
of Restoration and Reconstruction.2012.
http://www.jmari.med.or.jp/research/summ_
wr.php?no=482 (in Japanese)
15. Eguchi N. and Deguchi M. JMARI Working
Paper No. 273: Attitude Survey of Physicians
about Medical Care in Afflicted Areas –
Physicians in Three Tohoku Prefectures. 2013.
http://www.jmari.med.or.jp/research/summ_
wr.php?no=499 (in Japanese)
16. JMA Training Course on JMAT Activities
in Disaster Medicine (March 10, 2012)
http://dl.med.or.jp/dl-med/eq201103/jmat/
jmat_20120310.pdf (in Japanese)
17. JMA Symposium on Health Policy “Disaster
Medicine and Medical Associations”(March
11, 2012). http://www.med.or.jp/jma/policy/
symposium/000880.html (in Japanese)
Masami Ishii
Executive Board Member,
Japan Medical Association,
Tokyo, Japan
E-mail: jmaintl@po.med.or.jp
JAPAN Disaster
220
UNITED STATES OF AMERICAAir Pollution
Polycyclic Aromatic
Hydrocarbons
Endocrine disruptors are chemicals that
interfere with hormone signaling systems
in the human body, potentially affecting
reproductive, metabolic, nervous, and im-
mune system functions (1,2). Endocrine
disrupting chemicals (EDCs), natural or
synthetic, can be found in many different
environmental media: food, water, soil, and
air. Most indentified EDCs are produced
by indoor sources, and therefore indoor air
concentrations may better predict a person’s
exposure to EDCs than outdoor air con-
centrations (3). However, outdoor air is a
significant source of exposure to one group
of EDCs, the Polycyclic Aromatic Hydro-
carbons (PAHs). The health consequences
of these exposures for children include neu-
rodevelopmental disruption, DNA damage
leading to increased cancer risk,and epigen-
etic changes that are potentially the basis
for other diseases, including asthma.
What are PAHs?
PAHs are a family of chemicals formed as
a by-product of incomplete combustion.
PAHs are created when organic material
combusts, such as when fuel is burned, food
is cooked, or cigarettes are smoked. Signifi-
cant outdoor urban sources are coal-fired
power plants, incinerators, furnaces in resi-
dential buildings, and the internal combus-
tion engines of automobiles, trucks, buses,
and trains. PAHs can be found in gaseous
form or adsorbed onto particulate matter,
with the tendency of each PAH to do so
depending on its molecular weight.
The PAHs which are suspected endocrine
disruptors based on animal or human
studies include: acenaphthylene, benzo
(a) pyrene, benzo (b) fluoranthene, benzo
(k) fluoranthene, 3-methylcholanthrene,
chrysene, dibenzo (a,h) anthracene, inde-
no (1,2,3-cd) pyrene, naphthalene, phen-
anthrene (1,4,5).
Health Effects of Prenatal and
Childhood Exposures to PAHs
Exposure to PAHs is a concern throughout
an individual’s life; however, gestational and
childhood exposures have been the focus
of several studies, and have revealed several
important health consequences in this pop-
ulation. Perera et al. have studied prenatal
PAH exposure and its effects on cognitive
and behavioral development for a cohort of
children in New York City.
They found that prenatal exposure to PAHs
above the median of 2.26 ng/m3
was posi-
tively associated with developmental delay
at three years, reduced IQ at five years, and
symptoms of anxiety/depression and atten-
tion problems at seven years (6–9). A simi-
lar study in Tongliang, China, did not find
an independent association between PAH
exposure and impaired IQ, but found an in-
verse correlation between PAH-DNA ad-
ducts in cord blood, a biomarker of prenatal
exposure to PAHs, and motor, language,
and overall development in children at two
years old (10,11).
Studies in Krakow, Poland, similarly found
a decrease in IQ for 5 year olds exposed in
utero to average air concentrations of PAHs
above the median of 17.96 ng/m3
(12). Pre-
natal PAH exposures in Krakow, New York
Air Pollution: a New Concern. Polycyclic Aromatic
Hydrocarbon Endocrine Disrupting Chemicals
in Urban Outdoor Air and Children’s Health
A Brief Public Health Overview of Recent Literature
Peter Orris Erica Burt
221
UNITED STATES OF AMERICA Air Pollution
City, and Tongliang were also associated
with decreased fetal growth: birthweight,
length, and/or head circumference in Pol-
ish-Caucasian, African-American, and
Chinese populations (11,13,14). Studies in
the Czech Republic support these associa-
tions (15,16).
Human evidence also suggests that despite
an approximate 10-fold lower dose of PAHs
received by a fetus relative to the mother,
the amount of carcinogenic DNA dam-
age caused by the exposure is greater to the
fetus (17). This damage is a covalent bond
between the PAH and DNA, known as a
DNA-adduct,and is a known biomarker for
cancer risk. The exact relationship between
this carcinogenic damage and carcinogene-
sis is not clear in humans,but animal studies
clearly demonstrate a relationship between
in-utero PAH-induced DNA damage and
cancer of the liver,lung,nervous system,and
lymphatic system of the offspring (17–19).
It is hypothesized that not only is a child’s
DNA affected by in-utero exposure to
PAHs, but his/her gene expression may
also be altered. Such changes are associated
with cancer and other diseases, and may
have transgenerational effects. Evidence for
these epigentic changes have come through
studies looking at the methylation and de-
methylation by PAHs of cord-blood cells
(20,21).
One health end-point suspected to be a
result of such PAH-induced epigenetic
changes is childhood asthma.Asthma is one
the most common chronic health problems
facing children today, with approximately
14% of 13–14 year olds worldwide experi-
encing symptoms in the last year (22, 23).
PAHs may help to initiate, exacerbate, and
hinder treatment of asthma. Initiation of
asthma could occur in several ways, one of
which is alteration of epigenics contributing
to asthma biomarkers.
A case control study in Saudi Arabia found
significant associations between serum
levels of PAHs and biomarkers of asthma
(24). Another possible mechanism for ini-
tiation of asthma by PAHs, which may
also contribute to continued asthma symp-
toms, is through increasing a child’s sensi-
tivity to certain allergens (25,26). There is
some evidence for exacerbation of asthma
symptoms by PAHS; a study in California
of the United States showed a mild trend
of increased wheeze in 6–11 year old chil-
dren with asthma after ambient exposure to
PAHs increased, but other studies have not
seen an association (26,27). Another New
York study showed respiratory symptoms
and probable asthma are more prevalent
among children exposed to PAHs and en-
vironmental tobacco smoke in early child-
hood (28). Relatedly, prenatal exposures to
PAHs are suspected to increase the occur-
rence and duration of respiratory symptoms
(29). Furthermore, in vitro evidence sug-
gests that exposure to PAHs may decrease
the responsiveness of lung tissue to asthma
medication (30).
Prevention
While this paper has not highlighted the
sources of airborne PAHs in the indoor en-
vironment, reduction of these is often easier
than tackling the job out of doors. Proper
venting or reduction of the use of organic
fuel use for cooking and heat within living
quarters is an important intervention in
much of the world where the indoor smoke
pollution often rivals that generated com-
munally.The elimination of cigarette smok-
ing by adult family members is well known
to reduce the incidence of both asthma and
cancer in children.
Minimizing exposure to PAHs outdoors in
urban areas is of great importance despite its
difficulty.The generation of energy utilizing
fossil fuels and the incineration of wastes
are major sources of PAHs that are able to
be eliminated through sustainable urban
planning. PAH concentrations emanating
from major roadways train tracks, or water
transportation routes are again susceptible
to reduction through urban planning that
distance housing units and accommodates
the prevailing winds.
Factories and homes themselves are major
sources of outdoor PAHs when organic
heating fuel is used. Reduction or elimina-
tion of this ubiquitous exposure is reachable
only through the substitution of wind, wa-
ter, or solar energy generators. Such a sub-
stitution has been demonstrated to be ad-
equate for the world’s energy needs through
2030 and at approximately the same cost as
allocated today (32). However, there may
be some relevant policy solutions, and here
is a list of ideas for further exploration and
research:
The immediate effect of such an interven-
tion is documented in Tongliang, China,
where the closing of a coal fired power plant
reduced the health effects associated with
prenatal PAH exposure in the community
(32).
Conclusion
Through the disruption of the endocrine
system and DNA damage, PAH exposure
from combustion sources such as power
plants, vehicles, and home-heating and
cooking systems can cause negative health
consequences to the most vulnerable in our
community, our children. PAH air pollu-
tion is associated with developmental delay,
decreases in IQ, behavioral problems, in-
creased cancer risk, and asthma. While in-
door exposures can be minimized through
family choices, outdoor exposures cannot be
reduced with such ease. Community, state,
and national policy changes are necessary to
reduce community air pollution exposures
to this class of compounds.
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disrupting chemicals: associated disorders and
222
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13. Choi H, Jedrychowski W, Spengler J, Camann
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16. Sram RJ, Benes I, Binkova B, Dejmek J, Horst-
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M, Bernert T, et al. Biomarkers in maternal and
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18. Rice JM, Ward JM. Age dependence of suscep-
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19. Bulay OM, Wattenberg LW. Carcinogenic ef-
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20. Tang WY, Levin L, Talaska G, Cheung YY,
Herbstman J, Tang D, et al. Maternal exposure
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21. Herbstman JB, Tang D, Zhu D, Qu L, Sjodin
A, Li Z, et al. Prenatal exposure to polycyclic
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22. Worldwide variation in prevalence of symptoms
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24. Al-Daghri NM, Alokail MS, Abd-Alrahman
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25. (25) Perzanowski MS, Chew GL, Divjan A,
Jung KH, Ridder R, Tang D, et al. Early-life
cockroach allergen and polycyclic aromatic hy-
drocarbon exposures predict cockroach sensiti-
zation among inner-city children. J Allergy Clin
Immunol 2013 Mar; 131(3):886-893.
26. Miller RL, Garfinkel R, Lendor C, Hoepner L,
Li Z, Romanoff L, et al. Polycyclic aromatic hy-
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lergy Immunol 2010 Mar; 21(2 Pt 1):260-267.
27. Gale SL, Noth EM, Mann J, Balmes J, Ham-
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drocarbon exposure and wheeze in a cohort of
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28. Miller RL, Garfinkel R, Horton M, Camann D,
Perera FP,Whyatt RM,et al.Polycyclic aromatic
hydrocarbons, environmental tobacco smoke,
and respiratory symptoms in an inner-city birth
cohort. Chest 2004 Oct; 126(4):1071-1078.
29. Jedrychowski W, Galas A, Pac A, Flak E, Cam-
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and the occurrence of respiratory symptoms
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20(9):775-782.
30. Factor P, Akhmedov AT, McDonald JD, Qu
A, Wu J, Jiang H, et al. Polycyclic aromatic
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31. (31) Kaivosoja T, Viren A, Tissari J, Ruuskanen
J, Tarhanen J, Sippula O, et al. Effects of a cata-
lytic converter on PCDD/F, chlorophenol and
PAH emissions in residential wood combustion.
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32. Jacobson MZ, Delucchi MA, Providing All
Global Energy With Wind, Water, And Solar
Power. Energy Policy 2011, 39: 1154–1169.
33. Perera F,Li TY,Zhou ZJ,Yuan T,Chen YH,Qu
L, et al. Benefits of reducing prenatal exposure
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Erica Burt, MPH and Peter Orris,
MD, MPH, FACP, FACOEM
University of Illinois at Chicago School of
Public Health’s Great Lakes Centers For
Occupational and Environmental Health
A WHO Collaborating Center
E-mail: porris@uic.edu
UNITED STATES OF AMERICAAir Pollution
223
Antimicrobial ResistanceSWEDEN
Antibiotics is a foundation for the provision
of modern health care but we have to de-
velop strategies to better manage this great
discovery. In 2009 the Standing Committee
of European Doctors (CPME) adopted a
resolution addressing the need to invest in
research of finding not only new antibiotics,
but also new ways of combining old antibi-
otics.In the light of the increasing problems
with antimicrobial resistance another reso-
lution was adopted in April 2013 encourag-
ing member states to develop strategies for
a sustainable use of antibiotics.
Even though Sweden is one of the countries
with the lowest consumption of antibiotics
Swedes run the increasing risk of developing
resistant bacteria. Therefore, rational use of
antibiotics is of paramount importance. One
of the problems is the big regional differenc-
es in prescription rates as there is a lower rate
in rural areas and a higher rate in urban areas.
In Stockholm, for example, the rate is about
410 recipes for antibiotics per 1000 inhab-
itants while in a rural area, such as Väster-
botten, the rate is about 290. The aim is to
decrease the national average rate to 250.
Variation in the prescription rates between
countries is substantial.The European Cen-
tre for Disease Prevention and Control
(ECDC) has revealed that the consump-
tion of antibiotics varies threefold between
the countries consuming most compared to
those consuming least.
In Sweden we find a similar pattern in the
variation of consumption in dental care. In
Skåne regional council,where the consump-
tion is the highest, 35 out of 1000 inhabit-
ants received a prescription of antibiotics by
a dentist between July 2011 and July 2012.
Stockholm had about the same rate while in
Västerbotten the rate was only 15.
In animal care and veterinary care in Swe-
den the consumption has declined from
about 20 tons in 1996 to 12 tons in 2012.
Antibiotics of the right sort should be used
in the right doses and when there is a need
in order to decrease the pain of the animal.
Since 2006 antibiotics may not be used in
the EU to increase the growth of the ani-
mal. It may only be used to treat bacterial
diseases. The sale of antibiotics varies a lot
between the EU/EEA-countries. For ex-
ample, the use of antibiotics for animals is
269 milligram per kilo in Hungary com-
pared to 8 milligram in Iceland.
In 2010 about 90% of the sale of antibiotics
in the EU was intended for the medication
of animals. In Sweden the corresponding
share was only 10 %.In many countries more
antibiotics are prescribed to animals than to
humans which is the case, for example, in
Denmark. In countries with extensive use of
antibiotics the problems with antimicrobial
resistance is rather a rule than an exception.
The key problem concerns the issue of pre-
scriptions.A survey by the CPME earlier this
year shows that in several European countries
there is a lack of guidelines for the prescrip-
tion of antibiotics in primary health care.
Only doctors, dentists and veterinarians are
allowed to prescribe antibiotics. It is of ma-
jor importance that the right to prescribe is
not extended to other professions. In live-
stock farming it is of great importance that
a veterinarian makes an examination be-
fore antibiotics is used and that antibiotics
should be used on a case by case basis.
Doctors, dentists and veterinarians should
not be allowed to sell antibiotics, a common
practice in some countries.To prescribe an-
tibiotics for earning money from their sale
is a harmful incentive when the goal is to
decrease the consumption.
The patient’s right to choose the doctor or
the dentist or the animal breeder’s right to
choose the veterinarian could also lead to an
increase in the prescription of antibiotics.
One usually tries to have a good relation-
ship with the patient or the animal breeder.
Informed patients and animal breeders are
crucial in order for the professionals to have
a good dialogue with them regarding the
guidelines for a prudent use of antibiotics.
In the basic medical training and the con-
tinuing professional development of doc-
tors, dentists and veterinarians there should
be more focus on antibiotics, antimicrobial
resistance, and prevention of the spread of
deceases.
In the EU open labour market a lot of doc-
tors, dentists and veterinarians move across
the borders. They have different medi-
cal backgrounds and experiences when it
comes to antibiotics. As a tool for ensuring
qualitative use of antibiotics in Sweden we
have proposed a requirement for continuing
professional development of doctors, den-
tist and veterinarians. Higher competence
is required to defeat resistance!
Marie Wedin,
President of the Swedish Medical Association
Defeating Resistant Bacteria with Knowledge
Marie Wedin
224
Regional News LATVIA
On the Eastern shore of the Caspian Sea,
between Uzbekistan, Afghanistan and Iran
develops the great nation of Turkmenistan,
wisely led by Gurbanguly Berdimuhame-
dow.
I visited Turkmenistan accepting the invi-
tation from the Minister of Health. There
are no non-governmental organisations in
Turkmenistan, however, President Gur-
banguly Berdimuhamedow has recently
announced that they will be allowed and it
seems the first one to be established is the
dentists association with Gurbanguly Ber-
dimuhamedow as honorary president. The
Minister of Health hopes that in the nearest
future there will be a medical association, a
medical journal and post-graduate educa-
tion.
The Great President of the State Gurban-
guly Berdimuhamedow, a dentist by pro-
fession, was elected president of the state
six years ago when Turkmenistan was in
mourning because of the death of the Fa-
ther of the Nation, President for Life Sa-
parmurat Niyazov (Türkmenbaşy). The for-
mer Minister of Health and Prime Minister
Berdimuhamedow had also served as the
Dean of Medical University and he was
obliged to follow the traditions and rhetoric
founded by his predecessor. However, there
is a difference – when Niyazov was still
alive, his gilded monuments were erected all
around the country, it does not take place
now and the Constitution stipulates no
presidency for life.
I was invited to visit a conference and an
exhibition. Almost any stand in the ex-
hibition, including those of Siemens A.G.
or Bayer, was decorated with a large-scale
portrait of the Great President of the State
Gurbanguly Berdimuhamedow.
More than sixty companies were represent-
ed in the exhibition. As it turned out later,
there is a portrait of the President in a doc-
tor’s white coat in every doctor’s office. The
July page of monthly calendars reveals the
same portrait and I have no reason to think
that other pages display different photos.
It was a surprise to see that after the open-
ing speech, delivered by the Deputy Prime
Minister at 11 a.m., at 12 p.m. thousands of
doctors entered the hall, most of them mid-
dle-aged ladies wearing traditional national
gowns and bright scarves around their
heads. It is almost impossible to inveigle
doctors when an exhibition dominated by
pharmacy companies takes place in Europe.
All presentations in the conference started
and finished with expressions of thanks to
the strategic leader, the President of the
State. It was widely reported on TV and
in newspapers accentuating the thanks not
medical aspects of the reports. Along with
the exhibition a new six-storey dental centre
in the form of a molar tooth was opened.
The centre can be reached by a hundred
metres long suspension bridge that crosses
the yard.The premises, spacious lobbies and
conference halls, are decorated with Turk-
men carpets and TV sets.
I had an opportunity to visit the neigh-
bouring health centres. There are at least 15
newly-built centres-hospitals.The first one –
cardiological – was built in 1998 by the pre-
vious President and its six storeys host 27
beds; it was built for the government needs.
Today the President acts as a trustee for a
new block of the centre while the cardiology
diagnostic is available to everybody.
There is already a 500 beds Maternity
Health Centre built, but there is a 600 beds
centre planned to be constructed next year
(there is also Children Hospital and Mater-
nity Hospital). So it seems that the govern-
ment is demonstrating its attitude to health
issues by enhancing the construction work.
Turkmenistan counts 5 million inhabitants
while 1.2 million live in Ashgabat.
As it is expensive to transport patients
across the deserts, similar centres are be-
ing built in all major cities. The principle
of reconstruction is to start new buildings
after the old ones have been destroyed. The
new Emergency Hospital with 400 beds is
going to be opened this year, but a signifi-
cantly bigger Red Cross Hospital is already
functioning.
As far as I know,there is no other country in
the world with such a ratio of hospital beds
per capita. Technologies used are mighty,
modern, mostly non-compatible and not
effectively used.
The colleagues are open to conversations
and genuinely interested in modern medi-
cine, most of them have graduated from
Moscow or Minsk University. The white
and spacious building of Ashgabat Medi-
cal University fascinates with its enormous
gilded domes. I am not too modest and ask
about the colleagues’ personal attitude to
their President of the State. Many of them
had met him during his doctor’s, Dean’s or
Turkmenistan on the Roud to Democracy
Peteris Apinis
225
Regional NewsLATVIA
hospital manager’s career and remember
him being hardworking and friendly, how-
ever, demanding. His two theses were su-
pervised by Academician Leontyev (former
President of Russian Medical Association
and member of WMA) and defended in
Moscow.
The foreign language skills of Turkmen
doctors are surprisingly good, they speak
English, Russian and German. It is con-
trasting greatly with police officers one
can meet on every corner and next to any
building, as they do not speak any foreign
language.
There are numerous sanatoriums built by
the state. To maintain their activities, at
least one third of the nation has to visit
them yearly and the expenses are covered
by the employer (usually a ministry or de-
partment). Health is promoted by apply-
ing mud, salts and herbs. The method has
a proper basis as Academician, Dr.med. and
Dr.oec. Gurbanguly Berdimuhamedow has
just finished his monograph “Medicative
Herbs of Turkmenistan” in three volumes.
It has already been translated into Eng-
lish, Russian and six other languages. The
directions of health care in the country are
determined by the President’s monograph
“Scientific Principles of Health Care in
Turkmenistan”.
While the President was Minister of Health,
a sixteen storey building for the Ministry of
Health was constructed. A really significant
part of the state budget (which is not pub-
licized in Turkmenistan) is spent on health
issues; doctors are supplied with apartments
in a special area close to the Ministry and
newly built health centres.
The state health care strategy exceeds ex-
tensive building of huge centres and quite
chaotic purchases of new technologies.
The Great President is also an outstanding
sportsman, who personally supports sports
and healthy lifestyle. Women in Turkmeni-
stan never smoke or drink alcohol, which
is based on tradition, Islamic laws and the
President’s instructions. However, they do
not do any sports. Either it is the new times
or tradition to be blamed, but most women
are obviously overweight.
In contrast to other Muslim countries, men
in Turkmenistan consume alcohol a lot,
which is heritage from the USSR. It is de-
clared that men practice martial arts, horse-
riding and football.
Eight new sports stadiums and several ice
halls have been built in Ashgabat. As the
city is preparing to host the Asian Olym-
pic Games or Asiade in 2017, a new sports
stadium with the capacity of 100, 000 seats
and many other sports premises are under
construction. However, one cannot see any-
body running or cycling in the city.
There is a special 8.6 km long Health Track,
particularly favoured by the President, built
in the vicinity of the city; initially you have
to climb about 350 metres and the track
leads you over the hilltops, then it goes
down near town Bagira where a mighty
fortress and a temple were erected before
Christ. From time to time it was invaded by
Alexander of Macedonia, Persian sultans or
just Kazakh or Mongolian warriors.
The President is said to walk the track once
a month together with all his ministers.The
track is covered by a concrete layer; its width
is about 1.5 metres, both sides are secured
with metallic rails, stairs installed in steeper
parts and nice gazebos on hilltops. At the
very top of the hill there is a landing field
for helicopters in case someone gets faint
after ascending the hill.The track is a work-
place for several dozens of Turkmen – at
least four militia officers guard both ends
of it, a group of men work on maintenance
compacting concrete, while women carry
water from big tanks in buckets.
There are cedars, thujas and silvery pines
planted on the hill that are taken care of
by gardeners. Actually, I did not meet any
health addicts on the track. It could be be-
cause even at 42º Celsius no water is sup-
posed to be supplied on the whole length
of 8.6 km.
The main natural resource of Turkmenistan
is gas and oil. The economy of the state is
based on gas fields that rank the 4th
largest
in the world. Pipelines transport the gas to
the whole world through Russia and Iran.
Every inhabitant possessing a car is entitled
to 1.5 tons of petrol a year for free while
petrol costs about 25 US cents per litre.
Flat rent and public utilities billing is quite
symbolic; for a spacious flat it makes about
10 USD per month. Gas is free and heat-
ing during winter is free as well. Taxes on
income make about 10%; however, mostly
for foreigners.
The capital city Ashgabat makes you feel
surprised – the construction boom is more
impressive than anywhere in the world.
Ministry buildings, blocks of flats, universi-
ties, schools, factories – all kinds of build-
ings are being erected everywhere. The
streets are as smooth as glass with at least
three lanes in each direction.
Actually, there is a new twelve to sixteen
storey white marble city standing next to
the old one. Architects are French, con-
struction managers and supervisors are
Turkish while the buildings resemble the
classicism of the 20th
century of America in
the thirties and Russia of the fifties. There
are thousands of snow-white buildings
with stained glass windows illuminated at
night; at least ten impressive obelisks glo-
rifying independence, neutrality, heroism
of ancient Turkmen, the former President
Türkmenbaşy Niyazov etc.
The fountains are illuminated at night-
time as well.The ever biggest flag is hoisted
at the museum building the exposition of
which displays the Turkmen nation as one
of the largest and most significant in the
world.
226
CHINANon-Communicable Diseases
The city itself is fascinating. If there are no
construction works going on, new trees are
planted (mostly pines and cedars); each tree
gets an individual water supply pipe.
In twenty years Ashgabat will be green and
surrounded by forests.
Our hotel is situated on the main road,
the other three corners are occupied by the
President’s Palace, the Ministry and Acade-
my of Defence and the University.Thus, the
priorities of the former President are clearly
seen. Every country and nation has its own
path to follow. Turkmenistan is aiming at
becoming the tiger of Central Asia, mostly
through construction and pomposity. How-
ever, no one could deny that a great deal of
profit from the national land deposits re-
turns to its people.
The President of the State is a doctor and
his priority is people’s health, the civil ser-
vice although poorly educated does their
best to implement this priority. Doctors
are trained in-service in France and Ger-
many, knowledgeable professionals come
to Turkmenistan to perform model opera-
tions, new directions in medicine are being
developed. I believe that the Medical As-
sociation of Turkmenistan will be founded
this year.
Dr. Pēteris Apinis,
Editor-in-Chief of World Medical Journal,
President of Latvian Medical Association
Today, Non-Communicable Diseases
(NCDs) – cancer, diabetes, chronic respira-
tory and cardiovascular diseases lead to 63%
of annual deaths worldwide. They are rec-
ognized as a global killer and major health
challenge. They affect individuals as well as
society with an economic burden estimated
to reach $30 trillion over the next 20 years.
The situation in low-and middle-income
countries is no different in this regard; ac-
cording to WHO data,80% of NCDs occur
in low- and middle-income countries. Part
of the solution lies in the fact that NCDs
are preventable to a large extent through
better self-care as up to 80% of heart disease,
stroke and type-2 diabetes and over a third
of cancers could be prevented.
Self-care is a holistic and very powerful con-
cept well known to doctors and other health
practitioners. It involves people making
healthy lifestyle choices ranging from regu-
lar exercise, healthy eating, good hygiene,
avoiding risky behavior such as smoking,
but also getting vaccinated, using sunscreen
and the rational use of self-care products,
services and medicines.This should go hand
in hand with improving health knowledge
and becoming more aware of physical and
mental conditions. If practiced 24/7, self-
care makes a huge difference to wellbeing
and longer life expectancy.
Although there has been some progress in
recognizing the crucial role of self-care in
the prevention of NCDs, it is still not suf-
ficiently appreciated by the general public
globally, to make a tangible difference. In-
ternationally, 1 in 3 people smokes while
tobacco is the single greatest cause of pre-
ventable deaths in the world today, killing
more than 5 million people a year – more
than HIV/AIDS, TB and malaria com-
bined.
Part of the problem is that self-care is also
not seen as integral part of effective and
cost-efficient health care systems, which are
currently oriented to disease treatment.Pre-
vention is understood mainly in the context
of disease and not encouragement of ‘well-
ness’. We need to look on a global and na-
Zhenyu Guo David Webber
Helping Put Self-care Center Stage with Patients and Policy-Makers
in Combating 21st
Century Killer Diseases
227
Medical Students
tional level to reform health systems to shift
from treating the citizens as passive victims
of diseases to active shapers of their own
well-being. We should support behavioural
change by creating self-care friendly poli-
cies, also outside current health systems –
from town planning, through to transport
and education. This will not only help to
save lives but also to reduce the burden on
healthcare systems.
Exchanging and promoting best practices
among different countries should be a part
of the way forward as well. We already see
some optimistic tendencies. Initiatives in
support of self-care are taking place around
the world. In 2011 the International Self-
Care movement, which celebrates 24 July as
International Self-Care Day to remind us
all of the benefits of self-care, was launched
in China and has since spread to Vietnam,
Indonesia, Myanmar, and Nigeria. Interest-
ing activities are also taking place in Aus-
tralia, the United States and in the United
Kingdom.
As the challenge is global, the International
Self-Care movement is calling on UN to
recognize International Self-Care Day on
24 July each year. This could largely help
to raise awareness and encourage people to
be active participants in their own self-care
and also motivate governments to create
self-care friendly policies.
In the meantime, doctors and health prac-
titioners have a key role to play in helping
their patients understand the need to take
responsibility for their wellness. Patients
should have a right to health but they also
have a responsibility to play their part in it
and help avoid becoming a burden to fami-
lies and society. International Self-Care
Day can support health practitioners and
reinforce the message that Self-Care is not
difficult.
We invite doctors, nurses and other health
practitioners to join the self-care move-
ment by passing on the word to their pa-
tients. Combining our efforts, we can not
only support a grass roots movement and
we can encourage policymakers to turn self-
care into an integral part of a new collective
compact for managing health, which will
help achieve healthier and more produc-
tive societies and focus public healthcare
budgets in areas where there is the greatest
need.
Dr. Zhenyu Guo, Chairman,
International Self-Care Foundation,initiator
of the first Self-Care Day in China in 2012
 
Dr. David Webber, founding director
International Self-Care Foundation
IFMSA has been at the forefront of cultural
exchange, building friendships, and health
action in young aspiring doctors for over
60 years. More than five hundred medical
students from around the world, represent-
ing collectively as a Federation more than
a 100 nations, gathered at the 62nd
General
Assembly of the International Federation of
Medical Students’ Associations (IFMSA),
August Meeting in Santiago, Chile to strive
toward making a difference in the world.
However, this General Assembly was a de-
fining one in IFMSA history as IFMSA
has taken milestone steps towards creating
a new birth for a Federation, in hopes of
creating a Federation that has greater reach
into improving the health and well-being of
communities around the world.
In this past year, IFMSA has been pri-
oritizing its global advocacy in several key
areas, but not limited to: Universal Health
Coverage, Social Determinants of Health
with a focus on Sustainable Development,
Climate Change, Open Access to Essential
Medicines and Research, Human Resourc-
es for Health and Post-2015 Development
Agenda.The Federation has represented the
emerging voice of future doctors and ac-
tively participated in more than fifty global
and regional meetings – not only highlight-
IFMSA: Striving Toward an Future that
Medical Students Want
228
Speaking Books
ing the valuable role that young people can
have, but demonstrating that young people
are leading the innovative drive for social
change. For instance, IFMSA hosted the
first Pre-World Health Assembly (WHA)
workshop for Youth on Global Health Di-
plomacy  – where the Federation brought
together more than 40 young health leaders
from over 25 countries, six different disci-
plines to create joint strategy for the world
health assembly on health issues that are
important to young people. As a result of
this multi-disciplinary and strategic col-
laboration, IFMSA at the WHA66 has had
significant increase in meaningful engage-
ment with member states and stakeholders.
Moreover,IFMSA held its first-youth host-
ed side-event at the WHA66 on Investing
in Girl’s Health, which was co-hosted by
the World Medical Association, Norad and
UNFPA.
As the global community strives to set the
next global agenda on development and
health, medical students, as future doctors
and health leaders of the world, aspire for
creating an IFMSA that has limitless op-
portunities, so they can achieve more for
their communities. IFMSA at the 62nd
General Assembly, a meeting devoted to
IFMSA’s Reform process, opened with a
announcement of a collaboration agree-
ment between IFMSA-PAHO by our
key note speaker, the director of PAHO,
the WHO regional office for the Ameri-
cas – Dr. Carissa Etienne – that “it can-
not be business as usual” and to “strive for
change.” IFMSA President, Roopa Dhatt
echoed to IFMSA members to “let us en-
sure that the Federation that emerges from
this reform process to create the IFMSA
we want and let us together be the genera-
tion that, with dynamism and optimism,
with unity amidst diversity, will create a
better future for the world’s medical stu-
dents to reach our communities for better
health.”
During the assembly students, while partic-
ipants focused on capacity building, project
brainstorming, training and advocacy, they
also explored greater questions of transpar-
ency, institutional strengthening, financial
management, sustainability, and operations
to further to the Federation. Additionally,
it was all historic in that the World Health
Student Alliance, an agreement between
International Pharmaceutical Students’
Federation (IPSF) and International As-
sociation of Dental Students (IADS) was
formalized  – creating an alliance between
medical, pharmacy and dental students for
advocacy and collaboration. At the conclu-
sion, the general assembly, with consen-
sus, adopted the Santiago Resolution on
Strengthening IFMSA – a commitment of
the Federation to focus on addressing the
needs of the Federation to create an IFM-
SA that the members want.
The world had its eyes on this General As-
sembly, and more than 100 national mem-
bers organizations have been awaiting
the conclusions that were accomplished
in Chile. It was amazing to see how all
delegates, from all regions of the world,
regardless of cultural background, came
together to work on institutional change,
to take this dream and strive to create an
IFMSA a more sustainable, visionary Fed-
eration.
IFMSA President
Roopa Dhatt 2012/13
Rotary International and UNICEF Paki-
stan, partners in the Global Polio Eradi-
cation Initiative since 1988, launched a
Speaking Book titled “A Story of Health’”
to mark World Polio Day on October
25th
. “A Story of Health” or Sehat ki Ke-
hani in Urdu is an educational tool that
enables community workers to inform
men, women, children on the impor-
tance of sanitation, hygiene, and vacci-
nation in preventing the spread of polio.
The Speaking Book has been developed
for the Pushtun speaking communities
across Pakistan.
The launch ceremony, held at Indus Valley
School of Art & Architecture, had as Mas-
ter of Ceremonies, Zubair Anwar Bawany,
UNICEF Pakistan’s Lead for CSR, Corpo-
rate Engagement & Partnerships. Speakers
included prominent guests like the Senior
Minister for Education, Sindh Mr. Nisar
Ahmed Khuhro,who applauded Rotary and
UNICEF’s initiatives and stressed the need
for more of this type of education as key in
polio eradication.
The District Governor, Dr. Pir Syed Ibra-
him Shah, gave a regional perspective on
having no polio cases in Balochistan since
last year versus having three in Sindh. He
urged Rotarians to renew efforts to eradi-
Rotary and UNICEF Launch a Speaking Book to Prevent
the Spread of Polio on World Polio Day
229
Speaking Books
cate polio from Pakistan just as they have
been instrumental in polio eradication
worldwide,particularly taking the lead from
efforts in Manilla, Philippines which were
later expanded to a global initiative.
Dr. Andro Shilakadze, Chief Field Office,
UNICEF Sindh, thanked Rotary for their
collaboration on the Speaking Book, saying
that UNICEF is proud to be part of this in-
novative initiative and particularly pleased
the launch involved school children. He
offered UNICEF’s continued support to
eradicate polio and educate Pakistani chil-
dren,commending Pakistanis for their resil-
ience and commitment to education.
The National Chair, Polio Plus Committee,
Aziz Memon, discussed the global collabo-
ration effort among partners throughout the
development and production of the Speak-
ing Book. He described how the Speaking
Book was first pioneered by a South Caro-
lina Rotarian, then sponsored by Rotary
International, designed in South Africa,
written, illustrated, voiced over in Pakistan,
and finally printed in China. The National
Chair also pointed out that literacy is the
first step towards polio eradication, men-
tioning Sri Lanka, with 100% literacy level,
completely eradicating polio 20 years ago,
and other nations with high literacy levels
having similar success.
Following the speeches, the National Chair
officially launched the Speaking Book and
presented it to the Chief Guest and Dr. Al-
taf Bosan, who then read a few pages from
A Story of Health to the children huddled
around him in the garden, listening atten-
tively. All of the children from the local
school were given polio mobilization items
such as pencils, badges, plastic mugs, and
books.
The Speaking Books team is thrilled and
encouraged by the phenomenal collabo-
ration between Speaking Books, Rotary
International, and UNICEF. We under-
stand and promote the power of education
in enabling people to live healthier and
more productive lives. We see this Speak-
ing Book as another incredible initiative
to help improve lives. We’re proud to be a
part of this effort and look forward to con-
tinuing the work to wipe out polio around
the world.
Alina Visram, Pakistan
E-mail: polioplus11@gmail.com
Brian Julius, USA and Africa
E-mail: bj@speakingbooks.com
230
CPME News
The Standing Committee of European Doc-
tors (CPME) represents the National Medical
Associations of 32 countries in Europe. We are
committed to contributing the medical profes-
sion’s point of view to EU and European pol-
icy-making through pro-active cooperation on
a wide range of health and healthcare related
issues.
CPME leading a tender on
Continuous Professional
Development
For this reason, the CPME has recently
appliedto and won a call for tender issued
by the European Commission, concerning
the review and mapping of continuous pro-
fessional development (CPD) and lifelong
learning for health professionals in the EU
and the EFTA/EEA countries. The final
result of the study aims to explore the ex-
isting evidence base on CPD practices and
identify emerging trends to provide a more
comprehensive European overview.
The active participation of every member
represented by the CPME and experts in
health policy will be fundamental to col-
lect data and information and have a bet-
ter picture of the situation on CPD in
Europe. Anotherimportant achievementis
the provision of greater transparency and
the improvement of mutual understand-
ing of CPD systems and practices in the
EU. The CPME, as leader of a Consor-
tium composed of European Council of
Dentists (CED), European Federation of
Nurses (EFN), European Midwifes Asso-
ciation (EMA), European Public Health
Alliance (EPHA) and European Group of
Pharmacists(PGEU), will be involved in
this project for 12 months.
Ethics committees and informed
consent under serious threats
The European Union is currently legis-
lating on two major pieces of legislation:
the General Data Protection Regulation
(2012/0011 (COD)) which aims at secur-
ing the processing,storage and exchanges of
personal data at a European level – includ-
ing health and medical data; and the Clini-
cal Trials Regulation (2012/0192 (COD))
which is meant to facilitate the conduct
of research and foster the development of
medicines in Europe.
CPME has been actively monitoring the
development of negotiations and fueled
the debates with the views of the medical
profession.Both draft regulations have been
adopted by the European Parliament, now
the next step is for the Parliament to reach
agreement with the Council – representing
the 28 EU Member States. The objective is
for these regulations to be formally adopted
in the first half of 2014.
However, even if the legislative process is
not over yet, CPME is extremely worried
about the orientation of negotiations. We
do see a tendency of the legislators to put
into question and even weaken the founda-
tions of medical ethics, in particular ethics
committees and informed consent in re-
search.
First, the role foreseen for ethics commit-
tees in the course of a clinical trial’s approval
procedure, is being dangerously diminished.
Indeed, the current text of the clinical trial
regulation limits the function ethics com-
mittee to a sole examination role of the
trial protocol. In otherwords, the final deci-
sion of the ethics committee based on the
assessment of the protocol, is not binding
any longer. We fear that in practice, this
will result in clinical trials being conducted
despite the negative assessment of the trial
protocol by the ethics committee.
Second, the widely agreed ethical standard
by which an individual who is about to take
part in a medical research study should be
substantially informed of the characteristics
of the study before he consents to it, is at
stake.
This is the case both in the data protec-
tion and the clinical trial regulations. In
this context, identifiable health data of an
individual could indeed be accessed by a
researcherwhile the concerned individual
has never given his informed and explicit
consent to it. We believe this is a very dan-
gerous step which will without doubt have
disastrous effects on research integrity, but
also on the patients themselves.
The World Medical Association’s Decla-
ration of Helsinki which was renewed at
the WMA meeting in Fortaleza, Brazil in
October 2013 and which highlights these
key ethical principles is to be respected.
The CPME together with WMA has lob-
bied and will continue to lobby in favour of
those principles. When research involves
human beings, ethical principles are not
negotiable.
For further information on CPME’s activi-
ties and policies: www.cpme.eu
Dr Katrín Fjeldsted,
President of the Standing Committee
of European Doctors
Ms Birgit Beger,
Secretary General of the Standing
Committee of European Doctors
News from the CPME: Up-date on policy
developments in the European Union
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WMA News
Memorandum of Understanding
European Forum of Medical Associations – World Medical
Association Handbook
The European Forum of Medical Associa-
tions (EFMA) was established in Decem-
ber 1984, following an invitation from the
WHO European Region to a joint meeting
with the National Medical Associations to
discuss Health for All in Europe and other
common issues. From this date until the
present, a joint annual meeting has been
held, hosted by different NMAs.
Information about participating National
Medical Associations, their aims and ac-
tivities was first collected in a printed hand-
book (herein “the handbook”), as a joint
venture between the Norwegian Medical
Association and EFMA-WHO in 1991.
The handbook was updated and published
by the Norwegian Medical Association ev-
ery year since then until 2009, when it was
transferred to the EFMA website: www.ef-
ma-forum.com and www.efma-forum.org.
In 2012, the Norwegian Medical Associa-
tion decided that they are no longer able to
maintain and update the EFMA handbook.
At the EFMA Forum in Riga in March
2013, it was decided that this will be taken
on by the World Medical Association.
This agreement is between the European
Forum of Medical Associations (herein
“EFMA”) and the World Medical Associa-
tion (herein “WMA”).
In consideration of the mutual promises
contained herein, the parties agree as fol-
lows:
The handbook will be co-branded as the
EFMA-WMA handbook and will be
posted on the WMA platform. The Ser-
bian Medical Chamber will undertake
the upkeep of the handbook and will host
the handbook on their server. The EFMA
website, which includes details of EFMA
meetings and activities will be separated
from the EFMA-WMA handbook and will
also be hosted and updated by the Serbian
Medical Chamber.
1. The handbook will include all members
of EFMA and the WMA, including
those who are members of only one of
the two organizations. The WMA will
work to extend the handbook to include
associations from other parts of the
world.
2. Both parties, EFMA and the WMA,
will appoint representatives to form a
review committee. It is the responsibil-
ity of each party to ensure that they are
involved in the upkeep of the handbook
and encourage their members to update
their profiles.
3. The handbook will consist of two parts:
the names, addresses and contact details
of the NMAs and a more descriptive
section about the role of each associa-
tion and its activities.The handbook will
also include a section where associations
state which international organisations
they are a member including but not ex-
clusive to: EFMA, WMA, CPME and
UEMS.
4. The WMA will clarify in the handbook
that they are listing the true number of
doctors in their country and not the de-
clared numbers the WMA asks for in
their membership. WMA members will
not be penalised if there is a discrepancy
between the two figures.
5. The handbook will include the logos of
both EFMA and the WMA, and will
clearly state that the handbook is the
product of joint cooperation between
EFMA and the WMA.
6. If the WMA add accompanying sec-
tions to the handbook they will receive
sole credit for such additions.
7. If either party intends to revise or pub-
lish future editions of the handbook,
that party hereby grants the right of first
refusal to the other association to par-
ticipate in the modification or editing of
the work. If either association does not
provide an acceptable revision within a
mutually agreed upon reasonable time,
or should one of the associations be
unable or unwilling to revise the hand-
book, the other party may revise or edit
the future edition. The associations will
consult with each other when the hand-
book is considered for uses other than
the ones for which it was produced.
8. If the Serbian Medical Chamber or the
WMA decide to end their involvement
in the publication of the handbook,
EFMA will do its utmost to find a re-
placement.
9. This Agreement constitutes the entire
understanding between EFMA and
the WMA with respect to the EFMA-
WMA handbook, supersedes any and
all prior understandings and agree-
ments, oral and written, relating hereto,
and may be amended at any time only in
a writing signed by both parties.
Signed by
Dr. Otmar Kloiber
Secretary General, WMA
Adv Leah Wapner
Secretary General, EFMA
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WMA News
New WMA Cooperating Center
The Steve Biko Centre for Bioethics, University of the Witwatersrand,
Johannesburg, South Africa has been awarded the title WMA Cooperat-
ing Center. WMA Cooperating Centers are academic institutions that
support the WMA with scientific advice and on specific projects. The
WMA currently has five cooperating centers. The Steve Biko Centre for
Bioethics is the first in Africa.
WMA Executive Committee decided to award the title WMA
Cooperating Center to the Steve Biko Centre for Bioethics, Uni-
versity of the Witwatersrand, Johannesburg, South Africa. This is
remarkable in several ways. Steve Biko was an anti-apartheid activ-
ist who died in police custody as a result of torture. The failures of
the (white) medical community in South Africa at that time finally
led to a split in the World Medical Association. The failure of the
Medical Association of South Africa and the WMA to clearly stand
up for human rights at that time was certainly one of the serious
mistakes of these organizations.  Steve Biko’s death was one of the
critical events that finally led to the isolation of the apartheid re-
gime. 
There has been increasing cooperation between the Steve Biko
Centre for Bioethics and the WMA for more than a decade. We
have continuously worked together on issues of research involving
human beings,with a focus on questions of placebo use and research
in resource poor settings, and on new ways to empower illiterate
communities using speaking books that bring health education to
them. Prof. Ames Dhai, the head of the Steve Biko Centre, is cur-
rently President of the South African Medical Association. By af-
filiating ourselves with an organisation bearing this name, we not
only pay tribute to an academic partner we have held in high estime
for many years now, but also to a man to whom we owe praise for
his sacrifice: Steve Biko.
World Medical Association has, for the first time, issued a joint
press statement with the UN Special Rapporteur for the Right to
Health, Armand Grover. Following the protests at Gezi Park in
Istanbul and in other Turkish cities last summer, the government
has now prepared a law that would require special permission and
registration to provide assistance in extraordinary circumstances like
catastrophes and riots. The intention is very obvious: the govern-
ment wants to discourage health professionals from providing first
aid and medical assistance to government opponents or, if they do
register, to be able to easily get hold of them and the names of those
they treated.This is an old trick. In the nineties, the Turkish govern-
ment required those treating torture victims to hand over the names
of their patients. Intimidation is a powerful tool for denying access
to health care to political opponents. 
As then, so too now Turkish doctors are resisting, and we stand
by them.  The Special Rapporteur and the WMA are extremely
concerned about the new law which contains draconian sanctions
for those who do not comply. Grover warned that, “Enacting laws
and policies criminalizing provision of medical care to people op-
posing the State, such as political protestors, will certainly deter
healthcare workers from providing services due to fear of prosecu-
tion”. 
The Turkish Government is taking an absurd route in fighting its
own civil society. We need to stand by our Turkish colleagues in up-
holding medical neutrality and support their commitment to pro-
viding aid in critical situations. We are convinced that we stand on
the side of righteousness. But for our Turkish colleagues this is not
without peril. As Voltaire put it, “It is dangerous to be right when
the government is wrong.”
Dr. Ames Dhai Director of the Steve Biko Centre for Bioethics
and WMA President Dr. Margaret Mungherera
Human Rights
The World Medical Association has, for the first time, issued a joint press
statement with the UN Special Rapporteur for the Right to Health, Ar-
nand Grover. Following the protests at Gezi Park in Istanbul and in
otherTurkish cities last summer, the government has now prepared a law
that would require special permission and registration to provide assis-
tance in extraordinary circumstances like catastrophes and riots.The Spe-
cial Rapporteur and the WMA are extremely concerned about the new
law which contains draconian sanctions for those who do not comply.The
law is designed to deter healthcare workers from providing services to
government opponents due to fear of prosecution.
(09.12.2013)  GENEVA – The UN Special Rapporteur on the
right to health, Anand Grover, and the World Medical Associa-
233
WMA News
tion (WMA) urged today the Turkish Grand National Assembly
(Meclis) to reconsider a draft law that would criminalize the provi-
sion of medical care by qualified independent practitioners during
emergencies after the arrival of a state ambulance.
“If adopted, Article 33 will have a chilling effect on the availability
and accessibility of emergency medical care in a country prone to
natural disasters and a democracy that is not immune from demon-
strations,” Special Rapporteur Grover said.
“Enacting laws and policies criminalizing provision of medical care
to people challenging State authorities, such as political protestors,
will certainly deter healthcare workers from providing services due
to fear of prosecution,” Grover warned, quoting his latest report* to
the UN General Assembly on the enjoyment of the right to health
in conflict situations. “Sanctioning such laws and policies will also
discourage other segments of the population from seeking health
services due to fear of being suspected in the involvement in pro-
tests,” he stressed.
“The mere presence of ambulances would be considered grounds
not only to prevent emergency medical care by competent,indepen-
dent physicians, but also to prosecute those medical responders up
to three years of imprisonment and a hefty administrative fine for
acting under the International Code of Medical Ethics to provide
care to those in need,” the WMA’s Secretary General, Otmar Kloi-
ber, underlined.
Dr. Kloiber pointed out that “in times of urgency, from earthquakes
to floods to protests and demonstrations, the international stan-
dards for emergency medical care are based on the medical need of
the wounded and sick rather than the presence of official medical
transport.”
The two experts noted that international medical and human
rights standards make it clear that it is a humanitarian duty of
doctors, nurses, paramedics, and other health workers to give
emergency care to those in need. “They must be able to carry out
their professional responsibilities without interference or fear of
reprisal,” they said.
The Special Rapporteur and the WMA had written individually to
the Turkish Government expressing their grave concern about the
requirements of Article 33 of the draft health bill. “Now we urge
the Meclis to consider the right of the Turkish people to emergency
care and ensure the respect for medical ethics and independence
health workers in Turkey.”
“We hope parliamentarians will make the right call on the Article
33 and scrap it, as it should be,” the experts said.
Successful Climate and Health
Summit in Warsaw
On 16 November the 2nd
International Climate and Health Summit
took place in Warsaw alongside the official UNFCCC  COP19 cli-
mate negotiations.
The Summit was organised by the Global Climate and Health Alliance
(GCHA) together with the World Medical Association and supported by
the WHO. Prof. Vivienne Nathanson (British Medcial Association) rep-
resented the WMA at the event. 
Warsaw 15/11/2013 – Health and medical organizations from
around the world are convening in Warsaw this week to emphasize
the urgent need to prioritize the protection and promotion of health
within global and national policy responses to climate change.
The Global Climate and Health Summit 2013 will take place on
16 November 2013, during the UNFCCC’s COP19 meetings in
Poland, and is organized by the Global Climate & Health Alliance
(GCHA) together with the World Medical Association and with
support form the World Health Organization.
The Summit will highlight the dangerous impacts of climate change
on human wellbeing, the health benefits of mitigation and current
efforts to make the health system more sustainable. It will build a
road-map for the international health community to work towards
in the run-up to the 2015 climate negotiations in Paris.
Research shows that climate change already contributes to over
400,000 deaths every year. If there is a continued lack of political
will, these figures are expected to increase dramatically as the im-
pacts of climate change worsen:
• Populations at risk of infectious diseases such as malaria may
grow to 170 million in Africa by 2030 whilst those at risk of den-
gue fever may increase to over 2 billion globally by 2080
• Climate change will worsen the impact of urban air pollution
which is already directly responsible for over 1.2 million deaths
each year
• The impact of coal plant emissions in Europe alone contributes
to 18,000prematuredeathsandfourmillionlostworkingdays –with
all healthcostscombinedtotalingnearly43billionEuroseveryyear 
• By 2080, over 100 million more people each year risk being ex-
posed to coastal flooding by predicted sea level rises.
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WMA News
Human health is profoundly threatened by our global failure to
halt emissions growth and curb climate change. GCHA argues that
strategies to achieve rapid and sustained emissions reductions and
to protect health must be implemented in a specified time frame to
avert further loss and damage.
In addition to calling on governments to commit to a binding treaty
at the 2015 COP in Paris, GCHA is also encouraging the interna-
tional community to ensure the resulting political, legislative and fi-
nancial frameworks reflect the full impacts of climate change on health
and ensure public health is protected by governments around the world.
IRCT defines way forward to
realise the right to rehabilitation
Beirut, Lebanon, 27–28 June 2013
Victims of torture have a right to rehabilitation. But how can we ensure
that this right becomes a reality in which victims enjoy access to appropri-
ate, holistic rehabilitation services that are funded through states?
This was the major question addressed at the pioneering scientific
conference The Right to Rehabilitation, co-organised by the Inter-
national Rehabilitation Council for Torture Victims and Restart
Center for Rehabilitation of Victims of Violence and Torture.
The experiences, best practices, lessons learned and priority path-
ways forward are now available in the conference report.
In collaboration with speakers and participants from 50 countries,
the IRCT has gathered the input to move forward on ensuring the
right to rehabilitation for all victims of torture. The IRCT recom-
mends that rehabilitation services be:
• State funded: Most significantly for the sustainability of the re-
habilitation movement, states are obligated to provide or ensure
provision of rehabilitation services to victims of torture,regardless
of resources or where the torture took place.
• Victim-centred: As mentioned by the UN Committee against
Torture in their General Comment No. 3, rehabilitation services
must consider the totality of the victim’s context and needs.
• Linked to national health and educational systems: To ensure the
continued growth of high-quality care,rehabilitation services must
build sustainability and quality through on-going collaboration
with current health and education systems. In addition, links with
health systems builds in improved referral systems for victims of
torture when they seek treatment through general practitioners.
• Multi-faceted services: Rehabilitation treatment should be holis-
tic, or multi-faceted, to encompass the multiple needs of victims,
including medical, psychological, legal, social, economic and asy-
lum needs. Furthermore, multi-faceted health organisations for
victims of torture may lessen the stigma for those needing to ac-
cess mental healthcare services.
Call to Action from Bellagio
Conference on Protection of
Health Workers, Patients and
Facilities in Times of Violence
In November 2013, the Center for Public Health and Human Rights of
the Johns Hopkins Bloomberg School of Public Health convened 19 ex-
perts from the fields of humanitarian practice, human rights, human
security, academic research, government, and philanthropy, along with
UN representatives and leaders from health professional associations, at
Bellagio, Italy to address the problem of attacks on and interference with
health care, particularly in times of armed conflict and internal distur-
bances. WMA President, Dr Margaret Mungherera, was one the experts
and a keynote speaker.
Noting that Violations undermine the human security and health of
conflict-affected populations, disrupt health systems and undermine eq-
uitable access to health care, resulting in avoidable loss of life and human
suffering, the experts agreed that urgent action is needed to address the
problem and call upon the international community to advance the se-
curity of health, particularly in situations of armed conflict and internal
disturbances through several actions.
Call to Action
Bellagio Conference on Protection of Health Workers,
Patients and Facilities in
Times of Violence
Bellagio, Italy
November 19–21, 2013
International humanitarian and human rights law recognizes the
obligation and/or the responsibility of governments and non-state
actors to respect and protect health workers,facilities,medical trans-
ports, and the people they serve. Violations undermine the human
235
WMA News
security and health of conflict-affected populations, disrupt health
systems and undermine equitable access to health care, resulting in
avoidable loss of life and human suffering.
We, the assembled, believe urgent action is needed to address the
problem and call upon the international community to advance the
security of health, particularly in situations of armed conflict and
internal disturbances, through the following actions:
1. States and armed groups at all times, including during armed
conflicts and internal disturbances, respect health care workers,
facilities, transports, and services, and persons seeking care, by
not attacking, interfering with, threatening or obstructing them;
refrain from punishing health workers for providing treatment
to individuals in need of medical care on account of the patient’s
ethnic,religious,national,political or military affiliation or other
non-medical considerations; and ensure availability of safe and
secure access to and equitable distribution of quality health care.
2. States train their military, police forces and other law enforce-
ment agents to adhere to legal standards and assure protection of
health services, health workers and people seeking care; armed
groups similarly raise awareness among their forces to comply
with their international obligations to respect health care work-
ers, facilities, transport, and services, and persons seeking care.
3. States, with the support of the UN, take action to stop attacks
and hold perpetrators to account in national and, where appro-
priate, international courts and/or special tribunals.
4. States make explicit in national law the respect for and protec-
tion of the delivery of health care and health workers in times
of armed conflict and internal disturbances, and reaffirm and
reinforce these norms through the UN General Assembly, the
Security Council and the Human Rights Council.
5. States, through Ministries of Health and other relevant agen-
cies and UN bodies, establish, strengthen and provide resources
for systematic monitoring and reporting of attacks on health
workers, facilities and transports, and individuals seeking care;
and support the implementation of ongoing initiatives by the
UN Special Representative for Children and Armed Conflict
and the World Health Organization designed to collect and dis-
seminate data on attacks on health services and encourage field-
based reporting by the High Commissioner for Human Rights.
6. States, through the UN, engage in processes such as Universal
Periodic Review, treaty body review and mechanisms for the
protection of civilians and children affected by conflict to pro-
mote compliance with international law and accountability for
perpetrators.
7. States, relevant UN entities, NGOs and professional health or-
ganizations and ministries of health promote, disseminate and
implement recommendations of the International Committee
of the Red Cross Health Care in Danger project to increase
security of health care services and health workers in the field.
8. Health professional organizations at the national and global
level promote universally accepted standards of professional
conduct among health workers in armed conflict and internal
disturbances,including training health workers on human rights
and medical ethics and advocating for protection and security of
health services and health workers.
9. States, WHO and the Global Health Workforce Alliance as
part of the UN post-2015 development agenda process incorpo-
rate strategies to address the problem of interference with health
care and attacks of health workers in the human resources for
health agenda and related initiatives.
10. Civil society actors actively engage States and relevant inter-
national organizations to advance protection of health care in
armed conflict and internal disturbances.
11. States and donors support civil society engagement through ca-
pacity building, technical assistance and funding.
12. States and other research funding bodies sponsor and research-
ers and practitioners conduct in-depth studies on the nature of
violations, the perpetrators, as well as the consequences of lack
of protection of health care functions on the health and devel-
opment of the population. Current research gaps are identified
in Annex 2 to this statement.
2013 Global Health Forum,
Taipei,Taiwan
From WMA Leaders’ blogs
WMA Secretary General Dr. Otmar Kloiber travels around the world
talking about the WMA’s work representing the millions of physicians
worldwide. Acting on behalf of patients and physicians, the WMA en-
deavors to achieve the highest possible standards of medical care, ethics,
education and health related human rights for all people. This blog will
chronicle these travels and important issues. (www.wma.net).
Taipei, Taiwan to Frankfurt, Germany. Should all ministers be
health ministers? For sure, at least in a way…
There is no sector of government that does not have relevance for
health and health care.Whether the actions of a ministry have direct
effects, such as setting financial budgets for health care or payments,
or indirect effects for example upon peace, the availability of work
and housing, social protection, road safety, education, occupational
and environmental safety, international cooperation, trade and aid,
climate change, or research financing, there is virtually no section of
government that is not connected in some way with health.
236
WMA News
Next generation had a strong representation at the Global Health
Forum: Roy Jen-Hsiang Shen, WMA-JDN-Member, Dr. Ot-
mar Kloiber, WMA, Dr. Yung-Tung Wu, Past-President TMA,
Dr. Andy Hsieh, (Dental Surgery), Dr. Ray Wu, (Dental Surgery).
But how to get health into the minds of the politicians? This awfully
difficult question was debated at the invitation of the Taiwanese gov-
ernment at the 2013 Global Health Forum in Taipei from November
23-24,2013.In a section on the “Physicians’role and response to pro-
moting Health in All Policies in an NCD era” I stressed our holistic
approach to tackling non-communicable disease (NCDs). This has
two major pillars: Firstly, the right to health as a human right, and
secondly a focus upon the social determinants of health as the under-
lying causes of many diseases in this world.
The WMA was irritated when in 2011 the World Health Organiza-
tion went back to the old silo approach of listing four disease areas
(cancer,cardio-vascular and lung diseases and diabetes) in their pro-
gram on NCDs.Just three years previously in 2008,thirty years after
the Alma Ata Declaration of the WHO, a ground breaking World
Health Report on “Primary Care – Now more than ever” clearly
demonstrated that the sectorial approach,tackling a limited number
of infectious diseases, had not shown the desired effects. And yet,
while finally tackling NCDs after decades of ignoring them, the
WHO now falls back on the same old and insufficient strategy.
This is even more startling since, at the same time, the WHO has
not only made a new start on primary care (World Health Report
2008) – much more realistic than ever before – and developed a
report on Social Determinants of Health (“Closing the Gap in one
Generation” WHO 2008) under the chairmanship of Sir Michael
Marmot, it has also embarked on health system strengthening and
is advocating loudly for universal health coverage.
The challenges are overwhelming – we still don’t see enough poli-
cies taking account of their effects upon health, whether they are
directly related to public health, such as fostering tobacco control,
or indirectly, such as providing enough funding for affordable and
high quality education for all. While Africa still has a homeopathic
average per capita health expenditure of around 100 USD per year,
problems of equity exist within all nations, regardless of whether
they are rich or poor.
The Taipei conference ended with a call upon the politicians of this
world to be aware of their responsibilities regarding health. How-
ever, as the conference was mainly attended by experts on public
health, this was a bit like preaching to the converted. One positive
aspect was the presence of a lot of young people at the conference.
Medical students, young physicians and other young health profes-
sionals gave the conference a strong youthful perspective, and the
hope that our voices will be heard in the future. And of course it is
always good to meet up with members of the WMA Junior Doctors
Network (JDN).
The fact that Taiwan, having been a very poor country just few
decades ago, is now a leader in health system development, pro-
viding comprehensive and efficient health care to all of its people,
is really very inspiring. And it is also clear that the health of the
nation is not merely a result of strong economic development, but
rather a condition for it. For all those who are struggling to build
a health care system, the bottom line is: Yes, it can be done, even
against all odds.
A big thanks to the Taiwan Government, the Minister for Health
and Welfare, Dr. Wen-Ta CHIU for inviting the WMA again and
the Taiwan Medical Association for facilitating this!
Meetings
Health care in danger: From consultation to
implementation
WMA President Dr Margaret Mungherera gave a key note address
on the importance of healthcare in times of conflict and violence at
the expert conference organized by the International Committee
of the Red Cross (ICRC), together with the Conflict and Catas-
trophes Forum of the Royal Society of Medicine (RSM) and the
British Red Cross on 3 December in London.
197th
WMA Council Session, April 2014
The 197th
Council session will be held from 24–26 April 2014 at the
Hotel Nikko Tokyo, in Tokyo, Japan. The registration is open and
higher fee will be applied after 24 March.
WMA General Assembly, Durban 2014
The General Assembly in 2014 will be held from 8–11 October
2014 at the Durban International Convention Centre, in Durban,
South Africa. Please save these dates in your calendar.
200th
WMA Council Session, April 2015
The 200th
Council session will be held from 16–18 April 2015 in
Oslo, Norway. Please save these dates in your calendar.
237
WMA News
World Health Professions Regulation Conference 2014
To be held in Crowne Plaza Hotel, Geneva, Switzerland 17–18
May 2014. WMA is co-organizer.
International update
Call to end attacks on health workers
On 24 October 2013, the UN Special Rapporteur on the Right to
Health, Anand Grover, presented the latest report to the General
Assembly, dedicated to the right to health obligations of States and
non-State actors towards persons affected by and/or involved in
conflict situations. It describes a wide range of abuses against health
workers and highlights the need for better monitoring and account-
ability.The Special Rapporteur’s report is the first UN human rights
analysis to describe the responsibilities of countries to provide and
protect health workers and services in conflict.
Resolution supports torture victims’ right to rehabilitation
On 12 November, 193 States of the UN General Assembly adopted
a resolution reiterating the absolute prohibition of torture and, sig-
nificantly, the obligation on states to ensure victims have prompt
access to appropriate rehabilitation services. This resolution is par-
ticularly important since not all countries around the world have
ratified the UN Convention against Torture.
Third Global Forum on Human Resources in Health (HRH)
The Forum, held in Recife, Brazil, emphasized the importance of
HRH in implementing universal health coverage and discussed
what universal health coverage means for various stakeholders.
WHO Member States adopted the Recife Political Declaration,
which outlines the type of actions and commitment required at na-
tional and global levels to address international HRH challenges.
Education and training for 21st
century
WHO has developed a website on “Transforming and scaling up
health professionals’ education and training”. The guidelines are
expected to give rise to regional- and country-based policy and
technical dialogues with key stakeholders across education, health,
finance and labour, on how best to finance health professional train-
ing and prepare health professionals for the 21st
century.
Green news
WHO calls to phase out mercury from measuring devices
On 11 October 2013, to mark the signing of the Minamata Con-
vention on Mercury, WHO and Health Care without Harm joined
forces to launch a new initiative to have mercury removed from all
medical measuring devices including fever thermometers and blood
pressure by 2020. WHO media release
New UNEP Website of the Minamata
Convention on Mercury
The Minamata Convention for Mercury is a global treaty to pro-
tect human health and the environment from the adverse effects of
mercury.
Publications, courses,
conferences, calls for papers
Research Ethics Course – TRREE
Research Ethics Course – Training and Resources in Research
Ethics Evaluation (TRREE) in collaboration with the Institute
of Health Law, University of Neuchâtel, is available on the WMA
website.
The Prince Mahidol Award Conference (PMAC)
The Prince Mahidol Award Conference is an invitation-only con-
ference hosted by the Prince Mahidol Award Foundation and the
Royal Thai Government in cooperation with several partners. The
Conference, entitled “Transformative Learning For Health Equity,”
will be held in Bangkok, Thailand, 27-31 January 2014. WMA is
part of the conference advisory committee helping develop the con-
ference program.
Ambulance and pre-hospital services in risk situations
Written by the Norwegian Red Cross with support from the In-
ternational Committee of the Red Cross (ICRC) and the Mexican
Red Cross, this report sets out ways to make pre-hospital care and
ambulance services operating in areas of armed violence safer.
238
Personal Opinion NIGERIA
State of the World Population Report 2013
The State of the World Population Report 2013 “Motherhood in
Childhood:Facing the Challenge of Adolescent Pregnancy”released
by UNFPA finds that more than 7 million girls in poor countries
give birth before 18 years old each year with two million of them
14 or younger. The report, which focuses on adolescent pregnancy,
highlights its challenges and consequences on the health, education,
employment and rights of millions of girls around the world.
Guidance note on disability & emergency
risk management for health
The WHO and partners have launched a guidance note on disabil-
ity and emergency risk management for health – a short, practical
guide that covers actions across emergency risk management.
New Detention Monitoring Tool
This tool developed by Penal Reform International (PRI) and the As-
sociation for the Prevention of Torture (APT) addressing risk factors to
prevent torture and ill-treatment.It aims to provide analysis and practi-
cal guidance to help monitoring bodies to fulfill their preventive man-
date as effectively as possible when visiting police facilities or prisons.
Recognizing Victims of Torture in
National Asylum Procedures
A new report by the International Rehabilitation Council for Tor-
ture Victims (IRCT), conducted an 18-country overview of asylum
systems in Europe, North America and the Pacific. It gives a com-
parative overview of early identification of victims and their access
to medico-legal reports in asylum-receiving countries.
Guidelines on Human Rights Education for Health Workers
These guidelines present approaches to be adopted when planning or
implementing human rights education for health workers related to six
key structural areas: the human rights-based approach to human rights
education; core competencies; curricula; training and learning process-
es; evaluation; and professional development and support of trainers.
New database of health and human rights syllabi
To assist university-based teachers and others teaching health and
human rights,the University of Southern California (USA) has cre-
ated a database of syllabi on health and human rights concepts and
methods. In providing these syllabi, the initiators hope to stimulate
and support efforts to integrate health and human rights into a wide
variety of specific and general curricula.
150th
Anniversary of the World Veterinary Association
The 31st
World Veterinary Congress (WVC) took place in Prague
(Czech Republic) from 17 to 20 September. This year, the WVC
was marked by World Veterinary Association’s 150 years Anniver-
sary celebrations.This year, the WVA-WHO-OIE-FAO 2nd
Global
Summit focused on strengthening institutional collaboration and
cooperation between animal and public health in education and re-
search.
Prologue
The United Arab Emirates consist of seven
semi-autonomous emirates with three li-
censing bodies for medical and paramedical
professionals.
The Dubai Health Authority (DHA) li-
censes doctors and other paramedical profes-
sionals to work in the Emirate of Dubai.The
Health Authority of Abu Dhabi (HAAD) li-
censes doctors and paramedical professionals
to work in the Emirate of Abu Dhabi and Al
Ain city.The United Arab Emirates Ministry
of Health (MOH) licenses doctors and para-
medical professionals to work in the remain-
ing five emirates namely Sharjah,Ajman,Um
al Quwain, Ras Al Khaimah and Fujairah.
The Scene
I am a Nigerian general medical practitioner
with thirty-seven year unbroken experience
in private medical practice. I desire to retire
from hospital practice at age sixty-five, and
start a medical tourism business. In pursu-
ance of this, I opted to work in the United
Arab Emirates few years before this venture,
in order to have firsthand knowledge of the
health establishments/institutions relevant
to this ambition, gain knowledge of the
laws guiding hospital practice and business
in the country, be familiar with the coun-
“A Doctor’s Experience of Injustice in the
United Arab Emirates, a Caveat”
239
Personal OpinionNIGERIA
try’s financial institutions and know the
traditions and customs of its people. Also
working in the UAE will give me the much
needed base for the take off of the venture,
since I already have enough field experience
in my country which is to be used as the
main field for take-off.
I flew into Dubai in June 2011 to complete
the necessary formalities to be a DHA-
licensed practitioner. I was scheduled for
an academic interview on September 14,
2011, which I passed. I had my result and
certificate issued online two days after.
I was in Dubai on 14th
may 2012 to search
and start work. I had non-attractive job of-
fers necessitating my decision to return to
my country, after staying in Dubai for two
months.
A day before i exited Dubai, precisely on
11th
July 2012, I decided to trade in my
DHA certification for an MOH certifica-
tion, a recently introduced and permitted
procedure. In pursuance of this, I filled a
ministry of health form online and upload-
ed all requested documents. The third item
on the first page of the form was my date
of birth which I clearly inserted as May 19,
1951.
Also uploaded on the form was my passport
page on which my date of birth was clearly
stated.
After waiting for four months, and without
any information from the ministry on the
application inquired and was told by the
ministry that I am yet to pay its application
fee of Aed 100! (about $30).In other climes,
the application would have been formally
acknowledged as received and request made
for the application fee.
By the time the ministry processed the ap-
plication, my DHA certificate has lapsed
and the ministry then claimed it could
not use a lapsed certificate to grant me its
MOH certification.It requested i sat a fresh
assessment by entering for its prometric on-
line examination. It gave me the guidelines
for the examination, and also requested
I visit its website to peruse its requirements
for certification. In all the information it
gave to me including that on its website, the
word age was NEITHER mentioned NOR
appeared on them.
I entered for the ministry’s examination and
paid the necessary fees. I sat for the exami-
nation on 16th
February 2013 and passed. It
sent me a letter of congratulations the next
day. By an email dated 1st
April 2013, the
ministry requested I visited its customer
department to collect my evaluation certifi-
cate.
I arrived in UAE on 17th
August 2013, col-
lected the certificate on the 21st
, instantly
and immediately started applying online
for jobs. I attended interviews and had good
offers. However the procedure in UAE re-
quires an employer to apply to the ministry
for the release of the licence of any prospec-
tive employee, paying a non refundable fee
of AED 2600 (about $800).
As a precaution not to lose such money,
an employer will normally make prelimi-
nary enquiry on whether a prospective
employee’s licence will be released to it or
not. Such preliminary enquiries by employ-
ers regarding me were not responded to by
the ministry. After not responding to my
formal enquiry on this behaviour, the min-
istry head of licensing eventually told me
on phone that I am over aged to work in
the UAE!
My age was on the application form; like-
wise the passport page uploaded on the
form. Age was not even mentioned in its
“conditions for evaluation of physicians/
dentists”displayed on its website.In this age
of the versatility of the computer, why did
the ministry fail to programme its computer
to screen off overage applicants? Why ask
me to travel all the way from my country to
pick up an evaluation certificate when you
have already predetermined i wouldn’t be
allowed to use it to gain employment? Why
collect money for application and examina-
tions? Why make me go through the physi-
cal, mental and financial stress of an ex-
amination? Four air trips to the UAE, four
months stay in UAE idling while searching
for jobs, TWO UAE licensing bodies’ cer-
tifications passed and yet I cannot work?
WHAT ELSE IS INJUSTICE IF NOT
THIS?
To call this an injustice is an understate-
ment. There are demeaning and ap-
propriate words to describe this action
which civility will not allow me to use in
this article. It is worse than a swindle!
I have written more than two dozen letters
separately to the UAE Prime minister, the
ministers of health, justice and foreign af-
fairs, without the courtesy of a single reply
from any of them. I even wrote to them that
I was no longer interested in working in the
UAE, but requested compensation for the
expenses incurred, time lost and wasted in
this venture spread over three years,Through
the ministry’s administrative incompetence,
sheer ignorance, deliberate misguidance or
all combined.
I DID NOT HAVE ONE REPLY. At
a certain point in time the ministry of
health even shut off its computer from ac-
cepting my e-mails! This was the same
ministry that could not programme its
computer to screen overage applicants!
I learnt that my experience wasn’t the first
case. I learnt of a Spanish surgeon that was
treated similarly.
I even appealed to the ministry to amend
the information on its website to reflect age;
it simply ignored the advice. I have made a
decision to make colleagues to beware and
be aware by writing this article, lest they fall
into similar predicament or do we call it
the ministry’s “trap” if they are intending to
work in the UAE. If a government ministry
can so treat an individual, what can one not
expect or experience with private organisa-
tions?
240
SRI LANKARegional and NMA News
Epilogue
The fortune or misfortune of not being
allowed to work in UAE is least of my
problems. I have done well in life without
leaving my country. What i find very repul-
sive and damning, and which mutates my
indifference to the whole saga, is the com-
placency of the ministry in not accepting
its blunder and offering a simple apology;
also its set agenda to continue to mislead
and misguide doctors who may want to seek
its services. Why did it refuse to amend the
wrong information it placed on its website?
I write this article in good faith and with
an unbiased and unperturbed mind. All as-
sertions in this article are backed by docu-
ments which are available on request.Please
do not ask me if i intend being in UAE in
future? I may in the next world!
Like a friend once remarked. Being re-
ferred to as a developed country or nation
takes more than skyscrapers and boule-
vards! Respect for humanity, rights and
dignity are key requirements for a nation
or country to be labelled and acknowl-
edged as a developed and civil country.
Dr. Francis Olubunmi Ilori
The Sri Lanka Medical Association
(SLMA) is the apex academic medical
institution in Sri Lanka and is the oldest
such institution in Asia and Australasia.
The SLMA has been in existence for 126
years from 1887. The registered address
of the organisation is Wijerama House,
No.6, Wijerama Mawatha, Colombo 7, Sri
Lanka. All doctors registered with the Sri
Lanka Medical Council are eligible to be-
come members of The Sri Lanka Medical
Association.
The SLMA is a purely academic organisa-
tion concerned with Continuous Profes-
sional Development of doctors and policy
discussions on all aspects of healthcare. It
has also performed an important function
in an advocacy and advisory role for the
government of the Democratic Socialist
Republic of Sri Lanka.
Many of the activities of the organisation are
carried out be Expert Committees and Work-
ing Groups. The functioning of the institu-
tion are overseen by an Executive Committee.
The current members of this committee are:
1. President: Dr. B.J.C.Perera
2. Immediate Past President: Professor
Vajira H.W. Dissanayake
3. President Elect: Dr. Palitha Abeykoon
4. Vice Presidents: Professor Rohan Jayas-
ekera, Dr. Kalyani Guruge
5. Hony. Secretary: Dr. Samanmaali Su-
manasena
6. Hony. Asst. Secretaries: Dr. Shyamali
Samaranayake, Dr. B. Kumarendran,
Dr. Navoda Atapattu, Dr. Sanjeeva Gu-
nasekera
7. Hony.Treasurer: Dr. Ruvaiz Haniffa
8. Hony. Asst.Treasurer: Dr. Leenika Wi-
jeratne
9. Hony. Social Secretaries: Suriyakanthi
Amerasekera, Dr. Gamini Walgam-
paya
10. Public Relations Officer: Dr. Deepal
Wijesooriya
The Association has its Anniversary Sci-
entific Medical Congress in July every
year and the Foundation Scientific Ses-
sions in October every year. In addition
many Provincial Academic Meetings are
organised in collaboration with Regional
Clinical Societies. All these are designed
to bring state-of-the-art knowledge and
the latest developments in medicine to
doctors from all over the island. Over the
last couple of years the SLMA has ex-
panded its activities to allied healthcare
professionals as well.
The SLMA can be accessed at
http://www.slmaonline.info/
https://www.facebook.com/SLMAonline and
http://www.linkedin.com/in/slmaonline
Sri Lanka Medical Association
III
ROMANIA Regional and NMA News
Over 10,000 professionals from the Roma-
nian health system (doctors, dentists, phar-
macists, nurses, psychologists, biologists,
biochemists) protested in Bucharest for an
increased budget for health and professional
dignity. The protest was called The March of
Silence, and it took place on November 2nd
2013,on a 3 km route – Romanian Govern-
ment – Romanian Parliament.
Since it was a silent march, protesters only
marched and displayed boards with mes-
sages such as: “I  will deal with the Inter-
national Monetary Fund,” “I want to work
in Romania”, “I’m a Romanian doctor and
I care”, “I won’t be silent anymore”, ”6% of
GDP for health”.
The March of Silence was organized by
the Coalition of Health Professionals, after
the picketing the Ministry of Health and
Ministry of Finance for 10 days at the end
of September with 150 health profession-
als each day, coming form all parts of the
country. Following these pickets, we began
negotiations with the Ministry of Health,
Ministry of Finance and Ministry of Labor,
negotiations which are still held.
In Romania, the current situation of health
professionals in general,and doctors,in par-
ticular, is difficult from many perspectives.
One of them is that the number of doctors
is not enough for the 19.000.000 people
living in Romania. In present, only 39.800
physicians and 14.000 residents are working
in the health system. Only 14.487 of them
are working in hospitals (in 2011 the num-
ber of physicians working in hospitals was
20.648).
Because of the difficult situation, all the
health professional organizations decided
to gather in the Coalition of Health Pro-
fessionals, which includes: The Romanian
College of Physicians, Sanitas Federa-
tion, The Romanian College of Dentists,
The Romanian College of Pharmacists,
The Romanian College of Psychologists,
the Romanian Order of Nurses and Mid-
wives, the Romanian Order of Biologists,
Biochemists and Chemists, the Federation
of Physicians ”Dr. Ioan Cantacuzino”, the
Association of Resident Doctors, The Fed-
eration of Medical Students, the Romanian
Society of doctors working in collectivities
of children and young people, the Associa-
tion of Ambulance Services, The National
Association of Pharmacists from Hospitals
in Romania.
The Health Professionals Coalition advo-
cates for getting at least 6% of GDP for the
health care system, legislation to guaran-
tee the professional independence of those
working in the public and health sector, a
wage law specific for the health system (in-
creased wages),double wage for the resident
doctors,defending the dignity and giving up
denigration of professionals by the authori-
ties; organization of medical units with beds
in the public system to ensure prompt and
quality services for patients; real consulta-
tion with the Health Professional Coalition,
regarding any measure which may affect the
functioning of the health system.
We obtained the recognition that with-
out health professionals, the health sys-
tem is unsustainable, scholarship for
residents in the amount of 150 Euros,
legislative changes (on going) to pro-
tect doctors from external interferences,
the release accompanied by funding of more
than 1200 posts in the health system, the
return to the payment of work during the
weekends and legal holidays, the refinanc-
ing of services in dental medicine (this year
the budget of dental medicine covered only
two months).
We didn’t succeed to obtain the increas-
ing of the salaries for the physicians, we
received only promises that the additional
funds that occur during 2014 will be di-
rected to Health’s budget and that some of
them will be used to increase revenues doc-
tors.We didn’t obtain an increase of health’s
The Physician’s Situation in Romania
IV
Contents
budget to 5% of GDP in
2014, which now is only
4,3% of GDP.
Unfortunately, the an-
nounced strike was can-
celled because SANITAS
Federation (the trade union
from the Coalition, made
up mostly from Nurses) de-
cided to sign the Collective
Labor Agreement, which
means they are not al-
lowed to trigger strike. The
Federation of Physicians
”Dr. Ioan Cantacuzino” is
not nationally representa-
tive and cannot trigger the
strike by herself.
But, maybe the most im-
portant gain of this period
is the changing attitude
of the physicians. If, until
now, they were pessimists,
they always used to say:
we can’t win anything, it
is no use going on strike,
the physician’s place is not
in the street, now they are
more united and prepared to fight. That is
the reason for what in present we are trying
to build a powerful physician’s trade union,
in order to have a better represented cause
and to fight for physician’s rights.
Prof. dr. Vasile Astărăstoae
President of Romanian College of Physicians
Communication of Results and Incidental Findings
in Medical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Working for Health Equity: The Role of Health
Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Great East Japan Earthquake . . . . . . . . . . . . . . . . . . . . . . 213
Air Pollution: a New Concern . . . . . . . . . . . . . . . . . . . . . . 220
Defeating Resistant Bacteria with Knowledge . . . . . . . . . . 223
Turkmenistan on the Roud to Democracy . . . . . . . . . . . . . 224
Helping Put Self-care Center Stage with Patients and
Policy-Makers in Combating 21st
Century Killer Diseases . . . 226
IFMSA: Striving Toward an Future that Medical
Students Want . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Rotary and UNICEF Launch a Speaking Book to Prevent
the Spread of Polio on World Polio Day . . . . . . . . . . . . . . 228
News from the CPME: Up-date on policy developments
in the European Union . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Memorandum of Understanding European Forum
of Medical Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
New WMA Cooperating Center . . . . . . . . . . . . . . . . . . . . 232
Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Successful Climate and Health Summit in Warsaw . . . . . . 233
IRCT defines way forward to realise the right to
rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Call to Action from Bellagio Conference on Protection
of Health Workers, Patients and Facilities in Times
of Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
2013 Global Health Forum,Taipei,Taiwan . . . . . . . . . . . . 235
Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
International update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Publications, courses, conferences, calls for papers . . . . . . . 237
Green news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
“A Doctor’s Experience of Injustice in the United Arab
Emirates, a Caveat” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Sri Lanka Medical Association . . . . . . . . . . . . . . . . . . . . . 240
The Physician’s Situation in Romania . . . . . . . . . . . . . . . . . iii