WMJ_2022_03_final-1

ISSN 0049-8122
Official Journal of The World Medical Association, Inc. Nr. 3, November 2022 vol. 68
Contents
Editorial   3
Dual Loyalty/Military Medicine   4
Resolution of the 9th Latvian Congress of Physicians   8
Impact of COVID-19 on HIV Care in Africa   10
HIV Adherence to Antiretroviral Therapy in Latvia: Still a Long Way to Go   15
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022   17
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?   27
Primary Health Care Systems across the Globe: Does One Size Fit All?   36
World Medical Association Officers, Chairpersons and Officials
Dr. Osahon ENABULELE
President
Nigerian Medical Association
8 Benghazi Street,
off Addis Ababa Crescent
Wuse Zone 4, P. O. Box 8829
Wuse, Abuja
Nigeria
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Jung Yul PARK
Chairperson, Finance and
Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40
Cheongpa-ro,
Yongsan-gu
04373 Seoul
Republic of Korea
Dr. Lujain ALQODMANI
President-Elect
Kuwait Medical Association
123 Fifth Avenue,
1202
Kuwait
Dr. Tohru KAKUTA
Vice-Chairperson
of Council
Japan Medical Association
113-8621 Bunkyo-ku, Tokyo
Japan
Dr. Jean-François RAULT
Chairperson,
Socio Medical Affairs Committee
French Medical Council (Conseil
National de l’Ordre des Médecins
(CNOM)) France
4 rue Léon Jost
75855 Paris Cedex 17
France
Dr. Heidi STENSMYREN
Immediate
Past- President
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Ravindra SITARAM
WANKHEDKAR
Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
Dr. Jacques de HALLER
Chairperson, Associate Members
Swiss Medical Association
(Fédération des Médecins Suisses)
Elfenstrasse 18, C.P. 300
3000 Berne 15
Switzerland
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Marit HERMANSEN
Chairperson,
Medical Ethics Committee
Norwegian Medical Association
P.O. Box 1152 sentrum 107
Oslo
Norway
www.wma.net
Official Journal of The World Medical Association
Editor in Chief
Dr. Helena Chapman
Milken Institute School of Public Health, George Washington University, United States
editor-in-chief@wma.net
Assistant Editor
Mg. Health. sc. Maira Sudraba
Latvian Medical Association
lma@arstubiedriba.lv, editor-in-chief@wma.net
Journal design by
Erika Lekavica
dizains.el@gmail.com
Publisher
Latvian Medical Association
Skolas Street 3, Riga, Latvia
ISSN 0049-8122
Opinions expressed in this journal – especially those in authored contributions –
do not necessarily reflect WMA policy or positions
3
Editorial
Editorial
BACK TO CONTENTS
The coronavirus disease 2019 (COVID-19) pandemic and
monkeypox virus outbreaks,which are recognized as public
healthemergenciesofinternationalconcern,havepropelled
global dialogue and actions to strengthen pandemic
preparedness and response efforts, better understand the
human-animal-environment nexus, and critically examine
theeffectsofclimatechangeonpopulationhealthandhealth
systems. Global leaders are attentive and observe ongoing
transmission, with an estimated 630 million COVID-19
cases and 6.5 million deaths worldwide, reported by the
World Health Organization (WHO), and an estimated
78,964 monkeypox cases in 110 countries, reported by
US Centers for Disease Control and Prevention (CDC)
(as of 9 November 2022). Health professionals, who are
already experiencing workplace burnout amidst a global
health workforce shortage, will need to reflect on existing
and emerging global health challenges, leverage expertise
across disciplines, and discuss next steps to ensure global
health security and health system preparedness.
Pivotal global meetings will occur in November 2022 –
including the Group on Earth Observations (GEO)
Week in Ghana and the 27th Conference of the Parties to
the United Nations Framework Convention on Climate
Change(COP27)inEgypt–andthetopicofclimateaction
will be forefront. The recent launch of the One Health
operational definition and the joint plan of action (2022-
2026), supported by the WHO, Food and Agriculture
Organization (FAO), United Nations Environment
Programme (UNEP),and World Organisation for Animal
Health (OIE), offers technical guidance to expand One
Health activities and capacities across six areas.
The 221st World Medical Association (WMA) General
Assembly was held in Berlin, Germany, from 5-8 October
2022. This event highlighted the 75th anniversary of the
German Medical Association (GMA), incorporating
scholarly addresses by key leaders in the GMA as well
as within the local political arena. The official ceremony
was held to recognize Dr. Heidi Stensmyren (WMA
President, 2021-2022) for her leadership efforts as well as
welcome Dr. Osahon Enabulele (WMA President, 2022-
2023) to his new position with support for his future action
plan. Also, WMA members discussed policy statements,
recommended relevant revisions to WMA resolutions,
and connected with colleagues. Of notable achievements,
the revisions to the WMA International Code of Medical
Ethics were adopted, commenting on four elements: 1)
duties to the patient; 2) duties to other physicians, health
professionals, students, and other personnel; 3) duties
to society; and 4) duties as a member of the medical
profession.
In this issue, Dr. Cecil Wilson described the ethical issue
of dual loyalty in military medicine. The Latvian Medical
Association shared information about the Latvian
Congress of Physicians, which was held in September
2022. Dr. Michael Willie and Dr. Sipho Kabane offered
an update on the impact of COVID-19 on human
immunodeficiency virus (HIV) care in Africa. Mr.
Andris Veikenieks presented a historical context of HIV
adherence to antiretroviral therapy in Latvia. Dr. Ramona
Coelho, Dr. Sonu Gaind, Dr. Trudo Lemmens, and Dr.
John Maher reviewed the Canadian experiences and
specific challenges related to the Medical Assistance in
Dying legislation. Dr. Skander Essafi, Dr. Lekha Rathod,
Dr. Mercy Wanjala, Dr. Andrey Cruz, Dr. Dabota Yvonne
Buowari, Dr. Wunna Tun, Dr. Yassen Tcholakov, and Dr.
Flora Wendel provided an overview of primary health
care systems across eight selected countries and reflections
about Clean Air Day for Blue Skies.
We are honored to present this third issue of the World
Medical Journal, which includes high-quality articles to
complement the scientific literature. The collective article
commemorates Clean Air Day for Blue Skies, which
provides a closer look at activities and reflections across 13
countries and raises awareness and advocates for actions to
reduce air pollution. We hope that WMA members will
be inspired by these insightful articles and motivated to
share their articles in future issues. Together, we represent
a medical community of diverse specialties, and with these
differences lie our greatest strengths: global leadership
to advance scientific knowledge and promote health and
well-being.
Helena Chapman, MD, MPH, PhD
Editor in Chief of the World Medical Journal
E-mail: editor-in-chief@wma.net
4
Military medicine is described as
the ethical issue of dual loyalty, and
how it relates to those health care
personnel who are both officers in
the military and are medical officers
such as doctors and nurses. And, it
has great expectations and challenges.
Some years ago, I graduated from
medical school and took the
Hippocratic oath. This oath states
that: “I will apply, for the benefit
for the sick, all measures which are
required, avoiding those twin traps
of over treatment and therapeutic
nihilism.” This phrase embodies
Primum non-nocere – first, do no
harm. My primary loyalty is to the
patient, whether in the office, the
hospital, in combat or in prison.
The next day, I became a member of
the United States Navy as an officer.
And I swore to my country that:
“I, _____, having been appointed
an officer in the Navy of the United
States, as indicated above in the grade
of ____ do solemnly swear (or affirm)
that I will support and defend the
Constitution of the United States
against all enemies, foreign and
domestic; that I will bear true faith
and allegiance to the same; that I
take this obligation freely, without
any mental reservation or purpose
of evasion; and that I will well and
faithfully discharge the duties of the
office upon which I am about to
enter; So help me God.”
My primary loyalty is to my country.
Medical ethics in times of armed
conflicts is identical to medical ethics
in times of peace. According to the
American Medical Association
(AMA)’s Declarations of Professional
Responsibility, “It involves respect for
human life and the dignity of every
individual.Refrain from supporting or
committing crimes against humanity
and condemn any such acts.Treat the
sick and injured with competence and
compassion and without prejudice”
[1].
Notably, I wear two hats − one to my
country as an officer and one to my
patients as their doctor. This clinical
role may bring conflict between
professional duties to a patient and
obligations − expressed or implied,
real or perceived, to the interest of a
third party such as an employer, an
insurer or the state − that can violate
patient’s rights. Dual loyalty, in this
case, is simultaneous for obligations
expressed or implied to a patient and
a third party such as the military.
During my 10 years as a Navy
physician, there was never a time
when conflict arose. When I asked
others in the military service,
their impression was that usually
when there was a conflict, the
problem was eventually resolved.
However, in cases that involved an
unresolved conflict, it could mean
that health care professionals in the
military experienced catastrophic
consequences for his or her life’s work.
The following three examples depict
public (but anonymous) scenarios of
such unfortunate consequences.
Primary Care Physician (Early Career):
A young female primary care
physician deployed in Afghanistan
was directed to perform physicals
on male detainees prior to their
interrogations. Female physicians
performing exams on males of
Islamic faithcan be considered highly
embarrassing. As the physician, she
refused considering it a problem
of her relationship as a doctor to
the patient, and she was threatened
with court martial. The following
day, she subsequently conducted the
physicals, although fearing the risk of
a court martial and serving a two-year
jail term. This doctor had a young
daughter and did not want to be
sentenced to jail and miss time with
her daughter.
Team Physician (Mid Career):
This physician on duty for critical
care transport (flying intensive care
unit) stationed outside the United
States, was directed to transport
four critically ill civilians to another
hospital. This transfer referred
to leaving a front-line battlefield
location to a civilian hospital. The
physician onboarding the plane
determined that the facilities of the
previous hospital were able to provide
better patient care, and he directs the
pilot to return the plane. The pilot
refused as he had different orders,and
there was potentially a court martial.
Navy Nurse (Senior Level):
This nurse refused to force-feed
Guantánamo prisoners and was
threatened with court martial because
he refused to manage tube feedings
of prison hunger strikers. He was
removed from his duties treating
captive patients. He was described
as an 18-year active duty sailor, with
only three years before retiring, and
a one-time submariner who became
a nurse and commissioned officer at
Dual Loyalty/Military Medicine
Dual Loyalty/Military Medicine
Cecil B. Wilson
BACK TO CONTENTS
5
the U.S. Navy’s urging. At one point,
he was threatened with court-martial
for insubordination,but the personnel
board would not agree to have a
court martial, and he was returned to
regular duties. The nurse was going
to be able to go back to work, and
have every reason to believe that he
completed his honorable service in
the U.S. Navy.
These examples describe three service
personnel who volunteered to serve
in their military, who were dedicated
to patient care, and who expected
the service to be rewarding and
honorable with a future. However,
they have experienced abrupt
changes in their careers. First, the
primary care physician will face the
realization the she did not care for
her patients. She will have to decide
whether to continue with a career
in the military or not. Second, the
mid-career physician will be faced
with the positive or negative finding
that he did meet the order of his
commandeering officer. This may
lead to a lack of promotion or
exclusion from the service. Third,
the exonerated nurse will face the
realization that there will be some
individuals in the military that feel
he made the wrong decision. Even
in retirement, there will be a message
of what he did – rightly or wrongly
– rather than caping off a long
honorable career.
During the years following the New
York attacks on 11 September 2001,
and the housing of prisoners at the
Naval Base at Guantanamo, there
have been conflicts about how the
prisoners were treated, including
water boarding and tube feeding for
prisoners who protested by fasting.
Having health personnel (physicians)
being directed to participate in these
practices is contrary to medical ethics.
From 2001 to the present, there
have been multiple communications
from the AMA to the U.S. President
and the Secretary of Defense of the
AMA’s position that health personnel
should not be ordered to participate.
On 29 January 2013, the Acting
Under Secretary of the Department
of Defense (DOD) requested that
the Defense Health Board (DHB)
review the unique challenges faced by
military medical professionals in their
dual-hatted positions as a military
officer and a medical provider (dual
loyalty).Two questions were asked for
evaluation.
• How can military professionals
most appropriately balance their
obligations to their patients
against their obligations as
militaryofficershelpcommanders
maintain military readiness?
• How much latitude should
military medical professionals
be given to refuse participation
in medical procedures or request
excusal from military operations
with which they have ethical
reservations or disagreement?
The DHB is an appointed civilian
group, a Federal Advisory Committee
totheSecretaryoftheDOD,providing
independent recommendations on
matters pertaining to military health
and ethics. The DHB subcommittee
reviewed current civilian and military
health care medical professional
practice policies and guidelines as
well as medical ethics, education,
and training in DOD and civilian
institutions.
Panel discussions were held with
subject matter experts, and DOD
personnel, including active duty,
National Guard, Reserves, retired
military health care medical
professionals and line officers, and
healthcare professionals in civilian
institutions. Among the civilian
organizations, the World Medical
Association (WMA), AMA,
American Nurses Association,
American Psychiatric Association,
and the American Psychological
Association were included. As I
represented the WMA, my remarks
focused on the WMA’s history,
goals, mission, and purpose, where
I moderated extensive discussions
and positions of the WMA policies
related to medical ethics, including:
• WMA International Code of
Medical Ethics [2]
• Statement on the Protection and
Integrity of Medical Personnel
in Armed Conflicts and Other
Situations of Violence [3]
• WMA Statement on Regulations
in Times of Armed Conflict
Declaration of Tokyo [4]
• Guidelines for Physicians
Concerning Torture and other
Cruel, Inhuman or Degrading
Treatment or Punishment in
Relation to Detention and
Imprisonment [5]
Medical Ethics Landscape
• The current medical ethics
landscape, recognized by the
DOD, includes the following
reflection – What is the nature
of potential problems that can be
seen today? – and the following
eight elements:
• Societal and media perceptions of
military medical practice
• Varying influences on ethical
thought and practices dependent
on age, cultural and economic
background, and religious beliefs
of providers, both military and
civilian
• Advances in medical technology
Dual Loyalty/Military Medicine
BACK TO CONTENTS
6
• Determining the roles of patients’
providers in decision-making
• Potential conflicts between
autonomy and beneficence
• Ethical practices in deployed
environment
• Appropriate parameters of patient
and healthcare professionals
• Confidentiality and disclosure of
Personnel Health Information
• Military mission and chain of
command influence and potential
conflict of interest
Based on the two-year evaluation
of medical ethics, the DHB report
entitled, “Ethical Guidelines and
Practices for U.S. Military Medical
Professionals”, highlighted 16
recommendations and was published
on 11 February 2015. This report
led to the formation of a Defense
Medical Ethics Center (DMEC),
established at the Uniformed Services
University (USU). The DMEC
vision is to facilitate a common
cultural ethos throughout the
Medical Health System (MHS), to
serve as a knowledge repository and
consultancy resource for all military
health professionals, and to provide
that:
• Health care personnel will adhere
to principles of medical ethics
• Baseline and periodic updates
will be disseminated in medical
ethics education and training
• Systematic and integrated DOD
Medical Ethics Program will be
formed
• Consultations will be provided by
fully trained experts in medical
ethics
• Medical ethics leadership,
composed of senior medical ethics
in military ethics, will promote
ethics conduct and culture across
the MHS and DOD
• Health care personnel must
protect their patient’s privacy
MHS leaders must:
a. Unless it could have
an adverse impact on military
readiness, unit cohesion, and good
order and discipline, the Armed
Forces will accommodate individual
expressions of belief of a member
of the armed forces, reflecting
the sincerely held conscience or
moral principles of the member.
b. In so far as practicable, the
Armed Forces may not use such
expression of belief as the basis
of any adverse personnel action,
discrimination,ordenialofpromotion,
schooling, training or assignment.
c. This paragraph is applicable
to individual expressions of belief
of a health care professional,
reflecting the sincerely held
conscience or moral principles of the
individual that are grounded in an
applicable professional ethics code.
d. No element precludes
disciplinary or administrative action
for conduct that is proscribed by the
Uniform Code of Military Justice,
including actions and speech that
threatens good order and discipline.
The principles of medical ethics,
promoted by the DHB, have
now been established, and the
MHS embraces the principles of
professional ethics of America’s health
care professions whose members
are represented in the military. The
ethical code developed by health care
professional organizations recognize
the responsibility to patients first
and foremost and to society. The
MHS views the responsibilities of
health care personnel and military
professionals as mutually reinforcing,
and will
• Provide competent health care
with compassion and respect for
human dignity and rights. All
individualsaretreatedwithrespect
and tolerance. Discrimination on
the basis of age,sexual orientation,
gender, race, ethnicity, language,
disease, disability, religion, or
rank is forbidden because it is
inconsistent with the ideals and
principles of the MHS.
• Uphold the standards of
professionalism. Members must
be honest in all professional
interactions, support open and
honest communication among
members of the health care
team, and promote the utmost
professionalism of all health care
colleagues.
• Advocate for the best possible
health interests of patients while
respecting the law and lawful
military authority.
• Respect the rights of patients,
colleagues, and other health care
personnel, and safeguard patient
confidences and privacy within
the constraints of the law.
• Complete appropriate education
and training, as necessary, and
provide competent and ethical
health care.
• Support patient-centered
decision-making, engaging
patients, surrogate decision-
makers, and members of
the health care team in
decisions, as appropriate.
BACK TO CONTENTS
Dual Loyalty/Military Medicine
7
• Use the expertise of the health
professions to minimize the
incidence and severity of injuries
and illnesses.
• Consider the context of local
culture, custom, capabilities,
and sustainment in overseas
humanitarian and disaster relief
activities and use available
resources to achieve the greatest
good for the greatest number.
• Uphold responsibilities under
the law in caring for enemy
combatants. Responsibilities
include,but are not limited to: not
participating in or acquiescing
to torture or cruel, inhumane
or degrading treatment or
punishment in the battlefield or
detention settings. It is important
toreporttoappropriateauthorities
all suspected violations of these
obligations.
• Regard responsibility to the
patient as a primary responsibility,
but recognize that there may
be extraordinary circumstances
associated with the mission
or military necessity that may
require additional considerations
and ethical consideration.
This multi-year process started
with the 9/11 attacks, involved the
housing of prisoners at the Naval
Base in Guantanamo, presented the
evolution of the issue of dual loyalty
for the uniformed US forces, and
finally lead to the present times.
Multiple dedicated individuals
and organizations were involved,
including DHB, AMA, and WMA
leadership.
Dual loyalty brings great opportunities
and challenges to which medical
ethics is the common denominator.
References
1. American Medical Association.
AMA Declaration of Professional
Responsibility [Internet]. 2001
[cited 2022 Aug 16]. Available
from: https://www.ama-assn.org/
delivering-care/public-health/
ama-declaration-professional-re-
sponsibility
2. World Medical Association.
WMA International Code of
Medical Ethics. 1949 [revised
2006 Oct 1; cited 2022 Aug 16].
Available from: https://www.
wma.net/policies-post/wma-in-
ternational-code-of-medi-
cal-ethics/
3. World Medical Association.
Statement on the Protection
and Integrity of Medical
Personnel in Armed Conflicts
and Other Situations of Violence.
2011 [cited 2022 Aug 16].
Available from: https://
www.wma.net/policies-post/
wma-statement-on-the-pro-
tection-and-integrity-of-med-
ical-personnel-in-armed-con-
flicts-and-other-situations-of-vi-
olence/
4. World Medical Association.
WMA Regulations in Times
of Armed Conflict and Other
Situations of Violence. 1956
[revised 2012 Oct 1; cited 2022
Aug 16]. Available from: https://
www.wma.net/policies-post/
wma-regulations-in-times-of-
armed-conflict-and-other-situa-
tions-of-violence/
5. World Medical Association.
Guidelines for Physicians
Concerning Torture and other
Cruel, Inhuman or Degrading
Treatment or Punishment in
Relation to Detention and
Imprisonment. 1975 [revised
2016 Oct; cited 2022 Aug 16].
Available from: https://
www.wma.net/policies-post/
w m a – d e c l a r a t i o n – o f- t o –
k y o – g u i d e l i n e s -f o r-p h y –
s i c i a n s – c o n c e r n i n g – t o r-
ture-and-other-cruel-inhu-
m a n- or- d e g r a d i n g-t r e at-
ment-or-punishment-in-rela-
tion-to-detention-and-imprison-
ment/
Cecil B. Wilson, MD, MACP
Former WMA President
Former President,
American Medical Association
E-mail: cecilbwilson@earthlink.net
BACK TO CONTENTS
Dual Loyalty/Military Medicine
8
The Latvian Congress of Physicians,
which is recognized as the largest
medical forum in Latvia, offers
physicians from Latvia and other
countries to connect every four years
and discuss emerging health priorities
across Latvia and the world.
Reflecting on history, the first three
Latvian Congresses of Physicians
were held during the first half of the
20th century, between World War
I and II. In efforts to support these
global events, three orthopaedic
surgeons – Dr. Bertram Zarins
(Boston University), Dr. Kristaps
Keggi (Yale University), and Dr.
Viktors Kalnberzs (Riga Institute of
Medicine) organized the First World
Congress of Latvian Physicians in
Riga in 1989, which became one of
the most significant events in Latvia’s
history. This event paved the way for
health care reform and democratic
movements within the country.
Supported by the Latvian Medical
Association, the subsequent
coordination of Latvian Congresses
of Physicians provided an overview
of medicine in Latvia and globally
as well as highlighted key events
and milestones within the country’s
health system. At the 9th Latvian
Congress of Physicians, participants
contributed to the four-day agenda,
where they strengthened cooperation
among colleagues to achieve common
goals and launched joint projects in
various fields of medicine. Notably,
they participated in scientific debates
and discussions, which led to the
approval of resolutions during the
plenary sessions.
Due to the coronavirus disease 2019
(COVID-19) pandemic, the 9th
Latvian Congress of Physicians was
postponed in 2021 and rescheduled
from 21-24 September 2022 in
Riga, Latvia. With more than
2,300 participants participating
in-person and remotely, this event
commemorated the 200th anniversary
of the Riga Physicians Society, which
was established on 15 September
1822.
This meeting focused on the
importance of modern health care
in the development of the country’s
national economy and the public
welfare (Photo 1-3). Since well-
organized, timely, and effective health
care increases the capacity of the
health workforce, it is an important
guarantor of national security and
sustainability.
Resolution of the 9th Latvian
Congress of Physicians
Qualitative and Accessible Health Care
– The Guarantor of the Existence of the
Latvian State and Society
Modern, value-based and patient-
centered health care cannot be
provided without sufficient funding.
Health care organization and
sector reforms must be planned and
evaluated comprehensively before
they are approved and implemented
in practice. The introduction of a
new remuneration model for medical
personnel is one solution to the health
workforce shortage and will enable
the successful future implementation
of patient-centered health care that
focuses on maternal and child health.
Since novel discoveries and
advancements in medical science
can strengthen clinical management,
increase the quality of health care
services, and improve clinical
competences, increased state support
will be essential to expand research
in the biomedical and public health
disciplines. Continued support for
the involvement of Latvian specialists
in international collaborations can
broaden their clinical competences as
well as help recognize the contribution
of Latvian medical leaders on the
global platform.
Resolution of the 9th Latvian Congress of Physicians
Resolution of the 9th Latvian Congress of Physicians
Ilze Aizsilniece
BACK TO CONTENTS
Photo 1. Ceremony performed prior to the opening
session of the 9th Latvian Congress of Physicians.
Credit: Latvian Medical Association
9
The medical treatment process
incorporates close interactions
between patients and diverse clinical
specialties, including physicians,
physician assistants, nurses, midwives,
physiotherapists, pharmacists,
and other allied health care
professionals. This process is based
on fostering collaboration and mutual
understanding, displaying respectful
and empathetic attitudes towards
each other, and strictly observing
ethical principles in practice.
Since such interactions cannot be
implemented without knowledgeable
and responsible patients, restoring
health education in school programs
and improving health literacy in
Latvian society will help increase
patient satisfaction and participation
in the treatment process.
Since rehabilitation is an integral part
of result-oriented, patient-centered
health care, it is important to ensure
the availability of rehabilitation
services at all stages of medical
treatment. Rehabilitation may be
included as a mandatory component
in health care, as it is currently
prioritized in psychiatry and oncology
services.
Effective primary and secondary
disease prevention is essential for
ensuring public health. In Latvia,
a sports medicine strategy must be
developed to ensure that sufficient
human resources and high-quality
health care services are available for
all citizens, including athletes. In
order to emphasize the importance
of the prevention of cardiovascular,
oncologic, and other diseases, sports
medicine physicians should be
included on the specialist list for
family medicine referrals.
The high professionalism and
evaluation of Latvian doctors has
been a collegial and independent
process since the restoration of
Latvia’s independence in 1991. The
existing system of certification and re-
certification is a democratic process,
ensured by professional medical
associations and with the support
of the Latvian Medical Association.
We concur that professional
medical associations are recognized
with the authorization to validate
continuing education, certification,
and re-certification measures, which
should not be replaced by an official
procedure.
Associate degrees and postgraduate
education of physicians must be
planned,according to the needs of the
health system. University graduates
and young physicians should have the
opportunity to pursue postgraduate
training in Latvia, which can reduce
their emigration from Latvia to other
countries for advanced training and
employment opportunities.
It is a timely moment to implement
qualitative and functional digital
solutions in health care service
delivery. Health data analyses offer
a foundation for decision-making
and evidence for the creation and
implementation of new strategies that
support health system reform.
Prepared and adopted by delegates
of the 9th Latvian Congress of
Physicians on 24 September 2022, in
Riga, Latvia.
Ilze Aizsilniece, MD
President, Latvian Medical Association
E-mail: lma@arstubiedriba.lv
Resolution of the 9th Latvian Congress of Physicians
Photo 3. Dr. Bertram Zarins, from Boston University, described key highlights about the f irst Latvian
Congress of Physicians, which was held in 1989. Credit: Latvian Medical Association
Photo 2. Dr. Maris Plavins, Vicepresident of the Latvian Medical Association, presented an overview of
the past 200 years in medicine in Latvia. Credit: Latvian Medical Association
BACK TO CONTENTS
10
Impact of COVID-19 on HIV Care in Africa
BACK TO CONTENTS
The human immunodeficiency virus
(HIV), the virus that can cause the
acquiredimmunodeficiencysyndrome
(AIDS), continues to be one of the
world’s most serious diseases [1]. In
1981, AIDS was first identified in
the United States [1,2]. By the end of
2021, 38.4 million people were living
with HIV on a global scale [3,4].
The World Health Organization
(WHO)’s African Region continues
to be the most severely affected, with
nearly one HIV infection in every
25 adults (3.4%), or more than two-
thirds of the world’s HIV-positive
population [3].
The Joint United Nations Programme
on HIV/AIDS (UNAIDS) initiated
the 90–90–90 objectives in 2014,
which seeks for 90% of HIV-infected
people to be diagnosed by 2020, 90%
to be on antiretroviral medication
(ART), and 90% to achieve sustained
virologic suppression [5,6]. However,
most nations trailed behind these
global targets, marking this 2020
deadline as unrealistic [5-7]. The
UNAIDS targets for 2025, which
were amended in December 2020,
called for 95% of individuals living
with HIV to know their status, 95%
of those who know their status to be
on ART,and 95% of those on ART to
have viral suppression [8,9].The HIV
targets (cascade) has increasingly
been used to direct and assess
programs to improve ART coverage
within the population, a vital element
of treatment prevention strategy [10].
HIV care was adversely impacted
as the coronavirus disease 2019
(COVID-19) threatened progress
toward achieving the HIV care
cascade [11].These goals are related to
reducing new HIV infections among
people who are already infected.
For this reason, it is necessary to
investigate the direct and indirect
effects of the pandemic on health care
resources, access to HIV services, and
the availability of support structures
to evaluate the impact of COVID-19
on HIV care [11,12].
Impact of COVID-19 on HIV
Prevention Measures
During the pandemic, health care
practitioners were compelled to focus
primarily on COVID-19 patients,
overlooking in many instances
equally significant acute and chronic
disorders [13]. One of the most
noteworthy challenges, especially for
low-resource communities and health
systems, was a disruption in access
to routine HIV-centered healthcare
[13-15]. Consequently, HIV
screening and diagnosis efforts may
have been considerably compromised,
and there were missed opportunities
to treat opportunistic infections and
slow HIV progression to AIDS [16].
These changes in the provision of
health services led to downstream
effects on health prevention and
promotion measures for global HIV
care. According to the US Centers for
Disease Control and Prevention, the
number of HIV diagnoses fell by 17%
in 2020, when compared to reports
in the United States from 2019
[17]. Also, the number of HIV tests
performed by commercial laboratories
dropped by more than 50 percent
by the end of April 2020 in Jiangsu,
China [18].
Similar phenomena on prevention
measures were also observed in
some African countries during the
COVID-19 pandemic. In South
Africa,there was a drastic reduction in
voluntary medical male circumcisions
(MMC), from 600,000 in 2019-
2020 to 130,000 in 2020-2021 [19].
Also, one national study across 65
primary health care clinics found that
HIV testing and ART services were
severely impacted [20].Another study
that included 2,471 public sector
facilities reported that ART services
decreased sharply in all provinces in
2020, when compared to 2019, with
a slight recovery between COVID-19
waves in October 2020 [21]. Similar
observations were noted in countries
such as Ghana, where there was also
a decline in service uptake, including
HIV testing, missed appointments,
and defaulting [22].
Teenage Pregnancy, Male
Condoms, and COVID-19 in
South Africa
It is estimated that young women
between ages 15 and 24 become
infected with HIV around five to
seven years earlier than their male
Impact of COVID-19 on HIV Care in Africa
Michael Mncedisi Willie
Sipho Kabane
11
Impact of COVID-19 on HIV Care in Africa
counterparts, and approximately
one in every four new infections
occurs in young women of this age
range [23]. During the COVID-19
pandemic, South Africa, like many
African nations, observed a surge
in teenage birth rates [24,25]. Just
over one-third (33.8%) of all births
registered in 2020 were linked to
adolescent girls under age 18, making
this demographic the single largest
contribution to the country’s overall
birth rate and increasing their risk of
HIV infection. The South African
Medical Research Council (SAMRC)
reported that 31% of South African
girls aged 15-19 did not have
access to contraception, and 21% of
respondents reported having trouble
accessing condoms, as a direct result
of the COVID-19 lockdown [25].
Reflecting this challenge,the UNAID
report highlighted a significant
decline in male condom access for
many South Africans between 2019
and 2020 [26,27]. Figure 1 depicts a
significant 17% decline in the number
of male condoms distributed between
2019 and 2020 [19].
Effect of COVID-19 on UNAIDS
Targets
A few studies illustrate the effect
of COVID-19 on the UNAIDS
90–90–90 targets. For example,
researchers compared the 90–90–90
targetsin2020,duringtheCOVID-19
pandemic, with the targets spanning
the period 2017-2019 in people
with HIV and found a considerable
loss in 2020, when compared with
2017-2019, due to the COVID-19
pandemic [28]. South Africa
is transitioning to the 95–95–
95 targets set by the National
Strategic Plan (NSP) for HIV,
tuberculosis (TB), and sexually
transmitted infections (STIs) [29].
Looking ahead to 2023-2028, South
Africa is well below the targets,
when compared to neighbouring
countries such as Lesotho and
Botswana [29,30]. According to
the WHO, just nine countries –
Botswana, Cabo Verde, Kenya,
Lesotho, Malawi, Nigeria, Rwanda,
Uganda, and Zimbabwe – are on
pace to meet the 95–95–95 targets
by 2025 [30]. Figure 2 illustrates that
the Kingdom of Eswatini met and
exceeded the 95–95–95 targets by
September 2022 [31].
COVID-19 and HIV Vaccines
In nearly four decades of
research, scientists have not
been able to develop an effective
vaccine against HIV. Table
1 illustrates vaccine innovations for
11 diseases [33].Since the late 1980s,
several potential vaccines against
HIV have been produced, but none
of them have demonstrated effective
prevention [34,35]. Particularly, one
Thai study reported a 31% lower
HIV infection rate in vaccinated
individuals than the placebo group,
representing the only HIV vaccine
experiment that has shown promising
findings [35]. Since vaccine licensure
requires an efficacy of at least 50%,
exploring virus complexity will
remain a challenge [34].
Figure 1. Number of male condoms distributed in South Africa from 2017-2020 (millions), adopted
from SANAC [19].
Figure 2. The current status of selected African countries to achieve the HIV 95–95–95 cascade levels
by 2025 [31,32].
BACK TO CONTENTS
12
Impact of COVID-19 on HIV Care in Africa
“In comparison to SARS-COV-2,
the HIV virus is complex, and
there’s proof to be a formidable
foe,” commented Dr. Linda-Gail
Bekker, CEO of the Desmond Tutu
Foundation and former president of
the International AIDS Society [34].
Conclusion
The COVID-19 pandemic prompted
health leaders to comprehensively
examine the evidence-based
literature about disinfection virology
and immunology as well as the
development of targeted medicine
and vaccinations. However, although
some African countries prospered
during the pandemic, HIV care
generally deteriorated across the
globe. Disruptions in health care
services rendered specific prophylactic
measures ineffective,such as voluntary
MMC. Most countries have a long
way to go before reaching the HIV
cascade targets of 95-95-95 by 2025.
Botswana and Eswatini are two
African countries that are notably
leading the way in achieving these
objectives. By examining Botswana’s
and Eswatini’s experiences, other
countries can acquire invaluable
insight.
References
1. Centers for Disease Control.
Pneumocystis pneumonia—Los
Angeles. MMWR Morb Mortal
Wkly Rep. 1981;30(21):250-2.
2. Sharp PM, Hahn BH. Origins
of HIV and the AIDS pandemic.
Cold Spring Harbor Perspectives
in Medicine. 2011;1(1):a006841.
3. World Health Organization.
Global health observatory: HIV
[Internet]. 2022 [cited 2022 Oct
17].Available from: https://www.
who.int/data/gho/data/themes/
hiv-aids
4. United Nations International
Children’s Emergency Fund.
Although strides have been made
in the HIV response, children
are still affected by the epidemic
[Internet]. 2022 [cited 2022
Oct 17]. Available from: https://
data.unicef.org/topic/hivaids/
global-regional-trends/
5. Joint United Nations Programme
on HIV/AIDS. 90-90-90
treatment target [Internet]. 2022
[cited 2022 Oct 17]. Available
from: https://www.unaids.org/
en/90-90-90
6. Gisslén M, Svedhem V, Lindborg
L, et al. Sweden, the first country
to achieve the Joint United
Nations Programme on HIV/
AIDS (UNAIDS)/World Health
Organization (WHO) 90-90-90
continuum of HIV care targets.
HIV Med. 2017;18(4):305-7.
7. Joint United Nations Programme
on HIV/AIDS. HIV prevention
2025. Getting on track to end
AIDS as a public health threat
by 2030 [Internet]. 2020 [cited
2022 Oct 17]. Available from:
https://www.unaids.org/sites/de-
fault/files/media_asset/preven-
tion-2025-roadmap_en.pdf
8. Samuel K. Getting to 95-95-
95: global use of HIV generics
would result in large reductions
in spending, new infections and
deaths [Internet]. 2021 [cited
2022 Oct 17]. Available from:
https://www.aidsmap.com/news/
jul-2021/getting-95-95-95-glob-
al-use-hiv-generics-would-re-
sult-large-reductions-spending-
new
9. Frescura L, Godfrey-Faussett P,
Feizzadeh AA, El-Sadr W, Syarif
O, Ghys PD, et al. Achieving
the 95-95-95 targets for all: a
pathway to ending AIDS. PLoS
One. 2022;17(8):e0272405.
10. Lebelonyane R, Bachanas P,
Block L, Ussery F, Alwano MG,
Marukutira T, et al. To achieve
95-95-95 targets we must reach
men and youth: high level of
knowledge of HIV status, ART
coverage, and viral suppression
in the Botswana Combination
Prevention Project through
universal test and treat approach.
PloS One. 2021;16(8):e0255227.
Disease
Year of
disease discovery
Year of vaccine
approval (USA)
Malaria 1880 N/A
Tuberculosis 1882 N/A
Meningitis 1889 1981
Polio 1906 1955
Chickenpox 1953 1995
Measles 1953 1963
Hepatitis 1965 1981
Ebola 1976 2019
AIDS 1983 N/A
Coronavirus disease 2019 2020 2020
Table 1. Vaccine innovations on selected diseases from 1880-2022. Source: Vanderslott, Dadonaite,
Spooner, and Roser (2013) [33].
BACK TO CONTENTS
13
11. van Staden Q, Laurenzi CA,
Toska E. Two years after lock-
down: reviewing the effects of
COVID-19 on health services
and support for adolescents living
with HIV in South Africa. J Int
AIDS Soc. 2022;25(4):e25904.
12. Jardim CGR, Zamani R,
Akrami M. Evaluating the
impact of the COVID-19
pandemic on accessing HIV
services in South Africa: a
systematic review. Int J
Environ Res Public Health.
2022;19:11899.
13. Mazzitelli M, Ciccullo A,
Baldin G, Cauda R, Rusconi
S, Giacomelli A, et al. Has
COVID-19 changed the
approach to HIV diagnosis?: a
multicentric Italian experience.
Medicine (Baltimore). 2021;
100(41):e27418.
14. Hung C-C, Banerjee S,
Gilada I, Green K, Inoue Y,
Kamarulzaman A, et al. Impact
of COVID-19 on the HIV
care continuum in Asia:
insights from people living with
HIV, key populations, and HIV
healthcare providers. PLoS One.
2022;17(7):e0270831.
15. Yang X, Zeng C, Tam CC, Qiao
S, Li X, Shen Z, Zhou Y. HIV
service interruptions during
the COVID-19 pandemic in
China: the role of COVID-19
challenges and institutional
Response from healthcare
professional’s perspective. AIDS
Behav. 2022;26(4):1270-8.
16. DiNenno EA, Delaney KP, Pitasi
MA, MacGowan R, Miles G,
Dailey A, et al. HIV testing before
and during the COVID-19
pandemic — United States, 2019–
2020. MMWR Morb Mortal
Wkly Rep.2022;71(25):820-4.
17. Kuehn BM. Reduced HIV
testing and diagnoses during
COVID-19 pandemic. JAMA.
2022;328(6):519.
18. Shi L, Tang W, Hu H, Qui
T, Marley G, Liu X, et al. The
impact of COVID-19 pandemic
on HIV care continuum in
Jiangsu, China. BMC Infect Dis.
2021;21(1):768.
19. South African National AIDS
Council. 2020 Global Aids
Monitoring Report [Internet].
2020 [cited 2022 Oct 5].
Available from: https://sanac.org.
za/wp-content/uploads/2022/07/
South-Africa-2020-GAM-Re-
port.pdf
20. Dorward J, Khubone T, Gate
K, Ngobese H, Sookrajh Y,
Mkhize S,et al. The impact of the
COVID-19 lockdown on HIV
care in 65 South African primary
care clinics: an interrupted
time series analysis. Lancet HIV.
2021;8(3):e158-65.
21. Benade M, Long L, Rosen S,
Meyer-Rath G, Tucker J-M,
Miot J. Reduction in initiations
of HIV treatment in South
Africa during the COVID
pandemic. BMC Health Serv
Res. 2022;22(1);428.
22. Abraham SA, Berchie GO,
Doe PF, Agyare E, Addo SA,
Obiri-Yeboah D. Effects of
COVID-19 pandemic on ART
service delivery: perspectives of
healthcare workers in a teaching
hospital in Ghana. BMC Health
Serv Res. 2021;21(1):1295.
23. Abdool Karim Q, Baxter C.
COVID-19: impact on the HIV
and tuberculosis response, service
delivery, and research in South
Africa. Curr HIV/AIDS Rep.
2022;19:46-53.
24. Willie MM. Teenage pregnancy
during a pandemic. International
Journal of Women’s Health Care.
2021;6(3):218-9.
25. Jones K; South African Medical
Research Council (SAMRC).
Teenage pregnancy during
COVID-19 in South Africa:
a double pandemic [Internet].
2022 [cited 2022 Oct 5].
Available from: https://www.
s a m r c . a c . z a /n e w s / t e e n –
age-pregnancy-during-cov-
id-19-south-africa-double-pan-
demic
26. Bolarinwa OA.Factors associated
with limited access to condoms
and sources of condoms during
the COVID-19 pandemic in
South Africa. 2021;79:186.
27. Pilane P. Condom crisis hits safe
sex during Covid-19 [Internet].
The Mail & Guardian. 2021
[cited 2022 Oct 5].
Available from: https://mg.co.
za/health/2021-03-19-condom-
crisis-hits-safe-sex-during-cov-
id-19/
28. Guaraldi G, Borghi V, Milic J,
Carli F, Cuomo G, Menozzi
M, et al. The impact of
COVID-19 on UNAIDS 90-90-
90 targets: calls for new HIV care
models. Open Forum Infect Dis.
2021;8(7):ofab283.
29. South African Government.
Minister Joe Phaahla: SA
satellite on 90-90-90 progress
and recovery from Covid-19
[Internet]. 2022 [cited 2022 Oct
5]. Available from: https://www.
gov.za/speeches/health-minis-
ter’s-speaker-notes-sa-satellite-
90-90-90-progress-and-recov-
ery-covid-19-29-jul
30. World Health Organization.
Africa cuts HIV infections,
BACK TO CONTENTS
Impact of COVID-19 on HIV Care in Africa
14
deaths but key targets still elusive
[Internet]. 2021 [cited 2022 Oct
5]. Available from: https://www.
afro.who.int/pt/node/15580
31. U.S. Department of State.
Eswatini surpasses UNAIDS
fast-track targets for treatment
and viral suppression [Internet].
2022 [cited 2022 Oct 5].
Available from: https://www.
state.gov/eswatini-surpasses-un-
aids-fast-track-targets-for-treat-
ment-and-viral-suppression/
32. Joint United Nations
Programme on HIV/AIDS. Fact
sheet 2022. [Internet]. 2022
[cited 2022 Oct 16]. Available
from: https://www.unaids.org/
sites/default/files/media_asset/
UNAIDS_FactSheet_en.pdf
33. Vanderslott S, Dadonaite B,
Spooner F, Roser M. Our World
in Data: Vaccination [Internet].
2015 [cited 2022 Oct 5].
Available from: https://our-
worldindata.org/vaccination
34. Dutton J.Can mRNA technology
help scientists produce a viable
HIV vaccine? [Internet].
2022 [cited 2022 Oct 16].
Available from: https://www.
de v e x .c om /ne w s /c a n-m r-
na-technolog y-help-scien-
tists-produce-a-viable-hiv-vac-
cine-104020
35. Vaccari M, Poonam P, Franchini
G. Phase III HIV vaccine
trial in Thailand: a step toward a
protective vaccine for
HIV. Expert Rev Vaccines.
2010;9(9):997-1005.
Michael Mncedisi Willie,
MBA, MSc
General Manager,
Policy Research and Monitoring,
Council for Medical Schemes
Pretoria, South Africa
Email:
m.willie@medicalschemes.co.za
Sipho Kabane, MBCHB, MBA,
M. Phil (Economic Policy), PhD
Council for Medical Schemes
Pretoria, South Africa
BACK TO CONTENTS
Impact of COVID-19 on HIV Care in Africa
15
Antiretroviral therapy (ART), which
was discovered in 1996, effectively
reduces the mortality of human
immunodeficiency virus (HIV)
positive patients by stabilizing the
HIV viral load to an undetectable
level (e.g. not a source of further HIV
transmission). Adherence, which is
fundamental for clinical management,
depends on patients’understanding of
and conscious participation in their
disease management. As a chronic
disease,effective ART requires regular
supervision by health professionals as
well as community support to reduce
HIV/acquired immunodeficiency
syndrome (AIDS) stigma and
discrimination.
As a global society, we must reflect on
some key questions: How do people
living with HIV access ART services?
How responsible are their actions
towards their own health and society?
What barriers prevent them from
achieving undetectable levels of HIV
viral load, especially with gratuitous
health care services and treatment?
HIV in Latvia
HIV/AIDS cases have been reported
in Latvia since 1987, initially in men
having sex with men [1]. As a result,
mandatory nationwide HIV/AIDS
screenings were conducted with high-
risk population groups, including
health professionals, blood donors,
and prisoners [1]. The first reported
case of heterosexual transmission
was discovered in one female patient
in 1990. Although mandatory
screenings were eliminated in
1993, epidemiological surveillance
programs were strengthened in
collaboration with the World Health
Organization and European Center
for the Epidemiological Monitoring
of AIDS [1]. Until 1997, HIV
transmission rates were low and
occurred predominantly through
sexual contact. However, in 1997,
HIV infections were reported among
injection drug users (IDUs) and
spread very rapidly through shared
syringes [1].
In 2001, Latvia reported the highest
peak of HIV transmission in one
year – 807 new HIV cases. Since
then, HIV incidence has decreased
each year. On 1 January 2022, health
leaders reported that 5,983 Latvians
were living with HIV, and 2,450
deaths [2]. In 2020, the three highest
HIV transmission rates (per 100,000
people) in the European Union and
European Economic Area were
reported in Malta (15.9), Latvia
(13.5), and Cyprus (11.8) [3].
Since 2010,the Latvian health system
has provided free consultations with
infectious disease specialists and has
reimbursed ART fees to patients
throughout their HIV diagnosis and
treatment. Over the past decade, the
national health system increased ART
coverage to Latvian citizens living
with HIV albeit financial barriers.
During the Latvian financial crisis
from 2008-2010, Latvia modified
the treatment algorithm for HIV-
positive patients,where ART care was
initiated with less than 200 CD4+ T
cells per mm3
of blood [4]. Then, in
2015,ART care was revised to start at
350 CD4+ T cells per mm3
of blood,
and subsequently at 500 CD4+ T cells
per mm3
of blood. More recently, in
2018, these specific criteria of CD4+
T cells were eliminated, and all HIV-
positive patients were eligible for
ART care [5].
Threeelements–diagnosis,treatment,
and adherence – are important to limit
HIV infection across communities.
Although significant strides have
been accomplished in Latvia, the
large number of HIV cases who are
not receiving ART care remains a
concern. Hence, adherence to ART
therapy was crucial for positive health
outcomes. By fostering an open and
trusting partnership with health
professionals,HIV patients could seek
comprehensive examinations, receive
general lifestyle and nutritional
recommendations,and be empowered
to take ART medications.
Next Steps
Moving forward, increased attention
to ART adherence will be crucial to
meet national goals of the Latvian
MinistryofHealthaswellasthetargets
and indicators of the 2030 Agenda for
Sustainable Development. Although
several obstacles to treatment exist,
one primary concern is existing HIV/
AIDS-related stigma, discrimination,
and myths within communities [6].
This stigma can drive denial about
HIV infection, which ultimately
hinders early diagnosis, creates
disbelief about ART benefits, and
affects the complex management of
HIV/AIDS. One primary question
remains: what actions are needed to
encourage HIV-positive persons to
adhere to ART care in Latvia?
HIV Adherence to Antiretroviral Therapy in Latvia: Still a Long Way to Go
Andris Veikenieks
HIV Adherence to Antiretroviral Therapy in Latvia:
Still a Long Way to Go
BACK TO CONTENTS
16
First, it is essential to develop health
courses in primary and secondary
school programs across Latvia to
improve health literacy on HIV/
AIDS awareness. These efforts,
coupled with community health
education campaigns, can strengthen
the dissemination of public health
advisories. Second, in order to fill
the acute shortage of infectious
disease physicians and other health
professionals across national health
institutions, health leaders can
develop initiatives that encourage
health professional students to pursue
advanced training in internal medicine
and infectious disease in Latvia.
Third, since some patients live more
than 100 kilometers away from health
centers, the Latvian health system can
expand primary care clinics to reach
these marginalized communities.
Finally, future collaborations with
social services, state, and non-
governmental organizations can
increase awareness and provide
support for the implementation of
ART adherence among the HIV-
positive community.Non-government
organizations play a valuable role in
society, where they can help identify
knowledge gaps and community needs
and connect HIV/AIDS patients and
families with outreach resources [4].
Specifically, HIV/AIDS treatment
programs that incorporate support
groups can have a positive impact on
adherence, quality of life, and health
outcomes [7].
World AIDS Day,which was founded
in 1988,is commemorated annually on
1 December. This 1 December 2022,
the Joint United Nations Programme
on HIV/AIDS (UNAIDS) promotes
a call to action – “Equalize” theme –
to identify and minimize inequalities
that hinder access and availability of
essential HIV/AIDS services [8].
To support World AIDS Day
initiatives, UNAIDS Executive
Director Ms. Winnie Byanyima said,
“We can end AIDS – if we end the
inequalities which perpetuate it. This
World AIDS Day we need everyone
to get involved in sharing the message
that we will all benefit when we tackle
inequalities. To keep everyone safe, to
protect everyone’s health, we need to
Equalize” [6].
References
1. Ferdats A. HIV/AIDS in Latvia.
In: Twigg JL, editor. HIV/AIDS
in Russia and Eurasia, Volume II.
New York: Palgrave Macmillan;
2007.
2. Centers for Disease Prevention
and Control (Latvia). [HIV/
AIDS statistics]. 2022 [cited
2022 Aug 2]. Latvian. Available
from: https://www.spkc.gov.lv/lv/
hivaids-statistika
3. European Centre for Disease
Prevention and Control. HIV/
AIDS surveillance in Europe
2021 (2020 data). 2021 [cited
2022 Aug 2]. Available from:
https://www.ecdc.europa.eu/
en/publications-data/hiv-aids-
surveillance-europe-2021-2020-
data
4. World Health Organization;
United Nations Office on Drugs
and Crime. Mid-term evaluation
of the Latvian National HIV
Programme: 2009-2013
[Internet]. 2011 [cited 2022
Nov 5]. Available from: https://
www.vm.gov.lv/lv/media/2389/
download
5. Latvian Television. HIV
treatment restrictions to be
lifted. 2018 [cited 2022 Aug
2]. Available from: https://eng.
lsm.lv/article/society/health/
hiv-treatment-restrictions-to-be-
lifted.a292749/
6. KontomanolisEN,Michalopoulos
S, Gkasdaris G, Fasoulakis Z.
The social stigma of HIV-AIDS:
society’s role.HIV AIDS (Auckl).
2017;9:111-8.
7. Bateganya MH, Amanyeiwe U,
Roxo U, Dong M. Impact of
support groups for people living
with HIV on clinical outcomes: a
systematic review of the literature.
J Acquir Immune Defic Syndr.
2015;68 Suppl 3(0 3):S368-74.
8. Joint United Nations Programme
on HIV/AIDS. World AIDS
Day 2022. 2022 [cited 2022
Oct 18]. Available from:
ht t p s : // w w w.u n a i d s . o r g /
en/2022-world-aids-day
Andris Veikenieks
Chairman, AGIHAS (Support Group
for People Living with HIV/AIDS)
Riga, Latvia
E-mail: agihas.lv@inbox.lv

AGIHAS – SUPPORT GROUP for PEOPLE LIVING WITH HIV/AIDS

BACK TO CONTENTS
HIV Adherence to Antiretroviral Therapy in Latvia: Still a Long Way to Go
17
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
BACK TO CONTENTS
The International Day of Clean
Air for Blue Skies (https://www.
cleanairblueskies.org/) is recognized
each year on September 7, and
nations increase awareness of the
annual theme through community
events, media releases, and social
media campaigns. The 2022 theme,
“The Air We Share”, provides
an opportune moment for global
citizens to learn about the current
state of our atmosphere, understand
the anthropogenic influences (e.g.
emissions from fossil fuel combustion)
on the Earth’s systems, and recognize
the intricate links between air
pollution, health, and climate [1,2].
Exposure to air pollution, which
can increase risk of respiratory and
cardiovascular disease, is associated
with 6.5 million premature deaths
each year [3].
An estimated 99% of the global
population is exposed to air that
exceeds the limits reported by
the World Health Organization
(WHO)’s Global Air Quality
Guidelines [3].These guidelines offer
evidence-based recommendations
about the limits of harmful exposure
to pollutants, including carbon
monoxide (CO), nitrogen dioxide
(NO₂), ground-level ozone (O₃),
particulate matter (PM2.5
and PM10
),
and sulfur dioxide (SO₂) [3]. Air
pollution can significantly alter
the delicate balance of the natural
ecosystem of plants and animals, by
harming soil and vegetation, affecting
the reproductive health of animals,
and influencing eutrophication in
water bodies [4].
Nations should identify best
approaches to achieve the targets of
two Sustainable Development Goals
(SDGs) – SDG 3 as good health and
wellbeing (Target 3.9: Reduce the
number of deaths and illnesses from
hazardous chemicals and air, water
and soil pollution and contamination)
and SDG 11 as sustainable cities
and communities (Target 11.6: By
2030, reduce the adverse per capita
environmental impact of cities,
including by paying special attention
to air quality and municipal and
other waste management). Indirect
links, however, can be made between
air pollution and SDG 13 (climate
action), SDG 14 (life below water),
and 15 (life on land). Global leaders
can use the One Health concept to
guide the development of strategies,
policies, and educational programs
for air pollution and climate action
[5]. In this article, physicians from
13 countries – Austria, Dominican
Republic, Hong Kong, Myanmar,
Nigeria, Philippines, South Africa,
Spain, Sweden, Thailand, Trinidad
and Tobago, Turkey, and the United
States − shared valuable insight,
reflections, and testimonies about the
International Day of Clean Air for
Blue Skies.
BACK TO CONTENTS
Credit:
TR
STOK
/
shutterstock.com
WMA Members Share Reflections about
International Day of Clean Air for Blue Skies 2022
18
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
Austria
Along with climate change, air
pollution is one of the greatest
environmental threats to human
health and livelihoods worldwide.
Austria is a country of 8 million
residents that is recognized for its low
levels of air pollution. Unique factors
to Austria include the high proportion
(48%) of forests, partial presence of
heavy industry, and only one city with
over one million residents. Air quality
is also positively impacted by the
mountainous terrain,where dust mites
as well as mold spores or bacteria do
not exist at 1,200 and 1,500 meters
above sea level, respectively. With
reduced levels of asthma and allergy
symptoms, citizens and tourists can
visit resorts, including special climatic
health resorts that promote “healing
landscapes” across the country.
Notable examples are the resorts
located in the Carinthian Nockberge
Region of southern Austria.
To Austrian physicians,it is important
that good air quality is maintained
through the implementation of
appropriate local and national
measures. In Austria, many initiatives
have been developed to reduce
ambient and indoor air pollution.
In 2021, the Environment Agency
Austria launched a national initiative
to reduce harmful air pollutants,based
on the new WHO guidelines for air
quality [6]. In 2022, the Austrian
Emission Control Act widely
introduced speed limits on highways
in order to reduce traffic-related air
pollution [7].
Physicians, who have significant
clinical and public health expertise
across specialties, can serve
as important role models and
influencers who disseminate key
recommendations to citizens across
health settings and via social media.
As a medical community, our actions
can encourage health leaders and
other decision-makers to develop
national collaborations as part of an
international alliance to combat air
pollution.
Dominican Republic
With air pollution as the leading
environmental health threat across
the globe, prompt action is needed
to examine air quality across all
urban and rural communities. The
Dominican Republic (DR), a country
of 11 million residents, has a highly
dense urban population in Santo
Domingo (2.9 million), Santiago de
los Caballeros (1.0 million), and San
Cristóbal (637, 429), according to the
DR National Statistics Office. With
these demographics, it is important
to recognize three key sources of air
pollution – power plants,automobiles,
and landfill emissions – directly affect
air quality and health across the
Hispaniola island shared by the DR
and Haiti.
First, nitrates, sulfur dioxide,
carbon soot, and mercury were
toxic substances released from the
country’s 10 thermoelectric plants
(including the recent construction
of “Punta Catalina”). As industries
use petroleum, their processes
generate sulfuric acid to produce
electricity. Second, carbon monoxide
concentrations from increased
vehicular emissions on roads and
highways have greatly impacted
the air quality in urban cities
(Santo Domingo, Santo Domingo,
Santiago de los Caballeros, La
Vega, San Cristóbal, San Francisco
de Macorís). For example, 310,081
new vehicles were registered during
2021 (compared to 2020), with a
total of 5.1 million vehicles in the
country [8]. Of this total, these
vehicles include motorcycles (55.8%),
automobiles (20.3%), sports utility
vehicles (11.0%), and cargo vans and
buses (12.9%) [8]. Third, as carbon
dioxide and methane emissions result
from solid waste degradation in
landfills (Duquesa Landfill of Santo
Domingo, Rafey Landfill of Santiago
de los Caballeros),the potential risk of
fires can also increase risk of exposure
to toxic fumes [9].
To address this national burden,
DR leaders have adopted the
environmental law (Law 64-2000),
whichhasfocusedontheconservation,
protection, improvement, and
restauration of the surrounding
environment and natural resources
using alternative energy. Current
adaptations have included using forms
of clean energy, such as hydroelectric
plants (34 active dams) and wind
farms (9 wind farms), and long-term
goals include the transition to electric
and hybrid vehicles. Alternative plans
will focus on improving air quality
and highlighting the three Rs (reduce,
reuse, recycle) for waste management.
Since national governments and
communities have leading roles in
developing initiatives that aim to
achieve the targets of the SDGs
– especially SDG 11, 13, and 15 –
our global community needs to act
quickly to build robust collaborations
and develop key interventions that
prioritize population health.
Hong Kong
Hong Kong, a metropolitan city with
an estimated 7.4 million residents,
can be described as an urban
environment with dense road traffic,
crowded buildings, coal-powered
power plants, and factories located in
Guangdong and Pearl River Delta.
Emissions from vehicles, burning
of fossil fuels, and container ships
can increase risk of cardiovascular
and respiratory diseases, as a result
of harmful exposures to SO₂ and
PM2.5
such as black carbon, dust,
and nitrates. According to the UN
Environment Programme, over 90%
of populations across the Asia Pacific
BACK TO CONTENTS
19
region are exposed to levels of poor
air quality that can pose a significant
risk to their health [10]. Furthermore,
an estimated 70% of annual deaths
associated with air pollution across
the globe occur in the Asia Pacific
region [11].
To address this regional burden,Hong
Kong leaders have led initiatives over
the past decade that support the
development of public green spaces
in urban communities. As a result,
an estimated 75 % of Hong Kong’s
territories has been covered with grass,
which offers residents an opportunity
to visit these urban parks for fresh air.
These green parks are protected from
future development,in national efforts
to reduce air pollution. In 2021, the
Hong Kong government launched the
Clean Air Plan for Hong Kong 2035,
which supports the “Healthy Living
Low-carbon Transformation World
Class” vision and identifies goals,
strategies, and challenges to improve
air quality across Hong Kong by 2035
[12]. Notably, one ambitious goal is
to attain zero vehicular emissions by
2035 [12].
As physicians, we should promote
clean energy and smart utilization of
our energy sources as well as educate
our global populations about the
health impacts of air pollution. As
children can develop severe illnesses
caused by air pollution, we need to
educate our next generation about the
associations between poor air quality
and respiratory illness, heart disease,
stroke, and lung cancer.
Myanmar
The Republic of the Union of
Myanmar, a country of 53 million
residents, is widely recognized for
its rich biodiversity and natural
resources [13]. Over the past
decades, the country has experienced
significant economic challenges due
to exploitation and mismanagement
of forest and marine ecosystems
[13]. As one notable health burden,
45,000 annual deaths are attributed
to air pollution (e.g. PM2.5
), due to
an increased risk of cardiovascular
and respiratory diseases, including
lung cancer, in adults and children
in Myanmar [14]. As health
professionals, we have a responsibility
to safeguard human life, advocate for
future generations’ right to life, and
protect the natural environment –
including promoting the importance
of clean air.
However, Myanmar’s military and
security forces, which consume fossil
fuels and emit harmful gases, pose
a threat to the natural ecosystem.
In October 2022, military forces
conducted an airstrike and bombed
a convent and 100 civilian homes
in Yangon, leaving 500,000 persons
internally displaced [15]. These
systematic, widespread events have
disrupted the natural ecosystem,
caused transboundary air pollution,
and negatively impacted health and
safety of Myanmar citizens.
The impact of the military sector on
air pollution, including the carbon
footprint, has been described, but not
well documented in the literature,
especially since they are not required
to report such harmful emissions
(e.g. greenhouse gas emissions) [16].
Moving forward, it will be important
for international organizations – like
the United Nations, WHO, and
World Medical Association (WMA)
–toexamineallsourcesofairpollution
(including military carbon emissions)
across the globe and develop prompt
interventions to mitigate risk. These
global actions can help countries, like
Myanmar, to develop policies that
support a more sustainable future
that protects original biodiversity and
natural resources.
Nigeria
Clean air is necessary for optimal
respiratory health. In Port Harcourt,
which forms part of the Niger Delta
region in southern Nigeria, the
emergence of black soot has impacted
air quality within this geographic
region.These emissions have resulted
from the activities of illegal refineries
(locally known as kpo-fire), which
processes involve the transformation
and use of local technology of locally
refining crude oil into petroleum
products (artisanal refining). No
safety measures are used after the
distillation of the petroleum products,
and by-products (black soot) are
released into the air [17].
Black soot can negatively impact
health, highway safety, housing,
and surrounding environments
[17]. First, inhalation of black soot
can increase risk of asthma and
respiratory infections, especially for
vulnerable populations like children
and elderly persons. Second, black
soot can affect drivers’ visibility on
highways. Third, deposits on physical
infrastructures like roofs can cause
rapid deterioration of such materials.
Finally, environmental deposits can
impact crop yields on farms and water
quality for aquaculture, which can
also be harmful for ingestion without
cooking.
Since community residents in Port
Harcourt and the Niger Delta spend
more money on purchasing cleaning
agents to remove black soot deposits
on furniture and clothing, they
conducted a peaceful protest called,
“Stop the Soot Protest”, on 19 April
2018. Since this event, the Nigerian
government has continued to take
proactive steps to reduce air pollution
in Port Harcourt, especially due to
artisanal refining. These efforts have
included the destruction of illegal
refineries in the bushes and creeks
BACK TO CONTENTS
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
20
as well as widespread messaging on
mass media and social media. Non-
government organizations, medical
professional associations, and good
Samaritans have been actively
involved in these campaigns to stop
black soot emissions in Port Harcourt
of Rivers State.
Philippines
The Philippines, a country with an
estimated 110 million residents, has
beenrecognizedfortakingtremendous
strides to reduce air pollution. First,
in 1999, the implementation of the
Republic Act 8749, also known as
the Philippine Clean Air Act of
1999, outlined the efforts of the
Department of Environment and
Natural Resources – Environmental
Management Bureau (DENR-EMB)
to reduce air pollution by supporting
environmental protection activities. It
adopted the “polluters pay principle”,
in order to promote behaviours for
self-regulation among the population.
Emission standards were set for all
types of motor vehicles and issuance
of pollutant limitations among
industries [18].
Second, in 2019, the Philippines
joined the rest of the world
in commemorating the first
International Day of Clean Air for
Blue Skies, which was spearheaded
by the DENR-EMB through the
Resolution No. 212, which was
adapted from the 74th session of
the UN General Assembly, on 19
December 2019. This day, which
aimed to showcase the importance
of clean air, and its effect on health,
the economy, and the environment,
demonstrated the link between air
quality and other environmental
challenges, such as climate change.
Director William Cuñado expressed
that this day reminds us of our
continuous drive to find solutions
and address various environmental
challenges [18,19].
Finally, in 2020, through the
Memorandum Circular 2020-003,
the DENR-EMB established an
Air Quality Network Center using
a Uniform Data Acquisition and
Handling System (DAHS). All
regional offices were mandated
to install a Continuous Emission
Monitoring System (CEMS) or
Continuous Opacity Monitoring
System (COMS), to collect all
data and information related to
industrial emissions. Subsequently,
the Memorandum Circular 2020-17
offered established guidelines on the
Issuance of Permit to Operate (PTO)
for Air Pollution Source Installation
or Equipment (APSI/APSE) [18].
South Africa
As a country of 57 million residents,
South Africa’s air quality has been
a mounting problem and has
contributed to the climate crisis.
The health sector is not exempt as a
contributor to greenhouse emissions;
globally,healthcare’s climate footprint
is equivalent to 4.4% of global
net emissions. The health sector’s
climate footprint emanates from its
carbon-intensive supply chain, chiefly
including fossil fuel-dependent
vehicle fleets, energy and heating
systems, waste disposal including
incineration, and the production
and supply of health goods such
as pharmaceuticals and food [20].
Industrial and domestic sources of
air pollutants compound the climate
footprint, and harmful exposures to
PM2.5
can increase risk of respiratory
and cardiovascular disease [21].
The dangerous air covering South
African cities and communities
is on account of South Africa’s
heavy reliance on coal-fired power
generation for industrial operations,
as well as vehicle emissions in heavily
motorised cities (like Johannesburg)
of CO, NO₂, and PM2.5
. On the
other hand, non-industrial events
or phenomena – such as windblown
dust, waste burning, veld fires, and
burning of wood or coal for domestic
use – are common in South Africa
and contribute significantly to poor
air quality. With more than 13 air
quality monitoring stations available
in South Africa, data show that
many areas, notably the Mpumalanga
Highveld region, have ambient air
pollution concentrations exceeding
acceptable thresholds established
by the WHO Global Air Quality
Guidelines [3].
South Africa’s decarbonisation efforts
have included the introduction
of several air quality legislations,
including the National Ambient
Air Quality Standards (2009),
the National Environmental
Management Act (Act 107 of 1998)
(“NEMA”), and the Air Quality
Act (Act 39 of 2004). Guaranteeing
clean air in South Africa, Africa, and
globally is a fundamental right for all
family members of the global village
to live and work in a safe and healthy
environment. By reducing acute
and chronic exposures to health-
damaging air-borne toxins,the burden
of respiratory and cardiovascular
diseases, cancers, and other air
pollution-related health problems
will be minimised. Clean air will bear
health dividends, which will translate
to reduced stress on the country’s
health system while ensuring better
quality of life, economic participation,
and life expectancy for South
Africans.
The South African Medical
Association has and will continue to
advocate for better air quality, clean
energy use,and the early identification
and treatment of health conditions
related to air quality. We encourage
all physicians and other health
professionals to commit themselves
to understanding and reducing the
healthcare sector’s contribution to the
overall carbon footprint.
BACK TO CONTENTS
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
21
Spain
Air pollution and climate change
pose the greatest threats to global
health.Half of the world’s population,
or more than 4 billion people, lives in
urban areas with levels of air pollution
above the WHO Global Air Quality
Guidelines [3].To address this global
burden, the Spanish General Medical
CouncilcontinuestosensitizeSpanish
doctors and take a proactive stance in
the decarbonization of the healthcare
system, as part of the 2030 Agenda
for Sustainable Development.
In 2021, the Council launched
the Health and Climate Change
Working Group (https://www.
cgcom.es/grupo-de-trabajos/salud-
y-cambio-climatico), through which
the Medical Alliance against Climate
Change was formed. This alliance
includes administrative bodies
in legislation and encourages the
application of public health laws and
programs. The Council’s Foundation
for Training promoted seminars and
courses to raise awareness among
citizens on the effects of climate
change on health. Specifically, the
second seminar, Health and Climate
Change, allows leading experts in
geology, architecture, and medicine
to share findings on the impact of
ambient and household air pollution
on urban health.
Moving ahead, in late 2022, the
Spanish medical profession will
launch its new Code of Ethics and
Medical Deontology,as a text that will
highlight the ethical duty to preserve
the environment and combat climate
change. Also, in October 2022, the
formation of the Federation on the
Fight against Climate Change will
be announced during the Assembly
of the European Union of Medical
Specialists – with more than 1.7
million European medical specialists
– in Athens, Greece.
Sweden
Over the past 20 years, European
countries have undergone significant
changes in the emissions of
atmospheric pollutants and their
effects on health. In Sweden, a
country of 10 million residents,
epidemiological studies have shown
that air pollution affects our health
in more ways than previously known.
Improved exposure estimates and
emission inventories have revealed
associations between long-term
exposuretoairpollutionandmortality,
respiratory and cardiovascular
diseases, detrimental birth outcomes,
dementia, and childhood allergies.
With thousands of annual excess
deaths in Sweden, scientists have
reported that local emissions are
important contributions to these
harmful exposures [22].
Toimproveairquality,globalmeasures
are required to encourage citizens to
seek sustainable lifestyles within their
environments. Smart urban planning,
by widening pedestrian and bicycle
paths, can promote active lifestyles
for citizens and discourage sedentary
behaviors and automobile use. The
use of green space in urban settings
can reduce ambient temperatures,
improve air quality, and promote
physical activity during the summer
months. If community leaders can
advocate for such significant changes
in the built and natural environments,
then we can support active lifestyles
and ultimately protect population
health.
Thailand
Clean air is undoubtedly a primary
need for all human beings. Clean
air should be free of pollutants,
particulate matter, and chemicals, and
hence have no smell, color or taste.
Although air pollution can result
from wildfires, most air pollution is
caused by human activities, such as
cooking, traffic, industries, and power
stations. Tobacco smoke, which
contains more than 1,000 chemicals,
heavy metals, and particulate matter,
is cancerogenic and can increase the
risk of chronic diseases. In Thailand,
a country of 69 million residents,
the particulate matter (PM2.5
)
concentration was measured at four
times higher than the WHO Global
Air Quality Guideline [23].
The Medical Association of Thailand
has collaborated with the Ministry
of Public Health and the Thai
Health Promotion Bureau to actively
support the Smoking Cessation
Program of the “Clean Air Project”
[24]. With the support of the Royal
Thai Government, the Tobacco
Product Control Act (B.E. 2560)
was implemented in 2017 [25]. This
new enactment, which combined
the tobacco control law and non-
smoker rights protections, prohibits
smoking in closed public spaces,
transportation, schools, universities,
and marketplaces.
In 2019, Thailand became a country
partner of the Climate and Clean
Air Coalition (CCAC), and leaders
conducted collaborative projects
with the Thailand Pollution Control
Department, Asian Institute of
Technology, and UN Environment
Programme, to examine PM2.5
emissions from water transport
in Bangkok and offer timely
recommendations to mitigate health
risks [4]. In 2021, Thailand and
CCAC launched a novel collaboration
with the Institute for Global
Environmental Strategies and the
Stockholm Environment Institute,
to quantify air pollutant emissions
and develop solutions that can reduce
short-lived climate pollutants (e.g.
black carbon, hydrofluorocarbons,
methane) [26]. These efforts aim to
improve air quality and human health
as well as help achieve climate goals
in Thailand.
BACK TO CONTENTS
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
22
Thai physicians recognize the urgent
need to reduce air pollution and are
leading national efforts to promote
public health through this “Clean Air
Project”. As a result of this initiative,
which promotes the importance of
clean air and healthy lives, fewer
smokers and cigarette butts are
observed in public spaces.
Trinidad and Tobago
The most pervasive air quality
problem in Trinidad and Tobago
(T&T), a country with 1.4 million
residents, is the increasing frequency
and intensity of Saharan dust, which
peaks between May and July each
year. It is linked to climate change,
drought, and desertification in West
Africa, and millions of tons of topsoil
are transported across the Atlantic
Ocean to the Caribbean basin and
the eastern coast of the United States.
The T&T Meteorological Service
issues warnings of impending Saharan
dust, advising vulnerable persons with
respiratory allergies and asthma to
take precautions. However, air quality
challenges that are more amenable to
local action include emissions from
industry, traffic of over one million
vehicles, and forest or bush fires.
Over the past 30 years, living in the
watershed north of the capital,Port of
Spain,Ihavenotedthatbushfireshave
become more frequent, last longer,
and spread further distances. These
events have simultaneously occurred
with increased development of
housing and informal settlements and
hotter and drier conditions resulting
from the effects of climate change.
Bush fires have many adverse health
and environmental impacts, including
fire hazards to lives and property,
destruction of habitats, reduced air
quality leading to increased asthma
cases, and tragic fatalities resulting
from burns. A large bush fire in 2020
prompted the evacuation of five wards
of the St. Ann’s psychiatric hospital,
when the flames threatened the
facility. However, 36 hours later, the
same fire reached our community,and
our neighbours and the fire services
all sprang to help keep houses from
burning.
The T&T Forestry Division of the
Ministry of Agriculture reports
hundreds of annual bush fires, caused
by people who use fire to clear land
or burn rubbish. In fact, they have
estimated that more than 300,000
acresofforesthavebeendestroyedover
the past 30 years. Furthermore, bush
fires can lead to the loss of watershed
forest cover, where rainfall that rushes
off the land can cause destructive
flooding of properties and businesses.
It can hinder soil health and forest
growth as valuable topsoil washes
away.The Forestry Division and local
non-government organizations, such
as the Fondes Amandes Community
Reforestation Project (https://facrp1.
webs.com/), make valiant efforts to
reforest burned areas. However, there
is an urgent need for coherent policy,
education, monitoring, and other
measures to reduce the incidence of
forest fires and its adverse health and
environment consequences.
Physicians in T&T should be aware
of the increasing risk to human
health and the quality of our air and
environment resulting from bush
fires. First, we can advocate for robust
implementations of national policy
and programs for forest fire prevention
and re-forestation. Second, we can
support educational programs for
patients and communities, especially
those persons with respiratory
conditions like asthma.Third, we can
recommend that people who live in
agricultural and forested areas should
not start fires during the dry season.
Finally, we can participate in data
collection (including citizen science
applications) for the monitoring and
surveillance of the adverse impacts of
poor air quality, by serving as sentinel
physicians for asthma and respiratory
allergies.
Turkey
Climate change and air pollution
are closely connected, resulting from
natural and anthropogenic sources
such as the use of fossil fuels in
industrial production, transportation,
and energy generation.Tackling these
dual environmental threats requires
the active participation of our medical
community to protect population
health. To address these challenges,
the Turkish Medical Association
(TMA) has contributed to two key
efforts over the past decade.
In 2015, the Right to Clean
Air Platform (https://www.
temizhavahakki.com/en/home/) was
founded by a collaboration of 16
professional and non-governmental
organizations including the TMA,
Turkish Neurological Society,Turkish
Society of Public Health Specialists,
Greenpeace Mediterranean, Health
and Environment Alliance (HEAL),
350.org, Climate Action Network
(CAN)-Europe, and World Wildlife
Fund (WWF)-Turkey. The platform
aims to advocate for clean air and
reduceemissionsfromcoal-firedpower
plants, support air quality monitoring
and data collection, strengthen
cooperation among medical
associations and environmental
organizations to develop relevant
policies and programs, and enhance
scientific communication (including
community awareness) on the health
impacts of air pollution. Then,
in 2020, they collaborated with
scientific experts and prepared the
WMA Resolution on Protecting the
Future Generation’s Right to Live in
a Healthy Environment [27].
Unfortunately, citizens’ right to clean
air in Turkey is jeopardized by the
country’s policies that are persistently
dependent on fossil fuels for energy
BACK TO CONTENTS
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
23
in heating, transportation, industry,
and electricity generation. Other risks
include systematic deforestation by
mining, transportation, unplanned
urbanization projects, and poor or
unlawful waste management practices.
While national environmental
legislation is comprehensive, the
legislative power is exercised
excessively in favor of the energy
companies – rather than focusing
on the impacts on population and
ecosystem health – and deliberately
overlooked by the implementing
agencies.
As health professionals, we have a
duty to respect and care for all life
forms on our planet.Together, we can
advocate for five prompt actions by
our governments, non-governmental
organisations, and academic
communities, to tackle air pollution
and climate crisis. First, academic
leaders can lead efforts to strengthen
medical curricula by incorporating
problem-based learning techniques
on complex environmental
challenges. Second, health leaders can
advocate for the necessary academic
and legal collaborations that can
offer insight to professional medical
associations on the invisible cost of
air pollution to health outcomes.
Third, by reviewing national and
international environmental and
health legislation, national leaders
can identify existing gaps and propose
more robust inspections (including
sanctions or banning products).
Fourth, national leaders can promote
the use of renewable energy resources
through energy and employment
policy development. Finally, they
can invest in appropriate policies
that build social protection for a fair
workforce transition to a low-carbon
economy and future investment in
renewable energy. It is important to
recognize the urgency, complexity,
and interconnectedness of the essence
of the climate crisis action and take
immediate action to protect the rights
of future generations for the sake of
climate justice – before we reach an
irrevocable point.
United States
With climate change negatively
impacting the health in the United
States and around the globe, the
American Medical Association
(AMA) adopted policy during the
Annual Meeting of its House of
Delegates in June 2022, declaring
climate change a public health crisis
that threatens the health and well-
being of all people [28]. Building on
existing efforts to address the climate
crisis, the new policy specifically
mobilizes the AMA to advocate for
policies that limit global warming to
no more than 1.5 degrees Celsius,
reduce U.S. greenhouse gas emissions
aimed at carbon neutrality by 2050,
and support rapid implementation
and incentivization of clean energy
solutions and significant investments
in climate resilience through a climate
justice lens. The recent passage of
the U.S. Inflation Reduction Act of
2022 marks the largest investment
in history to reduce emissions and
combat climate change has created
hope that it is now possible to reach
these goals.
The AMA has long advocated
for upholding the U.S. Clean
Power Plan by filing friend-of-
the-court briefs in West Virginia v.
Environmental Protection Agency,
and most recently filing an amicus
brief with the American Thoracic
Society and dozens of leading
medical organizations and public
health leaders to support clean air
initiatives. Also, as part of AMA’s
broader ongoing commitment to
address climate change, the AMA is
a member of the National Academy
of Medicine Action Collaborative
on Decarbonizing the U.S. Health
Sector [29] – a public-private
partnership among the health sector
aimed at mitigating climate change
and protecting human health, well-
being, and equity by addressing the
sector’s environmental impact.
Conclusion
As our global community
commemorates the International
Day of Clean Air for Blue Skies, we
learn about the ambitious national
initiatives across 13 countries, which
aim to protect population health
from environmental exposures to air
pollution. Using “The Air We Share”
theme, prompt global collective
action is indispensable to identify
best practices in energy conservation
and solid waste management as
well as explore renewable energy
sources. As WMA members with
extensive training in clinical and
surgical specialties, we have a moral
obligation to share our expertise
with key decision-makers, moderate
scientific debates and fora on timely
issues, present our critical analyses
and research findings in scholarly
publications, and lead community
health and advocacy activities.
Our contributions to local and
national health activities can raise
community awareness and encourage
scientific discourse on emerging
health topics, such as reducing air
pollution and combating climate
change. By fostering the development
of our professional medical networks,
we can promote One Health
collaborations across disciplines and
sectors that can guide forward steps
to achieve the targets and indicators
of the 2030 Agenda for Sustainable
Development.
BACK TO CONTENTS
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
24
BACK TO CONTENTS
References
1. United Nations. International
Day of Clean Air for blue skies,
7 September. 2022 [cited 2022
Oct 15]. Available from: https://
www.un.org/en/observances/
clean-air-day
2. Orru H, Ebi KL, Forsberg B.
The interplay of climate change
and air pollution on health.
Curr Environ Health Rep.
2017;4(4):504-13.
3. World Health Organization.
WHO global air quality
guidelines: particulate matter
(PM2.5 and PM10), ozone,
nitrogen dioxide, sulfur dioxide
and carbon monoxide. Geneva:
World Health Organization;
2021. Available from: https://
www.ncbi.nlm.nih.gov/books/
NBK574594/
4. Manisalidis I, Stavropoulou E,
Stavropoulos A, Bezirtzoglou
E. Environmental and health
impacts of air pollution: a review.
Front Public Health. 2020;8:14.
5. World Health Organization.
Tripartite and UNEP support
OHHLEP’s definition of “One
Health”. 2021 [cited 2022 Oct
15]. Available from: https://
www.who.int/news/item/01-12-
2021-tripartite-and-unep-sup-
port-ohhlep-s-definition-of-one-
health
6. Environment Agency Austria.
The way to clean air. 2021
[cited 2022 Sep 15]. Available
from: https://www.umweltbun-
desamt.at/news210922-2
7. Government of Austria.
Consolidated federal law: entire
legal framework for the
Emission Control Act – Air.
2022 [cited 2022 Sep 15].
Availab­le from: https://www.ris.
bka.gv.at/GeltendeFassung.wx-
e?Abfrage=Bundesnormen&Ge-
setzesnummer=10011027
8. Dirección General de Impuestos
Internos (Dominican Republic).
[Boletín Estadístico Vehicular
2021: Gerencia de Estudios
Económicos y Tributarios]
[Internet]. 2021 [cited 2022 Sep
9]. Spanish. Available from:
https://dgii.gov.do/estadisticas/
parqueVehicular/1Informes%20
Parque%20Vehicular/ParqueVe-
hicular2021.pdf
9. Ministerio de Medio Ambiente y
Recursos Naturales (Dominican
Republic). [Políticas para la
gestión integral de residuos
sólidos municipales] [Internet].
2016 [2022 Sep 20]. Spanish.
Available from: https://ambi-
ente.gob.do/wp-content/up-
loads/2016/12/Politica-Residu-
os-Solidos-Municipales.pdf
10. North CM, Rice MB, Ferkol
T, et al. Air pollution in
the Asia-Pacific Region: A
Joint Asian Pacific Society
of Respirology/American
Thoracic Society perspective
(Republication). Respirology.
2019;24(5):484-91.
11. UN Environment Programme.
Restoring clean air. 2022
[cited 2022 Sep 15].
Available from: https://www.
unep.org/regions/asia-and-pa-
cif ic /reg iona l-initiatives/
restoring-clean-air
12. Government of Hong Kong.
Government announces Clean
Air Plan for Hong Kong 2035
[Internet]. 2021 [cited 2022
Sep 1]. Available from: https://
www.info.gov.hk/gia/gener-
al/202106/29/P2021062900451.
htm
13. Yang B, Deng M, Zhang MX,
Moe AZ, Ding HB, Maw
MB, et al. Contributions to
the flora of Myanmar from
2000 to 2019. Plant Divers.
2020;42(4):292-301.
14. World Bank. Myanmar
Country Environmental Analysis
[Internet]. 2019 [cited 2022 Aug
28]. Available from: https://
www.worldbank.org/en/coun-
try/myanmar/publication/my-
anmar-country-environmen-
tal-analysis
15. PIME Asia News. Church and
convent bombed in Demoso
[Internet]. 2022 [cited 2022 Aug
28]. Available from: https://
w w w.asianews.it/news-en/
Church-and-convent-bombed-
in-Demoso-55324.html
16. Conflict and Environment
Observatory. The EU military
sector’s carbon footprint
[Internet]. 2021 [cited 2022 Oct
1]. Available from: https://ceobs.
org/the-eu-military-sectors-car-
bon-footprint/
17. Oriasi M, Rowland ED, Harry
AA. Spatial distribution of black
soot and its health effects in
Port Harcourt metropolis. J Env
Earth Sci. 2022;4(1):32-46.
18. Environmental Management
Bureau. DENR-EMB celebrates
the First International Day
of Clean Air for Blue Skies.
2020 [cited 2022 Aug 7].
Available from: https://
e m b. g o v.ph / w p – c o nt e nt /
upload s /2 02 0/0 9/ DENR-
E M B – C E L E B R A T E S –
T HE-F IR ST-IN TER NA-
TIONAL-DAY-OF-CLEAN-
AIR-FOR-BLUE-SKIES.pdf
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
25
BACK TO CONTENTS
19. United Nations Environment
Programme. International Day
of Clean Air for blue skies
highlights links between
human and planetary health. 2021
[cited 2022 Aug 6]. Available
from: https://www.unep.org/
news-and-stories/press-release/
international-day-clean-air-blue-
skies-highlights-links-between
20. Health Care Without Harm.
Health care’s climate footprint:
how the health sector contributes
to the global climate crisis
and opportunities for action.
2019 [cited 2022 Aug 30].
Available from: https://no-
harm-global.org/sites/default/
f iles/documents-f iles/5961/
Hea lthCa resCl imateFoot-
print_092319.pdf
21. Hayes RB, Lim C, Zhang Y,
Cromar K, Shao Y, Reynolds
HR, et al. PM2.5 air pollution
and cause-specific cardiovascular
disease mortality. Int J Epidemiol.
2020;49(1):25-35.
22. Andersson C, Ekman A,
Forsberg B, Grennfelt P,
Gruzieva O, Hansson H-C, et
al. Achievements and experiences
from science–policy interaction
in the field of air pollution.
2021. Available from: https://
mistrasafechem.se/english/
ivl/publications/publications/
achievements-and-experienc-
es-from-science-policy-interac-
tion-in-the-field-of-air-pollution.
html
23. World Health Organization.
The cost of clean air in
Thailand [Internet]. 2022 [cited
2022 Sep 20]. Available from:
https://www.who.int/thailand/
news/detail/08-06-2022-the-
cost-of-clean-air-in-thailand
24. Praphornkul P, Angskul T. Thai
Health Promotion Foundation
launches anti-smoking campaign
[Internet]. 2019 [cited 2022 Oct
15]. Available from: https://thain-
ews.prd.go.th/en/news/detail/
TCATG191210103931724
25. Somwaiya K, Rotjanapanya S;
LawPlus Ltd. Tobacco Products
Control Act of Thailand comes
into force [Internet]. 2019
[cited 2022 Oct 15]. Available
from: https://www.lawplusltd.
com/2017/08/tobacco-products-
control-act-thailand-comes-
force/
26. Climate & Clean Air Coalition.
Thailand and the Climate
and Clean Air Coalition
begin a major new initiative to
reduce air pollution, improve
human health and mitigate
climate change [Internet]. 2021
[cited 2022 Oct 15]. Available
from: https://www.ccacoalition.
org/en/news/thailand-and-cli-
mate-and-clean-air-coalition-be-
gin-major-new-initiative-re-
duce-air-pollution
27. World Medical Association.
WMA Resolution on Protecting
the Future Generation’s Right to
Live in a Healthy Environment
[Internet]. 2020 [cited 2022 Oct
1]. Available from: https://www.
wma.net/policies-post/wma-res-
olution-on-protecting-the-fu-
ture-generations-right-to-live-in-
a-healthy-environment/
28. American Medical Association.
AMA press releases [Internet].
2022 [cited 2022 Aug 24].
Available from: https://www.
ama-assn.org/press-center/
press-releases
29. National Academy of Medicine.
Action Collaborative on
Decarbonizing the U.S. Health
Sector [Internet]. 2022 [cited
2022 Aug 24]. Available from:
https://nam.edu/programs/
c l i m a t e – c h a n g e – a n d-h u-
man-health /action-collab-
o r a t i v e – o n – d e c a r b o n i z –
ing-the-u-s-health-sector/
30. World Health Organization.
Preventing disease through
healthy environments: a
global assessment of the
burden of disease from
environmental risks. Geneva:
WHO; 2018. Available
from: https://www.
w h o . i n t / p u b l i c a t i o n s / i /
item/9789241565196
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
26
Dabota Yvonne Buowari, MBBS
Department of Accident
and Emergency,
University of Port Harcourt
Teaching Hospital
Port Harcourt, Nigeria
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
Maymona Choudry, RN, MD, MPH
Department of General Surgery,
Vicente Sotto Memorial Medical Center
Cebu City, Philippines
Tomás Cobo Castro, MD
President, Spanish General
Medical Council (CGCOM)
Madrid, Spain
C. James Hospedales,
MBBS, MSc, FFPH
Trinidad and Tobago
Medical Association
Chaguanas, Trinidad, West Indies
Piero Lercher, MD
Head, Department of
Environmental Medicine,
Austrian Medical Chamber
Vienna, Austria
Mvuyisi Mzukwa, MBChB
Chairperson, South African
Medical Association
Pretoria, South Africa
Sofia Rydgren Stale, MD
President, Swedish Medical Association
Stockholm, Sweden
Wonchat Subhachaturasa, MD
Advisor and Past President,
Medical Association of Thailand
Bangkok, Thailand
Raymond Tso, MD, DABIM
Co-Chairperson, Advisory
Committee on
Communicable Diseases,
The Hong Kong Medical Association
Hong Kong SAR
Wunna Tun, MBBS, MD
Fellow, Medical Education
JDN Secretary
Yangon, Myanmar
Gamze Varol, MD
Head, Department of Public Health,
Tekirdağ Namık Kemal University
(NKU) Medical Faculty
Public Health Committee,
Turkish Medical Association
Tekirdağ, Turkey
Bienvenido Veras-Estévez,
MD, MPH
Department of Epidemiology,
Hospital Regional Universitario
José María Cabral y Báez &
Faculty of Health Sciences,
Universidad Católica del Cibao
Santiago de los Caballeros & La Vega,
Dominican Republic
Ellen Waterman
International Relations Consultant,
American Medical Association
United States
WMA Members Share Reflections about International Day of Clean Air for Blue Skies 2022
BACK TO CONTENTS
27
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
BACK TO CONTENTS
In 2016, the Canadian parliament
legalized “Medical Assistance in
Dying” (MAiD) [1], a new term
referring to both assisted suicide and
euthanasia. MAiD was introduced in
response to a 2015 Supreme Court
ruling that overturned an absolute
prohibition of these practices in
Canada’s Criminal Code [2]. To
accommodate this court ruling,
the Canadian parliament enacted
Bill C-14 in 2016, which created
a legislative exemption for assisted
suicide and euthanasia. MAiD
became legal for capable adults who
have an irremediable disease that
causes enduring and intolerable
suffering that cannot be alleviated
under conditions the person finds
acceptable, with an “irreversible
decline of capability”, and when
their natural death is “reasonably
foreseeable” [1,3].
Within five years of its introduction,
the Canadian parliament removed
several key safeguards embedded
in the law in its updated MAiD
legislation, Bill C-7 [4]. It did so
after the federal government failed
to appeal [5] a provincial (Quebec)
lower court decision which ruled that
the restriction of MAiD to natural
death being ‘reasonably foreseeable’
was unconstitutional [6]. The
government then expanded de facto
eligibility to include those not dying
but living with disabilities; and as of
March 2023, this will also include
those suffering solely from mental
disorders [4]. This commentary
reviews the Canadian experience to
date and raises issues to consider as
assisted dying policies or expansion
are considered in the rest of the
world.
Background
MAiD deaths have increased
dramatically year after year in the
short time since Canada’s legalization
in 2016. MAiD cases in Canada
involve almost exclusively euthanasia,
with death being administered by
the health care provider via lethal
injection [7].Within three years of its
introduction in 2016,the death rate by
MAiD had risen to 2% of all deaths.
By 2020, the rate had increased to
2.5% of all deaths, and by 2021, it
was 3.3% of all Canadian deaths,with
some provinces approaching 5% [8].
These figures largely represent the
escalating death rates even before the
government expanded MAiD to those
living with disabilities in 2021, which
reflect situations where natural deaths
were reasonably foreseeable (termed
track 1 for MAiD in Canada). In
2021, only 2.2% of MAiD reported
deaths were documented in those
living with disabilities who were
not approaching their natural death
(track 2 for MAiD in Canada)
because the expanded legislation was
only enacted in March 2021 [8]. Bill
C-7, which expanded MAiD and
lifted several safeguards, was passed
in the middle of the coronavirus
disease 2019 (COVID-19) pandemic
and received limited media attention.
Many Canadians were likely unaware
of the changes to the MAiD regime.
In coming years, death rates are
thus likely to increase even more
substantially as euthanasia and
assisted suicide for those not dying
but living with disabilities will be
more widely provided, as well as once
further expansion occurs in March
2023, to those living with sole mental
health disorders.
By 2021, there were 10,064 MAiD
deaths in Canada, bringing the total
number since legalization in 2016,
Ramona Coelho
K. Sonu Gaind
Normalizing Death as “Treatment” in Canada:
Whose Suicides do we Prevent, and Whose do we Abet?
Trudo Lemmens
John Maher
28
BACK TO CONTENTS
to 31,664 deaths. Within six years of
the introduction of MAiD, Canada
has surpassed all other countries for
its number of euthanasia and assisted
suicide deaths reported in 2021. The
Netherlands and Belgium, which
have allowed both euthanasia and
assisted suicide since 2002, have
experienced much more gradual
increases over many more years [9].
Particularly, the proportion of MAiD
deaths in the provinces of Quebec
and British Columbia [8] are now
already at a similar or higher level,
when compared to Belgium and the
Netherlands [10].
Misleading Nomenclature
and Concepts: The Artificial
Distinction between “Suicide” and
Canada’s Assisted Death Expansion
When the Canadian government
coined the acronym “MAiD” in
2016, Canada’s new assisted dying
laws included as key safeguard that
“MAiD” would only be provided
to those whose natural deaths were
“reasonably foreseeable,” which
arguably restricted it to the ‘end of life’
context [1,3]. “Assistance-in-dying”
may have seemed an apt description
for that practice, even though the
‘reasonably foreseeable death’criterion
was already quickly interpreted to
include persons without terminal
illness and no clear expectation of
approaching death [11]. With the
government’s expansion of assisted
suicide and euthanasia to those not
dying, the term “medical assistance
in dying” became a misnomer. Given
Canada’s assisted dying laws now
allow for the provision of facilitated
death to the non-dying, we revert
to the terminology of medically
administered death (MAD). To be
consistent with the actual practice in
Canada following the 2021 expansion
of euthanasia and assisted suicide to
the non-dying, the remainder of this
article will use the acronym “MAD”
instead of “MAiD” [12].
Overinclusion vs Underinclusion
In addition to the removal of the
restriction to “reasonably foreseeable
death”, Canada’s 2021 legislation
stripped away several other safeguards
which were in place to prevent
avoidable or wrongful deaths for those
who met the initial criteria. These
changes included, among others,
eliminating the previously mandated
10-day reflection period prior to
euthanizing those who wished to
die. In principle, this allows the same
day administration of death. As well,
there was an introduction of a limited
form of MAiD based on an advance
request, that is, allowing a waiver of
final consent. Two comprehensive
articles on the Canadian MAiD
regime were previously published in
the World Medical Journal and deserve
a full reading for greater perspective
on the problems within the entire
MAiD framework [13,14]. The
remainder of this article focuses on
the new MAD expansion outside the
end-of-life context, that is, providing
euthanasia and assisted suicide to
those living with disabilities who
potentially have decades to live.
In the decision that spurred the
introduction of MAD, the Supreme
Court only ruled that an absolute
prohibition restricted people’s
constitutional rights. Notably, it did
not impose any specific obligations
with respect to how to organize
MAD and how to ensure access.
But the decision has been popularly
framed, even by medical professionals
and medical organizations, as
somehow creating a broad positive
right of access to MAD. As a result,
the need to ensure access has arguably
been more the focus of attention
than the need to protect against
premature death.This is reflected, for
example, in an obligation introduced
by the medical profession’s regulatory
college in Ontario to provide an
effective referral when people
request MAiD, and physicians have
a conscientious objection [15]. The
preamble to the 2016 legislation
that partially legalized MAD further
emphasized the federal government’s
commitment to make it universally
available across the country, including
through obligations of provincial
health authorities to fully fund it [1].
As a result, there is a remarkable
situation in Canada that MAD is
fully funded and broadly accessible,
and available for disabled Canadians
who are otherwise not dying. At
the same time, access to adequate
health care and social support is not
guaranteed and, in many instances,
not given the same priority. In fact,
although basic health care services are
publicly funded, there is no positive
right to health care in Canada, as the
SupremeCourt[16]andmostrecently
again the British Columbia Court
of Appeal [17] have emphasized.
Canada’s funding for health care
and social support services sits below
the Organization for Economic
Cooperation and Development
(OECD) average [18]. Palliative
care, most speciality chronic care,
disability and community support
services are inadequately funded, and
in chronically short supply [19,20].
For any health care system, which
naturally has interdependencies
including balancing of fiscal
pressures, this should raise ethical
concerns. Providing state sanctioned
death to avoid life suffering is clearly
more cost effective than providing
state-supported health care and
community support to facilitate living
well. Canada’s federal parliament
and government have aggressively
promoted access to MAD and
imposed this as a practice that
provinces have to implement and
fund, but they have failed to do the
same for timely and adequate access
to many other components of health
care and social support.
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
29
BACK TO CONTENTS
To place this further in context,
MAD can be administered by any
of the 100,000 physicians or nurse
practitioners in our country of 37
million, and the federal government
ensures Canadians that “eligible
Canadians will be able to request
MAiD” [21], yet no right to health
care. The primary manner of causing
death via MAD is euthanasia, by
injection of toxic substances.
How MAD Works in Canada
In contrast with recent legislation
in New Zealand [22] and Victoria
(Australia) [23], there is no legal
prohibition on health professionals
suggesting MAD as an option to
patients. There are now several
media reports of patients being
profoundly and negatively impacted
by suggestions from their physicians
that they consider death [24]. In fact,
the Canadian Association of MAiD
Providers and Assessors, which has
received significant funding from
the federal government to provide
training to health care providers,
even recommends that all those who
“might qualify should be offered
MAiD” as part of the informed
consent process [25].This would thus
imply that a person with a disability
and “irreversible decline of capability”
(including a person with mental
illness, as of March 2023) who visits
a physician to have a medical issue
addressed that appears to create
serious suffering, would have to be
offered MAiD as one of the options.
No other country in the world
has normalized assisted suicide or
euthanasia in this way as a potential
first-line therapeutic option to
address suffering. (As below, Canada
does not have any actual safeguard
or requirement that other treatments
need to have been accessed or tried
first).
Those whose deaths are considered
“reasonably foreseeable” (track 1),
which has been taken to mean having
potentially several years of life left
to live [11], can receive MAD in
principle the same or next day, if two
assessors agree that they fit the criteria.
For those who are not dying (track 2),
Canada requires that the two MAD
assessors (medical doctor or nurse
practitioner) conduct a more detailed
assessment of patient eligibility. The
timing to die by lethal injection is set
at a minimum of 90 days after the first
MAD assessment is completed. This
period can be reduced if the assessors
agree that loss of capacity is imminent,
and if they can do their assessment
faster. In order to qualify for MAD,
a patient must be in a situation of
irreversible decline of capability, and
experience intolerable psychological
or physical suffering. These terms are
not further defined by the legislation,
and suffering is treated as purely
subjective [3]. If the patient says their
suffering is intolerable, there is no
requirement or provision for further
validation by clinicians, as there is in
Belgium and the Netherlands, where
physicians at least have to agree with
the patient [10].
Patients need to be informed about
alternative options to MAD, and
physicians have to ensure that patients
‘considered’ all these. However, there
is no legal requirement that the
other means of alleviating suffering
be accessible to the patient, nor is
there any requirement that standard
best-practice treatments have been
appropriately attempted prior to
providing death by MAD [26]. In
Belgium and the Netherlands, two
other jurisdictions that allow state-
sanctioned euthanasia or assisted
suicide outside the end-of-life
context, physicians need to agree
that there are no further medical or
social support options that can relieve
patients’ suffering. Canada thus has
now arguably the most wide-open
state-facilitated suicide process in the
world,whichcanbesubjectivelydriven
by patients declaring intolerable
suffering during periods of despair.
To reiterate this point: MAD can be
provided despite lack of access to care
and resources that could remediate
symptoms, or if the patient refuses to
try standard treatments in the depth
of their despair, despite scientific
literature demonstrating that this
treatment would overwhelmingly
lead to adjustment and recovery.
With the dangers of such broad
and imprecise legislation, access to
medical and social care in Canada is
often not timely,which directly fosters
and compounds patient suffering
and desperation. For example, the
average wait time to be treated by a
psychiatrist can exceed six times the
90-day waiting period to access a
lethal injection [27]. That is to say,
a person seeking treatment from a
psychiatrist and also asking for death,
could be given access to death long
before they get appropriate treatment.
Some MAD proponents have even
suggested that being on such a
waiting list for a long time should
qualify someone for MAD [28]. The
wait times for many other specialized
health care and social support
services, including specialized pain
clinics, specialized long-term care
homes, community-based housing,
and disability benefits, far exceed the
90-day assessment period [29].
Three United Nations representatives
[30], over a hundred Canadian
disability and social justice
organizations [31], Indigenous
advocacy groups [32], and hundreds
of medical and legal experts [12,
33], have argued that due to its lack
of safeguards, Canada’s euthanasia
and assisted suicide laws put the
lives of marginalized and vulnerable
Canadians at risk. Indeed, the law
uniquely fails to provide equal
protection against premature death
for persons with disabilities, by
offering only to them MAD as a
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
30
“reasonable” tool to relieve their
experience of suffering.
MAD’s Impact on Canadians with
Disabilities and Chronic Illness
As will be seen in the examples
provided below, some Canadians with
disabilities and chronic illness, who
should have the right to better living
conditions and care,are now choosing
death as their best “treatment”option.
Raymond Bounbonnais chose to
die rather than continue living in
a long-term care facility. Raymond
reported that his room would reach
temperatures as high as 30 degrees
Celsius in the summer. He always
had to leave his door open to benefit
from the air conditioning in the
hallway. The noise from the hallway,
coupled with the constant fear and
anxiety of another resident entering
and touching him or taking his
belongings, led him to ask for MAD
instead [34].
A national CTV news story recounted
how “Sophia” was unable to secure
affordable housing compatible with
her chemical sensitivities. She chose
MAD because she could not find a
healthy and affordable place to live
with her disability support income.
[35].
Donna Duncan suffered from a
concussion, and it took over a year for
her to receive the correct specialized
care,during which time she continued
to deteriorate. She received MAD
within four days after her initial
request. There is currently a police
investigation into the circumstances
surrounding her MAD death [36].
As we see in these examples, other
options should and could have been
offered to these people. Considering
the living conditions and lack of care
that they were forced to endure, their
tragic choices may be understandable.
However, we should ask ourselves
whether their choices for death in
these inhumane circumstances are
not the result of structural coercion.
In Canada, MAD expansionists have
seemingly shown little consideration
for how governments create and
sustain the predicaments that can
make death an attractive choice
for those who would have instead
benefitted from greater resources
and care. The obvious and better
solution would be to demand that
governments provide funding to
cut wait times and ensure access to
health care and community supports.
However, the reality is that MAD
costs less than state-supported health
and community care for the disabled,
which deliberately or not can create a
perverse incentive to guarantee access
to MAD, despite no guarantee of
access to care or community support.
MAD’s Impact on Canadians
Adjusting to New Disabilities or
Injuries
Evidence related to new illness or
injury shows that suicidality is often
present at the outset, for a period
following loss of function, but it
is not enduring in the long run. In
one recent study, which followed
patients with spinal cord injury, half
of the participants reported suicidal
ideation within the first two years of
experiencing a spinal cord injury. In
retrospect over the longer term, no
participants thought that they would
have been able to make an informed
decision about MAiD in the early
years after their injury and none
wanted MAiD after they had time to
adjust to living in the community [37].
One of the authors,Dr.Karen Ethans,
spoke at a press conference about
Bill C-7. She highlighted that many
people with a new spinal cord injury
are suicidal, but within a few years,
these individuals rate their quality of
life as high; many individuals in fact
rate their quality of life higher than
that of the non-disabled population
after rehabilitation and integration
back into the community. She shared
that in her experience, acute care
health care professionals do not
always have an informed idea about
disabilities and may inaccurately
present future outcomes as negative
to patients [38].
Mental Illness, Suicidality, and
MAD
The Canadian government has
committed that MAD will be provided
to Canadians with sole mental
disorders by March 2023. Evidence
and scientific research highlight the
dangers of this expansion, including
the known risk of providing psychiatric
MAD to suicidal individuals who
would otherwise benefit from suicide
prevention strategies [39]. Data
from the few European jurisdictions
currently providing MAD for
mental illness show that women and
marginalized individuals suffering
from unresolved loneliness and poverty
disproportionately seek and receive
psychiatric euthanasia [40]. Despite
this, MAD expansion proponents
ignoredtheseknownriskstovulnerable
populations in calling for expanded
access to MAD. In all its written and
verbal testimony leading to Bill C-7’s
MAD expansion and the provision to
allow psychiatric euthanasia by 2023,
the Canadian Psychiatric Association
never once raised concerns about
suicidality risks associated with mental
illness, nor mentioned the importance
of suicide prevention – indeed, never
once mentioned any variation of the
word ‘suicide’ during Bill C-7 public
consultations on mental illness and
death [41-45].
Contrary to this ideologically
driven policy push, the majority of
psychiatrists in Canada and related
organizations have challenged the
government’s decision to implement
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
BACK TO CONTENTS
31
MADforthosewithasolediagnosisof
mental illness, as there is no adequate
scientific evidence that mental illness
in any individual can be predicted
to be irremediable. From the world-
renowned Centre for Addiction and
Mental Health (CAMH) [46] to the
Canadian Association for Suicide
Prevention (CASP) [47],experts have
warned that it is impossible to predict,
as per the language of the law, the
“irremediability” of mental illness for
any individual. Cautions have been
raised to not conflate life suffering
and other resolvable social woes with
mental illness “irremediability” [48].
The Canadian Mental Health
Association (CMHA) [49] and the
Ontario Association for ACT &
FACT (experts providing front-line
care to those with the most severe
mental illnesses, OAAF) [50] both
stand in strong opposition to this
expansion of MAD for mental illness.
In a recent survey, the overwhelming
majority of Ontario psychiatrists
who responded said that they oppose
MAD solely on the grounds of
mental illness [51]. Evidence-based
reviews by the Expert Advisory
Group in 2020 and 2022 likewise
concluded that determinations of
“irremediability” in individual cases
of mental illness cannot be made
[52]. This evidence raises concerns
that those seeking MAD for mental
illness will be wrongly informed,
during periods of despair, that their
conditions are “irremediable” and
will not improve, despite this being
impossible to predict. Combined
with the known high prevalence of
psychosocial suffering in those with
mental illness, this escalates concerns
that those receiving MAD for mental
illness could have gotten better,
but will instead be provided state-
sanctioned death while suffering
from symptoms of despair fueled by
life suffering.
These concerns are validated by the
factthatinthefewEuropeancountries
that provide euthanasia for mental
illness, those requesting it for this
reason are disproportionately seeking
relief, not from their mental illnesses
per se but because of marginalization,
including unresolved social and
economic suffering and loneliness –
problems that are remediable [53].
We know that lack of access to care
for mental health needs is a problem
in Canada [54]. The Mental Health
Commission of Canada tells us that
fewer than one in three adults get
the mental health care they need.
Canadians may have to wait years for
specialized tertiary psychiatric care.
Knowing the failures in the delivery
of mental health care, one must
question why the federal government
is prioritizing MAD instead of heavily
focusing resources on the timely and
needed delivery of patient care.
Conclusion
The federal government, when
introducing a bill to expand MAiD
(now MAD), asked the Canadian
parliamentary budget officer to
estimate the potential financial
impact of doing so [55]. As would
be expected, this review found cost
savings will be greater. This will be
even more when we end the lives of
people prematurely by many years
who had higher care needs, especially
when we factor in social services,
disability benefits, equipment, and
other costs on top of the direct savings
to health care budgets.
However, these financial savings will
come at the high cost of prematurely
ending the lives of those who could
have thrived or recovered and enjoyed
long meaningful lives with family
and loved ones. Patients in Canada
deserve a health care and social
system and a government that is
responsive to their needs, that at the
very least aims to provide them with
an adequate quality of life and care,
no matter the complexities of their
illnesses, their disabilities or their
economic situations.
The legalizing of MAiD, or MAD,
has been claimed to offer ‘choice’ to
Canadians, despite the known gaps
in our health care system that fail to
provide medical care or community
support to the chronically ill, the
disabled, and the mentally ill.
Particularly, the expansion of MAD
provides the illusion of choice, while
in reality it pushes the most vulnerable
and marginalized Canadians towards
choosing an enticed death instead
of allowing them a meaningful and
fulfilled life [56].
With the recent expansion of
MAD, Canadians with disabilities
are deprived of an equal protection
against premature death and suicide,
which others continue to receive.
Canadians are increasingly opting to
receive medical state-funded death,
not because they no longer want to
live, but because our society has failed
them.
Note: The primary author, Dr.
Ramona Coelho, was an expert
witness before the House and Senate
committees examining Bill C-7 and
the Special Joint Committee on
MAiD (https://www.youtube.com/
watch?v=XI5SSMz_rU8) in May
2022. She is a founding member of
Physicians Together with Vulnerable
Canadians (https://maid2mad.ca/).
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
BACK TO CONTENTS
32
References
1. Parliament of Canada. Bill C-14
[Internet]. 2016 [cited 2022
Oct 4]. Available from: https://
www.parl.ca/DocumentViewer/
en/42-1/bill/C-14/royal-assent
2. Supreme Court of Canada. Cart-
er vs. Canada (Attorney General)
[Internet]. 2015 [cited 2022 Oct
4]. Available from: https://scc-
csc.lexum.com/scc-csc/scc-csc/
en/item/14637/index.do
3. LemmensT,KimH,KurzE.Why
Canada’s Medical Assistance
in Dying Law should be charter
compliant and what it may help
to avoid.McGill J Law & Health.
2019;11(1):S61-148.
4. Parliament of Canada. Bill C-7
[Internet]. 2021 [cited 2022 Oct
4]. Available from: https://parl.
ca/DocumentViewer/en/43-2/
bill/C-7/royal-assent
5. Lemmens T, Jacobs L. The latest
medical assistance in dying
decision needs to be appealed:
Here’s why [Internet]. The
Conversation. 2019 [cited 2022
Oct 5]. Available from: https://
theconversation.com/the-latest-
medical-assistance-in-dying-de-
cision-needs-to-be-appealed-he-
res-why-124955
6. Cour. Supérieure. Truchon c.
Procureur general du Canada,
2019 QCCS 3792. 2019
[cited 2022 Oct 5]. Available
from: https://www.canlii.org/en/
qc/qccs/doc/2019/2019qccs3792/
2019qccs3792.html
7. Downie J, Green S. A step
forward for self-administered
MAiD in Canada [Internet].
Impact Ethics. 2017 [cited
2022 Oct 6]. Available
from: https://impactethics.
ca/2017/12/13/a-step-forward-
for-self-administered-maid-in-
canada/
8. Government of Canada. Third
annual report on medical
assistance in dying in Canada
2022 [Internet]. 2022 [cited 2022
Oct 4]. Available from: https://
www.canada.ca/en/health-can-
ada/services/medical-assis-
tance-dying/annual-report-2021.
html#a3.1
9. Buchholz K. Forbes. Where
most people die by assisted
suicide [Internet]. Forbes. 2022
[cited 2022 Oct 4]. Available
from: https://www.forbes.
c o m / s i t e s / k a t h a r i n a –
b u c h h o l z / 2 0 2 2 / 0 8 / 1 2 /
where-most-people-die-by-as-
sisted-su ic ide-in fog raph-
ic/?sh=71835cfd49a3
10. Lemmens T. Charter Scrutiny
of Canada’s Medical Assistance
in Dying Law and the
Shifting Landscape of Belgian
and Dutch Euthanasia Practice.
Supreme Court Law Rev (2nd
ed). 2018;85:453-539.
11. McMorrow T, Wiebe E,
Liyanage R, Tremblay-Huet S,
Kelly M. Interpreting eligibility
under the Medical Assistance
in Dying Law: the experience
of physicians and nurse
practitioners. McGill J Law &
Health. 2020;14(1):51-108.
12. Physicians Together with
Vulnerable Canadians. MAiD-
2MAD letter calling for
physician signatories [Internet].
2020 [cited 2022 Oct 4].
Avai­lable from: https://maid-
2mad.ca/#DeclarationEnglish
13. Herx L, Cottle M, Scott J. The
“normalization” of euthanasia
in Canada: the cautionary tale
continues. World Medical
Journal. 2020;66(2):28-37.
14. Leiva R, Cottle M, Ferrier C,
Rutledge Harding S, Lau T, Mc-
Quiston T, et al. Euthanasia
in Canada: a cautionary tale.World
Medical Journal.2018;64(3):17-23.
15. College of Physicians and
SurgeonsofOntario.Advicetothe
profession: medical assistance in
dying [Internet].2021 [cited 2022
Oct 4]. Available from: https://
www.cpso.on.ca/Physicians/
Policies-Guidance/Policies/
Medical-Assistance-in-Dying/
Advice-to-the-Profession-Medi-
cal-Assistance-in-Dyi
16. Supreme Court of Canada.
Gosselin v. Québec (Attorney
General), 2002 SCC 84. 2002
[cited 2022 Oct 4]. Available
from: https://scc-csc.lexum.com/
scc-csc/scc-csc/en/item/2027/in-
dex.do
17. Court of Appeal for British
Columbia. Cambie Surgeries
Corporation v. British Columbia
(Attorney General), 2022 BCCA
245 (CanLII). 2022 [cited 2022
Oct 10]. Available from: https://
canlii.ca/t/jqh1s
18. Whitelaw S, Lemmens T, Van
Spall HG. The expansion of
medical assistance in dying in
the COVID-19 pandemic era
and beyond: implications for
vulnerable Canadians. Can Journ
Gen Int Med. 2022;17(2):17-21.
Erratum in: Can Journ Gen Int
Med. 2022;17(2).
19. Henteleff YM, Shariff MJ,
MacPherson DL. Palliative care:
an enforceable Canadian human
right? McGill Journal of Law and
Health. 2011;5(1):109-52. Avai­
lable from: https://canlii.ca/t/7jc
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
BACK TO CONTENTS
33
20. Government of Canada. Home
and community health care
[Internet]. 2016 [cited 2022 Oct
4]. Available from: https://www.
canada.ca/en/health-canada/
services/home-continuing-care/
home-community-care.html
21. Government of Canada. Medical
assistance in dying [Internet].
2022 [cited 2022 Oct 4]. Available
from: https://www.canada.ca/
en/health-canada/services/medi-
cal-assistance-dying.html
22. Parliamentary Counsel Office,
New Zealand. End of Life
Choice Act 2019: Section 10
[Internet]. 2019 [cited
2022 Oct 10]. Available from:
https://www.legislation.govt.
nz/act/public/2019/0067/latest/
LMS195465.html
23. Department of Health Victoria
(Australia). General information
about voluntary assisted dying
[Internet]. 2019 [cited 2022 Oct
10]. Available from: https://www.
health.vic.gov.au/patient-care/
general-information-about-vol-
u n t a r y – a s s i s t e d- d y i n g # –
can-someone-be-pressured-in-
to-asking-for-voluntary-assist-
ed-dying
24. Coelho R. Coelho: Medical
assistance in dying overused in
Canada even before expansion
[Internet]. London Free Press.
2022 [cited 2022 Oct 4].
Available from: https://lfpress.
com/opinion/columnists/coel-
ho-medical-assistance-in-dy-
i n g – o v e r u s e d – i n – c a n a –
da-even-before-expansion
25. Canadian Association of MAID
Assessors and Providers.Bringing
up MAiD [Internet]. 2020 [cited
2022 Oct 4]. Available from:
ht t p s: //c a m a p c a n a d a . c a /
wp-content/uploads/2022/02/
Bringing-up-MAiD.pdf
26. Lemmens T, Shariff M, Herckx
L. How Bill C-7 will sacrifice
the medical profession’s standard
of care [Internet].Policy Options.
2021 [cited 2022 Oct 4]. Available
from: https://policyoptions.irpp.
org/magazines/february-2021/
how-bill-c7-will-sacrifice-the-
medical-professions-standard-of-
care/
27. Moir, M, Barua, B. Waiting your
turn: wait times for health care
in Canada [Internet]. Fraser
Institute. 2021 [cited 2022 Oct
4]. Available from: https://www.
fraserinstitute.org/studies/wait-
ing-your-turn-wait-times-for-
health-care-in-canada-2021
28. Wiebe E. AMAD committee
[Internet]. 2022 [cited 2022
Oct 4]. Available from: https://
pa rl.ca / DocumentViewer/
en/44-1/AMAD/meeting-9/
evidence#Int-11711733
29. Lemmens T, Krakowitz-Broker
L. Why the federal government
should rethink its new Medical
Assistance in Dying Law
[Internet]. CBC Opinion. 2020
[2022 Oct 10]. Available from:
ht tps://w w w.cbc.ca /news/
opinion/opinion-medical-as-
sistance-in-dying-maid-legisla-
tion-1.5790710
30. Quinn G,De Schutter O,Mahler
C. Disability is not a reason
to sanction medically assisted
dying – UN experts [Internet].
UN Office of the High
Commissioner. 2021 [cited 2022
Oct 4]. Available from: https://
www.ohchr.org/EN/NewsEv-
ents/Pages/DisplayNews.aspx-
?NewsID=26687&LangID=E
31. Vulnerable Persons Standard.
Open letter to members of
parliament. [Internet]. 2021
[cited 2022 Oct 4]. Available
from: http://www.vps-npv.ca/
stopc7
32. Levitz S. Assisted-dying bill
sends wrong message to young
Indigenous people, advocates
argue [Internet]. The Canadian
Press. 2020 [cited 2022 Oct
4]. Available from: https://
www.theglobeandmail.com/
canada/article-assisted-dy-
ing-bill-sends-wrong-mes-
sage-to-young-indigenous-peo-
ple/
33. Kaiser A, Grant I, Lemmens
T, Sheehy E. Maid bill is an
affront to equality [Internet].The
Toronto Star. 2021 [cited 2022
Oct 4]. Available from: https://
www.thestar.com/opinion/con-
tributors/2021/03/11/maid-bill-
is-an-affront-to-equality.html
34. Noël M. Dénoncer avant de
mourir [Internet]. La Tribune.
2019 [cited 2022 Oct 4]. French.
Available from: https://www.
latribune.ca/actualites/denonc-
er-avant-de-mourir-video-6b5b-
5b9901c42d9660ec5ba19a0e-
da78
35. Favaro A. Woman with chemical
sensitivities chose medically-
assisted death after failed bid to
get better housing [Internet].
CTV. 2022 [cited 2022 Oct
4]. Available from: https://
w w w.c t v ne w s .c a /mobi le /
health/woman-with-chemi-
cal-sensitivities-chose-med-
ic a l l y- a s s i s te d- d e at h- a f-
ter-fa i led-bid-to-get-bet-
ter-housing-1.5860579
36. Daflos P. Police investigation,
public outcry following B.C.
woman’s medically assisted death
[Internet]. CTV. 2022 [cited
2022 Oct 4]. Available from:
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
BACK TO CONTENTS
34
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
https://bc.ctvnews.ca/police-in-
vestigation-public-outcry-fol-
lowing-b-c-woman-s-medical-
ly-assisted-death-1.5881294
37. Tchajkova N, Ethans K, Smith
SD. Inside the lived perspective
of life after spinal cord injury: a
qualitative study of the desire to
live and not live, including with
assisted dying. Spinal Cord.
2021;59:485-92.
38. Cable Public Affairs Channel.
Physicians Together with
Vulnerable Canadians Press
Conference. Testimony of
Dr. Karen Ethans [Internet].
2020 [2022 Oct 4]. Available
from: https://www.cpac.ca/en/
programs/headline-politics/
episodes/66298144/
39. Council of Canadian Academies.
The state of knowledge on
medical assistance in dying where
a mental disorder is the sole
underlying medical condition.
Ottawa (ON): The Expert
Panel Working Group on MAID
where a Mental Disorder is
the Sole Underlying Medical
Condition; 2018. Available from:
https://cca-reports.ca/reports/
medical-assistance-in-dying/
40. Kim SYH, De Vries RG,
Peteet JR. Euthanasia and
assisted suicide of patients
with psychiatric disorders in the
Netherlands 2011 to 2014. JAMA
Psychiatry. 2016;73(4):362-8.
41. Gaind S. Professional medical
associations failing to provide
evidence in MAID debate
[Internet]. The Hamilton
Spectator. 2021 [cited 2022
Oct 4]. Available from: https://
w w w.thespec.com/opinion/
cont r ibutors/2 021/03/09/
professional-medical-associ-
ations-failing-to-provide-evi-
dence-in-maid-debate.html
42. CanadianPsychiatricAssoci­ation.
Brief to the Standing Committee
on Justice and Human Rights Bill
C-7 [Internet]. 2020 [cited 2022
Oct 4]. Available from: https://
www.cpa-apc.org/wp-content/
uploads/Brief-JUST-12-Nov-
2020-FIN.pdf
43. CanadianPsychiatricAssociation.
Brief to the Senate of Canada
Standing Committee on Legal
and Constitutional Affairs Bill
C-7 [Internet]. 2020 [cited 2022
Oct 4]. Available from: https://
www.cpa-apc.org/wp-content/
uploads/Brief-LCJC-23-Nov-
2020-FIN.pdf
44. CanadianPsychiatricAssociation.
Letter from CPA, to the Hon
Mobina Jaffer, Chair, Standing
Committee on Legal and
Constitutional Affairs [Internet].
2021 [cited 2022 Oct 4]. https://
sencanada.ca/Content/Sen/
Committee/432/LCJC/briefs/
CanadianPsychiatricAssocia-
tion_e.pdf
45. Senate of Canada. 43rd
Parliament, 2nd Session
testimony [Internet]. 2020
[cited 2022 Oct 4]. Available
from: https://sencanada.ca/en/
Content/Sen/Committee/432/
LCJC/02ev-55071-e
46. Centre for Addiction and Mental
Health. Policy Advice on
Medical Assistance in Dying and
Mental Illness [Internet]. 2017
[cited 2022 Oct 4]. Available
from: https://www.camh.ca/-/
media/files/pdfs—public-poli-
cy-submissions/camh-position-
on-mi-maid-oct2017-pdf.pdf
47. Canadian Association for Suicide
Prevention. Statement on Recent
MAiD Developments [Internet].
2021 [cited 2022 Oct 4].
Available from: https://suici-
deprevention.ca/media/state-
ment-on-recent-maid-develop-
ments/
48. Gaind KS. What does
“irremediability” in mental
illness mean? Can J Psychiatry.
2020;65(9):604-6.
49. Canadian Mental Health
Association. Statement
on Medical Assistance in
Dying (MAID) [Internet].
2021 [2022 Oct 4]. Available
from: https://cmha.ca/brochure/
statement-on-medical-assis-
tance-in-dying-maid/
50. Ontario Association for Act and
Fact. OAAF Position Statement:
Physician Assisted Suicide
[Internet]. 2018 [cited 2022
Oct 4]. Available from: https://
www.ontarioactassociation.com/
resources/
51. Gaind S; University of
Toronto Law Faculty. Canada’s
headlong assisted death
expansion [Internet]. 2022
[cited 2022 Oct 4]. Available
from: https://www.youtube.com/
watch?v=5nIxO_9S3K8
52. Expert Advisory Group on
Medical Assistance in Dying.
Canada at a Crossroads:
Recommendations on Medical
Assistance in Dying and
Persons with a Mental Disorder:
An Evidence-based Critique of
the Halifax Group IRPP Report.
2020:1-34.
53. Verhofstadt M, Thienpont L,
Peters G. When unbearable
suffering incites psychiatric
patients to request euthanasia:
qualitative study. British Journal
of Psychiatry.2017;211(4):238-45.
BACK TO CONTENTS
35
Normalizing Death as “Treatment” in Canada: Whose Suicides do we Prevent, and Whose do we Abet?
54. Centre for Addiction and
Mental Health. Mental illness
and addiction: facts and
statistics [Internet]. 2022
[cited 2022 Oct 4].Available from:
https://www.camh.ca/en/driv-
ing-change/the-crisis-is-real/
mental-health-statistics
55. Parliamentary Budget Officer.
Cost estimates for Bill C-7
MAiD [Internet]. 2021
[cited 2022 Oct 4]. Available
from: https://www.pbo-
d p b .­g c . c a / w e b /d e f a u l t /
f i l e s / D o c u m e n t s / R e –
p o r t s / R P -2 0 2 1- 0 2 5 – M /
RP-2021-025-M_en.pdf
56. Gaind S. Death shouldn’t
always be the sentence for
suffering Canadians [Internet].
The National Observer. 2022
[cited 2022 Oct 4]. Available
from: https://www.nationalob-
server.com/2022/07/12/opinion/
death-shouldnt-always-be-sen-
tence-suffering-canadians
Ramona Coelho, MDCM, CCFP
Family Doctor
London, Ontario, Canada
E-mail: drramonacoelho@gmail.com
K. Sonu Gaind, MD,
FRCP(C), DFAPA
Professor, University of Toronto
Chief, Psychiatry and Physician
Chair Assisted Dying Team,
Humber River Hospital
Toronto, Ontario, Canada
E-mail: sonu.gaind@utoronto.ca
Trudo Lemmens, LicJur
LLM (Bioethics), DCL
Professor and Scholl Chair,
Faculty of Law and Dalla Lana
School of Public Health,
University of Toronto.
Toronto, Ontario, Canada
E-mail: Trudo.lemmens@utoronto.ca
John Maher, MD, FRCPC
President, Ontario Association
for ACT & FACT
Editor-in-Chief, Journal of
Ethics in Mental Health
Barrie, Ontario, Canada
E-mail: jmaher@cmhastarttalking.ca
BACK TO CONTENTS
36
BACK TO CONTENTS
Primary Health Care Systems across the Globe:
Does One Size Fit All?
Historically, ensuring access to basic
healthcare has been considered an
essential component to achieving
the Sustainable Development Goals
(SDGs) [1,2]. These goals have been
addressed only to a certain extent;
people’s health needs remain unmet
because of increasingly complex
challenges [3,4]. At the centre of
these goals is SDG 3 – “ensure healthy
lives and well-being for all at all ages”
[5]. Therefore, the strengthening of
primary health care (PHC) systems
has been identified as a major vehicle
towards the achievement of universal
health coverage (UHC) and the
achievement of SDG 3. This has
also been stated in the Astana 2018,
which envisions that “governments
and societies prioritize, promote and
protect people’s health and well-being,
at both population and individual
levels, through strong health systems”
[6].
PHC addresses the broader
determinants of health and focuses on
the comprehensive and interrelated
aspects of physical, mental, and social
health and well-being [7]. It provides
holistic person-centred care for health
needs throughout the lifespan,not just
a set of specific diseases. Approaches
taken to achieve these objectives differ
from one country to another, based
on their distinct socio-cultural and
political context and implementation
strategies [7]. A PHC approach
includes three components: meeting
people’s health needs throughout
their lives; addressing the broader
determinants of health through
multisectoral policy and action; and
empowering individuals, families, and
communities to take charge of their
own health [7].
Loffreda et al. (2021) suggest that
“achieving UHC is an inherently
political process” [8]. Consequently,
PHCisaffectedbythepoliticalcontext
in each region.The global coronavirus
disease 2019 (COVID-19) pandemic
has impacted health systems
worldwide and led to disruptions of
Skander Essafi
Lekha Rathod
Mercy Wanjala
Andrey Cruz
Wunna Tun
Yassen Tcholakov
Flora Wendel
Primary Health Care Systems across the Globe: Does One Size Fit All?
37
BACK TO CONTENTS
Primary Health Care Systems across the Globe: Does One Size Fit All?
essential health services. However, as
a learning opportunity, it highlighted
that resilient health systems require
a robust frontline at the core of their
infrastructure [9].
At the World Health Assembly 2022,
strengthening PHC was a major
topic discussed among the Member
States and Non-State Actors [10].
It was underlined as a cornerstone
to achieving UHC and to enhancing
health systems’ resilience, cost-
effectiveness, and equity. Countries
across the globe with their respective
PHC systems need to continuously
adapt, improve, and implement their
strategies as per the local context
and determinants [3,4,11]. Several
initiatives have been suggested to
support this improvement with a no-
one-size-fits-all approach [12,13].
As part of the PHC working group
in the World Medical Association
(WMA) Junior Doctors Network
(JDN), several members gathered
on multiple occasions, in-person and
online, to share experiences within
their PHC systems. This narrative
review incorporates synthesized
data informed by published and
unpublished articles in the literature,
as well as from national and
international resources and registries.
Furthermore, data were collected
from first-hand experiences of the
junior doctors working in primary
health care in Brazil, Canada, Cuba,
Germany, India, Myanmar, Nigeria,
and Tunisia. In the discussion, we
conducted a Strengths, Weaknesses,
Opportunities, Threats (SWOT)
analysis of the described PHC
systems, using the Primary Health
Care Performance Initiative (PHCPI)
as a reference framework, which
“describes the critical components of
a strong primary health care system
and serves as the foundation of the
initiative’s activities” [13].
This review was conducted to provide
an overview of PHC systems across
the world, including the strengths
and gaps of various systems, and to
provide a brief overview of learning
opportunities for other systems. From
the point of view of junior doctors,
this paper offers a general overview
of the diversity of PHC systems and
describes the workforce and financing
across different countries and regions.
The working group has decided to
focus on the following domains for
the narrative review: service delivery,
PHC workforce, and PHC financing.
Findings
PHC systems are designed to provide
preventive, promotive, curative,
rehabilitative, and palliative health
care services, which are readily
accessible and available to the
community, and develop community
participation and engagement [7,14].
Each PHC system is defined by a set
of indicators that are shared publicly
and frequently monitored [13]. The
PHCPI has supported the process
of showcasing these indicators via a
conceptual framework and vital signs
profiles in the following domains:
System, Inputs, Service delivery,
Outputs, and Outcomes [13].
Service Delivery
Some aspects of PHC service
delivery across our represented
countries (Brazil, Canada, Germany,
India, Myanmar, Nigeria, Cuba, and
Tunisia) from the authors’ first-hand
experiences are summarized below:
Spectrum of Services
In all the observed countries, PHC
provides services like the treatment
and management of acute and chronic
diseases, immunizations, minor
surgical procedures (e.g. suturing
wounds or other procedures in local
anaesthesia), and health screenings.
Health promotion belongs to the
spectrum of services in all countries.
The availability of cancer screening
services and specific treatment
options for communicable and non-
communicable diseases vary among
the observed settings. In Brazil, PHC
provides social protection activities
to the communities; in India, health
education, family welfare services,
and water, sanitation, and hygiene
(WASH) actions are provided
directly within communities. In
Tunisia and Germany, nutrition
or tobacco counselling services are
only optionally provided in some
PHC centres. Family planning and
antenatal care forms part of PHC in
Tunisia, Brazil, India, and Canada,
whereas obstetric services are also
offered at PHCs in India, Canada,
and Myanmar. In Germany, antenatal
care and obstetric services are usually
provided by gynaecologists. In all the
highlighted countries, basic mental
health counselling is an offered
service at the PHC facility.
Infrastructure
Equipment for vital signs monitoring,
such as blood pressure, temperature,
and oxygen saturation, is available in
all presented countries. Most PHC
facilities have an electrocardiogram.
Ultrasounds are very common in
German PHC facilities, often in
Canadian PHC facilities, and rare in
Nigerian PHC facilities. In Tunisia,
some PHC facilities offer x-ray
services, and in Brazil PHC facilities
are equipped for dental care and public
pharmacy. Most PHC facilities in the
observed countries collaborate with
laboratories, while in some settings
(Nigeria,Tunisia, Germany) there are
point-of-care laboratories within the
PHC facility.
38
Referral Mechanisms
A gatekeeping system is in place in
India, Canada, and Brazil, where
the patient is referred to secondary
or tertiary care after visiting a PHC
centre. In Tunisia, referral to other
levels of care is only necessary in the
public sector. In the private sector, as
well as in Germany, self-referral or a
direct consultation at the secondary
or tertiary care level is possible.
In the private medical sector in
India, referrals are made within the
hospital or with established referral
connections of private medical
providers
PHC Workforce and Financing
Elements on PHC workforce and
system financing are summarized for
the respective countries (Table 1).
Data on the number of physicians per
10,000 population density, PHC out-
of-pocket (OOP) expenditure, and
external expenditure (USD) (23 July
2022) was extracted from the WHO
databases [15,16].
Brazil
Workforce
The workforce consists of two types of
teams: 1) the Family Health Strategy
included the family doctor (medical
residency or general practitioner,
GP), nurse, nursing technician, dental
surgeon, and community health
workforce; and 2) the “traditional”
team had GPs, nurses, and specialists
in preventive medicine, internal
medicine, paediatrics, gynaecology
and obstetrics.
The physician density is 23.1 per
10,000 population (2019) [15].There
is a two-year residency program in
Family and Community Medicine,
with the possibility of a one-year
additional training in specific
topics (i.e. health management and
preceptorship, preventive medicine,
palliative care) or access to other
specialty training (e.g. allergy and
immunology). Clinical guidelines for
the PHC setting are published by
the Ministry of Health and the State
and Municipal Health Departments
through the Unified Health System.
Financing
There is a salary-based payment for
PHC providers paid by public health
funds. The Brazilian Unified Health
System is a national health system
that is 100% financed with public
resources and has universal and
comprehensive access to all levels of
treatment, including the PHC.
Canada
Workforce
The PHC team consists of doctors,
nurses, physiotherapists, occupational
therapists, psychologists, social
workers, and other allied health
professionals. Physician density is
24.4 (2019) per 10,000 population
[15]. There is a two-year Family
Medicine specialty training (but
ongoing discussions towards
extending the duration of training to a
three-year program), with the option
of doing an additional fellowship of
3-12 months in other fields. While
the health systems are organized
at the provincial and federal levels,
the Canada Health Act dictates
several principles that underpin a
universal PHC system across the
country. Those principles include
public administration, accessibility,
universality, comprehensiveness, and
portability.
Financing
Health professionals are paid mostly
by the single-payer systems, except
for providers offering non-ensured
services. Although Canadian health
care systems are different in each
province, most care is covered by
a single-payer tax-funded system.
Some types of care, however, have
incomplete coverage, such as dental
care, eye care, psychological services,
and outpatient medications.
Cuba
Workforce
The PHC workforce (basic health
team) is comprised of a family
doctor and a nurse at the consultorio.
There are bigger teams made up of
8-10 basic work teams, plus other
primary care specialists – obstetrician,
gynaecologist, psychiatrist, statistician,
epidemiologist, internal medicine,
dentists, and ophthalmologist.
Additionally, there are supportive
teamsofotherspecialistsandtechnical
staff who run a clinic once a month
at the community polyclinics. The
physician density is 84.2 per 10,000
population (2018) [15]. There is a
general three-year competency-based
Comprehensive Medicine residency
program based at the consultorios for
Cuban medical residents (or two years
for international medical residents).
Regarding clinical guidelines, there
is a general national program on
implementation of primary health
care,family doctor and nurse program,
and other disease and age-specific
community health programs.
Financing
The PHC workforce receives a
salary paid by the state. There is
universal health coverage for Cuban
citizens, meaning that every health
and health-related service is paid
for by the state through a tax-based
system. There is a co-pay system
for medication with government
subsidies. For international residents,
Primary Health Care Systems across the Globe: Does One Size Fit All?
BACK TO CONTENTS
39
it is an insurance-based fee-for-
service system and OOP.
Germany
Workforce
The basic team consists of doctors,
nurses, and non-physician assistants.
Collaborations exist with other
internal medicine specialties,
physiotherapists, nutrition specialists,
and other health professionals. The
physician density is 43.7 per 10,000
population (2019) [15]. There is a
five-year residency program in GP
and Family Medicine, which requires
least two years of GP practice and at
least one year of internal medicine.
Clinical guidelines specific to the
PHC setting are provided by German
College of General Practice and
Family Medicine (DEGAM).
Financing
Payment mechanisms are mainly fee-
for-service mixed with capitation fee,
alongside Disease Related Groups.
GPs are self-employed or employees
in GP practices or medical centres.
Public health insurance funds exist
through shared contributions of
employer and employee (percentage
of gross income), and about 11% of
the population has private health
insurance.
India
Workforce
The workforce comprises one PHC
medical doctor, other specialists
visiting weekly, and alternative
health providers who may work
in some settings, as well as nurses,
auxiliary nursing midwifes, and
Accredited Social Health Activist
(ASHA) personnel. PHC is the first
point of contact between the village
community and the doctor having at
least 15 people including a medical
officer (MO) and a medical health
assistant. Physician density is 7.4 per
10,000 population (2020) [15].There
is a three-year MD (Master) and
DNB (Diploma) in Family Medicine.
Residency programs exist which
started because of advocacy due to a
need in the country, modelled on the
United Kingdom’s National Health
Service (NHS) and the US Family
Medicine programs.
There is a three-year MD (Master)
and DNB (Diploma) in Internal
Medicine who practice as GPs or
family physicians. Although clinical
guidelines are provided by the
government for public and private
hospitals, private hospitals have their
own rules in compliance.
Financing
PHC personnel are paid a fixed
amount by the respective government
department. Private GP practices
are self-owned. Private hospitals pay
a fixed salary to their employees,
although sometimes, allopathic
generalists may be paid the same
as alternative medicine graduates.
PHC services are funded by the
government, with minimal entry fees
in public hospitals and generally high
OOP (mixed payment structure).
Private health insurance is accepted in
both government and private set-ups.
National programs and social actors
help economically weaker sections of
the society.
Myanmar
Workforce
The PHC team is composed of a
doctor, nurses, female health visitor,
public health staff, community health
educators, midwives, and volunteer
health personnel in the public sector.
In private general practice clinic,
the team is composed of doctor
and nurses. Physician density is 7.4
per 10,000 population (2019) [15].
There is a one-year diploma program
in Family Medicine, and a three-
year MSc in Family Medicine is
being planned (temporarily halted
due to COVID-19 and military
coup). Clinical guidelines for health
care professions are provided by
the Myanmar Medical Association
General Practitioner Society.
Financing
In the public sector, there is a fixed
salary-based payment for most
employed health professionals. In the
private sector GP are self-employed.
A health insurance is under
development, but it has been halted
due to the coup and the COVID-19
pandemic.
Nigeria
Workforce
The PHC workforce is comprised
of doctors, community health
practitioners, health assistants, nurses
and administrative support staff.
Physician density is 3.8 per 10,000
population (2018) [15]. There is a
diploma in Family Medicine for a
duration of 18 months and a residency
training in Family Medicine for 4-6
years. Clinical guidelines are provided
by the National Primary Health Care
Development Agency (NPHCDA).
There are also standing orders
drafted for the community health
practitioners as there are primary
health centres without a physician.
In Nigeria, most of the PHCs are in
rural settings.
Financing
At the public PHCs, clinical and
non-clinical staff are paid by the
government. Although some
patients are enrolled in Nigerian
Health Insurance Scheme (NHIS),
Primary Health Care Systems across the Globe: Does One Size Fit All?
BACK TO CONTENTS
40
most patients pay out of pocket.
Furthermore, there are some
community-based health insurance
schemes.
Tunisia
Workforce
A PHC team consists of family
doctors (up to three), nurses,
midwives, dentists, and pharmacists,
visiting the PHC centre daily, and
fewer consultations of nutrition,
psychology, gynaecology, paediatrics,
and other medical specialties.
Physician density is 13.0 per 10,000
population (2017) [15]. There is a
three-year specialty training program,
rewarding with a specialty diploma in
Family Medicine. Clinical guidelines
for chronic diseases management
and public health measures are
provided by the Ministry of Health
and the National Institute of Health
Accreditation and Evaluation.
Financing
There is a salary-based system in
the whole public health care system
and fee-for-service in the private
sector for GPs. A public insurance
exists for basic health services in the
public sector as well as co-payments
and partial reimbursement for
contributors in the private sector.
Discussion
This review aimed to consolidate
PHC systems across the world and
highlight similarities and differences
across systems regarding delivery
of care, services, financing, and
workforce. The information from
Brazil, Canada, Cuba, Germany,
India, Myanmar, and Tunisia stands
for even more diversity across the
globe as well as regional, social,
cultural and political differences
within countries. Generally, countries
represented have several elements in
common:
-PHC workforce: Aphysician-centred
model and a team working within the
PHC centre, and training programs
of Family Medicine ranging from 2 to
5 years. This structure is in line with
the worldwide recommended capacity
building for the health workforce in
the PHC setting [17].
– PHC financing: Expenditures for
the PHC settings are multi-factorial
and can range from 40 to 50% of the
current health expenditures in most
countries represented, except Nigeria
(67%) and Myanmar (68%).
In addition, some aspects differ across
countries and highlight challenges at
the global level:
– PHC workforce: There is a great
diversity in physician density per
10,000 population (range from 3 to
84) from the countries represented.
There is also a difference in the PHC
teams, showing other possible models
(e.g. community health workers) or
additional competencies (e.g. tobacco
cessation counsellors, mental health
specialists, nutritionists).
-PHC financing: Paymentmechanisms
for health care professionals and
PHC services vary a lot and have been
developed in adaptation to the societal
and political contexts. Clinicians and
patients should not face financial
hardships, and clinicians’ financial
rights for provided services must be
ensured. Moreover, indicators related
to financing the PHC system are met
[13,18].
Overall, the importance of a strong
PHC system has been outlined
and prioritized in advocacy efforts.
Operational guidance for PHC
strengthening has been developed
to support governments and health
authorities undergoing health system
transformation and redirection
[7,9,13]. Notably, this article includes
authors working in the respective
systems from five continents and
countries of different income groups.
However, with limited availability
and comparability of national data
Table 1. Health expenditure (in USD, millions) across eight selected countries. Note: a
PHC expenditure data (Nigeria) from 2011, and OOP expenditure data
from 2019. b
PHC expenditure data (Cuba) from 2015. Source: World Health Organization’s Global Health Expenditure Database (n.d.) [16].
Brazil Canada Germany India Myanmar Nigeriaa
Cubab
Tunisia
Primary health care
(PHC) expenditure
40 48 48 45 67 68 42.6 48
Out of pocket (OOP)
expenditure
25 15 13 55 76 71 11 38
External expenditure – – – 2 10 15 – 1
Primary Health Care Systems across the Globe: Does One Size Fit All?
BACK TO CONTENTS
41
related to PHC indicators, the
authors relied on existing data from
the WHO database. Since only
one health system per country was
presented, the diversity of PHC
systems may have been overlooked.
To monitor indicators and ensure the
validity of future analyses, the authors
recommend that countries measure
and make PHC data available
annually for the general populace.
Call to Action
Sharing best practices and
exchanging national experiences
between countries can help with
the adaptation and implementation
of general recommendations to
strengthen PHC. By recognizing that
countries have diverse health systems,
collaborating and learning from each
other can lead to cost-effective and
feasible local solutions. Quantitative
and qualitative implementation
research studies are needed to
understand different contexts and
allow the adaptation of successful
interventions. Furthermore, global
health care systems should provide
easily accessible, high quality, and
equitable care at the PHC level.
However, the implementation of
PHC improvement strategies and
its translation to clinical practice are
not always guaranteed and should
be supported by the identification of
barriers that can be monitored and
addressed [19]. Overall, this global
representation comes with assets
showcased in the SWOT Analysis
(Figure 1).
Conclusion
As PHC is constantly evolving while
facing challenges all over the world,
the JDN PHC working group seeks
to facilitate a platform for junior
doctors working in PHC to share
their visions, experiences, ideas on
improvement, and lessons learned
to strengthen PHC systems. The
perspectives of health care providers
must be included at all stages of policy
making. Furthermore, strong political
commitment towards strengthening
and investing in PHC is needed,
placing PHC at the core of every
health care system. As this article
offers a general overview on how
PHC is addressed worldwide from
a junior doctor perspective, we hope
that it encourages readers to continue
their analyses.
References
1. Campbell DA. An update on
the United Nations Millennium
Development Goals. J Obstet
Gynecol Neonatal Nurs.
2017;46(3):e48-55.
2. Fendall NR. Declaration
of Alma-Ata. Lancet.
1978;2(8103):1308.
3. Langlois EV, McKenzie A,
Schneider H, Mecaskey JW.
Measures to strengthen primary
health-care systems in low-
and middle-income countries.
Bull World Health Organ.
2020;98(11):781-91.
4. Kruk ME, Gage AD, Arsenault
C, Jordan K, Leslie HH,
Roder-DeWan S, et al.
High-quality health systems in
the Sustainable Development
Goals era: time for a revolution.
Lancet Glob Health.
2018;6(11):e1196-252.
5. The Global Goals. Sustainable
Development Goals – Goal
3: goad health and well-being
[Internet]. n.d. [cited 2022 Aug
30]. Available from: https://
globalgoals.org/goals/3-good-
health-and-well-being/
6. World Health Organization.
Declaration of Astana. Geneva:
WHO; 2018. Available from:
https://w w w.who.int /pub-
l icat ions-deta i l-red i rec t /
WHO-HIS-SDS-2018.61
7. World Health Organization.
Primary health care [Internet].
n.d. [cited 2022 Aug 30].
Available from: https://
www.who.int/health-topics/
primary-health-care
Strengths
• Operational framework for
PHC performance
• Guidelines supporting clinical
practice and policy
Weaknesses
• Inconsistent PHC workforce density
• OOP expenditure is greater
than 35% in half of the
represented countries
• Lack of funding for PHC
Opportunities
• Collaborations between sectors and
at the global level
• Learning from best practices
Threats
• Implementation challenges
• Monitoring
• Transparency
Figure 1. Global representation of primary health care (PHC) systems using the Strengths, Weaknesses,
Opportunities, and Threats (SWOT) analysis.
Primary Health Care Systems across the Globe: Does One Size Fit All?
BACK TO CONTENTS
42
8. Loffreda G, Bello K,
Kiendrébéogo JA, Selenou I,
Ahmed MAA, Dossou JP, et al.
Political economy analysis of
universal health coverage and
health financing reforms in low-
and middle-income countries: the
role of stakeholder engagement
in the research process. Health
Res Policy Syst. 2021;19(1):143.
9. Organization for Economic
Co-operation and Development.
Strengthening the frontline:
how primary health care helps
health systems adapt during the
COVID 19 pandemic. 2021
[cited 2022 Aug 30]. Available
from: https://www.oecd.org/
coronavirus/policy-responses/
strengthening-the-frontline-
how-primary-health-care-helps-
health-systems-adapt-during-
the-covid-19-pandemic-9a5ae-
6da/
10. World Health Organization.
Primary health care: a key topic
at the World Health Assembly
[Internet]. 2019 [cited 2022 Aug
30]. Available from: https://www.
who.int/news/item/19-05-2019-
primary-health-care-a-key-top-
ic-at-the-world-health-assembly
11. Hanson K, Brikci N, Erlangga
D, Alebachew A,De Allegri MD,
Balabanova D, et al. The Lancet
Global Health Commission
on financing primary health
care: putting people at the
centre. Lancet Glob Health.
2022;10(5):e715-72.
12. World Health Organization.
Progressing primary health
care: a series of country case
studies. Geneva: WHO; 2018.
Available from: https://www.who.
int/publications-detail-redirect/
WHO-HIS-SDS-2018.17
13. PrimaryHealthCarePerformance
Initiative. The primary health
care performance initiative
conceptual framework [Internet].
2018 [cited 2022 Aug 30].
Available from: https://
i m p r o v i n g p h c . o r g /
phcpi-conceptual-framework
14. World Health Organization.
Universal health coverage
[Internet]. 2022 [cited 2022 Aug
30]. Available from: https://www.
who.int/health-topics/univer-
sal-health-coverage#tab=tab_1
15. World Health Organization.
Global Health Observatory:
medical doctors [Internet].
2022 [cited 2022 Aug 30].
Available from: https://apps.
who.int/gho/data/node.main.
HWFGRP_0020?lang=en
16. World Health Organization.
Global health expenditure data-
base. n.d. [cited 2022 Aug 30].
Available from: https://apps.
who.int/nha/database/Select/
Indicators/en
17. Michels NRM, Maagaard
R, Buchanan J, Scherpbier
N. Educational training
requirements for general
practice/familymedicinespecialty
training: recommendations for
trainees, trainers and training
institutions. 2018;29(6):322-6.
18. Alshareef A. Provider payment
mechanisms: effective policy
tools for achieving universal and
sustainable healthcare coverage
[Internet]. 2019 [cited 2022 Aug
30]. Available from: https://www.
intechopen.com/chapters/68032
19. Bazemore A, Neale AV, Lupo
P, Seehusen D. Advancing the
science of implementation in
primary health care. J Am Board
Fam Med. 2018;31(3):307-11.
Skander Essafi, MD
Family Medicine Specialist
Sousse, Tunisia
Lekha Rathod, MBBS, MScIH
Research Assistant,
Julius Global Health, UMC Utrecht
Utrecht, Netherlands
Mercy Wanjala, MBCHB,
MMED (Fam. Med)
MBA Healthcare
Management Candidate,
Strathmore Business School
Family Physician
Nairobi, Kenya
Andrey Cruz, MD
Faculty of Medical Sciences of
Santa Casa de São Paulo
São Paulo, Brazil
Dabota Yvonne Buowari, MBBS
Department of Accident and Emergency,
University of Port Harcourt
Teaching Hospital
Port Harcourt, Nigeria
Wunna Tun, MBBS, MD
Fellow, Medical Education
JDN Secretary
Yangon, Myanmar
Yassen Tcholakov, MD, MSc, MIH
JDN Chairperson
Assistant Professor,
Department of Epidemiology,
Biostatistics, and Occupational Health,
McGill University
Montreal, Canada
Flora Wendel, MD
JDN Working Group Chair on
Primary Health Care
Research Assistant,
Chair of Public Health and Health
Services Research, LMU Munich
Munich, Germany
Email: florakuehne@gmail.com
Primary Health Care Systems across the Globe: Does One Size Fit All?
BACK TO CONTENTS