WMJ_2023_03_FINAL

Official Journal of The World Medical Association, Inc. Nr. 3, September 2023
vol. 69
Contents
Editorial   3
Interview with the President of the World Federation for Medical Education   4
Interview with the Executive Director of the One Health Commission   7
WMA Members Share Reflections about International Day for Older Persons 2023 12
Modernizing Health Education: The Need to Address Planetary Health
by Taking a One Health Approach   22
The Health Care System in Canada: The Canadian Medical Association is Hosting
a Consultation Process on the Proper Mix of Public and Private Funding and Delivery    26
Violating the Principle of the Division of Powers Threatens our Profession   29
Revolutionising Medical Transportation: The Emergence of On-Demand
Ambulance Services through E-hailing Platforms   31
Current Status and Future Role of Paediatric Surgery in China   36
Confederación Médica de la República Argentina (COMRA)   41
Brazilian Medical Association (Associação Médica Brasileira)   42
Bulgarian Medical Association   43
German Medical Association (Bundesärztekammer)   44
Icelandic Medical Association (Læknafélag Íslands)   46
Liechtenstein Medical Association (Liechtensteinische Ärztekammer)   47
Macedonian Medical Association   47
Nepal Medical Association   49
Somali Medical Association (Ururka Dhakhaatiirta Somaaliyeed)    51
Spanish Medical Council (Consejo General de Colegios Médicos de España)    52
74th World Medical Association General Assembly in Rwanda   54
Obituary 55
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. Jack RESNECK
Chairperson,
Finance and Planning Committee
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chicago, Illinois
United States
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. Zion HAGAY
Chairperson,
Socio Medical Affairs Committee
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Heidi STENSMYREN
Immediate Past President
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Mr. Rudolf HENKE
Treasurer
German Medical Association
(Bundesärztekammer)
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Jacques de HALLER
Chairperson,
Associate Members
Swiss Medical Association
(Fédération des Médecins Suisses)
Elfenstrasse 18, C.P. 300
3000 Berne 15
Switzerland
Dr. Jung Yul PARK
Chairperson of Council
Korean Medical Association
Samgu B/D 7F 8F 40
Cheongpa-ro,
Yongsan-gu
04373 Seoul
Republic of Korea
Dr. Steinunn
THÓRDARDÓTTIR
Chairperson,
Medical Ethics Committee
Icelandic Medical Association
Hlidasmari 8
201 Kópavogur
Iceland
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 policies or positions
3
Editorial
Editorial
BACK TO CONTENTS
As our global medical community strives to uphold high-quality
ethical standards for our medical and public health practice,
we reflect on significant policies and guidelines that have been
developed, debated, revised, and adopted across our nations.
Over the past nine months,World Medical Association (WMA)
leaders contributed their valuable expertise to prepare and revise
key resolutions (e.g. situations of violence, discrimination),
timely press releases (e.g. workplace violence, physicians’ rights),
and public statements (e.g. universal health coverage, pandemic
preparedness) that have been widely circulated.The 15th World
Conference on Bioethics, Medical Ethics, and Health Law,
which will be held in Porto, Portugal, from 16-19 October 2023,
will offer an additional platform to broaden these important
discussions, including the International Code of Medical Ethics
that was recently highlighted in the BMJ Journal of Medical
Ethics publication by Dr. Ramin Parsa-Parsi, Dr. Raanan
Gillon, and Dr. Urban Wiesing (https://pubmed.ncbi.nlm.nih.
gov/37487625/).
Physical and mental health and well-being are influenced by the
social determinants of health, including access and availability
to health services, which complement these discussions focusing
on medical ethics and environmental justice topics. Emerging
risks across our global communities include, but are not
limited to, the direct and indirect effects of climate change on
health, harmful smoke emissions from wildfires, drought and
flooding events that influence agriculture and food security, and
increasing temperatures and land use changes that favour vector
habitat expansion and risk of disease transmission. As a timely
opportunity, One Health Day (https://onehealthday.com/) is
recognized on 3 November 2023, encouraging global citizens to
collectively brainstorm on novel approaches to address complex
global challenges that impact human, animal, and ecosystem
health.
However, the question remains: How is our global medical
community preparing to meet health priorities as well as
strengthen medical education and training across our countries?
Albert Einstein expressed the continuous need to advance
science through critical appraisal: “To raise new questions, new
possibilities, to regard old problems from a new angle, requires
creative imagination and marks real advance in science”.
Collectively, we can identify existing knowledge and practice
gaps in our clinical and surgical fields as well as encourage
conversations about how we can apply innovative technology
and data applications,such as artificial intelligence and machine-
based learning, to accelerate drug and vaccine discovery and
improve algorithms for disease early warning systems. Since our
national medical associations (NMAs) represent indispensable
leadership across hospital and community settings, our active
participation in WMA and our specialty conference proceedings,
are influential ways to advance science, leverage expertise to
support national and global preparedness, and hence strengthen
national and global health security.
The 74th WMA General Assembly will be held in Kigali,
Rwanda, from 4-7 October 2023. The Rwanda Medical
Association has shared the formal invitation in this issue, noting
the “Global Health Security” theme of the scientific session. At
this event, WMA members will contribute to key discussions
affecting physicians, review WMA statements and resolutions,
gain insight from invited speakers on global health security
topics, and expand networking opportunities with other NMAs
and WMA members.
In this issue, Dr. Ricardo León-Bórquez, Dr. Geneviève
Moineau, Ms. Romana Kohnová, and Dr. Cheryl Stroud shared
personal reflections on their leadership and training, current
and upcoming priorities, and opportunities to become involved
in World Federation for Medical Education and One Health
Commission activities, respectively. Dr. Deborah Thomson
and colleagues described the value of adding planetary health
into health education. Dr. Jeff Blackmer offered insight on
the ongoing discussion related to public and private funding
within the Canadian health care system. Dr. Ole Johan Bakke
and Dr. Axel Rød stressed the importance of the principle of
the separation of powers, showcasing the case of the Turkish
Medical Association. Mr. Michael Willie and Dr. Sipho Kabane
expressed enthusiastically how technology (e-hailing platforms)
can revolutionize medical transportation. Finally, Dr. Ni Xin
highlighted scientific advancements related to paediatric surgery
in China.
We acknowledge the admirable leadership contributions
that WMA members provide each day in their clinical and
community workplace. In this issue, 10 NMAs unveil key facts
about their leadership, history, mission and objectives, national
and international collaborations, current challenges, and future
vision. Also, we can learn from WMA members representing
nine countries who present policies and community activities
that support healthy aging and the International Day of Older
Persons 2023. Together, we can truly expand the current
scientific knowledge base by emphasizing how critical appraisal
is key to addressing emerging global health risks and hence
protecting population health and well-being. We look forward
to networking at the WMA General Assembly in Kigali!
Helena Chapman, MD, MPH, PhD
Editor in Chief of the World Medical Journal
editor-in-chief@wma.net
4
What is the World Federation for
Medical Education, and what are
the organisational goals?
The World Federation for Medical
Education (WFME) is a not-
for-profit and non-governmental
organisation that works to support
healthcare for all through promoting
high quality in medical education for
the physician workforce, prospective
students, and trainees. Established
in 1972 by the World Medical
Association (WMA) and the World
Health Organisation (WHO), the
mission of the WFME is to enhance
the quality of medical education
worldwide. To achieve this mission,
the WFME collaborates with doctors,
educators, and medical schools
worldwide through its six member
regional associations (https://wfme.
org/about/partner-organisations/)
for medical education, collectively
forming the WFME Executive
Council (https://wfme.org/about/
executive-council/).
The six regional associations include:
• Association for Medical Education
in the Eastern Mediterranean
Region (AMEEMR) (http://www.
ame-emr.org/)
• Association of Medical Schools in
Africa (AMSA) (https://wfme.org/
publications/amsa-brochure-2/)
• Association of Medical Schools in
Europe (AMSE) (https://amse-
med.eu/)
• Pan-American Federation of
Associations of Medical Schools
(PAFAMS) (http://www.
fepafempafams.org/)
• South East Asian Regional
Association for Medical Education
(SEARAME) (http://seara-meded.
org/)
• Western Pacific Association of
Medical Education (WPAME)
(http://www.wpame.org.au/)
Alongside the member regional
associations, the WFME Executive
Council comprises the WMA
and the WHO, together with the
International Federation of Medical
Students’ Associations (IFMSA)
(https://ifmsa.org/), Junior Doctors
Network (JDN) (https://www.wma.
net/junior-doctors/), the ECFMG®
(http://www.ecfmg.org/), a member
of Intealth™, and the Association
for Medical Education in Europe
(AMEE) (https://amee.org/).
What are the current WFME
priorities and activities for
2023-2024?
Our current priorities encompass
several key areas, including
promoting accreditation of basic
medical education through
the WFME Recognition of
Accreditation Programme (https://
wfme.org/accreditation/wfme-
recognition-programme/), raising
standards across various stages of
medical education (undergraduate,
postgraduate, continuing professional
development) and in distributed and
distance learning, and maintaining
the World Directory of Medical
Schools (http://www.wdoms.org/), a
comprehensive and free searchable
directory of undergraduate medical
education programmes worldwide.
For the period spanning 2023 to 2024,
the WFME has organised activities
related to the following areas:
Recognitionof AccreditationProgramme
The Recognition of Accreditation
Programme delivers an independent,
transparent, and rigorous method
of ensuring that accreditation of
medical schools worldwide is at an
internationally accepted and high
standard. The WFME evaluates
compliance of accrediting agencies
with pre-defined criteria, where
currently, 38 agencies have received
recognition and 17 agencies are
in process.
Ricardo León-Bórquez
Interview with the President of the World
Federation for Medical Education
Geneviève Moineau
Romana Kohnová
Interview with the President of the World Federation for Medical Education
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WFME Standards
In the WFME Standards project,
the focus is directed to the recent
publication of the revised WFME
Standards for Postgraduate Medical
Education (PGME) (https://wfme.
org/standards/pgme/), which has
been revised to be principles-based
rather than prescriptive-based. This
resource enables users to develop
their own local practice aligned
with their context and culture. As a
follow-up to the recent publication,
the WFME has been working on
developing a webinar series dedicated
to postgraduate medical education.
With the aim of transitioning all
WFME standards to a principles-
based approach,next steps include the
revision of the WFME Standards for
Continuing Professional Development.
World Directory of Medical Schools
The WFME will continue to
support this comprehensive and
valuable publication by updating the
content as new medical schools are
established and the status of existing
medical schools change. The World
Directory (https://www.wdoms.org/
about/), which is maintained jointly
with FAIMER®, a Member of
Intealth™, contains information on
over 3,700 operational and historical
schools. Each record highlights
available school details, including
year of establishment, school type,
operational and status, programme
details, and contact information.
The strategic objective involves
the integration of accreditation
information.
Engagement in Medical Education
Accreditation Scholarship
The WFME has taken a strategic step
to expand its activities by exploring the
creation of an International Research
Network to support the advancement
of scholarship in medical education
accreditation.
How has the coronavirus disease
2019 (COVID-19) pandemic
affected medical education across
the world?
The onset of the COVID-19
pandemic created a clear distinction
between medical students and
residents. Medical students could no
longer attend in-person classroom,
small group teaching sessions or
clinical clerkships.On the other hand,
medical residents were redeployed
away from their educational rotations
to provide clinical services, where
needed, regardless of the risks
involved.
Medical schools with a robust
infrastructure and financial
resources rapidly moved to online
education. Many regions of the
world, however, required innovative
academic approaches, which directly
depended on available technology
and connectivity. Learners at all
stages were also deeply affected by
the progressive burnout experienced
by their clinician preceptors who no
longer had the capacity to teach or
supervise.
These unprecedented times led to
unique levels of cooperation and
collaboration, while global medical
education leaders demonstrated
dedicated efforts to provide the best
education possible to their learners.
We also realized the extent to which
distance learning is possible and, in
2021,the WFME released distributed
and distance learning standards
(https://wfme.org/standards/ddl/).
What are the current challenges in
medical education across the world,
and how can these challenges be
addressed?
The COVID-19 pandemic has led to
a worldwide health workforce crisis,
and medical education is in great
demand. Medical education leaders
must engage with their governments
to ensure that they train physicians
to meet the diverse needs of the
populations they serve.
Medicalschoolcurriculamustadaptto
include the most pressing novel health
issues for society. Currently, these
Interview with the President of the World Federation for Medical Education
Photo 1. WFME Executive Council meeting in April 2023, Québec, Canada. Credit: WFME
6
topics include recognizing the value of
public health, training future primary
healthcare providers, becoming aware
of artificial intelligence and machine
learning as new tools in the delivery
of patient care, and understanding
the impact of the climate crisis on
health and healthcare providers’
urgent role to address planetary
health. The WFME Executive
Council has agreed to be a signatory
to the Academic Health Institutions’
Declaration on Planetary Health
(https://www.afmc.ca/initiatives/
planetaryhealthdeclaration/), which
calls on medical schools to educate
their students on planetary health,
conduct health research on addressing
the climate crisis, and advocating
for the responsible behaviours of
institutions and health systems in
reaching net-zero emissions.
As leaders in medical education, it is
our obligation to support the well-
being of our learners, educators,
preceptors, and clinicians through
healthy and safe learning and work
environments. Despite our rapidly
evolving world, the importance of
the human connection between
healthcare providers and their
patients will never change in medicine
and medical education, and that
ultimately, our patients will always be
our best teachers.
How can WMA members become
more involved in WFME activities
and help strengthen medical
education across their countries?
First, WMA members can engage
with medical schools in their countries
and medical education associations in
their region, to advocate for forward-
looking curricula delivered in
positive learning environments. This
advocacy for excellence in medical
education should include support for
strong accreditation environments
for medical schools and residency
programs. The WFME Recognition
of Accreditation Programme for basic
medical education and the potential
development of a postgraduate
recognition programme contribute to
the pursuit of excellence.
Second, the WFME and the
ACGME Global Services have
collaborated on the development of
the Global Postgraduate Medical
Education Survey (https://wfme.org/
wfme-and-acgme-global-services-
exploring-postgraduate-medical-
education-oversight-worldwide/).
WMA members can contribute
their perspectives on accreditation
practices in postgraduate medical
education worldwide. This project
aims to promote collaboration and
sharing of knowledge and best
practices among organisations
responsible for enhancing the quality
of postgraduate medical education
accreditation processes in their
respective jurisdictions.
Finally, the WFME is requesting
that all WMA members consider
being a signatory organisation on
the Academic Health Institutions’
Declaration on Planetary Health.
We look forward to seeing many
WMA members at the WFME
World Conference 2025 in Bangkok,
Thailand, on 25 to 28 May 2025.
At this event, your voices as medical
leaders will help shape the future of
medical education around the world.
Authors
Ricardo León-Bórquez, MD
President,
World Federation for
Medical Education
Geneviève Moineau, MD
Vice-President,
World Federation for
Medical Education
Romana Kohnová
Executive Assistant,
World Federation for Medical
Education Office
admin@wfme.org
Interview with the President of the World Federation for Medical Education
BACK TO CONTENTS
Photo 2. WFME team photo in January 2023, with Romana Kohnová, Barbora Hrabalová, Ricardo León-Bórquez,
Geneviève Moineau, Jana Cohlová (left to right). Credit: WFME
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BACK TO CONTENTS
For this interview, Dr. Cheryl Stroud,
executive director of the One Health
Commission (OHC) (https://www.
onehealthcommission.org/), a non-
profit organisation based in the
United States but working globally to
help the world understand our urgent
need for One Health, shares her
background,her leadership of the One
Health Commission, perspectives on
leverageing One Health expertise
across global networks, and how
World Medical Association (WMA)
members can contribute to the One
Health paradigm shift, with Dr.
Helena Chapman, the WMJ Editor
in Chief.
Please describe three key learning
moments during your veterinary
medicine and doctoral research
training and your career.
Because no one profession or
discipline can know everything, we
must join hands across professions
to share knowledge. This awareness,
concept, and approach is known
as One Health. I will answer this
question as key learning moments
on my journey to becoming a One
Health advocate and practitioner.
First, after four years studying
veterinary medicine to become an
animal health practitioner, I took the
Veterinarian’s Hippocratic Oath [1]:
Being admitted to the profession of
veterinary medicine, I solemnly swear
to use my scientific knowledge and
skills for the benefit of society through
the protection of animal health and
welfare, the prevention and relief of
animal suffering, the conservation of
animal resources, the promotion of public
health, and the advancement of medical
knowledge.
I will practise my profession
conscientiously, with dignity, and in
keeping with the principles of veterinary
medical ethics.
I accept as a lifelong obligation
the continual improvement of my
professional knowledge and competence.
I was aware,in that moment,standing
before the world in my graduation
robes, of my responsibilities not only
to animal health, but also human
health. I was literally taking an oath
to promote public health. It was years
later, however, that I came to fully
realise the significance of that oath
and to understand its meaning today
as a One Health practitioner. This
moment was a first step in my One
Health awakening.
Second, after working for a couple
of years as a veterinary clinician, I
decided to continue my education
with graduate studies in endocrine
physiology to gain research skills,
which are very different from clinical
practice skills. It was fascinating
to more deeply understand how
hormones – which regulate
our metabolism, bone density,
reproduction, and emotions – are
physiologically remarkably similar
across humans, non-human animals,
and even plants. In fact, one day, I
distinctly remember an “aha moment”
while sitting in my reproductive
physiology class, when I realised
that there are endocrine disrupters
in our shared environment that can
affect both animals and humans.
That was my awakening to the
interconnectedness of environment
and ecosystem health with health
of all life forms, and my realisation
of how animals, environments, and
humans form a triumvirate of health:
there is only One Health.
Plantsarealsofascinatinglivingtissues
that are affected by their environment
– by the soil microbiome, by climate,
and atmosphere – and can pass on
any harmful exposures to creatures
that feed on them. Increasing global
carbon dioxide levels and depleted
soils affect plant nutrient uptake,
resulting in nutritional deficiencies
among any creatures (animals or
humans) that depend on them for
nourishment [2,3]. Thus, I expanded
my understanding of One Health to
include plants and soil health.
Third, the emergence of the One
Health movement coincided with
my own mother’s neuro-degenerative
decline and death and offered a
very personal revelation. In the late
1990s and early 2000s, a discussion
emerged – first as ‘One Medicine’
and subsequently as ‘One Health’
– from ecologists and conservation
medicine practitioners highlighting
that many diseases are of zoonotic
origin. The conversation ramped up
in 2003, with the mpox outbreak
in the United States, global High
Pathogenic H5N1 Avian Influenza
scare, and the severe acute respiratory
syndrome coronavirus (SARS CoV-
1) epidemic in Asia [4-6]. Then,
the H1N1 Influenza A pandemic,
inadvertently referred to as swine
flu in 2009, the emergence of the
Middle East Respiratory Syndrome
Cheryl Stroud
Interview with the Executive Director
of the One Health Commission
Interview with the Executive Director of the One Health Commission
8
BACK TO CONTENTS
(MERS) in 2012, and other zoonotic
disease events were documented, all
preceding the coronavirus disease
2019 (COVID-19) pandemic [7,8].
Parallel to these events, in 1999, my
mother began displaying clinical signs
of dizziness and disequilibrium that
progressed over a nine-year period.
She was eventually diagnosed with
progressive supranuclear palsy (PSP,
a cousin to Parkinson’s disease) and
died in 2008, at the age of 76. It was
devastating to watch her suffering
and overall health decline. Little did
I know that that personal experience
would drive my own career path.
As I became more involved in the
One Health conversation, I helped
launch a North Carolina One Health
Collaborative (NC OHC) in 2010,
where I worked closely with many
human and animal health colleagues.
We frequently discussed vector-
borne diseases (VBDs). As I learned
more and reflected on my mother’s
clinical presentation and decline,
I realised that it was very similar to
degenerative neurologic syndromes
observed from some long-term VBDs
such as Bartonellosis and long Lyme
borreliosis. My family (mother, father,
brother) were very active outdoor
enthusiasts, spending a lot of time
game hunting (deer,wild boar,turkey)
in the southern United States. It
began to haunt me that my mother
might have been infected with an
undiagnosed VBD.
Although I will never know the exact
aetiology of my mother’s illness, I
often ponder: What if her illness was
the result of a VBD infection? What
if we had had better diagnostics for
Lyme disease and other VBDs? What
if her doctors had known about and
been able to diagnose or rule out
Bartonellosis or other VBDs? If this
information had been available,would
it have saved my mother and others
who have suffered from ‘invisible’,
difficult to diagnose, diseases like
Lyme borreliosis and Bartonellosis?
The more I learned, the more
committed I became to One Health
discussions that would pave the
way for enhanced information and
knowledge sharing between animal,
human, and environmental health
practitioners and drive collaborative
research to develop diagnostics for
acute VBDs.
What were the driving factors
that led to your collaborative
efforts leading the One Health
Commission? What challenges
has your team faced in leverageing
One Health expertise across global
networks?
In a very real way, it was my mother’s
death that has driven my passion
and commitment to the One Health
movement.AsaresultofmyNCOHC
work, where we were increasing local
awareness about One Health, I was
invited to serve on the OHC Board of
Directors in 2012, and later became
Executive Director in late 2013. The
OHC is one of many organisations
actively working to help the world
understand our urgent need to make
One Health tenets the default way
of thinking, acting, and living at all
levels of academia, industry, research,
government, and policy (https://
tinyurl.com/OHC-WW).
As for challenges, I have always
believed that you do not have to
have a lot of money to accomplish
great things, and the OHC has so far
demonstrated that point of view. The
OHC is led by volunteers working
under the slogan, “Connect, Create,
Educate.” In other words, we work to
‘connect’ One Health stakeholders, to
‘create’ teams and networks that work
together across disciplines to ‘educate’
about One Health and One Health
issues.However,even with volunteers,
enabling working group activities does
require money.The greatest challenge
for the organisation has been finding
sustainable funding for OHC staff to
support the working groups and OHC
initiatives. Over the years, a number
of organisations (https://tinyurl.
com/OHC-Sponsors-Donors) have
stepped forward to financially support
the OHC and its activities and for
that we are very grateful.
One Health is not a new concept.
Many indigenous cultures have
understood the interconnectedness of
animals,humans and environment for
millennia.However,as our knowledge
grew, systems were developed that
pushed us into educational and
professional silos – such as existing
systems for publishing research
findings in professional association
journals that only association
members could access, structural
barriers as government agencies work
in silos, and language barriers across
professions. The current conversation
that we call One Health, that began
re-emerging in the late 1990s, was
first picked up by veterinarians in
the early 2000s. other professionals
perceived this early movement as just
coming from veterinarians, and less
relevant for those working in public
health,human health or anthropology.
So, challenges faced in leverageing
One Health expertise include helping
other professionals, beyond veterinary
medicine, realise that they are critical
players in implementing this One
Health concept and improving global
understanding of the full scope of
One Health beyond zoonotic diseases.
Many of today’s primary challenges
– climate change, antimicrobial
resistance, and disaster preparedness
and response – and others of equal
importance – comparative medicine
and translational research, human-
animal bond benefits, and food
safety and security – are begging to
be addressed using a One Health
approach.
Interview with the Executive Director of the One Health Commission
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Please describe a few significant
contributions of the One Health
Commission for the global
community.
Over the past 10 years, we have been
able to support actions that promote
critical awareness, including:
• Starting and continuing to lead
an annual global One Health Day
since 2016 (https://tinyurl.com/
OH-Day-Home)
• Leading an annual One Health
Awareness Month (https://tinyurl.
com/OH-OH-Awareness)
• Creating and disseminating a
monthly One Health Happenings
Newsletter (https://tinyurl.com/
OHC-OH-Happening)
• Compiling and sharing a Who’s
Who in One Health series of
maps (https://tinyurl.com/OHC-
WW) to highlight individuals
and organisations working in One
Health and encourage networking
to synergize our efforts to further
One Health
• Creating more trans-professional
network teams (https://www.
onehealthcommission.org/en/
programs/), especially for One
Health Education
• Preparing the 2021 Annual Report
[9]
What are three One Health
challenges that WMA members
should better understand?
First, because no one profession
can know everything, the One
Health way of thinking and sharing
information across disciplines can
benefit all health professionals and
their patients. Notably, human health
practitioners are a critical and integral
part of this One Health conversation,
and WMA members are urgently
needed to bring forward their own
knowledge and skills. Without your
active participation, the world will
never really understand the urgency
for our patients, creatures, and planet
of implementing this interconnected
way of thinking, or experience how it
can benefit them.
Second, one of my professors in
veterinary school once said, “You
cannot diagnose something you
cannot think of”. Hence, I have
expanded that idea in my own One
Health thinking:
• You cannot diagnose something
you cannot think of.
• You cannot think of something that
you do not know.
• You cannot know about something
that you have not been taught or
that never gets shared across current
professional silos.
Therefore, One Health can help
us with the sharing of critical
information and knowledge across
professions.
Third, incorporating One Health
thinking into your daily practice
can benefit both you and your
patients. The knowledge you gain
from One Health conversations
with other professionals – animal
health practitioners, social scientists,
economists,and environmental health
specialists – can enable you and your
team to offer the highest standard
of care that will be life-saving and
economically beneficial for patients
and society. Here are some examples:
Benefits to physicians
As physicians, your increased
awareness of communicable and non-
communicable diseases, shared by
animals and humans, and interactions
with their shared environment will
help you ask patients more astute,
thoughtful, pointed questions when
taking a patient history. For example,
the following questions can be added
to your patient intake forms:
• Do you live or work with animals?
If yes, what types of animals and in
what capacity do you live or work
with them?
• Do you sleep with your pets?
• Are your pets up-to-date on their
vaccinations?
• Are there any ill animals in your
home or surroundings?
• How would you describe your home
and community environment?
• How would you describe your work
environment?
• How would you describe your
leisure or play environment?
• Do you spend much time outdoors
gardening, hiking or camping?
Knowing these factors about your
patient will improve your ability
to know what questions to ask and
what tests to order for more directed
and better focused discernment and
confirmation of a diagnosis. In short,
this information can often lead to
a shorter time to diagnosis, more
targeted therapy, less medical costs,
and less patient suffering.
Benefits to patients
• More targeted diagnostics
• Shorter time to more accurate
diagnosis
• More targeted therapy
• Less suffering
Interview with the Executive Director of the One Health Commission
10
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• Saving money
• Saving lives
The end result will be an overall
higher standard of care and economic
benefits to patients and society.
As first steps, how can WMA
members contribute their expertise
to One Health collaborations and
become more involved in local and
national initiatives?
Contributing your expertise
• Include questions (as noted above)
about animal interactions on all
patient intake questionnaires.
• Be cognizant of potentially
overlooked parasitic and zoonotic
diseases (e.g. campylobacter,
leptospirosis, larval migrans, ring
worm, sarcoptes, cryptosporidia,
salmonella).
• Teach colleagues, children, and
patients about rabies.[Note: Species
of caution will vary by global region.
For example, in the Americas
region, bat rabies education focuses
on the avoidance of touching bats
or reporting interactions with bats,
whereas in other geographies, the
concern remains in contact with
dogs.]
• Use the human-animal bond to
help patients understand that their
pet’s health is dependent on their
own health. For example, if patients
understand that cigarette smoking
is bad for their cat, dog or bird,
then they may be inspired to stop
smoking. If your patients recognise
the health concerns of obesity for
themselves and their pets, including
expensive medical treatment
for pets’ clinical management of
arthritis, diabetes, and heart disease,
then they may be motivated to take
appropriate steps for weight loss for
both themselves’and their pets [10].
• Review the evidence-based
literature on zoonotic and vector-
borne diseases, especially in One
Health journals (https://tinyurl.
com/OHC-Jour-Perio).
• Seek relationships with local
veterinarians,public health workers,
environmental health workers, and
animal control officers.
• Attend veterinary and
environmental health conferences
to enhance your own scientific
understanding.
• Support the call to action to
prevent the next pandemic through
bio-surveillance of wildlife and
companion animals in urban and
rural settings as well as caution for
wet markets (e.g. where live species
are brought together for slaughter
in close spaces with people).
• Place One Health educational
brochures in your waiting rooms
and nursing stations, including
Bat Rabies Education, VBD
brochures (e.g. Bartonella, Borrelia,
Leishmania), and Healthy Habits for
Backyard Chickens [11].
Becoming more involved in local and
national One Health initiatives
• Join the international One Health
community listserv to receive global
One Health news (https://tinyurl.
com/OHC-Listserv).
• Start an interprofessional local One
Health brown bag group or reading
club that meets monthly to discuss
One Health topics at the interface
of your disciplines. Encourage open
sharing of scientific publications
from human, animal, and
environmental health communities.
• Promote the One Health approach
to improve connections between
physicians and other health
professionals. Explain how being
cognizant of the interconnections of
animals, environments, and humans
help both physicians and patients.
• Call your lawmakers to establish
a relationship and indicate that
you are available to answer any
questions about One Health issues
that they might need to know
before voting on legislation. Share
your knowledge and understanding
of One Health and the need for
bio-surveillance of companion
animals and wildlife in urban and
rural areas. Highlight that there is
no federal agency in charge of this
bio-surveillance, and no Centres
for Disease Control and Prevention
(CDC) for animals.
• Become a One Health Champion!
In summary, remember:
• No one profession or discipline can
know everything, so we need to join
hands and share knowledge across
disciplines.
• In our current systems, One
Health collaborations will not
automatically happen. We must
create opportunities to form the
relationships needed to learn from
each other.
• No one species, arena or sector is
healthy until everyone is healthy,
because everything is connected.
References
1. American Veterinary Medical
Association. Veterinarian’s oath
[Internet]. n.d. [cited 2023 May
23]. Available from: https://www.
avma.org/resources-tools/av-
ma-policies/veterinarians-oath
Interview with the Executive Director of the One Health Commission
11
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2. Dance A. A warmer planet, less
nutritious plants and…fewer
grasshoppers [Internet]. Know-
able Magazine. 2023 [cited 2023
May 23]. Available from: https://
knowablemagazine.org/article/
food-environment/2023/climate-
change-effect-on-plant-nutrients
3. Morgan JB, Connolly EL.
Plant-soil interactions: nutri-
ent uptake. Nature Education
Knowledge. 2013;4(8):2. Avail-
able from: https://www.nature.
com/scitable/knowledge/library/
plant-soil-interactions-nutri-
ent-uptake-105289112/
4. Centres for Disease Control and
Prevention. Update: multistate
outbreak of monkeypox — Illi-
nois, Indiana, Kansas, Missouri,
Ohio, and Wisconsin, 2003.
MMWR Morb Mortal Wkly
Rep. 2003;52(27):642-6.
5. Centres for Disease Control and
Prevention. Highlights in the his-
tory of avian influenza (bird flu)
timeline – 2000-2009 [Internet].
2022 [cited 2023 May 23]. Avail-
able from: https://www.cdc.gov/
flu/avianflu/timeline/avian-time-
line-2000s.htm
6. LeDuc JW, Barry MA. SARS,
the first pandemic of the 21st
century. Emerg Infect Dis.
2004;10(11):e26.
7. Centres for Disease Control and
Prevention. The 2009 H1N1
pandemic: summary highlights,
April 2009-April 2010 [Internet].
2010 [cited 2023 Sep 20]. Avail-
able from: https://www.cdc.gov/
h1n1flu/cdcresponse.htm
8. World Health Organisation.
Middle East respiratory syndrome
coronavirus (MERS-CoV) [In-
ternet]. 2022 [cited 2023 May 23].
Available from: https://www.who.
int/news-room/fact-sheets/de-
tail/middle-east-respiratory-syn-
drome-coronavirus-(mers-cov)
9. One Health Commission. 2021
Annual Report [Internet]. 2021
[cited 2023 May 23]. Availa-
ble from: https://tinyurl.com/
OHC-AnnReport2021
10. Natterson-Horowitz B, Bowers
K. Zoobiquity: what animals can
teach us about health and the sci-
ence of healing. New York: Knopf
Publishing; 2012.
11. Varela K, Brown JA, Lipton B, et
al. A review of zoonotic disease
threats to pet owners: A com-
pendium of measures to prevent
zoonotic diseases associated with
non-traditional pets: rodents
and other small mammals, rep-
tiles, amphibians, backyard poul-
try, and other selected animals.
Vector Borne Zoonotic Dis.
2022;22(6):303-60.
Cheryl Stroud, DVM, PhD
Executive Director,
One Health Commission
cstroud@onehealthcommission.org
Interview with the Executive Director of the One Health Commission
12
WMA Members Share Reflections about International Day for Older Persons 2023
According to the World Health
Organisation, healthy ageing is
described as“the process of developing
and maintaining the functional
ability that enables wellbeing in older
age” [1]. The United Nations (UN)
Department of Economic and Social
Affairs reported that the estimated
population of older persons (over
age 65) increased from 260 million
in 1980 to 761 million in 2021 [2].
As the global population is expected
to reach 1.6 billion by 2050 – or 17%
of the total population – global health
leaders will need to discuss how this
demographic transition will impact
the national preparedness of health
care and social systems to address
the unique and diverse ageing needs
of the older population, especially
across low- and middle-income
countries (LMICs) [2]. Although
information and communications
technology continues to expand
social connections between families
and communities, loneliness and
social isolation are prevalent within
society and are linked to sedentary
behaviours, cognitive decline, mental
health disorders, and stress responses
associated with chronic diseases [1,3].
Celebrated annually on 1 October,the
International Day for Older Persons
aims to raise community awareness
of the physiological processes related
to healthy ageing and highlight the
need to develop appropriate health
and social protection measures for
older persons [2]. The UN General
Assembly recognised this annual
day through Resolution 45/106 in
December 1990, which was officially
adopted through Resolution 46/91
in December 1991 [2]. The 2023
theme, “Fulfilling the Promises
of the Universal Declaration of
Human Rights for Older Persons:
Across Generations”, offers an
unprecedented moment for the global
community to unite in reflection and
advocate for older persons’ rights,
protection, and safety throughout
the lifespan [2]. Community leaders
organise in-person and virtual events,
press releases, and social media
campaigns to promote a supportive
environment that encourages
older persons to remain actively
engaged and connected with their
families and communities as well as
participate in exercise and physical
activity (e.g. aerobic, balance, muscle
strengthening). Global health leaders
should examine how countries
can prepare for these projected
demographic trends and identify
age-friendly approaches for health
and social protection and rights that
reduce inequalities, discrimination,
and social isolation [1,3].
The Decade of Healthy Ageing
(2020-2030) reinforces the need to
implement evidence-based strategies
to protect physical and mental health
and well-being in older persons across
the world [1]. This initiative focuses
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WMA Members Share Reflections about
International Day for Older Persons 2023
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13
on four action areas, including age-
friendly environments (promoting
communities that integrate older
persons), combatting ageism
(changing perceptions on ageing and
ageism), integrated care (person-
centred integrated care delivery for
older persons), and long-term care
(increasing access and availability to
high-quality long-term care services).
It expands the agenda established by
the 2002 Madrid International Plan of
Action of Ageing, which incorporates
ageing into policy frameworks related
to economic, human, and social rights
[4].
Strengthening national policies and
actions that promote healthy ageing
and social protections will be essential
to advance progress toward the 2030
Agenda for Sustainable Development.
In this article, physicians from nine
countries – Algeria, Brazil, India,
Kenya, Nigeria, Pakistan, Taiwan,
Trinidad and Tobago, and Turkey
– highlighted insightful reflections
about International Day of Older
Persons community activities and
national policies that promote healthy
ageing across their countries.
Algeria
In Algeria, a country with 42 million
residents, the International Day of
Older Persons holds significance in
recognizing the contributions and
wisdom of older persons to Algerian
society and culture. In 2010, the Law
Concerning the Protection of the Elderly
was adopted to ensure that the elderly
(persons over age 65) have access to
in-home governmental assistance
for comprehensive care, including
physical and psychosocial health
support services, social protection,
and connections to cultural activities
[5]. In 2016, Dr. Abdelmadjid
Zaalani, the President of the National
Council for Human Rights, shared
a dual call to action to include
geriatrics as a specialty and create a
geriatric hospital to care for these
ageing needs [6]. Also, in 2016, the
Prime Minister of Algeria issued the
Executive Order No. 16-294 on the
Aid Measures and Special Care of the
Elderly at Home,which established the
formal guidelines for how the elderly
can request in-home governmental
assistance [7].
Algerian physicians and medical
students lead annual efforts to
raise awareness about active ageing,
including chronic diseases like
diabetes and hypertension. First, the
International Federation of Medical
Students’ Associations of Algeria
(IFMSA-Algeria) coordinates annual
activities such as “iftar” meals during
Ramadan and ensures elderly people
access to proper healthcare services.
Medical students from the city of
Batna also educate elderly citizens
about the dangers of self-medication
in order to promote responsible
medication use. Working with
medical specialists, IFMSA-Algeria
(Le Souk Batna) members conduct
annual health fairs to provide valuable
information about chronic diseases
and offer free health consultations.
They also coordinate medical caravans
with a team of medical professionals
to travel to remote areas and bring
healthcare services directly to the
citizens, including elderly population.
As physicians in Algeria and around
the world, our call is to prioritise and
advocate for the well-being, health,
and dignity of older persons by
raising awareness, promoting healthy
ageing, addressing geriatric health
concerns, preventing elder abuse,
and supporting family caregivers.
Health professionals, stakeholders,
policymakers, and governmental and
non-governmental organisations
should collaborate to develop an
effective task force that strengthens
the geriatric mental health response
to emerging health issues across the
country and region.
Brazil
Brazil, a country of 209 million
residents, has an estimated 30.1
million (14.3%) of persons over the
age of 60 years,which has significantly
increased from 2.6 million in 1950 [8].
With this significant demographic
transition across Brazil, it is
imperative to advocate for relevant
public policies and healthcare services
(including long-term care) to ensure
the inclusion and respect of senior
citizens. Local and national leaders
have coordinated numerous annual
events in schools and healthcare
centres – like academic lectures,
health fairs and seminars, and cultural
activities – to spotlight elderly
citizens’ rights and the significance of
active ageing.
One of Brazil’s pivotal laws for
safeguarding the elderly and
nurturing health and social well-being
is the Elderly Statute. On 1 October
2003, the Elderly Statute, enacted
by Law No. 10,741, stands as a legal
framework dedicated to ensuring the
rights of senior citizens within the
nation [9]. As it outlines an array
of rights, protective measures, and
mechanisms to guarantee an elevated
standard of living, respect, and
dignity for the elderly, it focuses on
priority access to public and private
services, free healthcare access,
safeguards against abuse and violence,
and judicial support.
In Brazil and across the globe, it is
essential to recognise and proactively
address the challenges confronting
the elderly. As societal demographics
shift, national leaders, including
physicians,should advocate for elderly
to have equitable access to high-
quality healthcare, emotional support
networks, and avenues for engaged
and meaningful ageing. Challenges
stemming from uneven healthcare
access, social isolation, loneliness,
maltreatment, and neglect necessitate
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WMA Members Share Reflections about International Day for Older Persons 2023
14
a collective approach. Through
heightened awareness, knowledge
dissemination, and collaborative
policies, we can collectively shape a
future where our elderly citizens are
honoured, their contributions are
acknowledged, and their well-being
are safeguarded, enabling them to
embrace a life marked by vitality and
significance.
Colombia
According to the Colombian
National Administrative Department
of Statistics (Departamento
Administrativo Nacional de
Estadística, DANE), Colombia
has 49 million residents, with an
estimated 6.8 million adults (51%
female, 49% male) living over the
age of 65 [10]. Like other Latin
American and Caribbean nations,
the Government of Colombia has
developed community programs and
policies that promote healthy ageing,
but gaps still remain in the older adult
population, including 14.5% illiteracy,
27% living in poverty, and 43%
living in rural areas [10]. Together
with these changing demographics,
physicians encounter barriers within
the health system, where their large
workload and limited time per patient
consultation hinder their autonomy
and ability to provide comprehensive
and holistic evaluations for older
adults [11].
Over the past two decades,
national leaders have supported
legislation to ensure health and
social protection of elder citizens.
First, the Law 931 of 2004 (Ley 931
de 2004) ensured social protection
against age discrimination for
employment opportunities, and the
Law 1251 of 2008 (Ley 1251 de 2008)
recognised diversity throughout the
lifespan and the need for continuous
medical and social attention to
the elderly [12,13]. Second, the
National Public Policy on Ageing
and Older Age, 2022-2033 (Política
Pública Nacional de Envejecimiento y
Vejez, 2022-2031), was adopted by
the Decree 681 in 2022, to ensure
appropriate conditions for the
healthy and dignified ageing of
older adults, to increase autonomy
and independence and reduce
discrimination [14].
The Department for Social Prosperity
of the Government of Colombia,
under the leadership of President
Gustavo Petro Urrego, has continued
the implementation of the Colombia
Elderly Programme (Colombia
Mayor Program) since 2012,as a result
of the Resolution No. 2958 of 2012 and
Resolution No. 0234 of 2020 [15].This
program offers social and financial
protection to older persons through
an economic subsidy (social pension)
for those living in extreme poverty
(e.g. homelessness, no pension) [15].
Currently, the Colombian Medical
Federation (Federación Médica
Colombiana, FMC) has brought
national leaders together to discuss
health system reform, especially with
adapted high-quality comprehensive
programs and policies to enhance
attention and empathetic care of elder
citizens. Specific priorities include
promoting holistic care for healthy
ageing, manageing chronic diseases,
and preventing complications for
high quality of life. As physicians,
we recognise the importance of the
International Day of Older Persons,
where we can collectively advocate
for equitable access to medical care,
encourage increased opportunities
for specialised medical training in
geriatrics medicine and research,
and emphasise the need for physical,
mental and social activities for elder
citizens across our countries.
India
India,acountryof1.4billionresidents,
has an estimated 104 million persons
over the age of 60, which is expected
to increase by 14% over the next
decade [16]. The UN Department
of Economic and Social Affairs
estimates that, India will represent
the nation with have the highest
numbers of elderly persons by 2050
[17]. Notably, the elderly population
living in rural areas is estimated at
8.5 million persons, when compared
to those living in urban areas at 8.3
million, hence giving rise to health
care needs which will require new
approaches to meet their needs. This
calls for financial resources to ensure
provision of adequate and quality
health care services for the elderly
population in India.
Over the past two decades, India has
taken various policies and initiatives to
ensure the welfare of ageing and older
persons. First, the National Policy on
Older Persons (NPOP) was launched
in 1999, to ensure that older persons
are treated with respect and dignity
in the society [18]. The policy
also provides a framework for the
welfare of older persons covering
areas such as health, nutrition,
housing, employment, social
security, education, and access to
information and services. Second,
the Government of India launched
the National Program for the Health
Care of the Elderly (NPHCE) in
2010, to guarantee better access
to quality health care services and
facilities for elderly persons,including
free medical consultations and
treatment for elderly persons living
in rural and urban areas [19]. Finally,
the Government of India adopted
various pension schemes, such as
the National Pension System (NPS)
and Pradhan Mantri Vaya Vandana
Yojana (PMVVY), which provided
regular income to senior citizens who
have retired from active employment.
These initiatives aim to ensure that
elderly people in India have access
to basic necessities and services that
will help them lead a comfortable life
throughout the lifespan.
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WMA Members Share Reflections about International Day for Older Persons 2023
15
The Government of India is also
taking steps to create a conducive
environment for ageing and older
persons through the implementation
of robust policies such as increasing
healthcare infrastructure,setting up of
specialised geriatric care facilities, and
improving long-term care services.
As physicians, we have the moral
responsibility to care and protect
our elder population and help them
build social networks within their
community. If health professionals
obtain a comprehensive directory of
elders who are living alone in their
homes, then we can work together
with social workers and community
members to help maintain the elders’
social networks and increase their
quality of life.
Kenya
Kenya, a country in East Africa
with a population of 47.56 million,
approximately 2.2 million are over
the age of 60 with an average life
expectancy of 66.7 years, as of 2020
[20]. The Constitution of Kenya
(2010) defines an older person as
any Kenyan aged at least 60 years
(Article 260) and recognises older
persons as distinct right holders
(Article 57), entitled to care and
protection from the State. Family
values about caring for older persons
are changing in Kenya, with more
households focusing on the nuclear
family, leading to the abandonment
of older persons. This is giving birth
to destitute older persons who, if no
intervention is implemented, will
die of neglect, especially since most
older adults in Kenya live alone in
the countryside. Public homes for
the poor and nursing homes offer
additional housing options for
improved socialisation and minimise
neglected life in the village.
Kenya has not yet achieved universal
health coverage and to access
healthcare, citizens require insurance
coverage to cover health expenses or
out-of-pocket payments. The health
system does not have a program for
the care of the older persons, so there
is no adequate health care for the
older persons,who typically rely solely
on their children for financial support
to pay for health services. As a result,
they may not seek primary care unless
they have a profoundly serious health
problem, such as bleeding and other
manifestations of complications of
chronic noncommunicable diseases
such as diabetes, hypertension, and
cancer.
As physicians in Kenya, the
International Day of Older Persons
serves as a reminder of both our
social and professional responsibility
to cater to the specific healthcare
needs of older persons, including
age-related health issues and the
promotion of active ageing, through
three initiatives. First, to enhance the
financial security of older persons,
the government-funded “Pesa ya
Wazee” (Cash Transfer Program for
the Older Persons) was started in
2007, providing cash transfers to poor
households that have at least one
member over the age of 65. In the
2020/2021 financial year, the number
of households with older persons
supported with cash transfers was
763,670 (91.6%) out of 833,129 older
persons.They received a cash transfer
as a monthly stipend (Kshs 2000,
or US$15 equivalent) and coverage
from the National Hospital Insurance
Fund [21].
Second, the Constitution (Article
57) obligates the state to take
measures to ensure older persons’
participation, personal development,
dignity, respect, and protection
from abuse as well as provision
of care and reasonable assistance
to older persons [22]. Enacted in
2009, the National Policy for Older
Persons and Ageing aims to address
the unique needs and challenges
faced by older persons, emphasise
active ageing, social inclusion,
and access to quality healthcare
services, foster intergenerational
understanding and support, and
encourage a holistic approach to
geriatric care in the country [23].
Finally, the Kenya Healthy Ageing
and Older Person’s Health Strategy
2022-2026 is a comprehensive
federal plan to promote active and
healthy ageing throughout the life
course, provide specialised healthcare
services for older persons, increase
public awareness about age-related
health issues, and advocate for policy
reforms to ensure the well-being
and social inclusion of older persons.
Through this strategy, Kenya seeks
to create a healthcare system that is
responsive to the unique challenges
and opportunities presented by its
ageing population, fostering a society
that values and supports the older
persons [24].
As physicians in Kenya, we recognise
the immense value and contributions
of our older population. We call
upon all healthcare professionals,
policymakers, and communities to
join hands in ensuring a dignified
and healthy life for all older persons.
First, we urge policymakers to
prioritise and invest in age-friendly
healthcare facilities that cater to
the specific needs of older persons.
This includes establishing geriatric
health clinics, providing specialised
training for healthcare professionals,
and ensuring access to affordable
and comprehensive geriatric care.
Second, as healthcare professionals,
we should push for the integration
of geriatric training into medical
education. By equipping ourselves
with specialised knowledge and skills,
we can better address the unique
healthcare needs of older patients and
deliver patient-centred care. Third,
we need to embrace the potential use
of technology, like telemedicine and
digital health solutions, to enhance
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WMA Members Share Reflections about International Day for Older Persons 2023
16
healthcare access and delivery for
older persons, overcome geographical
barriers, and ensure timely medical
consultations. Finally, by recognizing
the invaluable role of caregivers in
providing support and assistance to
older persons, we should advocate for
caregiver training programs, respite
care facilities, and financial support to
alleviate the burden on caregivers.
Nigeria
Traditionally, as African cultures
widely respect elder citizens, younger
persons who address an older person
would add a prefix to the name. For
example, a prefix of Baba for men
and Mama for women are added in
western Nigeria, Dede for men and
Dada for women are included in
eastern Nigeria, and Senibo for men
and Aya for women are incorporated
in southern Nigeria (Ibani people
of Rivers State). Since Nigerians
commemorate the Nigerian
Independence Day from colonial rule
on 1 October, leaders enthusiastically
celebrate the role of elder citizens in
society through International Day
of Older Persons campaigns in late
September or early October.
To date,there are no formal policies or
lawstoprotectolderpersons,especially
regarding health insurance and social
security (retirement age of 60 years,
except for lecturers and judges).
In 2018, the Nigerian government
enacted the Nigerian National Senior
Citizens Act, which established the
National Senior Citizens Centre
(NSCC), with its headquarters in the
federal capital territory of Abuja [25].
This act incorporated five parts: 1)
declaration of policy, establishment,
and composition of the national
senior citizens centre governing
board; 2) functions of the national
centre; 3) staff of the national
centre; 4) financial provisions; and 5)
supplemental.
Few Nigerian health professionals
have received specialist training or
continuing education courses in
caring for senior citizens, especially
with few geriatric centres in Nigeria.
Examples include the Care for
Elderly Person Unit (CEPU), located
at the University of Port Harcourt
Teaching Hospital (Port Harcourt,
Nigeria), and the Chief Tony
Anenih Geriatric Centre (CTAGC),
located at the University College
Hospital (Ibadan, Nigeria). In 2020,
the Elderly Friendly Hospitals
Initiative (ELDFHI) was launched
at the University of Benin Teaching
Hospital by the then Minister of
Health, Dr. Osagie Ehanire. As
forward steps, physicians should
advocate for political commitment to
establish geriatric training programs
across all the medical specialties
in Nigeria. Also, as the federal
government can develop relevant
policies that ensure health insurance
and social security provisions for older
persons, private sector establishments
should pay pensions to their staff
upon retirement.
Pakistan
In Pakistan,the shift from joint family
toindependentlivingforelderlypeople
has become increasingly common in
recent years. With changing societal
dynamics and individual preferences,
many young couples are choosing
to live independently rather than
in a joint family setting. Although
this transition allows them to have
more control over their daily lives,
maintain their independence, and
make decisions that align with their
personal needs and preferences, the
conventional care to older people
suffers.Hence,it raises the importance
of adequate support systems to
address any challenges that may arise
during this social transition.
The Constitution of Pakistan
upholds the principles of equality,
non-discrimination, and social justice
for all citizens, which are essential
for the well-being and protection of
elderly individuals [26]. Article 38
(a-e) describes the need to ensure
that elderly have access to healthcare,
social security, and other forms of
social support and protection to
improve their quality of life. For
example, the Constitution of Pakistan
specifically states that the State shall:
a) secure the well-being of the people
irrespective of sex, caste, creed and race,
by raising their standard of living; b)
provide for all citizens facilities for
work and adequate livelihood with
reasonable rest and leisure; c) provide
for all persons employed in the service
of Pakistan or otherwise, social security
by compulsory social insurance or other
means; d) provide the basic necessities
of life, such as food, clothing, housing,
education and medical relief, for all the
citizens; and e) reduce disparity in the
income and earnings of individuals
[26]. Furthermore, in 2022, Pakistan
signed the UN Madrid International
Plan of Action on Ageing, and since
its ratification, the government of
Pakistan had designed the significant
policies regarding the protection of
the senior citizens’ rights.
Together, the Pakistan Medical
Association and other medical
organisations are collaborating to
increase awareness of the complex
socio-economic and cultural care to
provide high quality of life and well-
being for the elderly population. As
a call to action, health professionals
should create an inclusive
environment that respects cultural
backgrounds, traditions, and values,
promote intergenerational activities to
maintainsocialconnectedness,provide
access to recreational opportunities to
increase physical activity, and foster a
sense of community and belonging.
By prioritising physical and mental
health needs, while addressing any
existing social isolation or loneliness,
we can help the elderly population
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WMA Members Share Reflections about International Day for Older Persons 2023
17
maintain their dignity, autonomy, and
overall happiness.
Taiwan
According to the 2018 estimates from
the National Development Council,
Taiwan’s population over 65 years
reached 3.31 million, or 14.1% of
the 23 million population, officially
entering the “aged society” phase
[27]. Noting these demographic
changes, Taiwan has taken proactive
measures to address the challenges
posed by an ageing society. Through
a combination of well-planned
healthcare systems, comprehensive
long-term care services, and
advancements in telemedicine, the
country is working towards ensuring
a high quality of life and well-being
for its elderly population, while
embracing technological innovations
for the benefit of all its citizens.
In 1986, the Taiwan Medical
Association, in collaboration with
the Taiwan Ministry of Health
and Welfare, implemented the
Medical Network Plan, which
emphasised hardware infrastructure
and manpower planning to ensure
comprehensive, continuous, and
coordinated healthcare services for
the older population [27].Since 1995,
the implementation of the National
Health Insurance has provided fair
medical treatment with a 99.8%
coveragerateandhasreducedfinancial
burdens for the population. By 2020,
Taiwan had set up 688 Integrated
Service Centres (A-units), 6,195
Multi-Service Centres (B-units), and
3,169 Community Stations (C-units),
creating a network of community-
based long-term care services [28].
Ongoing efforts to further promote
and expand the welfare programs will
strengthen the long-term care system
for older persons.
The Taiwan Medical Association,
in collaboration with the Taiwan
Ministry of Health and Welfare,
is using a multidisciplinary team
approach to design an integrated
care system that combines medical
and long-term care services and
provides transitional care from the
hospital to home-based medical
services. Significant strides in the
field of telemedicine have included
the Telemedicine Regulations of 2023,
revised by the Taiwan Executive
Yuan, which expanded the scope and
modes of remote healthcare services.
This initiative, guided by the World
Medical Association (WMA)’s
Statement on Digital Health, has
improved access to medical services
for home care and patients in long-
term care institutions, as well as
positively influenced healthcare and
individual well-being [29,30].
Trinidad and Tobago
Although ageing is inevitable, age-
associated stigma should not exist in
our society. Older persons represent
a unique community, as some people
are healthy and independent, while
others may be afflicted by geriatric
syndromes that negatively affect
their quality of life. Physicians across
Trinidad and Tobago recognise the
unique dedication to the older person’s
plight and advocate for relevant
policies and health campaigns, such
as the International Day of Older
Persons. For example, at the St. James
Medical Complex’s Geriatric Clinic,
multidisciplinary teams of physicians,
physiotherapists, dieticians, local
institutions (e.g. Diagnostic
Research Education Therapeutic
Centre, DRETCHI), and national
associations (e.g. Alzheimer’s
Association) educate patients
on strategies for healthy ageing,
which collectively demonstrate the
most appropriate resources to be
implemented.
TheTrinidad andTobago government
continues to promote the global call
to develop active ageing and geriatric
health policies and initiatives. First,
the Homes for Older Persons Act of
2007,which is awaiting proclamation,
details requirements for licensing
and other regulations to which elder
homeowners should adhere [31].
Second, the Geriatric Adolescent
Partnership Program, as part of the
Ministry of Social Development
and Family Services, offers elderly
assistancewithactivitiesofdailyliving,
transport to medical appointments,
and caregiving support [32]. Third,
the Trinidad and Tobago Medical
Association organised the North
Branch National Geriatric Meeting
in June 2023, which highlighted the
need for a multidisciplinary approach
to high-quality elder care.
Since ethical considerations are
essential to care for our elder
population, as physicians, our call
to action includes sensitising our
colleagues on the magnitude of issues
that arise in this vulnerable population
[33]. These issues can range from
physical or sexual abuse in homes to
financial abuse in situations where
there is improper or unauthorized
use of older adults’ money [34]. In
countries where laws are absent
or limited in providing health and
social protections, physicians should
advocate for their protection, ranging
from their well-being at home to fair
allocation of properties and incomes.
Turkey
In Turkey, a country with
approximately 83 million people,
the older population (over age 65)
represented 6.7% in 2000, and
increased to 9.5% in 2020 [35].
Since chronic diseases are frequent
diagnoses among this population –
including 90% with one, 35% with
two, 23% with three, and 15% with
more than four – protecting the
health and well-being of the elderly is
of utmost importance in Turkey [36].
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WMA Members Share Reflections about International Day for Older Persons 2023
18
According to the First Gerontology
Atlas of Turkey (Gero-Atlas), 38%
of elder citizens express loneliness,
hopelessness, and complain about the
future, 55% feel isolated from society,
and 42% commented that they want
to die [37]. To prepare for the future,
attending doctors in physical therapy
and rehabilitation, orthopaedics,
neurology, and geriatrics have gained
additional skills in the clinical and
surgical management of arthrosis,
osteoporosis, fractures, stroke,
Parkinson’s and Alzheimer’s diseases,
and rehabilitation.
To prioritise healthy ageing in the
populace, the Ministry of Health
of the Republic of Turkey launched
the National Plan of Action on
Ageing of Turkey in 2012, focusing
on increasing health and well-
being throughout the lifespan and
providing a supportive environment
with adequate facilities [38]. In 2017,
the Ministry of Health established
a healthy ageing research centre at
the University of Health Sciences, in
efforts to conduct scientific research
on healthy ageing and elderly care.
The 11th Development Plan (2019-
2023), approved by the Grand
National Assembly, included long-
term geriatric care services (e.g. inter-
institutional coordination, increased
support for the health workforce at
home and clinical settings), increased
efficiency of geriatric health service
delivery (e.g.increased geriatric health
experts,ongoing research applications
on dementia and gait prevention),
and active social and learning
environments (e.g. lifelong learning
opportunities, social activities) [39].
Moving forward, a Turkey Care and
Ageing Study, with oversight by the
Ministry of Health, will monitor
the efficiency of health services and
policies to support healthy ageing.
The Turkey Medical Association
continues to support national efforts
to ensure health care service delivery
and care for elder citizens. It supports
the Turkish Geriatrics Association,
whichorganisestheannualRespectfor
Elders Week during the third week in
March as well as endorses the Turkish
Journal of Geriatrics (http://www.
geriatri.dergisi.org/). As physicians,
we can advocate for the state budget
allocation to develop social support
programs for the elderly, expand the
coverage of geriatrics clinics, and
improve treatment, rehabilitation,
and home care services for elderly
patients. By increasing access and
availability of these services, the
financial burden related to such costly
medical and long-term care services
will be reduced for elderly and their
families. Furthermore, together with
policymakers, we can serve as clinical
expertsonthedevelopmentofrelevant
social policies that can be discussed
and adopted, leading to improving
health and social protection for elder
citizens.
Conclusion
The International Day of Older
Persons offers a platform for the
global community to discuss the
importance of healthy ageing in our
society, identify existing policy and
practice gaps that hinder the health
and social protection of older persons,
and advocate for timely initiatives that
safeguard their autonomy, dignity,
and independence throughout the
lifespan. The Decade of Healthy
Ageing (2020-2030) can help guide
how our society expands the view
of healthy ageing from a solitary
biological process to an interplay
of external factors – including the
natural and built environments, social
connections to family members,
neighbours, and community, local
and national policies and initiatives,
and overarching social security and
health systems – that influence health
and well-being [1]. Comprehensive,
person-centred care can revolutionize
health care service delivery for older
persons, where health professionals
can work directly with patients
to understand their health care
needs, conduct in-depth physical
and psychosocial health histories
and assessments, prioritise chronic
disease management, and evaluate for
signs and symptoms related to social
isolation, loneliness or other mental
health concerns [40].
WMA members represent a global
network of clinical and surgical
experts, who are proficient with the
complex physiological processes of
ageing and the need to maintain
active engagement to reduce
cognitive decline and maintain high
quality of life.As this collective article
describes timely policies, initiatives,
and community activities across nine
countries, other NMAs can learn
from these eloquent reports, reflect
on current national policies and
activities, and advocate for relevant
actions to protect older persons.These
collaborations showcase the political
commitment across the African,
Americas,Asian,East Mediterranean,
European, and Western Pacific
regions, as fundamental components
to help prepare all nations to
strengthen social security and health
systems to meet the diverse needs of
older persons,including the indicators
of the 2030 Agenda for Sustainable
Development.
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WMA Members Share Reflections about International Day for Older Persons 2023
19
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WMA Members Share Reflections about International Day for Older Persons 2023
21
40. Hammond L, Pullen RL Jr.
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Authors
Sharad Kumar Agarwal, MBBS,
MD (Forensic Medicine)
National President, Indian
Medical Association
New Delhi, India
Douaa Roufia Attabi, MD
Member, IFMSA-Algeria
(Lesouk Batna)
General Physician, Maternal
Neonatal Hospital
Biskra, Algeria
Damion Basdeo, MBBS,
Acute Medicine SCE (UK)
President,
Trinidad and Tobago
Medical Association
Port of Spain, Trinidad and Tobago
Dabota Yvonne Buowari, MBBS
Department of Accident
and Emergency,
University of Port Harcourt
Teaching Hospital
Port Harcourt, Nigeria
Brian Chang, MD
Secretary General, Taiwan
Medical Association
Chiayi, Taiwan
Helena Chapman, MD, MPH, PhD
Milken Institute School
of Public Health,
George Washington University
Washington DC, United States
Shun Chin Chang, MD
Director, Integrated Geriatrics
and Palliative Care Centre,
Da-Lin Tzu Chi Hospital
Chiayi, Taiwan
Shravan Dave, MBBS, MS (Surgery)
Chairperson, Global Surgery Working
Group, WMA Junior Doctors Network
National Co-convener,
JDN of the Indian Medical
Association (2019-2022)
Vadodara, Gujarat, India
Deniz Erdogdu, MD
Former Council Member,
Turkey Medical Association
Associate Professor, University
of Health Sciences
Dışkapı Yıldırım Beyazıt Training
and Research Hospital
Ankara, Turkiye
Isi Imasekha, MBBS
Chairperson, Non-communicable
Diseases Subcommittee,
Trinidad and Tobago
Medical Association
Port of Spain, Trinidad and Tobago
Ming-Nan Lin, MD
Vice Superintendent,
Da-Lin Tzu Chi Hospital
Chiayi, Taiwan
Wanjala Mercy, MBCHB, MSc,
MBA-Healthcare Management
Embu Division Chair, Kenya
Medical Association
National Secretary, Kenya
Association of Family Physicians
Embu, Kenya
Anilkumar J. Nayak,
MBBS, MS (Ortho)
Honorary Secretary General,
Indian Medical Association
New Delhi, India
Prof. Muhammad Ashraf
Nizami, MD, PhD
WMA Council Member
President, Pakistan Medical Association
Lahore, Pakistan
Thiago Vicente Pereira, MD
Member, Junior Doctor Network,
Brazilian Medical Association
Fellow Cardiologist, Instituto do
Coracao, University of São Paulo
São Paulo, Brazil
D. R. Rai, MBBS
Past Honorary Secretary General,
Indian Medical Association
New Delhi, India
Carlos V. Serrano Jr., MD
International Relations Director,
Brazilian Medical Association
Associate Professor, Faculty of
Medicine, University of São Paulo
São Paulo, Brazil
Ana María Soleibe Mejía, MD
President, Federación
Médica Colombiana
Bogotá, Colombia
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WMA Members Share Reflections about International Day for Older Persons 2023
22
As fires, floods, droughts, heatwaves,
and storms have illustrated more
starkly than ever before, the health
of all life on Earth depends on stable
natural systems. Medical education,
veterinary education, and their
counterparts across all other health
sectors, are being challenged to keep
pace with a changing world where
environmental health risks, emerging
and re-emerging infectious diseases,
and climate change are impacting
patient health. In addition, awareness
of the complex interplay between
public health, animal health, and
the state of our planet’s natural life
support systems is requiring educators
to breakdown disciplinary silos and
train competent healthcare providers
who can operate within multi-, inter-,
intra-, trans- and cross-disciplinary
workforces.
The last decade has seen a leap in our
understanding that the health and
well-being of humanity and the rest of
life on Earth depends fundamentally
on the state and stability of our natural
systems [1]. This understanding
drives the need to refocus health
education and is the reason why the
fields of “Planetary Health” and “One
Health” have evolved [2]. Today’s
complicated health challenges are
leading “Planetary Health” and “One
Health” to become more synergistic
than ever before.
Definitions
Medical students and professionals
may be more familiar with the current
definition of “Planetary Health” as “a
solutions-oriented, transdisciplinary
field and social movement focused on
analyzing and addressing the impacts
of human disruptions to Earth’s
natural systems on human health and
alllifeonEarth”[3]. Meanwhile,some
medical students and professionals
understand that “One Health” is
Modernizing Health Education: The Need to Address
Planetary Health by Taking a One Health Approach
Modernizing Health Education
BACK TO CONTENTS
Deborah Thomson Noel Lee J. Miranda Christina Pettan-Brewer Donald A. Donahue
Elizabeth Johnson Paul van der Merwe Charles Muleke Inyagwa Peter Rabinowitz
Samuel S. Myers
23
currently described as “an integrated,
unifying approach that aims to
sustainably balance and optimize
the health of people, animals, and
ecosystems. It recognizes the health
of humans,domestic and wild animals,
plants, and the wider environment
(including ecosystems) are closely
linked and interdependent”[4].These
two terms may lead to confusion
because “One Health” may also be
explained as a concept (strikingly
similar to “Planetary Health”) as
well as the aforementioned approach
[5]. Therefore, the authors here
emphasize the aspect of “One Health”
that relates to its holistic approach to
managing health challenges related
to people, animals, plants, and their
shared environment. As such, the
“One Health” approach relies on
teamwork (including communication,
collaboration, coordination, and
capacity building) between people
of different disciplines, backgrounds,
and strengths to prevent and respond
to “Planetary Health” challenges [6].
A Student-led Initiative in
Planetary Health Education
The growing recognition that the
Earth Crisis is driving a global
health and humanitarian crisis
requires an evaluation of how well
our educational system is exposing
health professionals to this reality and
providing them with necessary skills
to address the clinical and public
health aspects of these crises.Recently,
health professional (medicine,
nursing, pharmacy, physiotherapy)
students studying across 105 schools
in 13 countries (Australia, Canada,
India, Ireland, Germany, Greece,
Japan, Malaysia, New Zealand, South
Africa,Switzerland,United Kingdom,
United States) evaluated institutional
criteria, including the current state
of “Planetary Health” curricula, the
extent of interdisciplinary research
portfolios, and sustainability practices
on campus [7]. This initiative is
commendable for several reasons: 1)
it incorporates four schools of health
sciences, thereby implementing a
“One Health” approach, 2) it aims to
objectively evaluate schools of health
sciences in different countries, and
3) it establishes a global standard of
“Planetary Health” education.
Expansion of the Initiative
Health professionals (regardless of
the species of their patients) can no
longer effectively do their jobs while
the natural life support systems, upon
which all life depends, are eroding
under the weight of a degrading
and changing environment. While
health professionals recognize that
our planet is rapidly changing and
pose challenging environmental
health risks for our patients, we
currently do not have a grasp of our
educational strengths and weaknesses
in “Planetary Health” education
across the health sectors. In order
for us to better care for our patients,
their families, our communities, and
our planet, we must remain humble,
combine our clinical expertise, and
recognize gaps in the knowledge base.
Afterall,wecanagreethatourpatients
(human or otherwise) are highly
vulnerable to environmental health
risks such as climate change, natural
disasters, deteriorating resources,
habitat degradation, biodiversity loss,
and air and water pollution. However,
are all health-related sectors preparing
their students and professionals
with the appropriate knowledge and
skill set in patient care management
to apply their training on a rapidly
changing and challenging planet?
Therefore, the authors wish to
expand upon this promising student-
led initiative and advance the global
dialogue on “Planetary Health”,
by performing a gap analysis in
“Planetary Health” education among
health professional programs [8]. To
conduct this analysis, multiple experts
across several global associations,
such as the World Association for
Disaster and Emergency Medicine,
the International Network of Health
Workforce Education, the World
Veterinary Association, the Planetary
Health Alliance, and other interested
global associations, will be developing
a survey in multiple languages that
will be disseminated to a broader
audience. The aim is to reach beyond
the initial four health disciplines
(medicine, nursing, pharmacy,
physiotherapy) and involve both
students and professionals, in equal
measure, living and working across
high-, middle-, and low-income
countries of the Global North and
South. The inclusion of perspectives
from as many countries, cultures, and
backgrounds as possible will align
support toward a common goal: to
teach the global health workforce
to efficiently protect the health of
the planet and all living organisms
[9]. In the upcoming months, the
aforementioned team of experts will
distribute survey links to leading
organizations and their networks.
This gap analysis survey results will
allowforreal-timesnapshotevaluation
of the current state of “Planetary
Health” education, assess how well
aspiring health leaders are prepared
for our challenging and quickly
changing world, and empower health
professionals to change the paradigm
of global medical education.Through
purposeful collaboration across all
health professions, we can attain a
more comprehensive evaluation of
“Planetary Health” education around
the world. Identification of these
educational gaps have the potential
to drive improvements in medical
and other health education programs,
and ultimately promote a unified
approach to strengthen future efforts
in support of “Planetary Health”.
Call to Action
Through taking a “One Health,”
collaborative approach, health
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Modernizing Health Education
24
practitioners and advocates can
efficiently and simultaneously
achieve the common goal of
benefiting our patients and our
planet. As a call to action, we can
use our collective voices to make a
difference both locally and globally
by: 1) completing the aforementioned
survey to illustrate the current state
of “Planetary Health” education and
impact future teachings, 2) actively
inquiring about environmental health
risks when taking patient histories
in daily clinical practice, 3) sharing
our “Planetary Health” knowledge
with our friends and colleagues in
daily conversations, 4) asking local
health institutions about their current
“Planetary Health”-related activities,
and 5) creating or joining “Planetary
Health”-focused action groups within
local institutions and communities.
By working together across all health
sectors towards a common goal,
health professionals and advocates can
simultaneously improve educational
efforts that protect the integrity of
our planet and the health and well-
being of our patients, our generation,
and all future generations.
Acknowledgments: The authors wish
to thank Dr. Asger Lundorff Jensen,
Dr. James Ouma, and Ms. Doris
Ma, members of the World Veterinary
Association’s One Health Education
Subgroup, for their contributions to the
development and review of this final
draft.
References
1. Myers S, Frumkin H. Planetary
Health: protecting nature to
protect ourselves. Washington,
DC: Island Press; 2020.
2. One Health Initiative. ‘One
Medicine−One Health’: an
historic perspective. WMJ.
2023;69(2):18-27.
3. Planetary Health Alliance.
What is Planetary Health?
[Internet]. 2023. [cited 2023 Sep
8]. Available from: https://www.
planetaryhealthalliance.org/
planetary-health
4. One Health High-Level Expert
Panel (OHHLEP), Adisasmito
WB, Almuhairi S, Behravesh
CB, Bilivogui P, Bukachi
SA, et al. One Health: a new
definition for a sustainable and
healthy future. PLoS Pathog.
2022;18(6):e1010537.
5. Thomson DJ. The art of
science communication: sharing
knowledge with students,
the public, and policymakers.
Arlington, Virginia: Thomson
Publishing LLC; 2021.
6. Thomson DJ,Ma D,Lennard PR,
Ferri M. Evaluation of a global
training program in One Health
communication. One Health
Implement Res. 2023;3:55-68.
7. Planetary Health Report Card.
The Planetary Health Report
Card Initiative: an international
health student community
inspiring institutional change
[Internet]. 2023 [cited 2023
Sep 4]. Available from: https://
phreportcard.org/
8. Golden SH, Hager D, Gould LJ,
Mathioudakis N, Pronovost PJ.
A gap analysis needs assessment
tool to drive a care delivery and
research agenda for integration
of care and sharing of best
practices across a health system.
Jt Comm J Qual Patient Saf.
2017;43(1):18-28.
9. Pettan-Brewer C, Figueroa
DP, Cediel-Becerra N, Kahn
LH, Martins AF, Biondo
AW. Editorial: challenges and
successes of One Health in the
context of Planetary Health
in Latin America and the
Caribbean. Front Public Health.
2022;10:1081067.
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Modernizing Health Education
25
Authors
Deborah Thomson, DVM
Chair, One Health Education Subgroup
& Member, One Health Working
Group, World Veterinary Association
Founder and Executive Director,
One Health Lessons
Arlington, Virginia, United States
DeborahThomson@
OneHealthLessons.org
Noel Lee J. Miranda, DVM, MSc
Member, One Health Working Group
& Member, One Health Education
Subgroup, World Veterinary Association
Global Health Security & One
Health Advisor, Global Health
Technical Assistance & Mission
Support (GH-TAMS)
Manila, Philippines
nlmiranda@yahoo.com
Christina Pettan-Brewer,
DVM, MSc, One Health
PhD Candidate 2024
Member, One Health Working Group,
World Veterinary Association
Associate Professor, School of Medicine,
University of Washington
Seattle, Washington, United States
Belo Horizonte, Minas Gerais, Brazil
kcpb@u.washington.edu
Donald A. Donahue, DHEd,
MBA, MSJ, FACHE, FRSPH
President, World Association for
Disaster and Emergency Medicine
Assistant Professor, University
of Maryland Baltimore
Baltimore, Maryland, United States
ddonahue@wadem.org
Elizabeth Johnson, PhD
President, International Network
of Health Workforce Education
Dean, School of Medicine,
European University Cyprus
Nicosia, Cyprus
Paul van der Merwe, BVSc,
BVSc(Hons), MMedVet(Fer)
Member, One Health Working Group,
World Veterinary Association
President, South African
Veterinary Association
Pretoria, South Africa
wildlife.vet.serv@gmail.com
Charles Muleke Inyagwa, Dip
ANHE, BVM, MSc, PhD
Member, Education Working Group
and One Health Education Subgroup,
World Veterinary Association
Member, Kenya Veterinary Association
Nairobi, Kenya
charles.muleke@egerton.ac.ke
Peter Rabinowitz, MD, MPH
Director, Center for One Health
Research, University of Washington
Professor, Depts of Environmental/
Occupational Health Sciences,
Family Medicine, and Global
Health, University of Washington
Seattle, Washington, United States
Samuel S. Myers, MD, MPH
Director, Planetary Health Alliance
Principal Research Scientist,
Department of Environmental
Health, Harvard TH Chan
School of Public Health
Cambridge, Massachusetts,
United States
smyers1256@earthlink.net
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Modernizing Health Education
26
BACK TO CONTENTS
In 1911, a 7-year-old boy living on
a farm in rural Saskatchewan badly
injured his leg. His family could not
afford the necessary surgery. A local
doctor offered the family a deal: he
would operate on the leg free of cost
if his medical students could watch.
Following this experience, Tommy
Douglas, the young patient, became
convinced that all Canadians deserved
access to medically necessary care
regardless of their ability to pay [1].
As a politician, in 1961, Douglas’
New Democratic government
passed the Saskatchewan Medical
Care Insurance Act, as the first
comprehensive health insurance plan
in Canada. This was followed by the
introduction of National Medicare
in 1968. Today, Canada’s program
of universal medical insurance is
administered through the Canada
Health Act, a piece of legislation
that still includes the principles for
which Tommy Douglas advocated:
public administration, portability
accessibility, universality, and
comprehensiveness [1].
According to the Canadian
government [2]:
The Canada Health Act (CHA or the
Act) is Canada’s federal legislation for
publicly funded health care insurance.
The Act sets out the primary objective of
Canadian health care policy, which is “to
protect, promote and restore the physical
and mental well-being of residents of
Canada and to facilitate reasonable
accesstohealthserviceswithoutfinancial
or other barriers.”
The CHA establishes criteria and
conditions related to insured health
services and extended health care services
that the provinces and territories must
fulfill to receive the full federal cash
contribution under the Canada Health
Transfer (CHT).
The aim of the CHA is to ensure that
all eligible residents of Canada have
reasonable access to insured health
services on a prepaid basis, without
direct charges at the point of service for
such services.
As noted above, there are five criteria
for public health insurance set out in
The Canada Health Act [3]:
1. It must be universal,provided to all
residents of a province or territory.
2. It must be comprehensive,
covering all medically necessary
services provided by hospitals,
physicians and dentists (when their
services must be performed in a
hospital).
3. It must be accessible to any
resident with medical needs –
unimpeded by discrimination of
any kind, including the ability to
pay for services.
4. It must be portable, ensuring care
for residents who are travelling
within Canada or who move from
one province or territory to another.
5. It must be publicly administered,
operated as a non-profit by
a government or authority
accountable to it.
It is the fifth requirement that in
many ways separates Canadian health
care from that provided in the rest
of the world. Unlike most systems,
Canada does not (officially) have a
parallel private option available for
patients who pay out of pocket or
use private insurance. Every service
deemed medically necessary is
covered by the public system and (in
theory) Canadians cannot pay to get
faster treatment or jump the queue.
In reality,there exist pockets of private
care in Canada, where people with
the financial means can gain access
to care more quickly. For example, in
some provinces,there are private MRI
clinics where people can self-pay and
receive a scan within a day or two
(versus several weeks or months in the
public system). There are also private
surgical clinics where patients can pay
for faster access to procedures like
cataract surgery or joint replacements.
Provinces in Canada are responsible
for the delivery and funding of health
care within the borders of their
jurisdiction. However, the federal
government provides a significant
amount of public funding, called
the Canada Health Transfer, to each
province to assist with this. These
transfers are tied to each province
adhering to the requirements of
the Canada Health Act. Each
year, some provinces lose funding
or have it clawed back because of
non-adherence.
Jeff Blackmer
The Health Care System in Canada: The Canadian Medical
Association is Hosting a Consultation Process on the Proper
Mix of Public and Private Funding and Delivery
The Health Care System in Canada
27
Although not all aspects of care are
covered by Canada’s public health
care system, the primary focus is on
hospitals, diagnostics, and physicians.
If a patient needs a hip replacement,
it will be done without charge in a
hospital, but the outpatient physical
therapy required following the surgery
will be paid for by the patient (or their
private insurance plan).
And while public health care must be
overseen by provinces and territories,
they can choose private facilities or
providers to deliver care, as long as
patients are not charged for services
covered by the health cards in their
wallets [3].
The following graphic summarizes
the current state of health care
funding and delivery in Canada:
In Canada, approximately 72% of
health care is publicly paid for and
delivered [4].This is actually a smaller
proportion than in many other
wealthy nations, because Canada
does not currently comprehensively
cover services like dental care, home
care, community mental health care
(unless delivered by a psychiatrist) or
most medications.Instead,Canadians
pay for these out of pocket or through
privateinsurance,whichtheypurchase
individually or, more commonly,
receive through their employer.
Over the years, it has become an
article of faith that the vast majority of
Canadians see their public health care
system as part of the social fabric of the
country, in particular when compared
to our friends and neighbours to the
South in the United States. While it
means higher taxes, it also means that
no Canadian is likely to experience
poverty or bankruptcy as the result of
an illness or injury. It is often called
the “third rail” of Canadian politics –
no politician dares touch our publicly
funded health care system lest they
electrocute themselves and burst into
flames.
However, the coronavirus disease
2019 (COVID-19) pandemic has
exposed cracks in the system that have
long existed but were all too often
papered over by the selflessness and
dedication of physicians and other
health care providers. Wait lists have
lengthened considerably, and millions
of patients do not have access to a
primary care provider. Governments
are under tremendous pressure to take
action, and in this new environment,
innovative approaches to health care
funding and delivery are now being
discussed and considered in ways
that were not possible prior to the
pandemic.In many cases,this involves
the private sector.
It is in this environment that the
Canadian Medical Association is
embarking on a series of consultations
with the medical profession and
members of the Canadian public. We
recognize that there is no “perfect”
health care system or agreed upon
standard of public:private ratios of
funding and delivery. We are looking
at all of the various models that exist,
domestically and globally, with their
pros and cons, and speaking with
persons who have experience in
different systems to understand their
perspectives.
Over the next several months, we will
be completing an array of activities
to engage the general public and
medical community. First, we will be
working with one of Canada’s flagship
newspapers, the Globe and Mail,
to host a series of public town halls
across the country, where Canadians
will gather to discuss these issues.The
initial session was held in Toronto on
8 September 2023, and was attended
by hundreds of people in person and
virtually.Next,we have commissioned
polling of the public and the medical
profession to better understand their
views in a more nuanced way. We are
hosting small group sessions in most
provinces (and virtually) to meet with
physicians and patients. Finally, we
will be conducting targeted outreach
to vulnerable populations living in
rural and remote areas. In short, our
goal is to provide an open platform
for all Canadians to share their views
and input.
At the end of this process, our Board
Figure 1. Summary of the Canada Health Transfer flow
to provinces [2]
Figure 2. Summary of how care is funded and delivered in
Canada [3]
Figure 3. Summary of source of funding for health care in
Canada [4]
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The Health Care System in Canada
28
of Directors will meet to consider
what we have heard and discuss the
reports from the various engagement
initiatives. We will review our policy
and develop an advocacy strategy.
We do not know where all of this
will lead us – but we know that the
conversation, while difficult (and
at times quite emotional) is an
important one, and that we are best
situated to lead it. Our profession and
patients need to be actively engaged
in shaping the future of health care in
Canada, and the Canadian Medical
Association should provide them
with this timely opportunity.
References
1. Canadian Medical Hall of Fame.
The Honourable Thomas Doug-
las [Internet]. 2023 [cited 2023
Sep 13]. Available from: https://
www.cdnmedhall.ca/laureates/
thomasdouglas
2. Government of Canada. Can-
ada Health Act [Internet].
2023 [cited 2023 Sep 13].
Available from: https://www.
canada.ca/en/health-canada/ser-
vices/health-care-system/cana-
da-health-care-system-medicare/
canada-health-act.html
3. Canadian Medical Association.
Understanding public and private
health care [Internet]. 2023 [cit-
ed 2023 Sep 13]. Available from:
https://www.cma.ca/our-focus/
public-and-private-health-care/
understanding-public-and-pri-
vate-health-care
4. The Commonwealth Fund.
International health care sys-
tem profiles: Canada [Inter-
net]. 2020 [cited 2023 Sep 13].
Available from: https://www.
commonwealthfund.org/inter-
national-health-policy-center/
countries/canada
Jeff Blackmer, MD, MHSC,
FRCPC, MBA, CCPE
Chief Medical Officer and Executive
Vice President, Global Health
Canadian Medical Association
jeff.blackmer@cma.ca
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The Health Care System in Canada
29
BACK TO CONTENTS
Adapted from an editorial published in
the Journal of the Norwegian Medical
Association on 20 April 2023 [1].
The Board and the Secretary General of
the Turkish Medical Association (TMA)
stand accused of terrorist behaviour.
At the same time, the President of the
TMA has been deprived of central rights
while waiting for her appeals trial to be
scheduled.
France, the homeland of the
Enlightenment, has inspired the ideals
of freedom, the colours of national
flags, and principles underpinning the
Constitutions of Norway and other
global nations. The principle of the
separation of powers, developed by
the philosopher Montesquieu (1689-
1755), is deeply anchored in most
democracies, among them our own.
He divided the power of the state into
three branches: legislative, executive,
and judicial.
We are currently witnessing an
increase in authoritarian rule close to
our borders. Some of the characteristic
features of these regimes are flagrant
violations of the principle of the
separation of powers. One example
is the increased control of courts by
political leaders, turning courts into
instruments for the preservation of
power for incumbent regimes.
Today, our colleagues in Türkiye are
victims of such misuse of the judiciary.
This is not a new feature, however, for
a country that inherited the Ottoman
empire.TheTMA,which was founded
in 1954, has had 14 presidents, where
11 of these presidents have been
incarcerated.
In October 2022,theTMA’s president,
Dr. Şebnem Korur Fincancı, spoke on
the Medya Haber,a German television
outlet,concerningallegationsaboutthe
use of chemical weapons against Kurds
in northern Iraq. She disclosed her
affiliations as a professor and specialist
of forensic medicine, stating that an
independent review was required to
fully evaluate this scenario. Knowing
that Turkish authorities would react,
she travelled home to Türkiye and was
taken into judicial custody. Following
three hearings in the Istanbul court
apparatus, she was sentenced to two
years, eight months, and 15 days in
prison, for voicing “propaganda for a
terrorist organisation”[2].She has now
been released, pending the appeals
trial, which may take several years to
schedule within the courts.
At the same time, the TMA Secretary
General and 10 other board members
standaccusedofterroristactivity.All11
individuals are elected representatives
of approximately 110,000 physicians,
comprising more than 80% of the
country’sphysicians.Thefirsttwocourt
hearings were held on 28 February and
6 April 2023. The third hearing was
held on 22 June 2023, and the WMA
President, Dr. Osahon Enabulele, and
one author of this article attended.
The hearing ended in an open-closed
meeting, postponing the final decisive
hearing until 10 November 2023.
These continuous threats of legal
action challenge TMA’s autonomy
and independence. Furthermore,
focus on the work plan, activities, and
development of the TMA has been
difficult since significant energy has
been spent on these judicial hearings.
Political actions are dangerous because
they may be added to the accusations
in the ongoing trials.
Some national medical associations
(NMAs) still retain many roles that
the authorities have taken over in
Norway, including the approval of
specialists, national guidelines, and
reactions towards physicians in cases of
malpractice. Therefore, these NMAs
are,to a greater extent than in Norway,
regulated by law. Such regulations
have advantages and disadvantages
and require mutual respect and
understanding between NMAs and
the authorities. This situation works
well in open and democratic countries,
but with an increasing number of
autocracies and political interference
with the judiciary as witnessed in
Türkiye, the autonomy of the medical
profession and its organisations is
threatened.
The autonomy of the medical
profession, which is associated with
its traditional status as a liberal
profession, is closely linked with a set
of obligations and responsibilities for
professional practice.Correspondingly,
the professional (individual) autonomy
derives from the physician’s need for
clinicalindependence.Inbothinstances,
autonomy represents freedom to
practise without interference from the
Ole Johan Bakke
Violating the Principle of the Division of
Powers Threatens our Profession
Violating the Principle of the Division of Powers Threatens our Profession
Axel Rød
30
BACK TO CONTENTS
political administration or individual
politicians.
In Norway, less attention appears
to be paid to the autonomy of the
profession, NMA, and physicians,
as compared to other countries like
Türkiye. For example, Norwegian
physicians live and work in a country
where democracy stands strong,
and where trust is generally high
between the general population,
medical professionals, and authorities.
During the coronavirus disease 2019
(COVID-19) pandemic, however, we
witnessed instances where authorities
in some countries had abused the
populations’trust,which led to reduced
adherence to protective measures to
reduce disease transmission.Therefore,
we can assume that there is a greater
urgency to protect the autonomy of the
medical profession in some countries,
as opposed to others.
The Standing Committee of European
Doctors (Comité Permanent des
Médecins Européens, CPME) has a
clearstance that when clinical decisions
are undermined by administrative
interference to the physician’s role, a
patient’s right to safe medical help,
and high-quality health services is
threatened[3].In2013,theCPMEand
the European professional associations
for dentists, engineers, veterinarians,
and pharmaceuticals vocalised the
need to clarify how the autonomy of a
profession is in the population’s interest
[4].
Our support of our colleagues and our
sister organisation in Türkiye stands
firm. When the Turkish government
threatened to dissolve the TMA in
2020, both the CPME and the World
Medical Association (WMA) spoke
out. We underlined the importance
of independent, democratic medical
associations’ role in maintaining
patients’rights and medical ethics. In a
meeting with the TMA before the first
hearing in the case against president
Dr. Fincancı, the CPME reiterated
the importance of the independence of
medical professional associations.
As we witness a clear challenge to the
principle of the separation of powers
in several countries, the medical
profession and its organisations
remain vulnerable, because autonomy
and societal roles are based on fragile
mechanisms requiring a high degree
of trust. Autocratic developments
characterise Türkiye and Russia,as well
as other countries that are members of
the European Union (EU) and North
AtlanticTreaty Organisation (NATO).
Both nationally and at the EU level,
we see examples where ethical rules
are argued to become obstacles to
economic growth, and questions are
raised concerning the profession’s self-
regulation and autonomy.
As a medical profession and NMA in
Norway, we must ensure that ethical
rules and the prioritisation of patients,
both at the individual and population
levels,are respected.The current events
in Türkiye represent an example of a
medical profession boldly standing
up to their authorities’ violation of the
principle of the separation of powers,
general human rights, and harassment
of legitimate physician leaders. This
stance is taken in full knowledge of
the risk of judicial reactions towards
the medical association and individual
physician leaders. The courage and
stamina of Turkish physicians should
represent a model for physicians all
across the European continent.
References
1. Bakke OJ. Når brudd på mak-
tfordelingsprinsippet truer vår
profesjon | Tidsskrift for Den
norske legeforening (tidsskriftet.
no). Journal of the Norwegian
Medical Association. 2023. Nor-
wegian. Available from: https://
tidsskriftet.no/2023/04/leder/
nar-brudd-pa-maktfordeling-
sprinsippet-truer-var-profesjon
2. Associated Press. Turkish
medical group leader sentenced
to prison after urging chemical
weapons probe. National Public
Radio. 2023 [cited 2023 Jun 1].
Available from: https://www.npr.
org/2023/01/11/1148395326/
turkish-medical-association-pres-
ident-sentenced-prison-ter-
ror-propaganda
3. Standing Committee of European
Doctors. CPME Resolution
on Professional Autonomy and
Clinical Independence of the
Medical Profession in Europe
[Internet]. 2009 [cited 2023
Jun 1]. Available from: https://
www.cpme.eu/api/documents/
adopted/2009/CPME_AD_
Brd_130609_003_final_EN.pdf
4. Standing Committee of
European Doctors. Charter
for Liberal Professions
[Internet[. 2013 [cited 2023
Jun 1]. Available from: https://
www.cpme.eu/api/documents/
adopted/2013/CPME_AD_
EC_10102013_140_Final_EN_
Charter_Liberal_Professions.pdf
Authors
Ole Johan Bakke, MD
Specialist in public health
and family medicine
Board member, Norwegian
Medical Association
Vice President, Comité Permanent
des Médecins Européens
Holmestrand, Norway
ole.johan.bakke@holmestrand.
kommune.no
Axel Rød,
MPhil Comparative Politics
Norwegian Medical Association
Oslo, Norway
Axel.rod@legeforeningen.no
Violating the Principle of the Division of Powers Threatens our Profession
31
E-hailing services for ambulance
services, also known as on-demand
ambulance services, leverage
technology platforms similar to those
used by ride-sharing companies like
Uber or Lyft [1].These services aim to
provide quick and convenient access to
medical transportation when people
require urgent medical attention
or need to be transferred between
healthcare facilities [1,2]. Depending
on the service, the ambulance may
be equipped with basic or advanced
life support equipment, and trained
medical personnel may be on board
to provide emergency medical care
during transport [1-5]. The e-hailing
service operates through a mobile app
or web platform that allows users to
request an ambulance [3,4]. Users
are able to download the application,
create an account, and access the
service at any time.
When a user requires an ambulance,
they can open the app, input their
location, and request the nearest
available ambulance [5].The platform
uses GPS technology to determine
the user’s location and identify the
nearest ambulance [6]. Once the
ambulance is dispatched, users can
track its real-time location on the app,
similar to how ride-sharing apps allow
tracking of drivers en route to the
pick-up location [7]. The application
provides an estimated arrival time for
the ambulance, so users have an idea
of how long they will have to wait
for assistance [3,4,8]. Users handle
payments through the app, either
through credit and debit cards or
other digital payment methods, or in
some cases, insurance companies may
cover the cost [8].
The Potential Use of E-hailing in
African Healthcare
Ride-hailing apps and on-demand
delivery platforms like Bolt have
the potential to broaden access to
healthcare in Africa and transform
healthcare transportation and
delivery [1,9]. These services offer
a more reliable, affordable, and
convenient means of transport for
patients, particularly those residing
in rural or hard-to-reach areas where
public transport is often unreliable
or nonexistent [9-11]. Beyond
transporting patients to healthcare
facilities, e-hailing services can also
play a crucial role in the delivery of
medicines and other medical supplies
[1]. Patients with chronic illnesses
who require regular medication can
benefit greatly from the convenience
of having medicines delivered to their
doorstep, eliminating the challenges
associated with travelling to healthcare
facilities [12,13]. Moreover, e-hailing
services facilitate telemedicine
consultations, leverageing technology
to connect patients with healthcare
providers remotely and bridging
geographical gaps in healthcare access
[1,13,14]. This becomes especially
advantageous when patients and
healthcare providers are located in
different parts of the country or
even in different countries altogether
[13,14].
Several African countries face
challenges regarding the provision of
ambulance services, which are often
characterised by unreliability or even
absence, resulting in considerable
delays in the delivery of emergency
medical care [1, 9-12]. One potential
solution to mitigate this pressing
concern is the utilisation of e-hailing
services,which can provide immediate
access to ambulance services for
individuals requiring urgent medical
attention [1]. Quick response times
and efficient ambulance dispatch
through technology ensure that
emergency medical care reaches
patients promptly, potentially saving
lives [13,15]. The implementation
of e-hailing services in healthcare
requires close collaboration between
technology providers, healthcare
institutions, and regulatory bodies
[1,9]. Emphasising compliance with
medical standards and patient safety
is paramount to ensure the seamless
integration of these services into the
healthcare landscape [1,9,15,16].
Proper training for medical personnel
and drivers involved in emergency
medical services is essential to
guarantee that patients receive the
necessary care during transportation
[16-18].
Benefits of E-hailing Services for
Ambulance
E-hailing services for ambulances
offer expedited access to medical
transportation, presenting a faster
and more efficient alternative to
conventional methods [1,5,9,18].
Michael Willie
Revolutionising Medical Transportation: The Emergence of
On-Demand Ambulance Services through E-hailing Platforms
Revolutionising Medical Transportation
BACK TO CONTENTS
Sipho Kabane
32
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Real-time tracking capabilities enable
users to monitor the ambulance’s
location as it approaches, while
the app facilitates seamless
communication between users and
the ambulance crew [5,7]. The
implementation of technological
advancements in ambulance dispatch
can enhance the promptness of the
response to critical or life-threatening
situations,leading to improved patient
outcomes [19]. The convenience and
ease of use provided by the mobile app
interface further enhance the service’s
appeal [19,20].With just a few taps on
their smartphones, users can quickly
request an ambulance, streamlining
the process and minimising delays
[5]. Moreover, collecting information
on response times, user feedback, and
other relevant metrics, can facilitate
continuous improvement and data-
driven decision-making, ultimately
elevating the quality of service
provided [20,21].
Challenges and Considerations
Ensuring regulatory compliance and
guaranteeing appropriate medical
expertise are imperative for e-hailing
ambulance services to uphold patient
safetyandmaintainthehighestquality
of care [22]. Collaborating effectively
with these systems enhances the
seamless integration of e-hailing
ambulance services with existing
healthcare systems and emergency
response networks [17,23]. A broad
coverage area is essential to cater to
a wide range of urban and rural users
and ensure equitable access to medical
transportation services [9,10,18].
Ensuring the resolution of legal and
liability concerns holds paramount
significance for the provision of
such services [24,25]. In 2016,
the government of South Africa
undertook a comprehensive revision
of the National Land Transport
Act (NLTA) of 2009, specifically
identified as Act No. 5 of that year.
This revision was implemented to
encompass a crucial addition – the
inclusion of e-hailing services into the
existing legal framework governing
the realm of public transportation.
Prior to this revision, the regulatory
structure of the public transportation
system did not formally recognise or
address the operation of e-hailing
services. This significant amendment
signalled a progressive step toward
modernization and adaptation to the
evolving landscape of transportation
services within the country [24,25].
In response to industry complaints
and stakeholder concerns, the
Competition Commission in South
Africa issued a provisional report
in 2020, investigating e-hailing
services and metre taxis [26]. The
report acknowledged the challenge
of accurately quantifying the number
of illegal metre taxi operators but
suggests that a substantial portion of
drivers may be operating outside the
legal framework [25,26].
Guaranteeing consumer protection
and appropriate insurance coverage
and handling liability issues
effectively instills confidence in
both users and service providers.
However, despite the potential
benefits, efforts must be made
to overcome barriers related to
smartphone and internet penetration
to ensure that low-income and rural
populations have access to these
e-hailing ambulance services [27,28].
Additionally, constant evaluations
and improvements are necessary to
guarantee that e-hailing ambulance
services provide align with the
highest standards of care and patient
safety [22,27]. As with any emerging
technology, the success of e-hailing
services for ambulances depends on
effective implementation, continuous
improvement, and collaboration
with relevant stakeholders in
the healthcare sector [1,25,29].
Case studies
Uber and the American Red Cross
Partnership (United States): In
2017, Uber and the American
Red Cross joined forces to create
the Uber Health program [30].
This initiative aimed to provide
reliable transportation for patients,
including non-emergency medical
transportation and transportation
to and from blood donation centres
[18]. With the utilisation of Uber’s
technological advancements and a
vast pool of drivers, the objective was
to enhance the availability of medical
facilities for patients requiring
immediate attention [30]. The
partnership was deemed successful
in helping patients reach medical
appointments and blood donation
centres more conveniently [30]. The
mainlessonlearnedfromthisinitiative
was the importance of partnering
with established organisations in the
healthcare sector to ensure regulatory
compliance and proper integration
into existing medical systems [30].
Ambulnz in New York City
(United States): Ambulnz, a private
ambulance service, adopted a model
like Uber for emergency medical
transportation [31]. Using a mobile
app, they enabled users to request
an ambulance when needed. The
app provided real-time tracking and
estimated time of arrival, like how
ride-sharing apps work [6]. Ambulnz
aimed to optimise ambulance dispatch
and reduce response times [31].
The success of this model in New
York City highlighted the potential
for more efficient and effective
ambulance services in densely
populated urban areas [31]. One
important lesson learned from this
case is the need for strict adherence
to medical regulations and standards,
as emergency medical transportation
involves higher stakes compared to
regular ride-sharing services [18].
Revolutionising Medical Transportation
33
Careem NOW and Safe Ambulance
Service (Pakistan): In Pakistan,
the ride-hailing company Careem
launched the Careem NOW
platform, which offered various
services, including food delivery
and medication delivery [32,33].
Additionally, they collaborated
with the Safe Ambulance Service
to provide on-demand ambulance
services, and users could use the
Careem NOW app to request an
ambulance in case of emergencies.
This partnership aimed to address
the issue of delayed response times for
traditional ambulance services [33].
Respo App (South Africa): In South
Africa, Blessing Nzuza envisioned
that e-hailing an ambulance could
revolutionise life-saving efforts,
accessible with a simple tap on a
screen [3]. With the support of five
emergency service providers, Respo
aimstosignificantlyreduceambulance
response times during critical medical
situations [3].Users can easily register
on the platform, providing essential
personal information like their name,
contact details, and medical aid
particulars, along with those of their
spouse. Notably, Respo pre-loads life-
threatening emergency options, such
as heart attacks, severe bleeding, and
accidents, sparing users the need to
input this information manually [3].
When users require immediate help,
they can effortlessly select the nearest
emergency vehicle through the app
[3].
Flare App (Kenya): Flare has
ingeniously crafted a response
system, encompassing a hotline, user-
friendly mobile apps, and a backend
platform tailored for ambulance
companies – effectively creating an
“Uber for ambulances” concept [4].
This innovative solution seamlessly
connects subscribers with emergency
services, streamlining the process of
dispatching the nearest ambulance
[4]. Through user-friendly mobile
apps or the call centre, subscribers can
record emergencies with ease. Once
an emergency report is made, Flare’s
sophisticated system efficiently
identifies the closest available
ambulance and dispatches it promptly
to the scene [4]. This real-time and
geographically optimised approach
significantly reduces response
times, ensuring that critical medical
attention reaches those in need swiftly
and effectively. Flare’s comprehensive
response system has the potential
to revolutionise emergency medical
services, providing a seamless and
rapid solution akin to the convenience
of ride-hailing services like Uber [4].
Conclusion
The importance of forming
partnerships with established
healthcare organisations,
governments, or emergency response
services cannot be overstated when
implementing Uber-like models
in ambulance services. These
partnerships are crucial for ensuring
compliance, safety, and the smooth
integration of on-demand ambulance
services into the existing healthcare
infrastructure. In order to prioritise
the safety and well-being of patients,it
is essential for on-demand ambulance
services to strictly adhere to medical
regulations and safety standards,
considering the life-saving nature
of their services. The utilisation of
technology to optimise the dispatch
of ambulances and decrease response
times has the capacity to greatly
improve patient outcomes, especially
in densely populated regions where
timely access to medical assistance is
of utmost importance. Ensuring that
driversormedicalpersonneldelivering
the service possess the requisite
training and expertise to proficiently
manage medical emergencies is
of paramount significance. The
customization of on-demand
ambulance services to cater to specific
local needs is necessary to guarantee
long-term success and effective
implementation in diverse regions,
taking into account the cultural,
geographical, and infrastructural
variations. Finally, e-hailing services
for ambulance transportation
may require a distinct operational
framework, when compared to
conventional e-hailing services. This
differentiation pertains to the fee
structure, as well as the potential
deviation in utilisation patterns and
frequency of requests. Moreover, it is
worth noting that these services may
encounter affordability constraints
in rural areas. A potential catalyst
for ensuring sustainability could be
the establishment of partnerships
between the government, private
sector, and donors.
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Authors
Michael Mncedisi Willie,
BSc, MSc, MBA, M.Phil
Executive: Policy, Research
and Monitoring
Council for Medical Schemes
Pretoria, South Africa
m.willie@medicalschemes.co.za
Sipho Kabane, MBCHB, MBA,
M. Phil (Economic Policy), PhD
Council for Medical Schemes
Pretoria, South Africa
s.kabane@medicalschemes.co.za
BACK TO CONTENTS
Revolutionising Medical Transportation
36
BACK TO CONTENTS
In recent years,various sub-specialties
in paediatric surgery have made
different degrees of progress and
breakthroughs in clinical concepts,
diagnostic and therapeutic techniques,
and scientific research innovations.
The Chinese Medical Association
(CMA)’s Sub-Society of Paediatric
Surgery has organised sub-specialty
groups to review and summarise the
important disciplinary advancements
in paediatric surgery, with the hope
of making China’s voice heard on the
international stage and contributing
to the global paediatric surgical
field. This article aims to provide
an overview of the advancements in
various fields of paediatric surgery
in China, thereby highlighting the
directions for future developments in
paediatric surgery.
1. General Surgery
Biliary atresia, which is a severe
fibrotic occlusive disease of the bile
duct, commonly seen in infancy,
is one of the important causes of
progressive cholestatic liver disease
in children that ultimately leads to
liver failure. Cholangitis is one of the
most common complications after
Kasai surgery, with an incidence rate
of 30% to 90%, which affects the
prognosis, quality of life, and survival
rate of children with biliary atresia
[1]. One research study noted that
32% of children with biliary atresia
had a high-risk nutrition evaluation,
and 29% had abnormal growth
and development [2]. Therefore, in
clinical practice, it is crucial to pay
special attention to the systematic
and comprehensive evaluation of
the nutritional and developmental
status of children with biliary atresia.
For children with high nutritional
risks, parents should be provided
with relevant health information
to care for these special needs as
well as seek early collaborations
with nutritionists. Early jaundice
regression after Kasai surgery and the
prevention of early cholangitis are key
factors in improving the prognosis of
biliary atresia [3]. The Liver and Bile
Duct Surgery Group of the CMA’s
Paediatric Surgery Branch developed
the Expert Consensus on Diagnosis
and Treatment of Cholangitis after
Kasai Surgery for Biliary Atresia in
2022, to establish a clear and reliable
treatment plan for diagnosing and
treating cholangitis [4].
On the other hand, surgical repair of
esophageal hiatus hernia in children,
especially newborns, has always been
a challenge for paediatric surgeons.
Although laparoscopic surgery has
emerged as an alternative approach
to invasive surgery, significant
differences and controversies remain
in the specific steps of laparoscopic
surgery [5]. The Minimally Invasive
Surgery Group and the Thoracic
Surgery Group of the CMA’s
Paediatric Surgery Branch developed
the Expert Consensus on Operation
for Laparoscopic Repair of Esophageal
Hiatus Hernia in Children in 2021,
which clarifies the surgical methods
and operation steps of laparoscopic
repair of esophageal hiatus hernia
[6]. This resource aims to help
standardise procedures, improve the
success rate of the surgery, and reduce
postoperative complications.
2. Urology
Genitourinary system trauma
accounts for about 3% of childhood
trauma [7]. Kidney injury is the most
common type of urinary tract injury
in children, representing about 10-
20% of abdominal injuries in children
[8]. In order to standardise the early
diagnosis and treatment of kidney
injuries in children, the Paediatric
Urology Group of the CMA’s
Paediatric Surgery Branch developed
the Expert Consensus on Paediatric
Renal Trauma in 2022, based on a
comprehensive review of the literature
and national and international expert
opinions [9].
Posterior urethral valves are the
most common cause of congenital
lower urinary tract obstruction in
male children, with a poor prognosis
and a mortality rate of 30-46%
[10]. Although early diagnosis and
treatment can improve outcomes
to a certain extent, inconsistent
treatment standards related to timing
and surgical strategies challenge
physicians [11]. The Paediatric
Urology Group of the CMA’s
Paediatric Surgery Branch released
the Expert Consensus on the Diagnosis
and Treatment of Posterior Urethral
Valves in Children in 2021, based on
recent national and international
clinical research progress, with the
aim of standardising clinical practice
and laying a foundation for further
development of diagnostic and
treatment guidelines in China [12].
The clinical manifestations of renal
duplication anomalies are diverse,and
the treatment approaches are varied
and controversial, with no guidance
available in China before 2021. The
Ni Xin
Current Status and Future Role of Paediatric Surgery in China
Current Status and Future Role of Paediatric Surgery in China
37
BACK TO CONTENTS
Paediatric Urology Group of the
CMA’s Paediatric Surgery Branch,
in conjunction with the Paediatric
Urodynamics and Pelvic Floor Group,
compiled the Expert Consensus on the
Diagnosis and Treatment of Renal
Duplication Anomalies in Children in
2021, by referring to international
guidelines and incorporating the
diagnostic and treatment experience
of Chinese physicians [13]. The
consensus states that the treatment
of duplicated kidneys requires a
comprehensive and systematic
evaluation of the morphology and
function of the urinary system before
surgery, and that a personalised
treatment plan should be developed
based on clinical symptoms,caregivers’
preferences, and physicians’ technical
proficiency.
The reported incidence of testicular
tumours in children is low (0.5 to 2 per
100,000), accounting for 1% of solid
tumours in children [14]. In recent
years,there has been a gradual increase
in the incidence of testicular tumours,
resulting from delayed diagnosis and
treatment. The Paediatric Urology
Group of the CMA’s Paediatric
Surgery Branch reached a consensus
on the diagnosis and treatment of
testicular tumours in children and
developed the Expert Consensus on the
Diagnosis and Treatment of Testicular
Tumours in Chinese Children in
2021, to standardise the diagnostic
and treatment process in children
and improve the survival rate and
prognosis of affected children [15].
3. Orthopaedics
Supracondylar fractures of humerus
are the most common elbow fractures
in children. In particular, Gartland
type III fracture of the humeral
condyle often involves vascular and
nerve damage, and without early
treatment, it can result in lifelong
disability, including risk of late
cubitus varus or valgus deformity [16].
Since anatomical and biomechanical
structures are variable through
children’s growth and development,
individualised and precise minimally
invasive treatments are necessary
to improve clinical outcomes. One
clinical study indicated that 3D
printing technology can convert
digital simulation results into 3D
physical models for enhanced surgical
tools [17].
Furthermore, the anterior cruciate
ligament (ACL) injury is becoming
more common in children and
adolescents. Since the epiphyses of
children have not yet closed, a lack
of uniform standards exists for the
diagnosis and treatment of ACL
injury in children and adolescents.
The CMA’s Paediatric Orthopaedics
Group, the Chinese Orthopaedic
Trauma and Deformity Correction
Group, and the editorial department
of the Chinese Journal of Orthopaedics,
published the Guidelines for the
Diagnosis andTreatment of ACL Injury
in Chinese Children and Adolescents:
Injury to the Ligament Substance
in 2022, to improve the scientific
diagnosis and treatment of ACL
injury in children and adolescents,
and ultimately improve the quality of
medical services centred on affected
children [18].
4. Cardiothoracic Surgery
The primary paediatric thoracic mass
lesions are abnormal tissues formed
by remnants of embryonic tissues or
metastatic tumours. Although the
incidence of malignant thoracic solid
tumours in children is low (1 per
10,000), rates have been increasing
in recent years [19]. The CMA’s
Paediatric Surgery Branch and the
China Healthcare International
Exchange Promotion Association’s
Women and Children Healthcare
Branch jointly formulated the Expert
Consensus on the Surgical Diagnosis
and Treatment Process of Solid
Tumours in Children’s Chest in 2022,
to standardise the main treatment
principles and treatment process for
solid chest tumours in children [20].
At present, extracorporeal membrane
oxygenation (ECMO) has become
the most important mechanical aid
in the treatment of Chinese children
with critical heart disease. One
research team provided an update on
ECMO technology, noting existing
problems and countermeasures,
where physicians can help lead
advancements in paediatric critical
care medicine [21].
5. Neurosurgery
Neuroelectrophysiological monitoring
represents an indispensable
application in neurosurgery,
with unique roles in evaluating
postoperative visual function. One
study suggested that intraoperative
neuroelectrophysiological monitoring
may reduce postoperative
complications and unnecessary nerve
damage for patients undergoing
selective posterior root rhizotomy
[22,23].This technology is also highly
regarded in the surgical treatment of
paediatric brainstem gliomas, where
neuroblastomas account for 8-10%
of childhood malignant tumours,
with a mortality rate of 15% [23].
With diverse biological behaviour
and complex pathogenesis, tumor
heterogeneity is evident, especially
for high-risk neuroblastoma. Hence,
the International Neuroblastoma
Risk Group Classification can help
develop an appropriate diagnosis
and treatment consensus that can
be widely used across health centres.
The Neuroblastoma Collaboration
Group of the Chinese Anti-Cancer
Association’s Paediatric Oncology
Professional Committee revised
and improved the CCCG-NB-2021
Consensus for Diagnosis and Treatment
of Childhood Neuroblastoma in
2022, based on the international
Current Status and Future Role of Paediatric Surgery in China
38
BACK TO CONTENTS
diagnostic and therapeutic progress
of the treatment pre-stageing and risk
stratification of neuroblastoma [24].
In recent years, indocyanine
green (ICG) fluorescence-guided
technology, as an emerging
intraoperative navigation tool and
precision medical technology, has
been widely used in identifying tumor
lesions and anatomical resections,
defining tumor margins, locating
lung metastases, and exploring
sentinel lymph nodes, due to its
simple operation, safety, and real-
time imageing characteristics. Since
the technological applications are
still being evaluated, researchers
reviewed the robust applications and
current progress of ICG fluorescence-
guided technology in the surgical
treatment of paediatric solid tumours
[25]. Future standardised protocols
should be developed to improve
the specificity and accuracy of ICG
fluorescence imageing, which has
shown promising results for wider
applications in the diagnosis and
treatment of childhood solid tumours.
7. Organ Transplantation
With scientific and technological
advancements, paediatric organ
transplantation has become
increasingly sophisticated and
applied to various diseases (e.g. end-
stage renal disease, liver failure)
[26]. Kidney transplantation is
recognised as the best treatment
option for end-stage renal disease,
as it can help compensate for any
growth and development defects
[27]. Also, liver transplantation with
early combination therapy including
plasma exchange can help reduce risk
of acute antibody-mediated rejection
after transplantation.
8. Applications of Artificial
Intelligence in Paediatric Surgery
In recent years, artificial intelligence
has become a hot topic in medical
research applications, including
diagnostic radiology (e.g. ultrasound)
and speech recognition information
[28].It may be used in remote medical
treatment for low-risk, repeatable
work as well as help alleviate the
health workforce shortage, improve
diagnostic and treatment efficiency,
and ease resource management.
Many questions remain, including
identifying subjective diagnostic
differences between doctors and
technology, and the exploring if
combining such diagnostic efforts can
help avoid misdiagnosis in clinical
medicine.
In conclusion, the development
of paediatric surgery in China
faces significant challenges
and a long journey ahead. The
global development of paediatric
surgery relies on multidisciplinary
collaborations and scientific progress,
which can strengthen comprehensive
medical services to ensure positive
paediatric health outcomes. Major
achievements have been made,
ranging from general surgery to
organ transplantation, and Chinese
paediatric surgeons are dedicated
to continue advancing scientific
research and clinical care in the field
of paediatric surgery.
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2021;42(8):673-8. Chinese.
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2022;21(10):911-6. Chinese.
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lectrophysiological Monitoring,
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[Chinese intraoperative elec-
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NB-2021 protocol]. Chinese
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Busic M, Cortez-Pinto H, Craig
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Current Status and Future Role of Paediatric Surgery in China
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27. Stefano R,Zaccaria R,Claudio R.
Perioperative acute kidney injury:
prevention, early recognition, and
supportive measures. Nephron.
2018;140(2):105-10.
28. Chang AC. Artificial intelligence
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paradigm shift? Ann Pediatr Car-
diol. 2019;12(3):191-4.
Ni Xin, MD
National Centre for Children’s Health,
Beijing Children’s Hospital affiliated
to Capital Medical University
President, Chinese Society of Paediatric
Surgery, Chinese Medical Association
Beijing, China
nixin@bch.com.cn
41
Leadership (2012-2024)
President: Dr. Jorge Alberto Coronel
Vice President: Dr. Natalio Cantor
Union Secretary: Dr. Marcelo Mingo
Secretary of Finance and Administration: Dr. Jorge Alberto
Iapichino
Secretary of Press and Broadcast: Dr. Edmundo Filippo
Secretary of Minutes and Organization: Dr. Rodolfo Nery
Secretary of University and Scientific Affairs: Dr.Daniel Martelli
Secretary of Institutional Relations: Dr. José Lodovico Palma
Secretary of Federative Relations: Dr. Jorge Raúl Quiroga Mateos
Secretary of Health and Social Medicine: Dr. Jorge Hernán Yedro
Secretary of Sports and Culture: Dr. Juan Carlos Bordes
Secretary of Social Works and Prevention: Dr. Domingo Ubaldo
Astrada
First Alternate Secretary: Dr. Víctor Alberto Baldassini
Second Alternate Secretary: Dr. Daniel Alfredo Godoy
Third Alternate Secretary: Dr. Héctor Abel Sale
Confederation Court of Honor
Leaders
Dr. Eduardo Augusto Llahyah
Dr. Eduardo Rocha
Dr. Marta Enriqueta Rios
Alternates
Dr. Fernando Vazquez Vuelta
Dr. Rúben Villaroel
Dr. Horacio Carasso
Confederation Court of Honor
Leaders
Dr. Julio Obelar
Dr. Cristina Elia Rosales
Dr. Brígida Raquel Leguizamón
Dr. Adolfo Enrique Rodrigo
Dr. Rafael Ademar Meneses
CONFEDERACIÓN
MÉDICA DE LA REPÚBLICA
ARGENTINA (COMRA)
Jorge Alberto Coronel
NMA Highlights
Alternates
Dr. Alfredo Rodríguez
Dr. Roberto Scarsi
Dr. Hugo Omar Yatchesen
History in brief
On 22 May 1941,the first Medical Union Congress (which later
became the Medical Confederation of the Argentine Republic,
COMRA) was held, with over 3,728 doctors from the Medical
Federation of the Argentine Republic. They dedicated their
efforts to protect physicians’ right to practise the profession in
decent conditions and promote equal access to health for the
Argentine population.
Mission
The Medical Confederation of the Argentine Republic
(COMRA) is a medical union entity with more than 80 years of
experience in defending physicians’labour rights throughout the
country and the exercise of the right to health of all Argentines.
It brings together medical professionals from across the country
and is representative in each of the Argentine provinces.
National collaborations
COMRA leaders aim to protect physicians’rights by monitoring
actions of the Provincial and National Social Works,the National
Institute of Social Services for Retirees and Pensioners (PAMI),
and health authorities and institutions. It serves as a third-party
entity for its union actions that represent medical professionals
in leading organisations in each province.
With more than 80 years of leadership, COMRA has developed
tools such as the National Therapeutic Formulary (Formulario
Terapéutico Nacional, FTN COMRA) in 1978, where the
COMRA Medicine Commission aims to increase access to
essential drugs as well as enhance quality control and rational
use of medications.
In 1991, the pre-paid medical unions and medical federations
joined COMRA to form the Argentine Health Network (Red
Argentina de Salud, RAS), due to a desire for solidarity and
cooperation within the medical community.
The COMRA Code of Ethics incorporates new elements of
medical practice including technological advancements and
respects the deontological parameters of the medical profession.
On 22 July 2010, the Union of Confederations of Health
Professionals (UCOPS) was formed, comprised of the
Biochemical (CUBRA), Pharmaceutical (COFA), Dental
(CORA), and Medical (COMRA) Confederations, and aimed
to promote the spirit of cooperation and union ethics among
health professionals and coordinate actions that defend common
interests.
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42
NMA Highlights
International collaborations
COMRA was named a member of the World Medical
Association (WMA) in 1954. It has formed part of the
Latin American and Caribbean Medical Confederation
(Confederación Médica Latinoamericana y del Caribe,
CONFEMEL) since 1997, and the Ibero-American Forum of
Medical Entities (Foro Iberoamericano de Entidades Médicas,
FIEM) since 2007. These networks offer a space for members
to exchange information, cooperate, and seek consensus on
medical ethics and professional competences among medical
organisations in the region.
Current challenges
The COMRA continues working on physicians’ rights as part
of their professional practice in the public and private sector,
striving for a dignified and ethical professional practice.
Contact information
Address: Av. Belgrano 1235,
Ciudad Autónoma de Buenos Aires, Argentina
Email: comra@confederacionmedica.com.ar
Website: http://www.comra.org.ar
BRAZILIAN MEDICAL
ASSOCIATION
(ASSOCIAÇÃO MÉDICA
BRASILEIRA)
César Eduardo Fernandes
Leadership
President: Dr. César Eduardo Fernandes
Secretary General: Dr. Antônio José Gonçalves
Treasurer: Dr. Akira Ishida
Vice Presidents: Dr. Luciana Rodrigues Silva
and Dr. Jurandir Marcondes Ribas Filho
Scientific Director: Dr. José Eduardo Lutaif Dolci
Professional Defense Director: Dr. José Fernando Macedo
General Delegate for WMA and International Affairs Director:
Dr. Carlos Vicente Serrano
History in brief
• 26 January 1951: The current Brazilian Medical Association
(AMB) was created, focusing on defending ethical values and
promoting physicians’ professional practice and rights.
• 1953: The first Brazilian Code of Medical Ethics was created.
• 1957: The first Table of Fees for 2,040 procedures was released.
The Commission of Medical Fees (Comissão de Honorários
Médicos) started revising the Table periodically.
• 1958: Titles of specialists were awarded by the Specialty
Societies.
• 2000: The Project Guidelines (Projeto Diretrizes) was
launched to enhance the development and work of the
Specialty Societies.
• 2003: The first edition of the Brazilian Hierarchical
Classification of Medical Procedures (Classificação Brasileira
Hierarquizada de Procedimentos Médicos, CBHPM) was
published.
• 2021: The Extraordinary COVID-19 Monitoring Committee
(CEM COVID) was established, as an initiative that would
become a beacon of guidance and a milestone in Brazil’s
response to the COVID-19 pandemic.To strengthen medical
representation within the National Congress, the AMB
created the Parliamentary Action Center (NAP), based in
Brazil. The Alliance for Health in Brazil (ASB) collaborated
with partner entities on initiatives to advance medicine.
• 2023: The Brazilian Medical Demography 2022 was published
as the most comprehensive study conducted on the reality of
physicians working across Brazil.
Mission
The commitment of the Brazilian Medical Association is “to
defend the professional dignity and interests of the physician
and safeguard the quality assistance to the population health”.
Objectives
As a non-profit,federative and civil association,the AMB unites
doctors and medical students throughout the national territory,
focusing on key objectives that:
• bring together the country’s physicians, medical students, and
their representative entities with the aim of updating scientific,
ethical,social,economic,and cultural guidelines of the country
• propose models, contribute to the development of health
policies,and advocate for improved public and private medical
services within the country
• educate and guide the population in seeking primary health
care services
• grant the titles of specialists in accordance with the national
statutes and regulations
• defend, in court or out of court, the collective interests of its
members
• prepare, update, publicise, and recommend the classification
of medical procedures for providing medical services in the
country
• encourage continuing medical education programs across the
country
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43
• promote security and pension plans for associate members
• support the establishment of criteria for evaluation and quality
control of medical schools in the country
• promote social campaigns that prevent, preserve, and restore
population health
National collaborations
The AMB currently serves on the National Commission for
Medical Residency (CNRM), on the Permanent Committee
for the Regulation of Health Care (COSAÚDE), and has
seats on the Committees of the National Commission for the
Technologies Incorporation of the Brazilian Unified Health
System (CONITEC). It also collaborates with the Participants
of the Committee of Specialties (CME), composed by the
Federal Council of Medicine (CFM), the BMA, and the
National Commission for Medical Residency (CNRM) which
regulates the recognition and registration of medical specialties
and their respective areas of activity in the scope of the medical
councils.
International collaborations
The AMB works closely with international organisations such
as the World Medical Association (WMA) and the Latin-
Ibero-American and Caribbean Medical Confederation
(CONFEMEL).
Current challenges
• Role of social care in healthcare pathways: Social care plays
a crucial role in the Brazilian healthcare system, especially in
facilitating primary health care services. Special attention is
given to four chronic non-communicable diseases: cancers,
cardiovascular disease, respiratory disease, and diabetes.
Adequate resources and a sustainable health system can help
attract and retain qualified professionals in the social assistance
sector.
• Health inequalities: The AMB addresses health inequalities
through a multi-faceted approach, including improving access
to healthcare, education, and economic opportunities to
Brazilian medical doctors.
• Financial challenges in the Brazilian medical community:Like
healthcare systems in many countries, the Brazilian medical
community faces financial challenges. The AMB has focused
their efforts to obtain capital investment for maintaining and
improving healthcare services.
• Exponential growth of medical schools in Brazil:Their growth
between the years 2011 and 2018 can have both positive and
negative consequences. While it can help address a shortage
of healthcare professionals, it must be accompanied by
strict quality control measures to ensure that graduates are
adequately trained. The “Mais Médicos” program, which
aimed to increase the number of doctors in underserved areas,
has likely contributed to this growth.
• Improving medical education: The AMB aims to support
the development of a prosperous medical education with
intersectoral collaboration, involving various government
agencies and private partnerships.
Contact information
Address: Rua São Carlos do Pinhal, 324,
São Paulo, Brazil, 01333-903
Email: presidencia@amb.org.br
Website: https://amb.org.br
Leadership
Chairman: Dr. Ivan Madzharov
(2018-2021, 2021-2024)
Deputy Chairman: Dr. Nikolay Branzalov (2018-2021, 2021-
2024) and Assoc. Prof. Dr. Hristo Shivachev (2021-2024)
Secretary General: Dr. Valentin Peev (2021-2024)
History in brief
The first association of doctors in Bulgaria was founded
by Dr. Dimitar Mollov in 1901 in Sofia as the “Physico-
medical Society”. Its main objective was to address medical
and professional issues, prevention, prophylaxis, and disease
treatment.The idea of establishing a medical society in Bulgaria
was proposed two years earlier by Dr. Stoyko Yurdanov, in a
letter to Dr. Ivan Slavkov, who envisioned a society that would
unite and enrich the medical knowledge of Bulgarian doctors.
• 1883: The Varna Medical Society was formed.
• 1895: The Ruse Scientific Medical Society was established
and similar organisations in Plovdiv and other cities.
• 1900: 14 organisations united to form the Union of Physicians
in Bulgaria.
• 1901: The Bulgarian Medical Association (BMA) was
established as an influential force in organising medical care
and advocating for doctors’ rights and fees.
• 1947: The BMA was dissolved by the communist authorities,
BULGARIAN MEDICAL
ASSOCIATION
Ivan Madzharov
NMA Highlights
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44
causing significant damage to the medical profession.
• 1990: The BMA was restored after Bulgaria’s transition to
democracy. Today, the BMA represents over 32,000 medical
doctors and continues to promote and protect their interests.
• 1999: The BMA became an independent professional
organisation under the Law on Professional Organizations of
Medical Doctors and Dentists. The BMA and the Bulgarian
Dental Association drafted Codes of Professional Ethics,
imposed sanctions for misconduct, and required membership
for practising doctors and dentists. The BMA’s role in
negotiating the National Framework Contract in Bulgaria
representing the interests of medical doctors has been
mandated by law since the introduction of health insurance
in the country.
Mission
The BMA champions and safeguards the professional rights and
interests of physicians, encompassing enhancements in working
conditions, professional growth, and fair compensation. The
BMA ensures the utmost standards of physician competence
and qualifications, alongside with quality healthcare and
patient safety. The present BMA Board embraced the goal of
re-establishing physicians’ prestige in society, bolstering the
profession’s authority, reshaping perspectives and leading by
positive example, and countering global challenges of aggression
against medical practitioners.
National collaborations
In 2017,the BMA and the State Prosecutor General collaborated
to appoint a dedicated Prosecutor whose primary responsibility
was to oversee expeditious legal proceedings against individuals
involved in violence against ambulance medical teams.This joint
effort aimed to enhance the protection and safety of medical
professionals in the field. Building on this initiative, in 2020,
a significant milestone was achieved through the signing of
an Agreement between the BMA, the Prosecutor’s Office, and
the Ministry of Health. This Agreement solidified a collective
commitment to work together in mitigating, preventing,
and thoroughly investigating crimes perpetrated against
medical professionals, striving to uphold justice and protect
those dedicated to serving the health needs of the Bulgarian
population.This partnership seeks to create a safer environment
for healthcare professionals, ensuring their well-being and
enabling them to provide care without fear of violence or
harassment.
International collaborations
The BMA actively engages in collaborations with regional,
European, and international organisations of physicians, which
is driven by the belief that collective efforts can effectively
address the challenges confronting the medical profession. The
BMA’s collaborations span a wide spectrum of issues, including
medical education, post-graduate training, brain drain, quality
healthcare,medical ethics,and fair compensation for services.By
fostering these partnerships, the BMA seeks to find innovative
solutions, draw on best practices, and collectively strengthen the
medical community’s capacity to meet these pressing challenges.
Through its active involvement in international forums, the
BMA aims to benefit from shared expertise,stay informed about
global healthcare trends, and advocate for policies that promote
the well-being of both medical professionals and patients.These
dedicated efforts ensure that the BMA remains at the forefront
of positive change and advancement within the medical field in
Bulgaria and beyond.
Current challenges
• Raise awareness about the lack of political will to complete
the health reform and the absence of a clear healthcare sector
development strategy in Bulgaria.
• Highlight the concerning issue of “brain drain” among
Bulgarian doctors who leave the country to pursue their
careers elsewhere, and the need for urgent measures to retain
and support the talented medical workforce within the nation.
• Advocate for immediate legislative amendments to align the
medical standards with global best practices, ensuring both
top-notch services and physician safeguarding.
• Support national amendments related to Continuous Medical
Education (CME).
Contact information
Address: 2 Dospat str, Sofia 1606, Bulgaria
Telephone: +359 2 954 11 69
Email: blsus@blsbg.com
Website: https://blsbg.com
Leadership
President: Dr. Klaus Reinhardt (2019-2027)
Vice-Presidents: Dr. Ellen Lundershausen (2019-2027) and
Dr. Susanne Johna (2023-2027)
GERMAN MEDICAL
ASSOCIATION
(BUNDESÄRZTEKAMMER)
Klaus Reinhardt
NMA Highlights
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45
History in brief
The German Medical Association (Bundesärztekammer) is
the joint association of the 17 State Chambers of Physicians
(Landesärztekammer).
• 1947: Was founded as the Working Group of West German
Medical Chambers.
• 1955: Was recognised as the German Medical Association
(GMA). Following the reunification of Germany, the system
of medical self-governance was extended to the former East
German states, where State Chambers of Physicians were also
established.
Mission
The GMA is the central organisation in the system of medical
self-governance in Germany.It represents the professional policy
interests of the medical profession in Germany and plays an
active role in the opinion-forming processes related to health and
social policies and legislative procedures. Individual physicians
in Germany are GMA members via compulsory membership
in their respective local State Chamber of Physicians. As
corporations under public law,the State Chambers of Physicians
(Landesärztekammer) are responsible for the administration of
all matters related to specialty training and continuing medical
education in Germany.
Objectives
• Ensuring good medical care for the population through
regular exchange with the State Chambers of Physicians and
coordination of their common goals and activities
• Mediating the exchange of opinions and experiences among
the State Chambers of Physicians
• Fostering a feeling of unity among physicians practising in
Germany
• Ensuring the most uniform possible regulation of the
professional duties of physicians and the principles for
practising medicine in all fields
• Safeguarding the professional interests of the medical
profession in matters that extend beyond the jurisdiction of
one State (Land)
• Liaising with national government authorities and individual
political parties
• Communicating the position of the medical profession on
health policy and medical issues
• Promoting continuing medical education and continuing
professional development
• Promoting quality assurance
• Establishing relations with the medical community and
medical organisations abroad
• Overseeing and updating the 1) Model Professional Code,
which outlines the ethical and professional obligations of
physicians; 2) Model Specialty Training Regulations, which
outline the content, duration and objectives of specialty
training and specialist designations; and 3) Model Regulations
on Continuing Medical Education, which outline the
requirements and standards of continuing medical education
activities
It is ultimately the State Chambers of Physicians as corporations
under public law that adopt and implement these regulations at
the State level based on the GMA’s model documents.
National collaborations
The GMA collaborates with the Federal Government, the
Bundestag and the Bundesrat,ministries,and individual political
parties in Germany on issues that impact the medical profession.
The GMA also maintains ties with other medical organisations
in Germany, including the Kassenärztliche Bundesvereinigung
(National Association of Statutory Health Insurance
Physicians); the Marburger Bund, the trade union representing
the professional and political interests of medical students
and physicians employed in Germany; the Hartmannbund, an
organisation representing the professional, political, and social
interests of physicians, dentists, and medical students; and the
Virchowbund, the professional association for practise-based
physicians in Germany.
International collaborations
The GMA represents the interests of the German medical
profession on the international stage, by maintaining bilateral
relations with medical associations abroad and through its
membership in numerous international organisations.The GMA
Department for International Affairs serves as a point of contact
providing general information for physicians seeking advice on
working abroad, as well as for physicians from abroad who wish
to work in Germany. It plays a central role in representing the
global interests of the German medical profession by organising
and coordinating activities with an international focus. It
contributes to international work on human rights impacting
the medical profession, developmental analyses and trends in
international healthcare systems, supporting systems of self-
governance (e.g. Kosovo), and monitoring European-level
issues relating to the medical profession. The GMA, which also
maintains an office in Brussels, plays an active role in the World
Medical Association (WMA), European Doctors (CPME), the
European Forum of Medical Associations (EFMA), and the
ZEVA symposium, which is a platform for exchange among
representatives of medical chambers in Central and Eastern
European countries.
Current challenges
• Physician shortages, particularly in rural areas of Germany:
Although the number of physicians per 1,000 inhabitants in
Germany is comparably high compared to other countries,
the medical profession and general population in Germany is
ageing. Part-time positions are becoming increasingly popular
among physicians. To keep up with the increasing demand
for medical care for the ageing population and balancing the
number of physicians who will be retiring or reducing their
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46
working hours, the GMA has demanded 6,000 additional
medical training placements for students in basic medical
training.
• Digitalisation in healthcare: The GMA is involved in regional
discussions to debate the European Union (EU) Commission’s
proposal for the European Health Data Space. The GMA
President Dr. Klaus Reinhardt emphasised the importance
of safeguarding sensitive health data and respecting patient
autonomy to maintain a relationship of trust between patients
and physicians.
• Ethical implications of artificial intelligence (AI) for the
medical profession: In October 2023, the GMA will bring
together top AI experts and facilitate a discussion with the
German Minister of Health on opportunities and risks of
AI in medical treatment and research related to personal and
trust-based relationships between patients and physicians.
• Health impacts of climate change.
• Strategies for addressing medicine shortages.
Contact information
Address: Herbert-Lewin-Platz 1, 10623 Berlin, Germany
Email: international@baek.de
Website: http://www.baek.de
Leadership
President: Dr. Steinunn Þórðardóttir
CEO: Mrs. Dögg Pálsdóttir
History in brief
• 1918: The Icelandic Medical Association (IcMA) was
established.
• 2018: The IcMA hosted the WMA General Assembly, as a
part of its 100-year anniversary celebration.
ICELANDIC MEDICAL
ASSOCIATION
(LÆKNAFÉLAG ÍSLANDS)
Steinunn Þórðardóttir
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Mission
To promote the independence of the medical profession and to
advocate for the improvement of the health status of Iceland‘s
citizens.
Objectives
The IcMA is both a trade union and a professional organisation.
Almost all doctors practising in Iceland are members although
the membership is voluntary. The IcMA enters into collective
agreements on behalf of its members who work for the public
health care system regarding employment conditions, such as
salaries, working hours, sick and parental leave, and pensions.
National collaborations
The IcMA collaborates with the government and parliament as
well as national, regional, and local authorities.
International collaborations
The IcMA is a founding member of the WMA and has long-
standing collaborations with the medical association from other
Nordic countries,the Standing Committee of European Doctors
(CPME), and the European Union of Medical Specialists
(UEMS).
Current challenges
The challenges facing the Icelandic health care system are:
• strain on health care due to ageing population, tourism and
severe lack of general practitioners
• insufficient staffing of doctors both in urban and rural areas
• far to high utilisation of inpatient facilities
• difficulties in maintaining highly specialised services (e.g.
cardiothoracic surgery), mainly due to lack of doctors
• long waiting lists (e.g. children’s mental health services)
• burnout and brain drain of doctors
• unsafe legal environment when related to handling adverse
incidents
Contact information
Address: Hlíðasmári 8, IS-201 Kópavogur, Iceland
Email: lis@lis.is
Website: http://www.lis.is
47
Leadership
President: Dr. Johannes Jehle
Secretary General: Stefan Rüdisser
History in brief
• 2004: The Liechtenstein Medical Association (LMA)
was founded and succeeded the Liechtenstein Doctors’
Association as the professional association for medical doctors
in the country. Membership in the LMA is mandatory for all
doctors practising in Liechtenstein.
Mission
As part of the mission of the LMA, it represents, promotes,
and strengthens the interests of all doctors in Liechtenstein. ​​
It also has authorities which it exercises instead of the public
health administration.
Objectives
The LMA primary objectives are defending the profession
against excessive state intervention, increasing the attractiveness
of the location as a destination for doctors, and supporting
doctors with rising bureaucratisation in the healthcare sector.
National collaborations
The LMA is connected with numerous stakeholders within the
Liechtenstein healthcare sector, focusing on collaborations with
associations of other healthcare professions.
International collaborations
The LMA also collaborates with the World Medical Association
(WMA) and Consultative Meeting of German-Language
Medical Organisations (Konsultativtagung deutschsprachiger
Ärzteorganisationen).
LIECHTENSTEIN MEDICAL
ASSOCIATION
(LIECHTENSTEINISCHE
ÄRZTEKAMMER)
Johannes Jehle
Current challenges
• ensuring access to the entire spectrum of medical care
• continuous recruitment of new specialists in all medical
fields, with challenges related to physician retirement and the
shortage of doctors across the wider region
• fending off state interventions in the provision of medical care,
which are generally the result of budgetary considerations
within the government
Future vision
All Liechtenstein residents enjoy easily accessible and timely
medical care without regard to their personal financial
circumstances. The work of doctors is less bureaucratic,
adequately compensated, and not undermined by politics, thus
increasing the attractiveness of the location and encouraging
young doctors to settle in the country and stabilise the natural
workforce fluctuation.
Contact information
Address: St. Martins-Ring 1, 9492 Eschen, Liechtenstein
Email: office@aerztekammer.li
Website: http://www.aerztekammer.li
NMA Highlights
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Leadership
Term of office (April 2020-April 2024):
President: Goran Dimitrov, MD PhD
Deputy Presidents: Mirjana Shosholceva, MD PhD and
Boro Dzonov, MD PhD
General Secretary: Oliver Karanfilski, MD PhD
Members:
Prof. Slavejko Sapunov, MD PhD
Prof. Dragan Mijakoski, MD PhD
Sead Zejnel, MD
MACEDONIAN MEDICAL
ASSOCIATION
Goran Dimitrov
48
Prof. Marija Zdravevska, MD PhD
Ljuben Ristevski, MD
Prof. Niki Metveeva, MD PhD
Dimitar Arnaudov, MD
History in brief
• 12 August 1945: The Macedonian Medical Association
(MMA) was established in the postwar period of the People’s
Republic of N. Macedonia with the mission to promote
medical and related sciences, protect the interests of doctors,
and contribute to the growth of the medical profession.
• March 1947: The MMA played a crucial role in establishing
the Faculty of Medicine in Skopje, contributing to the
development of medical education in Macedonia.
• 1976: The MMA received high federal recognition, the Order
of Merit for the People with SilverRays, acknowledging its
significant contributions to the advancement of healthcare
services and medical education.
• 2005: On the occasion of its 60th anniversary, the MMA
received the “St. Kliment Ohridski” national award, in
recognition of its outstanding contributions to the healthcare
sector in the Republic of N. Macedonia.
Mission
The primary mission is to improve the health status of the
population and contribute to overall social development. The
MMA aims to strengthen medical education programs, protect
the interests of doctors,and support their continuous professional
development. At times when healthcare resources were limited,
the MMA played a central role in modernizing health services
in Macedonia and affirming its national identity and autonomy.
Objectives
• Continuing Medical Education (CME) and Professional
Advancement: The MMA places significant emphasis on
CME and continuous professional development to ensure that
healthcare professionals maintain their competences and skills.
The association organizes scientific congresses, symposiums,
and meetings, providing physicians with opportunities to
enhance their knowledge and remain updated with the latest
medical advancements.
• Fostering Medical Research and Scientific Advancement: The
MMA actively supports and promotes scientific research in
medicine. By organizing medical debates, discussions, and
public lectures, the association encourages the dissemination
of knowledge and the exchange of ideas among medical
practitioners.
• Advocacy and Engagement in Health Policy: The MMA
collaborates with the Ministry of Health, the Medical Faculty,
and other state bodies to participate in the development and
improvement of healthcare regulations and policies. The
association actively engages in discussions and policymaking
related to healthcare, working towards evidence-based and
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efficient healthcare practices.
• Promotion of Medical Ethics and Professionalism:The MMA
places great emphasis on promoting ethics and professionalism
among its members. Adherence to the Macedonian Code of
Medical Deontology and the International Code of Medical
Ethics is encouraged, and an the Ethical Committee upholds
the highest standards of ethical conduct in medical practice.
National collaborations
The MMA works closely with the Ministry of Health, the
Faculty of Medicine, and the Doctors’ Chamber of Macedonia
to develop and implement evidence-based health policies and
initiatives.TheMMAregionalandspecialistassociationsfacilitate
knowledge exchange, promote professional development, and
bring together medical professionals with shared interests and
expertise.
International collaborations
The MMA’s commitment to international collaboration
extends to prominent organizations such as the World Medical
Association (WMA), the European Forum of Medical
Associations (EFMA), the World Health Organization
(WHO), the European Union of Medical Specialists, as well as
the United Nations Population Fund (UNFPA), and the United
Nations Children’s Fund (UNICEF). These comprehensive
collaborations underscore the MMA’s dedication to remaining
at the forefront of global medical advancements and its
proactive engagement in international research initiatives.
By actively participating in a multitude of professional and
scientific conferences worldwide, the MMA members gain
invaluable opportunities for cross-cultural learning, which in
turn, contributes to the Republic of N. Macedonia’s heightened
integration into the global healthcare community. Through its
multifaceted partnerships, the MMA ensures that its members
are well-informed and plays an integral role in advancing
healthcare standards on both regional and international fronts.
Current challenges
The MMA faces several significant challenges in the current
healthcare landscape of Macedonia, including:
• addressing the persistent shortage of healthcare professionals
• ensuring accessible and relevant CME opportunities
• integrating technological advancements into healthcare
services
• reducing health inequalities that exist among certain
vulnerable populations
• advocating for evidence-based health policy reforms
Future vision
The future vision of the MMA is anchored in a commitment to
excellence,advocacy,empowerment,andglobalcollaboration.The
MMA aims to further enhance medical education and research
in Macedonia, foster partnerships with academic institutions,
49
and promote evidence-based practices. By actively engaging in
policy-making and advocating for health policy reforms, the
MMA seeks to strengthen the healthcare system and improve
healthcare access and outcomes for all citizens. International
collaborations will continue to play a pivotal role in promoting
knowledge exchange, research collaboration, and professional
development opportunities for its members, positioning the
MMA as a dynamic and influential force in shaping the future
of healthcare in the Republic of N. Macedonia.
Contact information
Address: Dame Gruev 3, Skopje 1000, N. Macedonia
Telephone: + 389 2 3162 577
Email: info@mld.mk
Website: http://www.mld.mk
Leadership
President: Dr. Anil Bikram Karki (2023-2026)
Immediate Past President: Dr. Lochan Karki
General Secretary: Dr. Sanjeeb Tiwari
Editor-in-Chief, Journal of the Nepal Medical Association:
Dr. Angel Magar (2013-present)
Chief Administrative Officer: Mr. Milan Chandra Khanal
History in brief
The Nepal Medical Association (NMA) is a non-profit national
professional organisation of Medical and Dental Doctors of
Nepal. Established with as few as 20 members, it has evolved
into a large organisation with more than 13,000 members, with
16 branches across the country.The Founding President was the
late Dr. Siddhi Mani A. Dixit. The NMA has been publishing
the Journal of Nepal Medical Association (JNMA) since 1963; it is
the first and oldest medical journal in Nepal.
NEPAL MEDICAL ASSOCIATION
Anil Bikram Karki
NMA Highlights
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• 4 March 1951: Was founded.
• 1959-1961: Request for the NMA recognition by His
Majesty’s Government (HMG).
• 1961-1963: The NMA was registered with the HMG,and the
constitution subcommittee was formed. The first issue of the
JNMA was published.
• 1963: The Nepal Medical Council (NMC) was established
by the NMA at the First National Medical Association
Conference.
• 28 February 1964: The NMC was recognized under the
Act of the NMC. Though established on due legal grounds,
the NMC was still non-functioning due to the lack of Rule,
Regulations/Bylaws as per the NMC Act.
• 13 September 1965: Rule, Regulations/Bylaws was published
in the Nepal Gazette for the first time, stating that under
the power delegated by Clause1 (III) of the NMC Act, His
Majesty’s Government has enforced 13 different Clauses.
• 9 June 1966:All other Clauses of the NMC Act were enforced
except Clause 26, and they were enforced in Kathmandu and
Biratnagar in July 1977.
• 1964-1966: Kathmandu and Biratnagar branches were
recognized. There was an appeal for diarrhoea, cholera, and
dysentery prevention to the honorary minister.
• 1966-1968: Affiliation to the WMA was requested. HMG
requested to waive the customary charges on the prices of
medicines, drugs, and medical equipment.
• 1 January 1968: The NMC Rules was approved by HMG.
Regular functioning of the NMC was started. The first issue
of the JNMA was published.
• 1968-1970: HMG requested to implement the NMC Act.
• 1970-1972: Proposal of special leave for higher studies for
doctors with two years of service. The first symposium on
“Social and Medical Aspects of Family Planning in Nepal”was
held at Bir Hospital. The proposal was completed to establish
the Central Medical Library. The code of medical ethics and
role of members of the NMC were discussed.
• 1972-1974: Planning for training of nurses, auxiliary, and
paramedical program.The NMA attended the World Council
for General Practice in Australia.
• 1974-1976: The Scientific and Public Relation subcommittees
and two more branches were established.
• 1976-1978: The provision of an allowance for private practice
compensation from working in a remote place and hazardous
conditions, was requested. A NMA representative was sent to
represent the Ministry of Health in “Long-term Planning”.
• 1978-1980: The NMA research fund was established.
• 1980-1983: Rural health survey was conducted; medical relief
fund was established; special fellowships for Nepalese doctors
for post graduate studies were established.
• 1983-1985: Blood donation program were initiated, and free
clinics were opened.
• 1985-1986: The NMA award for sincere long services was
established. Free health and eye camps and a smallpox vaccine
50
awareness campaign were conducted.
• 1986-1988: Community-oriented programs for awareness of
tuberculosis, leprosy, measles, and vaccines were conducted.
• 1988-1990: The formation of training and career
subcommittee for training and higher education of medical
doctors; team of doctors was recruited to examine the victims
of democracy movements and civil war.
• 1990-1992: The Health Service Act was proposed alongside
with the formation of Health Service Act subcommittee;
village health camps were conducted.
• 1992-1994: The establishment of the Society of
Dermatologists, Venereologists and Leprologists was
approved; subcommittee was formed to conduct family
planning activities.
• 1994-1996: Various campaigns including AIDS, tobacco
cessation, and drug abuse campaigns were conducted. The
concept of doctors’ insurance was introduced.
• 1996-1998: Advised for Continuing Medical Education in
coordination with the NMC; HIV/AIDS and STD care and
management programs were executed.
• 1998-2000: The NMA established discounts on eldercare (70
years and beyond).
• 2000-2002: The NMA endorsed the Medical Education
Act and increased awareness about violence against doctors,
influenza, smallpox vaccination, and tobacco cessation.
• 2002-2004: The doctors benefit fund was established.
• 2004-2006: The HIV/AIDS project was implemented. A
protest against violence against doctors occurred.
• 2005: Dr. Sudha Sharma became the first female NMA
president, Dr. Achala Vaida was appointed as the new JNMA
Chief Editor. Dr. Angel Magar was selected as Deputy
Executive Editor.
• 2006-2008: The idea of Legal Case-related Insurance for
NMA Life Members was formulated. Medical and logistical
support was provided to flood victims.
• 2007: The “Jail without Bail” movement was initiated for
violence against health professionals in Nepal.
• 2009-2010: Dr. Kedar Narsingh KC was appointed as new
President. Several protests and rallies were organised that
demanded the rights of health professionals. The National
Workshop on Kidney Transplantation was conducted.
• 28 June 2009: Dr. Angel Magar conducted the national
consultative meeting on undergraduate vs postgraduate seats:
rationale, challenges and future perspectives in Nepal. White
paper was submitted to the government to establish a single
medical university and common entrance and exit exams for
medical professionals. It ultimately led to the establishment of
a medical education commission in Nepal.
• 2013: Dr. Anjani Kumar Jha was appointed as new NMA
President, Dr Angel Magar was appointed as the youngest
Chief Editor of the JNMA, and the 50th Anniversary of
the JNMA was celebrated. The JNMA conducted various
training on research and scientific publications. The World
Health Organisation’s Office in Delhi digitised the old JNMA
journals. Financial support from the Ministry was obtained
for the JNMA printing. Amendment of the NMC Act.
• 2015: The new NMA building was constructed.
• 2015-2017: Amendment to the NMC Act. Psychological
counselling and post-earthquake psychological support and
counselling training was provided.
• 2017-2020: Dr. Mukti Ram Shrestha became the new NMA
President.A discussion on Organograms of the Health System
in Nepal was initiated.
• 2020: Dr. Lochan Karki led the NMA as the new president.
• 2021: Under the new president’s leadership. Dr. Angel Magar
led the first Women in Medicine in Nepal that highlighted
female doctors by the President of Nepal and also founded
and organised the 1st NMA National Health Summit.
• 2022: The 2nd Women in Medicine in Nepal and the NMA
Health Summit 2022 were organised.
• 2023: The 29th All Nepal Medical Association Conference
(ANEMECON 29) was organised.
Mission
• To ensure professional rights and promote the quality of
ethical practices in medical and dental professions in order to
develop and improve the healthcare sector in Nepal
• To uplift and preserve professional standards, values, and
freedom of NMA members
• To conduct academic activities which increase the knowledge
and skills of medical doctors working in the country
• To raise public awareness of different health issues and
contribute to programmes that can improve population health
• To enhance closer professional and scientific links between
medical doctors and strengthen relationships between doctors
and the general public
Objectives
• To safeguard the legitimate professional interest and promote
the spirit of harmony and cooperation among individual
members
• To encourage members to maintain the highest standard of
professional conduct, prioritising the health of the patient.
• To encourage research and studies to acquire the knowledge of
medical and allied sciences by all possible means (e.g. JNMA
publications, establishment of medical libraries, holding
symposia, seminars, and conferences)
• To assist in continuous professional development of doctors
via various accredited national and international training and
programs
• To develop high-quality educational trainings of all medical
and paramedical personnel based on international standards.
• To encourage and support the endeavour to develop and extend
the provisions of curative and preventive medical facilities
• To be willing to offer services and cooperation to the
government in its efforts to eliminate quackery from medical
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practice in Nepal
• To work to raise public awareness of the laws on healthcare,
hygiene, and cleanliness
• To perform duties to improve the health of the nation
• To disseminate state-of-the-art knowledge, clinical practice,
technology,and emerging concepts in medical sciences among
medical and allied health professionals
• To create public awareness about various health-related issues
National collaborations
The NMA serves an important role in the development of
medical science as the link between the government and medical
professionals.The NMA is associated with 36 societies in Nepal,
and it provides professional security by supporting its members
during various manhandling and vandalism incidents that
occur in the workplace. It also conducts various academic and
training programs, including various national-level programs in
collaboration with the World Health Organization.
International collaborations
The NMA is a member of the World Medical Association
(WMA), the Confederation of Medical Associations in Asia
and Oceania (CMAAO), and a founder member of the South
Asian Medical Association (SAMA). It is affiliated with the
Indian Medical Association, and it has helped to establish the
Bhutanese Medical Journal.
Current challenges
• Improving the efficiency of the hospital, motivating health
professionals, and using appropriate technology
• Ineffective using of resources and budgets allocated for
improving the quality of health
• Strengthening medical ethics, medical research, and scientific
publications
Future vision
• To establish research and development programs across the
country
• To establish the NMA as a think tank and contribute
significantly to policy-making in the medical sector
Contact information
Address:NMA Building,Siddhi Sadan P.O.Box 189,Exhibition
Road, Kathmandu, Nepal
Telephone: +977 1 4225860/4231825/4225300
Email: nma@nma.org.np
Website: https://www.nma.org.np/
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Leadership
President: Dr. Lul Mohamud Mohamed
Vice President: Dr. Asad Hassan Sheikh Mohamed
Secretary General: Dr. Liban Hassan Mohamud
Secretary for Public and International Affairs:
Dr. Kadra Dahir Abdi
Finance Secretary: Dr. Jamal Salad Hussein
Secretary for Social Welfare and Emergency:
Dr. Hassan Ahmed Abshirow
Secretary for CME and Research: Dr. Mohamed Ibrahim Abukar
History in brief
1999: The Somali Medical Association (SMA) was founded as
an independent professional union of doctors that supports the
professional and personal needs of doctors working in Somalia.
Mission
To build a sustainable professional association of medical
doctors that will advance the delivery of qualitative healthcare
services through continuing professional development,advocacy,
research, and public education in collaboration with other
stakeholders.
Vision
The SMA represents a professional body committed to promote
efficient healthcare delivery, support high ethical standards, and
protect the interests of its members.
Objectives
• To promote the medical and related arts and sciences and
to maintain the honour and the interests of the medical
profession
• To aid in advancing measures designed to improve public
health and prevent disease and disability
• To assist in promoting measures designed to improve standards
SOMALI MEDICAL
ASSOCIATION
(URURKA DHAKHAATIIRTA
SOMAALIYEED)
Lul Mohamud Mohamed
52
of hospital and medical services
• To advise the government, other medical bodies, and the
general public on matters related to health
• To promote continuing professional development through
periodic publications, seminars, and scientific conferences
• To enhance the relationship with international medical
associations around the world
National collaborations
The SMA collaborates with the Ministry of Health, National
Institute of Health (NIH), National Health Professionals
Council 
(NHPC), and the local organisations representing
patient interests, other healthcare specialists, and relevant state
institutions.
International collaborations
The SMA closely collaborates with the World Medical
Association (WMA), Arab Medical Union (AMU), Kenya
Medical Association (KMA), and Rwanda Medical Association
(RMA).
Contact information
Address: Jawhara Apartment Block D-Room2, KM5,
Hodan District Mogadishu, Somalia
Telephone: +252617677999 Mobile: +252615546032
Email: info@sma.org.so
Website: https://sma.org.so/
Leadership
President: Dr. Tomás Cobo Castro
SPANISH MEDICAL COUNCIL
(CONSEJO GENERAL DE
COLEGIOS MÉDICOS
DE ESPAÑA)
Tomás Cobo Castro
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History in brief
• 1893: A large part of the medical profession felt the need
to create a professional association. The General Council of
Official Medical Colleges (CGCOM) was established, as a
pattern for the constitution of different provincial colleges.
Zaragoza and Burgos proposed to have the Central College
with the headquarters in Madrid.Its mission would be solving
disputes between fellow associates as well as conflicts between
district and provincial Boards.
• 1899: The school of Seville proposed to hold a national
meeting of schools in Madrid with a specific program for
debates. The discussion topics would be holding a congress
on Medical Ethics (in 1903), mandatory membership, and
aspects related to the Health Law and tenure of doctors.
• 1 February 1900: The national meeting, which was sponsored
by Julián Calleja y Sánchez as President of the College of
Physicians of Madrid, was held over three days, with 46 of
the 49 invited provinces in attendance. The Madrid school
was designated as a representative of all national schools.
During the following decades, the different scientific societies
organised national assemblies in the Madrid College.
• 15 May 1917: The Prince of Asturias School for Medical
Orphans was established at El Pilar Street in Zaragoza by a
royal decree, with the aim to encourage consensus between
provincial schools on participation dues.
• October 1918: Another attempt aimed to bring the Boards
of Directors of the Medical Colleges together during the
National Congress of Medicine, although it was prevented
due to the influenza epidemic.
• 26 January 1919: Assembly of Boards of Directors, attended
by representatives from 33 provinces, was concluded with
issues related to regular doctors and pensions for families
of doctors who died in the recent epidemic; an executive
committee with its residence in Madrid and headed by
Augusto Almarza was created; a decision was concluded to
hold another assembly in the fall 1919. In this new meeting,
the creation of the Federation as a harmonious organisation of
all Medical Colleges was to be proposed.
• 6 November 1920: At the request of his college,the Assembly
of the Medical Colleges of Spain held in Valencia, finally
established the Federation of the Medical Colleges of Spain,
formed from Regional Confederations; a representative from
each would form the National Directory.
• 1921: Two Assemblies were held in June in Madrid and
in Barcelona in November; discussion topics included
relationships with Governing Boards and Board of Trustees
of Regular Doctors, the professional practice of international
doctors, and intrusion and quackery.
Mission and objectives
• The functions provided for the regulations on professional
colleges correspond to those of the General Council of Official
Colleges of Physicians, including:
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NMA Highlights
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• representing the Collegiate Medical Organization before
all international medical and health organisations
• representing the Collegiate Medical Organization
before the institutions of the European Union, related to
issues that affect professional practice and its ethical and
deontological aspects
• The following functions correspond to those of the General
Council of Official Colleges of Physicians:
• processing requests or claims of the Official Colleges of
Physicians addressed to the central bodies of the General
Administration of the State,provided that they do not fall
under the jurisdiction of the corresponding autonomous
council and so are the interests of the respective colleges,
where appropriate, without prejudice to the fact that can
send them directly or through the autonomous councils
• collaborating with the Government and other authorities,
at its own request or at the request of the Associations,
in the improvement and perfection of the regulations
on professional associations and mandatory inform of
any draft provision that affects the general conditions of
professional practice
• studying the problems of the profession, adopting, within
its scope of competence, the necessary general solutions
and proposing, on its own or at the suggestion of the
colleges,the pertinent reforms;intervening in any conflicts
that affect the medical profession and its corporate
organisation, exercising the rights in its representation,
without prejudice to the right that corresponds to
the colleges or, individually, to each doctor, or to the
competence of the corresponding autonomous council
• resolving the administrative appeals filed by the members
against agreements of the Official Colleges of Physicians,
in the absence of regulation in this regard by the regional
regulations and provided that this is established in the
particular Statutes of an Official College. Likewise,
resolving the appeals for reconsideration that are filed on
an optional basis against the agreements of the General
Council
Contact information
Address: Plaza de las Cortes, 11 – 28014, Madrid, Spain
Email: cgcom@cgcom.es
Website: https://www.cgcom.es/
54
Dear Esteemed Colleagues around
the World,
We are thrilled to extend a warm
invitation to you for the 74th World
Medical Association (WMA)
General Assembly, which will be
hosted in the beautiful and vibrant
city of Kigali, Rwanda, from 4-7
October 2023. This event represents
a global platform for medical experts
to address the most pressing issues
in healthcare today. It also holds
immense significance as it marks
the first time that Rwanda has been
chosen as the host country for the
WMA General Assembly.
Theme: Global Health Security
The theme for this WMA General
Assembly’sscientificsessionis“Global
Health Security.” We recognize that
global health challenges demand
global solutions, and this theme
reflectsourcommitmenttoaddressing
critical issues that affect the health
and well-being of our interconnected
world. It underscores the importance
of collaboration and preparedness to
ensure the health and safety of all.
A Comprehensive Program
The WMA General Assembly’s
program is designed to encompass
a wide array of activities over four
days. It will include statutory
meetings, a scientific session, and a
plenary assembly. Our program also
features specialised sessions tailored
for the Junior Doctors Network, an
environmental caucus, and a full-day
scientific session dedicated to the
selected theme for 2023. In addition,
the assembly will offer ceremonial
sessions, social events, and excursions
to various attractions across Rwanda.
Registration Information
We encourage all members of the
global medical community to register
for the event by using the following
link (http://cvent.me/4b4L4l).
Join Us in Rwanda
Weareexcitedaboutthecontributions
that this WMA General Assembly
can make to help advance healthcare
globally. Your presence and active
participation will enrich the
discussions and help shape the future
of medicine.
We look forward to welcoming you
to Rwanda, the Land of a Thousand
Hills, for the 74th WMA General
Assembly. Together, let us inspire
positive change and create a healthier
world for all.
Please mark your calendar for 4-7
October 2023, and join us in Kigali
for this historic event!
Rwanda Medical Association
Kigali, Rwanda
info@rma.rw
74th World Medical Association General Assembly in Rwanda
74th World Medical Association General Assembly in Rwanda
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Dr. Anthea Mowat passed away peacefully at her home in Morpeth,
United Kingdom, on 23 July 2023, in the loving presence of her husband
Andrew and their two daughters, Siobhan and Catriona. She had been
diagnosed with breast cancer in late 2022. Throughout her life, Anthea
has brought a major contribution to our medical profession, with an
acute sense of ethics, justice, and equal rights of all to the high-quality
healthcare they need.
Anthea Mowat was born in 1958 in Newcastle, UK, where she grew
up in a very supportive family. Already as a child, she became an active
participant in her community, including a Girl Guide and at Dame
Allan’s Girls’ School, and she won many academic prizes. By age 6,
she wanted to become a doctor, and she never let go of her passion for
our profession! She attended Aberdeen Medical School, where she
became actively involved in different associations, showing her interest
in supporting social causes and those in need in her community. But
above all, medical school is where she met Andrew, who became her
husband in 1984.
Interested in anesthesia, she completed her specialty in Inverness and
Aberdeen. After having her two children, she was attentive to her work-
life balance and took up a “Married Women Doctor Returner Scheme”
in a hospital near her home. Later, she returned to her specialty as a
senior hospital doctor, and thanks to her skill and experience, she
became Associate Specialist in anesthesia and chronic pain.
When a negotiating committee to represent doctors among hospital
management was selected for her institution, Anthea offered to join the
committee and served for over 20 years. As she was particularly skilled
in negotiating and representing her colleagues, she was elected chair of
this committee and held this position for more than 10 years. Notably,
she was the first Associate Specialist in the UK to hold this role, which
was obviously the start of her truly remarkable career in medical politics.
On a national level, Anthea Mowat revived her local geographic British
Medical Association (BMA) division to become one of the most active
national divisions. As Chair of the division, she could attend the BMA
Annual Representative Meeting (ARM), which is the main policy body
of the BMA. Her ardor in supporting issues relevant to her colleagues
back home, led to her election to the national Committee for Associate
Specialists and Specialty Doctors (“SAS Grade”), where she became
Conference Chair and later Deputy Committee Chair.
Clearly, the BMA had spotted her outstanding capacities. She led the
ARM Agenda Committee, and then became Deputy Chair and Chair
of the BMA Annual Representative Meeting. She was only the second
women – and first SAS Grade Doctor – to hold this remarkable position
since 1832. She used her role as BMA Chief Officer to lead for equality
and inclusion, true to her ideals and vision of medicine. She campaigned
against the gender pay gap and led reports highlighting homophobia,
bullying, and harassment within the healthcare system.
Beyond all this, Anthea kept working as an anesthetist and was much
appreciated in her hospital, reflecting that she had anesthetized about
90 people of her own staff! At the end of her term as Chair of the BMA
Representative Body, Anthea Mowat was called to become Honorary
Secretary of the national Medical Women’s Federation.
Shortly after she retired, the coronavirus disease 2019 (COVID-19)
pandemic started. She returned to work at her hospital, where she
helped with bereavement counseling and support for colleagues in
administrative duties.
Later, Anthea and her husband became active in their local church
community, singing with St. Mary’s Choir, and helping with fundraising.
Their faith was important to both of them.
In December 2021, Anthea was asked by the Chair of the WMA
Associate Members, the late Dr. Joe Heyman, to take over as interim
Chair, due to his terminal illness. He had selected Anthea for this
role, knowing that she was a respected person and passionate about
the ongoing important work he had initiated. She assumed this role
in her wonderful supportive and diligent manner, among other tasks
completing the update of the rules of the WMA Associate Membership.
At the end of her interim mandate, she became Past-Chair in the WMA
Steering Committee.
A few months later, in December 2022, Anthea Mowat was
unfortunately diagnosed with breast cancer; she dealt with this news
and the following treatment stoically and patiently. Remarkably, she
donated her hair before chemotherapy, and raised several thousands of
pounds for charities and her church.
Dr. Anthea Mowat was a truly remarkable person, dedicated to her
profession, and through it to her patients, and her colleagues. She
exhibited qualities and skills that are rarely found in one single person.
We will miss her dearly and remember her fondly.
Our heartfelt sympathy goes out to her family – to her daughters,
Siobhan and Catriona, and especially to her husband Andrew, a dear
Colleague and WMA Associate Member.
Jacques de Haller, MD
Obituary written by the Chair of the WMA Associate Members
Obituary
Anthea Mowat
Obituary
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