WMJ 04 2013

COUNTRY
• Declaration of Helsinki
• Strong Tobacco Policy
• Model of Colombian Social Security in Health
vol. 59
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 4, September 2013
Editor in Chief
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Latvian Medical Association
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121
The globalization in more narrow sense is
presenceof international contacts as well as
dependance of people and groups of people
on international activities. International
contacts have been taking place through-
out the history of the world. Since ancient
times trade, migration and wars have been
bringing together people from different
origins. The notion “citizen of the world”
belongs to Diogenes of Sinope, an ancient
Greek philosopher who lived in 4th
century
BC.
The term “globalization” and the concept
of global development emerged in the 80-
ties and was first broadly used in 1981 by
J. Mcleen and later expanded by R. Rob-
ertson in 1983. More detailed research of
globalization as a process or phenomenon
started in 90-ties. R.  Robertson’s “Glo-
balization”, was published in 1992, while
M. Waters’s fundamental work “Globaliza-
tion” came out in 1995.
The main achievements of XX century –
computers and space exploration,
globalization and communication,
antibiotics and hormone replacement
therapy in medicine
The XX century brought to humankind
huge changes and astonishing events, wars,
epidemies, discoveries, development, and
both human reasoning and insanity. There
was more news in the human world than in
the whole millennium before. New matters,
that were crucial for the formation of new
culture and new world, emerged.
Globalization is essential here. A human
life became completely different, particu-
larly the volume of received information
increased dramatically. One of the main
cornerstones of globalization was the devel-
opment of new means of On the other hand
this brought along dependence on informa-
tion and its carriers and changed the way
people communicated.
Globalization in XXI century means
different economic situations
Today the world is divided into two parts: the
economically developed one and the other
that suffers from stagnation. In addition, the
developed countries declare that they are try-
ing to eliminate the gap while in reality they
often do everything to deepen the gap. In the
context of globalization processes the world
economy is concentrated in three reģions
(Eastern Asia, North America, Western Eu-
rope). Meanwhile the interests of the devel-
oped countries determine the way science and
technologies move towards absolute privati-
zation, decentralization and liberalization.
Globalization is also charaterized by un-
balanced demographics – Asian numerous
dominance and African powerty. At the
same time there is economic growth in Chi-
na, India, Nigeria etc. That sooner or later
will lead to shift of economic centres.
The social strategy in the most of the world
is wavering between free market economy
and restricted social market economy that
is supplemented by moderate protection-
ism. Big companies more and more actively
become participants of co-operating net-
works while middle-sized and small ones
are subjected to huge management changes
and market demands. At the same time the
gap between socially integrated groups of
population and those socially outcast is con-
tinuously increasing, unemployment rates
grow and they move towards developed
countries. In the sphere of health care and
medicine prevention, diagnostics, treatment
and rehabilitatition both concerning quan-
tity and quality are determined by financial
capacities. Inhabitants of poor countries
suffer from diseases hardly imaginable for
an European doctor as they are caused by
insufficient nutrition or even hunger.
Globalization means speed.
Information is spreading fast, so are
diseases, however, particularly fast
travel people who spread the diseases
Not so long ago in the XIX century an epid-
emy of flu was travelling at speed of a horse
carriage while today it is taken around by
airlines. Any flight to a distant destination
is shorter than any period of incubation of
any infectuous disease.
Distribution of diseases in the age of glo-
balization is determined by changes in peo-
ple’s lifestyles, growth of population and the
process of urbanization, as well as migration
of peoples caused by wars or natural or hu-
man-inspired catastrophes and particularly
migration as a result of economic problems.
Travelling is also an important factor when
spread of diseases is concerned, as travellers
contact rain forests or other wild habitats
Pēteris Apinis
The Globalization and the Role
of Medical Professional Associations
122
Globalisation LATVIA
that serve as reserve for insects and other
animals that carry infections.
The third influence of globalization is the
one of medicine that happens through in-
ternational drug companies that develop
and produce medications and provide in-
ternational schemes and guidelines. The
consequence of this is increased antibacte-
rial resistance that is also based on uncon-
trolled use of pesticides in agriculture and
uncontrolled use of antibacterial substances
in animal and fish farming.
As the fourth aspect that essentially influ-
ences human health and medicine I would
name uncontrolled use of chemicals in
households, washing the linen and dishes,
car wash, machine oils, biotechnologies,
which results in chemicals being washed
away into oceans where after being absorbed
by plancton they return to dining tables of
people through prawns, fish and crayfish.
Human health is essentially influnced by
the harm done to nature by people. De-
forestation, irrigation, genetical crops have
caused changes both in human bodies and
recarriers of illnesses. Moreover, serious
changes have taken place in human behav-
iour, overexcessive amounts of medicine,
narcotics, alcohol; traditional family pat-
terns and sexual culture have changed a lot.
Globalization as loss of geographical
segmentation concerning food
Similarly to people goods and food travel
long distances. Today all food supplies have
become global – people consume more and
more international food and the role of lo-
cally grown and processed food has lost its
significance.This means that seafood is con-
sumed worldwide, tropical fruit is mostly
consumed in Northern countries in Scan-
dinavia, South-eastern Asian poultry can be
found anywhere in the world as well as lamb
from New Zealand and South American
beef. Globalization has brought along un-
justified schemes of nutrition,meals that are
easy to cook, but that do not contain neces-
sary ingredients and is referred to as junk
food – different kinds of macburgers, chips,
French fries, hotdogs.
The world tends to repeat mistakes once
made in the USA. If we observe the ten-
dency to obesity of the whole nation in the
USA in the end of XX century, we can pre-
dict that illness number one worldwide in
XXI century will be obesity carrying along
diabetes and cardio-vascular diseases. Ger-
mans (along with other Central Europe-
ans) have bread and sausage with beer for
lunch while Americans help themselves on
big burger and cola. In the evening football
match on TV is supplemented by chips in
Germany but Americans enjoy their French
fries with American football.
Globalization as changes in ideology
and lifestyle.Tobacco as an example
A classical example of globalization is
smoking. Bradford Hill in 1951 discovered
that smoking causes lung cancer. It was a
stunning discovery at that time as almost
every male adult in Europe was smoking.
During the war tobacco served as conso-
lation in all entrenchments; even if it did
not help to relax, it could serve as a pass-
time. In those times it was difficult to prove
that smoking caused lung cancer because
it was common among both the ill and
the healthy. In 1947. the Council of Brit-
ish Medical Research asked Bradford Hill,
Richard Doll, Edward Kenneway and Percy
Stock to find out whether smoking could
be the reason for the shocking increase of
death rate 15 times during the last 25 years.
Since 1951 it has been proven that smok-
ing is a threat to human life. Already in
70-ties doctors started to fight the calam-
ity of smoking while in 80-ties and 90-ties
both in USA and Western Europe merci-
less fight against smoking started. Major
Tobacco companies lost millions in courts,
lost their advertising facilities, started pay-
ing huge taxes. It seemed that smoking
was going to lose the battle. However, the
result was opposite.Tobacco companies felt
threatened and started fighting desperately
to win new markets.They best succeeded in
Eastern Europe, South Asia, North Africa
and Latin America.Tobacco companies en-
tered developing countries using excellent
marketing strategies, attractive advertising,
exact political approach and friendly atti-
tude to mass media. As a result number of
smokers in the world increased three times.
Globalization today is an economic
strategy that proposes unrestricted
free trade and free market economy
In the end of XX century globalization
came on the stage with a patented econom-
ic prescription for any situation  – privati-
zation above all. The state lost its position
of menufacturer and employer becoming a
judge, surveyor and dictator of the rules of
the game.
The process of globalization along with ex-
pansion of market economy caused not only
political changes in the map of the world
but also economic fluctuations. The market
of raw materials was redivided, this process
brought along the collapse of the Soviet
Union and Yugoslavia, a number of new
independent countries emerged. Any eco-
nomics has faced serious problems during
the last twenty years yet the most significant
crisis touched Mexico (1995), Taiwan, Ko-
rea (1997), Thailand (1998), Brazil (2000),
Argentina (2002), Baltic states (2008),
Greece (2009). In all mentioned countries
the economic difficultiess brought along so-
cial and health problems, besides in Mexico
and Thailand children’s health was severely
affected (they had to work and missed
school and medical examination), while in
Argentina – the elderly (the collapse of pen-
sion system, bankruptcy of social homes).
Economic crises in individual and national
level show as depression, alcoholism, family
123
GlobalisationLATVIA
unstableness, diseases determined by stress,
increased death rate from cardio-vascular
diseases, more suicides and lethal accidents.
There is even a new term in the world litera-
ture – the losses of transitional period.
Market took over everywhere including
medicine, however, the state should have
taken the best possible control of this mar-
ket. The role of the patient had changed –
the patient was not anymore a grateful
subject of help but a customer, who buys
services offered by a doctor, nurse, rehabili-
tation speciālist, laboratory assistant. Con-
sumer philosophy became a part of health
care. There are two axiomes in consumer
philosophy: “more medicine is better health”
and “expensive medicine is better than
cheap medicine”. This leads to get served as
royal customers not ill people. So the result
is that a person who suffers from an illness
is treated as a broken car.the situation when
those who are able to pay.
Medicine, if it has enough
funds is able to extend any
individual’s life essentially
This means that any individual is entitled
to significant amount of common funds to
prolong their individual life which causes
catastrophic lack of money in medical sec-
tor not depending on how rich the coun-
try is. Any resource (professional medical
knowledge, intuition, experience, working
hours, premises, equipment, medications,
money) that is invested in health care, spe-
cific prevention issues, diagnostics, treat-
ment and rehabilitation, prolongs an indi-
vidual’s lifespan and improves the quality
of life. This is where the main paradox of
medicine appears – the more money is in-
vested in health care, the longer people live
(and as it was mentioned before agree with
their chronical illness), the more resources
will be required for health care.
All the countries that have reached this
stage of economic development face rapidly
growing discontentment with the health
care system and financial regulation of
health care.
The proportion of medical expenses in the
big money purse of the world or global
economy has been increasing during last
thirty years. In the world as whole the
growth of funding medicine is 3–5% per
year, which is significantly more than total
global gross product. Consequently, rules
of globalization are dictated by economic
interest and market. Where big money is
present, business interests emerge.
Commerce has entered the medical world
through spirit of market competition,priva-
tization, rivalry, information technologies,
circulation of information, mass media and
other routines of globalization, which can
be seen in different ways in major capitalist
countries, Eastern Europe, as well as South
America and even Africa.
The biggest player in the arena
of global medicine – the BIG
PHARMA. Medication companies
have set their new goals to reach
every person on the planēt and make
them take medications every day
Pharmacy business is ranked as the third or
sixth by significance in the world depending
on methodology of accounting.
Moreover, pharmacy business is the sig-
nificant player in advertising market, direct
and indirect advertising expenses are higher
than those on cars, travelling and fashion
goods in total. There are 5 billion USD
(30–35% of all expenses) spent on farmacy
marketing .
The global pharmacy market is explic-
itly heterogeneous. 89% of funds spent on
medicine go to 11% people. More than
80% of the world population only use folk-
medicine and do not receive contemporary
medications.
In Europe 2/3 of total medications are pre-
scribed to people who are older than 66.
Polypragmasia dominates in treatment of
the elderly – on average 6 (2.7–9.3) medi-
cations. All the side effects elderly patients
face stand out against the background of a
number of medications. More than 50% of
elderly patients suffer from side effects as a
result of combination of polypragmasia and
disturbances of kidney function. The big-
gest problem is the situation that there is no
monitoring of medication for elderly people.
In the XXI century massive use of medica-
tions has reduced the role of other ways of
treatment (including rehabilitation). In the
XIX century as well as the most of XX cen-
tury in Europe there was equal proportion
regarding surgery, treatment using medica-
tions, physical therapy and psychotherapy.
In the end of XX century the role of surgery
became less important because of the phar-
macy business (e. g. stomach resection dis-
appeared, number of appendectomies de-
creased), physical therapy significantly lost
its weight,and psychotherapy lost a lot of its
position, while Eastern and non-traditional
methods of treatment came in. Consump-
tion of medications rose exponentially.
There is an opinion that pharmacy com-
panies invest their assets and profit in the
world’s biggest news agencies. As a result
the big pharmacy business on the earth has
merged with the big media.The industry of
farmacy supports the journalism of sickness.
In 2001 we had type C hepatitis,
– in 2003 there was Bovine spongiform
encephalopathy or Creutzfeldt–Jakob
disease,
– in 2005 – SARS,
– in 2007 – Bird flu,
– in 2009 – Swine flu.
Looking back, we can see that every two
years a new reason to spend money is in-
vented. It is easy to compare: every year
half a million peoplr die of common flu.
124
Bird flu took 250 lives in the period of 10
years, but what fantastic profit it gave to
BIG PHARMA! Half a million against 25
a year. Newspaper headlines inform about
bird migration that spreads bird flu. Birds
usually travel from North to South while flu
spreads from East to West!
Pharmacy companies try to supply every-
body wth everyday pills. One of the most
obvious examples is the presumption that
contraception pills is a must for every
woman every day while those in menopause
have to take hormones regularly at least to
prevent osteoporosis. This guarantees two
milliard pills a day and this where the big
business starts. Pharmacy companies do not
strive to create new medications that could
treat malaria or infectious diseases; they ac-
tively develop antidepressants, new ways to
reduce blood lipids, blood pressure, try to
find Viagra for women in order to gain their
interest from market.
An analogous situation: in the sphere of
transportation most funds go to develop avi-
ation while most of the world’s population
inhabiting India, China, countries of Indo-
chine mostly travels by rickshaw or bicycle.
So pharmacy as a part of medical treatment
becomes similar to aviation as a part of trans-
portation. The market structure changes,
medications leave chemist’s stores and go
to supermarkets or internet stores.
The traditional model of medical treatment
(a medical professional  – a patient who
needs help) is threatened; self treatment is
on the rise.
Medications leave for drugstores and to es-
cape the Swine flu every second british citi-
zen buys a thermometer and Tamiflu.
In the age of globalization the roles of doc-
tor and farmacist are taken over by internet.
Internet drugstores advertise their bene-
fits – no visit to a doctor is required, no pre-
scription, time and money are saved as they
say that the prices are lower.Today there are
drugstore systems that function as cartel all
around the world.
Serios changes concerning morbidity
The doctor of the XXI century is much more
than ever involved in the treatment process
of incurable patients suffering from chronic
illnesses. Most of those who would be con-
sidered sentenced to death today have be-
come survivors, however, chronically ill.They
are people who will have to agree with their
illness that is incurable in theurapetic or
surgical way until the end of their lives. Ac-
cordingly the frequency of different types of
illnesses has changed: today’s patient as a rule
is a chronic one while acuities are exceptional.
A typical patient, for example, is a 65-year-
old lady. Her diagnosis is the third stage of
adiposity accompanied by 2nd
type diabetes
mellitus, hypertension, cardiovascular in-
ability, as well as breathing inability. Exces-
sive weight has caused pain in knee and
hip joints. She has been prescribed eight to
twelve different medications to treat every
separate illness.
Polypragmasia is a problem of XXI century.
If there are more than three types of pills,
one can be almost 100% sure that there will
be confusion about which are to be taken
three times a day by one pill and which four
times a day by two pills. It is even worse if
several doctors have been visited; and every
of them did their duty giving a prescription.
Task shiffting and global migration
of medical workers in XXI
century are consequences of the
globalisation of medicine
Even in the beginning of XX century no-
body could imagine a Riva Rocci device
or a fonendoscope in the hands of a non-
medical person. Not longer than ten years
ago nobody could imagine ultrasound diag-
nostic device operated by someone whose
qualifications are not adequate. However,
the costs of educating a doctor are becom-
ing higher and higher, doctor’s work costs
more and more, while as a result of the ag-
ing of population has caused lack of doctors.
It is cheaper to produce “substitute doc-
tors”  – functional specialists, optometrists,
logopedes, ergotherapists, technical ortho-
paedists. In many countries a nurse has a
right to give prescriptions.
At the same time emmigration waves of
medical workers travel the world. At lest
70% of Philipinian nurses work abroad.The
most typical bramin exporters are India,
Pakhistan, Malaysia, Philipines as welll as
Eastern European countries. Doctors and
nurses from Eastern Europe are enticed by
massive advertising campaigns carried out
by Professional recruiting companies. An
opposie tendency is medical tourism. The
expansion of hospitals, that is becoming
more and more fashionable, ensures that
new medical centres emerge in developing
countries. For instance, in Thailand and In-
dia the most Professional doctors get con-
centrated in medical institutions belonging
to foreigners, working with foreign patients.
As a result of globalisation doctors can find
any education materiāls on the Internet in a
few minits; materiāls of almost all medical
congresses are available on the world wide
web. Exactly the same way possibilities to
contact and consult anyone are widely avail-
able as well as telemedicine.
Globalisation in medicine in
XXI century is often referred to
as a global crisis in health care.
Psychological pressure is applied
to medical workers widely exposing
negations in mass media
Health care expenses have been increasing
both absolutely and relatively related to na-
tional gross product in civilized countries. At
the same time it means longer lifespan.Every-
body wants to live longer not depending on
Globalisation LATVIA
125
being a labourer, doctor, journalist or politi-
cian.The last two wish to get it free of charge.
It is quite typical that politicans when they
talk about medicine not being competent
enough try to promote e-health, expensive
Technologies and premises but trying avoid
to pay the medical professionals.
The World Wide Web also anwers the
question about the people who are loudly
campaigning against doctors  – they are
middle-aged people wno are practically
healthy, however, in this economically com-
plex situation suffer from stress, emotional
disturbances and as a result from vegetative
disorders. They complain about palpita-
tion, frequent colds, dizziness etc. and they
wish to be cured by a doctor immediately.
This group of people are frequent visitors
at quack doctors and healers, and they con-
sume a lot of food supplements.
They feel they have paid their taxes, however
they do not get in return attention or finan-
cial value for that as most of the money goes
to elderly chronic patients.They have no idea
that after some time they will belong to the
category themselves. This unfair situation in
financing the health care is the key factor that
ruins reputation of doctors – someone who is
still young and pays taxes does not know that
at some point life starts turning down. So ev-
erybody declaring now that they do not need
this kind of doctors and health care sooner or
later will face the situation when they do.
On the other hand – those who form opin-
ions of humankind, country or just locality
as a rule are not chronic patients or elderly
people who are receiving more health care
than they are actually paying for.
The Professional prestige of
doctors (hospitals, whole medicine)
is falling in XXI century
The significance of doctor’s profession has
decreased, the role of bureaucracy has swol-
len, the profession has lost its autonomy.
World wide research results show that a
doctor (variously in different countries and
specialities) has to spend 50–75% of their
working time making written or digital re-
ports.
Is the decrease of medical professions pres-
tige reasonable? Doctors work better and
more professionally, which is proved by
lengthening the lifespan in the entire civi-
lized world. New technologies are applied
in doctors’work, which means fast and pre-
cise diagnostics, atraumatic operations and
safe application of narcosis. Every year new
medications – safer and more effective – are
developed while there is a new qualitative
improvement in pharmacy every decade.
Cancer is not any more one hundred per-
cent lethal not to mention infectious dis-
eases that have been threatening people for
centuries.
Firstly, the problem is caused by qualitative
changes in lifestyle, economic formation,
attitude to health issues simultaneously
changing opinions regarding fundamental
principles. For instance, in the beginning of
XX century the notion diet meant enough
of “proper food” as patients lacked food or
had food that was not nutritional enough.
In the beginning of XXI century diet means
necessity of “less food”.
In the beginning of XX century prescription
of sustaining regime meant warmed room
and lying in bed. In the beginning of XXI
century active movements, swimming in a
pool, running, and ways of toughening the
body are considered sustaining. There are
also changes in procedure of diagnostics –
a conversation between doctor and patient,
inspection and auscultation have been re-
placed by megacomputers that carry out vi-
sual diagnostics and complicated machines
that make analyses.
Today doctor’s opinion is substituted by re-
sults of proved research that are part of evi-
dence based medicine.
The patient today is much more educated,
which is ensured by extensive flow of infor-
mation coming from pharmacy companies.
As a resut quite often patients know more
about newest medications than overloaded
doctors who do not have enough time to
surf the internet.
Doctors who work to hard but do not get
rewarded neither financially nor morally
come to frustration regarding the medical
system and their job. TV and press abuse
and slander doctors that results in decreas-
ing self-confidence, patients do not trust
doctors and mutual co-operation rearding
the process of treatment becomes inef-
fective. The doctors’ frustration influences
heavily the quality of health care.
The only protection comes
through Professional medical
associations or chambers
Doctors elect their representatives who are
entitled to protect their interests. At the
same time electors are not always satisfied
with the potection they receive. Associa-
tions cannot cope with their duties because
government, the ministry, patients, journal-
ists and ordinary doctors oppose them.
The tasks of National medical associations
are:
• protection of doctors’ professional, eco-
nomic and legal interests;
• promotion of prestige and respect of doc-
tor’s profession as a free profession;
• perfection of doctors’ethical code and ca-
tering for professional ethics;
• facilitation of postgraduate education;
• improvement of professional skills and
perfection of professional knowledge;
• assessment of professional qualifications
of foreign doctors and dentists;
• improvement of health care organization;
• facilitation of improvement of the health
of society;
• certification and licensing;
• co-operation regarding legislation etc.
GlobalisationLATVIA
126
Professional medidal associations in differ-
ent countries function differently and they
reach their objectives by different means.
The new issues imposed by globalization
require serious financial way of dealing with
them instead of just public activities.
Contemporary medical non-governmental
organizations are non-profit organizations
in reality are non-profit organizations that
have thousands of shareholders thus being
transparent business structures. Mostly they
do not depend on the budget of the state,
functioning on finance obtained in other
ways.
Nacional medical associations are financed
by membership fees, income from certi-
fication and licensing, publishing books
and magazines, creating other mass me-
dia, income from post-graduate education,
organizing of conferences and congresses,
incomes from international funds of envi-
ronmental and public health, income from
international projects of health care over
the borders, donations and gifts, and differ-
ent kind of co-operation between pharmacy
and food companies etc.
The role of non-governmental
medical associations in the area of
public and environmental health
is continuously increasing
Only 7% of world’s population are con-
cerned about environmental health while
only 1% are ready to act in benefit of it.
Amazingly, the most interested people in
environmental issues are clinical doctors.
National medical associations can be con-
sidered as the most influential power re-
garding public and environmental health,
in some countries it is the only power. For
example, in some Eastern European coun-
tries National medical associations in reality
function as Green parties.
Public health is a science that is continu-
ously developing. Public health is based on
science, that is why only science performed
by doctors promotes health and quality life.
The main function of a medical association
is to serve as medium between doctors and
the government trying to explain doctors’
ideas to politicians.
It is true that politicians love saying that
doctors are interested in people being ill
and that is why doctors are not promoting
public health issues. The real truth is quite
opposite – all around the world doctors are
those who promote public health because
our profession due to its humanity is con-
stantly searching not only for solutions in
individual’s health but also in health of en-
tire humankind.This driving force has been
and still is obliged to work in the frames of
the system determinated by legislation and
state structure.
The crucial health issues that are to be
solved by National medical associations in
XXI century are:
• controlling tobacco consumption, active
fighting against children and young peo-
ple smoking. Prevention of children and
pregnant women from active and passive
smoking. Banning tobacco advertising in
mass media available to children.
• reducing of alcohol consumption in soci-
ety. World wide fighting against alcohol
consumption by young people until age of
21. Banning alcohol advertising in mass
media available to children.
• fighting against spreading of narcotics.
• elimination of trans fatty acids from
people’s food. Initially reach legislative
restrictions of not more than 2% trans
fatty acids from the whole amount of fat
in any product.
• eliminating sugary drinks from schools or
any places where children gather togeth-
er. Banning sugary drinks advertising in
mass media available to children.
• reducing the salt (NaCl) consumption in
food, reaching in average 5g daily;
• active fighting of sedentary lifestyle, pop-
ularizing the principle – sports at lest half
an hour at least 5 times daily.The balance
of calories organized in a way that people
can reduce the weight while the world
can fight the epidemy of obesity. Sports
as means of prevention and treatment of
illnesses.
• more fruit and vegetables in everyday
food (5 times a day), popularization of
fiber-rich food.
• popularization of breast-feeding, edu-
cation of young mothers and pregnant
women (The best progress in reducing
infant mortality is reachable by educating
women).
• fighting for clean air and water world-
wide, fighting against global warming.
• fighting against charlatanism and quack
doctors;
• popularization of healthy workplaces;
• promotion of prevention diabetes,cardio-
vascular diseases, obesity and other non-
contagious illnesses;
• promotion of prevention HIV/AIDS and
carrying out interpretive activities;
• cancer prevention, especially breast and
cervical cancer prevention;
• reducing of antibacterial resistance and
polypragmasia etc.
Working to improve public health, national
medical associations can obtain publicity
and recognition, which empowers them to
solve their main tasks – protection of doc-
tors’ rights, forwarding ethical issues.
The most significant goal
on the earth is clean air and
clean water as well as reducing
toxic and not tested chemicals
in everyday life
The most important issue for every per-
son is clean air and clean water, unpol-
luted environment. Air pollution is most-
ly caused by fossil fuels, road traffic and
volcanoes.
Usually when we talk about clean water we
mean clear and clean drinking water. Every
Globalisation LATVIA
127
Europe pays a hefty price for its slow ac-
tion on tobacco, both in economic costs
and harm to its citizens’ health and well-
being (1). Today, EU Health Ministers
will meet to agree a common position on
the revised,smarterTobacco Products Di-
rective (TPD) (2)
“A majority of Europeans support to-
bacco control policies (3). They deserve
a strong commitment both from the EU
Health Ministers and the outgoing and
upcoming rotating presidencies of the
EU  – Ireland and Lithuania respectively.
They should make sure that tobacco
products are not presented in a way that
manipulates people, in particular chil-
dren and youth, to pick up a smoking
habit,” said Monika Kosińska, Secretary
General of the European Public health
Alliance (EPHA).
This week five committees of the Euro-
pean Parliament (4) are giving their non-
binding opinions on the revision of the
TPD in a disappointing affair that widely
prioritises the interests of the tobacco in-
dustry(5)attheexpenseofpeople’shealth.
If European policy-makers keep on basing
their decisions on arguments by the tobacco
lobby, the final Directive will resemble a to-
bacco industry report. Additionally, if the
approval of the tobacco legislation does not
occur by the end of the year, it would put
its adoption dangerously close to the next
European Parliament’s elections, putting
the hard-fought political process back to
square one.
In a letter (6) co-signed this week, nine
public health organisations stress that
the current political procedure around an
year 1.5 million children die of diarrhea that
is mostly caused by polluted water.
Regarding chemical pollution today’s
world could be characterized being in
the state of chemical war. The largest ca-
tastrophe of the world last year was toxic
red sludge spill in a Hungarian aluminum
plant. Nobody ever expected chemical ca-
tastrophes. Nobody ever expected radio-
logical catastrophes  – neither Chernobyl
nor Fukushima.
Every rich country tries to get rid of their
chemical or nuclear waste preferably bury-
ing them in another country or sinking in
the sea.
During the last 60 years 70,000 new chemi-
cals have been introduced.15,000 chemicals
that are used in everyday life have not been
teted and there is no information about
their toxicity. In more than 90% cases there
is no information, what their impact on
children’s health is.
An average woman during their lifetime
feeds into her body about 80 kilograms
of different chemicals using cosmetics to
nourish their face and body skin. . At least
200 different compounds used in cosmet-
ics have harmful or as minimum negative
effect on one’s health. Human tissues and
parts of body have become a target for toxic
substances. Pollution heavily influences
human health and functioning – liver, kid-
neys, intestines, nervous system, skin and
immune system.The most sensitive parts of
human body are reproductive system and
immune system; they suffer from pollution
the most
Today’s reality is the fact that most of the
food we consume comes from supermar-
ket chains; it is no more grown in our farm
fields, gardens or cattle-sheds.
Today every animal that is grown by meth-
ods of intensive breeding gets antibiotics,
hormones and other stuff added to their
food aiming to speed up the process of
growth and prevent any disease.
The shop counter exposes genetically modi-
fied food (grain, root vegetables, soy). Even
if we do not buy them directly, we consume
it through animal food or as ingredients of
complex foodstuff.
In XXI century there is a rapid
upsurge of science for health and life
Prognosticating progress of science is a
complicated issue. In the 70-ties of XX cen-
tury scientists predicted that human genome
could be read at the end of XXI century, but
it was done almost a whole century earlier.
The most significant achievements and dis-
coveries of XXI century will be connected
with sciences about life. The competition in
the sphere of biomedical and genome tech-
nologies is going to be tough and expensive,
comparable to space investigation race in
XX century. Last century was the one of the
spaceship, nuclear power station, Internet
and mobile phone. At the same time people
discovered that environment has changed
not bringing along longer lifespan and bet-
ter health. In XXI century medicine will be
significantly driven by science.
We are living in a perspective era.There is
a lot to do for us.
Dr. Pēteris Apinis,
Editor-in-Chief of World Medical Journal,
President of Latvian Medical Association
EU Health Ministers Need to Agree on Strong Tobacco Policy
and Stop 650,000 Europeans from Dying Each Year
Tobacco
128
Tobacco
updated TPD represents a window of op-
portunity to better control the marketing
of an addictive product that kills half of
its users when used as intended. Some of
the letter’s signatories spell out why Health
Ministers, Members of the European Par-
liament and national authorities should take
this piece of legislation seriously:
“Tobacco kills over 650,000 Europeans
each year. It is 1,800 people each day, the
equivalent of three jumbo jets crashing
each day in the EU. This is unacceptable.
We need a bold new TPD so that our chil-
dren are not taken hostage by the tobacco
industry,” said Francis Grogna Secretary
General of the European Network for
Smoking and Tobacco Prevention (ENSP).
“The revision of the TPD is aimed at pre-
venting new generations from lighting up
by reducing the attractiveness of tobacco,
especially to children and young women. It
is very disquieting that even if all EU Mem-
ber States are committed to the WHO
Framework Convention onTobacco Con-
trol (FCTC), some of them still protect
the tobacco industry, in what amounts, to
put it mildly, to an unethical practice,” said
by Professor Aurelijus Veryga, President of
the Lithuanian National Tobacco and Alco-
hol Control Coalition.
“A strong European legislation prevent-
ing the uptake of smoking and making
tobacco less accessible and glamorous
is essential to protect EU citizens from
the hazards of smoking. Smoking causes
Chronic Obstructive Pulmonary Disease
(COPD), an irreversible chronic disease
that is not curable and reduces one’s life
expectancy of more than 10 years and one’s
ability to contribute to EU economy. EU
leaders must show they care by adopting the
proposed tobacco products directive,” said
Catherine Hartmann, Secretary General of
the European COPD Coalition.
“The Standing Committee of European
Doctors (CPME) warmly welcomes the
presidencies’ commitment to ensuring that
the TPD revision results in a meaningful
legal framework to reduce tobacco-related
harm. European doctors call on decision-
makers to keep health at the heart of the
negotiations,” Dr. Katrín Fjeldsted, Presi-
dent of the CPME.
“The EU faces a tobacco epidemic.Tobacco
is a lifestyle factor that causes huge number
of premature and preventable deaths every
year. Therefore, the EU’s transposition of
the FCTC is a crucial element to preserve
the health of people living in Europe,” said
Professor V.  Grabauskas, President of the
Health Forum.
(1) The estimated annual cost of tobacco
to the European economy is of more than
half a trillion euros, or about 4.6% of the
EU’s GDP. Furthermore, close to 13 mil-
lion people in the 27 countries of the EU
suffer from smoking-related diseases, with
devastating effects on economies, societies,
and healthcare systems – Study on liability
and health costs of smokingproduced for
the European Commission (DG SANCO,
2012).
(2) The revision addresses the following
main issues: (a) how to regulate products
which do not contain tobacco, for example
electronic cigarettes; (b) labelling and pack-
aging of tobacco products; (c) additives,
such as flavourings; (d) internet sales of to-
bacco products; (e) and racking and tracing
of these products.
(3) Attitudes of Europeans Towards To-
bacco, Report: Special Eurobarometer 385
(May 2012)
(4) The TPD is subject to co-decision pro-
cedure and therefore needs to be approved
by both co-legislators: the Council of the
EU representing the Member States (in
this case the Employment, Social Policy,
Health and Consumer Affairs Coun-
cil –EPSCO-) and the European Parlia-
ment (EP). As regards the EP procedure,
five Committees (IMCO, INTA, AGRI,
JURI, ITRE) are giving this week their
non-binding opinion to the leading Envi-
ronment, Public Health and Food Safety
(ENVI) Committee. After the final ENVI
vote in July, the EP Plenary will discuss the
proposal in September and vote it in Oc-
tober. Following the Plenary vote, the EP
will have the mandate to reach an agree-
ment with EPSCO in the few months be-
fore the end of this year.
(5) Tobacco companies claim that large
pictorial warnings and standardised pack-
aging of tobacco products will increase
smuggling, that tobacco product regulation
endangers European jobs, or that labelling
and packaging measures are ineffective.
There is strong evidence that these state-
ments are not just false but intentionally
aimed at preventing or delaying imple-
mentation of effective measures to reduce
smoking prevalence.Tobacco Products Di-
rective: fact not fiction (by the Smoke Free
Partnership).
(6) Public Health NGOs call for an updat-
ed EU Tobacco Products Directive
For more information, please contact:
Birgit Beger
CPME Secretary General
E-mail: secretariat@cpme.eu
www.cpme.eu
129
Tobacco
The European Union and tobacco legisla-
tion: revision of the Tobacco Products Di-
rective – opportunity to be seized
There are some products on the market that
always cause controversy when discussed
and even more – when regulated. However,
there is only one – tobacco – ‘legally avail-
able consumer product which kills people
when it is used entirely as intended.’  [1]
This is the same product – regarded in regu-
latory circles – that would probably not be
placed on the market if introduced today
due to the proven health risks. Govern-
ments across the world have tried to tighten
tobacco control policies to improve public
health, and the European Union (EU), an
economic and political partnership between
28 European countries, is no exception.
Although the proposal from the European
Commission regarding the revision of the
Tobacco Products Directive has the inter-
ests of public health at heart, the discus-
sions in two co-legislator institutions – the
Council of the EU (the EU Council) and
the European Parliament – show inconsis-
tent willingness to legislate in favour of the
health of European citizens for fear of eco-
nomic effects. Nevertheless, there is still a
chance for health community in the EU to
push further in support of common sense
and public health.
The situation in the EU is considered un-
satisfactory by the public health community.
Many EU Member States are ‘significant
offenders as key exporters of the tobacco
problem to the rest of the world,’and ‘many
EU countries are now falling behind best
practice in the WHO Framework Conven-
tion on Tobacco Control (FCTC) imple-
mentation.’ [2] It is the only international
treaty devoted solely to tobacco control
under the auspices of the WHO. [3] Mea-
sures taken to reduce smoking have made
a difference; however, tobacco use remains
the leading preventable cause of death in
the EU, and around 700  000 people die
from tobacco-related diseases each year.The
number of smokers has dropped but is still
high  – around 28% population-wide, and
even higher for young people aged 15–24 at
29% in 2012. [4]
Eleven years after an agreement on the first
Tobacco Products Directive in 2001, the
European Commission tabled a proposal
to revise the Directive (COM(2012)788)
in December 2012. ‘From a broader per-
spective, the revision will contribute to the
overall aim of the EU to promote the well-
being of its people [..], as keeping people
healthy and active longer, and helping peo-
ple to prevent avoidable diseases and pre-
mature death, will have a positive impact
on productivity and competitiveness.  [5]
However, taking into account that 70% of
smokers start before the age of 18 and 94%
before the age of 25 years in Europe [6] the
focus of the revised Directive is on children
and youth. In essence – its aim is to pre-
vent young people from starting to smoke.
To achieve this, the Commission proposes
to make pictorial warnings mandatory,
to increase the size of combined text and
pictorial warnings on both sides of a pack
to 75%, to ban slim cigarettes and to pro-
hibit characterising flavours such as vanilla
or menthol. The proposal suggests tobacco
should smell and taste like tobacco, and
most importantly  – should be packaged
in a way that accurately informs consum-
ers of its risks, while making the product
less attractive to children and young people.
Moreover, the Commission proposal estab-
lishes measures such as security features on
packs, which are designed to reduce coun-
terfeiting of tobacco, along with tracking
and tracing features to better control the
supply chain. Furthermore, the proposal
regulates those products which do not
necessarily contain tobacco, but are closely
linked to smoking, for instance, nicotine
containing products. In brief, the proposal
of the Commission favours public health
interests by trying to deter young people
from starting to smoke.
According to the EU legislative procedure
there are several steps before the proposal
from the European Commission can come
into force.There are two co-legislators – the
EU Council and the European Parliament.
Agreement first has to be reached separately
in the EU Council among Member State
governments and in the European Parlia-
ment among parliamentarians elected by
Europeans every 5 years. Afterwards both
institutions as co-legislators have to reach
an agreement between themselves by com-
promising. Both have made an effort and it
seems they would like to get an agreement
by the end of 2013 before the elections of
the Parliament next year.
The EU Council, where governments of
all EU Member States are represented, has
Peteris Ancans
The European Union andTobacco Legislation:
Revision of the Tobacco Products Directive –
Opportunity to be Seized
130
managed to reach ‘a general approach’ on
the Directive under the Irish Presidency
after heavy and intense discussions during
the first half of 2013. The Council’s posi-
tion, described by the Minister for Health
of Ireland, Dr. James Reilly, as ‘a remarkable
achievement for the Irish Presidency,’  [7]
was forged in a number of meetings among
representatives mostly from the Ministries
of Health (Health Attachés) in Brussels and
was officially finalised during the Council
of Health Ministers in Luxembourg on
21 June.
The agreement, however, was a compro-
mise between Member States as not all 27
(Croatia joined later on 1 July) could sup-
port the proposal as put forward by the Eu-
ropean Commission. Therefore, substan-
tial changes were introduced to the initial
Commission’s proposal. Although the EU
Council accepted a ban on characterising
flavours, it could not reach agreement on
the ban on slim cigarettes, and that provi-
sion was removed. The size of combined
picture and text health warnings was also
reduced from 75% to 65%. Regarding nico-
tine containing products, such as electronic
cigarettes, Member States maintained the
Commission’s principle. These products
should be regulated depending on their
nicotine content  – as consumer products
but with health warnings if nicotine levels
fall below a certain threshold; and only as
medicinal products if they contain nicotine
above this threshold. Nevertheless, Mem-
ber States maintained the option of allow-
ing individual Member States to go further
than EU legislation. For example, individ-
ual Member States could introduce plain
standardised packaging like in Australia on
a national level under the approach adopted
by the EU Council. It should be stressed,
however, that the agreement between
the Health Ministers on 21 June was not
unanimous. It was a result of intense dis-
cussion process led by the pro-health Irish
Presidency that had to reach a compromise
which took into account the differing posi-
tions of all Member States.
The position of the EU Council regarding
this Directive is prepared in discussions
among Member States’ representatives,
whereas the position of the European Par-
liament, the other co-legislator, is adopted
in debates among Members of the Euro-
pean Parliament (MEPs) that take place in
Committees, and a final vote – in a plenary
session. The plenary vote by 766 elected
members from all 28 Member States for
the Directive is scheduled for early Sep-
tember. The Directive is steered through
the European Parliament [8] and discussed
in several Committees. After votes in five
opinion Committees, the sixth  – lead
Committee – Environment, Public Health
and Food Safety (ENVI), voted on its po-
sition on 10  July. The ENVI Committee
not only accepted a ban on characterising
flavours but also voted for the prohibition
of slim cigarettes, a different position than
that of the EU Council. Although plain
standardised packaging, initially suggested
by MEP Linda McAvan,was not approved,
the size of health warnings was kept at the
level of 75% as proposed by the Commis-
sion. Regarding electronic cigarettes, the
ENVI Committee voted in favour of their
regulation as medicinal products regardless
of nicotine content, thus eliminating the
thresholds limits proposed by the Com-
mission. The position of the ENVI Com-
mittee will be a basis for the vote in the
plenary session in September during which
the position of the Parliament shall be ap-
proved.
At times the process both in the EU Coun-
cil and the European Parliament was any-
thing but smooth.There are several Member
States who do not support the new measures
proposed by the Commission and continue
to object to some aspects of the Directive
or delay the legislative process. The Irish
Presidency diligently managed to carve out
a compromise that at the same time unfor-
tunately involved weakening some aspects
of the Commission’s proposal. However, it
was not enough to sway Poland, Czech Re-
public, Bulgaria and Romania which voted
against the particular compromise proposal
during the Ministerial meeting on 21 June.
For example, Poland wished to have the
possibility to keep menthol cigarettes, and
the Czech Republic objected generally to
the proposal.
Although there were four Member States
that voted openly against the compromise,
some presume that there are more which are
working in silent opposition and making it
harder for the EU Presidencies to reach
agreement on the Directive. Media reports
have documented reluctance to support
the Directive also in several other Member
States.
It seems unclear and controversial espe-
cially as Europeans of all Member States
ask for more decisive action and a major-
ity of them support strong tobacco control
policies. A Eurobarometer published in
2012 [9] shows, for instance, that 76% of
the EU population supports putting pic-
torial warnings on all packages of tobacco
products and 57% support a ban on lo-
gos, colours and promotional elements on
packs – which means there might be a sup-
port for plain standardised packaging like
in Australia.
However, it seems that the public adminis-
trations of these countries are keeping their
‘eyes shut’ to public opinion and scientific
medical evidence. Moreover, their attention
to the voice of the tobacco industry along
with their disproportionate focus on alleged
disastrous economic effects of the tobacco
regulation, sheds doubts on their compli-
ance with Article 5.3 of the WHO FCTC.
This Article requires all Parties, ‘when set-
ting and implementing their public health
policies with respect to tobacco control’, to
‘[..] act to protect these policies from com-
mercial and other vested interests of the to-
bacco industry in accordance with national
law.’ [10]. As surprising it could be it ap-
pears that there might be Member States
who only partly care about the health of
their citizens and especially the health of a
Tobacco
131
new generation putting other, for instance,
economic interests as first priority. By doing
so they prevent other EU Member States
from reaching the agreement that would
bring maximum benefit to the health of all
Europeans.
Unfortunately, the same can be said about
a number of Members of the European
Parliament (MEPs) who voted to weaken
the legislative proposal and ignored public
health aspects. In June four opinion Com-
mittees – on legal affairs, agriculture, inter-
national trade, and industry – voted to wa-
ter down the Directive significantly. A fifth
Committee, dealing with consumer affairs,
had a more balanced approach. Despite the
fierce opposition,the ENVI Committee ad-
opted a health focused report,strengthening
several measures in the proposal. The Rap-
porteur Linda McAvan will now have to
face the plenary session in early September
where it is assumed that the strong health
position of the ENVI Committee might be
watered down as lobbying is expected to in-
tensify from the side of the tobacco industry
and their allies.
The EU Council is waiting for the posi-
tion of the European Parliament to start
negotiations towards a final agreement
among both institutions. There are a num-
ber of European countries who support
the strongest possible tobacco legislation
to help safeguard their citizens’ health. As
the decision has to be made together with
other Member States and in negotiations
with the European Parliament afterwards,
the outcome is unclear. The new Lithu-
anian Presidency of the EU Council that
took over from Ireland on 1 July seems to
be aware of the tense situation. Minister
for Health of Lithuania, Dr. Vytenis Povi-
las Andriukaitis, in a passionate speech in
the ENVI Committee on 11 July, thanked
ENVI for their vote the day before and
added: ‘I know that the negotiations on
Tobacco Products [Directive] are diffi-
cult because of influential tobacco indus-
try lobbying but many non-governmental
organizations at the EU and a big part of
the voters support those measures on to-
bacco control or even stricter regulation.
The WHO FCTC also obliges us to im-
plement more active tobacco control mea-
sures.’ [11].
As outcome is still unclear, health care pro-
fessionals in Europe play a crucial role in re-
minding their politicians of the importance
of health both at national and EU level.
Their engagement in promoting a sound
Tobacco Products Directive by contacting
their national public administration or their
MEPs could help to achieve healthier Eu-
rope.
Hippocrates said  – ‘wherever the art of
medicine is loved, there is also a love of
humanity.’This is why physicians enjoy the
trust of people – they possess knowledge
and they also care to use it when needed.
Hippocrates also noted that time is of
importance, but sometimes an opportu-
nity matters the most. This might be one
of those opportunities to make an impact
and reach the agreement that supports
strong public health interests in the EU
that might have an effect outside Europe
as well.
References
1. The Oxford medical companion, 1994.
2. Arnott D., Berteletti Kemp F., Godfrey F.,
Joossens L.,King J.,Ratte S.,Turnbull A; Out of
Step: Shadow Report from EU tobacco control
NGOs on the European Commission’s report
‘Dancing the Tango’, 2012., p.3.
3. WHO FCTC; http://www.who.int/fctc/about/
en (2013.07.01.)
4. Special Eurobarometer 385, May 2012; http://
ec.europa.eu/health/tobacco/docs/eurobaro_
attitudes_towards_tobacco_2012_en.pdf
(2013.06.28.).
5. (COM(2012) 788 final; 19.12.2012) The Pro-
posal for a Directive of the European Parliament
and the Council on the approximation of the
laws, regulations and administrative provisions
of the Member States concerning the manufac-
ture, presentation and sale of tobacco and related
products, p.4.
6. (SWD(2012) 452 final; 19.12.2012) EC
IMPACT ASSESSMENT of the Proposal for
a Directive of the European Parliament and
the Council on the approximation of the laws,
regulations and administrative provisions of the
Member States concerning the manufacture,
presentation and sale of tobacco and related
products.
7. Further eu2013ie success in Health field with
agreementonTobaccoProductsDirective;http://
www.eu2013.ie/news/news-items/20130621
postepscohealth (2013.06.22.).
8. MEP Linda McAvan is from the United
Kingdom in Group of the Progressive Alliance
of Socialists and Democrats in the European
Parliament.
9. Special Eurobarometer 385, May 2012; http://
ec.europa.eu/health/tobacco/docs/eurobaro_
attitudes_towards_tobacco_2012_en.pdf
(2013.06.28.)
10. Guidelines for implementation of Article 5.3 of
the WHO Framework Convention on Tobacco
Control; http://www.who.int/fctc/guidelines/
article_5_3.pdf (2013.06.05.)
11. Speech by Vytenis Povilas Andriukaitis,
Minister of Health, at the European Parliament,
Environment, Public Health and Food Safety
Committee; http://www.sam.lt/go.php/eng/Full
_Article_/4001 (2013.07.14.)
Peteris Ancans
Advisor to the Smoke Free Partnership
Former Health Attaché of Latvia
to the European Union
SFP is a partnership between the European
Respiratory Society, Cancer Research UK, the
European Heart Network, Action on Smok-
ing and Health UK, and the Irish Cancer
Society. SFP aims to promote tobacco control
advocacy and policy research at EU and na-
tional levels in collaboration with other EU
health organisations and EU tobacco control
networks.
Tobacco
132
WMA news
Important progress in revising the Dec-
laration of Helsinki was achieved at the
final WMA stakeholders meeting held in
Washington DC on August 26. As a re-
sult, a final draft document was developed
to be sent to the WMA’s Medical Ethics
Committee and then the Council in For-
taleza, Brazil, for forwarding to the WMA
General Assembly for adoption. The one-
day Washington meeting, hosted by the
American Medical Association at the Hay-
Adams Hotel opposite the White House,
was originally intended to be a routine
meeting of the WMA workgroup set up in
2011 to progress the revision of the Dec-
laration of Helsinki. However, following a
decision taken at the Council meeting in
Bali in April, the meeting was extended
to include interested national medical as-
sociations and stakeholders and as a result
more than 70 people attended the gather-
ing in the US capital.
An impressive line-up of outside experts
and leading figures from 13 NMAs spent
the day discussing the draft revised Decla-
ration paragraph by paragraph, line by line
suggesting further changes and alternative
wording.
The meeting was opened by Dr. Ardis D.
Hoven, President of the American Medi-
cal Association. She welcomed people to
Washington, reminding them that their
drive towards reaching the goal of a revised
Declaration of Helsinki was coinciding
with the 50th
anniversary celebrations in
Washington that week of the Poor People’s
March in the city and the ‘I Have a Dream’
speech by Martin Luther King.
Dr. Mukesh Haikerwal, Chair of the
WMA, said that the Declaration of Hel-
sinki was a seminal document that guided
the way physicians worked and the way that
ethics were protected. He said that Dr. Ce-
cil Wilson, President of the WMA, was to
have addressed the meeting, but because of
illness could not attend. So Dr. Haikerwal
read the words he would have spoken.
Dr. Wilson declared: “Physicians are most
credible when we speak from a platform
based on ethics and principle. As physicians
we must have moral authority and speak
and act with moral authority. That means
we must speak out on broad public health
issues. Doing that makes our message more
credible and more effective when we advo-
cate on matters of public policy.”
He said that those physicians from around
the world who came together to form the
World Medical Association in 1947 un-
derstood that an organization was needed
to become the authoritative voice on global
standards for medical ethics and profes-
sional conduct, rather than focusing solely
on protecting the interests of the profession.
They recognized the importance of endeav-
oring to achieve the highest possible stan-
dards of medical care, ethics and health-
related human rights for all people.
“There is perhaps no clearer example of ad-
dressing ethics in medicine than the Decla-
ration of Helsinki that advises physicians on
doing medical research on human subjects.
Today we benefit from truly astounding ad-
vances in development of medications and
devices that save lives and relieve suffering.
This would not be possible without research
involving human subjects. Fortunately the
public in general accepts the importance of
research, and in fact many volunteer to par-
ticipate out of a desire to help others. That
participation is dependent on having trust
in those who conduct research.
It is important to have an international
standard for research in a world where stud-
ies on human subjects increasingly involve
multiple countries.The Declaration of Hel-
sinki is that key international standard, the
loadstone, the North Star if you will, that
guides physicians, governments and indus-
try in this area of advice on doing medical
research on human subjects. And adher-
ence to its principles is critical to preserv-
ing the trust of those who are subjects, our
patients – and those who conduct research.”
Dr. Wilson’s speech reminded the meeting
that the Declaration, adopted in 1964, had
had multiple revisions and the current pro-
cess begun in 2011 was based on being thor-
ough, transparent and reflecting of diverse
viewpoints.To that end the WMA had held
expert conferences to receive insights and
recommendations from ethics scholars, aca-
demicians, practicing physicians, govern-
ment officials and those engaged in spon-
soring clinical research.These had been held
in different parts of the world, including the
Netherlands, South Africa, Japan and now
Washington, D.C.
The speech concluded: “To reiterate points
made earlier, medical progress is dependent
on research that ultimately includes studies
Declaration of Helsinki
Stakeholders Meeting in Washington, DC
Nigel Duncan
133
WMA news
involving human subjects. The Declaration
of Helsinki provides the roadmap for trust
and duty,essential to the success of research.
The revisions being considered are impor-
tant and will preserve and strengthen that
roadmap.”
Dr. Raman Parsa-Parsi, Chair of the WMA
Workgroup, reminded the meeting about
how the workgroup was set up with a man-
date to develop a draft revised version of the
Declaration to be sent to the WMA’s Medi-
cal Ethics Committee for approval and then
to the General Assembly for adoption. He
said that during the public consultation that
took place in the summer 129 submissions
had been received from 36 different coun-
tries or regions.
He added: “We were extremely delighted
with this response to the public consultation
both for the broad range of respondents as
well as the carefully thought out comments.
All of the submissions were carefully re-
viewed and considered in the development
of a new draft version.”
Professor Urban Wiesing, one of the two
ethical experts on the workgroup, said that
the group had received suggestions from 150
public comments,50 expert presentations and
numerous articles. He detailed the changes
that had been proposed before the public
consultation, saying that they were based on
the document being more readable, provid-
ing more protection for participants and with
more precise post study arrangements.
He outlined why some of the suggested
changes that had been proposed would not
be appropriate.
He said the placebo issue was still contro-
versial, adding: “I am afraid that no guide-
lines will ever be able to end this contro-
versy.”The workgroup proposal in the draft
did not change the ethical principles from
the 2008 version, but set up a new paradigm
that was more comprehensive and more
systematic because it addressed not only
the controls but any control of less than the
best intervention. The workgroup did not
change the section from the draft for public
comment.
Also receiving much comment was the sec-
tion on research ethics committees. Prof.
Wiesing said that many commenters re-
quested more details for the committees.
The same was true for the section on in-
formed consent, but he said: “We received
so many suggestions to mention this and
this and this. We decided not to adopt fur-
ther changes to maintain the character and
length of the Declaration.”
The same problem was confronted with vul-
nerable groups. “We received many sugges-
tions by commentators to mention this or
another vulnerable group, at least a dozen.
The question was always which one shall
we take? Lists are never comprehensive. We
decided not to mention specific vulnerable
groups but rather to provide a general defi-
nition and general regulation.”
Many commentators had also suggested
that the Declaration should address all pro-
fessions involved in bio-medical research
and not only physicians. However, he said
that the mandate of the WMA was to rep-
resent national medical associations.
Dr. Jeff Blackmer, the second ethical expert
on the workgroup, explained the reasoning
behind the revisions that had been incor-
porated in the revised draft Declaration.
Much of the new wording had been intro-
duced for the purposes of clarification and
consistency, such as using the word ‘groups’
rather than ‘populations’ or ‘communities’.
The section on informed consent had been
amended in several areas to use the word
’must’ rather than ‘should’ to increase the
level of obligation on physicians.In addition
the document had been amended to clarify
the meaning of the word ‘competence’.
He referred to the issue of the well-being
of the individual research subject having
to take precedence over all other interests.
The new draft changed that to read: “While
the primary purpose of medical research is
to generate new knowledge, this goal can
never take precedence over the health, well-
being, safety, rights and best interests of the
individual research subjects.” This was one
of the more substantive changes made to
the document as a result of the consultation.
Other parts of the Declaration that had
prompted considerable comment included
physicians combining medical research with
clinical care, compensation for injury, privacy
and confidentiality,post-study provisions,tri-
al registration and publication of results and
unproven interventions in clinical practice.
The workgroup also changed “appropriate
caution must be exercised in the conduct
of medical research that may harm the en-
vironment” to “medical research should be
conducted in a manner that minimizes pos-
sible harm to the environment.” This pro-
vided increased specificity around minimi-
zation of harm.
Under measures to minimize risks, the
work group added that “the risks must be
continuously monitored,assessed and docu-
mented by the researcher.”
Ambassador Jimmy Kolker, Acting Head
of the Office of Global Affairs in the Of-
fice of the Secretary of the US Department
of Health and Human Services, said the
Declaration had been an important source
of ethical guidance in the conduct of clini-
cal research throughout the world for nearly
half a century. It was highly respected as a
source of fundamental principles and wide-
ly-held values.
“We support your efforts to maintain the
currency and relevance of the DoH through
periodic updates to address new ethical
challenges and make adjustments to reflect
new research practices and directions. We
commend the WMA for the integrity and
transparency of its consultative and delib-
134
WMA news
erative processes to revise the Declaration
and for giving due consideration to the per-
spectives of a wide variety of stakeholders
and interest parties.”
However, the HHS did have concerns
about several paragraphs. One of its gen-
eral concerns related to the prescribing of
specific procedural steps in a statement of
ethical principles.
“This presents a tension between the Dec-
laration and the mandatory procedures that
countries have in place to protect human
research participants. Such conflicts can di-
minish the impact of the Declaration as a
source of fundamental guidance. Procedural
details should not be mandated; the Declara-
tion should allow for more flexibility in how
the principle or safeguard is implemented.
The use of the word “must”can also establish
an ethical standard that may be impossible to
achieve. Establishing an unachievable stan-
dard as a global norm may inhibit ethical and
scientifically sound research.”
He said that the word “must” should be
used only in the articulation of an ethical
principle. However, there were a number of
instances in the revised draft in which the
word “must” was used regarding a process
or procedure.
Ambassador Kolker specifically raised con-
cerns about paragraph 10 which, as current-
ly written, stated that researches need only
“consider” the laws of their countries and
appeared to assert the Declaration’s primacy
over national laws.
“Ethical norms and standards and national
laws and regulations are both important,
but they are not equivalent. Researchers are
required to follow national laws and regula-
tions, but their duty to follow ethical prin-
ciples is a matter of medical ethics.”
He suggested a new wording to address this
concern – that “physicians must follow the
ethical, legal and regulatory requirements for
research involving human subjects in their
own countries as well as the ethical principles
underlying this Declaration and other appli-
cable international norms and standards. No
national or international legal or regulatory
requirement should reduce or eliminate any
of the fundamental protections for research
subjects set forth in this Declaration”.
With regard to paragraph 15 on compensa-
tion he agreed with its intent that at a mini-
mum researchers had an ethical obligation
to ensure that individuals received treat-
ment if they were harmed as a result of par-
ticipation in research. However, compensa-
tion for harms or costs of long term care was
a more complex issue and guaranteeing that
injured participants received compensation
was a standard that might not be achievable
in many countries.
He said that the responsibility for determin-
ing compensation for research injuries varied
among countries. For example, in the US
injured parties could seek remedy in a court
of law through the country’s tort system, but
there was no guarantee that they would re-
ceive compensation. There was recognition
that this current approach might not be suf-
ficient and there had been calls for further
study to determine whether a research-spe-
cific national system of compensation was
needed. For these reasons he recommended
that “must”be changed to “should”.
During the discussion that followed, the
meeting heard interventions from speak-
ers from many organisations, including the
Council for International Organisations of
Medical Sciences, the National Institutes of
Health and the World Health Organisa-
tion, proposing different wording for vari-
ous parts of the document.
Representatives from several National
Medical Associations also spoke, includ-
ing Dr. Antoine Mbutuku, President of the
Congolese NMA. He said that for the Af-
rican continent facing a lot of problems in
relation to human research, the Declaration
was a very important document. It was seen
in many African countries as the fundamen-
tal document on which the countries based
their own regulations to protect people.
He emphasised that there should not be
double standards and that the same stan-
dards should be applied in the north as in
the south for placebo control trials. It was
necessary in less developed countries to al-
low placebo controlled trials and not to have
too many barriers.
Dr.Mbutuku also referred to the idea of fair
benefit, suggesting that this was question-
able. It might be that participants in a trial
were seen from the north as a vulnerable
group when they were not regarded as such
in the south.
Roopa Dhatt,President of the International
Federation of Medical Students Associa-
tion, spoke about the special attention that
must be given to the storage of personal
information on digital platforms. This in-
formation must be encrypted to ensure the
privacy of the research subjects and only
available to the responsible of the study.
She said that consideration of social media
was applicable to digital platform use. Ev-
ery day, more patients’data was being stored
on digital platforms.These digital platforms
existed in hospitals, schools, research insti-
tutions and many others. Any access to the
platforms was a breach of privacy and viola-
tion of the rights of research subjects. The
system must be encrypted to ensure that
only those responsible for the research were
accessing that data. 
She added that while the argument for in-
cluding details was valid for many aspects of
the document,in the opinion of the IFSMA,
digital platforms were a reality of medical
research and care. Yet often the principles
of confidentiality, privacy and consent were
not implemented in the case of digital data,
especially when looking beyond clinical tri-
als and health systems research.
135
Health in all Policies
As for social media, she said that while it
might not be necessary to explicitly include
it in the Declaration, it was still an area that
required consideration in the areas of medi-
cal research.  
Dr. Blackmer, summing up the day’s dis-
cussion, said that many of the points raised
had already been made during the previous
expert conferences. Other points raised had
received conflicting views. They had not
heard complete consensus on any single
topic. Not surprisingly the paragraphs of
the Declaration that had engendered the
most focus and discussion during the day
were those on which the workgroup had
spent the most time and those upon which
they had received the most input from
stakeholders.
Dr. Otmar Kloiber, Secretary General of
the WMA, thanked the participants at
the meeting for a useful discussion: “We
hope that this gives another emphasis to
the question of research and research eth-
ics.We still think this is very necessary even
after 50 years.There are always some things
that we have to repeat and express more
precisely and more openly or to say more
provocatively.”
He said the WMA had always tried with
the Declaration of Helsinki to ‘set new
standards,to reach out to a new age,to drive
the environment, to be better, to be more
ethical and to be more responsible’.
Following the open discussion, the WMA
workgroup convened to consider the points
raised. Some further amendments were
made to the revised Declaration and it was
decided that the draft document should be
sent to the Medical Ethics Committee for
further debate and approval in Fortaleza,
Brazil, in October. The document would
then go to the WMA Council for forward-
ing to the General Assembly for adoption
on October 19.
Mr. Nigel Duncan,
Public Relations Consultant, WMA
Building on our heritage, looking to our future
The 8th
Global Conference on Health Promotion was held in Hel-
sinki, Finland from 10–14 June 2013. The meeting builds upon
a rich heritage of ideas, actions and evidence originally inspired
by the Alma Ata Declaration on Primary Health Care (1978) and
the Ottawa Charter for Health Promotion (1986). These identified
intersectoral action and healthy public policy as central elements
for the promotion of health, the achievement of health equity,
and the realization of health as a human right.Subsequent WHO
global health promotion conferences1
cemented key principles for
health promotion action.These principles have been reinforced in
the 2011 Rio Political Declaration on Social Determinants of Health,
the 2011 Political Declaration of the UN High-level Meeting of the
General Assembly on the Prevention and Control of Non-commu-
1 Subsequent conferences were held in Adelaide (1988); Sundsvall (1991);
Jakarta (1997); Mexico City (2000); Bangkok (2005); Nairobi (2009).
nicable Diseases, and the 2012 Rio+20 Outcome Document (the
Future We Want). They are also reflected in many other WHO
frameworks, strategies and resolutions, and contribute to the for-
mulation of the post-2015 development goals.
The 8th
Global Conference on Health Promotion (8GCHP) was
held in Helsinki, Finland, from 10 to 14 June 2013. The con-
ference was co-organized by the World Health Organization
(WHO) and the Ministry of Social Affairs and Health of Fin-
land (MSAH).
The plenary sessions and the press briefings were broadcasted
live on the Internet and may be viewed as recordings here: www.
healthpromotion2013.org/media-healthpromotion2013/videos
The presentations may be viewed here: www.slideshare.net/
stmslide
Further information: healthpromotion@who.int
The Helsinki Statement on Health in all Policies
The 8th
Global Conference on Health Promotion, Helsinki, Finland, 10–14 June 2013
Health for All is a major societal goal
of governments,and the cornerstone
of sustainable development
We, the participants of this conference
Affirm our commitment to equity in health
and recognize that the enjoyment of the
highest attainable standard of health is one
of the fundamental rights of every human
being without distinction of race, religion,
political belief, economic or social condi-
tion.We recognize that governments have a
responsibility for the health of their people
and that equity in health is an expression of
social justice.We know that good health en-
hances quality of life, increases capacity for
learning, strengthens families and commu-
136
Health in all Policies
nities and improves workforce productivity.
Likewise, action aimed at promoting equity
significantly contributes to health, poverty
reduction, social inclusion and security.
Health inequities between and within coun-
tries are politically, socially and economical-
ly unacceptable, as well as unfair and avoid-
able. Policies made in all sectors can have
a profound effect on population health and
health equity. In our interconnected world,
health is shaped by many powerful forces,
especially demographic change, rapid ur-
banization, climate change and globaliza-
tion. While some diseases are disappearing
as living conditions improve, many diseases
of poverty still persist in developing coun-
tries. In many countries lifestyles and living
and working environments are influenced
by unrestrained marketing and subject to
unsustainable production and consumption
patterns. The health of the people is not
only a health sector responsibility, it also
embraces wider political issues such as trade
and foreign policy. Tackling this requires
political will to engage the whole of gov-
ernment in health.
Health in All Policies is an approach to
public policies across sectors that system-
atically takes into account the health im-
plications of decisions, seeks synergies, and
avoids harmful health impacts in order to
improve population health and health eq-
uity. It improves accountability of policy-
makers for health impacts at all levels of
policy-making. It includes an emphasis
on the consequences of public policies on
health systems, determinants of health and
well-being.
We recognize that governments have a
range of priorities in which health and eq-
uity do not automatically gain precedence
over other policy objectives. We call on
them to ensure that health considerations
are transparently taken into account in pol-
icy-making, and to open up opportunities
for co-benefits across sectors and society at
large.
Policies designed to enable people to lead
healthy lives face opposition from many
sides. Often they are challenged by the
interests of powerful economic forces that
resist regulation. Business interests and
market power can affect the ability of gov-
ernments and health systems to promote
and protect health and respond to health
needs. Health in All Policies is a practical re-
sponse to these challenges. It can provide a
framework for regulation and practical tools
that combine health, social and equity goals
with economic development, and manage
conflicts of interest transparently. These
can support relationships with all sectors,
including the private sector, to contribute
positively to public health outcomes.
We see Health in All Policies as a constituent
part of countries’ contribution to achieving
the United Nations Millennium Develop-
ment Goals and it must remain a key con-
sideration in the drafting of the post-2015
Development Agenda.
We, the participants of this conference
• Prioritize health and equity as a core re-
sponsibility of governments to its peo-
ples.
• Affirm the compelling and urgent need
for effective policy coherence for health
and well-being.
• Recognize that this will require political
will, courage and strategic foresight.
We call on governments to fulfil their ob-
ligations to their peoples’ health and well-
being by taking the following actions:
• Commit to health and health equity as
a political priority by adopting the prin-
ciples of Health in All Policies and tak-
ing action on the social determinants of
health.
• Ensure effective structures, processes and
resources that enable implementation of
the Health in All Policies approach across
governments at all levels and between
governments.
• Strengthen the capacity of Ministries of
Health to engage other sectors of gov-
ernment through leadership, partnership,
advocacy and mediation to achieve im-
proved health outcomes.
• Build institutional capacity and skills that
enable the implementation of Health in
All Policies and provide evidence on the
determinants of health and inequity and
on effective responses.
• Adopt transparent audit and account-
ability mechanisms for health and equity
impacts that build trust across govern-
ment and between governments and their
people.
• Establish conflict of interest measures
that include effective safeguards to pro-
tect policies from distortion by commer-
cial and vested interests and influence.
• Include communities, social movements
and civil society in the development, im-
plementation and monitoring of Health in
All Policies, building health literacy in the
population.
We call on WHO to
• Support Member States to put Health in
All Policies into practice.
• Strengthen its own capacity in Health in
All Policies.
• Use the Health in All Policies approach
in working with United Nations agen-
cies and other partners on the unfinished
Millennium Development Goals agenda
and the post-2015 Development Agen-
da.
• Urge the United Nations family, other
international organizations, multilateral
development banks and development
agencies to achieve coherence and syn-
ergy in their work with Member States
to enable implementation of Health in
All Policies.
We, the participants of this conference
• Commit ourselves to communicate the
key messages of this Helsinki Statement
to our governments, institutions and com-
munities.
137
WMA news
The world has made tremendous strides in
improving health and there are many suc-
cess stories all over the world. Global ma-
ternal deaths have dropped nearly 50% since
1990. And in October 2012 we celebrated
the first ever International Day of the Girl
Child. Yet economic, social and political
barriers still exist for women and girls. For
instance, 287,000 expectant mothers die ev-
ery year, that is 800 women every day. In ad-
dition, more than 200 million women want
but do not have the tools they need to plan
their families.
Many countries will not be meeting the tar-
gets set and there are several discussions on-
going at various levels There are for instance
growing consensus that Non Communicable
Diseases (NCDs) and Universal Health Care
should be additional goals. There is also talk
about introducing Sustainable Development
Goals.
The stumbling goals to attainment of goals
differ in the different countries. Generally
the most important challenges are:
• Political will and commitment
• Ineffective leadership – within and out-
side Health Sector
• Poor prioritization – resource allocation
• Weak health systems – especially Human
Resource for Health
• Limited high impact solutions
• Sustainable interventions – impact
• Social mobilization – prevention, rights
• Inter-sectoral and intra-sectoral collabo-
ration
• Low literacy levels
Medical women can play an important role in
addressing the above issues in their countries.
However, as individuals, the impact is likely
to be minimal.However,as organized groups,
medical women can make a difference.
Indeed it will take a critical mass of strong
professional and influential medical women
who are strategically positioned and actively
engaged in in setting national and global
policy agenda.It will require women who are
focused and committed to improving access
to, and quality of health care, in line with
national and global goals and standards for
health and development. This requires more
support from Medical Women International
Association (MWIA) as regards:
• Encouraging mentoring programs aimed
at enabling medical students and young
women doctors become leaders.
• Training materials on advocacy, negotia-
tion, communication, etc
• Advocacyforgendertrainingofallhealthpro-
fessionals – pre-service and in-service (CPD)
• More active participation and visibility in
on-going global level discussions eg. Post
MDG
• Capacity assessment of medical women
associations vis a vis the MDGs.
• Capacity building opportunities. Eg. –
sharing information and training manu-
als, promoting joint projects, and even
twinning between the stronger and the
weaker associations.
• Identification of medical women who
have had extensive experience and en-
courage them to take up leadership roles
at national, regional and global levels.
• Emphasis should also be placed on groom-
ing the next generation of women lead-
ers – medical students and young women
doctors should receive mentorship.
All the above strategies will require MWIA
to form new alliances and partnerships at
global level with likeminded organizations.
The World Medical Association’s efforts are
aimed at that all the people in the world
have access to health care and therefore
subscribed to the MDGs. Therefore both
WMA and MWIA have a common interest,
one that needs alliances and partnerships.
During my own term as WMA President
which begins in October this year, I plan
to focus on the following key areas which
I strongly feel many countries especially the
low and middle income ones urgently need
to address in order to achieve the MDGs.
These are:
1. Engendering the Health Sector
2. The Human Resource for Health crisis
3. Integrating Mental Health into general
health services
4. NCDs
5. Preventive Medicine
6. The One Health approach.
The areas identified are also key areas for
MWIA. In conclusion, I look forward to
strengthened collaboration between the 2
organizations.Thank you for listening.
Dr. Margaret Mungherera,
President Elect,
World Medical Association
Advancing The Global Health Agenda: the Role for Medical Women
Keynote speech at 29th
Medical Women International Association Congress, Seoul, Korea – 1–3 August, 2013
Margaret Mungherera
138
UNITED STATES OF AMERICAPublic Health
The Chicago Department of Public Health and Healthy Chicago
Janis Sayer Raed Mansour Erica Salem Bechara Choucair
Background
The Chicago Department of Public Health
(CDPH), like many of the more than 2000
local public health agencies (LPHAs) in the
United States, has faced numerous chal-
lenges in ensuring the public health of its
residents [1]. Public health is responsible
for three core functions – assessment, policy
development and assurance – and a LPHA’s
strength lies in its capacity to provide essen-
tial public health services within these areas
[2]. Confronted by funding cuts, limited
resources and workforce shortages, LPHAs
must re-think the way they conduct busi-
ness.
In 2011, 57% of LPHAs (serving 65% of
the U.S. population) surveyed by the Na-
tional Association of County and City
Health Officials (NACCHO) reported
having reduced or eliminated service [3].
Since the most recent recession began in
2008, NACCHO reports that 39,600 local
public health positions have been lost due to
lay-offs and attrition [4].
Like other health departments, CDPH has
been forced to change its service array. Es-
tablished in 1835, the CDPH has a long
history of service delivery. Many services
and programs were initiated in response to
the emergence of new public health threats
(such as HIV and West Nile Virus). Un-
til recently, a large portion of CDPH re-
sources was directed towards clinical ser-
vices. While not core to public health, these
primary health care services were initially
needed to fill gaps in care in the 1970’s. In
2011, and in response to significant growth
in community based primary care capac-
ity, the Department transitioned its several
primary care centers to Federally Qualified
Health Centers that were better positioned
to deliver this care.
Budget cuts have necessitated that pub-
lic health concentrate efforts to those
at the core of the public health mission.
LPHAs have also sought out opportuni-
ties to increase their impact in the midst
of declining resources. In Chicago, these
challenges presented an opportunity to
envision public health in a new way. With
a commitment to strategically prioritizing
efforts and capitalizing on opportunities to
achieve the greatest public health impact,
Chicago’s public health system remains
vital.
Healthy Chicago
The challenges facing LPHAs in general
and CDPH specifically require that public
health efforts be both strategic and focused.
In Chicago, the Healthy Chicago public
health agenda provides that focus.
The Healthy Chicago agenda, released in
August 2011, serves as a blueprint for city-
wide public health action.The Agenda con-
tains 16 health outcome targets, 12 priority
areas, and 193 related policy, program and
public awareness strategies.The Agenda not
only presents concrete actions for commu-
nity health improvement, it also provides a
roadmap for partners and other stakehold-
ers to contribute to a healthier Chicago [5].
Key Elements of
Healthy Chicago
Of Healthy Chicago’s many features, three
have proven essential to the successes
achieved to date.The first has been the shift
from programmatic interventions to policy
solutions, which hold greater promise for
sustainable change. Policy changes make
healthy choices practical and available for
139
Public HealthUNITED STATES OF AMERICA
everyone, and can create a large and lasting
impact with little time and few resources.
The second critical element has been the
move to maximize and leverage partner-
ships.The third element is the utilization of
innovative technology, which has provided
new avenues for carrying out our essential
services, maximized resources and facilitat-
ed improved communication and informa-
tion sharing.
Focus on Policy Solutions
One of the best examples of this shift con-
cerns efforts to reduce tobacco use. Prior
to the development of Healthy Chicago,
CDPH’s tobacco prevention resources were
directed almost exclusively towards smok-
ing prevention and cessation efforts. Pre-
vention programming was directed towards
about 500 of the City’s 400,000 public
school students annually, while counsel-
ing and nicotine replacement therapy was
provided to a few hundred adults each year.
While these services undoubtedly affected
some proportion of the limited number
of persons reached, it was clear that more
could be done.Thus,efforts were re-directed
towards policy solutions. Within the first
18 months following the release of Healthy
Chicago, smoke-free policies were enacted
at five hospitals, four institutions of higher
learning, six behavioral health agencies, four
public housing developments (currently
nearly 1000 individual units of public hous-
ing), and more than 3,200 units of multi-
unit private housing. Legislatively, tobacco
enforcement laws were strengthened, fines
for illegal sales doubled, and tobacco vend-
ing machines were prohibited.
Opportunities for policy change also
abound in the area of obesity prevention.
For example, in collaboration with CDPH,
in late 2011, the Chicago Park District con-
verted all of their snack vending machines
to 100% healthy options. In April 2013,
in a multi-departmental effort, all snack
and beverage vending machines on City of
Chicago owned or operated property be-
gan offering healthier options. Under this
new policy, at least 75% of offerings must
meet specified nutritional standards. Pub-
lic schools have also implemented healthy
vending policies. Policy changes within the
City’s Department of Transportation have
dramatically increased opportunities for
active transportation, with over 200 miles
of on-street bikeways, including almost 35
miles of new barrier and buffer protected
bike lanes; a bike-sharing program and the
development of a Pedestrian Plan.
Policy solutions have also been imple-
mented in the area of maternal and child
health. One way to help improve outcomes
for infants is by breastfeeding. Rather than
promoting breastfeeding solely through
education, Chicago’s efforts have focused
on influencing the breastfeeding support
policies of its 19 labor and delivery hospi-
tals, thus increasing the likelihood that new
mothers will choose to breastfeed. With
federal support and in partnership with the
not-for-profit the Consortium to Lower
Obesity in Chicago Children, 15 Chicago
hospitals with Labor and Delivery services
have committed to support breastfeed-
ing and are currently working towards the
World Health Organization’s Baby-Friend-
ly designation which requires hospitals to
implement a breast-feeding policy. The ini-
tiative has been shown to dramatically in-
crease breastfeeding among its patients.
Leveraging Partnerships
A second contributor to the success of
Healthy Chicago is the priority placed on
partnerships. The complexity of the chal-
lenges facing public health necessitates col-
laborative responses that draw upon and le-
verage the expertise and resources of public,
private, and community-based partners.
The City’s work to eliminate food deserts
has been strengthened through such part-
nerships. Last year, CDPH and the Chi-
cago Department of Business Affairs and
Consumer Protection worked together to
pass a mobile produce cart ordinance, in
essence creating a new class of vending.
Subsequently, CDPH and the City’s De-
partment of Housing and Economic Devel-
opment partnered with Neighbor Capital,
LCC, to establish the “Neighborhood Cart”
system to increase access to fresh produce
and to create jobs for the unemployed and
underemployed. By providing training and
then leasing their carts, the partnership
provides an opportunity for meaningful
employment while promoting healthy foods
in underserved communities. A partnership
with Streetwise, a community organization
serving homeless persons, ensures these op-
portunities are presented first to those at
risk of homelessness. Over 60 people have
enrolled in classes to enter the program, 41
have completed job training, and 33 indi-
viduals have been placed in employment.By
the end of the year, a total of 30 carts will
be operating in Chicago’s low food access
neighborhoods.
Other partnerships have focused on in-
creasing physical activity. One example is
the Healthy Chicago PlayStreets initiative.
With support from Blue Cross Blue Shield
of Illinois, and in partnership with three
citywide and several community-based or-
ganizations,CDPH launched Healthy Chi-
cago PlayStreets to provide children and
adults with safe, supervised outdoor spaces
for structured and unstructured play and
physical activity. Sixty community-based
events were held in 2012 where either a
lack of park space or concerns about com-
munity violence were limiting the ability of
residents to be physically active, and close
to 50 will be conducted by the end of 2013.
Partnerships have also proven critical in
re-focusing CDPH’s efforts on core public
health services. In 2012, CDPH partnered
with the Cook County Health & Hospital
System (CCHHS) to better align Tuber-
culosis (TB) services. CDPH transitioned
responsibility for the clinical care of TB
140
cases to the CCHHS, which has a core fo-
cus on health care service delivery. CDPH
retained the core services of TB surveillance
and prevention. And as previously noted,
CDPH partnered with seven FQHCs to
provide primary care. In making this tran-
sition, CDPH retained its public health
presence in these centers and continues to
provide services such as HIV and Sexually
Transmitted Disease (STD) screening and
treatment, and women and children’s health
services such as the Women, Infant and
Children’s (WIC) supplemental food and
nutrition program.
The Role of Technology
in Healthy Chicago
The policy and partnerships that have to
date been the hallmarks of Healthy Chi-
cago efforts are strongly complemented by a
changing role in technology.There are many
ways LPHAs can use technology to support
public health’s mission. In Chicago, leader-
ship has facilitated communication with the
public through increased transparency and
liberating data through the Internet. This
liberated data, commonly known as online
open data portals, provides an opportunity
for CDPH to collaborate with nonprofits
and civic volunteers to not only make sense
of the data, but also to make it useful. And
as Internet usage moves more towards mo-
bile and smartphone use,opportunities arise
to reach a wider audience. With increased
mobile usage,a demand for useful health re-
lated applications usually follows. Support-
ing all of these technological innovations is
CDPH’s social media strategy. All of these
advancements in information technology
and social networking are used to drive our
Healthy Chicago agenda.
Social Media
In public health, offline strategies are used
to support online strategies and vice versa.
Choosing the channel on which a LPHA
should operate depends on where resi-
dents are having their conversations. For
CDPH, Twitter (https://twitter.com/Chi-
PublicHealth) and Facebook (https://www.
facebook.com/ChicagoPublicHealth) are the
two most frequently used social media
channels. CDPH’s social media strategy
does not exist to replace other communica-
tion channels. Rather, CDPH’s social me-
dia channels complement and support all
of the communication channels. CDPH’s
social media channels are supportive of the
Department’s website, which serves as the
information hub. Social media employs
two-way symmetric conversations as well
as one-way symmetric conversations[6]. To
obtain resident feedback on initiatives is a
great opportunity to either confirm strate-
gies are on target or possibly modify an
approach. Sometimes, CDPH will engage
with residents that may never have inter-
acted with the department before on social
media, thus increasing trust and comfort
level to interact with CDPH, which is es-
pecially important with vulnerable popula-
tions. Social media channels also serve to
frame messages so that all residents easily
comprehend them.
Social media performance metrics are
calculated to guide goals and objectives
to ensure that they are in line with the
Healthy Chicago agenda. They also help
give CDPH a glimpse into who the influ-
encers, key opinion and knowledge leaders
are, as well as ongoing health conversations
in general, through hashtag analysis. Tap-
ping into these social media resources aids
in building and solidifying necessary part-
nerships within CDPH’s Healthy Chicago
agenda.
Data Portal
The City of Chicago has established an
open data portal for many reasons, includ-
ing for increased government transparency.
The data portal has provided an abundance
of information to the public, such as the
locations of condom distribution centers,
clinics and immunization sites; food in-
spection results; and birth, death, and dis-
ease data (https://data.cityofchicago.org). Not
only does making this data readily available
to the public help to facilitate positive rela-
tionships with residents, it has also freed up
limited resources by reducing the number of
data requests.
Applications
A unique opportunity also arises by mak-
ing data readily available – application de-
velopment thrives. Civic programmers lend
their unique talents by taking open data and
visualizing complex data sets into applica-
tions they develop, usually through web
applications. The concentration of applica-
tion development lies in using HTML5 ap-
plications that removes barriers of needing
unique iOS or Android coding skills and
isolating groups of people that may or may
not be on either of these platforms. The ef-
fect is to reach a wider population, which
achieves almost universal access when no
operating system is favored over another.
The Chicago Flu Shot App (http://www.
cityofchicago.org/city/en/depts/cdph/iframe/
scc_app.html) and Back to School Immuni-
zation App (http://backtoschool.cdphapps.org)
are examples. Vaccination locations, which
are listed in the data portal, were format-
ted onto a map with an address finder that
finds nearby vaccination clinics or mobile
immunization vehicles based on a resident’s
location.These maps can be used on smart-
phones or on computers making vaccination
locations easier to find. Ultimately, applica-
tions like these make information relevant
to the user. Removing barriers to adoption
of technology is also accomplished since
these types of web applications do not need
to be downloaded. The only requirement to
use the application is the entry of the URL
into any web browser.
When LPHA utilize apps such as these,
public health work can be performed with
UNITED STATES OF AMERICAPublic Health
141
greater efficiency despite diminished re-
sources. By working with civic program-
mers,relationships are forged with residents
that volunteer their own skills for the great-
er good of their communities, thus, building
stronger relationships with the communi-
ties overall.
The CDPH found that many residents are
tweeting about their food poisoning symp-
toms and restaurant experiences on Twitter.
However, most food poisoning cases go un-
reported, and most times, it is because resi-
dents do not know that they can report this
to the city. The Smart Chicago Collabora-
tive, in partnership with local civic develop-
ers and the Chicago Department of Public
Health, launched Foodborne Chicago, an
innovative application that scans Twitter
for mentions of food poisoning in Chicago
(http://foodbornechicago.org).
This web app enabled CDPH to connect
with Chicago residents on Twitter through
@foodbornechi and encourage them to re-
port details of their food poisoning to the
CDPH Food Protection Division. Resi-
dents also get to see the inspection results
of their report through an online service
called 311 Service Tracker Chicago. In or-
der to determine if a tweet is relevant to
“food poisoning,” the web app has to clas-
sify tweets by sifting through Chicago’s
50,000 tweets/day as relevant or noise.
This classification is done via machine
learning. In this process, a mathematical,
natural language model was built using
existing tweets and human classifiers to
learn which tweets may be food poisoning
incidents.
FoodBorneChi has the capability of serv-
ing as a sentinel for outbreaks. As the app
gets smarter, it presents Tweets that are
more likely to be food poisoning cases,
increasing the chance of reporting by af-
fected residents. If the app shows one loca-
tion generating several complaints, a faster
investigation response can prevent more
people from being affected.This “real-time”
digital syndromic surveillance comple-
ments traditional methods of public health
surveillance and in the future, may be ap-
plied to increase response times to natural
disasters and flu outbreaks.
Big Data
Big data is a large and complex collec-
tion of data, that when presented without
any visualization or within a stand-alone
spreadsheet, makes little sense. CDPH,
along with several informatics research-
ers, collaborated to make sense out of de-
identified electronic health record data of
one million Chicagoan inpatient and out-
patient visits from 2006 through 2011.This
serves to provide information regarding
resident health and illness events, behaviors
and disparities.
A website was created, Chicago Health At-
las, that brings together many data sets to
make sense of diseases and healthcare de-
livery within the city as well as within the
77 neighborhoods in Chicago. Included
in the data are demographics, vital signs,
encounter types, diagnoses, medications
and lab tests (http://www.chicagohealthat-
las.org). The result is a website that can be
used to see prevalence of specific diseases,
health trends and outcomes within differ-
ent neighborhoods and can provide focus in
improving the public’s health.
Conclusion
By providing a focus for local public health
efforts,theHealthyChicagoagendahaspro-
vided CDPH the opportunity to maximize
the use of limited resources, strengthen its
use of policy development as a public health
tool, and establish a significant network of
partners who share the Department’s public
health mission. CDPH’s adoption of new
technology has not only served to promote
the work of Chicago’s public health com-
munity and Healthy Chicago, it has in it-
self, provided a new means to efficiently
address a wide-ranging number of public
health goals. Further, the adoption of new
technology created new partnerships and
strengthened existing partnerships within
the technology community.
The changing political and economic cli-
mate requires all LPHAs to focus on core
public health issues and to do so in ways
that have significant results. LPHAs cannot
singlehandedly create healthy communi-
ties, nor can they rely solely on traditional
interventions. Innovative efforts through
partnerships, policy, and technology can
provide significant and sustainable impact
with fewer resources. LPHAs must develop,
pilot,and share new interventions with oth-
ers as we work to keep our communities
healthy.
References
1. NACCHO. (2011). 2010 National Profile of
Local Health Departments. Accessed at http://
www.naccho.org/topics/infrastructure/profile/
resources/2010report/upload/2010_Profile_
main_report-web.pdf
2. Institute of Medicine. (1988). The Future of
Public Health. Washington, DC: National
Academies Press.
3. National Association of County and City Health
Officials. (2012). Research Brief: Local Health
Department Job Losses and Program Cuts:
Findings from the January 2012 Survey.Accessed
at http://www.naccho.org/topics/infrastructure
/lhdbudget/index.cfm
4. Ibid.
5. Chicago Department of Public Health. (2011).
Healthy Chicago: Transforming the Health of
Our City. Accessed at http://www.cityofchicago.
org/content/dam/city/depts/cdph/ CDPH/ Public
HlthAgenda2011.pdf
6. Grunig, L. A., Grunig, J. E., & Dozier, D. M.
(2002). Excellent Public Relations and Effective
Organizations. New York: Routlage Taylor and
Francis Group.
Janis Sayer, MSW;
Raed Mansour, MS;
Erica Salem, MPH;
Bechara Choucair, MD
Chicago Department of Public Health,
E-mail: Bechara.Choucair@cityofchicago.org
Public HealthUNITED STATES OF AMERICA
142
WMA news UNITED STATES OF AMERICA
Ardis Dee Hoven, M.D., an internal medi-
cine and infectious disease specialist from
Lexington, Ky., became the 168th
presi-
dent of the American Medical Association
(AMA) on June 18, 2013. In her inaugural
address, Dr. Hoven emphasized the tre-
mendous power physicians have to change
the course of history. (Watch or read the
entire address (http://www.ama-assn.org/
ama/pub/news/speeches/2013-06-18-hoven-
inaugural-address.page)
“The collective voice–the voice of America’s
physicians,” Dr. Hoven said, “has the power
to make a difference.”
Reflecting upon her decades of inspirational
efforts to improve access to care for the un-
insured and advance care for patients with
HIV/AIDS, Dr. Hoven pointed to the op-
portunity presented to physicians as they live
through a time of unprecedented change.
“I say we are lucky,” she told the assem-
bly. “Because the great thing about living
through history is we don’t have to just wit-
ness it. We can shape it.”
She called on physicians to face today’s
challenges head on. By working together,
she said,physicians can make strides in such
areas as combating the nation’s epidemic of
chronic diseases, fostering innovation in
medical education and creating a practice
environment in which physicians can thrive.
Reminding physicians of the century and a
half of history in which organized medicine
has won resounding victories for the health
of the nation, Dr. Hoven encouraged phy-
sicians to stand together and leverage the
power of organized medicine. “Today we
stand at a crossroads in the history of health
care in this great nation,” she said. “Let’s
never forget the future of American health
care is in our hands.”
Dr. Hoven has been a member of the
AMA Board of Trustees since 2005, serv-
ing as its secretary for 2008–2009, chair for
2010–2011 and immediate past chair for
2011–2012. Dr. Hoven is the third female
president in the organization’s history.
Prior to her election to the board, Dr.
Hoven served as a member and chair of the
AMA Council on Medical Service. She was
a member of the Utilization Review and
Accreditation Commission for six years
and served on its executive committee. Ad-
ditional activities have included service on
the AMA Foundation board of directors,
the Group Practice Advisory Council of the
AMA and an appointment to the Practic-
ing Physicians Advisory Commission. Cur-
rently Dr. Hoven serves as the AMA repre-
sentative on the Board of Directors of the
National Quality Forum and the Quality
Alliance Steering Committee.
Dr. Hoven’s involvement at the state level in
Kentucky has been extensive.She was presi-
dent of the Kentucky Medical Association
from 1993 to 1994 and served as a delegate
to the AMA from Kentucky prior to her
election to the AMA Board of Trustees.She
has also been actively involved in medical
staff issues at her local hospital where she
has held a variety of positions including
president of the medical staff, member of
the board of directors and president of the
hospital foundation board.
Born in Cincinnati, Ohio, Dr. Hoven re-
ceived her undergraduate degree in micro-
biology and then her medical degree from
the University of Kentucky, Lexington. She
completed her internal medicine and infec-
tious disease training at the University of
North Carolina, Chapel Hill.
Board-certified in internal medicine and
infectious disease, Dr. Hoven is a fellow of
the American College of Physicians and
the Infectious Disease Society of America.
She has been the recipient of many awards,
including the University of Kentucky Col-
lege of Medicine Distinguished Alumnus
Award and the Kentucky Medical Asso-
ciation Distinguished Service Award. In
2013 Dr. Hoven was named one of Modern
Healthcare Magazine’s Top 25 Women in
Healthcare.
American Medical Association Inaugurates New President
Cecil Wilson, MD, WMA President; Ardis D. Hoven, MD, AMA President;
Otmar Kloiber, MD, WMA Secretary General
143
Regional and NMA newsCOLOMBIA
As a result of the campaign in the year
1938 the Colombian Medical Federation
(FMC) managed to establish the Min-
istry of Hygiene, actually the Ministry
of Health. In the same year it also par-
ticipated in setting up the Committee for
Pharmaceutical Specialities and Medical
Board which resulted in the emergence
of medical specialities and the Colom-
bian Association of Scientific Societies
(ACSC).
Act 90 of 1946 stipulated the establish-
ment of compulsory social insurance and
in 1948 the Colombian Institute of Social
Insurance (ICSS) was founded. The Insti-
tute started as a private facility to insure
workers in the private sector receiving
contributions to the following amount
– 50% from employers, 25% from work-
ers and 25% from the State. Workers in
the public sector covered by the social
welfare were excluded, so that all social
benefits to the employees and workers of
the private sector equalled the compul-
sory social insurance through the ICSS
and the public benefits of the sector were
in charge of the National Fund of Social
Welfare – CAJANAL – and the depart-
mental and municipal funds. To embrace
all health services, there were included
hospitals receiving contributions from the
national Government for the operations
performed and caring for the unemployed
or low income people by means that was
known as subsidy to clinics, private or
religious or civil organizations, receiving
particular patients or offering services to
people of high income not covered by
other systems.
In 1973 by Decree No 1935 the Govern-
ment unilaterally changed the economic
framework of the ICSS and forgave the
debt that had since then started, but it re-
tained all its power of management and
administrative control. In 1977 Decree No
1650 was passed stipulating reorganization
of the ICSS and the establishment of the
ISS – Instituto de Seguros.
Until 1990 health care in Colombia was
under a completely vertical framework of
the National Health System, supervised
by the Ministry of Health that developed
policies and concentrated most of the re-
sources. The four-tier system consisted of
the national level represented by the Min-
istry of Health and the supervised estab-
lishments and decentralized institutions;
the sectional level, embracing 33 sectional
health services working under the direc-
tion of Head of Health Services and a
sectional meeting that operated in each
capital of the Departments and techni-
cally depended on the Ministry of Health;
the regional level comprised 107 regional
units and generally followed the directions
of the level II regional hospital; and the
fourth level consisting of local units and
functioning under the jurisdiction of the
municipalities and level I care, without in-
volvement in the decision making of the
respective municipality on health care is-
sues.
Health care was based on a model of
progressive complexity according to the
technical and scientific capacity of level I
or the primary level, offering basic health
services of first aid, emergency, general
dental medical care and sanitation; institu-
tions offering this care level were the local
hospitals and and health posts and cen-
tres; level II or the secondary level, having
greater technical and scientific possibilities
at its disposal and including level I, offered
outpatient and hospital care in the basic
medical fields: Internal Medicine, Gen-
eral Surgery, Paediatrics, Gynaecology and
Obstetrics, Surgery and Anaesthesiology
division as well; level III or the tertiary
level included the activities of the two
lower levels, as well as hospitalization and
different specialities and medical subspe-
cialties with high complexity diagnostic
and therapeutic procedures in a clinical
laboratory, diagnostic imaging, endoscopy,
medical and pathological anatomy; much
of it served as a basis for higher medical
education.
Social security establishments, such as
the ISS, funds of compensation, etc., and
the private sector functioned within the
framework of the national system, even
though they had autonomy in their in-
ternal organization. This system, known
as subsidy to the offer, implied that all
the entities from the public sector as well
as foundations and private institutions
that provided health care and who had
contracts or agreements with the State
to serve low income people, received re-
sources, requested by these entities at the
end of the year, from the annual budget.
The Central Government assessed the
costs and coverage for the following pe-
riod and the execution depended on the
income of the nation and was included
in its annual budget. In many cases this
system resulted in hospitals receiving
resources not for their performance, but
Model of Colombian Social Security in Health
Cesar Prieto Avila
144
COLOMBIARegional and NMA news
due to their political orientation or the
directors’ capacity of reaching the deci-
sion-making level at the head of the De-
partment of Health Care or the Ministry
of Health.
There were three sectors in health care.The
first was Social Security represented on the
one hand by a monopoly for the private
sector: ICSS that covered only workers
but, at the end of the 1970’s, included the
family medicine program and the Com-
pensation Family Funds, representing the
families of workers in the private sector
and on the other hand there was a system
of public welfare for the workers and em-
ployees in the public sector, with the Na-
tional Fund (CAJANAL) for the sector
and the majority of entities created its own
welfare system, e.g. such institutions as the
Congress, Ecopetrol, workers of ports, rail-
ways, public universities, etc., as well as the
armed forces and at the departmental and
local levels established funds for medical
employees. Each entity had its governing
bodies and their boards of Directors had
representation in the national Govern-
ment.
The second sector was that of welfare re-
sponsible of care for the population without
affiliation to social security or welfare funds.
The service network was formed by 906
hospitals, 3705 centres and health posts and
some foundations receiving official contri-
butions. It was supervised by the Ministry
of Health and addressed issues at national
level, while the sectional level was in charge
of the Departments and the local level – of
municipalities.
The third sector was private embracing pre-
paid medical entities, insurance companies
and institutions and professional groups
offering health services under the prepay-
ment of fees or by direct payment as pri-
vate entities, but under the surveillance and
control of the Ministry of Health through
the National Superintendence of Health, a
semi-centralized entity.
At that time according to the data released
by the Ministry of Health 34% of the popu-
lation were not covered by any health sys-
tem, i.e. the system-wide coverage was 66%
of the Colombians.
Act 10 of 1990 reorganized the national
health system, establishing that “…the pro-
vision of the health services, at all levels, is
a public service in charge of the nation, free
basic services for all inhabitants managed in
partnership with local authorities and local-
ly decentralized…”. Moreover, it provided
that “…the National Health System con-
sists both of the entity set public and pri-
vate health sector, as well as, in the relevant
institutions of other sectors that influence
health risk factors…”
This law reassigned the responsibility for
the provision of health services, it fractured
the vertical frame, made it more horizontal
by totally decentralizing it, thus:
• the municipalities were to provide the di-
rection and provisions of health services
at the primary care level that included lo-
cal hospitals, centres and health posts;
• the Departments were to provide the di-
rection and delivery of health services at
the second and third levels of care that
included regional, specialized and univer-
sity hospitals.
The responsibility of the managing bod-
ies was transferred to the regional and lo-
cal levels – the respective Governor, each
Department or Mayor of each municipal-
ity, through their respective Secretaries of
Health, as the search for resources at the
local level, reordered the offer of services to
decentralize the competences to the munic-
ipalities and Departments.The only institu-
tion remaining at the Central level was the
National Cancer Institute.
Social State Enterprises (ESE)
The enactment of Act 10 of 1990 intro-
duced structural, more radical transforma-
tion in the Law of Public Health, concern-
ing both the Health Promoting Companies
(EPS), lnstituto de Seguros Sociales (ISS),
Caja Nacional de Prevision Social (Cajanal),
the Fund of Social Welfare of the Ministry
of Communications – Caprecom – etc., the
institutions, health providers – IPS, and all
the network hospitals. The Law provided
provisions for receiving resources drawn
from the State: located Prosecutor, ceded
income, transfers, etc., to all territorial en-
tities to carry out the institutional trans-
formations necessary for the provision of
health services as stipulated in Article 6 of
this Law and, in particular, providing legal
status and an administrative structure of
health units.
Act 60 of 1993 already carried out the
constitutional reform of 1991, Social State
Enterprises (ESE) were established which
was a “special category of public entity, de-
centralized, with legal personality, its own
patrimony and administrative autonomy,
created and organized by law or by the de-
partmental assemblies and municipal coun-
cils”.The objective of that “will be the provi-
sion of health services, understood as public
service by the State and as an integral part
of the General Social security health sys-
tem”.
This situation, caused by the major system
change as it was suspension of the subsidy
offer to transform it into a demand subsidy,
created not only problems for the Colom-
bian population to create the provision of
subsidized health but the financial difficulty
and the collapse in the provision of the
health services in public hospitals.
Summary of the effect of this legislation:
Act 10/ 1990 and Act 60/ 1993 and its
regulatory decrees requiring administra-
tive processes and billing services to public
entities without training, without technol-
ogy, without accompaniment that very few
could meet, producing the greatest crisis of
the system of institutions providing health
services,providing system-wide entities pri-
145
COLOMBIA Regional and NMA news
vate technology on silver tray-staff trained,
without labour or performance loads the
new methods of recruitment of human tal-
ent, etc. that public institutions could not
provide.
The most dire consequence of the reform of
the system for involvement in the econo-
mies of scale of the neoliberal thought,
“tuning of the central power”, was the
loss of financial support from the State’s
hospitals and the obligation to all public
entities to have health care programs, re-
tain a high percentage of their income for
self-management without information and
registration systems, no studies of costs,
without training administrative personnel,
invoicing, marketing etc., but with high la-
bour costs and pension loads, low budgets
for the maintenance of buildings for many
years,all circumstances that made the public
entities to remain with a minimum option
to compete with the private Institutions
Providers of Services (IPS) for the sale of
health services, led to complete financial
crisis in hospitals, to have a minimum per-
centage of the total of the hiring by private
EPS, which implemented the construction
and adaptation of its own clinics IPS and
with legalistic manoeuvres achieved vertical
integration by means of which hire private
EPS with their own IPS insurers and round
off the business.
As coup de grace there was the rancid neo-
liberal strain of the 1991 Constitutional Re-
form that by approving two articles allowed
the health system, called the General Sys-
tem of Social Security in Health (SGSSS),
lead the country to the brink of collapse in
the social area: Article 480 deprived the
Colombians the right to health as a FUN-
DAMENTAL right and an INDIVIDU-
AL right and transformed it into the right
to buy health care according to the capacity
of payment and Article 49 suppressed the
State of its obligation to be responsible for
the public health, words that do not appear
in the constitutional text as there is only the
term “sanitation”.
LAW 100 of 1993
On the basis of the Constitutional reform,
in 1993 Law 100 was passed establishing
the General Social Security System, con-
sisting of three branches: health, pensions
and occupational hazards but, in a deci-
sion completely harmful to the majority of
Colombians and transcendental, delivered
the management of these branches to indi-
viduals, national and multinational private
capital.
Health developed the mandatory Plan
of Health (POS) according to which all
Colombians had to be affiliated to the
health system. But what we have seen is
that it is taking the country to a crisis in
health care, into bankruptcy and closure
of many hospitals in the network, to the
disappearance of all public Social Security
health care entities, income earned from
the provision of the health service to the
economy of scale, the law of supply and
demand but, the most disastrous, to cir-
cumvent the surveillance and control of
the system and accountability by the State
for public health.
There were established the National Coun-
cil of Social Security in Health (CNSSS)
with the power of advisory entity, unless
its decisions were enforced by the Govern-
ment, which was under the “dictates” of
the compulsory National Health Plan and
some Territorial Councils of Social Security
in Health (CTSSS) for Departments with
much less decision-making role; on the oth-
er hand the National Superintendence of
Health in a single office in Bogota, without
regional delegations and without legal or
logistical tools to exercise their theoretical
role of surveillance and control, especially
for the EPS, and private IPS was central-
ized.
All the public EPS ceased to exist and final-
ly there was the liquidation of the ISS, the
only insurance company that regulated the
entire system to introduce, now yes, “wild
capitalism”in terms of Social Security in our
country.
It developed the process in three different
regimens:
• contributory – for persons with the ability
to pay the entities to join public and pri-
vate insurance companies that are called
Providers of Health (EPS);
• subsidized – for the population of strata
0 and I without the ability to pay that
theoretically would receive a subsidy
from the State; surrendered the adminis-
tration and management institutions to
public and private managers subsidized
regime ARS. By Law 1122 of 2007 the
name was changed to the regime subsi-
dized EPS-S, but with the same vices of
the ARS;
• customs-related or UBN (unsatisfied ba-
sic needs) – for the population in poverty
and misery that even do not have access
to the subsidy, until then it could access
a subsidy, a term absurd as it is an impor-
tant part of the population not affiliated
to anything.
What is even worse that the process en-
visaged three types of patients and three
medicines: the contributory regime had
free choice of doctors and clinics, no more
problem of access to specialized medicine
and technology and the best hotel service
in private clinics. Those of the subsidized
regime had all kinds of geographic barri-
ers to access the same benefits, less lim-
ited by the attention on the part of auxil-
iary staff or basic drugs that could only be
those listed in an arbitrary manner in the
“Vademecum of the POS” and concern-
ing those whom no one wanted to attend
as there was no answer who should do it,
turning attention to hospitals in the net-
work that had hired the care for patients
of the subsidized regime, but to attend the
related tort-produced “billing surplus” that
the State did not recognize, and paying less
leading to deepening of the financial crisis
and putting at risk the survival of public
hospitals.
146
COLOMBIA
Another fundamental aspect that must be
analyzed concerns drugs in general, but
especially generic drugs in Colombia, and
there is a very serious problem of market-
ing and the POS drug supply and the situ-
ation posed by the recovery by the EPS and
the risk of the shot cost for patients after
signing of the terrible FTA with the Unit-
ed States and with the European Union
that is even more harmful than that of the
USA.
Figures for the recovery of drugs not in
POS of the EPS to the Fosyga spent $58
billion pesos in 2003 rose to 628 billion in
2007, according to these, 507 billion corre-
spond to the contributory scheme; for the
closing of the year 2008 the forecast was
that recovery via guardianship and the tech-
nical-scientific committees of the EPS, the
figure would reach $ 1 billion 139 million
pesos, these data mean that in two years,
by the year 2010, all the Fosyga and health
system resources would not be enough to
pay for medicines not POS regains. One
of the causes of morbidity and mortality in
the country, more than the epidemiological
transition,a profile of structural heterogene-
ity predominate while the diseases of pover-
ty are unequally combined with the diseases
of development, and in which the expres-
sion of the inequities of social and health
care that have characterized the Colombian
Health System for long is very strong. The
topical problems of today are high and early
deaths homicides and violence, though pre-
dominantly affecting young males,begins to
appear more strongly in other age groups;
the persistence of inequalities between re-
gions, between urban and rural areas and
genders; the deterioration in the living con-
ditions has deepened in recent years and the
high vulnerability of young people, women
and rural inhabitants.
This latest health reform in Colombia in
the 1990s failed to overcome the chronic
inequalities and exclusions from the Co-
lombian Health System. Executed in the
period of transition, the universality in the
assurance and approval of benefits plans
are promises unfulfilled and impossible
to realize in the midst of policy adjust-
ment, co-modification of health services,
and deepening of the neo-liberal social
policies. A big question is posed which has
proven to be the main achievement of Law
100/93, what was the assurance of the poor
people as the official figures show that for
the year 2006, 56% and 63% of the popula-
tion of deciles 1 and 2 respectively, was not
insured, the total coverage of the health
system in that same year was 64%; but as
regards the alleged coverage of the sub-
sidized regime another fallacy was used,
called “partial subsidies” which were those
vertical subsidies given to a person who did
not have coverage in case of disease, as they
called them traders of “high-cost” health
(cancer, AIDS, heart problems that re-
quire procedures of high complexity, etc.)
only for that person and for the respective
medical problem, implying support at any
time to the same person for other health
problems that appear and less for the other
members of the family. These subsidies
added, they inflate the number of patients
allegedly “covered by the system”.
Today the population, especially the poor-
est, spends more on health and the subsi-
dized regime affiliates receive from the plan
of benefits 30% fewer services than the con-
tributory scheme. For the population not
insured, “linked”, inequities are larger, and
the poor becoming poorer have decreased
the use of services and those who have most
increased spending in health care have fewer
opportunities and the levels of poverty and
misery have expanded dramatically and the
social gap between them and the rich in-
creases; increase in absolute numbers reveals
that more than 50% of the Colombians are
out of the health system in the 15 years of
implementation of Law 100 of 1993 and its
regulatory decrees.
Comprehensive addressing of the transfor-
mation of the health situation of the coun-
try requires acting in double perspective,
the construction of a model of alternative
development and, in this context, a new
system of health, both aimed at resizing
the social policy and equity, placing them,
instead of economic growth, as the axes of
the development agenda. Equity and social
policy understood as equality of opportu-
nity for all and the guarantee of universal
rights, to deploy capabilities and individual
freedoms that materialize the plural proj-
ects of good life of human groups, and not
as welfare, residual and subsidiary actions,
economic growth and financial sustainabil-
ity criterion.
The results of the current health system,
based on the cumulative evidence of the
poor health situation of the population with
a high percentage of Colombians that never
out of it, the inequalities between regions
of the country, the collapse of the hospital
network, the decrease in the coverage of the
system, the resurgence of priority of health
problems increased and all this in the midst
of increase of progressive resources both
public and private. The system caused cri-
sis due to structural reasons and not imple-
mentation because it was built based on
inequalities and therefore is self-destructive.
Numerous studies revealing the crisis of the
general system in all aspects, including the
most critical, its inability to respond de-
cently and humanely to the needs of citi-
zens in health or, perhaps better, its great
capacity for nugatory rights, even to the
services specified in the compulsory Health
Plan have been published in the ‘private’
contract that supposedly governs the rela-
tionship between the citizens and the insur-
ance companies in the contributory scheme,
or between the State and the corresponding
EPS in the subsidized regime.
The same studies that confirm the growth
of spending on health as a result of the Ref-
ormation (National Health Accounts) show
that spending grew only between 1993 and
1997 and then declined steadily until the
year 2003. Health expenditure increased
Regional and NMA news
147
from 6.2% to 9.6% of the GDP between
1993 and 1997 and fell from the 9.6% to
7.8 % between 1997 and 2003. It also shows
an increase of the expenditure per capita of
257 thousand pesos in 1993 to 403 thou-
sand in 1997 and a fall to 320 thousand pe-
sos in 2003.In addition,the expenditure per
capita grew significantly in the population
covered by the contributory scheme and did
not grow for the poor population.
It also shows increase of specific care spend-
ing of 10.6% between 1993 and 2003 (less
than the population growth in the same
period), and reveals a fall of per capita ex-
penditure in the resources actually allocated
to health care. This is the worst outcome to
demonstrate a reform. Moreover, the per
capita annual expenditure spent on outpa-
tient services fell unceasingly since 1995
when it reached 178, 000 pesos to 130,000
in 2003, and made the situation very seri-
ous and demonstrated the greatest failure
regarding the real access to early diagnosis
and treatment needs.
It should be noted at this point that “linked”
are not simply “not insured” as it is claimed
in the studies, at least not as it was implied
by the National Health System before the
year 1993. Linked are a construction of the
system, most of which have been excluded
intentionally from the benefits of the system
by the focus mechanism (Benefits System or
SISBEN) At the time when systematically
the hospitals cut their care resources it is
logical to find advantages of affiliates to the
subsidized regime with respect to those who
had been left intentionally at the gates of
health services. Therefore, we cannot prove
that members of the subsidized regime are
well or much better provided, what happens
is that the linked are really excluded, except
a few exceptions as in the district capital,
Bogota, and the Valle del Cauca that are
investing in this group significant resources
pursuing policies of their own.
Summarizing, we can point out that one
of the many goals Law 100/ 1993 was not
able to meet and could not meet because
the very structure of the Law was based on
inequality and made it self-destructive was
the idealistic “universal coverage” according
to which there would be health care for all
by the year 2000 and then as an electoral
strategy of the current Government which
set its deadline in 2005 there was passed the
famous Law 1122/07 or “Amendments to
Act 100”which lowered the “universal”cov-
erage at levels I, II and III of the SISBEN
and so spent the highest percentage of the
money of the health sector to increase that
coverage at the level of municipalities at the
expense of the subsidy to the offer and the
possibility of maintaining of level II care
hospitals functioning and financially stable
to meet their objectives of providing health
care of specialized medicine and advanced
technology to the most vulnerable part of
the departments for the uninsured poor
whereupon health care moved towards total
collapse.
The official sector has a network of public
hospitals monitored by the departments, by
the Ministry of Social Protection, the Na-
tional Superintendence of Health; each pri-
vate EPS has its own vertically integrated
network, adverse selection, the constraint
of professional practice, the labour abuse,
de-professionalization of medicine and the
delabourization of unregulated by the de-
partments health workers not integrated
in the surveillance systems, morbidity and
mortality committees that are only moni-
tored by the National Superintendence of
Health entity that is located in the capital
with a single office and only 100 employees
to cover the entire country.
Finally, it is necessary to point out that
Social Security is the best way to ensure
the health of Colombians and when ask-
ing about the current occurrences, it is
not questioning social security, or even
the delegation of public service to private
actors, what is in question is the absolute
lack of capacity of the system to address
and regulate the system, the deviation
from the objectives of a universal system
with equal benefits plan for all Colombi-
ans, the vulnerability of the majority of
workers in the country without formal
employment contract, the road taken from
the assistance and the political patronage
in the subsidized regime which disclaims
employers and leaves without rights work-
ers managing many EPS under the two
regimes (especially the ownerless), where
administrators steal or simply dispose with
total irresponsibility of money earmarked
for the health of Colombians and there is
development towards de-professionaliza-
tion of medicine and delaborization of the
medical profession.
The everyday positive account of the system
is contrary to what happens to the citizens,
the majority of whom do not find a decent
and humane response to their health needs
in the current operation of the SGSSS.
All this leads us to conclude that if noth-
ing is done, Colombia will become the only
country with no public Social Security in
which all health assurance will remain in
private hands and where there is private
monopoly in assuring the health of Colom-
bians in less than 15 years if implementing
the “Colombian model” which is nothing
to be proud of because instead of being an
advanced model it is totally regressive from
the social point of view, excellent in finan-
cial returns but without meeting any social
function of equity and universality.
Cesar Prieto Avila M.D.
President Colegio Medico del Valle del Cauca
Vicepresident Federacion Medica Colombiana
E-mail: colmedvalle@gmail.com
COLOMBIA Regional and NMA news
148
MYANMARRegional and NMA news
Founded in 1949, MMA is the only pro-
fessional organization of qualified medi-
cal doctors in the Republic of the Union
(ROU) of Myanmar. It is a registered, non-
political, non-governmental, non-profitable
organization and operates with its own
budget, generated from its activities and
membership fees. MMA has its own policy,
constitution, bylaws and regulations.
Member Strength of MMA
Over 18,000 of 33,000 registered doctors
are MMA members, out of which over
8,000 doctors are not involved in Public
Service (non-service personnel); they are
medical practitioners (General Practitio-
ners) in the community.
MMA Offices
Under MMA, 83 medical association offices
are located all over the country in major cities
(townships and districts) of the states and re-
gions, covering nearly the whole population,
except in a few areas where communications
is encumbered, the population density is low
and the doctor community is small.
There are 33 clinical and non-clinical spe-
cialist societies, and the General Practitio-
ners (GP) society is the biggest, strongest
and most active among the other societies.
Leadership
Organization leaders are elected (at all
levels every two years) by democratic vot-
ing, a system based on meritocracy and all
members enjoying equal rights. MMA has
been sharing responsibilities and working
together for the global aims of philanthropy
and altruism with true professionalism.
Vision
MMA vision is to be instrumental in
promoting the health of the people by
enhancing the professionalism of the
members and striving to work together,
sharing responsibilities and experiences,
with strong commitment towards quality
health care.
Mission
MMA mission is volunteer spirit on non-
profit basis, democratic leadership, shar-
ing responsibilities with equity and unity
among the members, private-public part-
nership approach to other health alliances,
working together for quality healthcare
for all.
Main Functions
1. Education and Training towards the
CME accreditation.
2. Clinical and Public Health Research with
ethical and professional needs and standard.
3. Community healthcare including pub-
lic health projects, health promotion in-
cluding reproductive health.
4. Maintain high professional and ethical
standard among the members.
5. Collaboration and coordination with
medical societies in the region as well as
outside the region.
6. Partnership approach to allied medical so-
cieties,INGOs,NGOs within the country.
7. Encourage and support total capacity
building of the association at all levels
with professional aspiration.
Myanmar Medical Association (MMA)
On the left, Professor Pe Thet Khin, Minister for Health, receiving the souvenir
from Professor Kyaw Myint Naing, President of Myanmar Medical Association,
on the right, at the Inaugural Ceremony of the 59th
Myanmar Medical Conference
(22 January 2013) held in Mawlamyaing, the fourth largest city of Myanmar.
149
GERMANY Medical Research
Activities in 2012–2013
1. Annual Meeting together with Annual
Academic Conference every January. In
2013 the 59th
Conference was held in
Mawlamyaing, the fourth largest city of
the ROU of Myanmar.
2. The 19th
Surgeons Conference was held
in November 2013 at Mandalay,the third
largest city of the ROU of Myanmar.
3. The 10th
O&G Conference was held in
February 2013 at Yangon, the second
largest city of the ROU of Myanmar.
4. The 21st
ENT Conference was held in
January 2013 at Yangon.
5. The 21st
Eye Conference was held in
November 2012 at Yangon.
6. The 14th
General Practitioners Scientific
Conference was held in November 2012
at Lashio, Northern Shan State.
7. The 9th
Rehabilitation Medicine Confer-
ence was held in October 2012 at Yangon.
8. The 2nd
International Pain Seminar was
organized by the ROU of Myanmar and
was held in January 2013 at Yangon.
9. There are 3 academic projects, and 18
public health related projects funded
by various International donor agencies
including Myanmar Medical Associa-
tion itself, covering 80 townships in the
ROU of Myanmar.
10. Support Group for Elderly Doctors
(SGED), care about doctors over the
age of 70 with sickness support, social
visits, regular medical check-ups, social
gatherings, support in cataract opera-
tions, and at funeral.
11. Lady Doctors Section organized to pay
homage to the elderly doctors residing in
Yangon every December of the year (the re-
cent data: 340 doctors over 75 years of age).
12. Emergency Ambulance Service has
been established and initiated and has
an appreciable performance in Yangon
by Myanmar Medical Association with
charity support.
Dr. Khine Soe Win, Executive Director,
Myanmar Medical Association
Incidental findings and chance findings en-
counter in many areas of medical investiga-
tions in diagnosis and research. But due to
the refinement of new technologies in the
context of medical research they appear
more frequently in modern clinical stud-
ies and biomedical research projects. In
general, the term “incidental finding” can
be considered to refer to an unexpected
medical (clinically uncertain or possibly
relevant) finding, whose presence was not
previously suspected, and which was not
specifically sought for during the research
procedure. Whereas “chance findings“ are
in fact, fairly probable due to the large scale
nature of a specific research process like in
medical genetics. Those findings are not re-
ally “incidental” [cf. Lanzerath et al 2013].
In particular the introduction of imaging
techniques (e.g. PET, MRT) to investigate
function and dysfunction of the human
brain produces incidental findings and has
initiated a vital ethical and legal debate on
the question to which extent investigators –
including doctors engaged in research  –
need to inform about these kinds of find-
ings and how they should deal in general
with pathological, or potentially pathologi-
cal, findings arising within the context
of a research project that are of no direct
relevance to the research question in hand.
Although data on this subject remain lim-
ited, empirical studies have shown that in-
cidental findings are widespread (up to 8%)
within brain imaging studies [Morris et al.
2009]. At the time of writing, no common
guidelines or laws are available to research-
ers in Europe that regulate this very specific
issue of the management of incidental find-
ings. Only general provision concerning the
researcher-participant-relationships and in
particular those on data protection are ap-
plicable here and create a pattern “that gives
rights to data subjects (those to whom the
personal data in question relates) and im-
poses duties upon data controllers (those
who control the processing of those data)”
[Townend 2013]. Only some professional
medical associations [e.g. GFHEV 2013]
or groups of researchers [e.g. Wolf et al.
2008 or Heinemann et al. 2013] published
specific proposals and statements concern-
ing the management of incidental or chance
findings in research.
Against this background the question arises
as to how ethical principles and rules estab-
lished over past decades should be speci-
fied and supplemented in order to create
ethically acceptable conditions for medi-
cal research. Some even suggest that the
normative obligations between researchers
and research subjects on the one hand, and
doctors and patients on the other, must be
fundamentally re-evaluated. This view indi-
cates that medical ethics and research ethics
Ethical Principles of the Management
of Incidental Findings in Research
Dirk Lanzerath
150
Medical Research GERMANY
differ more widely in the normative sense
than hitherto assumed. Others consider
this appraisal too far-reaching, and assume
that the updating of established medical
and research ethics will lead to an adequate
solution [Heinrichs 2013]. Most of those
involved are, however, in agreement that
binding ethical and legal standards – e.g.
included in professional law – should be es-
tablished in order to ensure equal clarity for
researchers and research subjects in terms
of the normative auspices under which the
relevant techniques within medical research
are applied.
Information, Autonomy,
and Knowledge
The management of incidental findings
touches upon certain fundamental ethical
principles that exert a reciprocal influence
on each other in both other areas of medical
care and medical research.The most promi-
nent of these are the right to informational
self-determination, and the associated right
of a research subject to receive comprehen-
sive information prior to the performance
of the study. This latter right includes en-
titlement to an adequate explanation con-
cerning the aim of the research, the data to
be gathered, and the techniques to be used
in order to ensure that research subjects
are in a position to provide informed con-
sent. In the sense intended here, however,
this right also includes the entitlement to
receive information regarding the possible
consequences of research participation.
These possible consequences include any in-
cidental findings, or indeed chance findings,
that may be detected during analysis of the
data. Thus first and foremost, we may speak
of a basic obligation to provide information
that data with this potential are to be gen-
erated. However, the question of how com-
prehensive this information may and needs
to be clarified. For example in the field of
whole genome sequencing many data will
be available even those which cannot be in-
terpreted for the moment. But the investi-
gator has the duty to explain and to specify
which kind of data will be analyzed and can
or cannot be disclosed to the state of the art.
Rights pertaining to the principle of the au-
tonomy of the research subject include not
only the right to know, but also the right
not to know. No individual may be forced
to (want to) know all that can be detected
in someone’s brain or discovered about
someone’s genetic constitution [Oviedo
Convention, Council of Europe, Article
10]. Although knowledge of this kind may
be of benefit to the individual in terms of
life planning, it may also prove very bur-
densome. For instance, awareness of a par-
ticular genetic predisposition may be asso-
ciated with serious disadvantages, and may
result in discrimination or stigmatisation
in day-to-day life (e.g. insurance cover, oc-
cupational status). Therefore this right not
to know has become an established ethical
principle, which is also reflected by several
legal regulations. However, this should not
to be confused with simple ignorance of
certain possibilities; what is meant here is
an enlightened desire not to know. If I am
the person who will be affected, then I must
know in advance what I am letting myself
in for if I do not wish to gain a particular
kind of knowledge. In other words, not
wanting to know does not obviate the need
for elucidation; rather the consequences of
not wanting to know must be elucidated in
advance.The decisive point is that this right
necessitates a limitation of elucidation, i.e.
it respects the wishes of individuals not to
be so informed.
Non-maleficence
versus Solidarity
Two further principles are of importance in
the ethical appraisal of strategies for deal-
ing with incidental findings and of the cri-
teriology that is to be elaborated for this
purpose. Medical intervention should not
cause harm (primum nil nocere). This has
been developed as a basic ethical principle
in medicine initiated already in the Hip-
pocratic tradition, as even though thera-
peutic interventions often result in damage
to health, they are necessary to prevent or
remedy even greater harm.Clearly the prin-
ciple of non-maleficence must be applied
more stringently in medical research than
in day-to-day medical practice, since heal-
ing a research subject is not the main pur-
pose of research,and even healing in general
is only one of its aims. Therefore, there is
no justification for causing detriment, not
even temporarily, such as can and must per-
tain to direct curative treatment. Scientific
enquiry may only expose research subjects
to risks that are not disproportionate to the
potential benefits of the research [Oviedo
Convention, Council of Europe, Article
16]. A common tendency exists among
medical professionals to consider the prin-
ciple of non-maleficence as being restricted
to instances of physical harm. However, the
spoken word can also cause considerable
distress, for instance in the course of a con-
sultation to explain findings or test results.
Evaluation of specific and problematic in-
cidental findings arising within a research
setting cannot be evaluated according to
criteria applied within a clearly defined
diagnostic and therapeutic context. The re-
lationship that exists between a physician
and a patient is typically of a diagnostic/
therapeutic nature which includes specific
legal implications. In the research context,
however, the ethical principles of solidar-
ity and common good must be taken into
account to justify that human subjects will
be involved as research subjects in research
projects. In Anglo-Saxon bioethics, such
principles are frequently subsumed under
the principle of justice. The performance
and success of medical research are by no
means guaranteed under all circumstances.
Firstly, they require enormous amounts of
money, and secondly they are contingent
upon the research being attractive to indi-
vidual researchers and scientific institutions,
as well as the preparedness of people to act
as research subjects. In many cases, these
151
Medical ResearchGERMANY
latter individuals are healthy volunteers in
no need of medical treatment.Although the
improvement of treatments and medicines
through scientific endeavour may be regard-
ed as conferring a high degree of social ben-
efit, this consideration does not override the
ethically justified rights of research subjects.
It must also be borne in mind that social
benefits including the increase of knowl-
edge do not accrue on the basis of any single
study – which may in any case fail to gen-
erate significant data – but rather from the
fact that this study is part of a general and
international body of biomedical research.
On this basis, it may be legitimate – under
appropriate circumstances and with appro-
priate deference to the principles of research
ethics – to engage healthy volunteers for
testing purposes and expose them to some
risks, if the anticipated benefit cannot oth-
erwise be achieved.It is then the task of Re-
search Ethics Committees to determine, on
a case to case basis, whether the design and
implementation of a given medical study
infringes upon the rights of research sub-
jects.The risks to research subjects posed by
participation in research should be justified
by the anticipated benefits to the subjects
or society.This process also involves scrutiny
of whether the proposed procedures with
respect to incidental findings are in accor-
dance with existing laws and guidelines for
research ethics.
Criteriological Considerations
Such general ethical principles do not,how-
ever,suffice as a criteriology for dealing with
incidental findings within the research set-
ting; they only provide a set of boundary
conditions.To establish the degree to which
researchers are obliged to provide informa-
tion concerning incidental findings, these
findings should first be categorised accord-
ing to their information content, since this
represents a means of assessing possible
benefits or detriment for research subjects.
Questions of relevance in relation to infor-
mation content are:
• Reliability of knowledge: What can be-
come known on the basis of the informa-
tion that has been obtained?
• Transferring medical knowledge into
personal knowledge: How might the
knowledge of a finding affect a person’s
life planning?
• Concernment of person involved, off-
spring or relatives: Who is affected by the
communication of findings?
• Therapeutic value of the knowledge: Can
the prognosticated disorder be treated
by preventative, therapeutic, or palliative
means?
• Pathogenic significance of the knowl-
edge: How serious is the prognosticated
disease?
• Prognostic value of the knowledge: What
is the likelihood that a condition will
manifest itself?
These questions categorize the different in-
cidental findings to constitute a framework
for recommendations for a criteriology for
use in communications with research sub-
jects in medical studies. [Lanzerath et al.
2013] Incidental findings are categorised
according to the respective degree of obli-
gation to provide information, and with re-
spect to the physician’s duty of care, and the
rights of the research subject to self-deter-
mination and to know or not to know. The
physician’s duty of care includes the offer of
information of relevance to the current or
future state of health. But the investigator
has to take account that the research sub-
ject might exercise his or her right not to
know, i.e. that a research subject does not
want to receive such information about a
finding.
Nevertheless, two potential conflict scenar-
ios remain. In the first case, the researcher
is of the opinion that the incidental genetic
finding is of major significance to the re-
search subject that its disclosure would be
of considerable benefit to them, but the re-
search subject has declared in advance that
he or she does not wish to be told (conflict
between the right not to know and duty of
care).In the second case,the researcher con-
siders the benefits of imparting information
to be questionable, or that the information
is based on unreliable data, but the research
subject wants to know more (“tell me every-
thing you did find”); however, the knowl-
edge may cause him or her unnecessary
disquiet. These conflicts cannot be resolved
through the presently proposed categorisa-
tion process, and must instead be clarified
ahead of study participation. Whether the
right to self-determination or the duty of
care should take precedence in such cases,
and whether research subjects who insist
upon not being informed about incidental
findings (even if these are of great potential
benefit) should be excluded from studies,
are matters of heated debate [cf. Lanzerath
et al. 2013].
Conclusion
Even if researchers – including doctors en-
gaged in research – implement the proposed
normative categorisation of incidental find-
ings in order to determine their degree of
obligation in terms of disclosure, they may
nevertheless find it difficult in individual
cases to make a reliable assignment. A di-
lemma emerges from the experience that
many incidental findings are of “unclear
significance”. The research subject faces an
unclear risk-benefit ratio when it is unclear
how this certain kind of knowledge can
be applied, in particular in the field of hu-
man genetics. The involved subject decides
on what kind of risk he or she is ready to
take. But this can be done only on a basis
of categorized types of data and informa-
tion. Raw data do not automatically cor-
relate with “information”; generating and
compiling reliable information emerges
from a prior interpretive and hermeneutic
approach. Therefore it must devolve upon
the specialist associations to formulate the
proposed categorisation in more detail, so
that even in the case of multi-centre stud-
ies, clearer criteria for the protection of the
research subject, which are oriented on the
152
Health Care REPUBLIC OF BELARUS
ethics of research practice, are generally
available. At the same time, there is a strong
need to specify the “counselling capacities”
(i.e. their skill in imparting information in
an appropriately empathic manner) of those
entrusted with the task of provide and dis-
close information to research subjects. Un-
fortunately, competency for this task cannot
be assured in all cases.
References
1. Council of Europe (1997) Convention on hu-
man rights and biomedicine. European Treaty
Series No. 164. Oviedo
2. GFHEV (2013): http://www.gfhev.de/de/
leitlinien/LL_und_Stellungnahmen/2013_
05_28_Stellungnahme_zu_genetischen_
Zufallsbefunden.pdf
3. Heinrichs B (2013) Incidental findings and the
right not to know. In: Lanzerath (2013), 83-92
4. Heinemann T et al (2013) Incidental Findings
in Neuroimaging Research: Ethical Considera-
tions and a Framework for Ethical Guidelines.
In: Lanzerath (2013), 59-73
5. Lanzerath D et al. (eds) (2013) Incidental
Findings. Scientific, Legal and Ethical Issues.
Deutscher Ärzte Verlag, Köln
6. Morris Z et al. (2009) Incidental findings on
brain magnetic resonance imaging: system-
atic review and meta-analysis. BMJ (2009), 17,
339:b3016
7. Townend. D (2013) Incidental Findings, Data
Protection, Privacy, and Politeness. In: Lanzer-
ath (2013), 27-43
8. Wolf SM et al. (2008) Managing incidental
findings in human subjects research. Analysis
and recommendations. In: J Law Med Ethics,
36, 219–211
Priv.-Doz. Dr. Dirk Lanzerath
Geschäftsführer / Executive Officer
Deutsches Referenzzentrum für Ethik
in den Biowissenschaften (DRZE)
German Reference Centre for
Ethics in the Life Sciences
Universität Bonn / University of Bonn
E-mail: lanzerath@drze.de
The Belarusian Medical Academy of Post-
graduate Education in Minsk, Belarus, has
developed speleotherapy as one of the per-
spective drug-free methods in the treatment
of bronchial asthma (BA), chronic obstruc-
tive pulmonary disease (COPD), allergic
processes (rhinitis, pollinosis, dermatitises)
which allows to prevent the development
of those diseases at the early stages of their
development, and it does not have any sig-
nificant side effects.
The Republican Clinic of Speleotherapy
(RCS) in Soligorsk has opened a unique
subsurface speleo complex, constructed in
the rock salt (halite) massif and the potas-
sium (sylvinite) layer.
34 thousand patients have been treated
there during the 23 years of its functioning.
The treatment efficiency is high. Positive
results have been achieved in 97.6% of the
cases.
The world practice has accumulated experi-
ence in the application of the speleotherapy
method for treating diseases of respiratory
organs, which testifies to the high effective-
ness without the risk of developing side
reactions due to the microclimate of salt
mines.
The RCS in Soligorsk carries out the spe-
cialized treatment with the speleotherapy
method by using the subsurface space, ex-
isting in different mining and geological
layers.
The uniqueness of the RCS subsurface spe-
leo complex manifests in the following:
1. It is in the rock salt (halite) massif and
the potassium (sylvinite) layer, pro-
viding the possibility of placing the
patients in different therapeutic envi-
ronment depending on the form of the
disease and individual reaction of the
organism to the speleo environment
[Figure 1].
2. The subsurface departments are built
according to the scientifically-based
project [Figure 2].
3. Special air intake labyrinths ensure the
air flow to the therapeutic area and also
individually to each ward.
4. The physico-chemical properties of the
microclimate in Soligorsk salt mines
significantly differ from those in other
speleo complexes. The sylvinite layer
near the halite layer of the salt exceeds
the potassium chloride content in the
air 20 times in comparison with other
similar mines.
The specific therapeutic effect of the speleo
environment is achieved due to the stable
microclimate, the optimal ionic composi-
tion, the presence of fine salt aerosol in it,
the absence of allergens and pathogenic mi-
croflora.
Characteristics of the
speleo environment:
• The optimal gas composition of the air
according to the content of oxygen (20,
80–20, 90 by volume) and according to
the content of CO2
(0.031–0.047 by vol-
ume); 0.35 mg/m3
• The total microbial contamination of the
air is 42–102 colonies in m3
.
Experience inTreating Patients in Sylvinite-Halite Mines
of Soligorsk in the Republic of Belarus
153
Health CareREPUBLIC OF BELARUS
• The following factors also apply to the
subsurface environment.
• The shielding effect of the rock mass from
the effects of radio frequency electromag-
netic fields; the psycho-emotional read-
aptation due to the strange conditions in
the underground.
Materials and methods
The RCS treats about 2000 people a year
average.The twice increased hospital capac-
ity in 2012 has increased the number of pa-
tients to 4000 respectively.
78 treatment courses of speleotherapy
have been performed during the period
2009–2013, lasting for not less than 12–
18 beds/days. 11407 patients have been
treated during this period. 6896(61%) of
them were women, 4421 (39%) were men
[Figure 3a]. The number of grown-ups was
9424(82.6%),children and teenagers – 1983
(17.4%) [Figure 3b].
Of all the patients treated in the RCS 58%
were 18–50 years old, it means the most ac-
tive working age. The average length of the
treatment is 17.4 days,the average amount of
speleo manipulations for one patient – 15.7.
The speleo manipulations are performed in
the day time and in the evening and at night
for 5 and 12 hours, during the above period
8924 (77.4%) patients with BA, 1540 (12%)
patients with COPD and chronic bronchi-
tis, 1095 (4.8%) patients with allergic rhini-
tis have been treated [Figure 4].The positive
effect is observed after speleotherapy among
the patients with allergic skin disease etiol-
ogy. The method of research: computer spi-
rometer was used in this work.
Results and Discussion
Speleo environment reduces allergic dis-
position of the body, reduces inflammatory
changes in the bronchi, helps to improve
the rheological properties of sputum and
1. Cloakroom
2. Wards in the halite layer
3. Remedial gymnastics rooms
4. Wards in the sylvinite layer
5. Doctors post
6. Treatment room
7. Nursespoint
Emergency exit
Ieeja
8. Junior medical staff
9. Technician
10. Recreation room
11. Garbage collection
block
12. Air feeding system
Figure 1. The structure of salt Figure 2. The subsurface speleocomplex
Medical indications to treatment Medical contraindications
• Bronchial asthma, all forms of light and
average course;
• RI(respiratory insufficiency) of 1st
degree;
• COPD, light and average course of RI;
• Chronic bronchitis;
• Pollinoses (before and during the pollen
season);
• Allergic rhinitis;
• Allergic urticaria.
• Acute diseases;
• Chronic diseases in the acute stage or in
the case of heavy clinical course;
• Asthma;
• Respiratory diseases with respiratory in-
sufficiency of 2nd
–3rd
degree;
• Malignant neoplasms of all localizations;
• Blood circulation system diseases with
cases of cardiac insufficiency;
• Mental insanity;
• Tuberculosis of various localization.
Women
61%
Men
39%
10–17 years
20% 18–30 years
10%
30–50 years
48%
50–60 years
20%
60–70 years
2% children
Figure 3a. The structure of the patients
by gender (2009–2013)
Figure 3b. The structure of the patients
by age
154
bronchial drainage function, has antibacte-
rial action, mild immunomodulatory effect,
which explains the wide list of indications
for speleotherapy [Figure 5].
Considering the information above, at the
RCS research has been performed focusing
on the influence of speleo treatment in the
course of allergic rhinitis, BA and COPD.
It was aimed at the development of various
methods of treatment, defining the modes
of speleo influence, duration and multiplic-
ity of speleotherapy courses depending on
the nosology and the severity of the disease.
The effectiveness of the method for patients
with different clinical forms of the disease
and severity was assessed by the severity of
the dynamics of the main functional pa-
rameters and immunological criteria. The
study revealed significant differences in the
dynamics of the functional parameters in
patients with different forms and levels of
BA. During the speleotherapy a statistically
significant increase in the basic forced ex-
piratory volume in the first second (FEV1
)
was observed in patients with controlled
BA allergic form by the end of the 2nd
week
of the treatment and it was 19.3 ± 8.4%. In
the following days, significant increase of
the indicator was not observed [Figure 5].
A slower dynamics of the Function of In-
ternal Respiration was observed in patients
with partly controlled allergic BA. The dy-
Bronchial asthma
77%
COPD
7%
Chronic bronchitis
5%
Pollinosis
6%
Other allergic
disturbances
2%
Other bronchial
obstructive
diseases
1% Accompanying
diseases
2%
Figure 4. The structure of the patients according to nosology
100
90
80
70
60
50
40
30
20
10
0
0 I II III IV
FEV1
Tiffnoindex
PEF50
PEF75
Figure 5. The dynamics of the Function of
Internal Respiration parameters
in patients with controlled BA
of allergic form
100
90
80
70
60
50
40
30
20
10
0
0 I II III IV
FEV1
Tiffnoindex
PEF50
PEF75
Figure 6. The dynamics of the Function of
Internal Respiration parameters
in patients with partly controlled
BA of allergic form
100
90
80
70
60
50
40
30
20
10
0
0 I II III IV
FEV1
Tiffnoindex
PEF50
PEF75
Figure 7. The dynamics of the Function of
Internal Respiration parameters
in patients with controlled BA
of mixed form
100
90
80
70
60
50
40
30
20
10
0
0 I II III IV
FEV1
Tiffnoindex
PEF50
PEF75
Figure 8. The dynamics of the Function of
Internal Respiration parameters
in patients with partly controlled
BA of the mixed form
100
90
80
70
60
50
40
30
20
10
0
0 I II III IV
FEV1
Tiffnoindex
PEF50
PEF75
Figure 9. The dynamics of the Function of
Internal Respiration parameters
in patients with COPD
Health Care REPUBLIC OF BELARUS
(PEF–peakexpiratoryflow)
155
namics of the main indicators of respira-
tory function was observed throughout
the treatment, but statistically significant it
was in the second week of speleo influence,
reaching the level of FEV1
12.8 ± 4.2%.Sig-
nificant differences in the dynamics of the
Function of Internal Respiration in patients
with the mixed form of BA, depending on
the level of control, have not been identified
[Figure 6].
A statistically significant increase in FEV1
in patients with controlled BA of the mixed
form was observed during the third week of
the treatment and amounted to 11.9 ± 4.4%
[Figure 7].
Partly controlled BA of the mixed form was
characterized by a gradual increase in the
values of the basic functional parameters,
reaching a statistically significant level dur-
ing the third week of speleotherapy – 12.5 ±
3.8% in terms of FEV1
[Figure 8].
The revealed changes in the level of the
investigated Ig were treated as the stabi-
lization of defense mechanisms at a lower
functional level by minimizing immune
stimulation. The identified functional and
immunological changes in patients with
light and moderate course of COPD had no
relationship to the severity of the disease and
therefore were joined into one observation
group. During speleotherapy a statistically
significant dynamics of the main indicators
of the Function of Internal Respiration was
observed in these patients during the third
week of the treatment [Figure 9].
During speleotherapy a statistically signifi-
cant increase in the basic of FEV1
at the end
of the third week of the treatment was 16.7
± 4.7%, which continued during the fourth
week, but had no statistical significance in
comparison with the levels achieved during
the third week.
Conclusions
1. The subsurface departments of speleo-
therapy based in Soligorsk sylvinites-
halite mines are unique in the structure
of salt and they are constructed accord-
ing a specially designed project.
2. Speleotherapy in Soligorsk sylvinites-
halite salt mines has a positive effect on
the course of allergic rhinitis, BA, COPD,
resulting in the possibility of its use in the
prevention of progression of these diseases.
3. It is appropriate to use differential treat-
ments of speleotherapy from 12 to 18
beds/days; it depends on the level of
control and forms of BA, severity of the
course of COPD.
4. A more rapid and significant therapeu-
tic effect of speleotherapy is achieved
among patients with the controlled
course of the disease.
5. According to our observations, the
effectiveness of the treatment is 97%
and it manifests as improving the qual-
ity of life of patients, long-term stable
remission of the disease, reducing the
frequency of asthma attacks, improving
the performance of the respiratory func-
tion, reducing pill burden.
References
1. Богданович А.  С. Специфические факторы
среды калийных рудников Солигорского
бассейна и возможность их использования
для спелеотерапии. // Здравоохранение Бе-
лоруссии. – 1985. №1. c. 39–40
2. Богданович А. С. Использование подземных
пространств для оздоровления методом спе-
леотерапии. // Горный журнал, 2003. №7. c.
62–64
3. Богданович А. С., Полещук В. Ф., Качур Т. З.,
Минюкович Н. Ф. Первый опыт спелеотера-
пии больных на базе Солигорского рудника
// Здравоохранение Белоруссии. 1991. №11,
с. 48–50
4. Левченко П. А., Лаптева Е. А., Дубовик Н. Н.
Bronhiālās astmas un HOPS ārstēšanas pieredze
silvinita un halita šahtu apstākļos Soligorskā
Baltkrievijas Republikā // Latvijas ārsts, с. 60–64
5. Скепьян Н. А., Богданович А. С. Здоровье и
бронхиальная астма. // Пульмонология, 2001.
№7, с,30–32
P. A. Levchenko, Y. A. Lapteva
State-owned enterprise The Republican
Clinic of Speleotherapy
Soligorsk, Belarus
The current global financial crisis inevitably
alters the quality of life of many individuals,
mainly (but not exclusively) its fourth – after
Guelfi – dimension: the economic one (a deeply
intricate component). Under these conditions,
we can only hope that the holistic and ideal-
istic definition of health, adopted by the World
Health Organization (WHO) more than 65
years ago, will maintain its contemporaneity
and applicability – from before the recession –
at least in the more developed countries/econo-
mies.This work presents a synthetic overview
of the main issues related to the notion of qual-
ity of life: the presence/absence of risk factors,
(especially) the ones associated to the “civiliza-
tion pathology”, wellness, current thinking/
paradigm (integrating the medical and social
models) of the WHO regarding human func-
tioning, (di)stress – including its relationship
to premature/pathologic ageing – respectively,
active prophylactic (relaxing, fitness/“mise en
forme” anti-stress, maintenance, rejuvenation/
anti-ageing/gero-prophylaxis) balnear therapy
courses.
Public HealthROMANIA
Basic Wellness Features and Some Rlated Actions Propensive
for Active and Healthy Ageing
156
ROMANIAPublic Health
Background.The WHO
definition of health.
Connected concepts
“Health is a state of complete physical,
mental and social well-being and not mere-
ly the absence of disease or infirmity” (1).
This definition was formulated almost sev-
en decades ago and it included a “wishful
thinking” dimension, representing, con-
ceptually, the option for the main strategic
target of general human progress and of
sustainable (peaceful) development: to en-
sure the quality of life (QoL). Nowadays,
this forward-looking strategic option is not
obsolete, but on the contrary, it proves to be
modern and desirable.
Effective physical well-being entails:
• the absence of medical disorders or/and
of physical overwork/strain
• the absence/alleviation of disease risk
factors (e.g., those for vascular pathology,
that may lead to strokes/lesional attacks
to virtually any organ – brain, heart, etc. –
relatively easy to avoid, modify or elimi-
nate: sedentary life,obesity,smoking,dys-
lipidemia, diabetes, hypertension, cardiac
dysrhythmia, hyperfibrinogenemia) (2)
Moreover, an optimal/complete state of
physical well-being requires not only the
mere absence of illness risk factors and/or
physical distress, but also a state of moder-
ate physical performance – fitness.
Fitness is defined as “good health or physi-
cal condition, especially as the result of ex-
ercise and proper nutrition or the extent to
which an organism is adapted to or able to
produce offspring, in a particular environ-
ment”) (3).
The definition of physical fitness also in-
dicates to the indissoluble relationship of
health with physical exercise and nutri-
tion  – major “poles” of the “lifestyle” no-
tion, a comprehensive concept that includes
many positive and negative factors (e.g.,
sedentary life – a negative factor, of course,
and a central pathogenic item of the “civili-
zation pathology” (4).
Effective mental well-being entails:
• the absence of psychological and/or cog-
nitive disorders and/or absence of psychic
distress
• the absence/alleviation of specific risk
factors (dissatisfaction, suppression, de-
nial, low self-esteem)
A simple, quick, orientative modality to as-
sess the cognitive function, frequently used
in clinical settings, is the Mini-Mental
State Evaluation (MMSE) (5).
Effective social well-being entails not
merely the lack of poverty, but also (con-
stant) decent living from an economic
point of view. Furthermore, certain social
conditions should be met: leading one’s
life in a democratic/constitutional state
with a valid system of laws and regula-
tions that are effectively enforced in a
civilized society, engaged in “sustainable
development”, characterized by tolerance
and cohesion, adhering to the principles
of non-discrimination and inclusion, with
increased consideration for the individuals
with special needs (including morbid obe-
sity or frail elderly, for example) and at the
same time, based on fair competition and
professional performance  –“knowledge-
based society”.
The current understanding of health as
physical, mental and social well-being is
based on two fundamental, strategic, com-
plementary concepts, which were brought
forth and intensively promoted by the de-
veloped contemporary societies:
• Quality of Life (QoL)
• Wellness (“well tempered hedonism”.)
The major determinants of the QoL are
physical and functional performance, psy-
chological well-being, social interactions
and the economic status (6).
The Flanagan Quality of Life Scale is a com-
monly used instrument for QoL assesment.
The concept of “wellness” – antonym to
the word “illness”, according to the Oxford
English Dictionary (cited by 7), generally
designates an adequate balance of “body,
mind, and spirit”, leading to a harmonious
interaction with the “constantly changing
total environment” (8).
An adequate physical, cognitive and spiri-
tual interaction with one’s environment (in
all its dimensions: physical, familial, pro-
fessional, social, economic, political, cul-
tural, etc.) leads, in turn, to a state/feeling
of general well-being, which represents far
more than the mere absence of illness. Con-
sequently, wellness may be defined as “an
integrated method of functioning, which is
oriented toward maximizing the potential
of which the individual is capable” (7).
“When we learn how to diagnose high-level
wellness through objective measures, we shall
probably find that a substantial amount of cre-
ative expression, altruism, and love in daily
life is essential for the approach to a high state
of well-being. Through the development and
application of these values in daily life, we will
achieve self-confidence and faith in ourselves.
This in turn will bring growth of self, develop-
ment toward fuller maturity, and a balanced
wellness of body, mind, and spirit.” (8)
(Di)stress is a concept of paramount impor-
tance, related to the QoL and wellness. In a
very general sense, at least for the biomedi-
cal field, the term stress, introduced since
the first half of the last century by the endo-
crinologist Hans Selye who has “fathered”
the stress research, is translated as pressure/
strain/tension. It must be underlined from
the beginning that both, the lack of stress
(such as a sedentary life or social margin-
alization) as well as the excess/overload are
equal sources of pathogenic stress (distress).
Historically, the first clinical preliminary/
collateral observations in connection to this
157
ROMANIA Public Health
subject were noted at the end of the 19th
century by one of the most celebrated and
contributive nurses Florence Nightingale
(”Notes on nursing: What it is and what it is
not”– cited by 9),but the Austrian-Hungar-
ian endocrinologist Hans Selye was the first
to develop the theory of “general adaptation
syndrome”/“diseases of adaptation” (10) as
a bio-physio-psychological paradigm to un-
derstand the concept of stress (initially, dur-
ing the interwar period, he had formulated
it as “the alarm reaction”) (11).
According to this paradigm, the general
adaptation syndrome is triggered by any
event that affects (to a lesser or more often
larger extent) the equilibrium state of an
organism – called stressor (10). The initial
response to distress is coordinated by the
hypothalamic-pituitary axis,a system which
will “gear the body for defence” (10). With-
in the reactivity to stress, the link between
the brain – as an initiator – and the immune
system [immune-neuro-endocrine interac-
tions (12)] involves the neuro-endocrine
system as a whole (12, 13).
Stress is one of the six major representative
situations/biological phenomena character-
ized by duality, where the physiological/the
functional is intertwined with the patho-
logical, listed here in the alphabetical order:
• ageing (through genetic program/a major
risk factor for old age polipathology)
• hyperthermia (reactional or therapeuti-
cal – fever versus pathological – burns,
insolation)
• inflammation (reactional versus patho-
logical)
• neuroplasticity (learning versus patho-
logical reorganization)
• pain (reactional – a physiological, biopro-
tective alarm response to nociceptive stim-
uli versus pathological, neuropathic pain)
• stress (eustress – a vital stimulus for the
antientropic behaviour of the organism
versus distress – pathogenic stress) (4)
From a medical and biological point of view,
the psychological distress influences the hy-
pothalamic–pituitary–adrenal axis (which is
connected and modulated by suprathalamic,
including centers), leading to the release (as
a neuro-endocrine mechanism of the “ad-
aptation syndrome”) of a large number of
hormones: CRH (corticotropin-releasing
hormone – from the paraventricular nucle-
us of the hypothalamus), somatotrophins
(from the anterior pituitary): ACTH (ad-
renocorticotropic hormone), GH (growth
hormone), PRL (prolactin), hormones from
the posterior pitutary: ADH (antidiuretic
hormone), respectively catecholamines
(epinephrine and norepinephrine, from the
adrenal medulla), cortisol (from the adrenal
cortex), insuline (from pancreas), as well as
neurotransmitters (serotonine, GABA –
gamma-aminobutyric acid) and neuromod-
ulators (endorphins, enkephalins), resulting
in a series of alterations of humoral param-
eters and/or organ functions (14).
All these changes induced by distress make
one prone to “organic body damage” (15),
generate major risk factors for phychoso-
matic syndromes and diseases.
Hence, gastroduodenal ulcer disease, ir-
ritable bowel syndrome, arterial hyperten-
sion, some forms of cardiac ischemia and/or
ischemic strokes, diabetes mellitus, amenor-
rhea, etc. can be considered as such condi-
tions. These add to a long list of disorders
also related to distress/overload that alter
the QoL and/or the work capacity/profes-
sional performance: neurovegetative dysto-
nias (including spasmophilic phenomena,
thermoregulation disorders, nycthemeral
rhythm alterations with, in a vicious circle,
disturbances of the circadian hormonal se-
cretion biorhythms), neurastenic/neurotic
syndromes, deconditioning syndromes, etc.
On the basis of the extremely tight and in-
tricate morph-functional immune-neuro-
endocrine connections/feedbacks most of
the substances released by stress alter the
functionality of the immune system. A
specific example is serotonine that seems
to act, in this context, directly on the lym-
phocytes with repressive effects on some
morph-functional changes which normally
take place before their blastic transforma-
tion (Rozman, cited by 14). In addition, it
is currently recognized that mental distress,
repeatedly present in everyday life, produces
in time, in both, experimental and clini-
cal situations, an activity decrease of NK
(natural killer) lymphocites, a decline in
interferon production, a lowering of IgA
(immunoglobulin A) serum titers and con-
sequently leads to the alteration of endog-
enous antineoplastic surveillance, as well as
to reduction of the organism’s resistance to
infections (14). In this respect, an example
of a disease that may also be considered psy-
chosomatic disorder is the chronic fatigue
syndrome.
Psychic (di)stress – including the one in-
duced by chronic/neuropathic pain – results
in lowering of the mass of cortical-thalamic
gray matter (and/or medullary neuron apop-
tosis – observed in rats with such suffer-
ance) by an excitotoxic mechanism leading
to functional overload atrophy – “overuse
atrophy”, associated with destructive, in-
flammatory phenomena (16). The (di)stress
of intense lumbar chronic pain can diminish
the brain volume by 11% in one year, more
precisely by 1.3 cm3
of gray matter – equiva-
lent to 10-20 years of normal ageing. This
fact highlights the psychosomatic link  –
“the mind-body connection” – manifested
in both, eustress and distress. The latter, es-
pecially when prolonged/chronic,affects the
high complexity levels of the organization
of living structures, the molecular geno-
type including. Chronic distress appears to
be an accelerator of telomere shortening;
telomeres are intimate markers of ageing,
but they are closely related with longevity,
as well as with various pathological condi-
tions. At an intimate level, chronic stress in-
duces cumulative lesional phenomena, with
repercussions extending to the DNA level.
These have micro- and macro- metabolic
consequences – including an increased risk
of developing obesity in the second half of
life – and on the processes of replication/
158
ageing/longevity, as well as the oncogenic
skidding (17), all primarily by:
• oxidative stress (including unbalanced
diet, quantitatively and/or qualitatively)
• increased telomeric activity/metabolism –
with accelerated shortening
• reduction of telomerase activity
A clinical study showed that healthy, pre-
menopausal women who reported the high-
est levels of perceived stress had shorter
telomeres by the equivalent of at least one
decade of additional ageing, in comparison
to those who reported low levels of stress
(18).
To date,there are arround 200 genes,among
which over 150 recently identified, consid-
ered to interfere (whose mutations affect
telomere length) with the telomere metabo-
lism/length: 2/3 shorten and 1/3 lengthen
them; they are generically called “clock”
genes, as they control – in an complex and
sometimes, apparently controversial/dialec-
tical way – ageing and, respectively, longev-
ity.
There is a definite connection between
stress and ageing: by accelerated telomere
shortening – linked with longevity but also
with illness, especially cancer, through telo-
mere length/metabolism.
It has been documented that mental distress
is associated with premature mortality and
increased risk of coronary heart disease, el-
evated blood pressure, type 2 diabetes (19),
and disability, while positive affective states
are protective (20, 21), though the pathways
leading to these effects remain still poorly
understood. Low levels of stress are associ-
ated with lower heart rates, lower cortisol,
lower plasma fibrinogen levels and smaller
fibrinogen stress responses; inversely, high
levels of psychological stress are associated
with accelerated heart rates, higher cortisol
levels (increasing the risk for arterial hyper-
tension and type 2 diabetes), higher plasma
fibrinogen (leading to an elevated risk of
atherosclerosis and ischemic heart disease)
and intense acute phase response (APR)
(20, 21).
The QoL of the elderly in
the contemporary society
Starting, especially with the last quarter of
the past century, there is an international
trend towards connecting and integrating
healthcare/medical assistance with social
care/social solidarity endeavors. As a result,
there emerged the modern idea of provid-
ing and maintaining an adequate QoL for
all society members, including the elderly.
The first decade of this millennium was
dedicated by the WHO, among other sub-
jects, to the QoL.
As a corollary to these contemporary con-
cepts and realities, in 2001, after more than
20 years from its precedent model (The In-
ternational Classification of Impairments,
Disabilities and Handicaps – ICIDH) (22),
and following almost a decade of prepara-
tion, the WHO published The Internation-
al Classification of Functioning, Disability
and Health (ICF-DH) (23).
ICF-DH is an universal, trans-cultural sys-
tem, taking into account not only the medi-
cal/health aspects, but also the social ones
and, thus, it holds a large applicability from
healthcare-related activities (prophylaxis,
medical therapy, rehabilitation, biostatistics,
research,medical management/health strat-
egies) to the ones related to social care and
social policy, environment adjustment and
protection, advocacy – to increase the QoL
and/or legislative measures (including those
related to protection of the individuals with
special needs, social reinsertion, profession-
al/vocational reorientation, etc.).
In conclusion,ICF-DH is designed to allow
through its implementation the syncretic
and integrative analysis and monitoring of
health and well-being states at an individual
level through the use of core sets, as well as
at a population (“macro”) level, by compar-
ing the results of various disability pattern
analysis, between (groups of) statuses from
different pathologic entities.
Statistical reports show that the average
life expectancy of Europeans has increased
over the last few decades (approximately by
0.25 years annually) while their number of
healthy life years (HLY – the lifespan spent
in good health) has remained unchanged
(24, 25). Thus, it can be inferred that the
average lifespan spent in poor health has
been increasing.The European Union (EU)
takes on a significant challenge – to increase
the number of HLY by two years by 2020.
Maintaining a good QoL in elderly, from
the point of view of physical well-being,
entails effective prevention, early detection
(using appropriate assessment tools) and
timely medical treatment of all disorders
that may lead to functional and/or cognitive
decline.
To optimize the social and psychological
well-being of the ageing individual, active
and independent living should be promoted
and extended for as long as possible, so-
cial inclusion should be maximized (e.g.,
by including the elderly in adequate group
activities at the community level) and assis-
tance with daily living should be provided
for those with functional and/or cognitive
impairments.To achieve these goals, educa-
tion/counseling of the patients, community
and healthcare workers may prove helpful;
for example:
• patient and caretaker education/counsel-
ing (information leaflets; e-learning)
• qualification courses on the management
of the elderly, for general practitioners
and specialist doctors
• courses on the psychology of elderly care
• teaching courses for community care vol-
unteers
• qualification courses for nurses/creating
of management teams for elderly home
and/or community care, etc.
However, the current global financial crisis
inevitably alters the quality of life of many
ROMANIAPublic Health
159
individuals, especially of the elderly, mainly
(but not exclusively) its fourth dimension:
the economic one. Under these conditions,
we can only hope that the holistic and ide-
alistic definition of health, adopted by the
WHO more than 65 years ago, will main-
tain its contemporaneity and applicability –
from before the recession – at least in the
more developed countries/economies.
The number of employment opportunities
for people with disabilities tends to decrease
during the economic crisis, leading to un-
wanted increase in the number of individu-
als receiving disability benefits. Moreover,
the ageing phenomenon in the European
population brings about a need for elderly
people to remain professionally active up to
an older age in order to avoid a decline of
productivity coupled with the accumulation
of the financial burden of pensions (24).
The contribution of Physical
and Rehabilitation Medicine
(PRM) to QoL/wellness,
active and healthy ageing
It is clear that the medical field contributes
only partly to the QoL/wellness through its
three types of chrono-interventional mea-
sures:
• primary prophylaxis (elimination or miti-
gation of risk factors)
• secondary prophylaxis – medical therapy
(aimed at preventing complications, re-
lapses and/or chronicization)
• tertiary prophylaxis – medical rehabilita-
tion (aimed at diminishing dysfunction/
chronic disability/invalidity)
• PRM is particularly concerned with the
enhancement of the QoL and a large
array of tools is available, applicable in
order to improve the functional capacity
and related to QoL:
• balneotherapy, climatotherapy, health
tourism
• physical medicine/physiatry, including
kinesiology
• assistive technologies and devices
• rehabilitative care/nursing (RC/N)
The great importance of anti-stress/relax-
ation, active prophylactic, “mise en forme”/
maintenance, rejuvenation/anti-ageing bal-
neotherapy courses in modern society has
already been revealed by the above discus-
sion. Regardless of how healthy individuals
will be after “the new revolution in regen-
erative medicine”, there will remain some
fundamental human behavioral traits whose
optimization will continue to be essentially
necessary.
The main types of methodological sequenc-
es used in anti-stress/wellness balneothera-
py courses are the following:
• techniques, possibly combined of extrin-
sic and especially intrinsic relaxation
• kinetic prophylaxis, mainly targeting:
general optimization of the muscle and
joint function – possibly with some ana-
lytical loco-regional accents (e.g., muscle
and posture rebalance of the cervical
region, associated with contracture re-
laxation in the middle trapezius muscles
for office workers, requiring for several
hours a day monotonous position of the
head – working at the computer with the
eyes focused on the screen or excessive
TV watching), increasing the physical
endurance, and possibly – if required and
no contraindications present – programs
to improve the somatic image, “body for-
mer”/aesthetics of the body
• for the overall objectives of relaxation
and maintenance/“mise en forme”, stated
above, the following are recommended:
land therapy, recreational occupational
therapy and various types and forms of
massage – appropriately, individually pre-
scribed
• various procedures of physiotherapy, in-
cluding water-based, and climatotherapy,
exploiting in a professional manner the
natural physical/chemical therapeutic
agents
• nutritional education and assistance
• individual and group psychotherapy
• health education
• biotrophic treatment (rejuvenation/“anti-
ageing”) general and/or cosmetic (for the
presenescent and elderly)
• alternative procedural sequences, such
as: chromotherapy, aromatherapy, and/or
melotherapy may be used in a comple-
mentary way
It is possible and advisable to combine these
sequences with recreational activities, like
cultural events, tourism and/or sports.
It should also be underlined in this context,
the particular value of sanogenous natural
factors such as: the sedative climate of the
hills, the lack of pollution, including the
phonic one and the aesthetic valences of the
landscape.
All the above recommend balnear resorts –
true “ecologic niches” – as optimal areas for
carrying out anti-(di)stress, active prophy-
lactic/rest, fitness/“mise en forme”/wellness,
maintenance/, rejuvenation (anti-ageing)
therapy courses.
The main Romanian climatic health re-
sorts appropriate for this purpose are:
Călimăneşti-Căciulata-Cozia, Olăneşti,
Govora, Felix, Herculane, Eforie Nord,
Mangalia, Techirghiol, Covasna, Sovata,
Slănic-Moldova, Sinaia, and respectively
Otopeni – the clinical premises of the Na-
tional Institute of Gerontology and Geriat-
rics “Ana Aslan”, Bucharest.
In recent years a modern concept is emerg-
ing, based inclusively on the experience and
many contributions in the field of the Ro-
manian medical school: complex “geronto-
prophylaxis”by physiatric,balnear,hygienic-
behavioral and pharmacological means.The
subject is quite vast, exceeding the current
approach framework. This concept is ex-
tended, incorporating the sustained efforts
to fight on daily basis the distress. Specifi-
cally, it involves daily, dynamic exercises –
tailored based on regular, individual clinical
and functional assessment of the exercise
ROMANIA Public Health
160
capacity, such as running (jogging) and/or
cycling, coupled with a balanced diet (with-
out excesses and avoiding highly processed
aliments) and taking once or twice a year, a
course of anti-(di)stress balneotherapy, last-
ing for 10–14 days.
Corollary of this current synthesis on such
an important subject matter – the strategic
attention of the European Commission
(EC) is to be underlined when considering
“Frailty in old age, a public health concern
at EU level” and, accordingly, supporting
the “European Innovation Partnership on
Active and Healthy Ageing” (EIP-AHA) –
with the involvement of members of the
Action Group on Frailty and Functional
Decline and respectively of the I2
FRESCO
project on integrated interventions for frail-
ty prevention in older people/patients (the
Comité Permanent/Standing Committee
of the European Doctors (CPME), includ-
ing in this field, very contributive, specifi-
cally by the sustained activity of its Working
Group on Active and Healthy Ageing).
References
1. Preamble to the Constitution of the World
Health Organization as adopted by the Inter-
national Health Conference, New York, 19-22
June, 1946; signed on 22 July 1946 by the rep-
resentatives of 61 States (Official Records of the
World Health Organization, no. 2, p. 100) and
entered into force on 7 April 1948
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4. Onose G. Recuperare, Medicină Fizică şi bal-
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6. Guelfi JD. Measuring quality of life. Ann Med
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8. Dunn HL. High-level wellness for man and so-
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9. Rice VH. Theories of Stress and Its Relation-
ship to Health – in: (Part II, Chap. 2) Rice VH
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10. Selye H. Stress and the general adaptation syn-
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11. Selye H. The Evolution of the Stress Concept:
The originator of the concept traces its develop-
ment from the discovery in 1936 of the alarm
reaction to modern therapeutic applications of
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12. Besedovsky HO, del Rey A. Immune-neuro-
endocrine interactions: facts and hypotheses.
Endocr Rev. 17(1): 64-102, 1996
13. Mormède P. Psychobiology of stress and im-
mune functions – in: Puglisi-Allegra S, Oliverio
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1990
14. Pereţianu D, Grigorie D, Onose G – Edit. Co-
ord. Imunoendocrinologie în boli de colagen şi
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15. Rotenberg VS, Schattenstein A.A. Neurotic and
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fect and health-related neuroendocrine, cardio-
vascular, and inflammatory processes. Proc Natl
Acad Sci USA. 102(18): 6508-12, 2005
22. World Health Organization. The International
Classification of Impairments, Disabilities and
Handicaps – A manual of classification relat-
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accordance with resolution WHA29. 35 of the
Twenty-ninth World Health Assembly, May
1976. Geneva, 1980. (http://whqlibdoc.who.int/
publications/1980/9241541261_eng.pdf)
23. World Health Organization. ICF International
Classification of Functioning Disability and
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cifre.it/documenti/icf_18.pdf)
24. Harbers MM, Achterberg PW (eds.). Europe-
ans of retirement age: chronic diseases and eco-
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62 51, implementing Framework Contract No
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jor_chronic_diseases/docs/rivm_report_retire-
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eu/portal/page/portal/statistics/search_data-
base).
Prof. Onose G, MD, PhD, MSc1, 2
,
Univ. Assist. Haras MA, MD, PhD1, 2
,
Prof. Sinescu CJ, MD, PhD1, 2
,
Univ. Assist. Daia CO, MD, PhD1, 2
,
Andone I, MD, Postgrad2
,
Onose VL, MD3
,
Assist. Prof. Capisizu A, MD, PhD1, 4
,
Assoc. Prof. Grigorean VT, MD, PhD1,2
,
Assist. Prof. Ciobotaru C, MD, PhD5,6
,
Sandu AM, MD, PhD2
,
Assist. Prof. Blendea CD, MD, PhD7,8
1 (State) University of Medicine
and Pharmacy “Carol Davila”, Bucharest.
2 Teaching Emergency Hospital
“Bagdasar-Arseni”, Bucharest.
3 Metrorex, the Medical Service, Bucharest.
4 St. Luke Hospital for Chronic Diseases,
Bucharest.
5 Ovidius University, Constanta.
6 County Teaching Hospital, Constanta.
7 Titu Maiorescu University, Bucharest.
8 County Teaching Hospital, Ilfov.
E-mail: geluonose@clicknet.ro
ROMANIAPublic Health
iii
KOREA Environmental Health
The WMA together with other health and medical organizations are
working on the preparation of a second Climate and Heath Summit
in parallel to the official conference.This will provide an opportunity
to share progress on the development and implementation of strate-
gies to build resilience to the impact of climate change on health.
Global Climate & Health Summit that will take place on the 16th
of November, in parallel to the official Conference Climate Change
Conference.
The Summit is co-organised by a range of organizations work-
ing on health and environmental matters, under the auspices of
WHO. The WMA is one of the organizers of the event. Prof. V.
Nathanson (BMA), who is co-chairing the Environment Caucus
together with Dr. DC Shin, will represent WMA at the meeting.
More information: http://www.climateandhealthalliance.org/summit/
summit-programme
UN Climate Change Summit
(http://www.cop19.gov.pl) will take place 11–22 November 2013,in Warsaw
The Environment Caucus was organized
with the purpose of exchanging opinions
among WMA members and related bod-
ies regarding WMA’s future activities re-
lated with “health and the Environment”,
when the working group devoted to the
topic completed its term as of the Council
Meeting in April 2011. Since its first gath-
ering at the 191st
Council meeting in April
2012 (Prague, Czech Republic), about 15
constituent members have participated in
the caucus held in conjunction with WMA
Council Session and General Assembly.
Prof. Vivienne Nathanson of the BMA
and Prof. Peter Orris of the University of
Illinois have been contributing as advisors
and myself is the coordinator. Ms Clarisse
Delorme from WMA secretariat provides
us support.
The main activity of the Environment Cau-
cus is to share global trends and conferences
information regarding environment, to
identify common topics of interest and to
discuss follow-up measures. It aims to share
the various wisdom and experience of each
member and observer and to encourage free
exchange of opinions by adopting such an
informal setting.
Major themes discussed at the Environmental
Caucus with regards to the direction of future
WMA activities include the role of physicians
and of constituent members in greenhouse gas
reduction, promoting research on the health
co-benefits of countering climate change and
expansion of green hospitals and clinics.
The Environment Caucus also monitors
how each member is utilizing the environ-
ment-related policies adopted by WMA and
studies ways of encouraging their utilization.
As a part of such efforts, a survey of mem-
ber NMAs was conducted in 2012. Accord-
ing to the survey results, members agreed
that WMA must continue to take an active
stance in tackling environmental problems.
A wide majority stated that they use WMA’s
environment-related policies in developing
their own policies or in raising awareness
among their members. Constituent mem-
bers expressed the opinion that WMA must
continue to place top priority on climate
change issues and provide guidance on en-
vironmental issues to medical professionals.
The WMA is also expected to set the ex-
ample by making WMA meetings greener.
Based on such feedback, the Environment
Caucus plans to diversify the direction of
WMA’s activities on Environment and as a
first step, to focus on promoting and encour-
aging the increase of green hospitals in each
country. Furthermore, the Caucus would like
to work on a WMA policy on pollution or en-
vironmental degradation from energy sources
by collecting data and conducting discussions.
Korea, an active participant in the Environ-
ment Caucus, established the Korea Society
for Green Hospital last June as the focal point
of information exchange and cooperation for
growth of green hospitals. This Society also
plans to collaborate with international or-
ganizations such as the WMA in the future.
To strengthen the network for Environ-
ment Caucus’ activity, a green page is es-
tablished on the WMA website devoted to
environmental issues, so that environment-
related activities of WMA and each con-
stituent members can be posted and various
information can be shared. We encourage
all members to actively use this section on
WMA website and also eagerly seek your
participation and advice in the future activi-
ties of the Environment Caucus.
Dong Chun Shin, MD, PhD
Prof. Dept. of Preventive Medicine
Yonsei Univ. College of Medicine
Chair, Executive Committee
of International Relations
Korean Medical Association
Activities of Environment Caucus in the WMA
IV
WMA news COUNTRY
Contents
The Globalization and the Role of Medical Professional
Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
EU Health Ministers Need to Agree on Strong Tobacco
Policy and Stop 650,000 Europeans from Dying
Each Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
The European Union and Tobacco Legislation . . . . . . . . . 129
Declaration of Helsinki . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
The Helsinki Statement on Health in all Policies . . . . . . . . 135
Advancing The Global Health Agenda . . . . . . . . . . . . . . . 137
The Chicago Department of Public Health and Healthy
Chicago . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
American Medical Association Inaugurates
New President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Model of Colombian Social Security in Health . . . . . . . . . 143
Myanmar Medical Association (MMA) . . . . . . . . . . . . . . 148
Ethical Principles of the Management of Incidental
Findings in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Experience in Treating Patients in Sylvinite-Halite Mines
of Soligorsk in the Republic of Belarus . . . . . . . . . . . . . . . 152
Basic Wellness Features and Some Rlated Actions
Propensive for Active and Healthy Ageing . . . . . . . . . . . . 155
Activities of Environment Caucus in the WMA . . . . . . . . iii
In the West African Region regulated by
the Economic Community of West African
States (ECOWAS), medical integration is
evolving favourably. (15 countries, 03 lan-
guages – population # 300 million) Recently,
April 3,2015,the Assembly of Health Minis-
ters adopted in Praia (Cape Verde) more doc-
uments to improve the effective integration;
• The Harmonised Codes of Conduct and
Exercise doctors and dentists (applicable
in 2015).
• The Training Curricula General Medicine
• The Curricula harmonized degrees (med-
ical specialties)
In Côte d’Ivoire, after a dozen years of
civil-military crisis marked by an episode of
armed conflict in 2011, the National Order
of Physicians of Côte d’Ivoire (ONMCI)
decided to write a “white paper” on the
Rights and Duties of Physicians face to vio-
lence, in period crisis and armed conflicts in
the exercise of profession.
This book recalls the summary:
1. ”Respecting and protecting health care in
armed conflicts and in areas not covered
by international humanitarian law situa-
tions” – technical specifications ICRC –
International Humanitarian Law in rela-
tion to The Geneva Conventions of 12
August 1949 and their Additional Pro-
tocols developed June 8, 1977, with the
duties and expectations of physicians.
2. The general guidelines of the World
Medical Association (WMA) in crisis
and armed conflicts.
3. The Code of Conduct (WMA): Duties
of physicians in crisis and armed conflicts.
4. The position of the World Medical As-
sociation Statement on Violence in the
Health Sector on the part of patients
and people close.
The characteristic of this book (A5) which
will be freely available to the Physicians
is that it contains several testimonials
from doctors and family doctors victims
of these sad events in the life of the Na-
tion. Particular emphasis was placed on
the prevention of violence by reactivating
Security Observatory of Physicians in the
course of their professional practice; struc-
ture that will be responsible for identifying
all the verbal and physical abuse, by mak-
ing available medical Corps as a whole
inspired questionnaire of our colleagues
from the College of Physicians of France
fighting this unfortunate phenomenon in
their country.
The West African region is unfortunately
not preserved by other episodes of crises
and armed conflicts which is why the Na-
tional Order of Physicians of Côte d’Ivoire
(ONMCI) will make this book available
to the West African Health Organization
(WAHO) for translation in English and
Portuguese for the 15 countries of the re-
gion.
Dr. AKA Kroo Florent
President of National Council of the Order
Physicians in Côte d’Ivoire
Medical West African
Region
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