14th issue of JDN NL_P2

Junior Doctors Network
Newsletter
Index
Working conditions and
leadership education: the
topics of JDN Meeting in
Riga …………………………. 1
Report from WMA
European Region Meeting
on End-of-Life Questions 4
A report of the WMA
African region meeting on
End-of-Life Questions
hosted by the Nigerian
Medical Association in
Abuja, Nigeria from
February 1-2, 2018…….. 7
Report from the WMA JDN
preWHA 2018 …………… 9
JDN at the 2018 Spring
Meeting of the European
Junior Doctors Permanent
Working Group …………. 11
Global surgery: a new and
emerging field in global
health? …………………….. 12
A Word from the Chair . 17
Opportunities to talk to
doctors around the world
across generations …….. 18
Members of the Junior Doctors
Network (JDN) of the World
Medical Association (WMA)
gathered for their April 2018
Meeting in Riga, Latvia, hosted by
the Latvian Medical Association
(LMA). The meeting took place on
April 25, 2018, at the LMA
premises in Riga, prior to the
209th Session of the WMA
Council also attended by JDN
representatives. Around 15 junior
doctors coming from Turkey,
France, Germany, the United
States of America, Lebanon,
Kuwait, Italy, Brazil, Nigeria,
Japan, Canada, Greece, Latvia,
and the United Kingdom
(European Junior Doctors
Association – EJD representative),
attended the meeting and
discussed current topics of interest
to junior doctors globally, as well
as relevant WMA policies to be
addressed at the Council Session
and forwarded for adoption at the
next WMA General Assembly
(GA) in Reykjavik, later this year.
The meeting started with a
welcome speech by the JDN
Chair, Dr. Caline Mattar, who
welcomed everybody to the Riga
meeting and briefly presented the
meeting agenda, offering
background information especially
to newcomers. Each participant
then took the floor and introduced
themselves, presenting their role
October, 2018
14th issue
ISSN (print) 2415-1122
ISSN (online) 2312-220x
Picture 1. Participants at the JDN Riga Meeting 2018 with the WMA leadership.
Working conditions and leadership education:
the topics of JDN Meeting in Riga
Konstantinos Roditis, MD, MSc*
within JDN and/or the junior
doctors’ organization in their
respective countries, as well
as their expectations from the
meeting.
Interestingly, as both the
WMA Council Session and
GA are organized in Europe
for the year 2018, special
attention was given by the
participants to certain junior
doctors’ issues in Europe. The
discussion was further
enriched by the introduction
given by Dr. Kitty Mohan,
President of the European
Junior Doctors Association
(EJD) who was also present as
a guest at the meeting,
followed by the
representatives of the Latvian
Junior Doctors Association,
who presented the challenges
they are facing both in their
post-graduate medical
education and training, along
with exhausting working
hours and unsatisfactory
working conditions.
The meeting was honored by
the presence of WMA
leadership, namely Prof.
Yoshitake Yokokura, WMA
President, Dr. Ardis Hoven,
WMA Council Chair, and Dr.
Otmar Kloiber, WMA
Secretary General, who all
greeted the participants,
wishing them a fruitful
meeting and great outcomes,
and at the same time
welcomed JDN at the 209th
WMA Council Session. All
participants were then split
into three small working
groups and addressed the
following topics, under the
WMA leadership:
1. Building regional
collaborations (Dr.
Yokokura) – The CMAAO
example and Japan
leadership role in its
development were
mentioned, with emphasis
in the historical
background and current
progress. Dr. Yokokura
also presented on the
Chinese-Japanese medical
association and its
evolvement throughout
the years, as an example
of regional partnership
between neighboring
countries. He then
received questions by the
participants, specifically
on how he envisions the
role of smaller,
underdeveloped nations in
the proceedings of such
regional collaborative
initiatives.
2. Healthcare systems
reforms – Primary
healthcare (PHC) and the
role of other health
professionals (Dr. Kloiber)
– A presentation was given
on challenges arising from
introducing nurse
practitioners and
pharmacists into PHC
structures, followed by
discussions on the
alienation between doctors
and patients due to super-
specialization in medicine,
certain PHC reforms and
decapitation of physician
care (being paid per
capita), the introduction of
pharmacies in super
markets and shopping
malls, as well as the
prescription of
medications and
diagnostics by non-
physicians and on the
related WMA position.
3. How to engage people to
work in a certain field (Dr.
Hoven) – Emphasis was
given on the example of
the WMAAssociate
Members targeting public
health physicians and
medical ethics experts and
the role of emotional
influence in increasing
individual commitment to
collaborative work by Dr.
Hoven.
The next point in the agenda
was a brainstorming session
(splitting into smaller groups)
tackling:
-Structure of JDN meetings
(facilitators: K. Roditis and
A. Fontaine)
-JDN membership (facilitator:
C. Mishima)
A workshop led by Dr. Yassen
* Resident, Department of Vascular
Surgery, Korgialeneio-Benakeio
Hellenic Red Cross Hospital,
Athens, Greece / Chair, JDN-
Hellas / Secretary, Junior Doctors
Network , World Medical
Association
roditis.k@gmail.com/
secretary.jdn@wma.net
2
Picture 2. JDN participants socializing at a Riga pub.
Cholakov on Climate Change
followed. First, he offered a
brief presentation on United
Nations Framework
Convention on Climate
Change (UNFCCC) history of
climate change, mentioning
health in negotiations, working
towards the Paris Agreement
and the role of WMA in
climate change policy / JDN’s
contribution (revision of the
Delhi Declaration).
Participants then were once
again split into smaller groups
and went through the National
Determined Contributions
(NDC) interim reports of all
different signatory countries,
as listed on http://
www4.unfccc.int/ndcregistry/
Pages/All.aspx. Then, there
was a discussion about health,
air pollution, healthcare
resilience, and nutrition in the
reports, addressing various
reasons why these topics were
not mentioned. Further ways
of engaging WMA’s National
Medical Associations (NMAs)
into contributing more
resources to Climate Change
talks were also explored at the
end of the workshop.
As the JDN meeting had no
central theme this time, the
participants focused on several
issues the JDN is currently
working on, mainly the work
being done within JDN’s
working groups (WG).
The future of JDN’s WG on
Working Conditions
monopolized the discussion,
starting with a brief
introduction given by Dr.
Caline Mattar on the work
completed so far by the WG.
All participants were engaged
in suggesting ways of moving
forward with the WG, in terms
of producing actual results and
achieving specific goals.
Approaching possible partners
from the Academia,
conducting a well-designed
survey on working conditions
among JDN members in
different world regions,
creating an online platform for
the referral of violations of
working conditions by JDN
members, writing an
introductory article on existing
working conditions regulatory
systems around the globe to be
published in the World
Medical Journal, organizing
solidarity campaigns to
support our colleagues in
countries with challenging
working conditions, were
among the ideas mentioned by
the participants.
The meeting concluded with a
Leadership in Healthcare
3
Picture 3. JDN participants at the Opening Reception of the 209th WMA
Council Session.
Picture 4. JDN participants in front of the Livonian medieval Castle,
joining the post-meeting tour in the Latvian countryside town of Cecis.
workshop, offered by Drs.
Greg Radu and Paul Kneath
Jones, both experts in running
leadership workshops in
international conferences
worldwide. The participants
received a comprehensive
presentation on different
leadership theories and ways
and tools to build a strong
leadership profile in healthcare
settings.
All in all, the meeting was a
success for JDN, as the
participants had the chance to
meet again with colleagues
from all over the world,
exchange ideas, build strong
connections, and enjoy the
Latvian culture, cuisine, and
nightlife! At this point, we
would all like to thank our
Latvian hosts for their
hospitality, with our special
thanks going out to Ms. Maira
Sudraba, who was always
there to accommodate us. The
next rendez-vous for the JDN
members will be the JDN
Annual Meeting, taking place
in Reykjavik, Iceland in
October 2018. Until then…
The World Medical
Association (WMA) European
Region Meeting on End-of-
Life Questions was held in the
Vatican on November 16-17,
2017, which was hosted by the
German Medical Association
in collaboration with the
WMA and the Pontifical
Academy for Life in the
Vatican. This event included a
series of regional workshops
that focused on dynamic
discussions on euthanasia and
physician-assisted dying and
its ethical dilemmas relating to
end-of-life issues. The
discussion was first started in
Oslo, Norway, in April 2015,
in the 200th
WMA Council
Session, where WMA
reaffirmed the “WMA
Declaration on Euthanasia”. It
was then followed by the
regional meetings in Tokyo,
Japan in September 2017, the
Vatican in November 2017,
and Abuja, Nigeria in
February 2018.
The End-of-Life discussions
seemed particularly important
in the European region,
because a variety of
standpoints and legal settings
towards euthanasia or
physician-assisted suicide
(PAS) were observed among
the European countries.
Referring to the result of
questionnaires from 19 Asian
countries at the End-of-Life
symposium in Tokyo, Japan,
in September 2017, the
majority of Asian countries
showed negative attitudes
toward “active euthanasia”.
Furthermore, it was implied
that the way of religion or the
view of life are involved in
thinking and decision-making
processes for end-of-life care
4
Picture 5. JDN folks having a great time at the 209th WMA Council
Session Reception.
Report from WMA European Region Meeting on End-of-Life Questions
Maki Okamoto, MD*
* Deputy Chair, Japan Medical As-
sociation Junior Doctors Network
(JMA-JDN)
deputychair_internal@jmajdn.jp
in Asia. In contrast with this
trend in Asian countries, the
European region had different
religious backgrounds, and
each country had its own
perspectives about euthanasia
or PAS. This emphasized the
fundamental significance of
having a regional conference
in Europe and attracted
attention from all participants
in the Vatican. For this two-
day conference, European
medical professionals, legal
authorities, experts in
palliative care and medical
ethics, theological scholars
and philosophers were all
gathered in the Vatican,
debating end-of-life questions
from different perspectives.
The discussion first began
with providing the setting and
perspectives from the WMA
as well as the country where
the euthanasia or PAS is
allowed. Professor Dr.
Montgomery, the president of
the German Medical
Association, spoke about the
perspectives from the WMA.
Despite the fact that the
practice of active euthanasia
with physician assistance has
been legalised in some
countries, the WMA strongly
encourages all National
Medical Associations and
physicians to refrain from
participating in euthanasia,
even if the national law allows
or decriminalizes it. On the
other hand, Dr. René Héman
took part in showing the
viewpoint from the
Netherlands, where euthanasia
is authorized under certain
conditions. The six due care
requirements for euthanasia
are as follows; 1) There is a
voluntary and well-considered
request; 2) There is an
unbearable suffering and no
prospect of improvement; 3)
The patient is informed about
the situation and future
prospects; 4) There is
conviction that no other
reasonable solution for the
patient’s situation is available;
5) One other independent
physician is consulted; and 6)
Termination of life or assisted
suicide is performed with due
care. In addition to these
requirements, there is no
obligation for physicians to
perform euthanasia, and it
relies on the physician’s
compassion. However, it is
still not a simple pathway, and
physicians who perform
euthanasia also experience
intense psychological
suffering. Dr. Yvonne Gilli,
from the Swiss Medical
Association, presented the
current situation of assisted
suicide in Switzerland. She
indicated that the number of
assisted suicides in
Switzerland has increased
from 2% to10% over the past
15 years (2000-2014). She also
stated that the use of
continuous deep sedation as a
treatment method in end-of-
life-care has also increased
substantially in recent years.
Additionally, she mentioned
the importance of organizing
the end-of-life-care guidelines
especially for the palliative
sedations, as well as
reconsidering the importance
of physicians conversing with
patients about this delicate
decision.
The second part of the
conference was based on
theological views. Ethical
specialists interpreted the
Catholic, Jewish, and Islamic
perspectives by providing
different interpretation of
death. Dr. Daniela Mosoiu, an
experienced palliative care
physician from Romania who
has dedicated her work in
hospice, presented real clinical
cases from her practice. Most
of the patients were suffering
from the anxiety of not
knowing what to do. In
addition, patients, families,
and health professionals
collectively suffer. However,
the important element is to
provide “curing” and
“healing” for patients, where
“curing” refers to the
physiological reconstruction of
the physical body, and
“healing” refers to mainly
mental meanings, such as
inner peace, forgiveness,
removal of stigma, and
elimination of social barriers.
Transformation of suffering,
acquaintance with one’s death,
and gratitude and worship are
essential keys to achieve
“healing”.
The third part of the
conference was related to laws
or delineating euthanasia and
PAS, which was presented by
Professor John Keown,
Professor Dr. Volker Lipp, and
Dr. Laurence Lwoff.
Euthanasia, defined as
intentionally killing another
person in order to relieve this
person’s suffering, is divided
into three sub-groups: 1)
voluntary, or a person who
follows the person’s will; 2)
non-voluntary, or a person
incapable of making decisions
(such as coma, mentally
retarded or dementia); 3)
involuntary, or a person who
5
“I will stand in front of him, behind him and next to him,
when he needed my care.”
wants to live but was killed.
While PAS is defined as
suicide with assistance of a
physician, there is also another
context that has become
widely accepted in principle,
such as “letting die”, defined
as limiting, terminating, or
withholding life-sustaining
treatment because it is futile or
according to the patient’s will.
In terms of criminal law, most
European countries, except the
Netherlands, Belgium, and
Luxembourg, ban all forms of
euthanasia. The Netherlands
allows non-voluntary
euthanasia of terminally ill
newborn babies. In countries
such as Switzerland or
Germany, PAS is legal under
certain conditions, while
euthanasia is banned in those
countries. However, these
definitions of each term
overlap in many ways, and we
have a variety of conditions in
laws, religions, histories,
cultural backgrounds or
patients’ conditions, which
make the discussion over
euthanasia and PAS more
challenging. Some highlighted
that the discussions regarding
the decision-making processes
are as follows: How can we
define the patient as incapable
to decide or who is to decide
for them? How can we deal
with the will of patients with
dementia or senility? How can
we decide whether or not to
withdraw fundamental life
support (such as hydration or
nutrition) compared to medical
life-prolonging treatments?
In the latter half of the
conference, the discussions
moved to the theme regarding
compassionate use and
conscientious objections, the
right to determine one’s own
death, and choice of treatment
limitations as an alternative to
euthanasia. Many specialists
from all backgrounds were
gathered to openly discuss
these topics. Roughly
estimated, the number of
people euthanized each year in
the Netherlands is set to
exceed 7,000, and it rose 67%
from five years ago. The
number of persons receiving
euthanasia in Belgium is
estimated to be as high as
4,000 each year. However, it
means that approximately half
of all requests were granted,
and the other half of all
requests were denied. This fact
implies that more alternatives
are available before selecting
the ultimate choice such as
euthanasia or PAS. Professor
Dr. Leonid Eidelman, from the
Israeli Medical Association,
presented the clinical case of a
patient who was suffering
from intensive back pain and
shouted for someone to kill
him. However, after he was
treated with continuous
infusion of anesthesia to his
spine, his pain was relatively
cured, which produced a smile
and allowed him to travel
around the world before he
died. This case suggests the
importance of reconsidering
this possible treatment as an
end-of-life-care measure. Dr.
Anne de la Tour, a palliative
care physician from France,
explained the possibility of
deep and continuous sedations.
Patients who live in countries
that do not allow euthanasia or
PAS, can also be free from
unbearable pain through deep
and prolonged sedation
continued until death.
However, this measure must
be conducted within the legal
authorization, when a patient
is in the terminal phase and
suffers from a serious and
incurable life-threatening
condition.
The discussion over euthanasia
and PAS will never end. As
more people, especially from
western Europe, are in favor of
PAS, it is important to provide
patients with many different
choices and let them choose
what they are willing to
receive. At the same time, it is
more important to discuss end-
of-life care, build up the
system, and provide correct
information about all treatment
options to the public. As
physicians, we must think
about how we can dedicate
ourselves to people who are
suffering from terminal
illnesses. As such, the
conference was concluded
with this symbolic phrase: “I
will stand in front of him,
behind him and next to him,
when he needed my care”.
6
As part of the efforts of the
World Medical Association
(WMA) to generate open
regional discussions on the
dilemmas related to End-of-Life
issues, particularly with respect
to palliative care, euthanasia, and
physician-assisted suicide, the
WMA Council meeting held in
Livingstone, Zambia, in April
2017, encouraged the African
region of the WMA to organize
an African Regional meeting on
End-of-Life issues.
As such, the Coalition of African
Medical Associations authorized
the Nigerian Medical Association
to host the WMA African Region
Meeting on End-of-Life issues.
This WMA African Region
meeting on End-of-Life issues
(palliative care, euthanasia, and
physician-assisted suicide) was
hosted by the Nigerian Medical
Association in Abuja, Nigeria,
from February 1-2, 2018.
This meeting was born out of the
need for the WMA to generate
discussions and assess the scope
of the dilemma facing doctors in
different cultural domains. The
WMA aimed to better understand
the problem in order to
adequately address related
policies in the future. This was
one of the four WMA End-of-
Life meetings organized in the
Asia-Pacific, Europe, Latin
America, and Africa regions.
The End-of-Life meeting, which
held at the Transcorp Hilton
Hotel and Towers, Abuja,
promoted the theme, ”An
Excursion into the End-of-Life
Spectrum: Defining the
boundaries between Palliative
care, Euthanasia, and Physician
assisted suicide”. The Secretary
General of the WMA, Dr. Otmar
Kloiber, attended and presented
the WMA policy on End-of-Life
issues. Other dignitaries in
attendance were the presidents
and delegates of the National
Medical Associations from
Nigeria, Zambia, Kenya, South
Africa, Cote D’Ivoire, and
Botswana.
Activities conducted during the
meeting included the welcome
cocktail, formal opening
ceremony, scientific sessions
with presentations by various
guest speakers on End-of-Life
issues, breakout technical
sessions, local tourism activities,
and closing dinner.
The formal opening ceremony
was chaired by the Senate
President of the Federal Republic
of Nigeria, Senator Dr. Bukola
Saraki, who was represented by
Senator Dr. Lanre Tejuosho,
while the Honourable Minister of
Health, Professor I.F. Adewole,
represented the President of the
Federal Republic of Nigeria,
Muhammadu Buhari GCFR.
During the meeting, numerous
discussions focused on palliative
care, euthanasia, and physician-
assisted suicide with several
observations:
1) There is no specific policy or
legislation on euthanasia and
7
A report of the WMAAfrican region meeting on End-of-Life Questions
hosted by the Nigerian Medical Association in Abuja, Nigeria from
February 1-2, 2018
Ndiokwelu Chibuzo, MD, MWACP*
* Nigerian Medical Association /
West African College of Physicians /
Communications Director, Junior
Doctors Network, World Medical
Association / Member, West African
College of Physicians
thaemm2@gmail.com
Picture 1. Dr. Enabulele Osahon, past president Nigerian Medical
Association; Dr. Othmer Kloiber, WMA Secretary General; and Prof.
Ogirima Mike, Nigeria Medical Association.
physician-assisted suicide in
Africa.
2) Few countries, like Nigeria,
Zambia, Kenya, Uganda,
South Africa, and Botswana,
have policies, guidelines, and
practices on palliative care.
3) In the African culture,
tradition and religion, life is
held sacred, and families
never abandon their loved
ones at the End-of-Life period.
4) Palliative care as a concept
is generally accepted in the
African culture, tradition, and
religion.
5) Involvement of physicians
in euthanasia and physician-
assisted suicide is frowned on
as it is viewed as contradictory
to medical ethics and the
physicians’ pledge.
6) There is a low level of
awareness on End-of-Life
issues among African
populations and health
professionals.
7) There is a dearth of
standard health care systems
and medical personnel
equipped to deliver palliative
care.
8) There is a high poverty rate,
poor access to affordable,
equitable and quality health
care, and poor access to
palliative care in most African
countries.
Finally, the meeting ended
with some resolutions to guide
the WMA in further
discussions as they relate to
the African region.
1) African National Medical
Associations (NMAs) are
unanimously opposed to
euthanasia and physician-
assisted suicide in any form.
2) African NMAs support
policies and legislations
permitting and strengthening
palliative care.
3) African NMAs, non-
governmental organizations
(NGOs), and other agencies or
institutions need to embark on
enlightenment and advocacy
campaigns to government,
policy makers, and the general
public on the importance and
availability of palliative care.
4) There is great need to
strengthen African health
systems, promote universal
health coverage, improve
budgetary allocation to health
services, and integrate
palliative care and other
chronic medical conditions
into the health financing and
insurance schemes of African
countries.
Acknowledgements
Nigeria Medical Association, Report
of the WMA African region meeting
on End-of-Life Questions in Nigeria,
January 2018
8
Picture 2. A cross section of
delegates at the meeting.
Picture 3. WMA Secretary General on a sight-seeing trip to see the
Zuma Rock.
The Junior Doctors Network
(JDN) organized its annual pre-
World Health Association
(WHA) meeting on May 19-20,
2018, at the World Medical
Association (WMA) offices in
Ferney-Voltaire, France.
At WHA71, delegates engaged
in deep conversations with Dr.
Maria Neira, WHO Director of
the Department of Public
Health, Environmental and
Social Determinants of Health,
on issues related to
environmental health and
climate change. Many
highlighted the potential
leadership role that the WHO
could take in front of other
United Nations’ (UN) agencies
and organizations on issues of
climate change and air pollution.
The conversation even boldly
suggested that the WHO should
use its treaty-making powers to
create a Framework Convention
on (un)Clean Air in the near
future.
Thereafter, delegates worked on
issues related to nutrition and
noncommunicable diseases
(NCDs) and had the chance to
interact with an expert panel,
including Ms. Jess Beagley,
Policy Research Manager at the
NCD Alliance, Mr. Jack Fisher,
past Executive Director of NCD
Free, and Dr. Francesco Branca,
WHO Director of the
Department Nutrition for Health
and Development. Delegates
discussed the third High-level
Meeting of the General
Assembly on the Prevention and
Control of NCDs, how food
policy is different than policy on
other NCD risk factors, and how
to examine conflicts of interest
when engaging with the private
sector in health interventions.
Lastly, Ms. Diah Satyani
Saminarsih, WHO Advisor on
Gender and Youth, presented
the new WHO vision to be
adopted through the 13th
General Programme of Work
(GPW13), under the leadership
of Dr. Tedros Adhanom, WHO
Director-General.
Additionally, the WHO
organized the first-time event,
“Walk the Talk”, as a walk/run
activity around Geneva to
promote healthy lifestyles and
physical activity. PreWHA
delegates participated in the
event, by walking or running the
8.6km distance, while some
finished the race hand in hand
with Haile Gebrselassie,
multiple Olympic and World
Champion long distance runner
and world record holder.
Lastly, all delegates attended the
briefing for delegates to the
WHA organized by the Geneva
Graduate Institute. After
* Socio-Medical Affairs Officer,
Junior Doctors Network, World
Medical Association
yassentch@gmail.com
9
Picture 6. Dr. Othmer Kloiber,
Secretary General WMA; and
Dr. Tanko Sununu, Secretary
General, Nigerian Medical
Association wearing local
traditional attire.
Picture 4. Arrival at the airport. Picture 5. Smiles at the
closing dinner.
Report from the WMA JDN preWHA 2018
Yassen Tcholakov, MD, MSc*
Picture 1. Briefing session for
delegates at the Geneva
Graduate Institute.
learning about the GPW13
and WHA procedural rules,
they gained insight on four
important WHO topics, such
as the polio transition, health
emergencies, pandemic
influenza preparedness plan,
and nutrition.
While the preWHA agenda
has varied from those of
previous years, the JDN’s
participation in external
events organized by the WHO
has helped foster engagement
and communication with other
groups with similar interests.
10
Picture 4. JDN session on Environmental Health with Dr. Maria
Neira at WMA Offices.
Picture 3. Alice McGushin, JDN
delegate to WHA, crossed the 8.6km
run finish line with Haile
Gebrselassie, multiple Olympic and
World Champion long distance
runner and world record holder.
Picture 2. JDN delegation ready to participate in the “Walk the Talk:
The Health for All Challenge”.
The Junior Doctors Network
(JDN) was invited to the 2018
Spring meeting of the European
Junior Doctors Permanent
Working Group (EJD), which
was held at the “Andrija
Štampar” School of Public
Health at the University of
Zagreb in Zagreb, Croatia, from
May 4-5, 2018. I attended this
meeting on behalf of the JDN
membership.
All meeting hosts, including Dr.
Kitty Mohan, the EJD President,
and the Management team,
developed a high-quality
program agenda and positive
networking environment for
conference participants.
Participants included members
of the European Junior Doctors
Associations and other invited
guests. The opening ceremony
addressed “Employment and
Free Mobility”, and was
attended by top Croatian
government officials and the
Croatian Medical Association
leadership. Interactive panel
discussions and meeting
sessions provided opportunities
for participants to elaborate on
this topic. Coordinated social
events incorporated formal and
informal networking dinners as
well as a collective walk around
the ancient City of Zagreb that
we experienced with a rain
shower.
In addition to my participation
and contribution to different
panels and sessions, I had the
opportunity to introduce the
objectives and mission of the
JDN, describe our structure
within the World Medical
Association (WMA), and
mention our past and current
professional activities. In
fostering our existing
collaborations, I stressed the
commitment of the JDN in
partnering with the EJD in areas
of mutual interest. For example,
as one mutual interest is the
Working Group on Junior
Doctors’ working conditions,
Dr. Kitty Mohan joined the JDN
Working Group on Working
Conditions.
As JDN members, we believe
that the collaboration with the
EJD is one that should be
nurtured and encourage future
relationships with other regional
Junior Doctors Organizations.
* Deputy Chair, Junior Doctors
Network, World Medical
Association / Member, West
African College of Physicians
ccoreah@gmail.com
11
JDN at the 2018 Spring Meeting of the European Junior Doctors
Permanent Working Group
Chukwuma Oraegbunam, MBBS, MWACP*
Picture 1. Cross section of delegates to the 2018 EJD Spring Meeting.
Picture 2. (Left to Right) Dr.
Kitty Mohan, EJD President;
Dr. Chukwuma Oraegbunam,
JDN Deputy Chair; Dr. Ellen
McCourt, former UK Junior
Doctors Committee Chair.
“Global Surgery”, what’s
in a name
Global Surgery was described by
The Lancet Commission on
Global Surgery (LCoGS) in 2015
as “a field that aims to improve
health and health equity for all
who are affected by surgical
conditions or have a need for
surgical care.”(1) In 1980, Dr.
Halfdan Mahler, then the acting
director-general of the World
Health Organization (WHO),
described adequate surgical care
as a key factor in achieving
health care for all.(2) However,
outbreaks of communicable
diseases like the human
immunodeficiency virus (HIV)
and tuberculosis (TB)
overshadowed the need for
affordable surgical care, and
consequently, global surgery had
been neglected until the start of
the 21st
century.(3)
Currently, an estimated 5 billion
people have no access to timely
and adequate surgical care, and
this is responsible for the deaths
of 17 million people annually
predominantly in low- and
middle-income countries
(LMICs) and the poorer wealth
quintiles in all countries.(1) Each
year, 401 million Disease
Adjusted Life Years (DALYs)
are lost due to inadequate
surgical care, compared to 214
million DALYs lost in the same
time period for HIV, TB, and
malaria combined.(4) DALY is a
measure of population health,
and it calculates the relative
impact of a certain disease
category on the overall burden of
disease for a population. It
combines the Years of Life Lost
(fatal burden of disease) with the
Years Lost to Disability (non-
fatal burden of disease), and is
the preferred metric to analyse
and compare the burden of
diseases.(4) The global health
community is starting to realise
that we need to address this
alarming situation.(1,4)
Traditionally, week-long surgical
missions and provision of money
used to be the answer, but now
there is an appreciation that a
broader focus and a need for a
different approach are necessary.
(3) Currently, five key players
are shaping this changed
approach: the LCoGS, the World
Bank, the WHO, Harvard
Medical School (HMS) and the
G4 Alliance, which is the Global
Alliance for Surgical, Obstetric,
Trauma, and Anaesthesia Care.
(1,5–8)
The World Bank challenged the
LCoGS in 2014 to produce
consensus-based indicators to
evaluate progress in surgical care
delivery in LMIC.(9) The
LCoGS responded in 2015 by
producing a report, Global
Surgery 2030, in which they
outlined an approach through
investigation, innovation, and
implementation.(1) To monitor
the universal access to safe,
affordable surgical, anaesthesia,
and obstetric care (SAO) care,
the LCoGS used six core-
indicators: access to timely
essential surgery; specialist
surgical workforce density;
surgical volume; perioperative
mortality rate; protection against
impoverishing expenditure; and
protection against catastrophic
expenditure.(1)
However, to implement this new
approach, the LCoGS was in dire
need of other partners. The
World Bank started collaborating
with the global surgery systems
and included the six indicators in
their new World Development
Indicators dataset in 2016.(6,9)
Additionally, they included
global surgery in their latest
Disease Control Priorities
publication in 2015, attributing a
whole volume to the topic.(4)
Around the same time, HMS
started an initiative, the Program
in Global Surgery and Social
Change, to strengthen global
surgical systems through
advocacy, research, and
implementation science based on
the LCoGS’ six indicators.(5)
The WHO has been involved in
the field of global surgery since
12
*1 University Children’s Hospital
Queen Fabiola, Department of
Pediatric Surgery, Brussels,
Belgium
*2 University of Khartoum, Faculty
of Medicine, Khartoum, Sudan
*3 Universidad Nacional
Experimental Francisco de Miranda,
Dr. Augusto Diez General Surgery
Residency program, Coro, Falcón,
Venezuela
*4 Muhimbili University of Health
and Allied Sciences, Department of
Epidemiology and Biostatistics, Dar
Es Salaam, Tanzania
*5 Humanitas University, Faculty
of Medicine and Surgery, Rozzano,
Milan, Italy
*6 KU Leuven, Faculty of
Medicine, Leuven, Belgium
Correspondence: Manon Pigeolet
manon.pigeolet@outlook.com
Global surgery: a new and emerging field in global health?
Manon Pigeolet, MD, MA(candidate)*1
, Sara A.M. Alam Eldeen, MD*2
, Antonio R. Reyes Monasterio,
MD*3
, Godfrey Sama Philipo, MD, MPH*4
, Irene Schirripa, MD(candidate)*5
, Jef Van den Eynde, MD
(candidate)*6
2005, through their Global
Initiative for Emergency and
Essential Surgical Care
(GIEESC).(7) One of their
main achievements is the
development of the Surgical
Safety Checklist, which aims
to decrease errors and adverse
events, and increase teamwork
and communication in surgery.
(4,7) In light of the
negotiations of the new set of
Sustainable Development
Goals, in May 2015, the WHO
underscored the idea that
universal health coverage must
include SAO care, and
reemphasized this view in
their 13th
general program of
work 2019-2023, adopted at
the 71st
World Health
Assembly in May 2018.(7,10)
And last but not least, to
advocate for the neglected
surgical patient, a fifth party,
the G4 Alliance was formed in
2014: a coalition of more than
85 of the world’s leading SAO
care organisations. They aim
to provide a united call for
access to safe, essential, and
timely SAO care.(8)
However, even if the problem
has been clearly outlined by
the LCoGS, important
strategic challenges have
emerged in setting global
surgery as a political priority
both at the local and
international levels. The global
surgery community is a very
fragmented one, with its first
challenge being governance.
(11) There is still no consensus
about how guiding institutions
can facilitate collective
actions, and more importantly
which institutions should take
on this leading role.(11) This
lack of guidance has led to a
lack of process on defining
shared solutions on agreed
problems; that is, agreement
on the fact that surgical care is
neglected but there is
disagreement on what level of
essential surgical care should
be provided.(11) Lastly, one of
the biggest challenges is that
public opinion tends to
misinterpret the cost-
effectiveness of surgery, with
many thinking it is a luxury
when, instead, it is a very cost-
effective tool to fight non-
communicable diseases,
maternal and child health
issues, and injuries among
others.(11–13)
We need to overcome these
challenges to ensure collective
action for equal access to
surgical care around the world.
As indicated above, global
surgery is an evolving
discipline acting on the
frontier between clinical
surgery, public health, and
global politics. Many of the
challenges ahead can only be
tackled if representatives from
these different fields unite and
work together in an
interdisciplinary manner on
the local, national, regional,
and international levels.
InciSioN: uniting the
future global surgeons,
anaesthesiologists and
obstetricians of the
world
With growing attention for
global surgical and anaesthesia
care, and with many medical
curricula lacking attention for
global surgery and anaesthesia
care, the need for an
association where global
surgery enthusiasts could
discuss and take action
together became a pressing
issue. Out of this need, and
under the wings of the
International Federation of
Medical Students’
Associations, the International
Student Surgical Network
(InciSioN) was born as an
informal group in 2014 and
became a fully established
independent organization in
2016. InciSioN is an
international non-profit
organisation, comprised of
medical students, residents,
and young doctors from
around the world, who work
together to educate on,
advocate for, and perform
research in global surgery.
InciSioN consists of an
international core team
charged with overseeing the
projects and activities done
under the InciSioN flag
globally, and an international
Board of Trustees, guiding the
13
Picture 1. Surgical Interns at AIC Kijabe Hospital in Kenya.
work of the core team. The
actual work on the ground is
done by 2,800 members
globally, working in over 20
national working groups
spread all over the world. For
their advocacy efforts, they
have often collaborated with
the G4 Alliance, and for their
research efforts, previous
collaborations included the
GlobalSurg 1 and 2 (14–21)
research initiatives, and
reporting about basic surgical
indicators worldwide.(22) A
multitude of events have been
organised by InciSioN,
including trainings and
conferences, with their latest
event being the International
Global Surgery Symposium
(IGSS2018) this May in
Leuven, Belgium.(23)
IGSS2018 at a glance
IGSS2018 brought together
over 200 global surgery
enthusiasts from over 45
different countries
representing all different
continents.(24) Another
impressive achievement, and
unfortunately still a rarity at
global surgery conferences,
was the creation of travel
scholarships by IGSS through
which they were able to
welcome 11 international
scholars coming from various
LMICs. Each and every one
of those 11 scholars are true
leaders in the field of global
surgery and made IGSS2018
truly global, creating
opportunities to discuss,
exchange, and interact
between the attendees. The
conference programme had a
wide range of speakers,
including Dr. Walt Johnson
(Director of GIEESC at the
WHO), Dr. Kathleen Casey
(from the G4 Alliance), and a
number of practicing SOA
specialists from around the
world. The conference was
energetic and motivated the
attendees to work towards
improving surgical and
anaesthesia care globally.
Below is a short overview of
the topics discussed.
• Trauma is making its way
up in the burden of
disease statistics, with a
projection of 7 million
deaths worldwide due to
injuries by 2030.(25) This
will be a clear challenge
to come for LMICs and its
SAO providers. The lack
of human resources for
health to address this issue
was emphasized by Dr.
Basem Higazy from the
WHO, who stressed the
dire need of trained health
personnel, in particular
SAO providers in LMICs.
• Various speakers touched
upon the need for
adequate surgical training
in LMICs. The newly
established surgical
training programme by the
College of Surgeons of
East, Central and Southern
Africa in 15 African
countries remains one of
the most important
achievements in this field.
• Technology is also finding
its way into surgery in
LMICs. For example,
Lifebox has developed a
super-resistant pulse-
oximeter that is usable for
both adult and pediatric
patients in low-resource
settings. It has been
developed in collaboration
with WHO and adapted to
local needs in LMIC. It is
resistant to power outages
up to 14 hours and
unstable electric current,
water-resistant and thanks
to its protective case also
resistant to falls from
heights.(26) Peer-support
programmes where
interventions can be
followed and discussed
live via social media are
finding their way into the
operating room.
Inexpensive virtual reality
headsets, like Google
Cardboard or open source
programs such as Touch
Surgery, create local
possibilities to improve
the surgical skills of
residents in LMICs.
• However, there is no safe
surgery without safe
anaesthesia. The World
Federation of Societies of
Anesthesiologists and
Lifebox talked about the
critical need for
anaesthesia providers
worldwide. LMICs have a
low anaesthesia provider
rate (this includes general
physicians providing
anaesthesia) ranging
between 0.19 and 6.89 per
100,000 population,
compared to an average of
17.96 for the high-income
countries.(27) Or when
put in a more general
context of SAO-provider
rate, low-income countries
achieve an average of 0.7
and lower-middle-income
countries an average of
5.5 both per 100.000
population.(28) These
numbers remain far below
the LCoGS Global
Surgery 2030 objective of
20 SAO-prividers per
100.000, which aims to
strengthen the specialist
surgical workforce
density. The essential role
of anaesthesia in the
provision of surgical care
is not always well
understood by decision
makers, and as a
consequence,
development of
anaesthesia care has often
been given a lower
priority than the
development of surgery
per se.(29) Lack of
14
infrastructure and
equipment for anaesthesia
provision in LMICs
worsens this situation.
• The conference concluded
by briefly touching upon
the topic of women in
global surgery. Gender is
increasingly being
discussed during
conversations about human
resources for health.
Female health workers tend
to compensate for the
shortcomings of many
healthcare systems around
the world, at times at the
expense of their own health
and well-being.(30) Many
of these female health care
providers do this in an
informal setting, where
they are poorly supported
and poorly paid or not paid
at all.(31) When looking
specifically at women in
surgery, the LCoGS,
estimates there are only
around three females
surgeons for every one
million people in low
income countries. (32)
IGSS2018 a formula for
success?
Congresses such as IGSS2018
have great potential to be a
driving force for global
surgery. As with any
movement, having some
organisations and activities at
the basis is essential to foster
action and to provide a means
for the diffusion of ideas.
IGSS2018 emphasised the
inclusion of participants
regardless of gender, ethnicity,
professional titles, or country
of work. A diverse range of
speakers represented the
diverse range of countries and
realities that the topic covers.
The atmosphere in which
IGSS2018 took place was one
of equity regardless of gender,
race, or professional titles. A
funding program was even
arranged to cover the traveling
costs of the 11 international
scholars. Speakers came from
all over the world, so that the
countries and realities that we
were talking about were
actually represented in the
symposium itself. IGSS2018
was a home for alike thinking
people to share their
experiences, learn from each
other’s stories, and to motivate
each other to take on new
endeavours. Specialists,
residents, and students all had
the opportunity to build new
contacts, drawing the
blueprints for future
collaborations. With
confidence, we can say that
IGSS has given rise to new
projects: some participants
have created new InciSioN
National Working Groups after
returning back to their home
country, others have been
inspired to do research in the
field of global surgery, and
people already involved in the
field saw the influence of their
work confirmed.
We believe that IGSS2018
provided an excellent example
for many more symposia to
come: the combination of an
international audience, diverse
and enthusiastic speakers, and
a shared passion. The general
thought permeating the whole
congress was that global
surgery is an important,
recently revived, rapidly-
evolving, and exciting field
that more than deserves greater
attention, a thought to which
we certainly subscribe to.
Conclusion
Global surgical debt and
access to safe surgery is an
aspect that not only concerns
the doctors of LMICs, but also
surgeons and doctors in high-
income countries and doctors
advising health policies around
the world. We are hopeful for a
time when the geographical,
political, or socio-economic
circumstance of a person will
not affect access to safe,
essential, and timely surgical
care. We are a generation that
has the responsibility to do
what others could not do in
past decades. We live in a time
where the platform for global
surgery has been established in
the global health arena, and we
have an abundance of
opportunities at hand to create
a world where surgical care
will be truly accessible for all.
We would like to acknowledge the
following people for their
contributions towards the writing of
this article. Hanne Gworek
(Belgium), Megan E.H. Still (Texas,
USA), Sebastiaan van Meyel (The
Netherlands), Florence Van
Belleghem (Belgium), and Falke Van
Winckel (Belgium).
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16
More than half way through this term, it is time
for us to reflect once more on the achievements
our Network has accomplished, and to set sight
on the future.
We have continued to grow, and now the JDN
comprises members from over 70 countries and
counting. Standardization of our processes, re-
porting and terms of reference has been com-
pleted. We have a newly revamped newsletter,
whose quality reflects the enthusiasm, profes-
sionalism and hard work of a dedicated publica-
tions and management teams. Our Strategic
Plan, through a lengthy and comprehensive con-
sultative process, is now complete and ready for
approval. We have worked to strengthen our
collaboration with Regional Platforms. We are
proud of our engagement with the European
Junior Doctors Permanent Working Group, and
are looking forward towards building bridges
with other regions around the world.
On the external front, we have continued our
engagement on Climate Change, and Antimi-
crobial Resistance, among others, and we have
strengthened our position as a Global Actor ad-
vocating for Human Resources for Health, as
well as the role of physicians and Junior Doc-
tors in the provision of Primary Care services.
We are now a full member of the World Federa-
tion for Medical Education’s Council, and we
look forward to further contributions to various
Global advocacy issues.
The Junior Doctors Network this year celebrat-
ed its 7th
anniversary. This adventure started in
2010 in Vancouver, and has continued to grow
exponentially. Every day, more young doctors
are joining the JDN to connect with colleagues
and work towards matters of interest to them
locally and nationally, but also current issues in
the global health realm.
Once more, I would like us to remember the
mission we set for our network to: “Empower
young physicians to work together towards a
healthier world through advocacy, education
and international collaboration”.
I would like to thank the management team, and
each and every one of you who has spent time
and effort for the advancement on our network
this year. This tremendous work would not have
been possible without your dedication.
Please remember that the JDN team is always
open to your suggestions and feedback,
Looking forward to meeting many of you in
Iceland,
17
A Word from the Chair
Caline S. Mattar, MD
Chair, Junior Doctors Network,
World Medical Association
Dear colleagues from around the world,
18
Opportunities to talk to doctors around the world
across generations
Kazuhiro Abe, MD
Publications Director, Junior Doctors Network,
World Medical Association
I am pleased to present the 14th issue of the
Junior Doctors Network (JDN) Newsletter to
junior doctors around the world.
The 13th
issue of the JDN Newsletter was pub-
lished by the JDN in April 2018. For the first
time in two years, it was also released on the
World Medical Association (WMA) website
and mailing list. We were very pleased that our
dedicated efforts to promote this high-quality
scientific product were acknowledged. I believe
that the JDN newsletter should empower criti-
cal analysis and reflection on essential global
health topics among junior doctors around the
world. In addition, I expect that the JDN
Newsletter will be a catalyst to encourage com-
munication between WMA and JDN members
as well as between national medical associa-
tions and junior doctors in each country across
generations.
This 14th
issue includes thought-provoking arti-
cles prepared by junior doctors about their com-
munity health initiatives and experiences. I
hope that these articles will add value and in-
sight for all readers.
In publishing this issue, I sincerely express my
appreciation for the outstanding efforts of all
editors of the JDN publications team, officials
of the JDN management team, and leaders of
the WMA. Please enjoy the articles published
in this 14th
issue.
Dear JDN colleagues,
Caline S. Mattar, MD
Chibuzo Ndiokwelu, MD
Helena Chapman, MD, PhD, MPH
Konstantinos Roditis, MD, MSc
Mariam Parwaiz, MB ChB, MPH (Hons)
Mineyoshi Sato, MD
Ricardo Correa, MD, EsD
Wunna Tun, MBBS, MD
(alphabetical order)
Editors in the Publications Team 2017-2018
* The JDN Publications Team requests volunteers to assist with editing article submissions and
checking English grammar. If you are interested in this opportunity, please feel free to email our
team at jdn-publications@googlegroups.com.
The Junior Doctors
Network (JDN) is made up
of junior doctors who
independently join the
World Medical Association
(WMA) as Associate
Members, although many
are also representatives of
their respective National
Medical Associations.
Its mission is:
“Empowering young
physicians to work together
towards a healthier world
through advocacy, education
and international
collaboration”.
Junior Doctors Network
Newsletter
14th issue
ISSN (print) 2415-1122
ISSN (online) 2312-220x
Published by the Junior
Doctors Network, World
Medical Association on
October, 2018.
Opinions expressed in this
newsletter do not necessarily
reflect WMA and JDN
policy or positions.
Contact:
jdn@wma.net
Junior Doctors Leadership 2017-2018
Japan
Kazuhiro Abe
Publications Director
Caline S. Mattar
Chair
Lebanon
Chukwuma Oraegbunam
Deputy Chair
Nigeria
Konstantinos Roditis
Secretary
Greece
Yassen Tcholakov
Socio-Medical Affairs Officer
Canada
Audrey Chloe Fontaine
Education Director
France
Sydney Chileshe
Medical Ethics Officer
Zambia
Chiaki Mishima
Membership Director
Japan
Chibuzo Obiora Ndiokwelu
Communications Director
Nigeria
19
Ahmet Murt
Immediate Past Chair
Turkey
Paxton Bach
Immediate Past Deputy Chair
Canada