wmj27

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, Inc
G20438
Nr. 3, June 2010
WMA Secretary General’s Report to 185• th
Council
The History of the Placebo•
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
Emiliano Di Cavalcanti, Maternidade –
“Motherhood”, 1942, Oil Painting.
Emiliano Augusto Cavalcanti de Albuquerque
Melo (1897 – 1976), known as Di Cavalcanti,
was a Brazilian painter. He in 1926 adopted the
national issue as the main theme of his work,
specially the social problems. As a defensor
of figurative art, in 1942 he paints the picture
Motherhood. At that time he also positions
himself against the abstrac art that is starting to
grow in Brazil.
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Dr. Dana HANSON
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Members
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Israel Medical Assn
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Dr.Torunn Janbu
WMA Chairperson of the Medical
Ethics Committee
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Norway
Prof. Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
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Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. José Luiz
GOMES DO AMARAL
WMA Chairperson of the Socio-
Medical-Affairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP
Brazil
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
87
WMA news
Policy & Advocacy
1.1 Multi Drug Resistant
Tuberculosis Project
During the third phase of the Lilly
MDR-TB partnership we finalised the
TB refresher course for physicians and
launched it during the GA 2009 in Delhi.
The purpose of the TB refresher course
is to set the baseline for basic knowledge
on the subject, with the existing Multi-
Drug Resistant TB course providing more
advanced knowledge. However, because
the refresher course was developed after
the more advanced MDR-TB course, the
layout of the MDR-TB required some
adaptation to conform more closely with
the layout of the refresher course. The TB
refresher course was nominated by the
United States Centre of Disease Control
(CDC) as educational highlight. Over
time, both courses will be translated into
different languages.The Georgian Medical
Association kindly offered to translate the
TB refresher course.
To increase the outreach of our TB and
MDR TB educational activities WMA
held train-the-trainer courses in TB and
MDR-TB based on the 2 existing train-
ing materials in South Africa and India. In
April of this year, WMA and the Chinese
Medical Association (ChMA) organised
a third workshop in Hangshuang with the
help of the Chinese Thoracic Society. Thirty
leaders of TB hospitals from all over Chi-
na took part in the training and will pass
on their knowledge to their colleagues. In
China, TB hospitals and CDC Centres are
the only facilities that treat TB patients.The
government and the provincial health de-
partment honoured the activities of WMA
and ChMA.
The WHO is in the final process of devel-
oping a policy on ethics in the TB setting,
and will launch the policy during a confer-
ence and workshop in Athens just prior to
the 185th
Council Session in Evian. The
WMA was invited to address the issues in
the policy related to health professionals
and Dr. Jeff Blackmer from the Canadian
Medical Association kindly offered to draft
Secretary General’s Report
(October 2009-April 2010) to 185th
Council
88
WMA news
this part of the policy, which addresses the
duty to treat, risks, and obligations to pa-
tients. It also elaborates obligations related
to facilities, patient support, training and
supervision as well as capacity building.
While there are many TB programmes and
activities taking place in English speaking
parts of Africa, there is far less involvement
by French speaking areas in international
humanitarian activities related to
TB. During the Lilly MDR-TB
Partnership meeting in Mexico,
a workshop was organized to
increase activities in this part of
the world and connect the part-
nership members with the na-
tional governments, WHO and
local NGOs. During the meet-
ing WMA, together with the
International Council of Nurses
(ICN), International Hospital
Federation (IHF) and Interna-
tional Committee of the Red
Cross (ICRC) decided to con-
tinue their series of inter-pro-
fessional workshops on health
care worker safety and infection
control in the context of drug
resistant TB. A third workshop
will be organised in Benin in
June 2010, involving health pro-
fessionals from Burkina Faso,
Mali, and Senegal, Through this
workshop we hope to engage our
francophone African Members
more and try to connect with or-
ganisations in other countries.
1.2 Tobacco project
The WMA joined the imple-
mentation process of the WHO
Framework Convention on To-
bacco Control (FCTC) http://
www.who.int/tobacco/framework/
en. The FCTC is an international
treaty that condemns tobacco as an
addictive substance, imposes bans
on advertising and promotion of
tobacco,and reaffirms the right of all people to
the highest standard of health.The first inter-
national treaty negotiated under the auspices
of the WHO, the FCTC entered into force
in 2005.It is the most widely embraced treaty
in UN history, with 168 signatories and 154
ratifications to date.
WHO FCTC held a workshop on Article
14: “Measures Concerning Tobacco De-
pendence and Cessation” in New Zealand
in February 2009 to finalise the draft article
for the next Conference of the Parties in
November 2010. The New Zealand Medi-
cal Organisation participated in this meet-
ing on behalf of WMA.The working group
stated again how important physicians are
in the cessation, support and the education
of patients.Therefore, countries should em-
phasize smoke free health care settings in
which physicians and other health profes-
sionals can serve as role models.
1.3 Health Workforce
WMA continues its close involvement in
the Positive Practice Environment Cam-
paign (PPE). This global 5-year campaign
– spearheaded by World Health Professions
Alliance members together with the World
Confederation for Physical Therapy and the
International Hospital Federation – aims to
ensure high-quality workplaces for quality
care. The first activities on a country level
started in Uganda, Morocco, Zambia and
Taiwan. A national PPE secretariat was set
up to link the national member organisa-
tions and develop cooperation with the
government. National researchers began
conducting studies about the working con-
ditions of health professionals. The first is-
sue of the newsletter reporting the various
activities of the campaign was circulated in
February. A workshop bringing together
national/local health professionals took
place in Zambia last March, with others to
follow in Morocco, Uganda and Taiwan. In
April, a website was launched and the PPE
Campaign was highlighted during the Ge-
neva Health Forum 2010, on the occasion
of the parallel session on retention strate-
gies for health professionals.
The Dutch Royal Tropical Institute or-
ganised a conference on Human Research
for Health in Amsterdam in March 2010.
Dr. Julia Seyer was invited to present the
PPE campaign. During the conference the
advantages and disadvantages of decentrali-
sation of health care and health care educa-
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WMA news
tion were discussed and a special focus was
placed on how to assure quality of care and
education.Another discussion point was the
financing of national health care systems.
None of the international and multilateral
donors report how much money from verti-
cal programmes is allocated to human re-
sources in health and to education. Money
that is not reported money cannot be moni-
tored and managed.
The participants of the Seminar in Reykja-
vik on Human Resources for Health and
the Future of Health Care last year defined
ideas to facilitate WMA policy develop-
ment in this area. The WMA Advocacy
Working Group has considered the oppor-
tunity to collect best practices.Task shifting
remains as a monitoring item of the Work-
ing Group.
In March 2009, WMA was invited to take
part in the planning process of the next
Conference on Workplace Violence in
the Health Sector, which is scheduled
to take place from 27-29 October, 2010
in Amsterdam. The event is supported by
the Global Health Workforce Alliance
(GHWA), WHO, International Labour
Organisation (ILO), the International
Council of Nurses (ICN), Public Servic-
es International (PSI) and other relevant
health organizations.
WHO is in the final stage of the develop-
ment of guidelines on retention strategies
for health professionals in rural areas. The
objective is to attract and retain
health care professionals in rural
areas.Theguidelineswillbebased
on three pillars: educational and
regulatory incentives, monetary
incentives and management,
environment and social support.
Decision makers on the national
and local levels and health fa-
cilities should receive evidence
on the impact and effectiveness
of various retention strategies
that have been tried and tested.
In November 2009 WHO, to-
gether with the Asian-Pacific
Action Alliance on Human
resources for Health (AAAH),
held a conference to discuss with
governments in Asia this topic
in general and, in particular,
how the guidelines need to be
adapted to be better accepted by
governments.
WMA participates as a member
of steering groups in two proj-
ects commissioned by the Euro-
pean Union on the Mobility and Migra-
tion of Health Professionals. One project
is led by the European Health Care Man-
agement Association and the other by the
Research Institute of the German Hart-
mann Bund, a private physicians organiza-
tion. The general objective of the research
projects is to assess the current trends in
mobility and migration of health profes-
sionals to, from, and within the European
Union, including their reasons
for moving. Research will also
be conducted in non-European
sending and receiving coun-
tries, but the focus lies within
the EU. This research project
is a medium-scale collaborative
project with a goal of facilitat-
ing informed policy decisions
on health systems by develop-
ing a scientific evidence base re-
lated to the impact of mobility
of health professionals.
In January 2011 the Global Health Work-
force Alliance will organise the 2nd Global
Forum on Human Resources in Health
(HRH) in Thailand. WMA is part of the
thematic focus committee for this event. In
an initial meeting, two main themes were
proposed: improving quantity and quality
of health workforce for equitable access to
primary health care within a robust health
system and financing HRH in the light of
the global financial crisis.
1.4 Counterfeit Medical Products
Counterfeit medicines are manufactured
which are below established standards of
safety, quality and efficacy. They are delib-
erately and fraudulently mislabeled with
respect to identity and/or source. Counter-
feiting can apply to both brand name and
generic products and counterfeit medicines
may include products with the correct in-
gredients but fake packaging, with the
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WMA news
wrong ingredients, without active ingredi-
ents, or with insufficient active ingredients.
Counterfeit medicinal products threaten
patient safety, endanger public health
by increasing the risk of antimicrobial
resistance, and undermine patients’ trust in
health professionals and health systems.The
involvement of health professions is crucial
to combating counterfeit medical products.
WMA and the members of the WHPA
developed the “be aware” toolkit for health
professionals and patients to increase
awareness of this topic and provide practi-
cal advice for actions to take in case of a sus-
pected counterfeit medical product.WHPA
is stepping up its activities on counterfeit
medical issues with an educational grant of
Pfizer Inc. and Eli Lilly. The toolkit will be
updated based on the input of the national
member organisations of the alliance. A
mission and NGO briefing was organised
in collaboration with WHO and IMPACT
in March and a workshop in either Africa
or Asia is being planned. Here
we would like to ask our mem-
bers to inform us of possible
national events where we could
link in a combating counterfeit
medical products event. WHPA
developed a statement on coun-
terfeit medical products, setting
principles for procurement, dis-
tribution and reporting of coun-
terfeit medical products.
1.5 Alcohol
In May 2008, the World Health Assembly
adopted a resolution requiring WHO to in-
tensify its work to curb harmful use of alco-
hol and to develop a global strategy for this
purpose. The resolution requests the WHO
Director-General to consult with intergov-
ernmental organizations, health profession-
als, nongovernmental organizations, and
economic operators regarding ways in which
they can contribute to reducing the harmful
use of alcohol. In January 2010,
the WHO Executive Board
126th Session passed the resolu-
tion on “Strategies to reduce the
harmful use of alcohol” which
recommends to the 63rd
World
Health Assembly (May 2010)
the adoption of a resolution en-
dorsing the global strategy.
As an implementation measure
of the WMA Statement on Re-
ducing the Global Impact of
Alcohol on Health and Society,
the WMA secretariat moni-
tors the drafting process of the
WHO strategy, informs WMA
members on a regular basis of
developments in this area, and
has developed contacts with rel-
evant WHO officials and civil
society organisations to collabo-
rate in the process. Such activi-
ties include:
•  On  23  October  2008,  the 
WMA Advocacy Advisor,
Ms. Clarisse Delorme, moderated an
NGO briefing on reducing the global
harm caused by alcohol, organised by
GAPA (Global Alcohol Policy Alliance).
The objectives of the briefing were to un-
derstand the WHO process related to the
strategy, to begin discussions on substan-
tive and political proposals to promote an
effective, evidence-based global strategy,
and, finally, to develop further working
relations between civil society actors in-
volved in this area.
On 24 November 2008, Dr. Otmar Kloi-• 
ber and Ms. Delorme, participated in the
WHO roundtable meeting with repre-
sentatives of NGOs and health profes-
sionals on ways they could contribute
to reducing harmful use of alcohol. This
was an opportunity to raise, amongst oth-
ers issues, WMA’s desire that medical as-
sociations and individual physicians be
fully involved in the WHO strategy on
alcohol.
As a follow-up to this, Ms. Delorme, to-• 
gether with George Hacker from GAPA,
met with several Permanent Representa-
tives (Denmark, Sweden, Norway, Chile,
South Africa, US, New Zealand) in Ge-
neva to discuss countries’ positions and
involvement within the WHO regional
consultative process on the draft strategy.
During the 126•  th
Session of WHO Ex-
ecutive Board, Ms. Delorme made a
public statement on behalf of the World
Health Professional Alliance supporting
the strategy and recommending more
91
WMA news
attention to the pivotal role that health
professionals can and do play in terms of
education, advocacy and research.
WMA sponsored•  an alcoholpolicybrief-
ing, which took place on 20 April in Ge-
neva during the Geneva Health Forum.
The briefing was organised by GAPA and
other relevant civil society actors.
WMA members are encouraged to sup-• 
port the adoption of WHO draft strategy
by the World Health Assembly in May
2010.
1.6 Public Health
In 2007 Governments requested WHO
to prepare a Global Action Plan on Non-
Communicable diseases (NCD), based on
the Global Strategy that was amended at
the WHA in the year 2000.
The Global Strategy Action Plan aims to:
(i) map the emerging epidemics of NCDs
and analyse their social, eco-
nomic, behavioral, and political
determinants; (ii) reduce the
level of exposure of individuals
and populations to the common
modifiable risk factors; and (iii)
strengthen health care for people
with NCDs by developing stan-
dards and guidelines for cost-ef-
fective interventions and by ori-
enting health systems to respond
more effectively in managing
NCDs. To increase the aware-
ness and the commitment of
governments and NGOs,WHO
organized the First NCDnet
Global Forum in Geneva in
February 2010.
1.7 Patient safety
WHO stepped up its commit-
ment on patient safety and de-
fined it as a major global prior-
ity in health care. To deliver safe
health care, clinicians require
training in the discipline of pa-
tient safety,which includes an understanding
of the nature of medical error; how clinicians
themselves can work in ways that reduce
the risk of harm to patients; techniques for
learning from errors; and how clinicians can
harness quality improvement methods to
improve patient safety in their own organi-
zations. WHO responded to this need by
publishing the Patient Safety Curriculum
Guide for medical schools, and is now un-
dertaking a major consultation
exercise to develop a Multi-pro-
fessional Patient Safety Curricu-
lum Guide. WMA is member of
the reviewing committee for the
multi-professional guidelines.
1.8 Health care systems
Primary health care
The WMA advocacy workgroup
plans to develop an advocacy
brief on Primary Health Care, as a tool
to influence decision-makers at the na-
tional and international level and for raising
awareness on this matter.
Global Charter on Health Data
Global health systems face the challenges of
delivering high quality,accessible care under
increasing budgetary pressure. Health data
have a critical role to play in improving the
quality, accessibility and efficiency of health
services – and, therefore, an important role
in ensuring that health systems continue to
improve. However across all health systems
there are situations in which accurate health
data are not available.The lack of availabili-
ty and access to health data can result in un-
safe or ineffective services or lead to a waste
of resources. The World Economic Forum
organizes a working group to develop and
define the principles of a Global Charter
on Health Data. The WMA represents the
physicians’ and patients’ perspectives in this
working group and demands the anonymity
and aggregation of data and the right of the
patient’s ownership of the data.
Relationship between Physicians and Com-
mercial Enterprises
The International Federation of Pharma-
ceutical Manufactures and Associations
IFPMA invited Dr. Julia Seyer to present
the revised WMA Statement concern-
ing the Relationship between Physicians
and Commercial Enterprises during their
92
WMA news
committee meeting in February this year.
IFPMA would be pleased to start a dia-
logue again with WMA to exchange codes
of conduct and share information and ex-
periences.
1.9 Health and the environment
The WMA Workgroup on Health and
the Environment, chaired by the Canadian
Medical Association, was established in the
summer of 2008. For 2009, the workgroup
agreed to focus its attention on health and
climate change in view of the global United
Nations conference on this topic in Copen-
hagen in December 2009. For 2010, the
workgroup decided to continue its advocacy
work on climate change in the context of
the UNFCCC process and also to develop
a proposed policy paper on environmental
degradation and the built environment.
Climate change
In January 2009, the workgroup produced
a set of recommendations, which were ap-
proved by the 182nd
Council session in May
2009. A WMA conference on health and
climate change took place on 1 Septem-
ber, 2009 in Copenhagen, with a view to
further development of WMA recommen-
dations,based on the contributions from in-
vited experts. Following further revision of
the recommendations after this conference,
the WMA resolution was approved by the
Council at its pre-Assembly meeting and
then adopted (as the Delhi declaration) by
the 2009 General Assembly.
Immediately after the General Assembly,
the WMA secretariat prepared an advoca-
cy kit for its national member organisations.
Based on the new WMA policy adopted,
medical associations were invited to lobby
relevant national decision-makers for a
health perspective to be included in the fi-
nal official conclusions of the UN Climate
Change Conference 2009 (COP15) which
took place in Copenhagen in December
2009.
Furthermore, the Danish Medical Associa-
tion represented the WMA at the COP15
– as part of the delegation headed by the
Health and Environment Alliance (HEAL)
and Health Care Without Harm (HCWH).
The delegation, composed of health leaders
and representing a diversity of medical and
public health organizations,emphasized the
fact that climate change profoundly impacts
on human health. The DMA acted on the
basis of the WMA Delhi Declaration and
in cooperation with other NGOs acting in
the same area.
As a follow-up to the COP15 (Bonn and
Mexico conferences in 2010), the Work-
group on Health and the Environment has
developed an advocacy strategy for WMA,
with the aim of supporting members as-
sociations in lobbying their governments
to place health at the core of international
climate change debate and to increase the
medical community’s voice as an important
stakeholder in climate discussions.
Mercury
Following the adoption by the 2008 Gen-
eral Assembly of the WMA Statement on
Reducing the Global Burden of Mercury,
WMA joined the UNEP Global Mercury
Partnership in December 2008 in order to
contribute to the partnership goal to protect
human health and the global environment
from the release of mercury and its com-
pounds.
With the support of Health Care With-
out Harm, an information session on the
Mercury-Free Health Care initiative was
held during the General Assembly 2009.
Health Care Without Harm1
and the
World Health Organization are co-leading
this global initiative (partnership) to achieve
virtual elimination of mercury-based ther-
Health Care Without Harm (HCWH): Global1.
coalition of 473 organizations in more than 50
countries working to protect health by reducing
pollution in the health care sector – http://www.
noharm.org.
mometers and sphygmomanometers over
the next decade and substitute them with
accurate, economically viable alternatives.
Mr. A.K. Sengupta, National Professio-
nal Officer (Sustainable Development &
Healthy Environment) from the WHO
India Country Office presented activities
undertaken in this area, with a focus on
activities in India. This information session
constituted concrete follow-up to the adop-
tion of WMA Statement on Reducing the
Global Burden of Mercury.
In early March, Ms. Clarisse Delorme met
with representatives of the Mercury Part-
nership to explore stronger involvement of
the WMA in UNEP’s mercury initiatives.
Options discussed included the opportunity
to make health professionals more vocal in
the context of the current drafting process
of a global legally binding instrument on
mercury. Another strategic approach for
WMA would be to target manufacturers of
products that contain mercury. WMA and
its members could have an impact in reduc-
ing supply of these products through lobby-
ing and awareness-raising actions.
Chemicals management
In December 2009, the WMA secretariat
was approached by the Chemicals Branch
of the United Nations Environment Pro-
gramme (UNEP) in the context of the
development of a Strategic Approach to
International Chemicals Management
(SAICM). The SAICM, adopted in 2006,
is a multi-sectoral and multi-stakeholder
policy framework aimed at promoting the
sound management of chemicals and haz-
ardous waste in the context of sustainable
development. In 2009, the International
Conference on Chemicals Management
requested the development of a strategy
for strengthening the engagement of the
health sector in the implementation of the
Strategic Approach, in consultation with
WHO. The SAICM secretariat is therefore
willing to engage medical associations in
the process.
93
WMA news
Based on this resolution, the SAICM sec-
retariat prepared a questionnaire for the
health professionals’ community to evalu-
ate the engagement of the health sector
in the management of chemicals. WMA
secretariat circulated the questionnaire to
WMA members. A summary of responses
obtained were compiled and made available
on SAICM website.
A consultative meeting was then organised
on the 4–5 February in Ljubljana, Slov-
enia. Dr. Dong Chun Shin, from the Ko-
rean Medical Association, and member of
WMA workgroup on Health and Environ-
ment, represented WMA at the meeting.
1.10 Human Rights
Right to health
The WMA was actively involved in the
preparation of the joint Seminar on the
“Right to Health as a Bridge to Peace in
the Middle East”, which took place on 27-
30 October 2009 in Turkey. The seminar
was organised by the International Federa-
tion of Health and Human Rights Organi-
sations (IFHHRO), the Norwegian Medi-
cal Association (NMA), the Human Rights
Foundation of Turkey (HRFT), the Turk-
ish Medical Association (TMA) and the
WMA. The objectives of the meeting were
to discuss what role the medical profession
can play in securing equal access to health
care for the population and to facilitate
communication among health professionals
in the participating nations.
During the reporting period, the WMA
secretariat maintained contact with Anand
Grover, the UN Special Rapporteur on
Health to increase the role of health profes-
sionals in the promotion of the human right
to the highest attainable standard of health.
Physicians & patients in distress worldwide
In November 2009, the WMA secretariat
sent to Iranian President, Mahmoud Ah-
madinejad, and to the Iranian Minister of
Health, the WMA Resolution adopted in
Delhi supporting the rights of patients and
physicians in the Islamic Republic of Iran.
In the accompanying letter signed by WMA
President Dr.Dana Hanson,the Iranian au-
thorities were asked to take urgent actions
in conformity with Medical Ethics Princi-
ples and with International Human Rights
Law principles.
During the same period, the WMA secre-
tariat sent the WMA Resolution on Leg-
islation against Abortion in Nicaragua to
the President of The Republic of Nicaragua,
the Minister of Health, and the President
of the Parliament. In February, the WMA
secretariat was made aware by Amnesty In-
ternational of a case in Nicaragua in which a
woman with metastatic cancer was reported
to be denied adequate treatment, as she was
10 weeks pregnant. Doctors felt unable to
act because of the law prohibiting abortion,
although the woman gave her consent for
the cancer treatment. A second letter was
therefore sent to the Minister of Health
reiterating the conclusions of the WMA
resolution on this topic and reaffirming that
health of the patient should be the priority
of physicians. The letter also expresses seri-
ous concerns that doctors might be unable
to proceed with treatment of their patients
because of fear that the anti-abortion law
could be used to prosecute them.
Prevention of torture
In November 2009, Ms. Clarisse Delorme
attended as an elected member the council
session of the International Rehabilita-
tion Council for Torture Victims (IRCT),
which took place in Nairobi. During that
session, she was elected member of the Ex-
ecutive Committee and therefore attended
the Excom meeting in February in Copen-
hagen. It is hoped that this new position
will allow WMA to develop more actively
its work on torture prevention. It should
also allow the IRCT to integrate more sys-
tematically the perspective of health profes-
sionals in its activities.
On the 9th
of March 2010, the WMA and
IRCT organised a joint side-event at the
occasion of the Human Rights Council,
13th
Session entitled “Exploring sustain-
able ways to document torture – The role
of health professionals”. The event was
94
WMA news
moderated by Manfred Nowak, UN Spe-
cial Rapporteur on torture. Dr. Poul Jaszc-
zak from the Danish Medical Association
and members of the Danish Rehabilitation
Council, presented WMA’s policies and
highlighted the role that physicians and
medical associations can play in torture
prevention. Other speakers included repre-
sentatives from the Turkish Medical Asso-
ciation, the UN Subcommittee on the pre-
vention of torture and the Association for
the Prevention of Torture (APT). A press
release “Physicians call for effective measure
to document torture allegations” was issued
on this occasion.
Women and health
In October 2009 in Delhi, the WMA
workgroup on violence against women
and children (VAWC) met for the first
time. The workgroup is composed of the
Ethiopian Medical Association (chair), the
Canadian Medical Association, the British
Medical Association, the American Medi-
cal Association, the Israel Medical Associa-
tion, the Indian Medical Association, and
the ICRC. Dr. Barbara Roberts participates
in the WG activities as an advisor. During
the reporting period, the group worked on a
draft resolution on violence against women
and girls as well as on a proposed revision of
WMA resolution on family violence.
On the 5th
of February, the WMA and
the International Federation of Gynaecol-
ogy and Obstetrics (FIGO) issued a joint
press release to mark the International
Day of Zero Tolerance to Female Geni-
tal Mutilation (FGM) on February 6. The
two organisations strongly condemned the
medicalisation of female genital mutilation
and underlined the unique role that health
professionals can play in working towards
the elimination of FGM to ensure that girls
and women enjoy the full extent of human
rights and freedom.
Early March, the WMA was consulted on
a draft Global strategy against health care
providers performing female
genital mutilation prepared by
WHO, UNICEF and UNFPA.
This strategy is part of the imple-
mentation process of the WHO
resolution on the eradication of
FGM adopted in 2008. WMA
workgroup on violence against
women and children made com-
ments on the draft that were
then forwarded to the WHO
secretariat in charge.
1.11 Ethics
At the General Assembly 2008,
the Declaration of Helsinki was
amended.At that time the debate
had a strong focus on the use of
placebo in medical research. If
a proven effective intervention
exists, the Declaration of Hel-
sinki allows the use of placebo
controls, though only in very
limited circumstances. However
this opening raised some con-
cerns. In order to analyze the
use of placebos in medical research a WMA
working group was installed. The working
group invited a number of renowned ex-
perts to discuss the issue at a conference
held in Sao Paulo, Brazil in February this
year with the help of the Brazilian Medical
Association.
During the conference it became clear that
the current version of the Declaration ad-
dresses the issue of placebo controls quite
well. However, recent research on placebo
use provides a much broader and complex
view on the role of placebos in medical re-
search then we had before.
Furthermore it was acknowledged that the
same ethical questions might arise with any
control group that receives a treatment less
then the “best current proven intervention”
(which is currently required by the Declara-
tion).The overriding question of the placebo
controversy now appears to be: “To what ex-
tent and under which circumstances is it eth-
ically acceptable to provide a control group
with an intervention less effective than the
“best current proven one” in a clinical trial.
This includes a placebo control as well as a
control with a second standard or no treat-
ment.This problem is aggravated by the fact
that in many circumstances we do not know
for sure which is the “best proven”treatment.
This work has been scientifically supported
by the WMA Cooperating Centre, Insti-
tute of Ethics and History of Medicine at
the University of Tübingen, Germany.
1.12 Speaking book
The WMA launched the speaking book
on clinical trials during the General As-
sembly in Seoul 2008. This project was a
collaborative effort with the South African
Medical Association, the SADAG (South
African Depression & Anxiety Group)
95
WMA news
and the Steve Biko Centre for Bioethics in
Johannesburg and the publisher “Books of
Hope”. The speaking book on clinical trials
in English-Hindi & Telugu was launched
at the 2009 General Assembly in India.The
purpose of the project is to provide proper
information on clinical research to illiterate
populations so that they can make informed
decisions about participation. The project
was made possible by an unrestricted edu-
cational grant provided by Pfizer, Inc.
In March 2010, Books of Hope, with the
support of Pfizer,the Chinese Centre of Dis-
ease Control, the Chinese Medical Doctors
Association, the Chinese Association on To-
bacco Control and the World Medical As-
sociation presented a speaking book on the
dangers of smoking. It targets a low literacy
community, which has experienced signifi-
cant increases in smoking rates over the last
decades,yet cannot benefit from much of the
written informational products on tobacco
and smoking dangers and cessation.
Each of the impressively illustrated 16 page
books, with easy-to-read text and/or voice
on command, is expected to be received by
around 27 people as research has shown.
Thus the first 5000 books have the potential
to impact 50,000 to 100,000 people. Like
the other speaking books, the newest one
will also be accompanied by research ana-
lyzing its impact on health literacy.
1.13 Caring Physicians of the World
(CPW) Initiative (Leadership Course)
The CPW Project began with the Caring
Physicians of the World book, published
in October 2005 in English and in Span-
ish in March 2007. Regional conferences
were held in Latin America, Asia-Pacific
and Africa regions. The CPW Project was
extended to include a leadership course or-
ganized by the INSEAD Business School
in Fontainebleau, France, in December
2007, in which 32 medical leaders from a
wide range of countries participated. The
second Leadership Course was held at the
same place in December 2008 for one-week
with 30 participants, also with continued
successful results and positive feedback.The
third Leadership Course at the INSEAD
Business School was successfully held in
Singapore, 8–13 February 2010, with 29
participants. The curriculum includes train-
ing in decision-making, policy work, nego-
tiating and coalition building, intercultural
relations and media relations. The courses
were made possible by an unrestricted edu-
cational grant provided by Pfizer, Inc.
This work has been supported by the WMA
Cooperating Centre at the Centre for Glo-
bal Health and Medical Diplomacy in the
University of North Florida.
1.14 Medical and Health
Policy Development
In the past years the Centre for the Study
of International Medical Policies and
Practices, George-Mason-University,
which is one of our Cooperating Centres,
studied the need for educational support
in the field of policy creation. The surveys
performed with cooperation of the World
Medical Association found a demand for
education and exchange. Finally the Cen-
tre invited WMA to participate in the cre-
ation of scientific platform for the inter-
national exchange on Medical and Health
policy development.
In the fall of 2009 the first issue of a scien-
tific journal the World Medical & Health
Policy was published by Berkeley Electronic
Press as an online journal. It is accessible
under http://www.psocommons.org/wmhp.
External Relations
2.1 World Health Professions Alliance
After 10 years of successful collaboration,
the WPHA celebrates its anniversary at
the Leadership Forum in Geneva in May
in 2010. The four main health professions –
physicians,nurses,pharmacists and dentists –
have shown that working in collaboration
instead of along parallel tracks, benefits the
patient and the health care system. WHPA
amplifies the policy and advocacy messages
of member organisations and facilitates co-
herence and synergies among the messages
of national member organisations.
The World Confederation of Physical
Therapies WCPT was a strong and reliable
partner of WHPA for several years. We are
proud to announce that WCPT joined the
WHPA in May.
96
WMA news
2.3 Administration
In October 2009, the WMA re-launched its
website which now provides the platform for
cooperation with the members of WMA,
allows online payments for meetings, books
and associate membership dues, and, most
of all, facilitates more timely presentation of
content on the public website.
3. WMA Governance
Membership
During the reporting period, the following
association applied for full membership to
the WMA:
Associação Médica de Moçambique• 
(AMMo)
3.2 Medical organizations
in Arabic Countries
The Secretariat is continuously reaching out
to Medical Associations in Arabic countries.
We were pleased to have participation from
Egypt, Iraq and Palestine at our conference
“Right to Health as a Bridge to Peace in
the Middle East”. We offered to visit the
medical associations in Syria, Jordan and
Egypt and we hope that our offer will be
accepted during the year.
On the initiative of the German and Nor-
wegian Medical Association we are explor-
ing the possibility of holding a conference
or event planned and co-organized with the
Emirates Medical Association and possibly
the Arab Medical Union.The current idea is
to hold this event early in 2011,hopefully in
Dubai. We are also exploring the possibil-
ity of holding the fourth CPW Leadership
Course in the United Arab Emirates as IN-
SEAD has its third campus in Abu Dhabi.
Acknowledgment
The Secretariat wishes to record its appre-
ciation to member associations and inter-
national organizations for their interest in,
and cooperation with, the World Medical
Association and its Council during the past
year. We thank all those who have repre-
sented the WMA at various meetings and
gratefully acknowledge the collaboration
and guidance received from the officers, as
well as the Association’s editors, its legal,
public relations and financial advisors, and
its officials.
Dr. Alan J. Rowe
The report on the 185th
Council meeting will
appear in the next issue WMJ 56.4.
The photographs above are those of partici-
pants at the 165th
Council meeting.
Dr. Torunn Janbu, president of the Norwe-
gian Medical Association, has been elected
chair of the World Medical Association’s
medical ethics committee.
She was elected unopposed at the WMA’s
Council meeting in Evian, France in May
and succeeds Dr. Jens Jensen, from Den-
mark, who has taken up a post with the
Danish health service as medical direc-
tor and CEO in one of Denmark’s five
healthcare regions. Dr. Jensen had been
chair of the ethics committee for less
than a year.
Dr. Janbu has been president of the Norwe-
gian Medical Association since 2005 when
she became the first female president in the
120 year history of the Association.Previ-
ously she was chair of the Oslo Medical As-
sociation and vice president of the Norwe-
gian Medical Association .
She is chief surgeon and specialist in gen-
eral surgery and orthopaedic surgery, pres-
ently on leave from her job at Oslo Uni-
versity Hospital while working full time as
president. She took her medical degree at
the University of Oslo in 1979.
Since taking over as President of the Nor-
wegian Medical Association, Dr. Janbu, has
been widely praised for the way she has
handled several difficult issues.
She has chaired the Ethics and Professional
Codes subcommittee in CPME (Comité
Permanent des Médecins Européens) until
it was abolished recently during the reor-
ganisation of CPME.
Dr. Janbu emphasizes the important role of
the WMA in medical ethics worldwide,and
especially mentions the Declaration of Hel-
sinki. She also said that health inequalities
could be an important topic for future work
in the committee.
Dr. Janbu was for several years an aerobic
instructor in Oslo. She is married to politi-
cian and physician Kjell Maartmann-Moe.
Norwegian Doctor to Head
WMA’s Ethics Committee
97
Regional and NMA news
Soon after the earthquake hit Haiti on 12
January, the Brazilian Medical Association
(AMB) started to receive numerous calls
from doctors asking how they could help.
Two days later, a cabinet crisis was installed
at the AMB´s headquarters to organise
the available resources. On 15 January, we
started an online application at our web-
site to register all the volunteers to help the
victims of the tragedy. In 15 days, we had
976 healthcare workers volunteering to go
to Haiti.
While resources were being organised in
Brazil, Ricardo Affonso Ferreira, leader of
“Expedicionários da Saúde” (a NGO part-
ner of the AMB), went to Haiti to access
the situation. He found the Brenda Straf-
ford Hospital, in Les Cayes, a small town
situated 192 kilometres from Port au Prince
that was not affected by the disaster.Within
a few days the local population doubled af-
ter the arrival of 60 000 refugees.The Bren-
da Strafford Institute is an ophthalmology
and otolaryngology hospital that later was
adapted to treat orthopaedic trauma pa-
tients.
In 45 days the AMB sent three teams to
Haiti, 28 doctors (among them our presi-
dent), 12 nurses and 4 radiology techni-
cians. A lot of equipment, donated by pri-
vate companies and public institutions, was
carried by the three teams to treat patients.
To give an idea, the second team alone,
took 1500 kilos of equipment with them.
The first two teams used regular commer-
cial flights to go to Haiti, arriving at Santo
Domingo, Republica Dominicana and then
they travelled by bus to Les Cayes. The last
team was taken straight to Port au Prince by
the Brazilian Air Force.
The three teams performed 219 surgeries in
148 patients, mostly in men, the mean age
was 31 years. Lower limbs were the most
affected segments and the use of external
fixator was the most common type of treat-
ment. At the outpatient clinic, over 1500
people were treated.
“I consider that all three missions were
successful. We felt privileged to be able to
represent all physicians who could not go.
The continuity of this work will be done in
different ways and one of them is the cre-
ation of a task force trained for disasters«,
said José Luiz Gomes do Amaral, president
of AMB. “We also look forward to estab-
lishing a worldwide network of physicians,
national medical associations and resourses
ready to be used after a disaster of this pro-
portion.”
Helena Fernandes,
Communication Department,
Brazilian Medical Association
Brazilian Medical Association – SOS Haiti
98
Regional and NMA news
Sao Tome is one of the world’s most iso-
lated countries, located 300 miles west of
the African continent. With 160 000 in-
habitants and very few medical doctors, the
country has difficulty providing basic health
services.This need inspired Taiwan Medical
University, partly supported by the Taiwan
International Corporation and Develop-
ment Foundation, to send in more than a
dozen health professionals since last De-
cember.Prior to their dispatch to Sao Tome,
many of the Taiwan doctors and nurses did
not know of this island country.
During routine rounds in local hospitals,
TMU’s Dr. Yu-Tai Chang was troubled by
the cases of three children with burns over
large areas of their bodies. He emailed pho-
tos of the burns to Taipei and asked about
a timely consultation while working with
his team in a shanty clinic.The chief plastic
surgeon in Taipei, Dr. Cliff Chen, suggested
a videoconference on treatment options in
March.
However, most Sao Tome internet service
was too limited to carry real-time images
and voices to Taiwan. Dr. Chang persuaded
Taiwan’s ambassador in Sao Tome to offer
his embassy office, complete with satellite
communication system, to serve as the vid-
eoconference site. During this examination,
the scars over the burned areas were seen to
have already contracted the children’s bod-
ies. Dr. Chen advised that the scars would
continue to limit them, and recommended
timely reconstructive surgery to protect the
patients from irreversible lifetime defor-
mity.
The decision to bring the children to Tai-
wan was a difficult one for the university
and hospital doctors. The Taiwan Medical
University team faced daunting financial
and technical challenges in transferring the
patients,but within days of publicising their
cases generous pledges were made to sup-
port the children’s treatment.
Dr. Chang drove to the patients’ villages
and helped the families with paperwork
and reassured the mothers, who had never
left their villages before, about the voyage of
more than 10 000 miles.They had not heard
about Taiwan before learning that their in-
jured children might receive treatment here
that would enable them to lead normal lives
again. Unfortunately, before they could de-
part the youngest patient, a 5-year-old girl,
died of infection.
The two boys, both 7 years old, ar-
rived from SaoTome & Principe atTaoyuan
International Airport on 11 April, accom-
panied by their mothers and a doctor from
their country. They arrived exhausted and
could hardly walk without assistance due to
contractures from scarring over large areas
of their bodies as well as 36 hours of flights
and transfers from Africa via Lisbon, Am-
sterdam and Bangkok.
The doctors and nurses of the university’s
affiliated Wanfang Hospital conducted
several operations and logged more than a
hundred consultations and procedures to
rebuild the skin over the children’s scars, re-
placing areas from scalp to torso. One child
could again close his eyelids and mouth af-
ter months when that had been impossible.
Both patients’elbows could again reach nor-
mal extension, and the boys enjoyed their
new freedom of motion by playing football
and jumping around during their weeks of
reconstruction and rehabilitation.
Now the two young burn patients are get-
ting ready to go home.As the university and
hospital receive calls from around Taiwan
pledging assistance and donations, people
in the African children’s home villages are
learning about their expected recovery and
return. We salute the bravery of these in-
jured children who came so far to stay with
us. Because of their courage, hundreds of
people in very different countries have
shared medical knowledge and our com-
mon humanity. Everyone can celebrate this
happy outcome of Taiwan’s medical diplo-
macy.
Peter Chang, MD, MPH, ScD
Professor and International Dean
Taipei Medical University
Advisor, Taiwan Medical Association
Peter.chang3@gmail.com
Burn Victims Bring Taiwan,
Sao Tome Closer Together
99
Regional and NMA news
Geneva, 18 May, 2010
The World Health Professions Alliance
(WHPA www.whpa.org) today urged fur-
ther action against counterfeiting of medical
products, a vile and serious criminal offense
that puts human lives at risk and under-
mines the credibility of health systems.
Speaking for more than 26 million health
professionals in more than 130 countries,
WHPA is extremely concerned that the
infiltration and sale of counterfeit medical
products in the legitimate supply chain can
cause death and misery to tens of thousands
of patients around the world. The only rea-
son to combat counterfeit medicines is the
protection of public health – disputes in
trademark infringement and other intel-
lectual property related crimes should never
ever be the basis on which to define if a
medical product is counterfeit or not.
“Falsely labelled, fake, spurious or counter-
feited medical products which misrepresent
an otherwise legitimate medical product
pose a very serious public health threat
which demands sustained and co-ordinated
international action to control. Failure to
act against this criminal activity would be
a fundamental breach of the trust placed
in public health structures by patients,”
said Mr Ton Hoek, General Secretary and
CEO, International Pharmaceutical Fed-
eration (FIP) and WHPA spokesperson.
WHPA represents more than 26 million
Health Professionals worldwide.
So that health care professionals are bet-
ter equipped to combat counterfeits, the
WHPA announced that it is stepping up its
commitment to this issue, with the launch
of the ‘Be Aware, Take Action’ campaign
www.whpa.org/counterfeit_campaign.htm
against counterfeiting of medical products.
This campaign focuses on public health and
patient safety issues and enhances the role
of health professionals and associations.
Through regional workshops dedicated to
anti-counterfeiting, the WHPA aims to
strengthen advocacy for appropriate in-
vestments in the education and capacity of
health professionals to detect, report and
prevent counterfeit medical products.In ad-
dition, the WHPA Be Aware, Take Action
toolkit and other campaign resources are
provided for health professionals, health-
care advocates and patients
The main channels for fake medical prod-
ucts supply include street markets in devel-
oping countries and the Internet. The harm
caused by counterfeit medicines is greatest
in those communities least able to afford
effective regulatory systems and quality
health care.
Said Ton Hoek, “Public health and patient
safety are being put at risk and now is the
time to act.
Increased vigilance by health care profes-
sionals and patients can help make public
and individual health safer. Health pro-
fessionals need to increasingly consider
counterfeit medicines as a reason for non-
response or unexpected response in phar-
macotherapy in the patients they care for.”
Education of health professionals is crucial
for detection and prevention of counterfeit
medical products and is required in order
for them to educate patients and popula-
tions about the risks of buying counterfeit
medical products from unknown and unre-
liable sources.
WHPA recognizes also that for health pro-
fessionals to be able to effectively play their
role, national authorities must set up effec-
tive systems for the collection of informa-
tion and increase national drug and medical
device regulatory capacity to support the
enforcement of pharmaceutical guidelines.
About WHPA www.whpa.org
The World Health Professionals Alliance
WHPA is a unique alliance of The Interna-
tional Council of Nurses (ICN) www.icn.ch,
the International Pharmaceutical Federation
(FIP) www.fip.org,
The World Confederation for Physical
Therapy (WCPT) www.wcpt.org, the FDI
World Dental Federation (FDI) www.fdi-
worldental.org and the World Medical As-
sociation (WMA) www.wma.net. WHPA
addresses global health issues striving to
help deliver cost effective, quality health
care worldwide. Together, the partners of
the WHPA include more than 600 national
member organizations, making WHPA the
key point of global access to health care
professionals within the five disciplines.
Member Organisations
The International Council of Nurses (ICN)
is a federation of national nurses associa-
tions,representing the more than 13 million
nurses working worldwide. www.icn.ch
The International Pharmaceutical Federa-
tion (FIP) is the global federation of na-
tional organisations of pharmacists and
pharmaceutical scientists representing more
than two million pharmacists around the
world. www.fip.org
The World Confederation for Physical
Therapy (WCPT), the global voice for
physical therapists / physiotherapists, has
101 national member organisations repre-
senting over 350,000 members of the pro-
fession. www.wcpt.org
The FDI World Dental Federation (FDI) is
a federation of approximately 200 national
World Health Professions Alliance calls for
increased action against counterfeits
100
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
dental associations and specialist groups
representing more than one million dentists
worldwide. www.fdiworldental.org
The World Medical Association (WMA)
is the global federation of national medi-
cal associations from around the world,
directly and indirectly representing the
views of more than nine million physicians.
www.wma.net
For more information about Be Aware,
Take Action, please see www.whpa.org/
counterfeit_campaign.htm
or send an email to whpa.campaign@wma.
net
The World Health Profession Alliance
WHPA
WHPA Secretariat • 13, Chemin du Levant 
• BP 63 • 01210 Ferney Voltaire, France
Tel.: +33 (0) 450 40 75 75 • Fax: +33 (0) 450 
40 59 37 www.whpa.org • 
E-mail: whpa@wma.net
Huge potential exists to improve pub-
lic health by reducing exposure to harm-
ful environmental pollutants and through
certain measures to tackle climate change,
according to Génon K. Jensen, Director
of the Health and Environment Alliance
(HEAL). HEAL advocates changes in Eu-
ropean policy that could reduce the burden
of chronic disease in Europe.
In the world’s wealthy countries, the burden
of disease is dominated by chronic, long-term
conditions. According to the World Health
Organisation, 77% of the burden of disease in
high income countries is attributable to non-
communicable conditions,with only 8% of life
years lost to communicable disease [1].
The incidence of certain cancers,chronic re-
spiratory disease, diabetes and obesity is ris-
ing. Many leading European scientists say
that part of this growing burden of chronic
disease is due to harmful contaminants in
the everyday environment.
Given that the European Union is respon-
sible for setting about 80% of the environ-
mental policy that is later applied in Mem-
ber States, European institutions play a very
significant role in public health protection.
How can changes in environmental
policy reduce cancer rates?
In the European Union, one in three people
will develop some form of cancer during
their lifetime.Although genetics are respon-
sible for a proportion of cancer incidence,
some cancer rates are increasing so rapidly
that genetics alone cannot be the driver.
Other explanations for rising rates of can-
cer incidence include an aging population
or better screening programmes, or changes
in “lifestyle”factors,such as smoking and al-
cohol consumption. But such explanations
cannot account for all the increases. For ex-
ample, the number of cancer cases among
children is increasing by at least 1% every
year [2].
Many researchers and policy makers in-
creasingly point to the connection with en-
vironmental factors, at least in part.
The Health and Environment Alliance
(HEAL) has brought two recent scientific
reviews addressing the links between en-
vironmental chemical contamination and
diseases to the attention of European policy
makers. Substances known as “endocrine
disrupting chemicals”(EDCs), which inter-
fere with or damage the human hormone
system, have been shown to produce “gen-
der bending” effects in animal studies, with
significant implications for human health
effects.
The literature and analytical reviews link
EDCs with rising rates of breast cancer and
How Can Changes in Environmental Policy
Help Reduce Rates of Chronic Disease?
Opportunities for prevention in the European Union
Genon Jensen Diana Smith
101
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
with testicular dysgenesis syndrome (TDS)
[3, 4]. TDS is a grouping which comprises
male genital defects at birth (cryptorchid-
ism, hypospadias), impaired semen quality,
and a type of testicular cancer (testicular
germ cell tumours). Like breast cancer,
TDS has been linked with fetal exposure to
EDCs. Some leading European toxicolo-
gists are convinced that breast cancer rates
will not be brought down until the issue
of everyday exposure to harmful synthetic
chemicals is addressed.
Examples of endocrine disrupting chemi-
cals mentioned in the reviews include: Bis-
phenol A – used in plastics and resins in
baby bottles and can linings that may leach
into drinks and foods; insecticides and pes-
ticides, such as DDT and methoxychlor,
which have been banned in Europe since
1978 and 2003 respectively, but are still
found in people’s bodies; UV filters, such
as benzophenone and 4-MBC, which may
be used in sun screens, are another example
[5].
Because of concerns, France and Sweden
are currently considering banning Bisphe-
nol A for use in baby bottles as evidence
increases on the need to protect biologi-
cally vulnerable groups such as babies and
toddlers.
Although the EU has not yet banned
Bisphenol A and many other important
EDCs, some European policy is already
beginning the process of protecting human
health through stricter regulation of uses of
harmful chemicals. In 2007, a new law on
chemicals called REACH (Registration,
Evaluation, Authorisation and restriction
of chemical substances) was agreed to en-
sure that all chemicals on the EU market be
registered. Those considered to be “of very
high concern” to human health are gradu-
ally being put through a market authorisa-
tion process.
Two years later, the so-called “pesticides
policy package” was agreed. One of its ob-
jectives was to reduce the impact of pesti-
cides and harmful effects on human health
and the environment. It will remove the
sale and use of pesticides linked with can-
cer, DNA mutation, reproductive toxicity,
and hormonal disruption. It also recom-
mends that pesticide use in parks, schools
and gardens around hospitals is minimised
or avoided. For the implementation of this
package the national level is crucial as EU
Member States have to set up their own
National Action Plans by 2012.
HEAL is currently involved in looking at
how the review of the EU’s biocide law can
lead to better health protection.Biocides are
defined as “chemical substances capable of
killing living organisms, usually in a selec-
tive way”. They include rodenticides, wood
preservatives,insecticides and anti-microbi-
al, such as disinfectants. A particular con-
cern is that the growing use of biocides is
contributing to antibiotic resistance.
Recently the European Parliament passed
a resolution which strongly underlines the
importance of dealing with environmental
factors when working to prevent cancer.
The report responds to the EU “Com-
munication” on Action against Cancer,
which already acknowledged that cancer
prevention should address environmental
and occupational causes on an equal foot-
ing with lifestyle considerations, such as
smoking, alcohol consumption and lack of
exercise.
A second example: chronic respiratory ill-
nesses
Environmental policy can also play an im-
portant role in reducing chronic health
problems associated with lung disease.
Lung disease is rising worldwide and its to-
tal financial burden in Europe amounts to
nearly €102 billion. Chronic Obstructive
Pulmonary Disease (COPD) contributes
almost one-half of this figure followed by
asthma, pneumonia, lung cancer and TB.
Although air quality has improved over the
past 20 years, it is still responsible for some
310,000 premature deaths within the Eu-
ropean Union, according to a report by the
European Commission [6].
Research commissioned by the Health and
Environment Alliance (HEAL) and others
in 2008 showed the extent to which better
air quality through strong climate change
policy would benefit health as a side effect
[7]. This would happen because reaching
climate change targets involves moving to
energy sources with lower of emissions of
carbon dioxide and other air pollutants,
which would result in cleaner air.
The review showed that if the EU moved
to a 30% target on greenhouse gas emission
reductions (compared with the EU’s current
target of 20% by 2020), 100,000 fewer years
of life would be lost to air pollution among
Europeans (over 30 years of age) every year
from 2020. In monetary terms, the overall
public health benefits of the 30% reductions
climate policy was estimated to be up to 25
billion Euros per year by 2020 [7].
The World Medical Association helped to
bring the message of these health co-ben-
efits of climate change policy to the atten-
tion of policy makers and the media, both
in Brussels and at the Copenhagen climate
summit at the end of 2009. WMA joined
102
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
HEAL and Health Care Without Harm
(HCWH) in an initiative known as the
“Prescription for a Healthy Planet”, which
aims to bring health to the centre of climate
change negotiations.
Looking ahead
Over the coming months there will also
be opportunities to influence EU policy
on REACH, biocides, the Community
Strategy for Endocrine Disruptors, and the
implementation of air quality legislation,
which includes for the first time a require-
ment for governments to better inform re-
spiratory and asthma patients on poor air
quality. HEAL and HCWH Europe are
also planning further research into how an
ambitious greenhouse gas emission target
can benefit public health in different EU
Member States. We hope that the WMA
and its member organisations will continue
to play its effective and prestigious role in
supporting advocacy work to improve pub-
lic health in Europe. We very much wel-
come your input into our work.
The Health and Environment Alliance aims to
raise awareness of how environmental protec-
tion improves health. The membership includes
a diverse network of organisations of citizens,
patients, women, health professionals and en-
vironmental experts across Europe. HEAL has
a strong track record in increasing public and
expert engagement in both EU debates and the
decision-making process. The author has been a
member of the WHO steering group the Eu-
ropean Environment and Health Committee
and sits on several EU expert and research ad-
visory groups as a policy advisor.
HEAL projects
HEAL has a variety of collaborative projects
running in several languages, which allow us
to focus on specific areas of priority.
Chemicals Health Monitor – ensuring
that scientific evidence on the links between
chemicals and ill-health are translated into
policy as quickly as possible. www.chemi-
calshealthmonitor.org
Sick of Pesticides – advocating for strong
regulation of pesticide use for better health,
especially to protect the most vulnerable
groups in society. www.pesticidescancer.eu
Prescription for a healthy planet – bring-
ing public health to the centre of the cli-
mate change debate, and uniting the in-
ternational health community behind four
principles: protect public health; set strong
targets on emission reductions; promote
clean energy; and fund global action. www.
climateandhealthcare.org
Healthier Environments for Children –
showcasing examples of good practice proj-
ects in children’s environment and health
throughout the 53 countries of the WHO
European region. http://cehape.env-health.org
Stay Healthy, Stop Mercury – raising
awareness of the potential health risks of
environmental mercury pollution. Calling
on the EU to show leadership in efforts to
control environmental mercury pollution
by securing a global ban on mercury. www.
env-health.org/stopmercury
References
World Health Statistics, 2009,Table 2.1.
Cancer rates in children, source: IARC paper2.
The Lancet, 11-17 December 2004
Factors influencing the risk of breast cancer -3.
established and emerging, ChemTrust, April
2008, http://www.chemicalshealthmonitor.
org/spip.php?rubrique100
Male Reproductive Health Disorders and4.
the Potential Role of Exposure to Environ-
mental Chemicals, ChemTrust, 2009, http://
www.chemicalshealthmonitor.org/spip.
php?rubrique16
Factors influencing the risk of breast cancer -5.
established and emerging, ChemTrust, April
2008, http://www.chemicalshealthmonitor.
org/spip.php?rubrique100 (page8)
Information on the impacts of air pollution6.
on human health up to 2020 www.duh.de/
uploads/media/EU_2005__02.doc (Assess-
ment of air quality in the EU, 21-22 February
2005, Clean Air for Europe (CAFE) Steering
Group, European Commission.)
HEAL, CAN Europe, WWF, 2008, The7.
Co-benefits to health of a strong EU climate
change policy, http://www.env-health.org/
IMG/pdf/Co-benefits_to_health_report_-
september_2008.pdf
Genon Jensen, Executive Director,
Health and Environment Alliance
Diana Smith, Communications and Media
Advisor, Health and Environment Alliance
103
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
Introduction
At the Inauguration Ceremony of the new
members of Nigerian National Assembly
in Abuja, the nation’s capital on 5th
June,
2003, the President, Olusegun Obasanjo
declared:
“Nigerians have for too long been feeling short-
changed by the quality of our Public Service.
Our Public offices have for too long been a
showcase for the combined evils of inefficiency
and corruption, whilst being impediments to
effective implementation of government poli-
cies. Nigerians deserve better. We will ensure
that they get what is better!” [1]
Prior to this, most of these government
agencies had been pronounced inefficient
compared to their privately run counter-
parts, and the Federal Government had
resolved to and undertook the process of
privatization and commercialization of pub-
lic enterprises in order to improve service
delivery to the nation’s citizens. The health
sector was no exception.
Nigeria’s peculiar health sector has been
discussed at various fora over the past
30 years since the military coup of 31st
De-
cember, 1983, which actually gave as one of
the reasons for that putsch as “our hospitals
have become mere consulting clinics” [2, 3].
The World Health Organization (WHO),
for these past decades, has rated the Nige-
rian health sector very low,more so with the
consistently low budgetary allocation to the
sector by successive government administra-
tions. Nigeria is classed among the “Low-
Expenditure, Low-Growth Health Econo-
mies”, a group of underdeveloped countries
which despite comprising a population of
2.6 billion people (about 40% of the world’s
population), is unfortunately credited with
less than 5% of the world’s health expendi-
ture [4]. Countries in this group suffer from
an absolute under-funding of their health
sector, along with a disproportionally high
disease burden.
From 1997 to 2001, Nigeria’s total an-
nual budgetary allocation to health tot-
tered around 1.7 – 2.1% (2.1%, 2.3%, 1.7%,
1.7% and 1.9%, respectively), compared to
Cameroon 4.1 – 7.9%, South Africa 10.9 –
12.4%, Namibia 12.4 – 13.1%, Canada
13.9 – 16.2%, and USA 16.8 – 17.6%, in
the same period; and the WHO prescrip-
tion is 15% of the Annual National Budget
[5,6]. Since health equated life, it was no
surprise that as the budgetary allocation to
the health sector, and consequently govern-
ment investment on health, dwindled, Ni-
geria’s average life expectancy dropped from
54 years in 1998 to 43.4 years in 2004 (166th
out of 177 countries). And till now, there
is no evidence on ground that these indices
are improving [7, 8].
The 2003/2004 Nigerian Living Standards
Survey (NLSS) conducted by the Nigerian
National Bureau of Statistics, with inter-
national technical assistance, documented
a national poverty rate of 54.4%, implying
that more than half of Nigerians live on
less than $1 per day (contrary to the WHO
stipulation of $5) [9]. Subjectively, 75.5%
of Nigerians regard themselves as poor,
with most of them situated in the agricul-
tural and informal sectors particularly at
the village levels.The picture could be scary
Re-Positioning of Service Delivery in the Nigerian Health System –
the Impact of SERVICOM on Emergency and Other Services in a
Tertiary Health Facility
Emejulu, Jude-Kennedy C. Igwegbe, Anthony O. Eleje, George U.
Ofiaeli, Robinson O. Nwofor, Alexander M. E. Anumonye, Charles O.
104
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
and gloomy, but more worrisome was the
attitude of administrators who appeared
not to be bothered by these troublesome
statistics.
The poor service financing, seemingly rubs
off on various aspects of the health sector,
not least, the emergency care services. On
most of Nigeria’s highways, there are no
readily available or accessible emergency
care units or squads equipped and prepared
to attend to road accident victims, rather,
the job is left to traffic marshals whose
outposts are very few and far between, and
communication equipment and vehicles are
acutely in short supply. The result remains
that most accident victims would not make
it to emergency care units even within the
golden hour, and naturally, this would im-
pact negatively on the outcome of most of
the cases.
With the unavailability of basic work tools
coupled with a low morale due to sub-opti-
mal remunerations, Nigeria’s public health
care providers are not usually as enthusi-
astic in discharging their duties as would
be expected of them in providing standard
services to combat the constant challenge
of avoidable deaths and long term debility.
This attitudinal short fall, appears to affect
not only the health sector but also all the
other sectors of Nigeria’s economy viz. law
enforcement, civil service, electricity gen-
eration/supply, transportation, telecommu-
nications, etc. and the impact on all fronts is
more visible in the government sector and
bureaucracy.
In December 2003, a research project was
commissioned to review service delivery
in Nigeria with a view to determining the
institutional environment for service deliv-
ery, the citizen’s views on (and experiences
with) service delivery and the designing of a
roadmap for a service delivery programme.
Subsequently, a report titled “Service Deliv-
ery in Nigeria: A Roadmap” was published
in February 2004, and the conclusions and
recommendations therein included:
services were not serving the people: they• 
were inaccessible, poor in quality and in-
different to customer needs;
public confidence was poor, and institu-• 
tional arrangements were confusing and
wasteful;
services should be re-designed around• 
clients’ requirements;
the success of the Programme would• 
require committed leadership from the
top;
ministers should demonstrate their com-• 
mitment with a leadership declaration
about Service Delivery;
there was need for a far-reaching trans-• 
formation of the Nigerian society through
a Service Delivery Programme as a step
in the process of moving to a govern-
ment that was more in touch with the
people.That Service Delivery Programme
should:
create citizens’ and customers’ de–
mand’,
instill higher expectations on public-
services,
communicate service entitlements and-
rights,
publish information about perfor–
mance. [10].
In March 2004, a Special Presidential Re-
treat was held to deliberate on this report.
The opening comment of the President
was:
“This Retreat is to assert our ownership of the
initiative to serve Nigerians better. We accept
full responsibility for driving it to a successful
end… It is also the message of leading from the
front in the battle to sanitize our system mor-
ally, politically and economically. Above all, it
is the message of the leadership that the Nige-
rian people can trust…”
And at the end of the retreat, the Federal
Government on 21st
March, 2004, resolved
to enter into a “SERVIce COMpact”
(SERV-ICOM) with the citizens of our
country for a commitment to their welfare
and satisfaction with service delivery; and
thus, was born the SERVICOM Charter
[1].
By SERVICOM, it was also agreed that all
Ministries, Parastatals and Agencies and all
other Government Departments will pre-
pare and publish,not later than the First day
of July 2004, SERVICOM CHARTERS
whose provisions would include:
quality services designed around the re-• 
quirements of their customers and served
by staff sensitive to the needs of their cli-
ents;
set out the entitlements of the citizens• 
clearly and in ways they could readily un-
derstand;
list of fees payable (if any) and prohibit• 
the demand for any additional payments;
commitment to the provision of services• 
(including the processing of applications
and the answering of correspondence)
within realistic set time-frames;
details of agencies and officials to whom• 
complaints about service failures may be
addressed;
publish these details in conspicuous plac-• 
es accessible to the public;
periodically conduct and publish surveys• 
to determine levels of customer satisfac-
tion.
Under this Charter, every government es-
tablishment outlined its goals and objec-
tives in the provision of optimal services to
the satisfaction of its clients. It became an
agreement with and a commitment to the
clients,who were advised to report to specific
officials when they get less than satisfactory
answers to their enquiries or less than opti-
mum satisfaction from services rendered to
them. Such reports would be treated with
seriousness, and sanctions meted out.
Nigeria’s health system operates on a cash-
and-carry basis whereby the client pays for
every service and treatment received at any
point in the hospital. However, a few years
ago, a National Health Insurance Scheme
(NHIS) was introduced for the benefit of
government employees, that allows each
105
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
employee and four registered family mem-
bers to receive care at subsidized rates for
some statutorily stipulated disease condi-
tions, but not for diseases outside the list.
The NHIS does not as yet cover many dis-
ease conditions.
On 10th
May, 2005, our institution fully
adopted and launched the SERVICOM
Charter in the provision of services to our
clientele, and we began to do everything
in a slightly different way. But it has been
known that putting people first as the focus
of service delivery reforms is not a trivial
principle, as it could require significant –
even if often simple – departures from
“business as usual” [11].
Nnamdi Azikiwe University Teaching Hos-
pital (NAUTH) Nnewi, was a secondary
health facility (State General Hospital) in
the 1970s which was upgraded to a Federal
Government training institution in 1992,
and since then, progressively grew into a
350-bed facility along with its five accredit-
ed outposts located in Onitsha, Neni, Ukpo,
Oba and Umunya, within Anambra State.
It has facilities for service delivery and man-
power training in the various specialties of
Medicine and allied health professions.
Nnewi is a semi-urban community with
a population of 204,000 persons located
in Anambra State – one of the five states
that constitute the South-East Zone of Ni-
geria. Anambra State has a population of
4,182,032 persons (2006 National Popula-
tion Census), and our teaching hospital is
the only tertiary health institution providing
services to the State and some other States
in the South-East Zone,as well as in parts of
two other Zones (South-South and North-
Central) of Nigeria. The total population of
these potential catchment areas is estimated
at 40.2% of Nigeria’s 140million population
(South-East 11.7%, South-South 15% and
North-Central 13.5%) [12, 13].
This study is a prospective evaluation of
the clientele turnover and outcome of
cases treated in NAUTH Nnewi after
the introduction of SERVICOM in May
2005, meant to assess the impact of this
Charter on the provision of services in our
tertiary health institution, and determine
its usefulness, or otherwise, in the im-
provement of the health of our catchment
population.
The question is: Has SERVICOM made
the desired impact on care delivery in our
health institution?
Methods/Patients/Materials
Data collection for this study started pro-
spectively as soon as the SERVICOM
protocol was introduced in May 2005, us-
ing the Microsoft excel broadsheet, and
collated on a monthly basis. The electronic
and hardcopy registers of the Department
of Health Records were used to crosscheck
the collected data of the different Units and
Departments. Statistical analysis was done
using the chi-square; with the significant p-
value taken as ≤0.05.
Because SERVICOM was introduced in
the second quarter of 2005, we agreed that
data from 2006 represented the transition
period, while 2007 onwards would more
appropriately reflect the impact of this pro-
gramme in the post-SERVICOM period,
and 2005 would be more representative of
the pre-SERVICOM status of service de-
livery in our Institution.
Results
By the end of 2006, numerical data began
to show a change in all facets of care deliv-
ery compared to the figures in the preced-
ing year in the hospital and quite remark-
ably, in the Accident and Emergency Unit,
as well.
For 2005, 2006, 2007, 2008 and 2009 at-
tendance at Consultant Out-patient Clin-
ics were 36032, 48703, 58530, 64931 and
66831 clients, respectively (Figure 1); Gen-
eral Out-patient Clinics for the same pe-
riod were 35866, 51520, 57830, 60056 and
62055 (Figure 2); Children’s Out-patient
Clinics 36032, 48703, 58530, 64931 and
66831 (Figure 3); Accident and Emergency
Unit 3988, 7034, 10503, 12224 and 14118
(Figure 4); Hospital In-patient Admissions
4718, 6067, 11874, 13750 and 15650 (Fig-
ure 5); Laboratory Services 58039, 62007,
81196, 93300 and 115301 (Table 1); Surgi-
cal Operations in the Theatres 1001, 1321,
3706, 4142 and 5642 (Table 2), and Baby
Deliveries in the Labour Room 596, 627,
1611, 2936 and 2123 (Table 3).
The gross clientele turnovers for the whole
Hospital in each of these five years (2005 –
2009) were 76452, 107884, 128474, 140147
and 145127 (Figure 6), while mortalities
from in-patients for the corresponding
years were 284 (6% of in-patients), 221
(3.64%), 200 (1.68%), 143 (1.04%) and 127
(0.81%) (Figure 7).Within the same period,
the maternal mortalities were 11 (1.84%), 9
(1.43%),7 (0.43%),8 (0.27%) and 3 (0.14%),
respectively (Table 3).
Discussion
At the inauguration of the SERVICOM
Charter, the management of our Hospital
identified key areas that required re-evalua-
tion and attention based on the submissions
of every service Unit and Department, after
an analysis of the Strengths, Weaknesses,
Opportunities and Threats (SWOT) of
each. A pre-SERVICOM workshop which
was supervised by the Federal Government
was held in the various institutions na-
tionwide to enable care providers enumer-
ate their current service capacity, and then,
based on their stated ideal objectives, risks,
shortcomings and strengths, identify the in-
stitutional needs that would enable them to
achieve their set objectives. With the reso-
lutions from the workshop, human and ma-
terial resources were upgraded in order to
address the identified risks and enhance the
capacity of each institution to attain these
set goals.
106
Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy
For example, changes employed in the Ac-
cident and Emergency Unit of NAUTH
Nnewi included:
the employment of more medical officers,• 
nurses and other health personnel;
procurement of more diagnostic and• 
therapeutic equipment;
availability of adequate supply of medica-• 
tions;
appointment of a new Head of Unit with• 
a brief to enforce discipline and compli-
ance with all the activities in the Unit;
daily morning audit of the clientele turn• 
over and treatment outcome in the Unit
for the preceding 24hours, by the hospital
management;
installation of free communication lines• 
for health personnel to easily make con-
tact with their colleagues, superiors or
hospital management round-the-clock
whenever there is an urgent need arising
from care delivery;
waiver on all hospital bills for all emer-• 
gency cases until resuscitation/salvage is
achieved or relatives who would make
payment arrive;
direct line for feedback from the clients• 
to the hospital management for whatever
impression they make of the care they re-
ceived;
24-hour electric power supply; structural• 
renovation of sections of the Unit.
Following these reforms, the time lapse be-
tween the arrival of a client, in our Accident
and Emergency (A&E) Unit, and review
by the doctor on call in the A&E Unit was
shortened to a maximum of 5minutes com-
pared to the previous scandalous records
that got as long as 2 hours in some instanc-
es. Also, the maximum time lapse between
review of the client by the doctor in the
A&E Unit and arrival of any specialist Unit
on call that is required to attend to the same
client was statutorily fixed at 30 minutes.
For the rest of the institution itself, a log
register was introduced and strictly en-
forced to monitor the movement of Staff
right from the moment of arrival for duties
till the commencement of duty and time of
departure, and appropriate sanctions were
spelt out on erring Staff. Similar changes as
in the A&E Unit were also introduced in
the Labour Room and Children’s Emergen-
cy Room, all of which we regarded as emer-
gency flashpoints in our service delivery.
As soon as the protocols of SERVICOM
were put in place, the attitude of our Staff
began to change remarkably. Every em-
ployee rushed to make it to the duty post
every day before the attendance register was
closed, and at the various service points,
clients were given timely and polite atten-
tion, medications were readily available and
no client was left unattended to merely on
account of lack of funds. Most importantly,
people felt that they were being listened to
and respected – a key aspect of what people
value about health care, similar to the expe-
rience reported in 2007 from Alaska, USA
and other parts of the world where some
health reforms were undertaken [14, 15,
16, 11].
With the gross annual clientele turnovers
of 107884, 128474, 140147 and 145127
from 2006 to 2009 in NAUTH Nnewi, it
was evident that there were geometrically
increasing patronage of 41% (p <0.05), 68% (p <0.05), 83.3% (p <0.05) and 89.8% (p <0.05), respectively, over the 2005 an- nual figure of 76452. In the A&E Unit, the clientele attendance of 3988, 7034, 10503, 12224 and 14118 for the same pe- riod equally translated to rises of 76.4% (p <0.05), 163.4% (p <0.05), 206.5% (p <0.05) and 254% (p <0.05), respectively over the 2005 figures. Both the difference in gross clientele turnover and A&E attendance when subjected to analysis were found to be statistically significant (p <0.05) in each of the years. Table 1. Laboratory services Year Total Laboratory Clientele Patronage (Total No. for 2005 = 58039) Increase over 2005 2006 62007 (3968) 6.83% 2007 81196 (23157) 39.9% 2008 93300 (35261) 60.8% 2009 115301 (57262) 98.7% Table 2. Surgical operations in the theatres Year Total No. of Operations (Total No. for 2005 = 1001) Increase over 2005 2006 1321 (320) 32% 2007 3706 (2705) 270.2% 2008 4142 (3141) 313.8% 2009 5642 (4641) 463.6% Table 3. Baby deliveries and maternal mortality Year Total No. of Deliveries (Total No. for 2005 = 596) Increase over 2005 Maternal Mortality (%) 2005 = (11) 1.84% 2006 627 (31) 5.2% (9) 1.43% 2007 1611 (1015) 170.3% (7) 0.43% 2008 2936 (2340) 392.6% (8) 0.27% 2009 2123 (1527) 256.2% (3) 0.14% 107 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy Prior to 2005, the impression of our clients and their relatives was that prompt and op- timal care was more likely to be obtained in private clinics in our locality than in the Teaching Hospital; and their reasons both- ered mostly on the attitude of health per- sonnel and non-availability of medications in government-run health facilities. The WHO had noted that people are increas- ingly impatient with the inability of health services to deliver levels of national cover- age that meet stated demands and chang- ing needs, and with their failure to provide services in ways that correspond to their expectations [4]. As a result, patronage of our government institutions remained very low and in most cases,was confined to those clients who could not afford the bills of pri- vate facilities, or victims of accidents whose identities and relatives were not known in the immediate post-ictal period. But, Nigeria was not alone in her inadequa- cies because studies by Halman, et al, Mil- lenson and Davies, had shown that in many parts of the world, there were considerable scepticism about the way and the extent to which health authorities assume their responsibilities for health [17, 18, 19, 20]. Surveys have shown a trend of diminish- ing trust in public institutions as guarantors of the equity, honesty and integrity of the health sector because on the whole, people expect their health authorities to work for the common good, do this well, and do so with foresight [21]. The increased patronage noted after the introduction of SERVICOM appeared, therefore, to indicate a restoration of public confidence in the capacity of the hospital to provide desirable services. And this seemed to cut across the entire service points of our hospital. In the Operating Theatre, some of whose clients pass through the A&E Unit, figures rose by 32% (p <0.05), 270.2% (p <0.05), 313.8% (p <0.05) and 463.6% (p <0.05), when compared to the 2005 sta- tistics, just as in the Labour Room where delivery of new babies rose remarkably by Figure 1. Attendance to Consultant Out-Pa- tient Clinics Figure 2. Attendance to General Out-Patient Clinics Figure 3. Attendance to Children’s Out-Pa- tient Clinics Figure 4. Accident and Emergency Cases Figure 5. In-Patient Admissions Figure 6. Gross Clientele Turnover Figure 7. In-Patient Mortality 108 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy 170.3% (p <0.05), 392.6% (p <0.05) and 256.2% (p <0.05), respectively for 2007, 2008 and 2009. The 5.2% rise recorded in 2006 was, however, not statistically signifi- cant on analysis (p >0.05).
Perhaps, even more compelling than the
absolute figures of patronage were the mor-
tality rates of our In-patients and pregnant
mothers, both which were on a persistent
decline despite the rise in total clientele
turnover. Mortality rates for In-patients in
the five years 2005 – 2009 were 284 (out
of 4718 admissions), 221 (6067 admis-
sions), 200 (11874), 143 (13750) and 127
(15650), which translated to 6%, 3.64%,
1.68%, 1.04% and 0.81% of all admitted
cases, respectively. When the post-SER-
VICOM mortality rates were compared
to 2005 (6% of 4718), the mortality rates
showed a marked progressive reduction by
39.3% (p <0.05) in 2006, 72% (p <0.05) in 2007,82.7% (p <0.05) in 2008 (p <0.05) and 86.5% (p <0.05) in 2009, respectively, all of which were statistically significant. After an assessment of the available data,we discovered that from 2006, when compared to the pre-SERVICOM era, there was: a progressive increase in clientele patron-•  age / turnover in all our service sectors – A&E,Out-patient,In-patient,Operating Theatre, Labour Room, Laboratories, etc; a progressive decrease in absolute mortal-•  ity rates of the In-patients per annum; a progressive decrease in maternal mor-•  tality rates per annum; a much greater decline in relative mortal-•  ity rates for all the in-patients and preg- nant mothers per annum. These findings strongly supported the fact that the introduction of the SERVICOM Charter stimulated several positive chang- es, and thereby, re-positioned our tertiary health institution towards a much better satisfaction of the demands of our clientele. They provided the answer to the question, thus: SERVICOM has made the desired impact on care delivery in our health insti- tution; even though it should be stated un- equivocally that there is still a lot of room for more improvement. It is worth noting that beyond attitude, the role of quality personnel,modern diagnostic and therapeutic equipments, and adequate remuneration of workers, would never be over-emphasized. Attitude alone may not be enough to sustain these massive gains for too long because it is only a portion of the whole armamentarium for a successful health care delivery system. Increasing Ni- geria’s annual budgetary allocation to health from the present 2% to the WHO recom- mended 15% as affirmed at the Abuja Ac- cord holds the surest key. Regular quality assurance of the human and material resources should be a comple- mentary aspect of the project of better ser- vice delivery in all sectors of the Nigerian economy, most importantly, the health sec- tor. More so, a host of other fairly low-cost policies (e.g. enhanced provision of water, medical drugs, or AIDS education/care) have been reported to lead to dramatic im- provements in life expectancy in developing countries,and these should be given priority by the various governments in Nigeria, as well [22]. Conclusion It is obvious that the structural and attitu- dinal changes introduced by SERVICOM, brought a very significant improvement in all our performance indices, and thus, con- tributed to the improved care delivery to our clients. Perhaps, one of the most likely handicaps that could stall or reverse these gains is the non-sustenance of the current momentum, but if this is sustained and in- troduced changes improved upon, health care delivery despite its various challenges would most likely continue to improve, and the life expectancy of the average Nigerian would record a change, from the appalling 43.4 years. References Kuru Declaration, 2003 National Assembly1. Inaugural Speech Service Delivery In Nigeria: A Roadmap - Time To Deliver; President’s Remark, Memorandum by the President of the Federal Republic of Nigeria; Federal Executive Council Report on the Establishment of Min- isterial SEVICOM Units. SERVICOM Office, http://www.servenigeria.com/misc/wendyre- port.pdf. Global Security: 1983 Buhari Coup. http://2. www.globalsecurity.org/military/world/war/ni- geria2.htm THIS DAY NEWSPAPERS: Osotimehin3. Canvasses Health Sector Reform. http://www. thisdayonline.com/nview.php 05.16.2009. WHO. The 2008 World Health Report: “Pri-4. mary Health Care – Now More Than Ever” 14 October 2008, Geneva. World Health Organization. World Health Re-5. port 2004: Selected National Health Accounts Indicators for all Member States http://www. who.int/whr/2004/annex/en/index.html National Health Accounts. World Health Or-6. ganization, Geneva 2008. http//www.who.int/ nha/country/en/index.html, accessed May 2008. UNDP. Human Development Report, Human7. Development Indicators, Country Fact Sheet: Nigeria 2006. P. 29–212. Vanguard Media Limited. Vanguard Comment8. Nigeria’s Lower Life Expectancy 1998–2005. htm. Monday, September 26, 2005. U.S. Ambassador Robin Reneé Sanders : Isaac9. Moghalu Foundation Leadership Lecture Ni- gerian Institute of International Affairs. Lagos, April 23, 2008. Wendy Thomson.10. Delivering Service in Nigeria: A Roadmap; Office for Public Service Reform, United Kingdom. http://www.servenigeria.com/ misc/wendyreport.pdf Eby D. Primary care at the Alaska Native Medi-11. cal Centre: a fully deployed “new model” of pri- mary care. International Journal of Circumpolar Health. 2007; 66(Suppl. 1): 4−13. Emejulu JKC, Osuafor CNC, Ogbuagu CN.12. Audit of the Demographic Patterns of Neuro- surgical Cases in a Tertiary Health Institution: the need to relate service delivery to disease pro- file in dwindling resources and manpower short- age. African Journal of Neurological Sciences. 2009; 28 (2). http://ajns.paans.org. AFRICA/NIGERIA MASTERWEB Spe-13. cial Feature: Nigeria 2006 Census Figures 109 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy http://www.africamasterweb.com & http:// www.nigeriamasterweb.com Eby D. Integrated primary care.14. International Journal of Circumpolar Health. 1998; 57 (Suppl. 1): 665−7. Gottlieb K, Sylvester I, Eby D. Transforming15. your practice: what matters most? Family Prac- tice Management. 2008; 15: 32–8. Kerssens JJ,16. et al. Comparison of patient evalua- tions of health care quality in relation to WHO measures of achievement in 12 European coun- tries. Bulletin of the World Health Organization. 2004; 82 : 106–14. Halman L et al.17. Changing values and beliefs in 85 countries. Trends from the values surveys from 1981 to 2004. Leiden and Boston, Brill, 2008 European values studies 11; http://www.world- valuessurvey.org, accessed 2 July 2008. Millenson ML. How the US news media made18. patient safety a priority. BMJ. 2002; 324: 1044. Davies H. Falling public trust in health services:19. Implications for accountability. Journal of Health Services Research and Policy. 1999; 4: 193–4. Mullan F, Frehywot S. Non-physician clinicians20. in 47 sub-Saharan African countries. Lancet. 2007; 370 : 2158–63. Gilson L. Trust and the development of health21. care as a social institution. Soc Sci Med. 2003; 56: 1453–68. Audrey B, Graves PE. Predicting Life Expect-22. ancy: A Cross-Country Empirical Analysis. Emejulu, Jude-Kennedy C, MBBS, FWACS Neurosurgery Unit, Department of Surgery & Accident and Emergency Unit E-mail: judekenny2003@yahoo.com Igwegbe, Anthony O, MBBS, FWACS, FICS Department of Obstetrics and Gynaecology Eleje, George U, MBBS Department of Obstetrics and Gynaecology Ofiaeli, Robinson O, MBBS, FMCS, FICS, FWACS Orthopaedic Surgery Unit, Department of Surgery Nwofor, Alexander M E, MBBS, FMCS, FICS, FWACS Urology Unit, Department of Surgery Anumonye, Charles O, BSc, FHR Department of Health Records and Statistics Robert Jütte Etymology The term “placebo” has not been part of medical usage for very long, but the phe- nomenon we refer to as the “placebo effect” has been known in medical as well as lay circles for a long time. The French phi- losopher and writer Michel de Montaigne (1533–1592) described the powerful effect of imagination on the human by using the example of a patient who received regular non-medical enemas given by his doctor and experienced the same effect from them as from enema that actually contained me- dicinal substances rather than just warm wa- ter [38]. It was not until the second third of the 18th century that the phenomenon, or at least a partial aspect of it, was first referred to as “placebo”.It was the Scottish physician and pharmacologist William Cullen (1710– 1790) who coined the expression. In 1772 he demonstrably used the term for the first The History of the Placebo1 This historical study is part of a larger project on1. the placebo effect undertaken by a group of ex- perts on behalf of the Wissenschaftlicher Beirat der Bundesärztekammer (Scientific Board of the German Medical Association) 110 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy time in his Clinical Lectures in connection with a patient to whom he gave an external application of mustard powder although he was not convinced of its specific effect: “I own that I did not trust much to it, but I gave it because it is necessary to give a med- icine, and as what I call a placebo. If I had thought of any internal medicine it would have been a dose of the Dover’s powders.” [10]. In another case that he considered to be hopeless he also prescribed a medicine that was ineffective in his view and justified his decision as follows: “I prescribed there- fore in pure placebo, but I make it a rule even in employing placebos to give what would have a tendency to be of use to the patient” [9]. Cullen’s “placebo” was not yet an inert sub- stance. He tended to use low doses of drugs which he thought to be ineffective given the severity of the disease. His main concern was not what to prescribe but how to fulfil the patient’s desire for a medicament, even though he did not personally believe in its pharmacological effectiveness (according to the state of knowledge at the time) [28]. At the time when Cullen introduced the term “placebo” into medicine it had a dif- ferent meaning in the English language. Since the 14th century “to sing a placebo” had meant as much as “flattering a person of high rank”[7]. It was an ironical application of a medieval antiphon from the mass for the dead. An antiphon is a short, memora- ble response in the liturgy, in this case the last verse of psalm 116, which in the origi- nal Hebrew reads: ‫ֶא‬‫ת‬ְ‫ה‬ַ‫ל‬ֵּ‫ך‬ְ, ‫ִל‬‫פ‬ְ‫נ‬ֵ‫י‬ ‫ְי‬‫ה‬‫ָו‬‫ה‬- ‫ּב‬ְ‫א‬ַ‫ר‬ְ‫צ‬‫,תֹו‬ ‫ַה‬‫ח‬ַ‫י‬ִּ‫י‬‫-ם‬ [24, 3, 40, 2]. In the King James Bi- ble it is translated as “I will walk before the Lord in the land of the living”. This version corresponds to the Latin translation by the church father Jerome (Vulgate) which fol- lows the Hebrew text (Ps 114.9): “Deambu- labo coram Domino in terram viventium”. In the Septuagint,the classical Greek trans- lation of the Old Testament, the Hebrew verb for “go” or “walk” is not rendered liter- ally but figuratively as ευαρεστισω. Jerome‘s Latin translation (the Gallicana version) of the Greek correspondingly uses the verbal phrase “placebo”. Translated into English the verse then reads: “I shall be pleasing in the sight of the Lord in the land of the liv- ing” [21]. Early uses of placebo Next to the Scottish physician and pharma- cologist William Cullen it was a German doctor who used the placebo effect in his own practice: Samuel Hahnemann (1755–1843), the founder of homoeopathy. He translated Cullen’sMateriaMedicaintoGermanwhich gave him the idea for his famous experiment with Peruvian Bark. Hahnemann was obvi- ously not familiar with the term “placebo”al- though he knew the principle which for him meant giving “something non-medicinal” such as raspberry juice or lactose. Early on in his homeopathic practice he encountered the problem that his patients were used to taking medicine on a daily basis as was cus- tomary in orthodox medicine at the time, while in homeopathy it was important, in his view, to allow the remedies to fully un- fold their action.In an essay that was printed in the Allgemeine Anzeiger der Deutschen in 1814 Hahnemann offered the following recommendation to his colleagues: “In the meantime, until the second medicament is given,one can soothe the patient’s mind and desire for medicine with something incon- spicuous such as a few teaspoons a day of raspberry juice or sugar of milk” [18]. In his work on the chronic diseases he advised: “If a homeopathic physician, doubtful without occasion,asks me how,during the many days after giving a dose of medicine that should continue to act undisturbed, to satisfy the patient who demands medicine every day, without harming him I reply in two words: “give him a daily dose of lactose, about three grains, at the usual time marking it with the continuous number”[17]. Hahnemann already experienced that the blinding was not always successful. One of his patients, also an eager reader of his writings, had seen through the deception but still remained loyal to Hahnemann: “The powder I took regularly although I am well aware that only number (figure illeg- ible, R.J.) is a medicine as instructed in your worship’s books which I looked into” [23]. In Hahnemann’s case journals, which are almost fully preserved, he marked placebos with the paragraph symbol (§). After first experimenting with ground oyster shells (Conchae) as placebo at the beginning of his homeopathic practice he later on al- most exclusively gave lactose in these cases to which the homeopathic Materia Medica does not attribute a medicinal effect [39]. On 21 June 1807 the then US president Thomas Jefferson (1743–1826) wrote to a Dr. Caspar Wistar: “One of the most suc- cessful physicians I have ever known, has assured me, that he used more bread pills, drops of colored water, powders of hickory ashes, than of all other medicines put to- gether. It was certainly a pious fraud. But the adventurous physician goes on, substi- tutes presumption for kno[w]le[d]ge” [25]. It cannot be fully ascertained but we can as- sume that the successful physician in ques- tion was Benjamin Rush (1745–1813), a James Lind 111 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy friend of Jefferson’s. The letter proves that, as early as the beginning of the 19th century, physicians consciously used the placebo ef- fect while being aware of the ethical impli- cations (“pious fraud”). During World War I a Jesuit priest employed as a nurse in a battlefield hospital,knowingly administered sodium chloride injections as placebos: “Every evening there was the fight about the morphine that the patients demanded. They begged and pleaded. But we used it sparingly and, if it was at all possible, we did not give them any. [...] If the lamenting did not cease we often had no choice but deceive them with a sodium chloride injec- tion. The moaning and groaning often con- tinued all through the night [...].”[Archives of the German Jesuit Province in Munich, 00/752vl, Kriegslazarett 8, vol. 1-2. P. 126] The placebo in clinical research The beginnings of the controlled trial (with simple, double and triple blinding) date back to the 18th century, though no placebo was used to start with. It began with the Scottish Naval Surgeon James Lind (1716–1794) [43]. In his Treatise on the Scurvy (1753) he described how he per- formed the first clinical drug testing on 20 May 1747 on board a British Navy vessel. Of 12 scurvy patients (“as similar as I could have them”) two were given cider, two vit- riol, two vinegar, two sea water, two orang- es and lemons, two an electuary of garlic, mustard seeds, balsam of Peru and gum myrrh. The patients who were fed citrus fruit recovered within six days. The com- parison group remained without treatment apart from “a little lenitive electuary”[32]. We know today that citrus fruits are the treatment of choice because they contain vitamin C the lack of which causes scurvy. As the vitamins had not been discovered yet at the time, lemon juice was seen as a cleansing agent that could rid the body of toxic particles. In 1784, a commission of experts that was appointed by the French king, Louis XVI (1754–1793), and includ- ed Benjamin Franklin (1706–1790),carried out simple blind trials to ascertain whether Franz Anton Mesmer (1734–1815) was right in claiming that the magnetic fluid (animal magnetism) had a healing effect. For the trial, the test candidates were sepa- rated from the physician, who was to mes- merize them, by a screen. The fluid transfer only worked if the test person knew about the treatment which led the commission to conclude in 1785: “this agent, this fluid has no existence”[27]. This by no means put an end to the debate about the effective- ness and effect of mesmerism. It continued right into the 19th century and there are still magnetisers today who see themselves as continuing Mesmer’s legacy [26, 42]. In 1799, the British physician Dr John Haygarth (1740–1827) tested in a simple blinded trial the controversial healing ap- proach of the American doctor Elisha Per- kins (1741–1799) who claimed he could deviate harmful energy (electroid fluid) from the sick body by means of a “tractor” made from two metal rods [19]. The test was performed in the following way: there were two groups, one of which was treated with the metal tractors and the other with wooden rods that were made to look exactly like the “genuine” ones. The treatment was similarly successful in both groups. The first controlled clinical trials with “in- ert” substances were developed by physi- cians who either sought to prove the ef- fectiveness of homeopathy or to expose this new healing system as “humbug” [11, 12]. The first was the German-Russian physician Dr J. Hermann who, in 1829, performed a kind of outcome study in a military hospi- tal in Tulchin, now Ukraine. He compared the treatment of malaria patients in a ho- meopathic and an allopathic ward [20]. In a follow up trial, which he was able to con- duct shortly after in a military hospital in St Petersburg under the supervision of a Dr Gigler, a third trial arm was added. The patients allocated to this group basically received only general care (baths, sufficient food and rest): “During that time the patients were kept in a state of innocent deception. In order to avoid the suspicion that they did not receive any medicine, they were prescribed pills made from white bread crumbs or cocoa, or sugar of milk powder, or salep decoctions as was also the case in the homeopathic ward” [31]. Interestingly, the best results were achieved in the group that was given no treatment apart from loving care. The first double blind trial with a placebo arm also served the assessment of homeop- athy. The initiative by physicians who were sceptical about homeopathy took place in a Nuremberg public house in 1835 [Stolberg, 1996]. The trial was performed as follows: A C30 solution of purified salt and distilled snow water was prepared. 100 vials were meticulously cleaned and numbered, then well shuffled and spread on two tables. Half of them were filled with the homeopathic solution, the other with pure distilled snow water. After a list of the vials and their con- 112 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy tent had been made and sealed, the vials were again thoroughly shuffled. Then the principal investigator gave each participant a vial which was also registered with the number and the participant’s name. Neither participants nor investigators knew who had been given which vial but this could be discovered with the help of the sealed lists. The outcome was not unambiguous. The homeopaths in particular were critical of the fact that the drug had been tested on healthy subjects. Still, the experiment was ground-breaking in one respect: it consti- tuted the beginning of the modern clinical trial, not yet randomised, but double blind. How progressive the study design was is shown by the forward-thinking comment made by the leading investigator: “Avoid anything that would enable the individual probands to surmise whether they have re- ceived distinctly homeopathic or distinctly non-medicinal test substances. Even the producers and distributors of the doses must not know, as was the case in our trial, what this or that person was given” [33]. In the course of the 19th century more pla- cebo controlled studies into homoeopathy were carried out [13], one of them in 1877 at Boston University Medical School in the United States by Conrad J. Wesselhoeft, sr (1834–1904) who tested Carbo vegetabilis using simple blinding [45]. Other treat- ments were also assessed in clinical stud- ies up to the outbreak of World War I, but they did not yet meet modern RCT criteria [27]. Despite a few pioneering efforts, more than a century went by before placebo controlled trials became the standard of clinical re- search, which was partly due to the lack of a methodology. Only in 1932, the Bonn cli- nician Paul Martini (1889–1964) submitted his Methodenlehre der therapeutischen Unter- suchung (Methods of Clinical Investigation) which saw four editions and was the first text book of its kind. Even though the term “placebo” was only introduced in the later editions, Martini was doubtlessly familiar with the problems surrounding the placebo effect as we can see from his preface: “The best way to exclude suggestive or other sub- jective factors is to keep the trial set-up un- known. Applied to the main group of our therapeutic armamentarium this means: the medicines must be offered to the patients in a form or disguise that does not reveal their special character or purpose; they must be masked”[36] . The medicine and the non- medicinal substance selected for compari- son had to be identical in form, colour and taste. Martini saw greater difficulties in the case of non-medicinal therapies. There it was important, he pointed out, “to com- pensate as much as possible through strict avoidance of any suggestion, even by using counter-suggestion” [36]. Between 1936 and 1939 Martini evaluated individual ho- meopathic medicines such as bryony, secale cornutum (ergot), sulphur and sepia (cuttle- fish) [34, 35]. From a modern point of view these trials can be criticised because of their ambiguous design with different verum and placebo phases, an insufficient number of probands, heterogeneous dosages, lacking control of carry-over-effects, simple blind- ing that allows manipulation through the examiner [44]. Compared to the drug re- search carried out by the Leipzig homeo- paths Martini’s studies were certainly more progressive in one respect: they were based on intra-individual placebo control. At almost the same time, the understanding grew in Britain and the USA that the factor “suggestion” had to be neutralised through blinding if at all possible.The work of Har- ry Gold (1899–1973) at Cornell University Medical School must be mentioned in this context, including his highly regarded study on methylxanthine in the treatment of an- gina pectoris [16]. One of his colleagues re- called later that the term “blind test”used by the study authors was inspired by a cigarette advertisement from the 1930s [40]. While the placebo controlled double blind trial had been known for some time many scientists did not see the necessity for ran- domisation. It was a statistician who first advocated it: R. A. Fisher (1890–1962) [47, 8]. In his book The Design of Experiments (1935) he emphasised the importance of randomised trials [14]. Most clinicians did not support randomisation at first because they felt it restricted them in their autono- mous therapeutic decision-making. Austin Bradford Hill (1897–1991) was an excep- tion. He carried out the first randomised double blind trial in 1948 to assess the ef- fect of streptomycin. In his memories he described to what length he had gone at the time to avoid the word “randomisation” in the study design so that he would not alienate his medical colleagues [22]. When asked in an interview in 1970 which fac- tors had contributed to the introduction of RCTs in medicine, Hill mentioned next to the development of a number of new,prom- ising medicines (sulfonamides, analgesics, antibiotics, cortisone preparations) also the research in military medicine during World War II, when new methods and study de- signs had been put to the test [40]. In 1955, the Journal of the American Medi- cal Association published a paper by Henry Knowles Beecher (1904–1976) titled “The Powerful Placebo” [5] in which he reviewed 15 different placebo studies on the treatment of headaches, nausea or post surgery pain. He arrived at the conclusion that of the 1082 patients who participated, an average of 35% reacted to placebos. For the first time the placebo effect was quantified and scientifi- cally documented on a relatively broad basis [critical: 29]. Today “The Powerful Placebo” is one of the most frequently quoted papers 113 Medical Ethics, Humam Rights, Socio-medical affairs and Environmental Policy on the topic of placebos. Its publication in a reputable specialist journal contributed to placebo controlled double blind studies grad- ually becoming the standard in pharmaceuti- cal research from the 1950s onwards. In the early 1970s, placebo research took a new direction when the responder concept which claims that some people are more sus- ceptible to placebos than others. A milestone on the way to the epistemic shift was Jerome D.Frank’s book Persuasion and Healing (1973) which focused on what is called the therapeu- tic setting [15].The change in expectations is seen as a crucial mechanism with the placebo effect. According to Frank, it was simply a matter of inducing hope for improvement in a patient who was seeking help. At the end of the 1970s, placebo research moved a step further after the discovery of endorphins. An American group of scien- tists showed that it was possible to stimu- late the release of endorphins with placebos and thus override pain receptors [30]. They were convinced that they had found the pla- cebo effect’s mechanism of action. Almost at the same time Robert Ader and Nicholas Cohen experimented with a strain of mice that spontaneously became sick due to an overreaction of the immune system which is usually treated with immunosuppressives [1]. The two researchers were able to dem- onstrate that conditioning made it possible to replace the verum with sugared water, thus proving that the placebo effect cannot be reduced to a particular human interac- tion. At the beginning of the 1980s there was a new development. In 1983, the Ameri- can anthropologist Daniel E. Moerman of Michigan University suggested replacing the term “placebo effect” by “meaning re- sponse” [37]. 1985 saw the first endeavours to bring the various research strands together. The American authors L. 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Cruttwell; 1801. Herrmann J.Amtlicher Bericht des Herrn D.Her-20. rmann über die homöopathische Behandlung im Militärhospitale zu Tulzyn in Podolien, welche er auf Befehl Sr. Maj. des Kaisers Nicolaus I. unter- nommen; nebst einer Abhandlung über die Kur der Wechselfieber. Annalen der homöopathischen Klinik. 1831; 2: 380–99. Hieronymus. Epistola CVI Ad Sunniam et Frete-21. lam: “Placebo Domino in regione vivorum [..] pro quo in Graeco legisse vos dicitis: Placebo in con- spectu Domini. Sed hoc superfluum est.” (http:// patrologia.narod.ru/patrolog/hieronym/epist/ epist04.htm, letzter Zugriff 19.10.2007) Hill AB. Suspended judgment: memories of the22. British streptomycin trial in tuberculosis. the first randomized clinical trial. Controlled Clinical Tri- als. 1990;11: 77-9. Holtz [Ziegeleibesitzer] an Dr. Samuel Hahne-23. mann, Brief vom 8.9.1832, Archiv des Instituts für Geschichte der Medizin der Robert Bosch Stif- tung, Stuttgart, Bestand B 321150. Jacobs B. Biblical origins of placebo. Journal of the24. Royal Society of Medicine. 2000; 93: 213–4. Jefferson T. Brief vom 21.6.1807 an Dr. Caspar25. Wistar. http://www.iupui.edu/~histwhs/h364.dir/ jeffwistar.html (letzter Zugriff 8.11.2007). Jütte R. Geschichte der alternativen Medizin. Von26. der Volksmedizin zu den unkonventionellen Ther- apien von heute. München: C. H. Beck; 1996. Kaptchuk T J. Intentional ignorance: a history of27. blind assessment and placebo controls in medi- cine. Bulletin of the History of Medicine. 1998; 72: 389–433. Kerr CE, Milne I, Kaptchuk TJ. William Cullen28. and a missing mind-body link in the early history of placebos.The James Lind Library (www.james- lindlibrary.org, letzter Zugriff 8.10.2007). Kienle GS. Der sogenannte Placeboeffekt. Illu-29. sion, Fakten, Realität. Stuttgart; New York: Schat- tauer; 1995. Levine JD, Gordon NC, Fields HL. The Mecha-30. nism of Placebo-Analgesia. Lancet. 1978; 2: 654–7. Lichtenstädt J. Beschluss des Kaiserl. Russ. Men-31. icinalraths [sic] in Beziehung auf die homöopa- thische Heilmethode. Litterarische Annalen der gesammten Heilkunde. 1832; 24: 412–20. 114 Regional and NMA news Lind J. A treatise on the scurvy […]. 2. Aufl. Lon-32. don: Millar ;1757. Löhner G. Die homöopathischen Kochsalzver-33. suche zu Nürnberg. Nürnberg: G. Löhner; 1835. Martini P, Brückmer M, Dominicus K, Schulte34. A, Stegemann A. Homöopathische Arzneimittel- Nachprüfungen. Naunyn-Schmiedebergs Archiv für experimentelle Pathologie und Pharmakologie. 1938; 191: 141–71. Martini P. Die Arzneimittelprüfung und der Be-35. weis des Heilerfolges. In: Allgemeine homöopa- thische Zeitung. 1939; 187: 154–67. Martini P. Methodenlehre der therapeutischen36. Untersuchung. Berlin: Julius Springer; 1932. Moerman DE. Physiology and Symbols: the an-37. thropological implications of the placebo effect. In: Romanucci-Ross L, Moerman DE, Tancredi LR,eds.The anthropology of medicine.New York: J. F. Bergin Publishers. P. 156–67. Montaigne M. Essays, übersetzt von Stilett, H.38. Frankfurt/Main: Eichborn; 1998. Papsch M. Krankenjournal D 38 (1833–1835).39. Kommentarband zur Transkription. Stuttgart: Karl Haug Verlag; 2007. Shapiro AK, Shapiro E. The powerful placebo:40. from ancient priest to modern physician. Balti- more: Johns Hopkins University Press; 1997. Stolberg M. Die Homöopathie auf dem Prüfstein.41. Der erste Doppelblindversuch der Medizinges- chichte im Jahr 1835. Münchner Medizinische Wochenschrift. 1996; 138: 364–6. Teichler JU. “Der Charlatan strebt nicht nach42. Wahrheit, er verlangt nur Geld.“ Zur Ausein- andersetzung zwischen naturwissenschaftlicher Medizin und Laienmedizin am Beispiel von Hyp- notismus und Heilmagnetismus. Stuttgart: Franz Steiner Verlag; 2002. Tröhler U.“To improve the evidence of medicine“.43. The 18th century British Origins of a critical ap- proach.Edinburgh: Royal College of Physicians of Edinburgh; 2000. Walach H. Die homöopathischen Arzneimittel-44. prüfungen von Martini (1936–1939). Allgemeine homöopathische Zeitung. 1991; 236: 137–42, 186–97. Wesselhoeft C Sr. A reproving of Carbo vegeta-45. bilis. Made for the purpose of demonstrating the necessity of countertests in drug-proving. Trans- actions of the Thirthieth Session of the American Institute of Homoeopathy. Philadelphia: Sher- man; 1877. P. 184–280. White LB,Tursky B, Schwartz GE. Placebo.The-46. ory, Research and Mechanisms. New York: Guil- ford Press; 1985. Yates F. Sir Ronald Fisher and the design of ex-47. periments. Biometrics. 1964; 20: 307–21. Prof.Robert Jütte, Director of the Institute for the History of Medicine of the Robert Bosch Foundation, Stuttgart. Kroo Florent At the invitation of the Commission of the West African Economic and Monetary Un- ion (UEMOA), the administrative and pro- fessional medical authorities of eight African countries (seven French-speaking and one Portuguese-speaking) met in Ouagadougou, Burkina Faso in March 2010. The purpose of the meeting was to reflect, analyze and consider the reduction of the medical evacu- ations out their regional space through better organization and medical collaboration. Context and justification The Member States of the UEMOA have the ambitious objective to develop their sys- tems of health.To this end, the structures of care are organized according to a medical pyramid with three levels. The first level is basic healthcare at the district level, under the responsibility of a general practitioner. The second level is under the responsibility of specialist doctors, who receive patients that are evacuated from the districts. The last level consists of hospitals, which are further equipped and are charged with de- livering even more specialized care. Facing a lack of resources, these West Afri- can states are confronted with two difficul- ties: to ensure the extension of basic care at the first and second levels in order to serve the greatest number, while also developing specialized care at the third level to ensure the care of the most severe cases. Progressively, with the consolidation of medical coverage, the need for evacuations to specialized hospitals continues to grow and diversify. Unfortunately none of these states has sufficient equipment to face the growing requirements.These states have thus relied on the hospitals of Europe, the United States, and North Africa (Morocco and Tu- nisia). These evacuations to facilities beyond the home community constitute significant expenditures (approximately 8 billion francs CFA per annum), without the possibility of improving the local medical system. Reduction of the Medical Evacuations Initiative of eight African western countries. Map of West Africa locating the 8 Member States of the UEMOA 115 Regional and NMA news General objective The general objective of the recent dialogue was to identify and evaluate the specialized care facilities in each country that could function as regional centers of excellence in order to reduce the medical evacuations out of UEMOA space. These evaluations were made by a competent authority1 under the supervision of an international expert2 . Results The total number of evacuations made by each country’s Council of Health during the years 2007 and 2008 is 1547 patients for the eight countries of the UEMOA. The evacuations organized by category are as follows: Cardiovascular system: 305 cases (22.6%)•  Musculoskeletal system: 245 cases (16%)•  Urinary tract: 237 cases (15.3%)•  Nervous system: 151 cases (10%)•  Ocular system: 142 cases (9%)•  Gynecological system: 133 cases (8.6%)•  Pathologies of these six systems account for 81% of the medical reasons for evacuations. These 1547 patients are distributed by coun- try as follows: Benin: 217 cases•  Burkina Faso: 182 cases•  Côte d’Ivoire: 29 cases•  Guinea Bissau: 747 cases•  Mali: 108 cases•  Niger: 203 cases•  Senegal: 28 cases•  Togo: 3 cases•  Among six countries (excluding Togo, whose Council of Health did not sit and consequently did not evacuate any patient during the period, and Guinea Bissau), 767 patients were evacuated by the Councils of Health out of the region in 2007 and 2008. The case of Guinea Bissau is to be taken separately because it evacuated nearly as many patients as all of the other UEMOA countries combined.Its 747 cases were evac- uated principally due to urinary pathologies (e.g., urolithiasis, hydronephrosis), which are dealt with successfully in almost all the UEMOA countries. Among the pathologies listed for the evacu- ations, most frequent are: cardiovascular: congenital cardiopathies,•  valvular diseases, auriculo-ventricular block musculoskeletal system: osteoarthritis of•  the hip and arthrosis of the knee cancerology (radiotherapy): uterine collar•  and breast cancer nervous system: encephalic tumour, men-•  ingioma, slipped disc ophthalmology: retinopathy repair, lesion•  of glazed, glaucoma Reasons given for evacuations are as fol- lows: insufficient materials•  insufficient human resources•  political or administrative pressure•  the kindness of the doctors•  insufficient hygiene in local health facili-•  ties Participants of Burkina Faso and Côte d’Ivoire surrounding the Head of the Department of Social and Cultural Development (March 2010) Participants of the Ouagadougou UEMOA meeting (March 2010) 116 Regional and NMA news The direct cost of these evacuations was evaluated at 13, 445, 421, 453 FCFA, or ap- proximately 7 billion francs per annum. Recommendations A list of one to four centers of special- ized care, based on facility and not specific pathologies, was proposed and validated. These centers will be the subject of a thor- ough evaluation,which will make it possible to classify them and to obtain a final list of centers of high-level care eligible to profit from the support necessary to become cen- ters of excellence in the UEMOA region. The recommendations are as follows: To work out a regional medical map of•  the centers of specialized care To educate and inform the decision mak-•  ers, health personnel, and the population To motivate health personnel•  To increase material resources•  To organize regular specialist missions in•  UEMOA countries for the local assump- tion of responsibility of certain prior- ity pathologies in Guinea Bissau and in other countries To plan the initial and continuing spe-•  cialized trainings of the health personnel and managers of these centers To create training structures for the main-•  tenance of medical material To establish the institutional environment•  (equipment,maintenance,administration, management, control, quality assurance) To institute a universal system of address-•  ing disease risk Conclusion This regional initiative requires the initia- tive of local actors and decision-makers in the health field to be coordinated with the integrated efforts of all countries concerned. Realizing this approach to medical col- laboration requires overcoming the difficul- ties inherent in any project in a developing country and making an effort to procure ad- equate technical material. National medical associations as well as institutional profes- sional organizations must be invested in the initiative in order to successfully address the challenge of integration. Kroo Florent AKA, MD President of National Order of Physicians. President of Ivorian Medical Association E-mail; onmci@yahoo.fr Côte d’Ivoire Jaroslav Blahoš The CzMA is a voluntary and independent organization of medical doctors, pharma- cists and workers in the healthcare services and related fields. Our membership has been gradually increasing since 1989 when the CzMA became a democratic institution with a democratically elected president and council members. Similarly, the chairs and councils of individual scientific societies are elected by secret ballot.The members of the CzMA are affiliated on the basis of their specialities in individual scientific societies. In larger cities the doctors organize the lo- cal medical clubs. Currently, 107 scientific societies and 40 local clubs are registered within the CzMA. The history of the CzMA dates from the middle of the 19th century and is closely lin- ked with the propagators of national Czech medical science. Their main representative was Jan Evangelista Purkyne (1787 – 1869), the world-renowned scientist,physician and humanist. In 1862, Purkyne and his collea- gues founded the “Club of Czech Doctors,” the predecessor of the CzMA. His name gives prestige to the title of our Association. By associating ourselves with this great personality we express our continuity with the tradition and his human and scientific legacy.The aim of J. E. Purkyne and his col- leagues was, above all, the development and propagation of knowledge of medical scien- ce and related fields and their application in healthcare for the people. These fundamen- tal aims remain unchanged to this day. The CzMA is the major representative body of scientific medical activities in the Czech Republic. It initiates and supports science and specialist work in a broader sense, not only within its own ranks, but also by of- fering its experience to other healthcare organizations, e.g., the Ministry of Heal- th, Ministry of Labour and Social Affairs, professional chambers, health insurance companies, and other domestic institutions, including organizations concerned with ethical, pastoral, and ecological issues, the environment, safety and health, and welfare institutions. The Association is strongly involved in post- graduate and continuing medical education in almost all fields of medicine, and orga- nizes many national and international con- gresses, symposia, and courses. The CzMA also takes an active part in organizing scien- The Czech Medical Association (CzMA) 117 Regional and NMA news tific meetings connected with the most im- portant medical and pharmaceutical exhibi- tions in the Czech Republic. The CzMA is editor of 29 medical journals, which are distributed in the country and abroad. The CzMA also has close relations with European and international medical associations. Of these, the most impor- tant are the World Medical Association (WMA), the Forum of European Medi- cal Associations, the WHO (in which the CzMA is represented in the Council), and the Council for the International Organi- zations of Medical Sciences (CIOMS). We work closely with our friends and collea- gues in the Slovak Republic even after the separation in 1993 from the Czechoslovak Medical Association. Our scientific societies are members of va- rious international organizations. Many of them are representatives in the committees and councils. The CzMA awards honours and prizes, which are received with gre- at respect. The most prestigious of these is the J. E. Purkyne Prize, which is awarded once a year to one distinguished medical personality, with the ceremony taking place at the castle of Libochovice (near Prague), Purkyne´s birthplace. Professor Jaroslav Blahoš, MD, DSc. President, Czech Medical Association Former President, World Medical Association The mission of the Brazilian Medical As- sociation (AMB),founded in 1951,is to ad- vocate for the professional dignity of physi- cians and for quality health assistance to the Brazilian population. AMB is composed of 27 State Medical Associations and 396 Regional Associations. Moreover, AMB’s Scientific Council is composed of 48 Medi- cal Societies, representing the 53 specialties recognized in Brazil. AMB is a member of the World Medical Association and is co- founder of the Portuguese Language Medi- cal Community. Areas of Action Professional Qualification Undergraduate Studies: AMB has been fighting against low quality medical schools since its foundation. Advocating for better medical professionals. Board Certification: Since 1958, AMB has been pursuing scientific improvement and professional recognition for physicians through board certification after approval in rigorous examinations. AMB also manages the credits required for updating the board certification through the National Accredi- tation Committee (CNA). Continuing Medical Education (CME): Physicians’ scientific knowledge is updated through the CME program. Developed in partnership with the Brazilian Council of Medicine, the program is online, free of charge and available for all Brazilian physi- cians. Guidelines Program: Since 2000, AMB designs medical guidelines based on scien- tific evidences in order to standardize prac- tices and support physicians on diagnosis and treatment. More than 300 guidelines have been created since then, all of them available at www.projetodiretrizes.org.br. Professional Recognition Regulation of the Medical Profession: AMB is actively involved in the discussions concerning Bill No 7703/06 (Medical Act), a proposal to regulate Medical practice. Brazilian Classification of Medical Pro- cedures (CBHPM): Developed and con- tinuously updated by AMB, the Brazilian Council of Medicine (CFM), the Physi- cians National Federation (Fenam) and the Societies of Medical Specialties, the Brazil- ian Classification of Medical Procedures (CBHPM) lists all medical procedures sci- entifically proved and became a reference of health quality for the population. Position, Career and Wages Plan: AMB is member of the Committee in charge of developing a medical career and wages plan for doctors working at the Brazilian Unified Health System (SUS). Dr. Pedro Wey B. Oliveira, International Affairs Division Brazilian Medical Association Brazilian Medical Association (AMB): Objective and Actions 118 Regional and NMA news The Republic of Macedonia is situated in the southern part of the Balkan Peninsula. Won independence after World War II, in which its citizens took an active part on the side of the antifascist coalition. After the war, Macedonia was part of Yugoslavia, as one of the six equal federal republics. With the dissolution of the federation, in 1991 the Republic of Macedonia gained its inde- pendence and sovereignty. Macedonia covers an area of 25,713 square kilometres, populated with 2,048,619 in- habitants, according to the data from 31 Poor Health System and Active Macedonian Medical Chamber The Medical Chamber of Serbia was revived in 2006, drawing upon the tradition of the Medical Chamber established in 1901 in the Kingdom of Serbia.The original Cham- ber played a very significant role in the work and life of physicians of that time, however, the functioning of the Chamber was banned after World War II by the new communist authorities, as was the case in all the coun- tries in our neighbourhood. Within the framework of the reform of the health sector in 2005, the Ministry of Health initiated the establishment of a medical chamber by virtue of the Law on the Chambers of the Medical Profession. Elections were organised to this effect, and MDs from both the public sector and the private sector were appointed to the Assem- bly of the Medical Chamber of Serbia thus establishing an integrated chamber of doc- tors of medicine in 2006. The beginning of the functioning of the Medical Chamber was not simple; we in- vested a lot of effort in the endeavour, and we did not hesitate to seek and accept advice from chambers with a longstanding experi- ence. Very shortly we drew up our Statute, and then, acting on the basis of the public authority we were vested with on the basis of the Law, we drew up our Code of Profes- sional Ethics, and proceeded with drawing up the full list of MDs and relevant records, and issuing licences and ID cards to eligible MDs, including the drafting of the neces- sary codes of rules for the functioning of the committees, and organising of our courts of honour, and all the other aspects necessary for ensuring continuous medical training. Our Chamber is a self-sustained and politi- cally and economically independent profes- sional organisation, financed from its own sources. All the MDs working in the bodies of the Chamber provide their services with- out any remuneration, being assisted in that process by the relevant support services in- volving lawyers, economists, IT experts, and others, who receive appropriate fees. OnthebasisoftheLawonHealthCareissued by the Ministry of Health of the Republic of Serbia, membership in our Chamber is man- datory, and membership fee is proportionate to the member’s monthly income. Currently, there are 29 500 doctors of medicine in Serbia, 26 200 of whom are public employees, while 3300 are in the private sector. Unfortunately, MDs from the private sector are not included in the health care system of our country, as a result of which patients have to pay for the relevant medical services from their own resources. The Medical Chamber is an institution performing the tasks delegated to it as well as other activities from the purview of the medical profession, and since we dispose of the professional potential of our mem- bers – MDs, as well as that of our support services, our objective is to become part of a health care system accessible to all MDs, through which they will be able to influence the resolution of issues relating to the medi- cal profession. We have a vision, and we are aspiring for becoming a significant factor in the decision taking process affecting the health care system of our country, as well as aiming to influence the content of all the laws relating to the medical profession. We take great pride in all that we have achieved over the past four years, particu- larly stressing the establishment of contacts and friendships with numerous chambers in Europe, the gathering together of the rep- resentatives of 15 chambers at the ZEVA Meeting in Belgrade, in September 2009, as well as the fact that we have been keeping abreast of all the developments at the level of CPE and EFMA, and most importantly, the fact that the procedure for the admis- sion of our Medical Chamber to the WMA is in process. Dr. Nada Radan-Milovančev President of subcommitee for international cooperation of the Medical Chamber of Serbia The Medical Chamber of Serbia Nada Radan-Milovančev 119 Regional and NMA news December 2008. The capital is Skopje, known as a city of solidarity, the name it got after the disastrous earthquake in 1963, when many countries around the world helped to build what was crashed by the natural disaster. After the liberation of Macedonia in 1945 it was not sufficiently built,without significant industrial facilities and with general poverty. The country was extremely poor, agrarian, with a developed trade production. Evident was the high mortality of the population that reached up to 21 per mille and mortal- ity of infants of 154 per mille. Sixty years later, the overall mortality rate decreased to 9 per mille, and the mortality rate of in- fants to 12.8 per mille (data from 2005). In 1945 there were in total, 123 physicians and dentists, 92 pharmacists and 120 nurses. There was no significant health infrastruc- ture. In addition to several hospitals, others were mostly small makeshift ambulances and health clinics. During this period the country faced major epidemics of malaria and tuberculosis. This situation changed over the years in former Yugoslavia and a significant improvement was the result of building health facilities supplied with new equipment and education and training of the medical personnel abroad (not only in more developed Yugoslav cities and hospi- tals, but in foreign countries as well). The first Medical School (Medical Faculty) wasestablishedinNovember1947,whenthe first generation of doctors began their stud- ies.The teachers of the first Medical School were not only Macedonians, but were most- ly from Croatia, Serbia, Russia and other countries. On the other hand, in the period between the two world wars many Macedo- nians studied medicine in several countries in Europe, mainly in France, in Bordeaux and Paris, in Switzerland, in Geneva, and in several universities in Italy. The state currently has three Medical Fac- ulties that educate medical staff. After the last complete independence of the country (1991), the state found itself in a poor situa- tion, as a result of the need for construction of the new state infrastructure, economic blockades, military conflict in the country in 2001, ongoing privatisation of commer- cial enterprises that produced many unem- ployed people and so on. Under such conditions, in 1995 the Parlia- ment adopted a new Law on health care that was supposed to follow new trends in health care in Europe,setting conditions for a modern health care system. Over the past fifteen years the law has experienced a total of 11 changes that harmonised the system with new experiences and achievements in the country and abroad. However, the low gross social product doesn’t allow develop- ing of the system that will fully meet the modern experience. Today in the Republic of Macedonia there are over 8000 active physicians in all spe- cialties. Most of them are doctors of general practice. Their number is around 2500. The number of unemployed doctors in the coun- try is around 350,so we are not in a shortage of doctors, on the contrary. Many of them are in specialisation training abroad, or they work abroad, and in the state are registered as unemployed. There are also trends in temporary employment abroad. Also, there are doctors that seek permanent employ- ment with the departure to other countries. What concerns, is the high age of doctors and uneven distribution in the country. The reform of the health system was started by the process of privatisation in the health care. All the doctors in primary care are pri- vatised, except a small number of them that take care of immunisation of the popula- tion. Doctors are paid through the so-called system according to the number and age of the patients attached. Similar processes are planned for consul- tative and specialist care. The next stage should be the transformation of hospital care, planned to function as public private partnership. Currently in Macedonia health care provid- ers are about 8000 doctors, 2500 of whom are primary care physicians, 2000 are spe- cialists in specialist consulting health care, or 2.5 doctors per 1000 inhabitants. The state has about 9500 hospital beds or one bed per 219 residents. At present time there is an ongoing process of building modern private health care fa- cilities – modern hospitals, organised with private venture capital from the country and abroad. They manage to survive by practis- ing medicine in areas not requiring lengthy and costly procedures for treatment. Thus, they are competitive on the market for health services and can afford to purchase modern equipment and high salaries paid to physicians. That’s why there is an ongo- ing process of migration of physicians from public to private hospitals. In contrast, state hospitals and university clinics as part of the public health, are suffering from insufficient funds with resulting constant problems to maintain the system. Obvious is the poor condition of many facilities equipped with outdated equipment, providing health care in the public health area. This is a basic situation that served as a background for foundation, organisation and operationalisation of the Macedonian Josif Dzockov 120 Regional and NMA news Medical Chamber. It was restored in 1992, even though, the first association of doctors in a chamber in the region of present-day Macedonia,which before World War II was called Vardarska Banovina – as a part of the Kingdom of Yugoslavia, was formed on 15December 1929. The Chamber has been active until the beginning of the Second World War. Today the activities of the Medical Cham- ber are going in two directions. The first is the scope of work arising from the Statute, Code of Medical Ethics and Deontol- ogy and the annual work programme, and the second is the public authority that the Chamber received on the basis of the Law on Health Protection. Macedonian Medical Chamber,in the place it has in the health system and organisa- tional structure,has adopted the work of the entities that make up the system. Besides the organisational activities arising from the work of the Chamber, through its rep- resentatives it actively participates in many bodies where health, health policy and re- lated professional activities are discussed. In this regard,we can say that there is relatively good co-operation with state authorities, the Parliament of the Republic of Mace- donia and its Ministry on Health, Health Insurance Fund and other institutions. Al- though representatives of the Chamber tend to be extremely co-operative, only an insig- nificant number of proposals are adopted by the competent authorities. In this direction, the Chamber frequently makes remarks to the public that it wants to be a part of the solution of the problem, but only if there is a respect to its proposals. The Chamber received public authority on the basis of the Law on Health Protection of 2004. Those were the Chamber’s sugges- tions dated back in the past. Unfortunately, the state authorities had no hearing on the proposals from the Chamber, although the proposals were based on international expe- riences. Although the Macedonian Medical Chamber was very ahead of the surround- ing countries, public authority was won and implemented much later, when these things were operating for many years in those sur- rounding countries. Public powers can be divided into three ar- eas. First, the Medical Chamber is leading the process of internship and exam taken by doctors who have completed medical school, after which they have the right to apply for a license to work. Second, the Chamber is au- thorised for the issue, continuance, renewal and the taking of the licenses for working. In connection with the licenses process, in the second phase, the Minister of Health is authorised to make the final decision.Third, the Chamber maintains a registry of doctors in the Republic of Macedonia, who have a license for working or general license. Achieved results confirm the correct move by the deviation of the Chamber’s authorities to the public powers. The exam is noted to be consistent with the educational process, es- pecially in the area of governance skills. Also the extension of the licenses triggered the process of continuous medical education and permanent professional development. Doctors’ Chamber permanently required being an active partner of the government in making the health policy in the state. Although this definition was introduced in the legislation, after a certain period, with changes in the law, it was withdrawn. Cur- rently the Chamber is on track to restore that right. The Medical Chamber seeks and ex- pects to receive request to be consulted when making decisions in the Health Fund. What in particular will the Medical Chamber con- tribute if getting the right place in the health care system,is the adoption of a Law for doc- tors’work, which has been in preparation for almost 15 years. Despite numerous attempts to enter the legal legislation, authorities have not accepted it untill now. Besides these high priorities, Medical Chamber has set many goals to get its valo- risation. Among other things, that is: pro- viding working conditions, receiving mod- ern equipment in public hospitals, a real appreciation of the work of doctors, etc. Medical Chamber has its own web page: www.lkm.org.mk and the periodical “Vox Medici”, which comes out every three months, printed in 6500 copies, and deliv- ered to all the doctors in the country. The journal publishes information of the Cham- ber’s work, and beyond, about the situation and problems in health care, educational materials and professional papers that are mandatory to review. There is also the Macedonian Medical As- sociation, as an association of specialist as- sociations in the state. Macedonia is a small and underdeveloped country. With the gross national income in 2008 of 2980 dollars per capita, Macedo- nian citizens were annually allocated 7.2 per cent of salaries or 160 Euros per capita.The real situation can be seen considering that the state has about 600,000 employees and the unemployment rate of 37.3 per cent – one of the highest in Europe. Despite this general condition, health care is delivered to all residents of the state. If one had in mind all this information, it would be clear that it is difficult to support a modern and quality health system in Macedonia, but we are do- ing everything we can. As a result of our tendency to be integrated in the general European medical processes, this year from 30 September untill 2 Octo- ber we will be the host for a ZEVA meet- ing – the Symposium of the Central and Eastern European Chambers of Physicians (for the second time). Sincerely we are hoping to meet as much participants from these countries, and also guests that are not in this group as we can. Josif Dzockov, Medical Chamber of Macedonia 121 Regional and NMA news Since 1990, after the changing of the po- litical and social regime, the health system in Albania encounters a lot of difficulties related to: very limited technical capacities to es-•  tablish policies, strategies and national plans; the insufficiency in the health care system•  financing and weak capacities in the field of health management; not yet applied institutional and individ-•  ual professional accreditation; the missing decentralisation of compe-•  tences ranging from government authori- ties to health institutions and public enti- ties and, as a result, not quite appropriate functioning of the orders and professional organisations; the lack of experience in monitoring and•  controlling the private activity; the lack of diagnostic equipment and cu-•  rative services. One of the acute problems is the unequal distribution of medical staff. Many com- munities are left uncovered by the health service. As a result of free movement and the migration towards big cities or abroad, the physicians have abandoned their work- ing places in remote rural areas. Taking into consideration the above- mentioned problems, the health reform in Albania was concentrated in an ambitious strategy that introduced many challenges to be faced. Facing these challenges,Albania has already gained advancements in many sectors, set- ting up of necessary structures in the sec- tors of Health Insurance Policies and Man- agement, Quality Control, Accreditation, Licensing, Monitoring, CME, Standardi- sation and Maintenance of medical equip- ment and others. Actually, the reforming policies concern-•  ing the health care system in Albania are directed towards: Improvement of the quality of health care.•  Augmentation of access and possibilities•  to offer health services nearer to the com- munities. Improvement of the budgetary and man-•  agerial capacities in the health care sys- tem. Inclusion in the health insurance scheme•  of all health services and liberalisation of health insurance trading. Improvement of the infrastructure and•  equipment of health institutions by intro- ducing contemporary technologies. Extending information technology to all•  of the system. Institutionalisation of the continuous•  medical education with accredited pro- grammes and, in relation to this, pro- fessional revalidation, recertification and periodic relicensing of health care system professionals. Accreditation and licensing of health in-•  stitutions, management of the risk and improvement of the quality of health in- stitutions, introduction of indicators for performance, efficacy and effective mea- surement. Connected to these, the National Centre for Continuous Medical Education and the National Centre for Quality, Assurance, and Accreditation of Health Institutions are established in Albania. Regarding this, spe- cial attention has been focused on the col- laboration and inclusion of the professional orders and associations. In this regard, after the changes in the so- cio-economic and political system, in 1994, by a law of the Albanian Parliament the Order of Physicians of Albania, as a new body without any precedent in the Albanian medical history, was created.This entity be- gan the activity in the circumstances of a very difficult transition in all sectors of the Albanian social life. Until 2000,the Order for reasons of a hand- icap to the first law was completely depend- ing on the Ministry of Health; its activity and competence were very restrained. In 2000,the new Law No.1615 “On the Order of Physicians in the Republic of Albania”, which considered the Order an indepen- Health Policy Reform in Albania and Development of the Order of Physicians of Albania Din AbazajShaqir Krasta 122 Regional and NMA news dent “public entity”, was promulgated. Just from this time the Order began to develop and enforce the institutional capacities and functioning as an effective, independent, professional body. The Law assigns the mission of the Order of Physicians, stimulation and preserving of high standards of practising, formation and professional education of the doctors, and protects patients and the public from the misuse and malpractice of health ser- vices. For the implementation of this mission, the National Council of the Order has oriented its work towards these main objectives: Raising the institutional capacity and ef-•  fectiveness of the Order. Establishing its indipendent budget.•  Creating the normative acts based on the•  Law, Statute, Code of Ethics and Medi- cal Deontology,and the regulations of the Order. Establishing the National and Regional•  Register of doctors, provision of its infor- matisation and updating;. Assigment of the medical practise stan-•  dards and the professional education of doctors. Fitness to practice.•  Relations and communication with the•  public. International relations.•  Partnership with the Ministry of Health,•  Faculty of Medicine and other health sy- stem actors. The progress during these years has been remarkable. The Order has raised the ad- ministrative capacity for all its stuctures. Nowadays the Order is functioning as an independent body and effective partner of the Ministry of Health. The new Code of Ethics and Medical De- ontology,as a data base of professional stan- dards, compulsory to be applied during the medical practice, is available to every doctor and stomatologist. The establishing of the National and Re- gional Register of the members of the Order and the inauguration of a website (www.urdhrimjekve.org) were the most important accomplishments during these years. This register, compiled as a data base, serves for the periodic professional revalida- tion of doctors and their relicensing to prac- tise profession. For the doctors, who are not fit to practice, disciplinary commissions of the first degree at the Regional Councils and the National Commission for Disciplinary Judgment of the second degree (appeal) are established. New regulations for the functioning of these commissions has been approved by the National Council. The Order of Physicians is a new body without experience, tradition and prec- edents in the Albanian Medicine. These circumstances dictate widening of the relations with homologous bodies of other countries and international forums. Except bilateral relations, the Order of Physicians of Albania is a member of a number of international organisations, such as: IAMRA (International Associa- tion of Medical Regulatory Authorities), WMA (World Medical Association), EFMA (European Forum of Medical Associations), CEOM (Conference des Ordres des Médecins), G.I.P.E.F. (Asso- ciation of the Medical Orders and Cham- bers of Mediterranean Countries), ZEVA (Symposium of the Medical Orders and Chambers of the Central and East Euro- pean Countries), etc. The extension and improvement of interna- tional relations aim at drawing the Albanian medicine nearer to and intergrating it with the European medicine. These initiatives have a positive impact and have “allowed the Order of Physicians of Albania to stand itself as a credible partner towards patients, the Ministry of Health and other factors and actors of the health system”. A positive influence on the increasing of credibility and recognition of the Order by the state structures as an independent body of medical self-regulation and on the con- solidation of partnership with these struc- tures have visits of many delegations of ho- mologous bodies and international forums and their meetings with the state authori- ties of our country. Actually the Order’s activity is aimed at these priorities: Perfection of the activity for increasing•  and consolidating the acknowledgment and credibility of the Order. Consolidation and the holding of a firm•  financial budget. Activities vitality and agility for standards•  of medical educations and everyday med- ical practices stimulation and iprovement Maintain the Code of Ethics and Medi-•  cal Deontology, and upwarding the moral image of doctors toward the society. The membership and registration to the Order of Physicians of Albania is compul- sory and a condition for practising the pro- fession. The constitutional bodies of the Order are: Order’s assemblies (National Assembly•  and Regional Assemblies). Order’s councils (National Council and•  Regional Councils). The Order’s councils are elected by the as- semblies, respectively the National Council by the National Assembly and the Regional Councils by the Regional Assemblies. The Regional Councils of the Order are set up and operated according to the adminis- trative division of the country in 12 dis- tricts. The assembly meetings and council elections are held every 5 years. Dr. Din Abazaj, President of the Order of Physicians of Albania Dr. Shaqir Krasta, General Secretary of the Order of Physicians of Albania 123 Regional and NMA news Stefan Konstantinov The Bulgarian Medical Association (BuMA) is a legal representative of doctors in Bulgaria. Membership is obligatory for everyone who wants to practice medicine in the country. The organisation was founded in 1901. During the communist regime it was banned. BuMA is comprised of 28 regional colleges of physicians with large autonomy. Every regional college maintains a registry of doc- tors with unique identification numbers given by the central office. At the begin- ning of 2010 the registry comprised about 34 000 doctors, the number of practicing doctors being about 30 000. Each regional structure appoints dele- gates who every 3 years elect the Board of BuMA. Besides the typical tasks of a medical cham- ber, such as preparation and surveillance of Professional Ethics Code, good medical practice, registry of doctors and continu- ous medical education, BuMA has specific tasks concerning professional interests of its members. The most important among them are the negotiations with the National Health Insurance Fund (NHIF) and sign- ing the annual frame agreement. In Bulgar- ia the National Health Insurance Fund is the major player in health insurance. Private funds hold a very small part of the market although their number is 21. The negotia- tions with NHIF quite often dominate over other functions of BuMA. What happened in health care in Bulgaria last year? There were two landmarks affecting it: the first – the general election held in 2009 and the second – the economic crisis. The centre-right GERB party,which won the general election last July,was expected to start the health reform. The list of the problems that had not been solved for years was quite long: chronically underfinanced health sector, low level and inefficacy of public expenses,in- crease of informal payments and decrease of patients’ satisfaction, young doctors leaving the country,heavy administration.But instead reforms the major changes which the Parlia- ment made were associated with a substantial reduction of the budget – especially concern- ing – from 476.192 million Euros (BGN 931.432 million) in 2009 to 362.439 million Euros (BGN 708.932 million) in 2010, i.e. approximately 222 million Euros less. At the same time the state presence in the otherwise independent NHIF was reinforced. And fi- nally and probably the most important – its financial reserve was included in the fiscal re- serve of the country in order to keep the bud- get deficit to an acceptable level. The financial restrictions led to significant delays of fund disbursements to doctors and hospitals by NHIF and resulted in wide- spread discontents which found expression in closure of medical offices in the period between 8th and 10th March 2010 and more feeble protests at the hospitals on 7th April. At the same time attempts to restructure and decrease the number of hospitals in Bulgaria failed.At present we have 331 hos- pitals in contracts with NHIF.This number is quite high for a country with a population of 7.607 million. As a whole, the task to implement a health reform under the conditions of an economic crisis and severe financial restrictions is left to the newly appointed minister of health care. Still the major challenges are open. Such as the way of financing hospital care. At present Bulgaria uses the so-called clini- cal paths. In the course of years the data of morbidity were distorted. Generally low prices and lack of efficient control led to the increase of hospitalisations on national level. There is a considerable disproportion between prices of different clinical paths due to lobbying. Despite the long-running discussion about the introduction of DRGs there still is no such decision. The problems of outpatient care are also important. Bulgaria has a system of GPs acting as gatekeepers. Access to a specialist is only by a referral from GP. Yet again fi- nancial restrictions make maintaining good level of health care difficult. The change of the way of regulation is necessary more than ever, but politicians are reluctant. Fears from unpopular measures like co-payment are stronger than the will for reforms. The membership of Bulgaria in the EU had no direct impact on health care because the country suffered to take advantage of Euro- pean funds. That is the environment in which BuMA works. Besides the internal affairs to deal with BuMa has representation in several in- ternational organisations – CPME, FEMS, AEMH – and closely monitors what hap- pens with the common problems of doctors in Europe. Dr. Stefan Konstantinov, Vice Chairman of the Bulgarian Medical Association Bulgarian Medical Association 124 Regional and NMA news MWIA is an association of medical women representing women doctors from 76 coun- tries in all five continents. MWIA is non- political, non-sectarian, non-profit-making. The different cultural backgrounds, medi- cal traditions and problems of its members provide a stimulating forum. There are four types of membership within the associa- tion: a) affiliated national associations, b) individual members, c) honorary members, d) members of honour. All medical women, qualified accord- ing to the accepted standard of the medi- cal profession in their country, are eligible for membership. It is also a requisite that all qualified medical women of the country (the National Association) must be eligible for membership irrespective of race, religion or political opinion. The powers of the association are vested in the delegates of the membership, which elect an Executive Committee to facilitate and expedite the handling of affairs of the association in the intervals between the tri- ennial meetings of the General Assembly. The legal Head Office of the association is in Geneva, Switzerland. The Administra- tive Headquarters are at the present time in Vancouver, Canada, where the activities of the member national associations and indi- vidual members are coordinated. The organisation is composed of 8 geo- graphical regions. Each region is repre- sented on the Executive Committee by its vice-president. The president, president- elect, treasurer, secretary-general and vice- presidents are elected by the members. The present aims of MWIA are: To offer medical women the opportunity to meet so as to confer upon questions concerning the health and well-being of humanity. To pro- mote the general interest of medical women by developing cooperation, friendship and understanding without regard to race, reli- gion or political views.To overcome gender- related inequalities in the medical profes- sion. To promote health for all throughout the world with particular interest in women, health and development. International congresses and general assem- blies are held every 3 years in various coun- tries of the world, e.g. 1998 in Sao Paulo, 2001 in Sydney, 2004 in Tokyo, 2007 in Ghana. This year the MWIA congress will take place in Muenster/Germany 28–31 July 2010. Topic: Globalisation in Medi- cine – Challenges and Opportunities. We as women and particularly women phy- sicians need to continue to make our voices heard, as we fight for the rights of women and women’s health care. In 2001, the Medical Women’s Internation- al Association wrote a Training Manual on Gender Mainstreaming to educate medical personnel on the importance of considering gender when providing health care. It can be accessed at www.mwia.net and speaks in language understandable by medical per- sonnel and gives case examples. MWIA was founded in New York, 1919. The various committees within the organi- sation provide the executive board with ideas and impulses for activities, be it topics for discussion, future projects or active par- ticipation with organisations sharing areas of common interest. The association has consultative status with the Economic and Social Council of the United Nations and is in official relations with the World Health Organisation. The activities of the association are supported by its members through dues and honorary service. Dr. Waltraud Diekhaus, 9 years Secretary- General of the organisation, since 2007 Vice-President Central Europe Medical Women’s International Association (MWIA) Cruise 2004, Tokyo, Mallorca,Schweden, ExCo, Sri Lanka 125 Regional and NMA news Minke van Minde For almost sixty years, medical students are joining forces to improve health all over the world. They organise projects and run ex- change programs coordinated on a local and national level. The national members are united by the International Federation of Medical Students’ Associations (IFMSA), one of the largest student organisations in the world. Currently IFMSA represents over 1.2 million medical students, in 2010 97 national organisations are members in 92 countries across the globe, covering all continents. The IFMSA is an independent, non-polit- ical organisation founded in 1951, officially recognised by the United Nations as a non- governmental organisation, by the World Health Organisation (WHO) and the World Medical Association (WMA) itself. The partnership with the WMA is a long- lasting and fruitful one. IFMSA’s General Secretariat is based in the WMA’s office and many IFMSA alumni are members of the WMA. After 59 years, IFMSA has now an ex- tremely large network due to its many active members from different backgrounds. The mandate of the IFMSA is to train medical students at an early age to become advocates for health issues that they will face after as practitioners. This is executed throughout different fields such as Medical Education, Professional and Research Exchange, Hu- man Rights and Peace, Public Health and Reproductive Health. Every year, around 10 000 students participate in the exchange programs of IFMSA abroad – gaining ex- posure to patients in an international set- ting, learning about new types of disease processes endemic to a different region, and experiencing first hand the cultural and eth- nic diversity of our planet. IFMSA national member organisations organise numerous projects in the fields mentioned above. 47 of them are IFMSA- recognised projects, which receive IFMSA international support and are often or- ganised in more than one country. Part- nerships are established between different organising countries as well as with other NGOs and organisations, which strength- ens the project and its cause. The IFMSA would like to encourage part- nerships between its national member or- ganisations and the national members of the WMA, which could have a beneficial outcome for both. Collaboration between doctors and medical students in one coun- try unifies the voice of the medical sector and empowers future doctors and medical professionals to develop themselves in their projects and resources. Medical students are always very eager to get into contact with medical professionals and learn from their experience. The same applies to medical students who would love to benefit from the knowledge of the medical association in their country. One of the projects that is organised by a majority of the IFMSA members is the Teddy Bear Hospital. Primary school chil- dren are invited to come to the hospital with their dolls or teddy bears who are ill and take them to the medical students who act like the “teddy bear doctors”. Children are introduced to wearing hospital clothes, x-rays, medicine and treatment. The focus of this project is the children dealing with the topic “hospital and illness”. Impressions and ideas, which children have acquired in family and from media, should be critically looked at and corrected in playing if neces- sary. The topical center lays in the meeting between child and future doctor. Aim of every medical work should not only be the treatment, but also the building of a solid foundation of confidence between the doc- tor and his little patient. Aim is to show the children that illness and the fight against it is part of everydaylife and does not neces- sarily have to be experienced as threatening or frightening. The medical students prac- tice in dealing with children in a hospital environment and are trained to develop skills in children’s communication. IFMSA has a range of donation-focused projects concerning organ donation, blood donation and marrow. One of the aims is to teach medical students about the aim of donation, while the other aim is to recruit new donors and educate the public using different methods. Medical students give peer education in high schools, organise street actions or active donations days. All this should meet the ultimate goal: decrease the list of patients waiting for organs, blood or marrow and improve their lives. In some countries a first aid course or train- ingisnotincludedinthemedicalcurriculum. That motivated many IFMSA members to organise this training to teach medical stu- dents the general skills they should be able to acquire as medical students. Workshops include reanimation, basic life support training, taking blood, and physical exams. After the course students have to take an exam to evaluate whether they possess the skills taught. In some faculties they liked the course so much that it is now included in the medical curriculum! Medical Students in Action 126 Regional and NMA news Apart from projects IFMSA organises several advocacy events. Major events are held in IFMSA member countries, such as World AIDS Day, Tobacco Campaign and World Tuberculosis Day. During these events medical students actively advocate in the benefit of reducing AIDS, tobacco use and tuberculosis. This is done by organising advocacy events and joint ventures all over the world. For example World AIDS Day is now organised in 40 member countries and more than 10 000 young people are reached. The IFMSA Exchanges are the biggest project run in the IFMSA. As mentioned over 10 000 participate each year.This needs a lot of coordination effort on a local, na- tional and international level. Luckily there are many doctors and professors willing to collaborate and invite an exchange student to their department, in order to give the student an amazing experience in a foreign hospital. Because of this collaboration IF- MSA can successfully organise its exchang- es for years now. The IFMSA is still working to improve itself and to move forward in this rapidly changing world. In order to do so and to execute our aims we are more than eager to work together with medical professionals to teach us skills and to enrich us with their knowledge. Let’s work together for a healthier tomorrow! For more information about IFMSA,please visit www.ifmsa.org Minke van Minde, IFMSA Vice President for External Affairs 2009/2010 CMA President warns “If we want to save Medicare we have to change it “ At its annual meeting in August this year the CMA annual meeting will debate a plan for transfiguration of the healthcare system. CMA President Dr. Anne Doig, speaking to the Canadian Club of Ottawa recently gave the above warning, saying that trans- formation is needed to ease pressure that is increasing in all health sectors. Illustrating this by referring to the fact that Canada has the highest bed occupancy among members of OECD at 91%, she pointed out that 25- 30% of those whose acute beds are filled by people who should even not be in hospital “Those patients need 24 hour supervised care, not hospital care”. She said that time had caught up with the five medicare principles outlined in the Canada Health Act (CHA). e.g. The CHA promised universality, but essentially, this applies only to hospital and physician serv- ices, at a time when demand for other types of care that are not covered is mushroom- ing. As a result, the burden of continuing care is falling on informal, unpaid caregiv- ers whose needs were not foreseen by the CHA. Because people are living longer, roughly one in five Canadians aged 45 and over are now providing such care. Dr. Doig said the CMA act of 1984 may have prom- ised comprehensive care, but in 2010 is un- able to deliver it. When the CHA became law in 1984,physi- cians and hospital services represented 57% of total health spending, and this had de- clined to 41% by 2008.“Today, programmes such as seniors’ drug coverage and home care that are not subject to CHA criteria consume over 25% of total public spending on health”. She concluded on a more optimistic note, pointing to innovations such as Quebec’s plan to introduce a personal annual health account to promote accountability and transparency, and the establishment of health “quality councils” in six provinces. “Innovation is happening across the coun- try ….. not by sacrificing the principles of the CHA, but by building on them. “We need to capture the momentum for change growing across the country and marshal that energy into a new national vision for health care” Euthanasia Bill crushed A private member’s bill seeking to legalise euthanasia and assisted suicide by amending Canada’s Criminal Code has been defeated in Canada’s Parliament.The bill would have allowed doctors to help people aged 18 or older “die with dignity”.The changes would have applied to those “experiencing severe physical or mental pain without any prospect of relief ” or who were suffering from a ter- minal illness after they had expressed “free and informed consent to die”. The bill was defeated by 228 to 59 in a vote that crossed party lines. In a letter sent to all members of Parliament before the vote, CMA Presi- dent Anne Doig said “the CMA supports enhancing access to palliative cared and suicide prevention programmes and under- taking a study of medical decision making during dying,” but it was worried that the bill would create “a slippery slope”. (by kind permission of CMA Bulletin) News from Canada 127 Regional and NMA news www.KnowYourAirForHealth.eu Helping communicate EU air quality information and alerts to allergy, asthma and COPD patients in Europe. Available in English, Suomi, Italiano, Lietuviu Kalba. A Joint EFA and Health and Environment Alliance Project. Health & Environment Alliance (HEAL) Formerly EPHA Environment Network (EEN) 28 Boulevard Charlemagne B-1000 Brussels Tel: +32 2 234 3646 Fax : +32 2 234 3649 E-mail:gill@env-health.org Website: www.env-health.org European Federation of Allergy and Airways Diseases Patients’ Associations (EFA) 35 Rue du Congrès 1000 Brussels Belgium email: info@efanet.org Website: www.efanet.org 128 WMA news World Health Professions Alliance, Geneva, May 2010 Secretary General’s Report (October 2009-April 2010) to 185th Council .........................................................................87 Norwegian Doctor to Head WMA’s Ethics Committee............96 Brazilian Medical Association – SOS Haiti...............................97 Burn Victims Bring Taiwan, Sao Tome Closer Together............98 World Health Professions Alliance calls for increased action against counterfeits .............................99 How Can Changes in Environmental Policy Help Reduce Rates of Chronic Disease? ..........................................100 Re-Positioning of Service Delivery in the Nigerian Health System – the Impact of SERVICOM on Emergency and Other Services in a Tertiary Health Facility.............................103 The History of the Placebo.......................................................109 The Czech Medical Association (CzMA) ...............................116 Brazilian Medical Association (AMB): Objective and Actions ..............................................................117 The Medical Chamber of Serbia...............................................118 Poor Health System and Active Macedonian Medical Chamber.....................................118 Health Policy Reform in Albania and Development of the Order of Physicians of Albania ......................................121 Bulgarian Medical Association.................................................123 Medical Women’s International Association (MWIA) ............124 Medical Students in Action......................................................125 News from Canada...................................................................126 Contents