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In keeping with our new tradition of featuring one of our mem-
ber countries on each cover of the World Medical Journal, I am
pleased to have Norway on our cover this month. Our cover shows
a Norwegian doctor who has arrived by sled to care for a sick child.
Norway can be proud of its exemplary medical care and its social
conscience. Medicine in Norway today is characterized by impec-
cable ambulatory facilities and super-modern clinics. The Norwe-
gian Medical Association was ahead of its time 25 years ago when
it undertook the goal of eliminating smoking in Norway. Although
this goal has only partially been reached, Norwegians can be proud
of having the lowest rate of smoking and alcohol consumption not
only in Europe but also in the world, as well as having among the
greatest longevity and lowest morbidity rates in the world.
When we look at the World Medical Association today, we see an
organization that has matured in 60 years to be a global force. Since
its foundation, the main goal of the World Medical Association has
been to establish and promote the highest possible standards of eth-
ical behavior and care by physicians.The WMA has adopted policy
statements on many ethical issues related to medical professional-
ism, patient care, research on human subjects and public policies,
taken a leadership role against smoking, detecting cervical cancer
early, increasing physical activity and exercise.
As doctors,we are aware of the deleterious eﬀects of smoking and as
a medical organization, the World Health Organization has taken
a very strong stand against smoking. I would like to urge us to take
an even stronger stand against exposure of children to secondary
smoke (passive smoking), as well as children smoking. Smoking in
an enclosed space ﬁlls the air with noxious substances such as am-
monia, arsenic, benzene, benzoapyrene, butane, cadmium, formal-
dehyde, lead, nicotine, propylene glycol and turpentine. In addition
to being carcinogenic, these harmful chemicals lead to vascular dis-
eases and pulmonary disorders. Toxins from cigarettes are inhaled
not only by the smoker, but also by non-smokers in the same room.
If the non-smoker is a child, subjecting the child to such poison
could be viewed as being as serious an oﬀense as physical violence,
paramount to sexual abuse, psychological trauma or other cruelty
to children. Punishment for any abuse against children, including
subjecting them to passive smoking, could be seen as a criminal of-
fense.
The Latvian Medical Association has endorsed laws that would
prohibit smoking in automobiles in which children are passengers.
Such laws have been enacted in Australia, 21 states in the United
States, parts of Canada, Cyprus and in other countries. We should
encourage the health organizations in our countries to prohibit
smoking in vehicles in which any passenger is younger than age 18,
in all public buildings, in all educational institutions and facilities
that deal with children, and in any building or room, including in
private homes, in which children are present.
Smoking in the presence of children should be recognized as child
abuse, since it is clear that passive smoking causes physical harm
to the child. We cannot allow the excuse that a person, even in his
own home, has the right to smoke if such smoking causes harm to
a child.
Physicians should take a leadership role in the battle against ciga-
rette smoking and set an example of a healthy lifestyle by not smok-
ing. It goes without saying that a doctor who smokes is an anachro-
nism. Let us lead by example and protect our next generation.
Dear colleagues!
Pēteris Apinis, M.D.
Editor-in-Chief of the World Medical Journal
Dr. Jón SNÆDAL
WMA President
Icelandic Medicial Assn
Hlidasmari 8
200 Kopavogur
Iceland
Dr. Kazuo IWASA
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
Dr. Yoram BLACHAR
WMA President-Elect
Israel Medical Assn
2 Twin Towers
35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
Dr. Eva NILSSON-
BÅGENHOLM
WMA Chairperson of the Medical
Ethics Committee
Swedish Medical Assn.
P.O. Box 5610
11486 Stockholm
Sweden
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. Nachiappan ARUMUGAM
WMA Immediate Past President
Malaysian Medical Assn.
4th Floor, MMA House
53000 Kuala Lumpur
Malaysia
Dr. Jörg-Dietrich HOPPE
WMA Treasurer
Bundesärztekammer
Herbert-Lewin-Platz 1
10623 Berlin
Germany
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
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. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
World Medical Association Oﬃcers, Chairpersons and Oﬃcials
www.wma.net
33
Editorial
In announcing the topic for World Health
Day 2008, Dt. Margaret Chan, DG WHO,
said “Health professionals are in the front
line in delaying the impacts of climate change.
The most vulnerable are in countries where
the health sector struggles to prevent ,detect,
control and treat diseases and health condi-
tions. including malaria, malnutrition and
diarrhoea….. we need to put public health at
the heart of the climate change agenda” and
on World Health Day 7th
April 2008 she said “
The warming of the planet will be gradual but
the eﬀects of extreme weather events – more
storms, ﬂoods, droughts and heat waves- will
be abrupt and acutely felt. Both trends can af-
fect some of the most fundamental determinants
over the past years faced major problems
over and above those arising from its basic
role in providing health care to individu-
als, to which we have referred in previous
editorials – such as those associated with
healthcare organisation, structure and func-
tion, changing roles, scientiﬁc advances
and their application to medical; practice –
not to mention HIV/AIDs, the threat of
pandemic spread of disease, (see editorial
WMJ53(4)).
Now new problems also threaten to add
to the burdens of providing health care to
those in need.
Already there has been increasing interna-
tional concern about the eﬀects of climate
change, which have become more apparent
in the context of the “natural disasters” af-
fecting many countries both in the east and
the west. These have added to the calls for
emergency medical care and other assist-
ance, including food and water supplies.
Now the problem of sustaining adequate
food supplies is extending beyond those
countries aﬀected by natural disasters, not
only increased by the eﬀects of armed con-
ﬂicts but by the realities of a wider problem
of producing enough food for an expanding
global population.
While international aid has been directed
to dealing with the consequences of natu-
ral disasters and the consequences of armed
conﬂict, looking to the future the problem
of coping with the diseases associated with
malnutrition and starvation may well be en-
larged beyond those countries aﬀected by
armed conﬂict and natural disasters in the
past…
As if this were not enough, the current
uncertain ﬁnancial climate, with potential
threats to global ﬁnancial structures, also
poses additional problems to those already
facing existing healthcare systems. While
the current trend to look towards preventive
measures to reduce the incidence of some
diseases and contain the ﬁnancial burden
of providing healthcare to treat them oﬀers
much for the future,the burden of such dis-
ease in likely to continue for some decades
to come. To meet this need the concept of
“ task shifting” to oﬀer some alleviation of
the problems of scarcity of human health-
care resources needs careful consideration,
not only to address the inequitable shortage
of health professionals in some countries,
but in all countries. This calls for realistic
approaches by all the health professions.
Likewise those responsible for health care
policies have a diﬃcult task in attempting to
balance the ﬁnancial burden needed to meet
the immediate and mid-term needs of the
present global population and the invest-
ment needed to extend disease preventive
action required to contain the health care
costs of future generations. For those suf-
fering disease, whatever its cause, care and
treatment are priorities, they do not have
time to engage in mid- to long-term strate-
gies to avoid disease. While lifestyle factors
play an important role in the development
of a number of diseases.it cannot be disre-
garded that in the working lifetime of many
practising physicians the burden of disease
has been increased not only by the substan-
tial increase in scientiﬁc knowledge and its
application in diagnosing and treating dis-
eases, but also by the substantial increase in
life expectancy in much of the world. This
is now reaching the stage in some countries
where the size of the retired population is
approaching if not exceeding that of those
who actively engaged in gainful employ-
ment, resulting in increasing strains on the
ﬁnancial resources which can be applied to
the provision of healthcare services to meet
While most of these considerations have
been addressed by economists, healthcare
providers and policy makers, they will now
assume an even greater urgency than they
have over the past few decades.
The combination of the possibility of im-
pending widespread recession coupled with
the growing inadequacy of basic food sta-
ples aﬀecting even bigger populations than
potential to not only increase the burden
of disease but also to threaten the nature
of medical care and treatment society will
be able to sustain. It is therefore incumbent
on NMAs to monitor and engage, where
appropriate, in discussions on the eﬀects of
climate change and the maintenance of ad-
equate resources for services to meet both
short and long term needs.
While the monitoring of such activities
fall naturally within the responsibilities of
NMAs, at this time of increased threats to
ﬁnancial systems,those arising from climate
change and to food supplies extending be-
yond national and regional limits, the need
for a united voice from the leadership of
the medical profession address these issues
(where appropriate) is essential to inform
and inﬂuence the political decisions which
will be taken both nationally and globally.
Dr. Alan J. Rowe
Co-Editor of the World Medical Journal
of health; air, water, food, shelter and freedom
The medical profession has increasingly
from disease.”
their needs.
have previously been experienced, has the
34
This is the name on a Forum organised
by the Global Health Workforce Alliance
(GHWA) in Kampala, Uganda 2-7 March
2008. The intention was to bring to light
the problems of critical shortage of health
workers in over 50 countries in the world
and what forces dictate the migration from
low income countries to high income coun-
tries. In the analysis of the problem during
the meeting it became obvious that this
problem is more complicated than it seems
at ﬁrst sight. Migration is also taking place
inside countries, where health professionals
leave the oﬃcial health service and either
move to the private health sector or leave
the health service altogether. Migration is
also taken place regionally from one low
income country to another. The push and
pull factors were discussed and to what ex-
tent these factors could or should be regu-
lated. Furthermore, the role of the various
stakeholders in this global problem was
discussed.
The Forum was attended by several stake-
holders. It was organised by the GHWA
and as this is an agency established by the
WHO, many oﬃcers of that organisation
were involved. The major focus was on the
situation of the health workforce in Africa
and therefore governmental oﬃcers; mostly
from African health authorities were pres-
ent but also some from the ﬁnancial de-
partments. There were also representatives
of development agencies and from sev-
eral NGO´s, not least from associations of
health professionals, both national and in-
ternational. The aim of the Forum was to
come to some mutual understanding of this
enormous problem by issuing a declaration
and in that regard, the meeting turned out
to be successful.
Before we go any further into this issue it
is important to look into the vocabulary
used. The WHO and the GHWA use the
term “health workers”which opens the pos-
sibility to include individuals with limited
or nonprofessional education and training,
but are nevertheless working in the health
service. The WMA and other Associations
of health professionals on the other hand
stress the importance of looking speciﬁcally
at the migration of health professionals and
the reasons for their choices. It is of impor-
tance to realise that migration is an individ-
ual choice based on reasons which are very
diﬀerent from case to case and it is only
when the total picture is analyzed that it is
possible to see a pattern.It is very important
that there will be no constraints by laws or
regulations on individual choices and it was
a relief to realise that no such ideas were put
forward in the discussions.
Those who gathered in Kampala are not
the only ones concerned were the problem.
The Lancet has recently published a spe-
ciﬁc number on this issue (Vol. 371; 9613:
February 23-29 2008). On the front page
of this number there is one sentence which
captures this huge problem very well: “Af-
rica carries 25% of the world’s disease bur-
den yet has only 3% of the world’s health
workers and 1% of the world’s economic
resources to meet that challenge.” This is
the problem in a nutshell this continent is
dealing with in the ﬁrst decade of the new
millennium.
What are the driving forces behind migra-
tion of health professionals? They are of
course many, but can be analysed separately
by using the terms “push factors” meaning
factors increasing the possibility to leave a
country or a profession and by “pull factors”
meaning those factors that are at play in the
recipient countries or services. The aim of
the meeting was not only to discuss prob-
lems but also to ﬁnd solutions.
Amongst problems and solutions to pull
factors discussed at the meeting were the
following:
Lack of health professionals in the• recipi-
ent countries. Countries receiving health
professionals from low income countries
should increase the number of educated
and trained health professionals in their
own country and subsequently be self
suﬃcient and not in need of recruitment
from other regions.
Ethical recruitment. There should be a•
generally accepted and respected ethical
conduct for recruitment of health profes-
sionals in order not to “attack” vulnerable
populations and strip them of well edu-
cated and trained people. However it is
acknowledged that individual freedom of
choice should not be constrained.
Amongst problems and solutions speciﬁc
for the push factors were:
Need for investment.The source countries•
should increase investment in health, both
through theirown means and by outside
contribution.
Investment in proper health education.•
This investment should be in education
and training of health professionals, in
increasing the oﬀers of jobs after training
and in making the work in the health ser-
vice attractive.
The role of International ﬁnancial agen-•
cies. There is compelling evidence that
the ﬁnancial requirements of the Interna-
tional Monetary Fund for investment in
the source countries makes investment in
public health diﬃcult and it will be very
Human Resources for Health
Jon Snaedal
President of the WMA
35
In an unprecedented move, the global or-
ganizations of nurses, pharmacists, physio-
therapists, dentists and physicians, and the
International Hospital Federation, joined
forceswiththesupportoftheGlobalHealth
Workforce Alliance to tackle a root cause of
the global shortage of health professionals.
Poor working conditions rank second only
toinsuﬃcientwagesasthekeyreasonhealth
professionals are leaving their countries
in such large numbers, creating this global
crisis. Even wealthy countries are witness-
ing emigration of health workers in search
of better working environments. Through
their campaign on Positive Practice Envi-
ronments (PPE), these global partners are
committed to promoting and facilitating
safer,more secure and more attractive work-
ing environments and practice conditions
for health care workers.
hard to increase the GDP proportion to
health without some deviation from these
requirements.
Task shifting. An increase in mid-level•
health workers and community health
workers is needed in the short term in
areas of most critical shortage, but task
shifting should not be a long term solu-
tion. There is a diﬀerence in opinion on
this part of the solution and it will be dis-
cussed separately.
In addition to these possible solutions to the
problem there are other issues that “bridge”
the push and pull factors or are part of both.
One is to make contracts between agencies
in both resource and recipient countries.
These can be hospitals which agree to ex-
change health professionals for work and
training, to provide technical material and
training and other issues. These agencies
can also be health regions or other speciﬁc
health service agencies.Examples of this are
to be seen in several arrangements between
hospitals in the UK and in South Africa,
leading to a substantial decrease in migra-
tion from South Africa to other countries
in recent years.
Positive Practice Environment is a speciﬁc
concept which includes various factors that
make work places attractive to work in. In
a pre-meeting organised by associations of
health professionals this was speciﬁcally ad-
dressed.There are many factors or incentives
that can be tailored for work places which
increase the likelihood of retention of health
professionals. These incentives can be cate-
gorised as ﬁnancial or non-ﬁnancial. Finan-
cial incentives are wages, bonuses, pensions,
insurance and other things, but there are
also various non-ﬁnancial incentives. Those
might include safe and clear workplace,
professional autonomy, sustainable employ-
ment, ﬂexibility in work time, support and
supervision, and occupational health and
counselling services. One issue speciﬁcally
mentioned was the fact that the prevalence
of HIV and AIDS is higher amongst health
professionals in many regions of Sub-Sa-
haran Africa than in the communities they
serve, but they do not receive the support
and counselling they need.
Task shifting is an issue that the WHO has
put on the agenda as a part of the solution
and this was discussed separately at a pre-
vious meeting in Addis Ababa last January.
Task shifting involves the transfer of tasks
in the health service from individuals or
professionals with high level of education
and training to those with lower level of
knowledge. That means, in practical terms
,that tasks are shifted from doctors to oth-
ers, but never the other way. This might
be a solution to an urgent problem, but is
problematic in the long run.One risk is that
health authorities would see this as a means
to decrease the cost of health services, but
then without thinking of the quality of ser-
vice provided. Another is that the shift of
priorities from longer professional educa-
tion and training to a shorter one will lead
to diminishing number of properly educat-
ed and trained work force. In the long run
this will lead to segregation of health service
between countries with diﬀerent level of
service, based on diﬀerent levels of knowl-
edge. It was clear that the health ministers
of Africa attending the Task shifting meet-
ing in Addis realised this and they stressed
that it was very important to prioritise the
traditional training and education.
A draft to the Declaration and an action
plan was distributed on the ﬁrst day of the
Forum in Kampala and after adjusting the
papers according to comments and critics;
the Declaration was accepted by all. In a
roundtable session of Health Ministers and
high representatives of WHO, the WMA
criticised however, the lack of transparency
and consultation in the preparation of these
documents as the drafts had been prepared
without any consultation with the global
associations of health professionals even
though the problem was so closely associ-
ated with them. We, the representatives of
the WMA, proposed several amendments
most of which were principally accepted in
the ﬁnal version. The WMA could then ac-
cept the declaration in spite of lack of clar-
ity on many points.
The Declaration and the Action plan are
primarily aimed at governments and it was
stated that due to the severity of this crisis,
it should be a priority of the heads of gov-
ernments, not only of health authorities.
It was ﬁnally decided that in two years time
the situation should be evaluated in order
to see the eﬀect of the Declaration and the
Action plan.
This article is based on a report made after the
Kampala meeting and reﬂects the views of the
author.
Positive Practice Environments (PPE) –
Quality Workplaces for Quality Care
36
Today,many countries have desperate short-
ages of health care professionals, impacting
negatively on patient care and health out-
comes and creating sub-standard practice
environments for those who provide care.
Countries in sub-Saharan Africa and in
parts of Southeast Asia have a particularly
low health profession-to-population ratio.
The reasons are complex: in most case low
wages and even concerns about whether
there will be a paycheque each month are
major factors driving out health profession-
als,especially physicians.Poor working con-
ditionsundermineprofessionalperformance,
put both patients and health workers at risk
and compel health professionals to search
for better, safer working environments. For
health professionals capable of speaking the
language of one of the rich countries in the
northern hemisphere, a ticket for a move is
practically already printed.
The World Health Organization’s (WHO’s)
core strategy to address the health workforce
crisis depends on what it calls Task Shifting.
Task Shifting is the substitution of health
professionals by lay persons and ultimately
assigns minimally trained community health
workers with the tasks of physicians, nurses
and midwives. With part of their jobs giv-
en away to lay persons, physicians may be
forced out of the public sector into private
practice, or out of the country. Even when
they remain in-country, this eﬀectively cre-
ates a two-tiered health system in which the
wealthy have access to qualiﬁed physicians
in the private sector while the health of ma-
jority of the population is left in the hands of
a non-professional workforce. The preferred
approach of PPE campaign members, who
represent the various health professions,is to
focus on stronger retention of health profes-
sionals through better working conditions.
Gathering the Professions
When the Global Health Work Force Alli-
ance held its 1st Global Health Workforce
Forum in Kampala in March 2008, the PPE
campaigners took the opportunity to assem-
ble for the ﬁrst PPE workshop. Health pro-
fessionals from all over Africa, Europe and
North America gathered to discuss and ex-
change views about how to strengthen health
systems through better working conditions.
As keynote speaker of the meeting, WMA
president, Dr Jon Snaedal, began by re-
minding the group of the alarming short-
age of health professionals worldwide, but
more critically in Sub-Saharan countries.
He reviewed the three key actions currently
identiﬁed and developed by decision-makers
to address this workforce crisis: education,
task shifting and retention. Unfortunately,
of these three strategies, task-shifting has
emerged as the prime focus of most eﬀorts.
Dr. Snaedal outlined the objections that
many – including African health ministers –
have against using task shifting as the pri-
mary solution to the health workforce short-
age. He referred participants to a response
developed by the World Health Profes-
sional Alliance and the global organizations
of midwifes and physiotherapists, to the
WHO strategy on task shifting. Presented
in Kampala, this resolution outlines twelve
key principles necessary to avoid disastrous
consequences from task shifting. (See Insert
2 for full text.) Dr.Snaedal emphasized that
education and retention are equally, if not
more important than task shifting,especially
when the objective is to build comprehensive
and sustainable health care systems. Positive
Practice Environments, he explained, is one
of the retention strategies.
The African participants shared the very
strong concerns on task shifting, yet recog-
nizeditasapossiblecomplementaryresponse
to health workforce shortage,if pursued with
the following approach:
Tasks must be shifted from one educated
group to another educated group (e.g., physi-
cians to nurses,nurses to assistant nurses,etc.).
When tasks are shifted to unqualiﬁed person-
nel – referred to as “community health work-
ers”– the creation of a second-class health care
system is inevitable. Task shifting should not
be used as a means to replace health profes-
sionals, but rather as a way to complement
their work. Task shifting requires signiﬁcant
supervision of community health workers by
health professionals and therefore does not
lead to a decrease in the workload for already
overworked health professionals. Even with
task shifting, a strong increase in the number
of health professionals is necessary.
It was clear that the current approach to task
shifting, as driven by WHO and donor or-
ganizations, is far removed from these prin-
ciples.
Quality Workplaces for Quality Care is the campaign title to promote Positive Practice Environments. The
5-year global campaign is spearheaded by key stakeholders – International Council of Nurses, International
Hospital Federation, International Pharmaceutical Federation, World Confederation for PhysicalTherapy,
World Dental Federation, World Medical Association and the Global Health Workforce Alliance. Its purpose
is to ensure safe, cost-eﬀective and healthy workplaces worldwide, thereby strengthening health systems and
improving patient safety.
Positive practice environments (PPE) is a recognized strategy to address the global health workforce crisis.PPE
are health care settings that support professional excellence by providing good working condition.They have the
power not only to attract and retain staﬀ, but also to improve patient satisfaction and outcomes, cost-eﬀective
services and most important health care safety.
The objectives of the PPE campaign are to:
Make the case• for healthy, supportive work environments, through evidence of their positive impact on
staﬀ recruitment and retention, patient outcomes and health sector performance.
Build a global platform –• share examples of good practices for healthy, supportive and eﬃcient workplaces.
For that the campaign will provide materials including an advocacy toolkit presenting evidence of the
beneﬁcial impact of PPE, a web based, user-friendly library of PPE reference materials or best practice
guidelines for the health workplace.
Drive a sustained trend• in establishing and applying the principles of positive practice environments
across the health sector.
Be open• to all countries, settings and health disciplines.The global campaign materials are open for adap-
tation to suit local preferences and to engage indigenous support and action.
Celebrate success• in support of eﬀective strategies that promote sustainable health systems.
37
Participants then turned their attention to
the PPE campaign and identiﬁed some as-
pects that must be addressed:
While health professionals work under
very diﬃcult circumstances to serve their
patients, their own health is often neglect-
ed. PPE should include proper access to
good quality health care for health profes-
sionals.
Instead of tolerating or even accepting bad
working conditions, health professionals
must advocate for, and actively drive, change.
In all countries,working conditions for health
professionals could be signiﬁcantly improved.
As conditions and priorities in each country
diﬀer,planning and implementation for PPE
must be undertaken at the national level.
After careful analysis, with particular atten-
tion to the situation in Africa, participants
identiﬁed two complementary strategies
to respond to the health workforce shortage
and to promote PPE:
Capacitybuilding:Currently,nationalorga-
nizations of the various health professional
groups are not equipped to create the strong
advocacy force required to impact decision-
making at the national level. Strong health
professional organizations could help to
propose, promote and implement eﬃcient
health policy. Capacity building for national
health professional organisations is there-
fore a critical priority.
National coalitions: Even where profes-
sional organizations are eﬀectively working,
their impact could be improved by better
collaboration at the national level. Many
participants recognized the value of meet-
ing as a global coalition in Kampala. Cre-
ating similar national forums where health
professionals’ organisations can meet and
exchange good practices, combine resources
and pursue common strategies, would be
extremely useful. Some suggested establish-
ing formally a national body composed of
representatives of health professions or-
ganisations to pursue joint actions, develop
campaigns and exert political leverage. In
addition, the need to promote a change of
mindset toward more solidarity and joint
mobilisation among nurses, physicians and
other health professionals was clearly evi-
dent and strongly supported.
Clarisse Delorme
Advocacy advisor, World Medical Association
28 February 2008
Joint Health Professions Statement
On Task Shifting
We,the representatives of more than 25 million health
professionals, are committed to providing safe, acces-
sible health care to the world’s people. We understand
all too well the impact of shortage of personnel, sup-
plies and equipment on patients, families and provid-
ers. We witness the impact daily of not enough staﬀ,
not enough clean water,not enough drugs,not enough
money to access services or to aﬀord life’s staples. We
see health professionals mentally and physically ex-
hausted daily. We struggle with the dilemma of re-
source restrictions and meeting the needs of everyone
– and the evidence that shows that better health out-
comes occur when higher numbers of professionals are
engaged in direct care.
We understand the need to address today’s human re-
source crisis. At the same time we are concerned that
task shifting and adding new cadres of workers result
in fragmented and ineﬃcient service through reduc-
tionist and vertical approaches. We believe that for
task shifting to be eﬀective:
Skill mix decisions should be country-speciﬁc and
take account of local service delivery needs, quality
and eﬀectiveness factors, eﬃciency, the current con-
ﬁguration of health services and available resources, as
well as production and training capacity, and include
the health professions in decision-making.
Roles and job descriptions should be described on the
basis of the competencies required for service deliv-
ery and constitute part of a coherent, competency-
based career framework that encourages progression
through lifelong learning and recognition of existing
and changing competence.
There needs to be suﬃcient health professionals to pro-
vide the required selection, training, direction, supervi-
sion, and continuing education of auxiliary workers.
Regulations for assistive personnel and task-shifting
need to be set with the professions involved. It should
be clearly stated who is responsible for supportive su-
pervision to assistive personnel. In any case the cur-
riculum development, the teaching, supervision and
assessment should always involve the health profes-
sionals from whom the task is being shifted.
There must be adequate planning and monitoring
to avoid the danger of generating a fragmented and
disjointed system that fails to meet the total health
needs of the patient,oﬀers a series of disconnected and
parallel services that are both ineﬃcient and confus-
ing, and may lead to de-motivation and high attrition
rates.
Assistive personnel need compensation and beneﬁts
that equal a living wage, a safe workplace and ad-
equate supplies to ensure their own safety and that of
patients. At the same time they should be expected to
work within the code of conduct of their employer.
Deploying assistive personnel will increase demand
on health professionals in at least three ways: (1)
increased responsibilities as trainers and supervisors,
taking scarce time away from other tasks; (2) higher
numbers will be needed to take care of the new pa-
tients generated by successful task-shifting; and (3)
health professionals will be faced with patients who
have more complex health needs (the simpler cases
will be covered by task-shifting) and thus require
more sophisticated analytical, diagnostic, and treat-
ment skills.
There needs to be credible analysis of the economic
beneﬁt of task shifting to ensure equal or better ben-
eﬁt, i.e. health outcomes, cost eﬀectiveness, productiv-
ity, etc. Ongoing evaluation, particularly in skill-mix
changes and the introduction of new cadres and or
new models of care, should systematically consider the
impact on patient and health outcomes as well as on
eﬃciency and eﬀectiveness.
When task shifting occurs in response to speciﬁc
health issues such as HIV, regular assessment and
monitoring should be conducted on the entire health
system of the country concerned. In particular, quality
assessment linked to overall health outcomes of the
population is essential to ensure that programs are im-
proving the health of patients across the health care
system.
Assistive workers should not be employed at the ex-
pense of unemployed and underemployed health
professionals. Task-shifting should be complemented
by fair and appropriate remuneration of health profes-
sionals and improvement of their working conditions.
Where task shifting is meant as a long-term strategy
it needs to be sustainable.If meant as short term,there
needs to be a clear exit strategy.
Assistive workers need to be integrated into health
care delivery systems and treated as part of the team.
Conclusion
In geographical areas facing a critical shortage of
health professionals, eﬀorts should be made and sup-
ported to increase professional training opportunities
(undergraduate and graduate), and to provide incen-
tives for the retention of health professionals.
Whatever the strategy selected, task-shifting should
not replace the development of sustainable, fully func-
tioning health care systems. It is not the answer to en-
suring comprehensive care, including secondary care,
is accessible to all.
International Confederation of Midwives
International Council of Nurses
International Pharmaceutical Federation
World Confederation of Physical Therapists
World Dental Federation
World Medical Association
38
A comprehensive prevention strategy for
reducing the threat of cervical cancer has
been called for by the World Medical As-
sociation and the Medical Women’s Inter-
national Association.
In a joint statement to mark international
women’s day (March 8), the two organisa-
tions demand action for women and girls
around the world to have equal access to the
highest quality prevention and treatment
options for cervical cancer and say that such
a strategy should include screening and vac-
cination.
Dr. Shelley Ross, Secretary-General of
the Medical Women’s International Asso-
ciation, said: ‘Cervical cancer is the second
most common cancer among women. But
it is now preventable due to the availability
of a vaccine against human papillomavirus
(HPV)’.
She said that every year cervical cancer af-
fected 500,000 women and took the lives
of a quarter of a million women worldwide.
Women in poor countries were the most af-
fected, with 80 per cent of the deaths from
cervical cancer due to extremely limited
screening and treatment availability.
Dr. Ross added: ‘When reﬂecting back on
major advances in women’s health in years to
come,HPVvaccinewillbelistedasoneofthe
major breakthroughs. It is urgent that gov-
ernments across the world start prioritizing
cervical cancer with sustainable political and
ﬁnancial commitments.Not doing so means
losing lives. It means also not granting to
women and girls in poor countries the right
to equal access to life-saving technologies’.
Four of the common types of HPV could
be prevented through vaccination although
there was currently no treatment available
which could cure an HPV infection. HPV
vaccine therefore had the potential to sub-
stantially reduce the prevalence of cervical
cancer, although not to eradicate it.
Dr. Jon Snaedal, President of the WMA,
said ‘Medical associations have a key role to
play in this strategy in making information
on HPV vaccine available to physicians and
to encourage physicians to alert their pa-
tients on this innovation’.
‘Cost must not be a barrier to making the
vaccine available to women and girls world-
wide. We are calling for a strong mobilisa-
tion of decision-makers, international or-
ganisations,international donor community
and development partners, as well as medi-
cal associations, civil society and industry to
act now for a change, to stop cervical can-
cer’.
In April 2008 the British Medical Asso-
ciation (BMA) published “Health profes-
sionals taking action on climate change”,
a web based resource which calls on health
professionals to take a lead in tackling cli-
mate change. As ambassadors of health,
doctors have both the opportunity and a
responsibility to highlight the public health
risks of climate change. The resource aims
to provide an overview of the science of
climate change and the resulting implica-
tions, particularly for health in the UK. The
key purpose is to highlight what practical
actions health professionals and healthcare
organisations can take in order to reduce
their carbon footprint. Some of the sim-
plest measures include turning appliances
oﬀ stand-by, reducing unnecessary heating,
repairing leaking taps, minimising waste,
and reusing items and recycling where pos-
sible.The resource also includes examples of
good practice and links to sources of further
information.
As well as reducing their own carbon foot-
print, health professionals are well placed to
inﬂuence and promote social change. With
a history of combating major public health
concerns, health professionals can play a vi-
tal role in tackling climate change and the
related adverse eﬀects on health. By high-
lighting the numerous health beneﬁts asso-
ciated with more environmentally friendly
activities and lifestyles, they can empower
individuals to become greener and encour-
age public debate.
Healthcare organisations are signiﬁcant
contributors to carbon emissions.In the UK
for example, the NHS is the largest single
organisation, with an annual purchasing
budget of around £17 billion. It employs
over one million people and emits around
one million tonnes of carbon every year.
There is huge potential for NHS to promote
combating climate change, through taking
practical steps to reduce carbon emissions
and by raising staﬀ and public awareness to
these initiatives.
The BMA believes it is essential that all
doctors and healthcare organisations lead by
example in reducing their negative impact
on the environment; work together to re-
duce the carbon emissions of healthcare or-
ganisations; and promote greener lifestyles
to ensure a healthy, sustainable future.
The web resource can be accessed by visiting
the BMA website at http://www.bma.org.
uk/ap.nsf/Content/climatechange
Call for Equal Access to Cervical Cancer
Treatment for All Women and Girls
Health Professionals Taking Action
on Climate Change
A web report from the British Medical Association’s Board of Science
39
Introduction
Mercury,one of the world’s most ubiquitous
heavy metal neurotoxicants, has been exten-
sively used in health care since antiquity. It
has been an integral part of many medical
devices, most prominently thermometers
and sphygmomanometers. These both add
to the global burden of mercury removed
from its below ground repository and spread
about on the surface to form highly neuro-
toxic organomercury compounds. Further,
these devices break or leak with regularity,
exposing health care workers to the acute
eﬀects of the inhalation of the metal itself.
In view of this, as part of a global initiative
to reduce the use and spread of mercury in
all aspects of society, health care providers
and institutions have begun to replace mer-
cury-based medical devices with aﬀordable,
accurate and safer alternatives.
In 2005 the World Health Organization
advised, in its eloquently crafted policy pa-
per on the topic, a global transition of the
health care sector toward the use of mercury
free care alternatives. Speciﬁcally, the paper
projected a 3 step approach:
“ShortTerm: Develop and implement plans
to reduce the use of mercury equipment and
replace it with mercury-free alternatives.
Address clean-up, storage and disposal.
MediumTerm:Increase eﬀorts to reduce the
use of unnecessary mercury equipment in
hospitals.
Long Term: Support a ban of mercury-con-
taining devices and promote alternatives.”
In Europe, reﬂecting the elimination of the
use of mercury devices by all major provid-
ers, several countries, including Sweden, the
Netherlands, and Denmark have banned
the use of mercury thermometers, blood
pressure devices and a variety of other mer-
cury containing equipment. In 2007, the
European Parliament extended the ban on
mercury thermometers to the entire Union.
In the United States, Canada, Mexico, Ar-
gentina and countries in between,thousands
of hospitals, pharmacies and medical device
purchasers have switched to digital ther-
mometers along with mercury free aneroid
and digital sphygmomanometers.These ini-
tiatives have become so widespread in the
U.S. that the health care market has been
fundamentally restructured toward mercury
free devices for all applications.
In Sao Paulo, Brazil, more than 92 hospi-
tals have signed agreements committing
to eliminate mercury-based thermometers
and sphygmomanometers – more than 42
have already done so. The Buenos Aires city
government, which runs the largest health
care system in Argentina, is implementing a
policy to phase out mercury-based medical
devices in 33 major hospitals and 38 small-
er health care centres and three Provinces
have issued letters of intent to phase-out
mercury-based medical devices. Cuba has
replaced nearly all of its mercury sphygmo-
manometers with aneroid devices.
In Asia and Africa as well, despite economic
constraints, a growing number of hospitals
have committed to going mercury-free, and
a number of large cities, states, and national
governments are developing model policies
for mercury-free health care. In India, the
Delhi city government is pursuing a mercury
free policy for its health facilities. The Prov-
ince of Kwa Zulu Natal in South Africa has
issued directives banning the purchase of mer-
cury thermometers and sphygmomanometers.
On a national level,the Philippines are devel-
oping an Administrative Order to phase-out
mercury in health care andTaiwan has banned
mercury fever thermometers.
The transition to mercury free health care
today is neither smooth nor universal. It
presents a series of challenges to the health
care sector that must be practically con-
fronted with evidence based solutions that
neither increase patient risks nor contribute
to the increasing costs of health care. Yet so-
lutions are available that permit health care
institutions to reduce their contribution to
this toxic environmental exposure that risks
patients’health and well being. Health Care
Without Harm, an international coalition of
medical providers, nurses, health care insti-
tutions, professional organizations, and envi-
ronmentalists seeking to reduce the environ-
mental impact of health care, has taken on
the challenge presented by these issues.
Physicians have a special role to play in this
eﬀort to improve the public’s health through
primary prevention. They are uniquely able
to translate the toxicologic and epidemiologic
information in the medical literature for the
public and policy makers. They are often the
leaders of health care institutions, always are
the key and deciding element in the provi-
sion of patient care, and they hold inﬂuential
positions in most countries as community
leaders. National and international medical
societies are playing and will continue to play
an important role in this global process.
The Problem
Mercury in the Environment
Mercury is a naturally occurring heavy met-
al. At ambient temperature and pressure,
mercury is a silvery-white liquid that read-
ily vaporizes. When released into the air,
mercury may stay in the atmosphere for up
to a year, and is transported and deposited
globally. It is within this environment that
inorganic and organic compounds of mer-
cury are formed.
Mercury-free Health Care
40
Since the start of the industrial era, the
total amount of mercury circulating in the
world’s atmosphere, soils, lakes, streams and
oceans has increased by a factor of between
two and four. This increase has been aﬀect-
ed by human endeavours, which include the
removal of mercury from its subterranean
home through mining and the extraction
of fossil fuels. Human exposure to mercury
can result from a variety of sources, includ-
ing, but not limited to, consumption of ﬁsh
rich in methyl mercury, and due to spills or
leaks of the metallic element itself.
Mercury causes a variety of signiﬁcant ad-
verse impacts on human health and the
global environment. Mercury vapour may
produce pneumonitis and pulmonary edema
if inhaled and toxic levels can be absorbed
through the skin due to handling of the liq-
uid metal especially if the epithelial barrier
has been broken due to cuts or abrasions.
Target organs other than the lungs include
kidneys, nervous system and GI tract. An-
ecdotal reports from hospitals utilizing mer-
cury thermometers report breakage ranging
from several to several hundred a month.
These reports are paralleled by those noting
leakages of mercury containing sphygmo-
manometers as well with the potential for
signiﬁcantly larger amounts released.
Yet, of even more concern is potential for
developmental neurotoxicity produced by
low dose methyl mercury exposure through
food. Elemental mercury accumulates in
lake, river, stream, and ocean sediments,
where it is transformed into methyl mer-
cury, which then accumulates in ﬁsh tis-
sue. This contamination of ﬁsh stock is
ubiquitously present in oceans and lakes
throughout the world, concentrating sev-
eral hundred thousand times as it moves
up the aquatic food chain.
Methyl mercury is of special concern for
foetuses, infants, and children because it
impairs neurological development. When
a woman eats seafood that contains mer-
cury, it accumulates in her body, requiring
months to years to excrete. If she becomes
pregnant within this time, her foetus is
exposed to methyl mercury in the womb,
which can adversely aﬀect the foetus’ cen-
tral nervous system. Impacts on cognitive
thinking, memory, attention, language, and
ﬁne motor and visual spatial skills have been
documented in children with exposure in
utero to levels of methyl mercury commonly
found in women of child bearing age.
Along with WHO, the United Nations
Environment Programme (UNEP) has
identiﬁed the adverse eﬀects of mercury
pollution as a serious global environmen-
tal and human health problem. The UNEP
Governing Council, representing all UN
represented countries, has targeted reducing
methyl mercury accumulation in the global
environment as a major global priority.
Sources of Mercury Pollution:
The health care sector is far from the great-
est source of organic mercury compounds in
the environment. Rather, coal-ﬁred power
plant emissions and mercury cell chlor-alkali
plants, along with artisanal gold mining and
battery disposal are all far more signiﬁcant
polluters. However, the health care sector
does play an important role as a source of
global emissions, as well as a source of low-
level, chronic and acute elemental mercury
poisoning.
Mercury can be found in many health care
devices and present in ﬂuorescent lamps as
well as dental amalgams. Mercury is also
found in many chemicals and measure-
ment devices used in health care laborato-
ries. Medical waste incinerators, as well as
municipal waste incinerators, emit mercury
into the atmosphere when they burn wastes
that contain mercury. According to the U.S.
Environmental Protection Agency (EPA),
in 1996, prior to the mercury phase-out in
U.S. health care, medical waste incinerators
were the fourth largest source of mercury
emissions to the environment. Hospitals
were also known to contribute 4-5% of the
total wastewater mercury load. And mer-
cury fever thermometers alone contributed
about 15 metric tons of mercury to solid
waste landﬁlls annually.
In 2005, Transande et al. using national
blood mercury prevalence data from the
US Centers for Disease Control estimated
that between in this century 316,588 and
637,233 US children each year have cord
blood mercury levels > 5.8 μg/L, a level as-
sociated with loss of IQ. They estimated
that lost productivity due to this amounts
to $8.7 billion annually (range, $2.2–43.8
billion).
While no comprehensive ﬁgures are avail-
able, anecdotal evidence suggests that in
most of Asia, Africa and Latin America,
mercury spills are not properly cleaned, nor
is the waste segregated and managed prop-
erly. Rather, it is either incinerated, ﬂushed
down the drain, or sent, via solid waste, to
a landﬁll.
Thermometer breakages on a case-by-case
basis pose some harm to patients, nurses
and other health care providers when mer-
cury is absorbed through the skin or mer-
cury vapour is inhaled. Only a relatively
small amount of mercury – roughly one
41
gram – is released when each thermometer
breaks. However, when taken cumulatively
on a hospital ward, in an entire hospital, na-
tionally and globally, the situation takes on
more serious dimensions.
In Buenos Aires, for instance, the city
government, which runs 33 hospitals and
more than 38 clinics, was purchasing nearly
40,000 new thermometers a year,until it be-
gan to switch over to alternatives in 2006.
Given that nurses and other health care
professionals often buy their own thermom-
eters to supplement the city’s procurement,
the city’s health system was using well over
40,000 thermometers a year, most of which
would break, and some of which would be
taken home (where most would ultimately
break as well). The system was ultimately
emitting in excess of 40 kilograms of mer-
cury into the local hospital environment
and into the global ecosystem every year.
If one were to use this ﬁgure and extrapo-
late for the entire country, one can estimate
that until recently thermometers broken in
Argentina’s health care system were spilling
826 kilos, or nearly 1 metric ton of mercury,
into the global environment every year.
In Mexico City, the 250-bed “Federico
Gomez” Children’s Hospital is a medical
service, teaching, and research hospital af-
ﬁliated with the National Autonomous
University of Mexico. This prestigious chil-
dren’s hospital documented a thermometer
breakage rate of 385 per month, or well
over 4,000 per year (see Table 1). The total
number of estimated broken thermometers
in this one hospital between 2002 and early
2007 is nearly 22,000 – the equivalent of 22
kilograms of mercury.
While the Federico Gomez hospital has
now committed to substitute its mercury
devices with alternatives, when it undertook
its initial assessment there was no clean-up
protocol for mercury spills. Rather, mercury
waste was deposited with both infectious
and biological hazardous wastes, or with
municipal wastes. Broken ﬂuorescent lamps
were also treated as municipal waste. Mer-
cury containing equipment was not repaired
if broken,and the procedure followed was to
merely register the loss and replace it with
new equipment.
The regular and ongoing breakage of ther-
mometers and the lack of mercury waste
management protocols and practices found
at the Federico Gomez hospital is not an
exception, but more generally the rule in
hospitals throughout much of the Global
South,where patients and health care work-
ers are regularly and unknowingly exposed
to this toxin.
This is the case, for instance, in India, where
far fewer thermometers are employed in
many hospitals). In a study of New Delhi
hospitals, the NGO Toxics Link found dan-
gerously high levels of mercury in a series
of indoor air samples. They found the “sub-
stantial presence of mercury in ambient air
of both the hospitals” studied. These levels,
which ranged from 1.12 microgram per cubic
meter to 3.78 microgram/m3
, were all higher
than numerous international standards.
One of the biggest mercury hot spots that
Toxics Link found in its study was the room
used to calibrate blood pressure devices
(sphygmomanometers), which contain 80-
100 grams of mercury or 80-100 times the
amount found in a single fever thermometer.
Mercury release and contamination from
sphygmomanometer calibration is a com-
mon problem throughout the world. Louis
Havinga, Manager of Health Technology
Services for the KwaZulu Natal Province
Department of Health in South Africa ex-
plained:
This is the most important point why the
Health Technology Services has moved
away from the use of mercury products.
The technicians were exposed to mercury
when they repaired mercury column sphyg-
momanometers. Special precautions and
equipment is needed if working with mer-
cury products like a dedicated fume/vapour
extraction unit within the maintenance
department. The mercury is extracted from
the device and placed in a special marked
container. The container must be able to
seal and should remain inside the fume/va-
pour extraction unit. Once the container is
full, the container must be disposed of in a
well documented and controlled manner by
making use of a recognized hazardous waste
disposal company which is very costly.
And while sphygmomanometers break less
frequently than thermometers, the spill-
age is signiﬁcant and therefore problematic
from an environmental health perspective.
At the Mayo Clinic in the U.S., between
1993 and 1995, 50 spills were documented
Table 1
Monthly Mercury Thermometer Breakage at
Frederico Gomez Children’s Hospital Mexico
City
Sevices Broken
per month
Intensive care unit 20
Postoperatory recovery 20
Emergency Room 30
Out-patient studies recovery 6
Surgery 15
Pediatric ICU 15
Surgery ICU 15
Nephrology 30
External consultation 20
General consultation 30
Out-patient surgery 2
Pediatrics I 15
Pediatrics II 30
Immunosuppressive illnessis 30
Chemotherapy 2
Urogical surgery 45
Special care 30
Orthopedics 30
Total:
Approximate yearly total:
385
4.620
Source; HCWH/CAATA, 2007
42
relating to leakage and spills from sphyg-
momanometers.
Overcoming the Obstacles:
Accuracy, Aﬀordability, Disposal
It is clearly in the interest of public health
and the environment to replace mercury-
containing measuring devices in the health
care sector. However, actually implement-
ing such a transition runs into three funda-
mental challenges.
First, is that the long term use of healthcare
mercury devices has helped to support a be-
lief that mercury products are accurate and
do not need calibration. Together with this
belief, there is a deep scepticism in much of
the medical community regarding the accu-
racy of alternatives. Second, replacing mer-
cury-based medical devices is often seen as
an expensive proposition that is unobtain-
able for cash-strapped health care sectors in
the developing world. Third, is the thorny
question of what to do with mercury that
is taken out of circulation in the health care
setting. Many governments lack the infra-
structure to manage mercury waste, so it is
often not clear what to do with this toxic
element once a hospital takes it out of cir-
culation.
These are relevant concerns and good ques-
tions, yet there are answers and proven ap-
proaches to replacing these devices.
Accuracy
Some medical professionals still consider
mercury to be the only accurate and consis-
tent method of measuring temperature and
blood pressure. Yet,as peer reviewed studies
from the last decade demonstrate,this is not
currently the case, and in fact our attitude
toward the accuracy of mercury thermome-
ters and sphygmomanometers was probably
overly positive in years past as well.
The mercury ﬁlled glass thermometer,
though easily and frequently broken, is one
of the simplest and most widely used diag-
nostic tools. It was therefore the ﬁrst clini-
cal mercury device to be evaluated for accu-
racy in comparison with a growing number
of available alternatives.
After considerable debate in the 1990s,
Leick-Rude and Bloom, during routine ac-
curacy testing in a study, reported that 25%
of the glass/mercury thermometers tested
diﬀered from the reference thermometer by
>0.2 degrees Centigrade. This ﬁnding was
consistent with the authors’ review of prior
work. Indeed, another recent study had re-
jected 28% of glass/mercury thermometers
due to inaccuracy.
Digital thermometers, the most commonly
used mercury-free temperature device, use
a thermistor to convert temperature into a
known electrical resistance, and are highly
sensitive. As with most products (mercury
or mercury free) their accuracy is dependent
on manufacturing quality and techniques.
Standards organizations such as the ASTM
International have developed protocols that
will help the healthcare community identify
accurate alternatives. It is imperative that
the healthcare community and governments
ensure that thermometers are purchased
from manufacturers that follow techniques
and testing protocols that are independently
certiﬁed by ASTM or other internationally
established regimes, so as to provide a prod-
uct that provides the accuracy required.
Sphygmomanometers represent the larg-
est reservoir of mercury in current medi-
cal use. As with thermometers, mercury
and non-mercury blood pressure devices
provide accurate measurement so long as
both instruments are calibrated. Examples
of both inaccurate mercury and mercury-
free sphygmomanometers can be found
in the medical literature, though this in-
accuracy is typically related to poor main-
tenance and calibration. A large number
of scientiﬁc studies have concluded that
mercury-free measuring devices produce
the same degree of accuracy as mercury
devices, provided they are properly main-
tained and calibrated. For instance, a study
at the Mayo Clinic in the US concluded
that aneroid sphygmomanometers provide
accurate pressure measurements when a
proper maintenance protocol is followed.
Some have argued that for accurate blood
pressure measurement the reference de-
vice used for calibration must be a mercury
blood pressure device (with a typical error of
±3 mm of mercury). Yet, when calibrating
a device the error of the reference pressure
should be added to the speciﬁed accuracy
of the instrument under test (±3 mm Hg)
to determine the working accuracy of a
calibration set-up. As a result, if using a
manometer (mercury column or aneroid
gauge) rated at ±3.0 mm Hg as a reference,
one will be able to determine the accuracy
of the gauge being tested to only ±6.0 mm
Hg. This is outside the range of ±5 mm
of mercury typically desired by medical
professionals. Many facilities and device
manufacturers are using a device (e.g., digi-
tal pressure standard) rated at ±0.1 mm Hg,
one will be able to determine the accuracy
of the gauge being tested to within ±3.1
mm Hg. This has been well documented to
be far less than the inter or intra provider
diﬀerences on multiple readings.
A U.S. study from 2003 concluded in sum-
mary that “research on sphygmomanom-
eters suggests that there are numerous good
alternatives to mercury sphygmomanome-
ters. Aneroid sphygmomanometers are cost
competitive, have a long history in the ﬁeld,
and have been found acceptable by many
hospitals.”
In a UK study, an aneroid device achieved
an A grade for both systolic and diastolic
pressures and fulﬁlled the requirements of
the Association for the Advancement of
Medical Instrumentation. The conclusion
was that the aneroid device could be recom-
mended for use in an adult population.
The UK Medicines and Healthcare Prod-
ucts Regulatory Agency (MHRA) states
that aneroid and mercury sphygmomanom-
eters both need to be checked regularly in
order to avoid errors in blood pressure mea-
surement; the British Hypertension Society
recommends testing every 6 to 12 months.
43
Frequently lost in the discussion over de-
vice accuracy, and equally important is the
issue of measurement technique. A 2002
Working Meeting on blood pressure mea-
surement in the United States highlighted
numerous studies which found that basic
measurement technique, inappropriate cuﬀ
size and poor cuﬀ size were providing sig-
niﬁcant errors in measurement.
Switching to mercury free sphygmoma-
nometers in clinical settings has not caused
problems in clinical diagnosis and monitor-
ing in Sweden or Brazil. The Swedish gov-
ernment, in fact, has completely eliminated
mercury column sphygmomanometers.
One problem that several hospitals in de-
veloping countries have encountered as
they substitute mercury-containing sphyg-
momanometers is that many aneroid and
digital devices are of poor quality yet many
devices currently produced satisfy the cri-
teria of professional organizations such as
the British Hypertension Society, the Eu-
ropean Hypertension Society and the As-
sociation for the Advancement of Medical
Instrumentation. The British Hypertension
Society (BHS) has created a list of vendors
of sphygmomanometers that have met the
BHS criteria and are suitable for clinical
practice and posted it on their web site.
As health care sectors in developing coun-
tries begin their substitutions, many are
ﬁnding the non-mercury alternatives to
be viable. As Louis Havinga, Manager of
Health Technology Services for the Kwa-
Zulu Natal Province Department of Health
in South Africa observes, before they de-
cided to phase out mercury-based medical
devices in the province, “clinical trials and
technical trials were conducted and various
electronic sphygmomanometers were found
to be consistent and within acceptable ac-
curacy range for clinical use.”
Aﬀordability
Many healthcare practitioners are concerned
about the availability of alternatives. In fact,
there are many mercury-free thermometers
and sphygmomanometers available from
major medical equipment suppliers who
service the global market.
Yet the issue of aﬀordability is still a chal-
lenging one, especially where the costs of
human and environmental impacts of mer-
cury releases are not included in the health
institution’s accounts or budgets. From a
developing economy’s perspective, these
costs must be taken into account in national
strategic planning.
In countries such as the United States,
where market demand for mercury alter-
natives has begun to be felt and clean up
costs quantitated a mercury free purchas-
ing policy has become the most economic.
Table 3
Costs of Mercury vs Digital Termometers. he experience of Posadas Hospital, Buenos Aires
Argentina: April-June 2006/ Before Mercury Replacement
Total thermometers Cost per Unit in $ US
equipment
Total cost
Mercury Thermometers 3152 1,33 4.192
Digital Thermometers 0 4,00 0
Total 3152 4.192
April-June2007/ as Digital Thermometers are Introduced
Total thermometers Cost per Unit in $ US
equipment
Total cost
Mercury Thermometers 335 1,33 445
Digital Thermometers 188 4,00 752
Total 523 1.197
Total savings for 3 months u.S.$ 2.995
Table 4
Estimated Costs of Replacing Mercury Equipment in Hospital Sao Luiz, Sao Paulo Brazil
Year 1 Year 2 Year 3 Year 4 Year 5
Digital Devices
Initial investment 9.412
Annual Maintnance 2.630 3.892 3.892 3.892 3.892
Total costs adjusted by 12%
annually for inﬂation
12.040 17.381 23.360 30.054 37.560
Mercury Devices
Annual Maintnance 5.923 5.923 5.923 5.923 5.923
Total costs adjusted by 12%
annually for inﬂation
5.923 12.559 19.991 28.314 37.37
diﬀerence 6.125 4.829 3.377 1.751 69
Annual savings after Year $2,031
Figures in US $ converted from Brasilian reals
Table 5
A Comparison of prices of Mercury and Digital Clinical
fever Thermometers in Selected Countries 52
Argen-
tina
Brazil Mex-
ico
India China Philip-
pines
South
Africa
USA Eng-
land
Czech.
Rep
Mercury
Thermom-
eters
$1.33 1.52 1.24 0.62 0.41 0.55 0.80 1,50 1.00
Digital
Thermom-
eters
4.00 10.52 3.77 5.35 4.65 4.67 4.37 2.09 7.00 5.00
Price ratio 3:1 6.9:1 3:1 8.6:1 11.3:1 8.5:1 5.5:1 0:1 4.6:1 5:1
44
In a study done by Kaiser Permanente, the
largest not-for-proﬁt Health Maintenance
Organization (HMO) in the United States,
it was determined that when associated life-
cycle costs are included (compliance, liabil-
ity, training, etc.) the total cost per unit of
an aneroid sphygmomanometer is about ⅓
that of a mercury-containing device. Mer-
cury-containing devices are no longer being
purchased by Kaiser Permanente.
Yet in the global market, mercury-based
medical devices are still signiﬁcantly less
expensive than their digital or aneroid
counterparts. In the absence of strict en-
vironmental health regulations, and with
limited healthcare budgets, many health
care systems and hospitals today still face
the challenge of deciding between a mer-
cury device and its alternative. Those facili-
ties with limited budgets have been able to
successfully avoid this road block through
operational strategies.
For example, when planning future budgets
hospitals are counting the frequent mercury
thermometer breakages for inclusion in the
cost of current practices for comparison
with the cost of a digital or mercury-free
alternative. Frequently, the additive cost is
comparable to the replacement cost of the
mercury thermometers, as the alternatives
are typically more durable.
The Hospital Posadas in Buenos Aires, Ar-
gentina pursued just such a strategy and re-
ported signiﬁcant savings when it replaced
all of its thermometers. Table 3 shows that
between April and June 2006, this 450 bed
hospital purchased 3,152 mercury ther-
mometers. A year later, during the same
period in 2007, it purchased 355 mercury
thermometers and 188 digital devices. The
cost savings totalled nearly U.S. $3,000.
At the Federico Gomez Children’s Hospi-
tal in Mexico, it is estimated that this 250
bed institution will save a minimum of U.S.
$10,000 over six years when replacing mer-
cury thermometers. This estimate includes
the costs of digital device and battery re-
placement, as well as mercury and battery
disposal.
In the Hospital Sao Luiz in Sao Paulo,
Brazil, a 116 bed hospital, health care of-
ﬁcials found that the costs of maintenance
and calibration of digital and aneroid ther-
mometers and sphygmomanometers were
signiﬁcantly lower than the costs of main-
taining existing mercury devices. In fact,
they determined if they were to replace all
sphygmomanometers, wall thermometers
and clinical thermometers in the hospital
with alternative devices, that the savings
on maintenance and calibration would pay
back the initial capital investment of more
than U.S. $9,000 in ﬁve years, while saving
another U.S. $2,000 a year thereafter (see
Table 4).
However, in some parts of the world, the
economic calculus is not yet as positive.
Mercury thermometers, most of which are
produced domestically, cost around U.S. $
0.62 in India – or half of what they cost in
many other places in the world. Meanwhile
a decent quality digital thermometer, most
of which are imported, costs USD $5.35, or
33 percent more than in much of the rest of
the world. The situation in China is similar
(see Table 5).
Disposal
The problem of what to do with other
mercury waste remains a vexing one. This
includes waste from spills that occur until
replacements are made, waste from mercury
devices that are taken out of use, the ongo-
ing collection of dental amalgam waste, and
waste from used digital thermometer bat-
teries that contain trace amounts of mercury
and ﬂuorescent bulbs.
One option for disposal, though not ideal,
occurs in North America and many Euro-
pean countries, where governments have
developed infrastructure for the collection
of mercury waste products. These wastes
are “recycled” into new mercury-containing
products. Ideally, these products involve
essential uses of mercury for which alter-
natives do not currently exist. While this
scenario provides healthcare facilities and
others with a means of removing mercury
waste from their facility’s waste stream, the
continued sale and use of mercury-contain-
ing products will invariably result in break-
age and escape to the environment during
product life or end of life.
The preferred scenario is one in which mer-
cury and mercury-containing products are
no longer used, and the mercury in use is
collected and no longer returned to the mar-
ketplace in products.There is no one simple
solution to the mercury problem, and until
the goal of mercury elimination is realized,
a variety of strategies must be implemented
that move toward this solution.
Conclusion
With Europe, North America, and individ-
ual countries, provinces, and cities through-
out the world well on the road to mercury-
free health care, shifting the production
and consumption patterns in developing
countries as a whole is the largest remaining
challenge to this transition.
Mercury free health care is not only pos-
sible, but if the right forces converge, the
day is not far oﬀ when most health care
institutions will be virtually mercury free.
Individual physicians, their specialty soci-
eties, and national medical associations are
and will continue to play a leading role in
this transition.
In October 2007 a resolution on control of
mercury pollution was passed from com-
mittee to the World Medical Association’s
Council at a meeting in Copenhagen,which
says in part:
“Major institutions around the world have
demonstrated that safe, eﬀective alterna-
tives exist for nearly all traditional health
care uses of mercury. Historical concerns
about the inaccuracy of mercury-free al-
ternatives, and the belief that the mercury
sphygmomanometer is the gold standard,
45
are not borne out by the experiences of the
multitude of institutions that have elimi-
nated their mercury sphygmomanometer
units.”
The resolution was approved for distribu-
tion and discussion amongst the WMA’s
national medical associations. It will be
acted upon with ﬁnal action at the 2008
Assembly meeting in Seoul Korea.
Joshua Karliner (josh@hcwh.org),
Jamie Harvie, PE, (harvie@isfusa.org) and
Prof. Peter Orris, MD, MPH (porris@uic.edu)
University of Illinois at Chicago School of
Public Health with Health Care Without Harm
Introduction
In recent years,much attention has been paid
to issues of healthcare in essentially every na-
tion in the world. The tasks of controlling
known chronic diseases, caring for those af-
ﬂictedwithinfectiousdiseases,andingeneral,
delivering healthcare to the masses, continue
to be a major ﬁnancial and social problems
for us all.A portion of the world’s population
that needs immediate attention is the elderly
(over the age of 65). They represent one of
the fastest growing proportions of world
population. The reasons for this growth in
population are multi-factorial including bet-
ter healthcare in some areas of the world,
more eﬀective treatments and prevention of
chronic disease, and in many cases, improve-
ment of social economic status which has
allowed individuals of age to thrive. With
the increase in numbers of the elderly, the
normal physiologic changes that occur with
aging need to be recognised by the medical
community along with how these changes
inﬂuence speciﬁc disease processes and inju-
ries. Many countries in the world have fully
developed specialties and subspecialties in
Geriatrics and Gerontology. As this portion
of the population in these countries increase,
one of the many issues in providing health-
care to the aged is the supply of healthcare
providers available. In emerging countries,
the issue is a need for recognition of the
elderly as a separate population; having dif-
ferent physiological responses and requiring
specialised care. To eﬀectively care for the
elderly population, it is important that we
recognise the normal changes that occur in
the human body over time. It is important to
remember that these changes are outside the
deﬁnition of acute and chronic disease, and
for the purposes of this discussion, also out-
side the eﬀects of any medications that may
be administered to the elderly.
In this discussion, we will focus speciﬁcally
on the physiologic changes that occur in the
human body that increased an elderly pa-
tients’tendency to fall.In the literature,a fall
is deﬁned as “a situation where a person comes
to rest inadvertently on the ground or a lower
level”.1
Falls are one of the most common
threats to the health and longevity of the
aged.It is also a signiﬁcant cause of death in
this population. Most of the discussions on
falls do not include those caused by a loss of
consciousness (i.e. syncope or seizures). Ap-
proximately 40 per cent of the elderly popu-
lation in the community over 65 experience
one fall.That percentage increases to 60 per
cent if there is a prior history of a fall. Fif-
teen per cent of falls result in serious injury.
The overall ideology of falls is often multi-
factorial. This complex interaction of many
factors intrinsic to the individual including
age related changes; chronic disease; illness;
medication; changes of postural control; in-
creased risk-taking behaviour; underlying
mental status; and other mediating factors.
The purposes of this discussion will be to
focus on multi-physiologic changes intrin-
sic to the individual.
Aging and Physiology
The normal physiologic changes in the el-
derly relevant to our discussion here include
changes in the muscular/skeletal system,
the neurological system, cardiovascular as
well as other constitutional environmental
changes that occur to the human body dur-
ing the normal aging process.
The Musculoskeletal System and its physi-
ological changes with aging comprise one of
the most important systems to consider.The
changes in skeletal muscle itself include a de-
crease in muscular strength, endurance and
bulk involving essentially all of the muscles
of the body except, interestingly, the dia-
phragm and cardiac muscles. These changes
obviously decrease an elderly person’s abil-
ity to react swiftly and with the amount of
physical strength needed to avoid certain
situations.The connective tissues in the body,
particularly those lining the joints and sup-
porting the joint spaces containing collagen
over time become more dry and brittle. This
change leads to stiﬀening and produces a sig-
niﬁcant change in the mechanical function
of joints and their articular surfaces. When
one considers these changes and their eﬀect
on something as simple as the posture, the
following eﬀects are observed. Elderly indi-
viduals are found to have ﬂexion at the hip
and knee joints which gives rise to the typical
Normal Physiologic Changes with Aging:
Inﬂuence on Falls in the Elderly
Mark D. Darrow, MD FACP
President and CEO of SEAHEC (South
East Health Area Education Center,
North Carolina)
46
posture seen in an elderly person; one needs
to simply watch an elderly individual walk
across a room. While their joints retain nor-
mal range of motion,they are stiﬀ and there-
fore, ﬂexion of the major joints in the hips
and legs persists with ambulation. A simple
solution is to prescribe a range of motion
and stretching exercises before even the most
common and rudimentary activities. In the
elderly female, it is common to see a kypho-
sis of the upper thoracic spine which further
ﬂexes her frame forward and forces her into
the commonly observed “forward slumped
posture”as she walks across the room. Given
this change and the postural change they
produce, along with the hip and legs joint
changes named above, it is easy to see how
there is an increased tendency toward falls in
the elderly female. In fact, it has been docu-
mented that wrist and hip injuries are more
severe in the elderly female population.
The second category of signiﬁcant change
with time is in the Neurological System.
There is a documented decrease in pro-
prioception in the extremities of elderly
patients. The vestibular system undergoes
changes that lend a tendency to an increase
in sway during ambulation. Additionally
there is a decrease in muscle activation and
co-ordination in this population as well.
These changes as a group place elderly in-
dividuals in a situation where they become
more dependent on visual cues for placing
their extremities while ambulating. Older
persons also become more dependent on vi-
sual reference points and on the use of their
hands and arms for stabilisation when walk-
ing than their younger counterparts because
of the issue of increased sway in their gait.
Signiﬁcant neurological change occurs in the
eyes.There is a gradual decrease in visual acu-
ity with age such that subtle changes in the vi-
sual ﬁeld may go unnoticed.The best example
of how this change may manifest is when one
considers a long hallway that ends in a set of
stairs.Often,the ﬂoors of the hallway and the
stairs have the same material covering them,
if the pattern is subtle and without contrast,
an elderly person may misjudge the distance
to those stairs because they are unable to see
them or distinguish them for the rest of the
hallway. This simple subtle fact may dramati-
cally increase their risk of falling,as again their
dependence on visual acuity is high. Another
vision change is Presbyopia, which is the in-
ability to see near objects because of stiﬀness
in the lens of the eye of the elderly. It is easy
to see how this can further create problems
for the older person.The most signiﬁcant and
common visual change with age is in light/
dark adaptation. An elderly person’s ability
to visually adapt from a dark room to bright
sunshine, or its reverse, is dramatically slowed
when compared to a younger person.It is easy
to imagine how this increases fall risk during
common daily activities. Imagine an elderly
person emerging out into bright sunshine
from inside a structure, particularly in unfa-
miliar settings. The bright light immediately
removes the visual cues for that elderly indi-
vidual. If they proceed without allowing for
adaptation to that new level of light, a fall or
injury usually ensues.
Changes in hearing are well documented.
In the elderly there is a decrease in pitch
discrimination on the high and low ends of
the scale, as well as a dramatic increase in
the hearing threshold. Particularly in public
settings, this leads to issues of being unable
to hear when there is a loud level of ambi-
ent noise. This hearing loss can lead to di-
rectional confusion and an inability to avoid
falls when auditory cues that potentially
warn cannot be heard.
The Cardiovascular System undergoes dra-
matic change in the elderly. While there are
many issues that one could discuss in the
cardiovascular system, the major focus needs
to be on the regulation of systolic blood pres-
sure and the maintenance of blood pressure
during activity and postural change. Regula-
tion of systolic blood pressure becomes more
diﬃcult in the elderly patient for several rea-
sons. There is a decrease in total body water
as the elderly person’s physiologic make-up
shifts more toward increased adipose tissue
as opposed to water soluble tissue; decreasing
the amount of total body water.This is further
aﬀected by a slowing in the response of the
renin-angiotensin axis and a decrease in the
aldosterone responsiveness. These changes
make the elderly patient less tolerant to hot
environments, allow them to become more
easily weakened and fatigued during times of
high musculoskeletal activity, and therefore
make them more prone to falls and injuries
at those times.
Postural changes in blood pressure response
also vary quite signiﬁcantly in the elderly.
One good example is post-prandial blood
pressure drop. This is a blood pressure drop
that naturally occurs in virtually all elderly
patients in mid-afternoon. It appears to be
associated with several normal physiologic
occurrences such as the swings in the renin-
angiotensin, aldosterone system as it varies
throughout the day, as well as the increased
activity of the digestive system after the
noon meal. This is thought to lead to a pe-
riod of time in the mid-afternoon when the
elderly may be more vulnerable to decreases
in blood pressure with postural change. Of
note, this time of the day also tends to be a
period of time when morning medications
given for blood pressure, diuresis or other
cardiovascularly active drugs reach their
peak activity. As one might expect, this is a
common time, particularly in nursing facili-
ties, when there are more reports of falls.
While there are many other physiologic
changes that occur with aging that may,
in a minor way, contribute to falls we have
focused above on the major ones. It should
be noted that the elderly population does
not have a natural understanding of these
changes,and because these changes occur to
an individual over time, they often go un-
noticed. It is this lack of education, lack of
modiﬁcation of environmental factors, and
recognition of home safety hazards that fur-
ther contribute to the multi-factorial nature
of falls in this population.
We wish to stress again, that we did not de-
tail here the age-related associated diseases
that are very common in the elderly such as
Parkinson’s disease, osteoarthritis, and cata-
racts, which aﬀects the major systems we
have outlined above and further place an in-
dividual at risk of a fall. Lastly, medications
47
including prescribed, over the counter, and
home remedies, are also major contributors
to falls. The good news here is that they are
the most easily modiﬁed group of risk fac-
tors in this population.
Evaluation
It is in the area of patient evaluation that
knowledge of the changes in aging by a
healthcare provider trained in the area of
Geriatrics is most important. Elderly indi-
viduals must be evaluated for their fall risk.
This evaluation involves assessments of many
of the issues outlined above and then the de-
velopment of a multi-factorial intervention
process to help prevent or decrease the risk.
Unfortunately, most elderly individuals usu-
ally present for medical care after the initial
fall.Ideally,however,as we develop awareness
for the speciﬁc and unique issues with aging,
this assessment needs to occur as a part of
the wellness evaluation of an elderly person.
The evaluation should include a thorough
history: gathering information, not only
about medical issues, but support, social and
economic issues that may be obstacles in the
care of the elderly patient.Finding out about
the person’s medications are also a part of this
history as is the recording of any risky be-
haviours or substance abuse habits that may
exist. A thorough assessment of their vision
with emphasis placed on their visual acuity,
light/dark adaptation, and the inﬂuence of
presbyopia in their vision is important. One
should also get a sense of how dependent
the individual is on their vision by assessing
some of the other systems outlined above. It
may be necessary to test a patient to assess
how dependent they may be on visual in-
puts for activity and locomotion. A gait and
balance assessment is important, keeping in
mind the physiologic changes noted above.
Simple observation of the gait is important,
as well as paying close attention to the use of
visual cues, arms and hands during ambula-
tion. A decrease in a person’s ability to reach
out may also place them at higher fall risk if
they are quite dependent on arms and hands
as they walk.Evaluation of lower limb joints,
range of motion, and particularly stiﬀness of
those joints must be documented. A screen-
ing neurological evaluation is needed in-
cluding an assessment of the ability of the
patient to transfer out of a chair.
Cardiovascular evaluations involve the as-
sessments of the included organ systems,
but in addition need to include an assess-
ment of blood pressure, as well as the mea-
surement for the presence of orthostatic
blood pressure changes. There are no stan-
dard laboratory diagnostic tests and evalua-
tions of an elderly person with a history of
falls or a high risk of falls.Obviously any ar-
eas of concern that come to light during the
history and physical examinations should
guide the physician towards any relevant
laboratory studies that may be required for
an individual elderly patient.
Treatment and Prevention
Treatment and prevention usually involves
multi-factorial interventions. An individual
provider using the information collected,
can often times set the interventions in mo-
tion to address many of the risk factors and
natural deﬁcits that occur in this popula-
tion. Interventions including exercise and
physical therapy particularly focused towards
strengthening of the leg and torso muscu-
lature, as well as range of motion exercises
and stretching activity is important. Modi-
ﬁcations of home hazards in consideration
of gait and visual diﬃculties; instructions
about patterns on carpeting, loose electrical
cords, and other pieces of furniture which
may present problems or obstructions in the
path of an elderly patient should be assessed
and ways to avoid these hazardous situations
can be taught. On occasion, cognitive behav-
ioural intervention is eﬀective, particularly in
individuals who may have particular habits
or activities that place them at higher risk of
falls. Frank conversations and education of
the individual about these activities can lead
to dramatic changes and habits. Adjustment
of medications, withdrawal of many medi-
cations in the elderly, particularly of those
with chronic disease is another important
and as mentioned before easily modiﬁable
risk factor. Nutritional support is important
particularly, as relates to an individual’s abil-
ity to maintain their blood pressure. One
must assure that they hydrate and consume
the proper numbers of calories and protein
as physiologically required. We have stressed
the importance of visual acuity in an elderly
patient and certainly any elderly patient who
is ambulatory should have a referral for cor-
rection of any visual deﬁciencies that they
have.Referral is also important in individuals
who may be signiﬁcantly hearing impaired.
Multi-disciplinary teaching, multi-factorial
health and environmental risk factor screen-
ing in intervention is always important,
particularly in this population of individu-
als. Instruction regarding support at home,
investigations into the type of care givers
and support an elderly individual has around
them at any given time is important to de-
crease their potential of getting into high risk
activity or situations where they are in dan-
ger of falling and causing serious injury. Re-
cently,there have been many studies showing
the beneﬁt to the prescription of hip protec-
tors in elderly individuals who are high-fall
risks or compliance with these garments.
While putting them on is at times diﬃcult
and while adherence to the use of the device
is low, some studies have shown beneﬁts in
decreasing hip fractures during falls in very
high risk ambulatory individuals.
Summary
In summary, while we have not intended
this article to be an outline all of the normal
physiologic changes that occur in the el-
derly and certainly have not undertaken an
exhaustive discussion of falls in the elderly,
it is important that these types of discus-
sions begin on the world stage to help us
recognise the unique issues and problems
that develop with aging of our populations,
and how the medical community needs to
and responds to these new challenges.
References
1. American Geriatrics Society. British Geriatrics Society and
American Academy of Orthopaedic Surgeons Panel on Falls
Prevention. Guideline for the prevention of falls in older per-
sons. J Am Geriatr Soc. 2001;49(5):664-672
2. Geriatrics Review Syllabus, 6th
edition. American Geriatrics
Society, 2006; pgs 201-209.
48
The Migration of Health Professionals
and its Impact on Patient Safety
Both European institutions – UEMS and
the European Parliament are at the same
age, both are well known in Europe and
beyond. At the same time, being a represen-
tative from one of the so- called new EU
Member States – Latvia – a professor who
has spent 30 years in post-graduate medical
training, I have to admit that those states,
which were for 50 years behind the Iron
Curtain, could fully recognize the value and
signiﬁcance of the work of both institutions
only during the last decades.
My beloved speciality was anaesthesiology
and intensive care. Today it may sound an-
ecdotic, but, under Soviet rule, we had to
provide so called primary specialization in
6 months time! For the next step in post-
graduate medical training – so called im-
proved qualiﬁcation – some more months
were added.
Slowly, step by step and with the help of the
European Academy of Anaesthesiology, we
tried to change the situation even before
the Soviet system collapsed. Today the pe-
riod of training in my speciality in Latvia
exceeds by two years the minimum,required
in the Directive 2005/36/EC of the Euro-
pean Parliament and the Council of 7 Sep-
tember 2005.
That gives our Ministry of Health the
chance to plan a shortening of the period
of training in accordance with the proposed
minimum of three years. The Latvian As-
sociation of Anaesthesiologists is convinced
that, taking into account the dramatic
changes – not only the new technologies,
that it is time to review and update the
length of training. But, it is of course up to
you to decide and to advise the European
Commission on this matter.
As many of you already know,the European
Parliament as a whole is quite often involved
in solving diﬀerent medical and health care
problems. In spite of the fact that the deliv-
ery of health services lies primarily within
the competence of the Member States, the
EU, adhering to the principles of subsidiar-
ity and proportionality, in accordance with
Article 152 of the EU Treaty, has a respon-
sibility where necessary to act so as to sup-
port Member States to co-operate and to
co-ordinate their activities.
Even more so, in the light of a January
2008 survey conducted by Eurostat in all
27 Member States, entitled “Citizens views
of the European Parliament: perceptions,
knowledge and expectations” where 39% of
all respondents answered that they would
like to see improvement of consumer and
public health protection given a priority
status.
The reﬂections on the Communications put
forward by the European Commission to
the European Parliament and the Council
which address health issues, falls within
the duty of the Rapporteur from the Com-
mittee on the Environment, Public Health
and Food Safety (ENVI). Diﬀerent health
topics are systematically discussed within
the framework of the Working Group on
Health which is a specialized Group set
up within the ENVI Committee. Apart
from that there are several diﬀerent inter-
est groups, meeting regularly under the pa-
tronage of MEPs (for example MAC – or
Members Against Cancer, the MEP Heart
Group or the Working Group on Diabetes).
I mentioned only those Groups in which
I myself am very active as is the case with
MAC or the other two which I have the
honour of being the co-chairman.
Working in close contact with correspond-
ing patient groups, medical and other ex-
perts as well as with representatives from
the Commission, it is possible to initiate
questions to the Commission, and to table
diﬀerent Motions for Resolutions or Dec-
larations.
As an example of such a Motion for a reso-
lution,which by the way deals also with your
competence, is the European Parliament
Resolution of 10 April 2008 on combat-
ing cancer in the enlarged European Union
which was adopted at the plenary meeting
with 621 votes in favour, 10 votes against
and 6 abstentions.
I want to quote just Recital S and Article 22
of this Resolution:
Recital S: “whereas oncology is recognised
as a medical speciality not in all Member
States, and whereas continuing medical
education needs to be provided”,
Article 22: “Urges the Commission and the
Member States to recognise oncology as a
medical speciality and to make provision for
lifelong learning for medical oncologists in
accordance with agreed guidelines.”
And now, some thoughts about the migra-
tion of health professionals and its impact
on patient safety: The European Commis-
sion launched on 25 March of this year an
eight week public consultation on patient
safety in order to help in the development
Prof. Georgs Andrejevs FRCA, MEP
The speech on the UEMS The Union
of European Medical Specialists) 50th
Anniversary Conference. Brussels,
18 april 2008
49
of the Commission’s proposal for general
patient safety issues planned for the end
of 2008. Patient safety is deﬁned as free-
dom for a patient from unnecessary harm
or potential harm associated with health-
care. Although patient safety is narrower in
its deﬁnition than healthcare quality more
generally, it is the foundation of any high
quality health system.
As such it is recognised as a major concern
for governments and competent authori-
ties, as well as health professionals and civil
society across Europe. The type of health-
care setting itself will also be an inﬂuencing
factor on safety levels. Therefore, the focus
should be a broad one. As it is well known
human resources are an essential factor in
the provision of health care, directly in-
ﬂuencing the performance of health care
systems. Accessible health care requires a
well-trained and well-motivated workforce
of physicians and nurses – of an adequate
size – that are able to deliver safe, high-
quality medical services. However, concerns
have been voiced in many EU countries, es-
pecially in the new Member States, that a
gap is increasing between demands for and
supply.
Due to an aging population, technological
advances and higher expectations from pa-
tients, demand is likely to increase. On the
other hand,supply is expected to fall as a re-
sult of physician and nurse workforce aging,
trends towards early and partial retirement
and the mobility of the highly skilled –
even Brain Drain of medical specialists and
nurses.
Migration of Health Professionals was the
main topic at the ENVI Working Group on
Health meeting in October last year. Our
guest speaker, Jean-Christophe Dumont
(representing the International Migration
Division at the OECD, Paris) gave us an
overview on recent migration ﬂows and
migration policies for health workers in the
OECD countries where a potential com-
petition to attract and retain health profes-
sionals exist. The question of “Brain drain”
from Central and Eastern Europe to the
Northern and Western Europe was also de-
bated. Although no precise data is available,
it is known that tens of thousands of doc-
tors and nurses have left their home coun-
tries because their national health systems
cannot compete with the salaries oﬀered by
other EU Member States and other coun-
tries, like the USA.
Having said this, I would like to mention
some of the available data to give you a
clearer idea about the scope and signiﬁcance
of this problem, especially in regards to the
situation within the new Member States.
In Ireland, the employment of nationals
from the new Member States (excluding
Malta and Cyprus, also called the EU8)
in the health sector doubled between Sep-
tember 2004 and 2005, from 700 to ap-
proximately 1300 persons; in Finland, 432
authorisations were issued to physicians
and dentists from the EU8 countries until
December 2005,and in Sweden the number
of authorisations granted to EU doctors
jumped from 230 in 2003 to 740 in 2004.
Available data from countries of origin
conﬁrm these trends: In Estonia, by April
2006, 4.4% of all health care professionals
had applied for a certiﬁcate to leave (61% of
them were physicians); in my home country,
Latvia, in 2005 more than 200 doctors ex-
pressed their intention to leave; in Poland,
between May 2004 and June 2006 more
than 5000 certiﬁcates were issued to doc-
tors (which is 4.3 % of the active workforce)
and 2800 to nurses (this equals 1.2 % of the
active workforce). Furthermore, some spe-
cialities seem to be more directly aﬀected
such as anaesthesiologists in Poland (16 %
were issued a certiﬁcate) or for instance
plastic and reconstructive surgeons in Esto-
nia where 30 % were issued a certiﬁcate.
Unfortunately, this study, although being
supported by a grant provided by the Eu-
ropean Commission, reﬂects the situation
only in 18 EU countries – which are mem-
ber States of the OECD. At this time, no
survey is available on this issue that would
reﬂect the situation in all EU member
States. A representative from DG SANCO
informed the participants, however, that
the mobility of health professionals would
be a priority issue in the Commission An-
nual Policy Strategy for 2008.It was assured
that the Commission needs to look into this
matter – even if it is in principle a responsi-
bility of the Member States.
Within the EU, the last enlargement has
had a considerable impact on the migration
of health professionals. There is, however,
little data on the actual migration ﬂows
and the OECD study is the ﬁrst one on
this subject. The collection of data is due
to improve, since the 7th
Research Frame-
work Programme will fund studies relating
to this issue. DG SANCO will also adopt a
non-legislative document on the mobility of
health professionals in the EU in 2008.
We have to deal with two sides of the same
coin called eﬀective health care and pa-
tient’s safety.
On one side is written that “there are im-
mense beneﬁts to health systems in Europe
and the health of European citizens from
the free movement of health professionals,
most of whom make a strong contribution
to delivering high quality healthcare”.
On the other side one must see the prob-
lem and the consequences of the Brain
drain. According to the Terminology on
International Mobility of Skilled Work-
ers, Brain Drain may occur if emigration of
tertiary educated persons for permanent or
long-stays abroad reaches signiﬁcant levels
and is not oﬀset by remittances, technol-
ogy transfer, and investments trade. A Brain
Drain reduces economic growth through
unrecompensed investments in education
and depletion of a source country’s human
capital assets.
50
History of UEMS
The Union of European Medical Specialists
(UEMS) was established in 1958, following
the signing of the Treaty of Rome in 1957.
In the Treaty of Rome harmonisation and
mutual recognition of diplomas is foreseen.
The objective of the UEMS has always been
bringing together the medical specialists of
the member states and reaching consensus
on content and quality of medical specialist
training and practice. The outcome of this
process was meant to serve as foundation
for EU legislation.
The start was slow, but in the seventies the
EU moved towards legal provisions in this
matter. The Specialist Sections were estab-
lished from 1962 onwards and the UEMS
with its Sections was instrumental in the
shaping of the “Doctors Directive” in 1975,
which established the mutual recognition
of medical diplomas between the member
states of the EU.
However, in the follow-up little attention
was paid to the contributions of the UEMS,
and quality requirements in the Directive
basically remained limited – also in Direc-
tive 93/16/EEC, the consolidation of later
updates – to the minimum duration of train-
ing (art. 26-27) and the requirement of rec-
ognized training institutions (art. 24).
The EU blocked progress of implementa-
tion of quality requirements in the Directive
during the eighties and a new approach was
required.
Nineties
The UEMS emphasis moved away from
providing the EU with recommendations
towards broadening the work on harmonisa-
tion and improvement of content of quality
of training and practice on the shop ﬂoor of
medical specialists.
For this purpose European consensus docu-
ments were developed during the nineties
concerning key-issues as professional train-
ing, continuing education, quality assess-
ment and tools like logbooks and visitation
of training centres.The outcome of this pro-
cess was embodied in the UEMS Charters.
These Charters were presented to the profes-
sional authorities in the European countries
as models and recommendations for national
policy. Although the Charters do not have
legal value, their inﬂuence upon national
regulations has been considerable.
Following charters were proposed by the
UEMS: a Charter on Continuous Medical
Education, a Charter on Quality Assur-
ance in Specialist Practice in the European
Union, a Charter on Visitation of Training
Centers, a Charter on Continuous Profes-
sional Development (also called the Basel
Declaration), the Declaration on Promoting
Good medical Care, Ensuring the Quality
of Medical Care (also called the Budapest
Declaration) and the Policy Statement on
Assessments during Postgraduate Medical
Training.
Actual situation
The philosophy of all national professional
medical organisations is that patient care
is best served when quality and content of
medical training and practice are the domain
of the medical profession. In each country
the profession is defending this position.
Unfortunately we are experiencing that this
defence is becoming more and more diﬃ-
cult. Governments, insurances, commercial
interests are eager to take over the quality
agenda.
A strong continuing eﬀort of the profession
is needed if the profession wants to maintain
and improve quality in the proper way.In or-
der to do this unity of purpose and action is
necessary. This requires balancing of profes-
sional and political views and interests.
National level
Uniﬁcation of policy has to start at national
level. The professional societies in the spe-
cialties at national level are doing a great
job in quality improvement. But this has
to be implemented at each level of medical
practice, all the way from individual private
practise to hospital management, training
requirements, certiﬁcation, validation, pro-
fessional regulations, national legislation.
The Union of European Medical Specialists
Dr. Hannu Halila, Dr. Cillian Twomey, Dr. Alexander Kuttner, Dr. Leonard Harvey, Dr.Zlatko Fras
51
Close cooperation of the professional societ-
ies with the political national medical asso-
ciations and societies is necessary to achieve
implementation of quality policy in a proper
way. Only with unity of purpose and policy
results can be achieved.
Unfortunately in many European countries
thisunityofpurposeandpolicyisnotthatwhat
it should be,and a greater eﬀort on this issue is
necessary. National professional organisations
should be more aware of the signiﬁcance of a
strong European representation.
European level
The lack of national unity of polic y reﬂects
itself immediately in the representation of
the medical profession on European level.
Too often delegates of organisations of the
same country are bringing opposing views in
diﬀerent European medical organisations.
European medical organisations
On the European scene there is the UEMS
with its UEMS Sections and European
Boards, the European professional Societies
in each specialty, but there are also the um-
brella organisations of the national medical
associations (Comité Permanent of Europe-
an doctors CPME), and other independent
medical organisations such as the European
associations of junior doctors (PWG), hos-
pital doctors (AEMH), salaried doctors
(FEMS). Basically each group started out
as a lobbying group for its own interests, but
progress in the unity of purpose and policy
has been made.This process of confederation
has to be pursued.
Future
The UEMS with its Sections and Boards is
by far the largest of all political European
Medical Associations,and it has an extensive
grass-root support.It has done a lot,but more
is needed.So far each country is autonomous
in health care matters,but European integra-
tion is gaining momentum. The profession
must be ready to play its role in a future inte-
grated European health care policy.
In order to meet the challenge of increas-
ing involvement of the European Union in
health care matters in an enlarging Europe,a
stronger position of the profession is needed.
It has to start at national level:
Unity of purpose and policy of national•
organisations,
Coordination of separate national organi-•
sations,
Enlargement of investment by national•
medical organisations in European medi-
cal matters, in imagination, in people, ex-
pertise and ﬁnancial means.
At European level a more uniﬁed voice of
the medical profession is needed, leaving
intact the professional independence of sec-
toral groups like medical specialists, general
practitioners, etc. Here the same unity as at
national level should be achieved.
Presently the Directorate Health and Con-
sumer Protection (SanCo) has only author-
ity in the ﬁeld of Public Health. Its main is-
sues currently are health surveillance, health
threats and health determinants.
Very likely EU authority will expand in the
future. The medical profession should bring
forward its views on the quality issue in one
voice. It should prepare itself to be ready to
provide the EU in the future with construc-
tive and well founded recommendations on
key issues.
Structure of the UEMS
To simplify UEMS can be seen as three dif-
ferent structures. First, the Council where
the National Medical Associations are meet-
ing, secondly, the Sections and Boards based
on the Specialties and thirdly, the youngest
“child”of the UEMS, the EACCME, Euro-
pean Accreditation Council for Continuous
Medical Education.
The Council is the oldest structure of the
UEMS and was called in the past Manage-
ment Council. It is the political body where
the decisions are made and statements are
taken on issues in the ﬁeld of Specialist Med-
icine. The National Medical Associations are
mainly organizations that represent Medical
Specialists in the diﬀerent European Union
Member States and the European Economic
Area and Switzerland. We have also repre-
sentatives of countries of Europe that are not
Member of the European Union.
The Sections and Boards were created more
recently but some of them have also a long his-
tory. They are based on the diﬀerent Special-
ties that are present in Europe and are made
up of two delegates of the countries where
their specialty exists. It represent so quite well
the ﬁeld of each Specialty in Europe and is
responsible for the harmonisation of training
throughout Europe, and the defence of their
specialty. This of course is also important for
the patient because quality of health care is
also in the beneﬁt of the patient.
In 1999 the UEMS created the EACCME
that started its operations in 2000.This struc-
ture of the UEMS tries to harmonize the
CME-CPD in Europe by helping the doc-
tor to have his credits earned at international
events approved by UEMS-EACCME ac-
cepted in all UEMS Member States.
Accreditation
CME/CPD is an important part of the
medical practice today. When we look at
the training to become a (specialist) doctor,
it starts with undergraduate and graduate
training at the University followed by the
Postgraduate Training that is done in coop-
eration between the Profession and the Uni-
versity ideally.
In the past this was the end of the process
but it is more than obvious that a long life
Dr. Bernard Maillet, Dr.Zlatko Fras
52
learning has to be done in order to maintain
knowledge and skills for the practitioner.
Here CME / CPD is an important factor.
It started with Continuous Medical Educa-
tion where mainly theoretical courses and
congresses were organized.
Nowadays this is completed by the improve-
ment of communication, IT, managerial and
social skills and is more concentrated on the
practice of each individual practitioner and
his or her needs.
The CME / CPD needs and the way it has
to be organized is a duty of the National
Accreditation Authority in each European
Union Member State and can be National
or Regional (or a combination of both).
The NAA has to deﬁne how many “credits”
and which kind of credits are needed each
year or each period of time.
It is more than obvious that one can not gain
all his or her credits by following only one
means of CME / CPD, meaning that for in-
stance not all credits may be earned by follow-
ing Long Distance Learning Programs only.
Other means such as Live Events, Enduring
Material, like CD-ROM’s, or articles have
also a certain role to play in the whole picture
of the CME / CPD of a (specialist) doctor.
It is clear that this remains a responsibility
of each NAA.
UEMS has started the EACCME®
in order
to help the European Medical Specialist to
have the credits he or she has earned by go-
ing to International Meetings approved by
his or her NAA in order to avoid a duplica-
tion of the process.
For instance when I as a Pathologist go to
a meeting organized by the British Division
of the International Academy of Pathology
and that has been approved for CME by the
Royal College of Pathologists of the UK,
why should the Belgian Accreditation Au-
thority starts the process of approval again.
This was the start of the EACCME®
where
we proposed to have a clearing house where
requests for European Accreditation could
be sent to.
The aim was to have an approval of both the
responsible NAA and the involved UEMS
Specialist Section.
The responsible NAA is the NAA of the
country (or of the region) where the event
takes place.
The involved Section is the Section of the
Specialty that is most involved with the
meeting for instance as a target audience.
As the Sections are constituted by two del-
egates representing the Specialty in each EU
Member State, they can be considered as
giving a quite representative opinion of the
ﬁeld on each evaluation.
History and political background
of European Accreditation
Council for Continuous Medical
Education (EACCME®
)
Continuing Medical Education (“CME”)
and Continuing Professional Development
(“CPD”) have always been one of the
major key elements of UEMS as it notably
promotes the quality of care and the best
level of training for medical specialists. This
became concrete in 1993 when “UEMS
Charter on CME” was adopted. Since then,
further work has been laid down in the ﬁeld
of CME and CPD and other declarations
and position papers were adopted such as
the “Basel Declaration on CME” (2001) or
“UEMS Declaration on the promotion of
good medical care”(2004).
At the same time, many European countries
have been taking steps towards mandatory
CME together with legal or professional
re-certiﬁcation or re-licensing, ﬁnancial in-
centives or contracts with insurances and
hospitals. Even though UEMS defends vol-
untary CME, it was felt appropriate to help
European medical specialists in this respect.
Therefore, in October 1999, UEMS Council
set up the European Accreditation Council
for CME (EACCME®
), with a view to:
Facilitating access to quality CME for•
European doctors;
Contributing to the quality of CME in•
Europe; and
Exchanging CME credits in Europe•
easily.
The quality control of CME activities is a key
element in this process. It was thus decided
to operate in a decentralised way by using the
expertise of existing European and national
professional bodies involved in accreditation.
The everyday management of European ac-
creditation by EACCME®
provides this link
between European and national levels. One
has to remind the political necessity to comply
with the political authority of national profes-
sional regulatory bodies,as these bodies are re-
sponsible for registering doctors’CME-CPD
and awarding licences to practice.
EACCME®
Structure
EACCME®
was founded in 1999 as a sepa-
rate entity from UEMS even if it was ruled
by its Management Council. In the revised
Statutes, it was proposed by the Executive
upgrading EACCME®
as one of the ﬁve
genuine bodies of UEMS in order to stress
the importance of this body.
EACCME®
management would though re-
main as it is:
The governing body is UEMS Council,•
which is made up of representatives from
national associations of each UEMS
member country.
An Advisory Council provides recom-•
mendations with regard to the manage-
ment of European accreditation. This
body is made up of representatives from:
National professional CME authori-•
ties, including national CME accredit-
ing bodies;
UEMS, including its Sections and•
Boards;
53
Professional specialist organisations•
and societies.
This Advisory Council provides full ex-
change of expert-knowledge and collabora-
tion between the various partners involved
in accreditation at European level. UEMS
convenes a meeting of this committee each
year as it is committed to the further evolve-
ment of EACCME®
procedures in coop-
eration with the members of this advisory
committee.
The daily proceedings of the EACCME®
are
managed by UEMS Executive in its Brussels
Secretariat.
Right from the start, it was clear that na-
tional professional regulatory bodies would
approve a structure, such as EACCME®
,
which would make CME credits in Eu-
rope exchangeable. The only condition was
that these bodies would remain in charge of
events in their own country and would have
a major input in the process of EACCME®
.
This is a political reality. Moreover, it is ex-
pected that within a few years mandatory re-
certiﬁcation would apply in several countries.
CME credits would then be the instrument
used in this respect.
Practical operation
EACCME®
received its mandate from na-
tional regulatory bodies together with sev-
eral distinct conditions.
National authorities are maintained.•
EACCME®
does not become a suprana-
tional body, but a link and clearing-house
between national regulatory bodies.
The ﬁnal word concerning accreditation of•
each activity remains the decision of the
national regulatory body in the country
where the activity takes place.
The Brussels administration should be as•
lean as possible.
Quality assurance and determination of•
number of credits of separate CME ac-
tivities would be decentralised, EACC-
ME®
relying upon the expertise of profes-
sional bodies in each specialty (such as the
UEMS Sections and/or Boards and Eu-
ropean Speciality Accreditation Boards).
This aims to avoid duplication of quality
assurance proceedings.
There would be no accreditation of com-•
mercially biased activities, internet activi-
ties and for the time being each activity
should be judged separately. So providers
are not accredited for series of activities
stretching over years.
Administrative expenses of EACCME• ®
are borne by the providers of activities
applying for European accreditation. Ex-
penses would be limited, avoiding dupli-
cation in Brussels of work already done by
other accreditation bodies.
The recognition of EACCME®
credits (EC-
MEC’s) is only guaranteed by national au-
thorities within the framework of these condi-
tions. EACCME®
strictly complies with this
set and operates according to the procedure:
The accreditation process in Europe involves
two partners, on the one hand the National
Accreditation Authorities and on the other
hand the UEMS Specialist Sections and/or
Boards. The responsible National Authori-
ties are determined according to the place
where the meeting is organized and the in-
volved Specialist Sections are determined
based on the specialty that is most involved
or to the target audience of the event.
Let us now look how the process works in
practice.
The organizer of an event send the request
form with all the relevant and needed docu-
ments to the UEMS – EACCME®
Oﬃce
in Brussels or ﬁlls in the webbased request
form.
Here the request form will be distributed to
the two partners.
The relevant UEMS Section and/or Board
assess the scientiﬁc value of the CME activ-
ity. This evaluation strictly follows UEMS
Quality criteria deﬁned in D-9908.
Both partners are requested to give in a well
determined time scale an approval or a re-
fusal for accreditation, the number of credits
being determined by UEMS – EACCME®
.
Flowchart of the process
Organiser
Request
> 3 months
UEMS – EACCME
N.A.A. Sections
Evaluation < 3 weeks Evaluation UEMS - EACCME Certiﬁcate of Recognition Organiser Credit system As the diﬀerent National Accreditation Au- thorities apply diﬀerent credit systems, the European CME Credits (ECMEC) were introduced in order to harmonise the num- ber of credits on the following basis: : 1 ECMEC per hour;• 3 ECMEC for half a day; and• 6 ECMEC for a full-day event.• National authorities can then convert these credits into national units, following the National rules. When both partners agree on the approval, the organiser will receive a letter conﬁrming the approval of the European Accreditation. This letter contains three sentences : the ﬁrst stating the approval and precises which part- ners have been involved. The second sentence gives the number of ECMEC’s granted to the event (and eventu- ally the number of National Credits granted following the rules of the National Accredi- tation Authority of the country where the event takes place). The third sentence informs about the mu- tual recognition of credits between UEMS – EACCME® and AMA PRA Class 1 credits. 54 Evaluation of events It is very diﬃcult (if not impossible) to fully evaluate an event before it is held based on documents that are provided by the orga- nizer. Therefore in the future eﬀorts will be concentrated to ask the organizers to have an evaluation of the event by the participants. This evaluation can be quite simple because at the end a too much detailed evaluation will be problematic to analyze. The main questions could be: was the event well organized.• did I learned something from the event.• will what I learned from the event change• my practice. did I felt any bias.• The evaluation can be graded from “fully agree” to “fully disagree” by ﬁve steps for in- stance. The principal aim of this evaluation is not to retrospectively throw away the allocated credits but rather help in the evaluation of the next meeting of the same kind orga- nized by the same people. EACCME is mostly involved in the evalua- tion of big international events that are recur- ring events so this will help in the process. Which added value? As shown, the added value of EACCME® lies in the link set up between the profes- sional societies, the CME providers and the national regulatory bodies. Any change to this procedure would need the consensus of national regulatory bodies. Any devia- tion from this consensus would defeat the purpose of the EACCME® and it would also mean loss of the agreement with the American Medical Association concern- ing mutual recognition of EACCME and AMA credits. From the point of view of the organizers of events, the added value sits in the interna- tional dimension that would be given to an event. More participants from abroad and also from the USA would be interested in joining their meetings. The agreement with the American Medical Association has been renewed and is now valid from July 1st 2006 for a period of four years. The long term beneﬁt is the link with the national regulatory bodies. These bodies are very keen to preserve their national author- ity in the awarding of credits to the doctors in their own countries. The EACCME® of- fers an institution in which they participate and have authority. In this way the profes- sion facilitates exchange of CME credits in Europe in a similar way as postgraduate diplomas are mutually recognised according to European law. At the end it are the National Accredita- tion Authorities together with the National Licensing Authorities that gives to license to practise. The ultimate goal is to develop a system that makes life easier for our colleagues and to provide them with recognised quality CME with the guarantee that they can use their CME credits to meet national require- ments. Fee The UEMS – EACCME asks a fee for the processing of the applications. This fee is based only on the number of participants and is a sliding scale. As we have two equal major partners in the European Accredita- tion, they also share their part of the fee. Dr. Bernard Maillet Secretary General I. Establishment of CMAAO CMAAO (Confederation of Medical As- sociations in Asia and Oceania) is a con- federation currently comprising 17 medi- cal associations. Established around 1958, CMAAO initially held Congresses once every two years, but now meets every year, with Congresses and Midterm Council Meetings held in alternate years. The objectives of CMAAO, as stated in its constitution, are to raise the health stan- dards of people living in the Asia-Paciﬁc region by promoting exchange between physicians in the region and establishing relationships and exchanging information with other world organizations, and to pro- mote friendship between member medical associations mainly through information exchange and discussion regarding shared medical issues. CMAAO began as the Southeast Asian Medical Confederation (SAMC) advocat- ed by Dr. Rodolfo P. Gonzalez of the Phil- ippine Medical Association (PMA), which played a central role in creating the organi- zation together with Dr.Taro Takemi men- tioned below. With the Australian Medical Association joining the SAMC, the organi- zation’s name was changed to the Confed- eration of Medical Associations in Asia & Oceania (CMAAO), and the 1st CMAAO Congress was hosted in Tokyo in 1959 by the Japan Medical Association (JMA) un- der the presidency of Dr. Gonzalez. History and Recent Activities of the CMAAO (Confederation of Medical Associations in Asia and Oceania) 55 At this Congress, it was decided that the confederation would initially operate on voluntary donations as the budget was as yet undecided, with the JMA donating $1,000 and the PMA donating $500. Furthermore, it was decided to base the CMAAO Secre- tariat permanently in Manila in the Phil- ippines and Dr. Victorino de Dios of the PMA was appointed as the inaugural Sec- retary/Treasurer who serves as both secre- tary and ﬁnancial oﬃcer. The JMA President at that time was Dr. Taro Takemi, a leader who served as JMA President for 25 years (1957-1982). Dr. Takemi said that one of the major objectives for establishing CMAAO was to create an organization in Asia to ensure the opinions and ideas of the medical profession in these areas to be reﬂected in the activities of the World Medical Association (WMA). CMAAO membership as recorded at the time of the 1st Congress comprised 11 national medical associations: Australia, Burma, Taiwan, Indonesia, the Philippines, Japan,the Republic of Korea,Iran,Pakistan, Thailand, and India. In discussions, the is- sue of international medical licensing was raised. At the 2nd Congress, held in Ma- nila in 1961, Dr. Takemi was appointed as CMAAO President. At this meeting, dis- cussion themes included prevention and eradication of malaria in the Philippines, research on Japanese encephalitis,Tsutsuga- mushi disease (trombidiasisi), and indepen- dent physicians and military medicine in the Philippines. This is how CMAAO operated in its early days. II Consolidation of the basis of the activities of CMAAO For the theme of the 10th CMAAO Con- gress, held in Tokyo in 1977, Dr. Takemi chose the issue of population aging, with particular emphasis on the need for health education in aging societies. He also point- ed out the seriousness of the eﬀect of pol- lution and waste as well as the huge impact of changes in the global environment, as well as the unavoidable problem of global healthcare economics as the burden of healthcare on government ﬁnances grew as health costs escalated with technologi- cal advances in medicine and the aging of society. He also mentioned the necessity of examining the issue of development and al- location of medical resources in relation to escalating costs and of providing welfare that enables better living conditions. These concerns clearly show Dr. Takemi’s far- sightedness, and it was under this vision- ary leader that CMAAO continued its ac- tivities. In commemoration of Dr. Takemi’s tremendous contribution since the incep- tion of CMAAO, a special lecture entitled the “Taro Takemi Memorial Oration” was established and is presented at each Con- gress by a distinguished expert in the medi- cal ﬁeld from the host country. At the 17th CMAAO Congress held in Hong Kong in 1991, the Takemi family and the JMA pre- sented CMAAO with a fund named “Take- mi Memorial Fund”to support the Oration. At the 2007 Congress held in Thailand, this Oration was presented for the 8th time. III. Recent CMAAO Activities and Future Perspectives At the 18th Congress, held in Malacca in Malaysia in 1993, the CMAAO Secretariat was moved from the Manila to Malaysia. The role of Secretary/Treasurer was also passing from the Philippines to Malaysia. Following some subsequent reorganiza- tion, the Secretariat was relocated to Tokyo where Executive Board member of the JMA in charge of international aﬀairs took oﬃce of Secretary General supported by Interna- tional Manager. CMAAO is now reaching its 50th anniver- sary, and the time has come to reconsider the organization’s role and activities. Initial- ly, CMAAO was established with the clear purpose of creating an organization that would represent the voices of Asian within theWMA.Since then,CMAAO operations have expanded based on this objective, and within this framework,the JMA had striven to further invigorate CMAAO activities.As part of these eﬀorts, the CMAAO SARS Network Oﬃce was set up within the JMA Secretariat to work to gather information about SARS and avian inﬂuenza in Asian countries. There are still many common is- sues for CMAAO to consider in the future, including issues unique to the Asia region. Some of the common problems are move- ment of physicians across borders,standard- ization of medical education in relation to medical licenses, continuing professional development, provision of healthcare ser- vices to foreign-national residents, and medical accidents or patient safety and those unique to these regions include vari- ous issues related to newly-emerging infec- tious diseases and the problems of medical assistance in the event of natural disasters such as tsunamis or earthquakes. Recently, together with proactive eﬀorts to resolve issues such as these, there have also been moves to revise the CMAAO Consti- tution and By-laws to be used for the next 50 years. As the CMAAO Secretariat, the JMA is working to devise the most ap- propriate way to manage the activities of CMAAO to improve healthcare in the Asia-Paciﬁc region based on our long expe- rience as a WMA member as well. Masami Ishii, MD Secretary General of CMAAO, Executive Board Member of the JMA and Hisashi Tsuruoka, Manager, International Aﬀairs Division, JMA 56 The Permanent Working Group of Euro- pean Junior Doctors (PWG) was formally created in Bad-Nauheim, Germany, in May 1976. Since then, the PWG has become the European medical organisation with the most comprehensive national membership, representing the junior doctors of 26 Euro- pean countries. The PWG’s initial objectives include safe- guarding the interests of the junior doctors in Europe, improving relations between its member organisations and narrowing the gap between the junior doctors of the Eu- ropean Union and those of other European countries. Over the last three decades, the PWG has actively intervened in defence of the medical profession in Europe with the purpose of contributing to the development of junior doctors’ work and education and has had an important role as a background group for the organisations of junior doctors in countries preparing to join the European Union. From the beginning of the PWG’s existence, it became evident that the junior doctors of the various countries have many similar experiences and diﬃculties.Therefore, after pooling the information and exchanging ideas,the PWG was able to identify the main areas of interest to junior doctors in Europe. The status of the medical workforce was one of the most important issues in the PWG’s early years. The PWG conducted several studies that drew the medical profession’s attention to the fact that this issue is not static and that long-term planning, though diﬃcult, is essential. The diﬀerent perspec- tives within the European Union inﬂuence the migration of doctors, as well as the working conditions, quality of training and quality of patient care.Therefore, the PWG has endeavoured to gain a better insight of the workforce policy of its member coun- tries in order to, where necessary, inﬂuence policy makers by providing examples of more successful planning. Other major ar- eas of interest to junior doctors, and to the PWG, have been temporary migration for educational purposes,postgraduate training, continuing medical education, future medi- cal work and working conditions. In its ﬁrst years, the PWG embarked on the important task of compiling information to facilitate the migration of doctors in training in Europe.The objective of this work was to provide true freedom of movement, in ac- cordance with the principles established by the Medical Directives in 1976.The PWG’s greatest contribution was the publication of a series of booklets containing relevant in- formation for doctors wishing to seek em- ployment or complement their training in a foreign country. In 1995, at its conference on “Postgraduate Training: a European Future”, the PWG publicly presented its most recent policy on this issue, which is still a reference for European doctors. This policy statement brings to light a signiﬁcant number of prin- ciples concerning the structure and quality of this phase of medical education, which coincide with several points in one of the most important oﬃcial documents on this issue, the 4th report of the Advisory Com- mittee on Medical Training (ACMT), published in 1997. In the same year we had the opportunity of disseminating an important new paper on “Future Medical Work”, which has proven fully up-to-date. This paper concerns the organisation of work in health services and its inﬂuence on the working conditions of junior doctors. The greater expectations of patients, allied with factors such as ageing, migration and mobility, have led to a progressive increase in healthcare costs. As a result, most Eu- ropean countries have undermined doctors’ working conditions with policies of eco- nomic management and redistribution of resources. Our recommendations include concepts such as the creation of a positive workplace, organisational development, project management and other strategies that enhance the structure, process and outcomes of health promotion for patients as well as doctors. In May 2000, the PWG published a policy statement on Continuing Medical Educa- tion/Continuous Professional Development (CME/CPD) and organised a conference in which it was possible for experts from various European medical organisations to exchange their views on CME/CPD before an expert audience. We have recently wit- nessed the publication of several diﬀerent documents on CME/CPD that generally defend the principles that became evident during the Conference. Fundamentally, the medical profession believes that CME/ The Permanent Working Group of European Junior Doctors 57 CPD is both a moral obligation and a right, and that access to appropriate CME/CPD must be ensured for all doctors, including those in training. The PWG’s Policy State- ment opposes a system of recertiﬁcation and states that it is a misconception that such a system would contribute to the identiﬁca- tion of unsuitable doctors, hence defending the concept of quality improvement, as op- posed to quality control. The PWG was actively involved in ﬁnding a solution to the problem that was created when the European Working Time Di- rective (Directive 93/104/EEC) excluded doctors in training from certain aspects of the organisation of working time. In De- cember 1995, the PWG, in collaboration with the European Commission, organised a major conference in Brussels to address the issue of junior doctors’ working condi- tions. In the year 2000, after many years of intense negotiations with the European authorities, the European Parliament and the European Council ﬁnally agreed to in- clude doctors in training within the scope of the European Working Time Directive (Directive 2000/034/EC). Although the PWG considers this agreement a posi- tive step forward in protecting the health and safety of doctors and their patients, it deplores the unnecessary delays to the full implementation of the Directive. The European Parliament and the European Council established a total transition pe- riod of nine years to reach the 48-hour week, which the PWG regards as unnec- essarily long because junior doctors often work until exhaustion in several European countries, jeopardising their health and safety, as well as that of their patients. The PWG continues to draw the attention of EU Member States to the need for real re- ductions in junior doctor’s working hours and the full implementation of this Direc- tive within the shortest possible time. Curiously, our organisation was founded as the “Permanent Working Group of Euro- pean Junior Hospital Doctors”, which later proved inappropriate because the PWG in- cludes doctors in training in non-hospital ﬁelds and there was no organised body of junior doctors in the ﬁeld of primary care. Therefore, in 1996, during an important re- vision of our statutes, by a working group coordinated by Dr. Kirsi Ailus (SF), we dropped the word “hospital” and became the Permanent Working Group of Euro- pean Junior Doctors. From the beginning, the PWG has sought to develop productive relations with vari- ous European medical organisations and authorities. We have had formal relations with the Standing Committee of European Doctors (CPME) since 1983 and we were granted consultative status in the Council of Europe in 1986. We also have good rela- tions with the Regional Oﬃce of the World Health Organisation, the European Parlia- ment and the European Commission. Since 1991 each UEMS Specialist Section and European Board has welcomed a represen- tative from PWG to represent European doctors in training. At the Executive meet- ing of UEMS in May 2007 it was agreed that PWG delegates also are invited to rep- resent doctors in training in UEMS Mul- tidisciplinary Joint Committees. The PWG has regular meetings with the most impor- tant European medical and medical stu- dents’ organisations to coordinate activities and increase eﬃcacy. In November 2000, these organisations approved a protocol governing the relations between them and the CPME. The PWG is now a member of a group of institutions that speak with one voice and represent the medical profession in Europe, although it is aware of the fact that it must maintain its independence and capacity of negotiation with the European authorities. Our top project at the moment is the Eu- roMedMobility; this a joint PWG/EMSA project that, among other objectives, aims to improve the mobility of doctors in train- ing within European countries, increasing the diversity in training opportunities for all European medical professionals. During the ﬁrst 31 years of the PWG’s ex- istence, it has organised numerous plenary Assemblies all over Europe and the rota- tion of meetings has ensured mutual under- standing and the exchange of information. Since its beginning, in Bad-Nauheim in 1976, the PWG has been presided over by Dr. Per Vagn-Hansen (DK), the ﬁrst Co- ordinating Secretary of the PWG for the 1976-1979 triennium, followed by Dr. An- ton Seiler (CH), Mr. Douglas Gentleman (UK) and Dr. Hans-Ueli Würsten (CH). Dr. Jesper Poulsen (DK) was the ﬁrst per- son to be elected President of the PWG (1994-1997), an indication of the positive development of this organisation. Eduardo Marques (P) was the second President of the PWG (until 2001) and the Dr. Nina Tiainen (SF) as the third (2001-2005). At the moment the president is under Portu- guese Presidency, Rui Guimarães (P). Many junior doctors from all over Europe have had greater or smaller roles in the PWG’s work and some are now accredited leaders in national or European medical organisa- tions. Some non-medical participants, who have witnessed the life of this organisation from the beginning, have generously placed their knowledge on issues of medical policy at our disposal. The junior doctors of 26 European countries now have an inﬂuential organisation that defends their interests ef- fectively and, due to the hard and dedicated work of many individuals, we are all proud of its achievements.However,there is always much to be done and we are aware that the structure of our organisation must evolve if we wish to maintain our recognised role and capacity of intervention. Rui Guimaraes www.juniordoctors.eu 58 The Taiwan Medical Association The Taiwan Medical Association (TMA) was established in 1930 to advance medi- cal knowledge, to uphold members’ rights, to strengthen physician-patient relations, as well as to advocate social services. The TMA is composed of regional medical as- sociations from 23 counties around Taiwan. Its membership is compulsory for every practicing physician. Among the total 36 991 TMA members (ﬁgure for the end of 2007), 30% practice in medical centres, 13% in regional hospitals, 18% in local hospitals, and 39% in private clinics. The physician- patient ratio is 1:653. The TMA has formed ten committees to carry out its various missions and duties. These include Health Care Policy Commit- tee, National Health Insurance Commit- tee, Health Industry Advisory Committee, Medical Laws and Regulations Committee, Academic Committee, Member Welfare Committee, Medical Ethics and Discipline Committee, International Aﬀairs Commit- tee, Public Relations Committee, and Pub- lications Committee. In many areas, ad hoc task forces are set up to study relevant issues and to provide policy suggestions for the Executive Board. For more than a decade, the TMA has ac- tively participated in several key areas to promote the health of all Taiwanese, in- cluding the formulation and revision of a patient-centred National Health Insurance Policy in Taiwan, the advocacy of quality of care and patient safety, the implementa- tion of continuing medical education, and the uplift of moral standards of health care professionals. In the international forum, the TMA joins forces with the rest of the world through the World Medical Associa- tion and CMAAO to increase its visibility, and to express Taiwan’s good will to serve the international community. In time of di- sasters and emergency around the globe,the TMA has taken little time in mobilising its members to provide emergency relief and medical aid to people in need. The TMA has established close interaction with the WMA in recent years by partici- pating in various programs and activities. The translation and publication of “Manual of Medical Ethics” of WMA enables TMA members to share WMA’s policy changes, its functions and the contribution to all physicians around the world. By working with the WMA in devising declarations and policies, the TMA acquires updated in- formation on medicine, ethics, and medical education. The TMA strongly believes in the col- laboration among all national medical as- sociations under the auspice of the WMA. The sharing of information and resources, and the joint eﬀort in international medi- cal assistance will enable us to create a truly global village. Dr. Ming-Been Lee, the President of TMA Taiwan Medical Assembly in 2007 59 Medical Association of Uzbekistan was the ﬁrst a non-state non-commercial medical or- ganisation (NGO) created in the Republic of Uzbekistan in 1992.The initiators of the As- sociation were: Khudaybergenov A.M., Ko- simov E.J., Asadov D.A., Rizaev M.N., Ir- gashev S.B., Mustafaev H.M., Sidikov Z.U., Junusov M.M., Akbarov A.A., Vajnshtejn V.S., Nurullaev L.D., Usmonhuzhaev A.H.. The Association was registered by the Min- istry of Justice of the Republic of Uzbeki- stan on 11th November 1999. The mission of the Association is - assistance to the development of medical practice and sci- ence for the preservation and strengthening of the health of citizens of the Republic of Uzbekistan. According to the Charter of Association its primary goals are: Participation in reforming the system of• public health services of the Republic of Uzbekistan; Medical, economic and legal aid to mem-• bers of Association; Support for private practice and private• medical institutions in medicine; Participation in the development of uni-• form standards for control and quality in public health services; Support of doctors of veterans and use of• their experience; Improvement of international co-oper-• ation, holding of conferences, seminars and symposiums. The Association has 14 regional branches in which have been registered as members 20 thousand doctors, and also a publication – “The Bulletin of the Medical Association of Uzbekistan”, which 4 times a year which has been regularly printed already for more than 10 years. In the publication are printed arti- cles devoted to management, economy, law, marketing, new methods of diagnostics and treatment, information on seminars, confer- ences and to the private sector in public health services. The general circulation of the publi- cation is more than 5 thousand,which extends to all medical institutions in the Republic of Uzbekistan.The president of the Medical As- sociation of Uzbekistan is Doctor of medical sciences, Professor Abdulla Khudaybergenov, and his assistants are Academician Tulkin Iskandarov and Candidate of Medical Sci- ences Zafar Sidikov. The executive director of the Association is Zakhid Abdurakhimov. The Medical Association of Uzbekistan since 1997 is a member of the European Forum Medical Association and takes part in them (Copenhagen, the Vienna, Berlin, Warsaw, Oslo,Lisbon and Israel). For the last the Medical Association of Uzbekistan took part in several grant aided projects and in 2008 has ﬁnished the grant of the World Bank on “Monitoring of rendering of medical aid in jails”. The ba- sic purpose was the monitoring of jails re- garding protection and maintenance of the rights of prisoners to medical aid.Informing the public on the condition and problems of public health services in jails will allow the taking active actions by various NGOs, initiative groups and funds on improvement of the health of prisoners. In turn improve- ment of preventive and medical work in prisons will allow the reduction of disease, physical inability, and also the death rate among prisoners, which will allow them to join more quickly civilian life after being re- leased from jail. As a result, we would like to emphasise, that reform in the sphere of public health services spent by Uzbekistan, is carried out everywhere, including in the corresponding services of prisons. The measures directed to strengthening of health of citizens being held in prisons, car- rying out preventive and explanatory work among prisoners concerning a healthy way of life, developing of the activity of the medical personnel, and increasing their knowledge in the sphere of maintenance and protection of the rights of prisoners, will allow the reduction of the burden on the system of public health services of the country as a whole and keep what is most valuable the health of a person. The Medical Association of Uzbekistan be- ing the representative of a civil society is not indiﬀerent to problems of the health of the nation, and so systematically and consist- ently carries out activities on improving of the public health of society and citizens of the Republic of Uzbekistan and also pro- tects the interests of medical workers and their associations. Professor Abdulla Khudaybergenov Medical Association of Uzbekistan – Experience and Perspectives Presidentof MedicalAssociationof Uzbekistan, Professor Abdulla Khudaybergenov 60 The Canadian Medical Association (CMA) was born in October 1867, barely three months after the birth of Canada, and it has been the main national body representing Canada’s physicians since then. Following that ﬁrst meeting, the CMA had 167 members. Today, it has more than 67,000 members living in Canada’s 10 provinces and three territories, and approxi- mately 50 other countries. Membership is voluntary, and approximately 70% of eli- gible physicians choose to join. The online archive of the Canadian Medi- cal Association Journal (www.cmaj.ca), which contains all articles published since the jour- nal’s launch in 1911, provides a fascinating look at how far Canada, its physicians and the CMA have come since then. It also provides a suitable backdrop for the CMA’s two-part Vision Statement, “A healthy population and a vibrant medical profession.” One of CMAJ’s ﬁrst reports in- dicated that the infant mortality rate in the city of Ottawa – the nation’s capital – stood at 224 deaths per 1,000 live births in 1908. One hundred years later, Canada’s nation- wide infant mortality rate is 4.63/1,000. The CMA was the national medical voice that helped make many such improved health outcomes possible. It was the driving force behind the creation of national bod- ies to regulate medical education and certify new doctors, which in turn set the stage for the development of a science-driven, rig- orously regulated medical profession that quickly earned the public’s conﬁdence. Once that conﬁdence was earned,the public listened when the CMA supported public health initiatives such as the pasteurization of milk and the need for safe, reliable drink- ing water. In 1961, the CMA told members they had a duty to warn patients about the link between smoking and cancer, and the proportion of smokers has fallen to less than 20% of adults. Today, Canadians’ average life expectancy of 80.34 years is among the highest in the world. The second part of the Vision Statement, “a vibrant medical profession,” also occupies a large share of CMA eﬀorts because the coun- try’s health care system is under considerable stress due to funding issues, human resource shortages and an aging population. One sign of this stress became clear when the CMA conducted a survey in 2003 and found that 46% of physicians considered themselves “burned out” by their work. The CMA responded by creating the world’s ﬁrst Centre for Physician Health and Well- Being, which also links physician health programs across the country. On the human resource front,Canada is still paying for a 1992 decision to cut medical school enrolment in the face of rising gov- ernment deﬁcits and a perceived “surplus”of physicians.Today that surplus has turned in to a serious shortage, with an estimated ﬁve million Canadians having no regular access to a family physician. The CMA recently launched a national public relations cam- paign to draw attention to the issue. The CMA has also enjoyed unique success among medical organizations because of its early and successful eﬀorts to help members in areas such as retirement and ﬁnancial planning. The CMA entered the ﬁeld in 1957 after its extensive lobbying of the fed- eral government meant Canadians could set aside tax-free retirement savings for the ﬁrst time. The CMA launched its ﬁnancial sub- sidiary that same year with an investment of $50,000. Today that company – MD Man- agement – manages more than $25 billion in investments for CMA members and their families. In 2008, with Canada’s population having passed 33 million, the CMA remains the national voice for the country’s physicians, and it works closely with its divisions in the provinces and territories to respond to and deal with members’ priorities. Its message does appear to be getting through. A recent survey of Canadian politi- cians and senior public servants found that, among a dozen major national organizations in ﬁelds ranging from health care to brewing and broadcasting, the CMA ranked ﬁrst in all categories, and that 79% of respondents considered it “very”or “somewhat”inﬂuential in setting the country’s national priorities. The CMA has also been an active participant in the World Medical Association since its inception.Recent contributions include revi- sion of several key WMA policy documents, individually or as part of working groups,and the chairmanship of the WMA’s Ad Hoc Committee on Advocacy by Dr. Dana Han- son, a CMA past president. Dr. Henry Haddad, another CMA past president, also chaired the Sociomedical Committee for several years, and in this role was instrumental in introducing the consent agenda to the WMA. The CMA looks forward to hosting the WMA General Assembly in Vancouver in October 2010. This will mark the third time the meeting has been held in Canada,and the ﬁrst time since it was held in Ottawa in 1998. Barbara Drew, Associate Secretary General and Chief Operating Oﬃcer The Canadian Medical Association 140 Years and Counting 61 First, we would like to thank the people in charge of the World Medical Journal for the space oﬀered to the Medical Union of Uruguay in order to be able to brieﬂy up- date on the general situation of health in our country and of the doctors in particular. 2008 has begun and the sector of health has been immersed in a process of change, of transformation. The Medical Union of Uruguay on many occasions has speci- ﬁed its opinion in relation to this issue and has participated in all the events to which it was invited by the sanitary au- thorities. For the Union it is of historical importance and related to the commit- ment to healthcare of the Uruguayans, so non-participation was out of the question. We have applauded the ﬁrm stand of the government on healthcare reforms and the creation of a coordinated and eﬃcient Na- tional Healthcare System,which would pro- vide a rational use of resources, focusing on the most vulnerable groups of population. The position that the national medical body has expressed through the Medical Union of Uruguay has not always been well under- stood. We recognise the necessity for change and this is so because the general and basic principles of transformation of the health sys- tem have been originated by this very Union. These principles were not only generated but also defended, considering that they form the solid base of the Healthcare System. The complementary and diﬀerent vision of the proposed reform as oﬀered by the Medical Union of Uruguay does not con- stitute an obstacle but a contribution which we considered essential to reach the goals in the shortest time possible, to meet the expectations of the Uruguayan society to enjoy better care constructed on ﬁrm basis. Doctors constitute the foundation on which a health system would be built; they are the central axis of the structure and a very complex organisation united by a common and principal mission to maintain health and to ﬁght diseases. The doctor is the professional who is suitable, trained and qualiﬁed to fulﬁl this task. Therefore the Medical Union of Uruguay maintains that all reforms, all changes in the healthcare system must take into consideration the medical profession- als, from the pre-degree to the retire- ment group. This practice cannot be op- tional; it must be the rule if we really wish to aﬀect the health-disease process. The conditions and form of work of the doctors must change; it is essential to im- prove labour concentration, also education- al and investigation activities, establishment of a principal national award, the search of real alternatives for the introducing of the young doctor into the labour market, solu- tions that give opportunity for a worthy re- tirement from the medical profession, the relation between the professionals and the administration of institutions, considering the essential necessity that nowadays for doctors to stay qualiﬁed, they have to be en- gaged in lifelong education. The implementation of these changes will ensure a new form of work for the doctor but, more importantly, it will give an answer to manyofthecomplaintsraisedbythepatients and their relatives in relation to medical care. There are many and varied instances on which, throughout its history, the Medical Union of Uruguay has indicated the ne- cessity that the healthcare system should be considered an object for urgent trans- formation because it has been delayed. It is obvious for the patients and doctors alike, that the present system has deﬁcien- cies which make a change essential. Fragmented, unavailing and with super- structures that make it ineﬃcient, this system (asistema or “non-system” as some prefer to call it to demonstrate how little system that it has), implies for a good part of Uruguayans the serious problems of fair treatment and access,whereas for the doctor it is strongly indicative of wide conspiracy against the quality of life of the profession- als, the capacity of their performance, suit- able attention and institutional attachment. In view of the accomplishment of the last Consultative Council (the nucleus of all the actors involved in the health-disease pro- cess) in the past year we left the position of the medical union in the sense that obvi- ously the year of 2008 had to be the year of the change in the conditions and the form of work of the doctors and that this had to be considered by all healthcare actors as a basic and fundamental element to really ob- tain consolidation of the reform process. The MUU (SMU) is going to put in maxi- mum eﬀort and will dedicate all the re- sources that are at their disposal so that the change in the conditions of work of the doctors is a reality in the short term, thus contributing to the overall consolidation of the healthcare system as a whole and in particular, oﬀering the best-quality care to the patients. Dr. Alfredo Toledo Ivaldo Medical Union of Uruguay Dr. Alfredo Toledo Ivaldo, President of the Medical Union of Uruguay 62 The Malaysian Medical Association (MMA) is the ﬁrst and currently the largest pro- fessional medical association in Malaysia. Though many medical associations have sprung up after that, representing various interest and speciality groups, the Malaysian Medical Association still remains the largest and one of the more active associations in the country. It was formed with a commit- ment to promote the highest possible pro- fessional and ethical standards of health care. The MMA has ever since played a promi- nent role in promoting quality and equitable health care, while preserving the autonomy and professional integrity of the physician. The forerunner to the MMA was the Straits Medical Association (SMA) which was the oﬃcial association of the then Malaya and the Straits Settlements. The SMA was started and operated by expatriates working here and this was later replaced by the Ma- laya Branch of the British Medical Associa- tion (BMA). When Malaya became inde- pendent in August 1957, Singapore chose to remain a British Colony, but the BMA Malaya Branch still remained the only pro- fessional medical association for both these countries. In 1958 two separate associations representing the two countries were formed namely the – The Malayan Medical Associ- ation and The Singapore Medical Associa- tion. The Malayan Medical Association in 1971 grew to become the Malaysian Medi- cal Association with the inclusion of the states of East Malaysia. Currently there are many sections and so- cieties under the MMA representing the various activities of the association. There are two main sections of the MMA namely the SCHOMOS and PPS. The SCHOMOS or Section Concerning House Oﬃcers and Spe- cialists was formed in 1981,creating an oﬃcial channel of communication between govern- ment and doctors in the public sector. Since its formation SCHOMOS has had protract- ed and diﬃcult negotiations on behalf of the government doctors with diﬀerent authorities championing their cause. The results reached through these negotiations have made many positive changes to the working conditions, allowances, promotions and other issues ben- eﬁting all government doctors. The Private Practitioners Section (PPS) was oﬃcially registered in 1991 to address the various issues faced by the private practitio- ners. The terms of reference for this section was – “To represent views, interests and as- pirations of members of the MMA in pri- vate practice. – To study problems faced by private practitioners and commend solutions to the MMA Council. – To encourage the active participation of private practitioners in activities related to healthcare and to assist them to adequately respond to changes.” Ethics Committee This was one of the ﬁrst committees to be formed after the registration of the MMA. The initial task of this committee was to draw up the ethical code of ethics, in the context of the local medical situation and culture. The ethical code has been exten- sively revised twice, once in the year 1998 and again in 2001, to incorporate emerging ethical issues. The Association has encour- aged the correct behaviour of the mem- bers of the profession, by guiding and giv- ing advice on good medical practice while reprimanding unethical conduct. An essay competition on diﬀerent aspects of medi- cal ethics is organised annually in conjunc- tion with the world ethics day of the World Medical Association to create an interest in ethics among medical students. The ethics committee is active in organising seminars and updates on ethics of medical practice on a regular basis to update the members. Medical Education The training of suﬃcient and appropriate number of doctors has been a challenging task for many countries including Malaysia. The ﬁrst medical college was established in the University of Malaya in 1964 and was the only college for many years. Over the last few years there has been a ﬂurry to open new medical colleges both public and pri- vate.The rapid expansion of medical colleg- es in the last few years is a cause for concern as it has stretched the available resources of both manpower and facilities. The Malay- sian Medical Association has on a few occa- sions brought together all interested parties, universities, Ministry of Health, Ministry of Education and held Medical Education Conferences to chart the future of Medical education in the country. Estate Medicine Committee Healthcare provision in the rubber and palm oil estates has generally lagged behind na- tional healthcare provision in the country and has been semi-independent. Though some larger estates had reasonable healthcare facilities and personnel most estates only had a rudimentary service.The distance of estates from hospitals and government health fa- cilities made it diﬃcult for estate workers to obtain proper medical care.The MMA com- missioned study, on the availability of health facilities for the estate workers, painted a bleak situation and the study was presented to government and concerned authorities. Though there were some remedial measures taken as a result, health care provision in the estates remains inferior to that of the coun- try. The MMA continues to champion the right of health for the estate workers and for The Malaysian Medical Association Dr. Nachiappan Arumugam WMA Immediate Past President 63 estate health system to be incorporated into the mainstream healthcare delivery system of the country. Physicians for the Prevention of Nuclear War committee The Physicians for the Prevention of Nuclear War committee has highlighted the dangers of nuclear warfare and its disastrous eﬀects on health. It has persistently lobbied against the production and stockpiling of nuclear arms. The committee and its long standing chair- man Datuk Dr Ronald McCoy, also a past president of the MMA, received interna- tional recognition by being appointed to the Canberra Commission on the Elimination of Nuclear Weapons in 1996. The Canberra Commission on the Elimination of Nuclear Weapons was established as an independent commission by the then Australian Govern- ment in November 1995 to propose practical steps towards a nuclear weapon free world including the related problem of maintaining stability and security during the transitional period and after this goal is achieved. Continuing Professional Development Committee (CPD) The MMA has in collaboration with Uni- versities, hospitals and pharmaceutical com- panies been organising medical meetings for many years to update the members on the developing trends in medicine. Initially the Continuing Medical Education (CME) committee was formed to co-ordinate the activities and latter the name was changed to Continuing Professional Development Committee (CPD) committee to be more reﬂective of the work it was doing. In 1995, the CPD was formalised with the Malay- sian Medical Council and the MMC-CPD Grading system was introduced and the MMA was made the secretariat for running the system.This voluntary system enabled all doctors to register all their continuing medi- cal education and professional development activities with the MMA and the MMC is- sued certiﬁcates of attendance annually. International Medical Associations The Malaysian Medical Association is a member of important regional and inter- national organisations namely, Medical Associations of South East Asian Nations (MASEAN), Commonwealth Medical Association (CMA), Confederation of Medical Associations in Asia and Oceania (CMAAO) and World Medical Association (WMA). The MMA has taken an active part in the activities of these associations and some of the leaders of the MMA have held various posts in these organisations. It was indeed a historic occasion for MMA when Datuk Dr Arumugam was elected and installed president of the WMA in 2007.It was also an honour when Datuk Dr T.P. Devaraj was chosen as one of the Car- ing Physicians of the World by the WMA. Public Health and Community Service The Malaysian Medical Association has been in the forefront of public education. It has initiated and carried out many public health campaigns to raise awareness of the public to various diseases and healthy living. Action on Smoking and Health (ASH) Committee One of its earliest public health activities was to discourage students from picking up the smoking habit and to encourage smokers to quit smoking. MMA was one of the pioneer organisations in this country to have started the anti-smoking campaigns through the MMA–ASH committee and has continued to be committed to this activity till today.The MMA has over the years promoted the An- nual No-Smoking Day and incessantly high- lighted the dangers of smoking to the citi- zens of the country. The association has also organised scientiﬁc meetings and workshops to stimulate interest in anti smoking activi- ties among the doctors and allied health staﬀ. The MMA-ASH committee has over the years helped to draft and successfully lob- bied for the implementation of various rules and laws to discourage and curb smoking in ﬂights, restaurants and public places. Adolescent Health Committee Adolescent Health has now become an im- portant sub-specialty with its unique set of problems and needs. The MMA adolescent Health sub committee organised courses to upgrade the understanding of the health needs of this group in diﬀerent states for health personnel. The committee also had awareness programmes and hepatitis B im- munisation for some school children. Health of the Older Person Committee In view of the increasing number of older per- sons in the country, a Committee was formed to create an interest in the health of the aged among the profession and awareness in the society of the problems and challenges faced by this population. In 2005 a ‘Senior Citizen’s Charter”was launched by the MMA. As this older population face special medical prob- lems the committee has ventured in educating doctors on these common conditions aﬀecting this group of patients.The association also has activities to mark Senior Citizens Day on 1st October 2006. The association, as the largest professional medical organisation in the coun- try, through representation in many govern- ment and non-government organisation and many of it committees like theTraditional and Complimentary medicinecommittee(TCM), Society of occupational and Environmental Health (SOEM), Ophthalmological society, Public health society,Sports Medicine society, Accident prevention committee has not only advanced the interests of its members and profession, but also the health and welfare of the citizens of the country. Dr. Nachiappan Arumugam 64 The Finnish Medical Association (FMA) was founded in 1910 and is already prepar- ing for its centennial celebration that takes place in just under two years. Since its es- tablishment the association has defended the professional, social and economic inter- ests of its members and strived to develop health care and advance medical expertise, safeguarding thereby the interests of both doctors and their patients. The Finnish health care system In Finland the organization health care is a public responsibility. The system is ﬁnanced both by taxes and through a statutory health insurance scheme.User charges exist also,and they are relatively high in a European com- parison. The organizational model is decen- tralized; the local government (municipality) level is responsible for arranging health and medical care for the citizens.There are about 400 municipalities and they are relatively free to choose how they organize primary health care. In addition to the public service that is available to everyone, employers are obliged to provide occupational health ser- vices to all their employees. Primary care is mainly arranged in health centres that the municipalities operate either individually or together. Physicians working in health cen- tres are therefore municipal employees, even those who work under the system of “per- sonal doctors”, a Finnish variant of the fam- ily doctor. For specialized medical care the country is divided into 20 hospital districts. All municipalities are obliged to belong to one of these through federations formed by them. Each of the districts is responsible for providing and coordinating the specialized services within its area. The quality of ser- vices and health care facilities are of a high standard. The population of 5.3 million in- habitants is also in general satisﬁed with the services, although regional variations exist. Finland was the ﬁrst country in Europe to introduce a law on patients’ rights in 1993. The main challenges facing the system are related to manpower planning and the co- ordination of operational costs and capital investments. Role and Structure of the FMA The FMA acts both as a professional or- ganisation and a trade union. It is a proac- tive and well respected consultation partner for the government and parliament in all aspects of health policy. Developing educa- tion of physicians together with the medi- cal faculties forms an important part of the association’s activity. It also has a major role in organising and overseeing continuous professional development of its members. As a trade union the FMA negotiates the salaries and working conditions of the phy- sicians working in the public sector. The FMA membership is voluntary and indi- vidual.Some 94 % or 21.400 of all physicians licensed to practice in Finland are members. The association forms an umbrella structure both for the specialists’, GP’s and junior doctors’ national associations, as well as foe organisations based on geographical loca- tion or specialty. The FMA therefore truly unites the opinions of doctors in Finland and enables the profession to speak with one voice.The decision-making is based on elec- tions held every three years, where all mem- bers choose their representatives to the 60- member FMA “parliament”, called Delegate Committee. That then elects the board and its members, including the president who has a one-year renewable term. The FMA oﬃce has some 70 members of staﬀ, who serve the members in various ways, prepares the policies for the board to adapt and implements them. The FMA publishes a weekly journal that reaches the whole membership free of charge.The FMJ is a scientiﬁc journal as well as a major fo- rum of health policy discussion in Finland. Ethics and the professional oath A core activity of the FMA throughout its existence has been to promote and develop medical ethics. In 1910, the ﬁrst President of the association expressed the hope that the FMA would become the heart and con- science of the medical profession.That wish has since become a reality. The FMA pub- lishes a regularly updated book on medical ethics. This compilation of ethical thinking and approved guidelines oﬀers the members a toolkit that helps them to make diﬃcult decisions in their everyday work. The book is published in both the oﬃcial languages (Finnish and Swedish) and it is distributed to all the members of the FMA, as well as to medical students. An ancient tradition of the honorary position of the Archiater, the eldest of the medical profession still exists in Finland.This title,which can only be held by one person at a time and is awarded by the President of Finland, has existed since the days Finland was part of the kingdom of Sweden, over 200 years ago. Today the Archiater is the moral leader of the profes- sion and actively participates in the public The Finnish Medical Association Approaching One Hundred Years of Promoting good Quality Healthcare and Physicians’ Interests Dr. Heikki PälveDr. Olli Meretoja 65 The Foederatio Medicorum Helveticorum (FMH) or Swiss Medical Association is the umbrella organisation for the medical pro- fession in Switzerland. Just over 90% of the approx.30,000 physicians in the country are signed-up members. As a professional or- ganisation, the FMH aims to: • ensure a high standard of medical care in Switzerland; • promote the professional development of physicians; • foster relations between its members; and • actatthepoliticalleveltocreateaframework in which physicians can work eﬀectively. Structure and bodies at the FMH activities Legally speaking, the FMH is an association. Its two main bodies are the Medical Council which has 200 delegates and acts as the‘parlia- ment’, and the 11-member Central Commit- tee which serves as the ‘government’. A 33- member Delegates General Meeting (DGM) advises and supports the Central Committee in all important subject areas. The DGM is also authorised to make decisions itself, espe- cially in the ﬁeld of health policy.To become an ordinary member of the FMH, the ap- plicant must be able to show that he or she has a Swiss medical degree or its equivalent, works in the healthcare sector in Switzer- land, and is of reputable character. Ordinary members automatically become members of one of the local organisations. The FMH’s General Secretariat in Bern has a dual role of a service centre and the head oﬃce. About 75 people work there in the various departments which include: Members Services• Undergraduate, Postgraduate &• Continuing Medical Education Fees Guidance• Legal Service• Data, Demographic Information &• Quality Management Prevention• Communications & PR• One of the main tasks at the FMH is to monitor the specialist training of physicians after their state examinations.In most cases, this training leads to the title of ‘specialist’. The FMH is also active in the ﬁelds of qual- ity management, working closely with the specialist medical associations and the par- ties involved in negotiating doctors’ fees. The Schweizerische Ärztezeitung (‘Swiss Medical Journal’) is a major platform and source of information for the medical pro- fession in Switzerland. Published by Edi- tiones Medicorum Helveticorum in Basel, the FMH’s oﬃcial journal comes out on a weekly basis (www.saez.ch). On behalf of its members, the FMH campaigns exten- sively and maintains close networks with politicians and the media. Its motto – “No healthcare policy without the FMH!” – comes over loud and clear. The President’s Oﬃce As President and Chairman of the Central Committee, Jacques de Haller has been in charge at the FMH since 2004. Under his managementoverthelastfouryears,theFMH has succeeded in shaping a coherent policy for the medial profession in Switzerland and in creating a distinct and credible proﬁle,both in the eyes of the public and of other major play- ers in the Swiss healthcare sector. One great challenge facing the FMH is safeguarding the ‘freedom of occupational practice’, a right which is increasingly com- ing under attack from many a side — the insurance companies and the state in its role as regulator, for example. The task of the FMH here is and will be to organise politi- cal campaigns and lobby on a broad basis to ensure that traditional values are maintained and that relevant threats are averted. Only with a united association, speaking with one voice and represented by a strong and professional leadership, can these aims be achieved. D. Herzog, General Secretary of the FMH Swiss Medical Association discussion on medical ethics in the country. The association has also reintroduced the pro- fessional oath, which was earlier a part of the medical degree in the faculties. The swearing of the oath is now voluntary,but practically all the graduates choose to swear it at their grad- uation ceremony,where the Archiater and the president of the FMA are present. International activities The values and tasks of the FMA are not bound by the borders of Finland. The as- sociation is an active member of several international medical organisations, most importantly the World Medical Association (WMA), Standing Committee of European Doctors (CPME),European Union of Med- ical Specialists (UEMS),European Union of General Practitioners (UEMO) Permanent Working Group of Junior Doctors (PWG) and the Nordic Medical Council (NLR). Dr. Olli Meretoja, Dr. Heikki Pälve, Dr. Jukka Siukosaari Dr. Jacques de Haller, President FMH The FMH: the Professional Association for Physicians in Switzerland 66 The Polish Chamber of Physicians and Dentists (Naczelna Izba Lekarska) and the regional chambers of physicians and dentists (okręgowe izby lekarskie) are the organisational bodies of the professional self-government of physicians and den- tal practitioners who are associated in the chambers with equal status. The professional self-government of physi- cians and dental practitioners in Poland was founded in 1922, dissolved in 1952 and re- established in 1989. There are currently 23 regional chambers and a separate chamber of military physi- cians and dentists that has legal status of the regional chamber although it is active in the entire country. Chambers of physicians and dentists deal with all kinds of matters con- cerning the exercise of medicine and den- tistry in Poland. The highest authority of the Polish Cham- ber of Physicians and Dentists is the General Medical Assembly whereas the regional med- ical assemblies are the highest authorities of the regional chambers. In the period between assemblies – the Supreme Medical Council and regional medical councils respectively. The Supreme Medical Council represents the medical professions at the state level, and regional councils at regional levels. Membership in the chambers is mandatory. Every physician and every dental practitio- ner who holds the right to practice the pro- fession in Poland is a member of the cham- ber by virtue of the law. Number of members of the chambers in 2007: Physicians – appr. 128 000• Dental practitioners – appr. 34 500• Persons with both professional titles –• appr. 550 The tasks of the self-government of physi- cians and dentists include: supervising the proper and conscientious• exercise of the medical professions; determining the principles of professional• ethics and deontology binding all physi- cians and dentists and looking after their compliance; representing and protecting the medical• professions; integrating the medical circles;• delivering opinion on matters concerning• public health, state health policy and or- ganization of healthcare; co-operating with scientiﬁc associations,• universities and research institutions in Poland and abroad; oﬀering mutual aid and other forms of ﬁ-• nancial assistance to physicians and den- tists and their families; administering the estate and managing• the business activities of the chambers of physicians and dentists. The Chambers: award the right to practice the profession• of a physician or dentist and keep the reg- ister of physicians and dentists; negotiate conditions of work and remu-• neration; make decisions on matters relating to ﬁt-• ness to practice as a physician or dentist; co-operate in the ﬁeld of continuous• medical education; deliver opinion on draft legislation con-• cerning health protection and exercise of the medical professions; delivering opinions and making motions• regarding under- and postgraduate train- ing of physicians and dentists; act as medical courts in matters involv-• ing professional liability of physicians and dentists; defend individual and collective interests• of members of the self-government of physicians and dentists; co-operate with public administration• agencies, political organisations, trade unions as well as other social organisa- tions in matters concerning protection of human health and conditions of exercis- ing the medical professions. International Policy of the Polish Chamber of Physicians and Dentists One of the main priorities of the Polish Chamber of Physicians and Dentists is to take active part in international organisa- tions of physicians and dentists and to ac- tively co-operate with the medical and den- tal organisations and chambers abroad. The Chamber is active in the works of the fol- lowing international organisations of doc- tors and dental practitioners: Standing Committee of European Doc-• tors (CPME); European Union of Medical Specialists• (UEMS); European Forum of Medical Associa-• tions and the World Health Organiza- tion (EFMA/WHO); Symposium of Medical Chambers of• Central and Eastern Europe; Council of European Dentists (CED);• World Dental Federation (FDI);• European Regional Organization of the• World Dental Federation (ERO/FDI). Organisation of Professional Self-government of Physicians and Dentists in Poland Oﬃce of the Polish Chamber of Physicians and Dentists in Warsaw Meeting of the Supreme Medical Council 67 Medical Confederation of the Argentine Republic As a consequence of the implemented neo- liberal policies, the repetitive budget cuts have damaged the social, political and in- stitutional situation not only in our country, but in the entire Region. Health services have been deteriorating gradually, public healthcare spending is de- creasing in terms of the income per capita ratio, and the scarce resources had to be adapted by giving importance to treatment over prevention. At the same time, new changes have been introduced in the ﬁnancial aspect, and there is a rising tendency to privatization and the operating expenditure belongs to the user now. Within the framework of these neoliberal policies, several reasons were stated which privilege the following: expenditure is now aﬀorded by the users of the system, private resources are excessively used and the public services administration is decentralized. In addition to the aforementioned, the sec- tor shows extreme sanitary anarchy, and a lack of co-ordination between the public and the private sector, which results in the doubling and superposition of services and the low use of resources. Social Security deﬁnancing is a consequence of the unreleaved unemployment rate. The unemployed population lost their health in- surance coverage, which led to an overload of Public Hospitals, as well as a fall in the private sector provision of services. As a re- sult, doctors who perform in this subsector have been directly aﬀected. Given that the infrastructure and the public sector supplies are in a bad condition, doc- tors lack all kinds of support before patients. The latter not only demand a medical assis- tance that doctors cannot provide on their own, but also take legal action against them more frequently. Thus, a patient’s right before an undesired treatment result was turned into the so-called “medical malprac- tice insurance industry”. It is even worse when faced by the lack of- straint of relatives or the same patient, since they are becoming more and more aggres- sive, and may end up assaulting physically. Apart from these unfortunate situations, it must also be mentioned the doctor’s prole- tarianization, caused by several factors: Professional plethora which shows a doc- tor to patient ratio of approximately 360. In some large places, big urban centres, the ratio is 120 inhabitants per doctor. Increase of professional medical licenses up to 5 times faster than the population. No planning of geographical distribution. High percentage of specialists (80%,70% out of this 80% are in the big urban centres) After the proposal of the National Inte- grated Health System in 1973, which was injected, and laws 23660/61of the National Health Insurance (last essays on national policies), there was a crisis in the service provider which still continues, and signs in- dicate it will get worse. This deep crisis demands a health system reform in accordance with a State Policy under consensus of all participants, basing the system program on the following pro- posals: Give priority to Primary Attention (Moth- er & Child Programs, Special Plans for the needed, etc) as a response to the emergency. Complement all subsectors in order to shift the fragmenting system by using the idle installed capacity. Coverage based on an Obligatory Medical Insurance. State administration and regulation which comprises: High Complexity• High Medical Technology.• Medicine.• Regulation of professional practice which comprises: Adaptation of programs of study in the• Medical Schools. Planning the number of students who• enter Schools according to the needs of the system. Planning access to the work source.• Programming geographical distribution.• Professional certiﬁcation and recertiﬁca-• tion. Professional Career.• Regulation of specializations.• Dr. Jorge Carlos Jañez Dr. Jorge Carlos Jañez, President of the Medical Confederation of the Argentine Republic 68 MOTESZ – the Association of Hungarian Medical Societies – the largest organisa- tion based on voluntary membership – was founded in 1966 with the participation of 36 associations. During the almost forty years of existence, the objectives in the By- laws have only been changed by completing them with new ones meeting the require- ments of changing needs. The activity of MOTESZ can be seen at several levels manifested in co-operation with numerous organisations (governmental and public or- ganisations, universities). At the moment MOTESZ has 125 mem- ber-societies facilitating the connection of some 30 000 Hungarian medical doctors to the Association, and the most important aims of MOTESZ are to co-ordinate ac- tivities, collaboration of member-societies at the Association’s level, and to help with solving mutual problems. Levels of the activity Federal Council (consists of Presidents of member-societies, having meetings quar- terly); Presidium (consists of 9 members, having meetings monthly); The operative work is executed by Working Committees leading by vice presidents and members of the Presidium of MOTESZ and ad hoc committees. National activities The MOTESZ makes eﬀorts to represent the interests of the member-societies in the National Health care legislation and imple- mentation, and as a standing invited del- egate follows the legislation process of the Health Care Committee of the Hungarian Parliament expressing its own standpoints in issues inﬂuencing the Medical Society in a direct and signiﬁcant way. On request the MOTESZ has regularly been taking part in giving opinions to draft regulations aﬀecting Health Care forwarded by the Ministry of Health, and working out, forming and discussing those topics which aﬀect all the stakeholders of the Hungarian Health Care. It is provided by law that the MOTESZ or- ganises and implements the election of the National Advisory Boards, which are advi- sory bodies of the Minister of Health. This task was accomplished for the ﬁrst time in 2004 and for the next time it will be man- aged in the ﬁrst half of this year. In 2006 MOTESZ had a major role in inserting one of the most important pro- grammes,the Heart and Cardiovascular Pro- gram into the row of National Health Pro- grammes. MOTESZ also gained the task of co-ordination of all the four National Health Programs from the minister of that time.The remaining three are: Child Health, National Programme against Cancer, National Pro- gramme of Emergency care. In 2006-2007 the Association was partici- pating actively in the preparation and imple- mentation process of Health Reforms.Upon invitation of the Ministry of Health and Health Care Committee of the Hungarian Parliament the MOTESZ established ad hoc committees for development, reporting particular topics and drew representatives of member-societies and co-partners into the Committees’ work. In the framework of legislator’s support, the Association took part in seven working groups, which groups reviewed some areas of Health Care, out- lined the most important tasks, and deter- mined the action program. Some of the proposals drafted with the help of MOTESZ co-ordination were put into practice during the Reform process. The working groups established for assessment in primary care, out-patient care, in-patient care, human resources, public health and reform acts prepared working documents and informed the members of the Fed- eral Council continuously about the work completed. The MOTESZ also organised a National Forum in relation to issues of in- Association of Hungarian Medical Societies MOTESZ delegation in Beijing 69 patient care structure and prepared compre- hensive summary about it. On 1st March 2007, the Association was asked by the State Secretary of the Prime Minister’s Oﬃce to help in the activity of the Monitoring Working Group established within the Prime Minister’s Oﬃce, in order to follow the implementation of ongoing Health Care Reform. The Association in- vited its co-partners to share their thoughts, proposals about current issues, diﬃculties, impact of modiﬁcations in legislation – that concern and aﬀect all of us – concerning health care. Every week the MOTESZ re- ceived reports, completed by the comments of experts and forwarded them to the Prime Minister’s Oﬃce.The Association then reg- ularly was informed about the implementa- tion of the proposals. It is important to mention that MOTESZ has Agreements of Co-operation with four Medical Faculties. Besides the Association’s basic tasks, the MOTESZ Congress and Travel Agency play an important role in its activity. The MOTESZ not only facilitates participation of Hungarian doctors in events with inter- national participation, as well as in interna- tional conferences, in international recogni- tion of their knowledge, achievements, but these events are very important pillars for the domestic continues medical education. Another pledge of the successful and con- tinuous running of the programmes is the organisation of travelling, hotel accommo- dation of doctors, researchers and profes- sionals, as well as other programmes. The Association is proud of the MOTESZ Magazine, the informative professional journal which includes scientiﬁc, health policy issues and is published in 25 000 copies. In 2007 the International Editorial Advisory Board was established and promi- nent foreign experts were invited to partici- pate in its work in order to accomplish in the best possible way the tasks ahead of the MOTESZ. For those who follow modern sources of information, they could visit the MOTESZ website where besides others the latest issue of the Journal can be found.The topical issues are linked to the forums, so the visitor could participate in its formation in a direct way. Both the Magazine and the website give the opportunity for partners to communicate issues of health care policies to the public. The Association continuously makes eﬀorts to facilitate that its proposals, opinion and lobbying activity be included with due em- phasis in all processes that could modify e.g. the provision of health care or the health care structure itself etc, however the main goal remains unchanged: representation of professional interests of its member-societ- ies,putting forward the professional work in any activity that could eﬀect Medical Policy and Health Care. International activities The Association attaches great importance that its activities be integrated into national and international professional organisations. The most essential international relations at multilateral level are the following: Standing Committee of European Doc- tors (CPME); European Working Group of Practitioners and Specialists in Private Practice (EANA); European Forum of Medical Associations and WHO (EFMA/ WHO); European Union of General Prac- titioners (UEMO); European Union of Medical Specialists (UEMS); World Medi- cal Association (WMA). Since 1988 the MOTESZ has been taking part in the WMA as a full member and is proudthatithostedandorganizedtheWMA General Assembly in 1993. It is a great plea- sure that the MOTESZ representatives were elected Vice Presidents in two Organizations – UEMS and UEMO. Due to the broad in- ternational activity and WMA membership, the Association plays a major role in health care related legislation in Hungary. MOTESZ has bilateral agreements with the German Medical Chamber, the Royal Soci- ety of Medicine, Chinese Medical Associa- tion (CMA) and the Heilongjiang Univer- sity of Chinese Medicine (HLJUCM). The Association has very good relations besides others with the American Medical Asso- ciation, Conseil National de L’Ordre des Médecins. On the basis of the outstanding international relations, MOTESZ is able to follow in an up-to-date manner and in- ﬂuence to a certain extent the evolution of European guidelines that determine Hun- garian professional policy. In 2007 due to ﬁnancial diﬃculties the As- sociation was not able to participate at some meetings of International Organisations; however it sincerely believes that this year it will continue this activity under more fa- vourable conditions. Some suggestions relating future activi- ties of the WMA The MOTESZ would appreciate receiv- ing adequate information from the WMA relating to care of the elderly, genetics, and ethics of molecular bio-research. It would be also useful if the WMA could monitor the situation of health care workers in member countries, and could give guide- lines regarding competence levels, and min- imum terms/conditions for their members. Prof. Péter Sótonyi, Past President Prof. Kálmán Magyar, Vice President, President of International Committee Prof. Tibor Ertl, Vice President Dr. Ferenc Oberfrank, Vice President of InternationalCommittee Prof. Kálmán Magyar 70 Turkey is located between Europe and Asia with its geopolitical signiﬁcance. Accord- ing to oﬃcial statistics the population is 70,586,000. Acording to recent statistics given by the Ministry of Health and Higher Education Council there are 103 000 active practicing physicians (1).With these ﬁgures we can estimate that there is 147 physician per 100 000 population, but there are sig- niﬁcant variances between the regions and between the urban and rural areas. About 45 000 of these physicians are specialists. Turkish Medical Association is organized voice of doctors in Turkey, under the con- stitutional guarantee as a non-proﬁt, non- governmetal, public association, founded by law in 1953 in Istanbul. Then the associa- tion was moved to Ankara in 1983. Mem- bership to the Turkish Medical Association is throught the Medical Chambers located in provinces with more than 100 physicians. Currently there are 64 medical chambers. 80% of physicians are members of the Turk- ish Medical Association. Aim Turkish Medical Association was established with the aim to maintain and protect deon- tology and soldarity between physicians, to promote medical practice for the beneﬁt of the public and the individual and to protect the rights of the phsicians as a public profes- sional association. The Turkish Medical As- sociation besides these primary aims has the duty to promote health for the beneﬁt of citi- zens in Turkey and work for a high quality health care which is achieveble for everybody with suitable cost, promote professionalism, work on improving medical education at all levels and establish guidelines for ethical conduct among the members. Structure The Turkish Medical Associaion is an umbrella orgaization of 64 Chambers of Medicine. These chambers are founded in provinces with more than 100 physicians. Each chamber will have executive, auditing and discipline committees. Chambers with less than 500 members will have 5 members and those with more than 500 members will have 7 members in the execuive com- mittee.Each chamber will elect its delegates for the formatin of the main congress. The President of each chamber is a member of the main congress.The main congress is the main decisional organ guiding the council for political decisons. The other important duty of the main congress is election of the Council of Turkish Medical Associaton with the central auditing and high disic- pline committee. The number of delegates are determined by the number of members of that chamber. The Council of Turkish Medical Association is composed of 11 members who are elected by the delegates. The elected members both for the chambers and the council serve for two years and can be elected for only two terms. All these po- sitions are on voluntary basis without any payment. What does Turkish Medical Association do for the profession? One of the most imporant task and respon- sibilities of Turkish Medical Association is colloborate with the national authorities and give feed-back about issues and /or politics which may eﬀect the public health and the rights of the physicians. It has been the pri- mary force as the voice of the profession and the public against the signiﬁcant changes in the health system and politics that have been proposed and tried to be implemented in coordination with other associations, syndicates or unions. Various reports have been published on diﬀerent relevant issues, such as consequences of changes in health system, vital statistics, directives and laws in medicine, professional ethics etc. Turkish Medical Association has an impor- tant mission on improving medical educa- tion at all levels. It is puttinga report on undergraduate medical education everyoth- er year based on a questinnaire ﬁled by the medical schools.These reports is detailed on the current state of medical education re- garding the infrastructure, manpower, cur- riculum and developments in a quatitative manner. This year an qualitative evaluation on medical education was conducted based on Global Standards of WFME European Speciﬁcations. Together with the specialty societies Turk- ish Medical Association has been involved in forming specialty boards to improve the quality of postgraduate training in Turkey. To date, 28 member specialty societies have founded boards and commissions in their sections, 21 have prepared curriculums, 23 have prepared log-books, 17 have organised board examinations,and 2 have begun a vis- itation program in its own section’s teach- ing hospitals. These numbers are increasing every year and we aim to have active work- ing boards on education in every specialist section in our country. Currently re-licens- ing does not occur. However, re-licensing is being discussed now in various boards and we believe it will start to be used within the next 7-10 years. Turkish Medical Association was the driv- ing force for implementation of CME/ CPD in Turkey. After organizing a work- shop on CME it created awareness in the ﬁeld in 1991. A CME/CPD Accreditation Council of the Turkish Medical Associa- tion was founded in 1994 for accreditation of CME/CPD activities , provided the or- ganizer applies for accreditation. The coun- cil has reviewed the by-laws and changed various aspects parallel to the EACCME principles.The Turkish Medical Association has signed an agreement with the UEMS (February 2006) for mutual recognition of CME credits and CME accreditation. An- nually, 1,000-1,200 CME/CPD activities are reviewed for accreditation and 800- 1,000 of these activities are accredited by the council. A total of 7,560 activities have been accredited and the Council has award- ed 81,088 CME/CPD credits since 1994. Turkish Medical Association 71 Annually, on average 8-9,000 CME/CPD credits are being awarded when the last 6 years are evaluated.The activities accredited between the years of 2002-2006 were pro- vided by the professional societies in 38 % of the cases, and respectively, medical faculties in 32 %, chambers of medicine/medical as- sociation in 19 %, teaching hospitals in 6 % and others in 5 % of the cases. 27 activities in 2007 have been accredited jointly with EACCME: A recent workshop was organ- ized to create awareness and promote CPD activities for life-long learning. Turkish Medical Society organizes coner- ences, workshops, symposia, working group meetings and publishes various publications both for informing the members and con- tributing to their education. Politics Turkish Medical Association contributes to the health politics by representation in vari- ous commisions and committes. The asso- ciation gives their opinion regarding various professional issues and health politics. The public is informed as well. It is involved in thepreparation of various laws in the parlia- ment and other related institutions. International Relations At the international level,the Turkish Med- ical Association is a member of the World Medical Association, associate member of the UEMS. Ethics Ethics is one of the major areas in the Turk- ish Medical Association. The association has prepared a code of professional ethics to guide the members. The ethics committee prepares statements regarding various issues for medical practice, medical research and promotional activities (physician-pharma- ceutical industry relations). Turkish Medical Association informs the public about on various medical issues throught its publications both as hard copy and on the web site. It releases ﬁles to the press both for information and creation of awareness. Prepares reports regarding public health issues to inform the public.Radiation, clean water supply, environmental medicine, infectious diseases, smoking are some of the ﬁelds of information delivered. It prepares and shares reports on criticism of health re- forms which are related to the public. Human Rights Human rights have been another major area of interest for the Turkish Medical Associa- tion. The major areas are the right of living, patients rights, torture and hunger strikes and activities against war. In 1997 because of the activities related to human right the Turkish Medical Association was awarded Human Rights Award by the Physicians for Human Rights. National awards have also been given regarding the activities on hu- man rights. Iskender Sayek M.D., FACS. Council Member, Turkish Medical Association The Haitian Medical Association The Haitian Medical Association is an In- stitution created on 8th April 1948, which gathers the whole of the Haitian doctors militant on the territory in the various branches of medicine. It was recognised as public utility by presidential decree on 5th August 1974. The goals of the Haitian Medical Associa- tion are: To reinforce the links which exist between• the Haitian doctors To defend the medical interests of the• Haitian community To work with the advance of medicine in• Haiti and the establishment, on the sci- entiﬁc and medical level, of relations with foreign companies; To co-operate with national and inter-• national institutions concerned with the wellbeing of the Haitian population The Statutes and Rules of procedure of As- sociation envisage the existence of the fol- lowing Committees which are elected for a two (2) years mandate: The Board of Management of seven (7)• members; The General Council;• The Council of Mediation;• The Scientiﬁc Council.• The Haitian Medical Association includes diﬀerent members: active,adherent and hon- orary and these statutes are acquired follow- ing the handing-over of the form of adhesion and the payment of the annual contribution. However, only the active members and ad- herents are compelled with the payment of the annual contribution that gives them the right to become candidates at the elective stations within the Association and to also vote at the time of the elections which are held ewery two (2) years.In the rules of pro- cedure, in order to be an active or adherent member, the medical licensed doctor of Hai- tian nationality must submit to the Board of Management a completely ﬁlled form which is regarded as a request written for inscrip- tion. In its article III, the association is deﬁned as “a Company grouping a professional sector with an economic and social life and whose purpose is to defend the common interests of the doctors from the point of view of their profession”. There also local Commit- tees which function like peripheral antennas placed in the various geographical depart- ments of the country.They gather the doctors practicing in these areas who are informed of the scientiﬁc activities programmed and/or carried out by Association. Since its creation to date,the Association opened doors to the outside while being registered as a member of: The Association of the Doctors of the 72 Latin America (CONFEMEL) and the World Medical Association (AMM). The Association almost never misses the oc- casions to take part in work of these various entities and regularly pays the annual con- tribution.It maintains with them a relation- ship marked under the seal of the dynamic and eﬀective partnership. It establishes and maintains relations with the Haitian doctors practitioner living overseas who are gath- ered under the term of Association of the Haitian Doctors living Abroad (AMHE). The projects and activities carried out by the members of the AMHE on the Haitian territory, particularly those addressed to the young Haitian doctors who specialise at the Hospital of the Haitian State University, are done in co-ordination with the AMH and the agreement of the Ministry of Public health and Population and the Vice-chan- cellorship of the UEH. The Association exists only by and for its members and for this reason its interven- tions are always addressed to them. In a speciﬁc way, it always gives itself the means to ensure the continuing formation of its members at the time of the various con- gresses, seminars and workshops organised on the actual health problems which strike the population.The colleagues practicing in province are not always forsaken. Besides the local antennas in which they belong, they are also invited to share their fellow- member’s experiences working in a more favorable professional environment. The regular publication of the bulletin of the association constitutes an open window on the doctors practicing here and elsewhere since through this channel of communica- tion, the members are aware of the activities planned and organised by the association. In this same order of ideas, the relationship with the population is established directly with the doctors in their consulting-rooms. However, each time the need is felt, par- ticularly at the time of natural disasters or others, the Association answers always fa- vorably the call of the authorities to place at their disposal the competences of its mem- bers and in these particular cases, gifts in cash and in kind are sometimes collected to be distributed through the qualiﬁed struc- tures existing in the country. The relationships with the Ministry of Pub- lic Health and Population are always marked under the seal of the mutual respect for the beneﬁt of the Haitian population. The As- sociation is an active member of the various commissions and committees created by the Ministry to reﬂect on the great medi- cal challenges confronted in Haiti and its voice is very listened. A partnership is also established not only with other socio-pro- fessional organizations of health (ASPHA and ANILH) which militate in the country in the defense of the interests of health of the community, but also with the agencies of technical and ﬁnancial co-operation like the OPS/OMS, the UNICEF, the ACDI, USAID etc. Always in the same tread, an agreement of partnership was signed with the Association of the Dominican Doctors (AMD) and this results in technical and scientiﬁc exchanges between the two asso- ciations on the basis of their own availabil- ity and expertise. However, the Association knew dark mo- ments and one of them was the suspension of its activities for approximately ten years. At the time of the great sociopolitical events which shook the Haitian nation during these two last decades, the Association has to take serene positions recalling to the re- spect of fundamental freedoms and human life. The wind even badly turned during this same time for certain fellow-members who were embanked by political violence which continues to mark the Haitian landscape. The association still remembers some of its members who were assassinated within their private clinics or sometimes even inside their residences. However, the wisdom and the solidarity of our members made it possible to overcome these inherent diﬃculties. Thus, this spirit of mutual aid allowed the Association, sixty years after its creation, to concretize a dream cherished a long time and so expensive with several of our pre- decessors; it acts in the acquisition of our own registered oﬃce which now became a reality. This new building is a legitimate reason for pride for all the members since it was bought thanks to their contributions whereas work of reﬁtting was ﬁnanced with a support of the USAID through Project MSH. This building is located in a very strategic zone with: a room of conference which can contain a hundred participants, two other small rooms for approximately 25 people for companies and the subsidiary companies to hold their meetings,the presi- dent’s oﬃce and his secretariat. One of the major challenges which crossed all the existence of the Association consists in its possibilities of gathering the whole of the medical brotherhood since until date it never could cross the threshold of the ﬁve hundred (500) active members whereas there are more than one thousand medical doctors practicing in the country. In addition, the renovation of the executives also represents another shelf to be crossed because the young doctors graduated from the various Faculties of Medicine are rare to register like members and that in spite of the eﬀorts of bringing together authorised by the leaders and of the goodwill expressed by the chairmen of these schools of basic training to open to us the doors of these centers of knowledge and aca- demic excellence. Today, the AMH can be proud to have crossed the years and turpitudes of an ex- istence full of enriched experiments for the medical world. It became now a space of reﬂexion and together with the oﬃcial sec- tors and other organizations it can continue to carry out this permanent combat against the war of diseases and suﬀering. It has still many ways to traverse and it must continue to actively play its role of leader in the ﬁeld of health. May it obtain the instruments necessary to better serve its members and the Haitian Population. It is only thus and only as it will be able to continue to live again for another sixty (60) years. Dernst Eddy Jean Baptist General Secretary Contents Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Human Resources for Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Positive Practice Environments (PPE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Call for Equal Access to Cervical Cancer Treatment for All Women and Girls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Health Professionals Taking Action on Climate Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Mercury-free Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Normal Physiologic Changes with Aging: Inﬂuence on Falls in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 The Migration of Health Professionals and its Impact on Patient Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 The Union of European Medical Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 History and Recent Activities of the CMAAO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 The Permanent Working Group of European Junior Doctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 The Taiwan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Medical Association of Uzbekistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 The Canadian Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Medical Union of Uruguay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 The Malaysian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 The Finnish Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 The FMH: the Professional Association for Physicians in Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Organisation of Professional Self-government of Physicians and Dentists in Poland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Medical Confederation of the Argentine Republic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Association of Hungarian Medical Societies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Turkish Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 The Haitian Medical Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Editor in Chief Dr. Pēteris Apinis Latvian Medical Association Skolas iela 3, Riga, Latvia Phone +371 67 220 661 peteris@nma.lv 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 Dr. Ilze Hāznere wmjeditor@yahoo.com Journal design by Jānis Pavlovskis Cover painting : Is father at home? (Dr. Axel Johannesen in his sledge) 1891 Oil on canvas, 72x100 cm Painter: Erik Werenskiold, Photo: Stian Solum With kind permission of the Norwegian Medical Association. Acknowledgement to the Norwegian Medical Association Layout and Artwork The Latvian Medical Publisher “Medicīnas apgāds”, President Dr. Maija Šetlere, Hospitāļu iela 55, Riga, Latvia Publisher The World Medical Association, Inc. BP 63 01212 Ferney-Voltaire Cedex, France Publishing House Deutscher-Ärzte Verlag GmbH, Dieselstr. 2, P.O.Box 40 02 65 50832 Köln/Germany Phone (0 22 34) 70 11-0 Fax (0 22 34) 70 11-2 55 Business Managers J. Führer, D. Weber 50859 Köln, Dieselstr. 2, Germany IBAN: DE83370100500019250506 BIC: PBNKDEFF Bank: Deutsche Apotheker - und Ärztebank, IBAN: DE28300606010101107410 BIC: DAAEDEDD 50670 Köln, No. 01 011 07410 At present rate-card No. 3 a is valid The magazine is published quarterly. Subscriptions will be accepted by Deutscher Ärzte-Verlag or the World Medical Association Subscription fee € 22,80 per annum (inkl. 7%MwSt.). For members of the World Medical Association and for Associate members the subscription fee is settled by the membership or associate payment. Details of Associate Membership may be found at the World Medical Association website www.wma.net Printed by Deutscher Ärzte-Verlag Köln, Germany ISSN: 0049-8122 www.wma.net 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

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