wmj26

vol. 56
MedicalWorld
Journal
Official Journal of the World Medical Association, Inc
G20438
Nr. 2, April 2010
Placebo Controls in Clinical Trials•
The Climate Crisis and Global Health•
Editor in Chief
Dr. Pēteris Apinis
Latvian Medical Association
Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@nma.lv
editorin-chief@wma.net
Co-Editor
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Jānis Pavlovskis
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
Akseli Gallen-Kallela (26 April 1865 – 7 March
1931) is one of the most famous Finnish artists.
His illustrations of the Kalevala, the Finnish
national epic, are considered very important for
the national identity of the Finns.
In the 1880´s Gallen-Kallela studied in Paris at
the Académie Julian, the Atelier Cormon and
other schools.There he painted Mother with
her sick child (1888). Now this painting is one
the treasuries of the art collection of the Finnish
Medical Association.
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ISSN: 0049-8122
Dr. Dana HANSON
WMA President
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Dr. Masami ISHII
WMA Vice-Chairman of Council
Japan Medical Assn
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Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Mukesh HAIKERWAL
WMA Chairperson of the Finance
and Planning Committee
58 Victoria Street
Williamstown, VIC 3016
Australia
Prof. Ketan D. Desai
WMA President-Elect
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I.M.A. House
India
Prof. Dr. Jörg-Dietrich HOPPE
WMA Treasurer
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Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
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Dr. Yoram BLACHAR
WMA Immediate Past-President
Israel Medical Assn
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35 Jabotinsky Street
P.O. Box 3566
Ramat-Gan 52136
Israel
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
Prof. Dr. Karsten VILMAR
WMA Treasurer Emeritus
Schubertstr. 58
28209 Bremen
Germany
Dr. Edward HILL
WMA Chairperson of Council
American Medical Assn
515 North State Street
Chicago, ILL 60610
USA
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
43
The Vancouver Winter Olympic games are now history. We enthu-
siastically admired sports such as bobsled, skeleton and acrobatic
snowboard – sports in which very few people actually participate. If
we regard athletic activity as important for the health of a popula-
tion, these sports have little meaning given their expense and their
unsuitability for children and senior people. Actually, these sports
may not be very healthy pastimes.
If we analyze the contribution of sports to the field of health pro-
motion, popular sports such as hockey, football, and baseball fall
short. Millions of dollars are spent to support these activities, but
the greatest “benefit”for these sports is to the viewer sitting in front
of a television set with a beer in his hand. From the national point
of view in the 21st century we should value a sport first by its con-
tribution to health.
As physicians we should encourage physical activity and sports par-
ticipation. It is estimated that about 250-350 kilo-calories per day,
or 1000-1500 kilo-calories per week, are expended during exercise
that is intensive enough to cause perspiration. People should par-
ticipate in physical activities or sports five times a week.To motivate
people who do not exercise, one can recommend activities such as
climbing stairs, walking fast, working in the garden and dancing.
Walking 8000 to 10,000 steps a day, even going back and forth to
office, is beneficial.
Moderate athletic activity helps prevent illness, so it has an impor-
tant role in primary, secondary and tertiary health care fields. Basi-
cally, we recognize sport as a primary care resource in the popula-
tion because an active lifestyle lengthens life expectancy, diminishes
morbidity, decreases risk of chronic disease, rises work productivity
and noticeably promotes general economic and social development
of the country.
As a secondary prevention tool we know that adequate and pur-
poseful physical load reduces episodes of illness and lengthens re-
mission periods.
In tertiary prophylaxis, sport is an important component in the re-
habilitation process of successfully treated patients. Sport and phys-
ical exercises are widely used to avoid coronary and blood vessel in-
competence after operations, as well as to prevent the development
of secondary pneumonia or decubitus ulcers. Athletic-type activities
help to improve lymphatic flow, venous circulation, healing of the
bones and soft tissues.
In the 19th century, as well as during most of the 20th century,
lack of movement was not recognized as a disease risk factor. Ac-
tive movements were even considered to delay or interfere with the
healing process. During the first three quarters of the 20th century
confinement to bed was standard treatment for many medical dis-
orders. Only research conducted toward the end of 20th century
has proven that there is an inverse correlation between movement
activities and certain diseases.
Regular physical activity helps prevent cardio-vascular disease, as
well as improves treatment results for patients who already have
illnesses. Physical activity directly and protectively limits the de-
velopment of atherosclerosis, including coronary artery disease.
Moderate exercise also has an indirect influence on the profile of
the risk factors of cardio-vascular diseases. Physical activity reduces
plasma LDL (low-density lipoprotein ) cholesterol and triglycer-
ides, improves plasma HDL( high-density lipoprotein) cholesterol
diminishes adiposity and lowers blood pressure.Several studies have
shown that physical activity lowers the risk of non-fatal coronary
disease and death.
Regular physical activity has been shown to diminish the incidence
of cancerous diseases. It is thought that immunological factors may
be important in the prevention of oncologic processes. Several stud-
ies have shown that effective physical load suppress the malignant
processes in the body.Physical activity seems to diminish the growth
of malignant cells and may even create tumor-lysis. Sometimes the
severity of the oncology disease is determined by side-effects, such
as anemia, diarrhea, immunosupression, and fatigue, which actu-
ally are the most common symptoms of oncologic diseases. Proper
physical therapy during chemotherapy and beam therapy, especially
at the end of the therapy course significantly decreases these side
effects. Daily stamina training for cancer patients increase their joy
Sports at all ages – for a healthy
population
Editorial
44
WMA news
of living and increases their level of activity, thereby lessening the
psycho-motor stress level and decreasing side-effects.
Physical activity decreases insulin resistance and the disturbances of
dextrose tolerance, as well as post-prandial hyper-glycemia. Like-
wise, physical activity together with weigh loss diminishes the inci-
dence of new II type diabetes in a population that is at high risk for
developing diabetes.
Sport has a very important role in the management of depression
and other mental illnesses. Exercise has an anti-depressive influ-
ence. Any physical activity seems to be effective in the fight against
depression.
There is no age limit concerning sport activities.Several studies have
proved that purposeful training of old people in cycling sports in-
creases muscle mass, diminishes adiposity, normalizes blood pres-
sure, lessens the “number of falls”, and improves bio-chemical blood
indicators.
Those who are taking exercises regularly, even in the age groups of
80-90, usually do not need social services and tend to live longer,
more valuable lives, both physically and mentally.
In all countries where senior sport has been given priority by the
public health specialists, there has been enormous resistance from
the politicians, clerks, journalists, and sport experts. These people
have the common opinion that the main priority in preventive
health belongs to children and youth – to ensure good health of the
young. They propose that when these young people will grow up
they will continue their sporting activities and, therefore, will later
turn into healthy seniors.
Sports medicine as a branch of medicine is acknowledged today in
several countries. These doctors are important in promoting public
health through exercise. Our goal is: a healthier mankind. To reach
this goal I would encourage each of you each start with yourself
-just five times a week engage in some type of active exercise. Even
in the World Medical Journal we need to speak about the necessity of
acknowledging sport as a component of preventive medicine.
Pēteris Apinis, MD
Clarisse Delorme
Impunity is still the biggest impediment to
the prevention of torture. Insufficient in-
vestigations and persistent challenges in the
collection of evidence are significant factors
in the absence of action taken against per-
petrators of torture.
The issue of how to promote and institu-
tionalise the forensic documentation of al-
leged cases of torture was the subject for a
panel of renowned experts gathered in Ge-
neva on the 9th of March, chaired by the
UN Special Rapporteur on torture, Profes-
sor Manfred Nowak. The event, hosted by
the World Medical Association (WMA)
and the International Rehabilitation Coun-
cil for Torture Victims (IRCT), took place
in conjunction with the 13th regular session
of the UN Human Rights Council in Ge-
neva. The panel included Marija Definis-
Gojanovic, member of the UN Subcom-
mittee for the Prevention of Torture, as well
as representatives from the Turkish and
Danish Medical Associations, the academic
community and of the Association for the
Prevention of Torture.
With nearly 60 participants from govern-
ments, NGOs, the academic community,
UN agencies and health professional or-
ganisations, this successful event demon-
strated high interest in the subject. During
the discussion, several recommendations re-
lated to medical training advocacy and the
need for sustainable procedures were being
made. In particular, the cooperation among
the various stakeholders within the judicial
system and with the health professional as-
sociations was deemed necessary (see the
proposals in the separate box).
Many of those recommendations echo Pro-
fessor Nowak’s latest report to the Human
Rights Council, in which he wrote that
“All too often, the safeguards required by
international human rights law are neither
foreseen nor effective in preventing torture.”
He added that “Forensic medical science is
a crucial tool since it can establish the de-
gree of correlation of the medical findings
Exploring Sustainable Systems to Document
Torture – the Role of Health Professionals
45
WMA news
Proposals made during the discussion at the IRCT-WMA side-
event “Exploring sustainable systems to document torture – the
role of health professionals”
Developing training for health professionals
Increasing the number of forensic medical specialists worldwide•
to adequately cover the need of documenting incidences of tor-
ture.
Developing training of non-forensic physicians in examining de-•
tainees and alleged victims of torture.
Addressing the challenges for doctors working in the prison•
system that are isolated and do not always have the appropriate
training.
Developing proposals for streamlining torture prevention into•
medical education. National medical associations can play a
leading role in training physicians, as the example of the large
scale training of 4000 physicians in Turkey shows.
Advocatingfortheimplementationofinternationalinstruments
for the prevention of torture
Developing multidisciplinary actions for the implementation the•
UN Convention Against Torture and its Optional Protocol, the
international standards of the Istanbul protocol on documenting
and investigating torture, as well as the WMA medical ethics
guidelines on the role of health professionals in preventing tor-
ture.
Increasing the involvement of health professionals in National•
Preventive Mechanisms put in place under the OPCAT.
Developing sustainable and systematic procedures for torture
prevention
Some basic steps can be taken by all countries in order to support
the prevention of torture particularly in detention.Such procedures
should include:
Compulsory medical examination in confidentiality by forensic•
experts that should report directly to relevant authorities
Guaranteed confidentiality of those medical examinations•
Introduction of systematic examination of detainees before and•
after transfer, as a preventive measure
Development of independent mechanisms for systematic report-•
ing of report torture
Ensuring that domestic actors in the governmental and non/
governmental sector are working together
Involvement of a multitude of stakeholders – governmental and•
non-governmental as well as legal, medical and other relevant
experts – need to work more closely together in strengthening
independent investigation and monitoring systems.
A positive and collaborative attitude by all stakeholders, includ-•
ing health professional associations, involved in the administra-
tion of justice
with the allegations brought forward and
therefore provide evidence on which pros-
ecutions can be based.” (A/HRC/13/39, 9
February 2010, parag. 55).
“This event is a follow-up to the 2009 Hu-
man Rights Council resolution on the role
and responsibility of medical and other
health personnel in the prevention of tor-
ture.” said Dr. Dana Hanson, President of
the WMA. He continued, “The WMA has
a clear and long-standing commitment in
condemning all forms of doctors’ involve-
ment in acts of torture. But it is also an ab-
solute ethical duty for the medical profes-
sion to document torture and to denounce
it. In that sense, physicians can and do
prevent torture, but more must be done in
collaboration with other relevant actors to
eradicate these flagrant human rights viola-
tions.”
Ms. Clarisse Delorme,
WMA Advocacy Advisor
46
WMA news
A call to eliminate female genital mutila-
tion as a gross form of violence against
women has come from the World Medical
Association (WMA) and the International
Federation of Gynaecology and Obstetrics
(FIGO).
To mark the international day of ZeroToler-
ance to FGM (February 6), the two organi-
sations, representing millions of physicians
and 124 obstetrical and gynaecological as-
sociations worldwide,strongly condemn the
medicalisation of female genital mutilation.
Professor Gamal I. Serour, President of
FIGO, said: ‘Death, severe pain, haemor-
rhage, tetanus, sepsis, recurrent urinary tract
infections, pelvic inflammatory disease, in-
fertility, increased complications of subse-
quent pregnancy and childbirth as well as
adverse psychological and sexual effects are
just a few examples of its extreme conse-
quences. The practice of FGM violates hu-
man rights principles.’
He said that according to a recent World
Health Organisation report on women and
health there had been a small decrease in
the extent of FGM in recent years, a de-
cline in the average age at which FGM was
performed, and a marked increase in the
proportion of girls who underwent FGM
before the age of five years. The report also
said there was a growing tendency for FGM
to be carried out by health professionals.
Dr. Dana Hanson, President of the WMA,
said: ‘The medicalisation of FGM is a mat-
ter of deep concern for us. It blatantly in-
fringes the code of medical ethics. Physi-
cians should need no reminding about the
acute dangers of FGM for women and girls
to discourage them from performing or
promoting such practices. They are a viola-
tion of women’s human rights that physi-
cians and other health professionals should
never practice under any circumstances.
We would like to see physicians and medi-
cal associations taking a more robust stand
against these harmful and degrading treat-
ments.’
Professor Serour added: ‘Health profes-
sionals can play a unique role in working
towards the elimination of FGM to ensure
that girls and women enjoy the full extent of
human rights and freedoms, and are treated
with dignity and understanding.’
For further information please contact:
Clarisse Delorme, World Medical Associa-
tion, Advocacy Advisor
+33 4 50 407575 (office)
Nigel Duncan, WMA Public Relations
Consultant
+44 (0) 20 8997 3653 (work)
+44 (0) 7984 944 403 (mobile)
nduncan@ndcommunications.co.uk
Physicians Call for Elimination of Female
Genital Mutilation
Nigel Duncan
The way in which the health professions are
regulated has become a hot topic in recent
years, with the concept of self regulation
under the political spotlight as never before.
In May 2008 global representatives of the
health professions came together under the
umbrella of the World Health Professions
Alliance to hold a highly successful confer-
ence on regulation in Geneva looking at the
role and future of health professions regula-
tion.
Following the success of that conference,
the Alliance (the International Council of
Nurses, the World Dental Federation, the
International Pharmaceutical Federation
and the World Medical Association) in co-
operation with the World Confederation
for Physical Therapy, organised a second
conference in Geneva in February, focus-
ing on a theme of “Shaping the Future” of
regulation.
More than 300 representatives from the five
organisations gathered for two days to fo-
cus on three main objectives – to explore a
desired future for health professional regu-
lation, to examine the regulatory and pro-
fessional issues related to the international
migration of health professionals and to
evaluate the relationship between health
professional education, regulation and stan-
dards of practice.
Speakers from around the world were invit-
ed to address these objectives, backed up by
workshops and an intriguing survey of par-
ticipants about the state of regulation today.
Health Professions Consider
the Future of Regulation
47
WMA news
Although the conference did not achieve a
consensus, which was not its aim, it proved
to be a stimulating two days, highlighting
the common problems facing the different
health professions and the barriers to the
way forward. The main success of the con-
ference was the very fact that it was once
again bringing together the representatives
of 25 million health professionals to share
their ideas and prescriptions on one of the
major topics of the day.
The proceedings opened with a stark warn-
ing from Ann Morrison,of the Internation-
al Council of Nurses, that the pressures on
the regulatory environment were increasing
with self regulation now under mounting
threat. She said that with moves away from
the “professional elite”to more lay member-
ship, self regulation was too often seen as
a self serving or self interested system. The
aim of regulating the professions was to find
a balance.
With the keynote speaker, Franz Knieps
from Germany, unable to attend at the
last moment, Dr. Otmar Kloiber, Secre-
tary General of the World Medical As-
sociation (WMA), stepped in to speak
about the history and complexities of
regulation. He said there were many dif-
ferent models of self regulation, such as
councils, chambers and private associa-
tions, with a wide spectrum of both public
and professional functions. In some parts
of the world, such as the Nordic countries,
co-operative structures had evolved with
which all sides were happy. He also re-
minded the conference that many of the
Alliance organisations’ constituents were
regulatory bodies.
Dr. Kloiber said that the rights and privi-
leges to self govern, usually given by Par-
liaments to a profession or a group, had to
be balanced by duties and obligations. In a
democracy, self governance was a matter of
power sharing with appropriate checks and
balances, although often it was more of a
burden than a privilege. The three watch-
words were responsibility, transparency and
accountability.
During the first day’s proceedings, the
preliminary results of a survey on regula-
tion were revealed. The survey, the first ever
global survey on the subject, was designed
to find out about the current regulation
of health professionals around the world.
It was completed by those attending the
conference and gave a snapshot of what is
happening now. The full results will be an-
nounced in due course.
The preliminary findings, presented by Dr.
Paul Rockey, from the American Medical
Association, and Luc Besancon, from the
International Pharmaceutical Federation,
were based on more than 250 responses and
revealed the huge variety of different systems
of regulation that existed. In the Americas
and south east Asia, for instance, self regu-
lation was much more common than in the
rest of the world. The survey showed that
registration and discipline were the two
most common activities of the regulators,
followed by investigation and recertifica-
tion. The survey also examined the differ-
ences in regulation between federal and non
federal countries and also whether income
levels in a particular country materially af-
fected what system of regulation existed.
Dr. Rockey said that what he took away
from the early findings was that the com-
plexity of regulation was much greater than
he had thought. He was surprised by the
diversity of systems and said the results
showed little signs of any rapid move to-
wards harmonisation.
Looking ahead to possible reforms, Dr.
Ambrose McLoughlin, Registrar and Chief
Executive Officer of the Pharmaceutical
Society of Ireland, said that the European
Union had established effective regulatory
regimes for civil aviation, for food safety
and for maritime safety. But patient safety
had yet to be properly addressed. Now was
an opportune time for health systems to
look at their obligations to patients. A ma-
jor weakness in the current system was that
there was no formalised structure at EU
level providing for collaboration between
regulators of health personnel and services.
What was required were global regulatory
collaboration and the creation of a patient
safety authority.
Jan Robinson, Registrar and Chief Execu-
tive Office of the College of Physiothera-
pists of Ontario, Canada, said there had
been an increasing disintegration of public
trust in health professionals and the con-
ventional understanding of the social con-
tract between regulators,professions and the
public was no longer of primary relevance in
the 21st
century.
Dr.Christine Cassel,President and CEO of
the American Board of Internal Medicine,
said that for physicians in the United States
there was a mass of bodies holding them to
account.It was completely chaotic and there
was no coming together.
Dr. Mukesh Haikerwal, from the Austra-
lian Medical Association, spoke about e-
health in Australia and the role it was play-
ing in addressing inequities in access to care,
while Ivana Silva, from the Pharmaceutical
Group of the European Union, provided an
overview of the main issues around the mi-
gration of pharmacists in the EU. Dr Flo-
rent Aka Kroo, from the Ordre National de
Medecins in Cote d’Ivoire, spoke about the
harmonisation of GPs’ training curricula in
his country and the standardisation of qual-
ifications.
The second day’s debate opened with a dis-
cussion about evaluating the relationship
between health professional education, reg-
ulation and standards of practice. Dr. Mi-
chael Maves, CEO of the American Medi-
cal Association, spoke about the attempt
by some health professions in the USA to
expand their scope of practice. There had
been an increase in nurse prescribing,and of
podiatrists and optometrists doing surgery.
48
WMA news
The result was that there was a great deal of
confusion in his country about who was a
physician.The AMA’s response had been to
convene the Scope of Practice Partnership,a
forum where organised medicine discussed
legislative, regulatory and judicial strategies
emphasising health care practitioners’ edu-
cation and training.
Lesley Bainbridge, Director of Interprofes-
sional Education in the Faculty of Medicine
at the University of British Columbia in
Vancouver, Canada, said one of the primary
drivers of interprofessional collaboration
was patient safety. Yet the barriers to effec-
tive teamwork continued to impede a global
shift to collaborative practice models. She
said it was important not to ask practitio-
ners to work outside their scope of practice.
This was echoed by Dr. Jon Snaedal, past
President of the WMA, from Iceland, who
spoke about the various types of teamwork
and the difficulties involved in achieving
successful teamwork as a result of turf war
and professional rivalry.
The final part of the conference involved par-
ticipants dividing up into profession-based
group discussions. Although the feedback
from each group indicated that there was
little consensus or conclusions from these
workshops, the debates were often spirited.
The speakers who reported back from the
workshops effectively summed up the out-
come of the whole conference when they
said that discussions tended to raise more
questions than answers.
It will now be for the WHPA and the or-
ganisers of the conference to assess the suc-
cess of the event and to decide what further
action is now required.
Mr. Nigel Duncan, WMA Public
Relations Consultant
European colleagues from surgery and
laboratory achieve a remarkable break-
through
A child aged 10, suffering from Long Seg-
ment Tracheal Stenosis, has had a donated
trachea implanted,stripped of its cells trans-
planted and then applied with two types
of stem cells from the child’s marrow and
growth factors onto the implanted stripped
tracheal framework to rebuild the airway in
the body…
The trachea and the stem cells were pre-
pared by Dr. Mark Lowell, Director of Cel-
lular Therapy at the Royal Free Hospital,
the Surgical team implanting the new tra-
chea and repairing the damaged aorta was
led by Professor Martin Elliot University of
London (UCL) and Great Ormond Street
Hospital(GOSH),Professor Paolo Macchi-
arini Careggi University Hospital and Hon
Consultant GOSH and Hon Professor
UCL applied the cells and growth factor to
the trachea in the operating theatre, Profes-
sor Martin Birchall,UCL lead for regenera-
tive medicine led on ethics and regulatory
approvals.
Professors Birchell and Macchiarini
achieved the world’s first stem cell-based or-
gan transplant on an adult patient, in 2008.
Professor Birchell’s research programme
with Professor Elliott includes the absorb-
able stent used in this 10 year old patient.
The application of this technology should
reduce greatly the risk of rejection of the
new trachea as the child’s stem cells will not
produce any rejection.
http:/www.ucl.ac.uk/news/news-
articles/1003/10031903
(accessed 22.03.2010)
Revolutionary Transplant in University
College London – a world first
49
WMA news
The WMA endorsed programme to support
critical health care education to the most at
risk communities, saw the launch of the lat-
est in the series of Speaking Books for low
literacy communities, in Beijing, focusing
on the inherent risks of smoking.
Smoking has been identified as the single
most serious public health threat to China,
and if the country does not do more to re-
duce tobacco use, smoking deaths will dou-
ble to two million per year by 2020, health
experts predict
A speaking book is an interactive book
which consists of 16 pages of colorful illus-
trations supported by straightforward and
easy to understand text. For each page there
is a corresponding push button that triggers
a sound track of the text, so no matter the
level of reading comprehension, the infor-
mation will be seen, read, heard and under-
stood with powerful results.
The Chinese Speaking Book,“Stay Healthy
By Not Smoking” is aimed at school chil-
dren and tells the story of one young boy’s
struggle to stay healthy in a household
where the father is a heavy smoker. It en-
courages the family to declare their house a
smoke free zone and for the father and his
friends to attend a smoking cessation clinic.
The book has been developed in a partner-
ship between WMA, Pfizer, CDC Beijing,
CMDA and Chinese Association on To-
bacco Control.
The launch was attended by senior repre-
sentatives of Chinese Ministry of Health,
Chinese Health Education, Center for
Disease Control, Chinese Association on
Tobacco Control, Chinese Medical Doc-
tors Association, the Chinese media, school
children and their teachers, as well as Pfizer
executives from both the USA and China.
Following the launch the books are now
being donated to schools and medical clin-
ics in the Beijing area, as well as for distri-
bution by all the supporting agencies that
assisted in the creation of the book and at-
tended the launch.
Based on previous experience (and research
where an average of 27 users per book were
observed) this initial pilot of 5000 books
being distributed is likely to reach and im-
pact on 50,000 to 100,000 or more people,
at risk from smoking.
Dr. Soeren Rasmussen, Senior Director Ex-
ternal Medical Affairs and representing
Pfizer at the launch, says that this pilot is
just the first step in what should become
a much larger intervention to educate the
young on the dangers of smoking. Dr. Ras-
mussen firmly believes that a distribution of
many more books could make a significant
and measurable change in the smoking hab-
its of that community. “Reducing tobacco
usage in China is a huge challenge, and we
believe by educating young children with
these innovative Speaking Books, we can
make a real difference”, he says.
Brian Julius, President, Books of Hope
Pfizer Launches Speaking Book in China on
Dangers of Smoking
50
Medical Ethics, Human Rights and Socio-medical affairs
Christine K. Cassel
The World Health Professions Conference
on Regulation met for the second time in
Geneva on February 17 and 18, 2010. The
growing interest of health professions in
the importance of setting standards in the
public interest is evidence of consistent
pressure from countries worldwide for
more transparency and public engagement
in improving the quality of health care. In
many countries, government has a major
responsibility for financing of health care
and, in some cases, aspects of the delivery
system. Other countries are much more
heavily based on the private sector model.
All are beginning to ask questions about
how, in an era of increasing medical tech-
nical capabilities and with increasing costs,
governments can obtain the highest quality
care for the money spent.Private consumers
who pay for healthcare face the same chal-
lenge, perhaps even more intensely, because
of the impact of the cost of care on their
own finances. Some countries have been
energized to examine the issue of standards
even more aggressively because of very pub-
lic scandals involving specific incompetent
practitioners, a general diminishment of
confidence in the profession, or lack of ac-
cess to needed care. Regardless of the issue
driving these pressures, there is no doubt
that they will continue and are likely to in-
crease and accelerate.
I would like to draw your attention to a mod-
el that is working well in the United States
that is not government-run or even govern-
ment-mandated. This model is an example
of the profession as a standard setter based
on its own deep knowledge and expertise
from training in specific areas – reflecting
that expertise in standards, but functioning
very clearly in the public interest rather than
the self-interest of physicians. I endorse the
sense of urgency that has emerged from oth-
er presentations in this program and believe
that it is reflected in the growing interest
in the specialty-based standards model that
board certification embodies from countries
around the world.
Specialty boards are independent not-for-
profit entities constituted by each function-
ing specialty acting “of the profession and
for the public.” Interestingly, they are inde-
pendent in several dimensions.
First, they are independent of government –
they have a special status as tax-free organi-
zations in the United States, and to main-
tain that status they must show that they are
operating in the public interest and not for
financial gain. Secondly, they are indepen-
dent of membership pressures. The boards’
(many of which have public members as
well as members of the profession) financial
model is based on fees that the diplomates
who are certified pay for the assessment pro-
cess and for the maintenance of the certifi-
cation records within the organization.Spe-
cialty boards do not have members in the
way that a membership organization does;
they do not serve the functions of member-
ship organizations, such as advocacy on be-
half of the specialty or educational services
provided to the professional. Lastly, boards
are independent of industry influences and
are very careful to maintain a financial mod-
el that does not in any way involve potential
conflicts of interest.
Accountability and Transparency:
Two Pillars of the Health Professions in the
21st
Century
Figure 1. Model of Physician Responsibility in Relation to Influences on Health.
51
Medical Ethics, Human Rights and Socio-medical affairs
It is important to understand that spe-
cialty board certification is also a voluntary
model – it is an indication of professional-
ism driving a physician’s interest in doing
the work necessary to achieve and maintain
this credential. While it is voluntary, a very
large majority of physician specialists in the
United States are board certified, indicating
that the credential is valuable to them and
valued by them. The voluntary model also
allows for a higher standard to be set and
sustained.
Figure 1 identifies an ethical model of phy-
sician responsibility in relation to influences
on health that grew out of work done by
Richard Gruen, an Australian Harkness
fellow, during his time of study at Harvard
with colleagues there[1]. He identified the
direct areas of physician responsibility to be
individual patient care, access to care and
direct socio-economic influences that af-
fect health, such as diet, nutrition, smoking,
etc. Poverty may fall into this area as well
as into the broader influences on health,
both socio-economic and global health is-
sues. Gruen and colleagues have identified
all of these arenas as legitimate concerns
for the medical profession but have singled
out the first three as the specific domain
where professionals are obligated to focus
their concern by virtue of the ethical tra-
ditions of the profession. This is a much
broader concept of medical ethics than that
derived from the ancient historical texts of
Hippocrates, Maimonides and other still
important core codes to which our profes-
sion adheres. Gruen’s work was based on a
Physician Charter developed in collabora-
tion among the American College of Phy-
sicians Foundation, the American Board
of Internal Medicine Foundation and the
European Federation of Internal Medicine
and published in 2002 simultaneously in
Lancet [2] and the Annals of Internal Medi-
cine [3]. Since then it has been published in
numerous other journals, endorsed by more
than 130 medical organizations throughout
the world and translated into at least 10
different languages. This charter took as its
core principle the primacy of patient wel-
fare, which is consistent with the ancient
and venerable texts of medical history, and
it added two additional principles: patient
autonomy and social justice, both of which
are reflective of the context of the profession
and its expanding role in the 21st
century.
Derived from the fundamental principals
are 10 commitments, listed in Figure 2.
A Commitment to:
professional competence•
honesty with patients•
patient confidentiality•
maintaining appropriate relations with•
patients
improving quality of care•
improving access to care•
a just distribution of finite resources•
scientific knowledge•
maintaining trust by managing conflicts•
of interest
professional responsibility•
Figure 2. The Physician Charter.
In the United States the charter is widely
used in teaching and in the matriculation
and graduation ceremonies of medical stu-
dents and is often reviewed in discussions
of medical ethics. Indeed, it was the subject
of research by Campbell and colleagues[4]
where physicians throughout the United
States, in multiple specialties, were asked
whether they agreed with these 10 commit-
ments.The researchers found that there was
widespread agreement with the principles
espoused, but when physicians were asked
whether they behaved in accordance with
those principles their own self-reports indi-
cated a huge gap between the ideal ethical
behavior and the actual behavior.One exam-
ple concerns the responsibility of physicians
to report instances of significantly impaired
or incompetent colleagues in which 96% of
physicians responded that they had an ob-
ligation to report impaired or incompetent
colleagues to relevant authorities, and yet
fully 67% (two-thirds) said that within the
last three years they had had direct knowl-
edge of an incompetent physician colleague
and had not reported that individual to ap-
propriate authorities.
Similarly, 77% of physicians said that they
should undergo recertification examina-
tions periodically throughout their careers,
but only 33% had done so within the last
3 years. This type of evidence has led to in-
creasing public awareness of the need for
greater transparency and greater scrutiny of
the profession. Indeed, even we physicians
have joined the call for greater accountabil-
ity.
In the United States there are three key
types of physician organizations. One is
medical societies – colleges, academies and
associations, many of which are based on
specific specialties and which physicians
join as members and pay dues. These orga-
nizations promote education and provide
continuing professional development, de-
velop evidence-based clinical guidelines in
their specialty, and often publish medical
journals. In many cases they also are advo-
cates for specific approaches to payment for
that specialty and other legislative or politi-
cal issues that affect their practice and eco-
nomic situations.
A second group are licensing boards. These
boards are run separately by the many states
in the U.S., similar to other federated mod-
els in Canada and countries that have a
provincial or state-based government in
addition to a national government. These
licensing boards are also not-for-profit or-
ganizations, but are appointed – usually by
political forces, primarily a state governor
or legislature. Each state’s licensing board
issues and regulates the license, so criteria
vary from state to state. The license is le-
gally required for a physician to practice
and is often based on credentials or exams
at a very basic level – and not at a specialty
level. In order to maintain the license the
physician must be free of any disciplinary
actions, must pay a fee every 2-3 years and
52
Medical Ethics, Human Rights and Socio-medical affairs
usually must maintain some kind of records
documenting that he or she is engaged in
continuing medical education activities.
The third group are certifying boards – inde-
pendent, voluntary, national not-for-profit
standard-setting organizations that develop
assessment tools. These tools, including ex-
aminations, are specific to specialties so a
physician is able to say that he or she is a
“board certified cardiologist” or “board cer-
tified ophthalmologist.” Requirements for
certification are standard for all participants,
so “board certified”means the same thing in
Kansas as it does in California.
A recent article in the Journal of the Ameri-
can Medical Association compared the recer-
tification processes in the United States,
Canada and the United Kingdom and
identified the varying roles of government
oversight and independent physician over-
sight in these three countries[5]. All of the
countries are in active discussions about the
need for certification to be an ongoing and
periodically renewed credential indicating
that the physician is keeping up to date with
the field and, in many cases, also including
assessment of communication skills, profes-
sionalism and performance in practice.
You may wonder how these standards can
work if not required. My view is that physi-
cians are inherently driven by interest in the
public good, and the more the profession
itself sets high standards the more reward-
ing that public interest becomes. Physicians
also tend to be high achievers and inherently
competitive. When board certification was
first introduced in the United States a much
smaller percentage of specialists sought it
out; as it became increasingly recognized,
physicians who saw their colleagues becom-
ing certified also wanted to achieve that
level of recognition by their peers. Because
it is independent and evidence-based, the
assessment also has credible research be-
hind the tools that it uses[6]. Information
about whether a physician is board certified
is freely available to the public on the web,
which responds to a very important need
for greater transparency and availability of
information to the public. It also creates a
marketplace where external entities, if they
so chose,can set a value on physicians meet-
ing these standards. This could apply to in-
surance companies or to employer require-
ments. Increasingly, as mentioned, there
is a call for greater public input into these
standards and many boards have developed
ways of doing so ranging from public mem-
bers directly on the certifying board or vari-
ous approaches to public advisory groups.
It remains a question whether this model,
which has grown up over almost the last
80 years in the United States, could work
in other countries. We believe the potential
is there for at least some aspects of this ap-
proach to have relevance elsewhere. Over
the past five years, we have received a grow-
ing number of requests from a wide range
of countries throughout the world to learn
more about our process and to consider
adopting parts of the process for their own
healthcare systems. It is also the case that
biomedical science is a universal language,
and most physicians base their work and
practice on the same body of knowledge.
Thus, consistent standards are a reason-
able thing for people to expect, especially
in a world with increasing medical tour-
ism – destination medical centers through-
out world – and more widespread travel by
medical professionals themselves.
In conclusion, I believe that professional re-
sponsibility combines both identifying and
remedying ethical lapses in our profession
and also includes raising the bar of compe-
tence. Together with public voices this can
lead to greater public confidence and to a
response that gives specialists the measures
and tools for quality improvement which
will benefit all of us.
References
Gruen RL, et al. Physician citizens – public1.
roles and professional obligations. JAMA.
2004; 291: 94-8.
Horton R. The doctor’s role in advocacy. Lan-2.
cet. 2002; 359: 520-2.
Sox HC. Medical professionalism in the new3.
millennium: a physician charter. Ann Intern
Med. 2002;136(3): 243-6.
Campbell EG, et al. Professionalism in medi-4.
cine: results of a national survey of physicians.
Ann Intern Med. 2007; 147 (11) : 795-802.
Shaw K, Cassel CK, Black C, Levinson W.5.
Shared medical regulation in a time of increas-
ing calls for accountability and transparency:
comparison of recertification in the United
States, Canada and the United Kingdom.
JAMA. 2009; 302(18): 2008–2014.
Choudhry NK, Fletcher RH, Soumerai SB.6.
Systematic review: the relationship between
clinical experience and quality of health care.
Ann Intern Med. 2005; 142: 260-73.
Christine K. Cassel, M.D, MACP,
President of the American Board
of Internal Medicine
53
Medical Ethics, Human Rights and Socio-medical affairs
Urban Wiesing
The use of placebo controls is one of the key
issues in contemporary ethics of biomedical
research. Ever since critics in 1994 claimed
that certain clinical trials would violate
paragraph 29 of what was at that time the
current version of the Declaration of Hel-
sinki, this paragraph has remained the focus
of the debate on this subject [1]. In 2002,the
WMA added a highly controversial Note of
Clarification to this paragraph (which ap-
peared as a footnote in the document). In
2008, the Note was modified and incorpo-
rated in the main body of the text in §32 of
the version adopted that year. This remains
the current version of the Declaration of
Helsinki. It requires that a new interven-
tion must be tested against the best current
proven intervention, but provides for ex-
ceptions when two conditions are fulfilled:
when there are “compelling and scientifical-
ly sound methodological reasons” and pro-
vided that “patients who receive placebo or
no treatment will not be subject to any risk
of serious or irreversible harm”. However,
differences and contradictions between this
and other ethical or legal regulations1
(such
1
Our aim in this article is to analyse the proposed
norms for placebo controls of different ethical and
as those by CIOMS, the Council of Eu-
rope, ICH etc.) remain, and there persists
disagreement by some critics who ask for a
total ban of placebo control if a proven in-
tervention exists. This is a complicated and
unfortunate situation creating uncertainty
among researchers, research sponsors and
members of ethics committees. In an effort
to move closer to a resolution of this situ-
ation, we will analyse three aspects of the
problem: the scientific and methodological
aspects, the problem of weighing individual
risks and burden to social benefits, and fi-
nally the question of research in resource
poor settings.
Arguments from science and the
methodology of clinical trials
The opposite extreme positions in this
context would be that 1. placebo is always
required for methodological reasons to
legal guidance documents for biomedical research
and to relate them to the relevant arguments in the
bioethical debate. We do not distinguish such guid-
ance documents according to their legally binding
character for researchers, whether they mainly pro-
vide an ethical orientation or are indeed represent-
ing legal requirements.
provide comparative evidence for the effec-
tiveness of a new intervention 2
or 2. there
is never a methodological necessity to use
placebo instead of an active comparator [3].
The Declaration of Helsinki already covers
a middle ground between these positions,
as do some other commentators or guide-
lines, contending that there are in certain
circumstances “compelling and scientifically
sound methodological reasons” for placebo
controlled trials (PCTs) when there already
exist proven treatments. What could be
such reasons? The related arguments reach
from very detailed assumptions about the
placebo effect to general statements on sci-
entific progress and what is of real interest
for medicine.
The main controversial issues between the
opposed positions are:
1. Whether only placebo controls can
provide a reliable reference point in a
clinical trial, or whether they cannot,
because the placebo effect itself is sub-
ject to a high variability3
.
2. Whether active controlled trials (ACTs)
often lack the ability to distinguish an
effective from a non-effective treatment
(“assay sensitivity”)4
in many conditions
(e.g. depression), or whether ACTs can
avoid this and other methodological
problems including statistical signifi-
cance.5
3. Whether the important relevant knowl-
edge to be sought from a trial is whether
an experimental intervention is superior
to placebo6
, or, alternately, whether it is
superior or at least non-inferior to an
existing treatment option.7
The main problem in this context is to pro-
vide convincing empirical evidence for the
different claims on the placebo effect and
2
This position sometimes has been attributed to –
and contested by – the FDA, e.g. by [2], 255.
3
[4], 197.
4
[5], 456.
5
[6], 199.
6
[7], 467.
7
[6], 246.
Placebo Controls in Clinical Trials
Hans-Jöerg Ehni
54
Medical Ethics, Human Rights and Socio-medical affairs
its variability, as new research results on the
underlying neurobiological mechanisms are
available. These show how the placebo ef-
fect could be successfully analysed in par-
tial aspects (such as expectations of patients
or physician, and the behavioural context
of treatment8
). This will also contribute
to knowledge on the variability and the
methodological necessity of placebo con-
trols in different clinical areas (especially
psychiatry). Such evidence must be further
collected, analyzed, and criticized in a com-
prehensive overview. Researchers should
provide convincing empirical evidence for
their claims of a methodological necessity
of placebo controls. This also applies to evi-
dence concerning the need for an additional
treatment option that is equally superior to
placebo.
If there are indeed“compelling and scientifi-
cally sound methodological reasons”against
an ACT, an important precondition is met,
but a PCT still might not be justifiable con-
sidering the risk for the participants in the
control group. This leads to the question of
an acceptable risk of harm or burden.
Weighing individual risks and
burden against social benefits
Supporters of placebo controls in the case
where proven treatment exists are defend-
ing the acceptability of possible risks and
burden to trial participants in light of the
potential social benefits, and more specifi-
cally with arguments that these risks and
burden are coherent with others which are
generally considered to be acceptable, pro-
vided that the trial participants give their
valid informed consent.9
Minimal risks and
burden in research would have to be consid-
ered in the same way as minimal risk and
burden generated by patients who decide
regularly to forego treatment for conditions
such as common cold or headache.10
Even
8
See e.g. [8].
9
[5], 456.
10
[5], 467.
higher risks and burden might be justifiable
as they could be compared with risks and
burden that society considers to be accept-
able in high risk jobs, such as fire fighting.
In other words, they would be acceptable
if the social benefit is high enough.11
Such
risks and burden could often be reduced by
modifications in the trial design, such as
early escape options, add-on trials etc.12
The opponents of placebo controls in the
case where proven treatment exists are re-
ferring to two general ethical principles:
the priority of the individual over the inter-
ests of science and society, and the duty of
care of the physician—even in the role as a
researcher—to provide the best proven cur-
rent intervention.13
Both principles would
exclude withholding or withdrawing prov-
en treatment in a clinical trial in favour of a
placebo if there is no doubt that the proven
intervention is actually better than placebo.
Further,justifying the use of placebo in such
a situation by invoking the argument of in-
formed consent would not be sufficient, as
informed consent very often turns out to be
flawed by poor understanding by the subject
of scientific concepts (including the concept
of placebo), and also by a subject’s poten-
tial lack of understanding of the objec-
tives of research (the so-called therapeutic
misconception).14
In addition, even allow-
ing minor risks and burden would not be
permissible, as this would lead to arbitrary
decisions by Research Ethics Committees
about which kind of risk and burden are ac-
ceptable in different cases. 15
Clearly both lines of arguments are based
on different methods of ethics. While the
proponents of placebo controls mainly for-
mulate consequentialist arguments, which
allow the weighing of different total out-
comes in terms of social utility, their op-
ponents’ claims rest on the absolute and
11
[9], 484.
12
[7], 465.
13
[2], 253.
14
[4], 195.
15
[1], 398.
inviolable value of individuals and the strict
duties of physician researchers. However, it
is widely accepted from both perspectives
that some risks in research are ethically
justifiable. A total ban of placebo controls
if a proven effective intervention exists is
not convincing because the underlying ar-
gument that contends that physicians are
not allowed to expose research participants
to avoidable risks is not, in itself, convinc-
ing. Comparable risks are widely accepted
in medical practise (such as foregoing treat-
ment as a free and informed decision of the
patient) and other research contexts. In a
phase I and II trial a researcher exposes a
healthy volunteer or a patient unavoidably
to certain risks because nothing or little is
known about the new treatment. This is
ethically accepted; otherwise any phase I or
phase II trials (and consequently clinical re-
search as a whole) would have to be banned.
The same is true for research with a verum
to test e.g. QT-prolongation. Therefore
the modified central question becomes: To
what extent are physicians allowed to expose
research participants to risks by a placebo
control or by a control less effective than the
best proven intervention?
A well-justified, coherent position on gen-
erally accepted risks in medical practise
and biomedical research is required to an-
swer this question. A list with such risks to
compare the risks in certain trials could also
help Research Ethics Committees to avoid
arbitrariness. Another open question, how-
ever, is whether such risks also depend on
the context of a trial.
Research in resource poor settings
Particularly important examples for such
contexts are found in research carried out
in resource poor settings. This is a separate
problem closely but not exclusively related
to the problem of placebo control: Is the ab-
sence of a best proven current intervention
in resource poor settings a convincing argu-
ment to allow researchers to expose research
participants to higher risks than they would
55
Medical Ethics, Human Rights and Socio-medical affairs
undergo in wealthy regions where the con-
trol group would receive the proven inter-
vention? Does this lead to an ethical double
standard in research? And if such a study
would be acceptable, what other conditions
do apply? Particularly, who should benefit
and what should that benefit be?
Again, consequentialist and deontological
positions are conflicting. The most out-
spoken consequentialists endorse placebo
controls in the case of existing proven treat-
ment in resource poor settings, even if the
aim of the research is not the reasonable
availability of an alternative treatment op-
tion adapted to the local context. They are
claiming that the participants have at least
a 50:50 chance to benefit from a treatment
that they otherwise would not receive, and
that this clearly leaves them better off than
a situation in which the trial would not take
place at all or where it would be conducted
outside of that host country.16
However, this seems to be a minority po-
sition, at least considering the relevant
international guidelines, which generally
stipulate that such research has to meet the
health priorities of the host country and it
is only legitimate if the objective is to make
reasonably available a treatment option
adapted to that local context.17
Paragraph 17
of the Helsinki Declaration should be noted
in this context: “Medical research involving
a disadvantaged or vulnerable population or
community is only justified if the research
is responsive to the health needs and pri-
orities of this population or community and
if there is a reasonable likelihood that this
population or community stands to benefit
from the results of the research.”
The general problem therefore is to define
the conditions for placebo use in multina-
tional research in a systematic and com-
prehensive way, while preventing unethi-
16
[10], 207.
17
See e.g. [11] http://www.cioms.ch/frame_guide-
lines_nov_2002.htm [accessed 01.03.2010]
cal research, in particular exploitation, and
creating incentives for necessary research.
Such conditions have been suggested by the
CIOMS-guidelines and in a “benchmarks
for research in developing countries”-ap-
proach by Emanuel et al [12]. While the
dispute is still not settled, these attempts
provide good examples how such an agree-
ment could be reached, because they search
for widely accepted principles and for co-
herence with widely shared moral intui-
tions, and they a consensus based on fair
procedures.
Outline of a possible consensus
Clearly, the fundamentally different ethi-
cal positions and approaches described
above will complicate the formulation of
a consensus on the ethical acceptability of
placebo controls in clinical trials. However,
both positions must accept that resolution
of the fundamental conflict between conse-
quentialist and deontological philosophies
is unlikely to occur; neither side can rea-
sonably be expected to abandon its ethical
theory. Thus, the solution to the question at
hand must be found another way. Instead
of insisting on their general approach, both
sides should try to find rules on a middle
level, below their mutually exclusive first
principles This includes the recognition
of principles provided they are widely ac-
cepted, such as the priority of the individ-
ual over the interests of science and society.
Such principles must then be applied in co-
herence with equally widely accepted, more
specific ethical convictions that are already
expressed in ethical and legal regulations,
such as that it is generally accepted to ex-
pose some participants of clinical research
to some risks and burden for the benefit of
others in some cases – provided informed
consent is given. Empirical assumptions
made by either position should be based on
substantial evidence,and the need for future
research to provide such evidence should be
clearly identified. Finally, where disputes on
values cannot be settled easily, particularly
in international research cooperations, they
should be discussed and decided in a fair
process involving all parties concerned, such
as foreseen in the benchmarks by Emanuel
et al. [12]
In sum, a total ban on placebo controls
where proven treatment exists is not a
convincing option, in particular because it
would be inconsistent with widely shared
moral convictions about generally accept-
able risks in research. Precisely what these
risks are should be further elaborated and
discussed in detail. Unrestricted use of pla-
cebo controls would also not be acceptable,
because research participants would be ex-
posed to risks that would be unacceptable
anywhere else in clinical research. Consid-
ering the arguments both positions in the
placebo debate put forward, formulating a
compromise remains a difficult endeavour.
Nevertheless, we believe that it is achievable
if approached within the general framework
described in this article.
References
1. Rothman KJ, Michels KB. The continuing un-
ethical use of placebo controls. N Engl J Med.
1994; 331:394-8.
2. Freedman B, Glass KC, Weijer C. Placebo or-
thodoxy in clinical research. II: Ethical, legal,
and regulatory myths. J Law Med Ethics. 1996;
24:252-9.
3. Howick J. Questioning the methodologic supe-
riority of ‘placebo’ over ‘active’ controlled trials.
Am J Bioeth. 2009:34-48.
4. Michels KB, Rothman KJ. Update on unethical
use of placebos in randomised trials. Bioethics.
2003; 17:188-204.
5. Temple R, Ellenberg SS. Placebo-controlled tri-
als and active-control trials in the evaluation of
new treatments. Part 1: ethical and scientific is-
sues. Ann Intern Med. 2000; 133:455-63.
6. Freedman B, Weijer C, Glass KC. Placebo or-
thodoxy in clinical research. I: Empirical and
methodological myths. J Law Med Ethics. 1996;
24:243-51.
7. Ellenberg SS,Temple R. Placebo-controlled tri-
als and active-control trials in the evaluation of
new treatments. Part 2: practical issues and spe-
cific cases. Ann Intern Med. 2000; 133:464-70.
8. Finniss DG, Kaptchuk TJ, Miller F, Benedetti
F. Biological, clinical, and ethical advances of
placebo effects. Lancet. 2010; 375:686-695.
56
Climate change
Colin David Butler
Introduction
In her speech to the United Nations Con-
ference on the Human Environment, in
Stockholm in 1972, the British economist
Barbara Ward mentioned “the newly recog-
nised fact that our total natural system …
could be irretrievably upset by man’s activi-
ties”[1].Ward goes on to discuss the impor-
tance of reducing global inequality, the need
to rethink the meaning of economic growth,
and the vulnerability of the oceans. She did
not mention climate change, but I don’t
think she would be surprised to learn, 37
years later, that human emissions of green-
house gases are resulting in rapid ocean
acidification and are likely to soon damage
the marine food web [2, 3].
This paper arises from a talk I gave about
climate change, education, health, limits
and ethics, to a working group of the World
Medical Association in 2009, in Copen-
hagen, quite near Stockholm, and not far
conceptually from the themes mentioned
there by Ward. There is however an enor-
mous difference between now and then.
In 1972 few doctors seemed aware or con-
cerned about the global environmental di-
mension to these matters[4], though the
medical profession by then did have a long
history of working to promote health in low
income settings [5], exemplified by Albert
Schweitzer, who divided his time between
France and the hospital he had established
in Lambarene, French Equatorial Africa,
now known as Gabon[6].
Today, the issue of climate change has
moved to almost head the global health
agenda [7-10] . The literature on climate
change and health is now enormous, and
continues to grow rapidly. Health and cli-
mate change was the cover story of Nature
in 2005 [11]. At least two special journal
issues have recently been dedicated to this
problem [12, 13], while perhaps the long-
est single paper ever published in the Lancet
concerned climate change and health [9].
The World Medical Association has also
recently recognised and contributed to this
rapidly growing awareness, by releasing the
Delhi Declaration on Health and Climate
Change [14].
Health effects of climate change: primary,
secondary and tertiary
The list of health conditions associated
with climate change can seem bewilder-
ing; from the fairly obvious to the obscure,
such as gastroenteritis caused by Vibrio Pa-
rahaemolyticus [15]. One way to categorise
these diverse manifestations is by group-
ing the most obvious effects as “primary”
and less obvious effects as “secondary”[16].
Primary effects include heat waves, heat
stress, and the physical impacts from ex-
treme weather effects such as storms and
fires. The latter group includes ecologically
mediated vector borne diseases, such as
malaria, and other communicable diseases
whose epidemiology will be altered by cli-
matic and associated ecological variation,
from plague [17] to hantaviruses [18].
Many more details of these effects are
available elsewhere [16].
There is one more level of effect that must
be considered,“tertiary”[16,19].Ultimate-
ly, these effects are the most threatening to
health. Yet, among the vast literature con-
cerning climate change very little discusses
the likely impact upon global health from
the bleak social and physical conditions
to which much of the world appears to
now be heading. These consequences can
be conceptualized as “tertiary”. It perhaps
takes courage rather than imagination to
contemplate a nuclear-armed world in
which sea level has risen by a metre, and
where the grain yield in South Asia has
declined by 18 to 22% [20], even though
several hundred million additional South
Asians are then predicted to be alive. Yet
The Climate Crisis, Global Health,
and the Medical Response
9. Wendler D, Miller FG. Assessing research risks
systematically: the net risks test. J Med Ethics.
2007; 33:481-6.
10. Wertheimer A. Exploitation in Clinical Re-
search. In: Ezekiel Emanuel et al., ed. The Ox-
ford Textbook of Clinical Research Ethics. Ox-
ford University Press; 2008:201-210.
11. Council for International Organizations of
Medical Sciences (CIOMS). International Eth-
ical Guidelines for Biomedical Research Involv-
ing uman Subjects. 2002.
12. Emanuel EJ, Wendler D, Killen J, Grady C.
What makes clinical research in developing
countries ethical? The benchmarks of ethical re-
search. J Infect Dis. 2004; 189:930-7.
Prof. Dr. med. Dr. phil. Urban Wiesing,
Director of the Department for the
Ethics and History of Medicine, Medical
School, University of Tuebingen
e-mail: urban.wiesing@uni-tuebingen.de
Dr. phil. Hans-Joerg Ehni, Institut für
Ethik und Geschichte der Medizin
e-mail: hans-joerg.ehni@uni-tuebingen.de
57
Climate change
such conditions, interwoven with many
other difficulties, may occur within 70
years.Though the Intergovernmental Panel
on Climate Change forecast a maximum of
60 cm sea level rise by 2100, this is now
viewed as very optimistic. More recent es-
timates set the upper limit of sea level rise
by 2100 at two metres [21]. At least one
meter of sea level rise by 2100 seems all too
plausible, not least because of the recently
documented, satellite-observed loss of ice
from Eastern Antarctica, which until re-
cently had been thought to be accumulat-
ing ice [22-24].
The Future
Beyond the health literature, frank discus-
sion of the likely conditions in which hu-
manity will live in 2100 is also rare, and
where it exists, it is generally biased towards
the optimistic [25]. Official socio-economic
forecasts and scenarios are excessively hope-
ful,perhaps because humans cannot bear too
much pain, or perhaps because authorities
are concerned that bleak forecasts will be-
come self fulfilling. However, in addition, a
good deal of woolly thinking, “group think”
and frank denial is occurring, evidenced,
for example, by the way the global financial
crisis caught governments and their elite
economic advisers by surprise. This discon-
nect between prediction and reality likely
extends to the size of oil supplies [26], and
to other critical limits to growth [27, 28].
Irrespective of the reasons for this optimism
[25] the health consequences of future glo-
bal climate change are likely to be severely
underestimated, without consideration of
tertiary effects. Such effects are likely to ex-
ceed the other impacts, even if combined,
perhaps by one or even two orders of mag-
nitude. Apprehension of these tertiary ef-
fects, though poorly articulated, appears to
be a rational explanation not only for many
concerns expressed by youth about the fu-
ture [29], but also for the level of concern
about climate change in both the health and
wider literature [28, 30, 31].
Linking the global climate and global
health inequality crises
That humanity appears to be nearing an abyss
might surprise some readers. However, an-
other immense problem has co-existed with
our increasing prosperity,since at least World
War II [32] .This is the problem of appar-
ently intractable Third World poverty, and of
the resultant health gap between privileged
and poor populations. This gap takes many
forms.Most simply,it can be measured as life
expectancy [33] ,or as differences in the bur-
den of disease [34]. It is also obvious in dif-
ferent rates of childhood stunting,with other
markers of undernutrition and consequent
cognitive impairment [35, 36]. It can also be
expressed less precisely, such as by contem-
plating the global organ trade [37], daily life
at one of Uganda’s teaching hospitals [38] or
the medical brain drain [39].
In fact,the parallel problems of global health
inequality and of our trajectory towards
dangerous climate change can each be con-
sidered as manifestations of an intelligent
species, a clothes-wearing primate, who is
not quite as smart as s/he thinks. History is
replete with civilisations that have collapsed
[40, 41]. Even before humans had devel-
oped cities violent conflict among humans
has been documented, from the end of the
Pleistocene [42, 43].
Our species is territorial,inequitable,remark-
able but (in parts) also remarkably resistant
to science [44, 45]. Humans are ingenious
and co-operative [46]. Although the future
looks very troubling, hope is not yet lost. If
humanity is to traverse this future it will do
so in part because of the contribution of doc-
tors, together with many other actors and
new ways of social organisation [47].
The role of doctors in fostering a “muddle
through” world
It is easy for futurists to imagine solutions
to our problems. A new energy technology,
already invented, might be about to revolu-
tionise global transport. Genetic engineer-
ing might soon allow plants to thrive in
droughts, or to survive weeks inundated in
saline water [48].Unfortunately,even a suite
of technological breakthroughs will not be
enough.Replacing and upgrading global in-
frastructure, such as buildings, power plants
and sea walls cannot be done overnight, or
even in a single decade. Many behavioural
changes will also be needed, such as a lesser
dependency on private cars [49], and a re-
duction in the 150 trillion calories of food
currently wasted annually in the US [50].
It is perhaps easier for doctors to contem-
plate the likelihood of famines and wide-
spread population dislocation that appear
inevitable, without concerted climate miti-
gation. However, provided widespread war
can be avoided [51], and provided civiliza-
tion collectively undertakes the social and
technological re-organisation which is re-
quired to slow climate change then a “mud-
dle through” world may yet emerge.
All doctors have,at times,been involved with,
or have had to personally convey bad news
to their patients. Neither the most expensive
medication, nor the most sophisticated diag-
nostic test can always defer death. However,
the impermanence of life is not a reason to
turn against it. Similarly, doctors can play a
role in reassuring society that a good life is
still possible, even if we and our fellow crea-
tures need to live better within limits.
Conclusion
There is much to be done. There are many
reasons to be anxious about the capacity of
civilization to withstand the coming chal-
lenges, aggravated by climate change. Many
readers will understand that the ninety years
which remain in this century are not long.
And, of course, selecting 2100 as a criti-
cal year is completely arbitrary. It is likely
that tertiary health consequences of climate
change will unfold well before 2100. Indeed,
the future may show that phenomena such
as Cyclone Nargis [52], the overflow of the
58
Climate change
Khosi River in Bihar [9], and the conflict in
Darfur [53] were not isolated extreme events,
but early evidence of such tertiary events.
Doctors also understand the value of preven-
tion. Few of us have ever seen a case of small-
pox. Preventive medicine, the least glamorous
sphere of medicine, is the most powerful in
termsofdeathsavertedandyearsoflifegained.
Tackling the climate crisis is preventive medi-
cine.At the same time,doctors should also act
to reduce the crisis in global health inequali-
ties. In particular, doctors should add their
moral voice to resist any strategy of triage,
the abandoning of large populations to their
apparent fate. While it seems inevitable that
large scale humanitarian crises, dwarfing that
of the 2004 tsunami,will occur because of cli-
mate change, it is not inevitable that billions
must die as a result. But in order to make this
task possible doctors must join with the grow-
ing coalition of youth,activists,visionaries and
eco-billionaires who think similarly.
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20. Tubiello FN, Fischer G. Reducing climate change
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59
Medical Ethics, Human Rights and Socio-medical affairs
When was the last time a patient ap-
proached you,asking what to do if they have
side effects from their medicine or if they
are even taking it correctly? These questions
may not pop up in your practice every day
when seeing your patients, but they should
and we need to encourage it.
Knowing all the medications a patient takes
can help prevent errors, so it’s absolutely
critical that patients feel empowered to talk
freely with Climate change us about their
medication questions. Furthermore, open
communication is necessary, particularly
to help the more than 89 million Ameri-
can adults who have limited health literacy
skills.
A new online resource can help. It’s a one-
page tip sheet to help facilitate patients’
conversations with you about the medica-
tions they are taking, including vitamins
and drugs bought without a prescription,
and the questions they have or should be
asking. Print it off and keep it in your of-
fice or waiting room, and share it with the
patients in your practice.
It’s all a matter of keeping patients safe.
While we’re inundated with this thought
every second of every day, this particular
topic received plenty of clout on the na-
tional stage. The entire health care com-
munity, including the AMA and hospitals
and health care systems across the country,
took the time to help mark the importance
of patient safety during year 2010. National
Patient Safety Awareness Week and the
theme “Let’s talk: Healthy conversations for
safer health care.”
Kicked off March 7 by the National Pa-
tient Safety Foundation and being observed
through March 13, the week centered
around health care organizations promot-
ing patient safety and highlighting the work
they have done and are doing to improve
patient safety, health care quality and pa-
tient education. The AMA established the
foundation in 1996 and has since donated
more than $7 million to help fulfill its mis-
sion. As part of the week, the AMA also fo-
cused on medication safety with its annual
“Know what’s in your medicine cabinet”
reminder and the new patient tip sheet I
mentioned earlier.
Remind your patients that medical safety
starts at home, and that they are the ones
who play a key role in keeping their families
safe by making sure prescription drugs are
up to date and out of children’s reach. Tell
them to utilize the AMA Web site for guid-
ance on proper disposal of expired or unused
prescription medications when cleaning out
the medicine cabinet. And check out other
patient safety resources and programs from
the AMA that help strengthen the patient-
physician relationship and improve care by
preventing infections, as well as communi-
cation tools on medication reconciliation
and the AMA Physician Consortium for
Performance Improvement.
Let’s make a point to emphasize patient
safety and communication with our patients
every day throughout the year. It’s an on-
going effort together to promote excellence
in patient care. That’s our job as physicians,
and that’s what our patients deserve.
J. James Rohack, MD, President of the AMA
People are literally dying for the toilet.Join the
World’s Longest Toilet Queue (WLTQ) and
take a stand against this shocking injustice.
22 March was World Water Day, a global
observance of our planet’s most precious
resource. It is also a crucial moment in the
fight against the global sanitation and wa-
ter crisis that’s killing 4000 children every
single day. Just one month later, politicians
from across the globe will gather in Wash-
ington DC. to discuss what they need to do
to fulfil some of the most basic rights of the
world’s citizens – access to a safe toilet and
clean water.
TheWorld’sLongestToiletQueue(WLTQ)
may sound like a joke but it is a mass mo-
bilisation event and Guinness World Re-
cord attempt bringing together thousands
of campaigners from across the world to
demand real change at the meeting.
In 2009, the Standing Committee of Euro-
pean Doctors (CPME) accepted the British
Medical Association’s invitation to endorse
End Water Poverty, the international cam-
paign to end the global crisis in water and
sanitation. In 2010, the BMA is asking all
CPME member organisations to urge their
members to join the WLTQ. Many Euro-
pean countries have already confirmed that
they will be holding queues – among them,
Belgium, France, Italy, the Netherlands,
Denmark, Finland, Norway, Spain, Sweden,
and Turkey.
Our task is to make sure that as many people
as possible join the queues and show world
leaders that action is needed now.
http://www.worldtoiletqueue.org/eng/
Martin Carroll, Deputy Head
International Department
British Medical Association
London, UK
Tel: +44 (0)207 383 6231
End Water Poverty
Keeping the Lines of Communication Open –
and Patient Safety First
60
Multidrug-resistant Tuberculosis
Introduction
This year, we commemorate the 100th an-
niversary of Robert Koch’s death. Although
great diagnostic and therapeutic progress
has been made since his discovery of the tu-
bercle bacillus in 1882, tuberculosis (TB) is
still one of the most widespread infectious
diseases and one of the leading causes of
death worldwide.The situation was declared
an emergency by the WHO in 1993 [1],but
has become even worse since in several parts
of the world.
The aim of this article is to give an overview
of the present epidemiological situation,of the
main causes of this threatening development –
in particular of drug resistance – and of strate-
gies urgently needed to solve the problems.
Present epidemiological situation
According to the updated 2009 report of
the World Health Organisation (WHO)
on ‘Global Tuberculosis Control’,there were
in 2008 an estimated 9.4 (8.9 – 9.9) million
new cases of TB worldwide [2]. This figure
represents an increase from the 9.27 million
in 2007. However, since the world popula-
tion has also grown,the number of cases per
capita shows that there is a small decrease in
incidence of TB from 142/100,000 in 2004
to 139/100,000 in 2008. Figure 1 shows
the regional incidence of TB, while Table 1
contains statistics on the 22 ‘high-burden’
countries which comprise 85 % of all new
TB cases. In absolute numbers, China and
India are the leading countries due to their
large populations. South Africa and other
sub-Saharan African countries are foremost
in incidences.
In almost all industrialized countries the in-
cidences are constantly declining, but still far
from elimination of TB,defined as fewer than
one case per 1 million population per year [2].
An estimated 1.3 (1.1 – 1.7) million HIV-
negative people died of TB in 2008, an ad-
ditional 0.52 (0.45 – 0.62) million died of
Multidrug-resistant Tuberculosis:
Problems and Responses
R. Loddenkemper S. Castell B. Hauer
Figure 1. Estimated new TB cases (all forms) per 100000 population 2008 [2]
61
Multidrug-resistant Tuberculosis
TB among HIV-positive people (classified
as HIV death in the International Statisti-
cal Classification of Diseases) [2].
Mortality rates are highest in countries with
a high prevalence of TB/HIV co-infections,
up to 265/100,000. However, they reach al-
most 20/100,000 in some countries without
or with few cases with TB/HIV co-infec-
tion, e.g. 18/100,000 in the Russian Federa-
tion (Table 1).
Causes for the worldwide
increase in TB
In the 1970s, TB was thought to have been
nearly conquered. The two main reasons
why the opposite has occurred are the ap-
pearance of HIV in the middle of the 1980s
and the large increase of drug-resistant TB
cases which became apparent in the 1990s.
Both together were responsible for the dra-
matic situation in New York and other US
cities in the 1990s [3].
Additional factors are the demographic
development with population growth and
older age structures, migration, civil con-
flicts, increasing poverty in some parts of
the world and the lack or decreasing qual-
ity of medical facilities [4]. TB is mainly a
social disease!
Increasing drug resistance
In early 2008, the WHO reported an un-
expectedly large increase in drug-resistant
tuberculosis [5].An estimated half a million
(~ 5 %) of all new TB cases were infected
with multidrug-resistant strains (multi-
drug-resistant tuberculosis, MDR-TB), i.e.,
a strain resistant to (at least) isoniazid (H)
and rifampicin (R), the two most powerful
anti-tuberculosis drugs currently available.
Figure 2 shows the estimated percentage of
MDR among new and re-treatment TB cases
in 2007 with rates of more than 20 % in the
countries of the former Soviet Union, more
than 8 % in China, and 3 – 5 % in India [5].
For 2008, WHO estimated similar numbers
with almost 50 % of MDR-TB cases world-
wide occuring in China and India,and causing
about 150,000 deaths.The highest proportions
Table 1. 27 MDR high-burden countries 2008 [2, 6 and http://www.who.int/tb/country/data/
download/en/index.html (25.03.2010) ]
Country
Incidence
of TB (all
types) per
100 000
population
Mortality
per 100 000
population
(excluding
HIV)
HIV positive
TB patients
with known
HIV status
in %
MDR
among new
TB cases
in %
South Africa 960 39 60 1.8
Myanmar 400 57 100 4.2
Democratic Republic of the
Congo
380 77 18 1.8
Ethiopia 370 64 24 1.6
Nigeria 300 63 27 1.8
Phillippines 280 52 0 4.0
Pakistan 230 39 0 2.9
Bangladesh 220 50 no data 2.2
Tajikistan 200 44 1 16.5
Viet Nam 200 34 20 2.7
Indonesia 190 27 29 2.0
Kazakhstan 180 24 1 14.2
India 170 23 14 2.3
Republic of Moldova 170 4,6 5 19.4
Kyrgyzstan 160 25 no data 12.5
Uzbekistan 130 27 1 14.2
Azerbaijan 110 21 no data 22.3
Georgia 110 13 1 6.8
Russian Federation 110 15 3 15.8
Ukraine 100 15 8 16.0
China 97 12 3 5.7
Armenia 73 12 3 9.4
Lithuania 71 9,3 no data 9.0
Latvia 50 5,5 8 12.1
Belarus 43 5,2 3 12.5
Bulgaria 43 5,8 0 12.5
Estonia 34 1,9 11 15.4
62
Multidrug-resistant Tuberculosis
of MDR-TB ever documented in new cases
were reported for some regions in the Russian
Federation (22.8 – 28.3 %).
The WHO report also contains data on ex-
tensively drug-resistant tuberculosis (XDR-
TB), which was first described in 2006 [7].
By definition,XDR-TB is MDR-TB that is
additionally resistant to at least one of the
fluorochinolones and to one of the three in-
jectable second-line anti-tuberculosis drugs,
amikacin, kanamycin, and capreomycin.
Precise data on XDR-TB are not available,
because findings regarding resistance to sec-
ond-line drugs are not routinely reported.
XDR is thought to account for about 5 %
of MDR cases, but up to 20 % have been
observed in some regions [8], more than 58
countries up to now have found XDR-TB
cases in their population (Figure 3). How-
ever, it can be assumed that XDR-TB is
already present in many other poor coun-
tries where the capacities for testing the
sensitivity/resistance to anti-tuberculosis
drugs are not available [9]. A few cases of
extreme drug resistance (XXDR), defined
as resistance to almost all drugs [10], and
even total drug resistance (TDR), defined
as resistance to all currently available drugs,
have been reported, too [11].
Reasons for the development
of resistance
When streptomycin was introduced in 1944
as the first antibiotic for the treatment of
TB, the majority of those treated improved
dramatically.There were, however, many re-
currences of tuberculosis thereafter, because
of the selection of streptomycin-resistant
bacterial strains by monotherapy [12]. The
more widespread tuberculosis is in the pa-
tient’s body and the greater the number of
bacteria present, the more likely it is that
some of the pathogenic organisms will con-
tain spontaneous mutations inducing drug
resistance [13].
The need for combination therapy against
tuberculosis was recognised after the in-
troduction of para-aminosalicylic acid
in 1944, and of isoniazid, as the rate of
mutations inducing resistance to multiple
drugs is very low [14]. Furthermore, com-
bination therapy can better reach bacteria
with different levels of metabolic activity
at multiple sites in the body. The treat-
ment must be continued long enough to
kill ‘dormant persisters’ as well. The next
drugs to be introduced were pyrazinamide
and cycloserine in 1952, capreomycin in
1960, ethambutol in 1961, and rifampi-
cin in 1966. The introduction of rifampi-
cin and pyrazinamide enabled a marked
Figure 2. Proportion of MDR among new and re-treated TB cases 2007 [WHO 2009 modified
from Paul Nunn, Dubrovnik]
Figure 3. Distribution of countries and territories reporting at least one case of XDR-TB as of
January 2010 [6]
63
Multidrug-resistant Tuberculosis
shortening of the duration of therapy,
from 18 – 24 to 6 months (‘short-course
chemotherapy’), provided that the pa-
tient’s tuberculosis is fully drug-sensitive.
The recurrence rate after such treatment
is less than 5 % in patients who take all
their medications correctly every day, as
prescribed [14].
Faulty prescriptions, treatment compli-
ance problems, inadequate intestinal re-
sorption of drugs, and poor drug quality
are factors that can promote the devel-
opment of resistance [5, 15]. Multidrug
resistance was first recognised as a ma-
jor problem in 1992, when 12 % of the
tuberculosis patients in New York City
were found to have MDR tuberculosis
[3]. MDR tuberculosis spread around the
world because of the lack or inadequacy
of tuberculosis control programmes, in-
sufficient resources, and inadequate pro-
tective measures against infection, as well
as delayed diagnosis of tuberculosis, all
mostly man-made and thus to a large ex-
tent avoidable [16, 17].
The following are special risk factors for
MDR/XDR tuberculosis [18]:
Prior treatment with anti-tuberculosis•
drugs
Immigration from an area where MDR•
tuberculosis is highly prevalent (or con-
tact with MDR tuberculosis patients)
Imprisonment [19]•
Possibly, HIV infection [20]•
Prisons require special attention, particular-
ly in the Newly Independent States of the
former Soviet Union. Here, the high rates
of MDR-TB – sometimes accounting for
more than 30 % of overall incidence – and
the rising prevalence of HIV are causes for
concern. Prisoners have been found to have
higher rates of MDR-TB in Western, in-
dustrialised countries as well [19].
In some regions of the world, the so-called
Beijing genotype of Mycobacterium (M.) tu-
berculosis is associated with a high resistance
rate and, in particular, with a high MDR
rate (the ‘W’ strain) [21]. These strains may
be more virulent, and/or more likely to mu-
tate, and/or able to spread more easily be-
cause of poorer tuberculosis control in the
areas to which they are endemic.
Resistant tuberculosis and
co-infection with HIV
It is estimated that, in 2008, 15 % of the
9.4 million new TB cases were co-infect-
ed with HIV, with a high mortality rate
[2]. In some countries of sub-Saharan
Africa, the TB/HIV co-infection rate
has risen dramatically, up to 50 – 80 % [2,
22]. HIV-positive persons carrying a la-
tent M. tuberculosis infection are at mark-
edly higher risk of developing tuberculo-
sis [22]. Tuberculosis is one of the main
causes of death in HIV-infected persons
[22]. It is unclear whether HIV infection
is a risk for drug-resistant or multidrug-
resistant tuberculosis itself [5, 20]. Higher
Table 2. New WHO Classification of anti-tuberculosis drugs [30]
Group Description Substance/medication International
abbreviation
1 Oral first-line antitubercu-
losis drugs
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
Rifabutin
H
R
E
Z
Rfb
2 Injectable anti-tuberculosis
drugs
Kanamycin
Amikacin
Capreomycin
Streptomycin
Km
Amk
Cm
S
3 Fluoroquinolones Levofloxacin
Moxifloxacin
Ofloxacin
Lfx
Mfx
Ofx
4 Oral second-line anti-
tuberculosis drugs
Ethionamide
Protionamide
Cycloserine
Terizidone
P-aminosalicylic acid
Eto
Pto
Cs
Trd
PAS
5 Anti-tuberculosis drugs
with unclear effectiveness
and/or an unclear role in the
treatment of MDR-TB (not
recomended by the WHO
for routine use)
Clofazimine
Linezolid
Amoxicillin/clavulanic acid
Thiocetazone
Clarithromycin
Imipenem
Cfz
Lzd
Amx/Clv
Thz
Clr
Ipm
64
Multidrug-resistant Tuberculosis
resistance rates might be explicable as a
result of higher susceptibility to resistant
bacterial strains, which are often less viru-
lent than non-resistant strains, as well as
of the higher precentage of new infections
[20]. Other factors that can promote the
development of resistance in HIV/TB
co-infection include malabsorption, drug
intolerance, drug interactions, and non-
compliance among IV drug abusers [20].
Hospitalization also increases the risk of
exposure [18].
In 2006, a catastrophic development was
seen in South Africa, when XDR tuber-
culosis was transmitted from TB/HIV pa-
tients to members of a village community
with a high prevalence of HIV [23]. The
affected patients were hospitalised, where-
upon a large number of patient and hospi-
tal employees died within a few weeks. The
main causes for the persistent transmission
of XDR-TB in South Africa are, aside from
the high prevalence of HIV, delays in di-
agnosis and treatment and the inadequate
availability of modern diagnostic proce-
dures, second-line drugs, and infection con-
trol.
Another current cause for concern is the
rising rate of HIV infection in Eastern
Europe, particularly in the Russian Fed-
eration and the Ukraine [24]. Prisons in
these countries are high-risk areas for dual
infections because of an increasing rate of
IV drug abuse,combined with a high preva-
lence of MDR-TB [25].
The diagnosis of drug-
resistant tuberculosis
Drug resistance should be suspected if
one or more of the risk factors mentioned
above are present. Definite confirmation is
only possible with the aid of standardised,
quality-controlled bacteriological sensitivity
testing. Because directed therapy is possible
only on the basis of drug susceptibility test-
ing (DST), bacteriological proof of tuber-
culosis should always be attempted, even
in types of pulmonary or extrapulmonary
tuberculosis, where relatively few bacteria
are present.
The gold standard for DST are culture
techniques; such testing previously took
eight to twelve weeks, but its duration has
been shortened to two to three weeks with
the aid of liquid cultures and radiomet-
ric methods [26]. More rapid molecular
biological methods for the detection of
genetic mutations that induce resistance to
various drugs (rifampicin, isoniazid) are an
outstanding recent advance [26, 27]. Mi-
croscopic observation of drug susceptibil-
ity (MODS) is one of several promising
new techniques.
Resistance testing for second-line drugs is
highly demanding and requires the exper-
tise of specialised laboratories [15]. More-
over, in-vitro results often do not accu-
rately reflect drug efficacy. A rapid test for
tuberculosis that could be performed easily
directly on the sputum sample, with which
the pathogens could be simultaneously de-
tected and comprehensively tested for resis-
tance, would certainly be a milestone in the
fight against tuberculosis [28, 29].
There is an urgent need for more lab facili-
ties, which are the basis for the successful
treatment of MDR- and XDR-TB. Drug
susceptibility testing is performed with the
purpose of providing crucial information
for the treatment of the individual patient.
Second-line drugs should be given only on
the basis of appropriate drug susceptibility
tests [16, 30].
The treatment of drug-
resistant tuberculosis
Tuberculosis must be treated with a com-
bination of antibiotics [30]. The currently
recommended standard chemotherapy
of non-resistant tuberculosis consists of
the initial administration of four first-line
drugs (isoniazid, rifampicin, pyrazinamide,
and ethambutol) in combination for two
months,followed by a four-month stabilisa-
tion phase with a combination of isoniazid
and rifampicin [30].
Sensitivity testing should be performed as
rapidly as possible, particularly when drug
resistance is suspected, so that the develop-
ment of further resistance will not be pro-
moted by non-directed therapy [30, 31]. A
single drug should never be added to an ex-
isting regimen, as this creates the danger of
monotherapy [15, 30].
No randomised trials or evidence-based
data are available on the treatment of resis-
tant tuberculosis [28, 32]. The WHO rec-
ommends that patients who were previously
treated for TB should be treated with at
least three drugs that they have not received
before. When MDR is suspected, at least
four drugs that are still potentially effective
should be given [2, 30]. As a rule, complex
cases of resistant TB should be treated by
physicians with special experience in this
area.
The new WHO classification of first- and
second-line anti-tuberculosis drugs is
shown in Table 2. The fluorochinolones are
among the most important types of second-
line drugs [30].
The treatment takes up to two years and is
often poorly tolerated.It therefore requires a
high degree of patient cooperation, and the
default rate is higher than in non-resistant
tuberculosis (up to 30 %) [28, 32].Thus, ex-
tensive patient education is needed and the
patient should take the medications under
professional supervision, if possible. The
possibility of transmission necessitates ad-
equate infection control measures. Patients
who are unwilling or unable to comply with
such measures may need to be involuntarily
quarantined; such decisions are to be taken
on a case-by-case basis, according to the le-
gal regulations [33].
The success rate of treatment is lower for
MDR-TB than for less resistant or non-
65
Multidrug-resistant Tuberculosis
resistant tuberculosis, and it is lower still
for XDR-TB [34, 35], although, under
optimal conditions, better treatment out-
comes have been observed [36]. In HIV
co-infected patients it is much worse,
where a one-year mortality of 71 % for
MDR- and 83 % for XDR-TB patients
has been reported [37].
The relevant percentage of patients whose
therapeutic outcome is unknown, or whose
treatment has not yet been completed, can
substantially diminish the success rate, de-
pending on how this rate is defined [34,35].
Furthermore, the therapeutic outcome may
be difficult to categorise: for example, when
the treatment has been changed or inter-
rupted for a long time [38]. Nonetheless,
effective surveillance of DST findings and
therapeutic outcomes is very important if
the quality of tuberculosis control is to be
accurately judged.
Improved nutrition and improvement of
the patient’s social environment are among
the most important interventions that can
supplement drug treatment for TB [15, 32].
Surgical treatment, adjunctive to drug ther-
apy, may be indicated in cases of MDR- or
XDR-TB, especially if not enough medica-
tions are available, and also in cases of non-
conversion of sputum cultures, persistent
cavities, and/or mainly localised disease, as
long as there are no functional contraindi-
cations to surgery [32, 39, 40, 41]. Good
results have been described, but often with
quite high complication rates [32, 34, 40,
42]. There have been no controlled trials on
this subject; it seems likely that the operabil-
ity criteria that were applied led to selection
of prognostically more favourable cases.
The cost of treatment in cases with com-
plex drug resistance is several times higher
than that of drug-sensitive tuberculosis [43,
44]. Moreover, the indirect costs, includ-
ing those of prolonged inability to work,
are often substantial. When these costs are
taken into account, the cost of some cases
of MDR-TB in the USA is found to be in
excess of one million dollars [45]. The cost
of treating XDR-TB is even higher.
Strategies against drug resistance
In 2006, WHO announced an ambitious
global plan to lower the rate of new cases
of TB and the death rate from tuberculo-
sis to half of their 1990 levels by the year
2015 [46]. A further goal is the elimina-
tion of the disease by the year 2050, i.e.,
lowering the incidence to less than one
new case of tuberculosis per one million
population per year. The overall financing
plan envisions 56 billion dollars of financial
support for the period 2006 – 2015 [47].
More than one billion dollars are budgeted
for the successful treatment of MDR- and
XDR-TB cases in the year 2006 alone, in
addition to the necessary overall expendi-
tures for global tuberculosis control, which
amounts to 5.3 billion dollars. A basic pre-
requisite for the prevention of drug-resis-
tant tuberculosis is adherence to the stated
principles of treatment, in the setting of an
effective national tuberculosis control pro-
gramme, whenever possible [10, 16]. The
DOTS strategy (‘Directly Observed Treat-
ment Short Course’) is recommended for
implementation [46]; in recognition of the
problem of resistance, the DOTS strategy
has been extended to the so-called ‘DOTS-
plus strategy’,and to other action plans that
build upon it [43, 48, 49].The implementa-
tion of these plans is difficult, however, not
just because of inadequate financial means,
but often also because the necessary infra-
structure is lacking, e.g. adequately trained
personnel.
The Green Light Committee established
by the WHO provides technical support
to poorer countries and negotiates reduced
prices for quality-controlled second-line
drugs. A functioning national tuberculosis
control programme is a prerequisite [50, 51].
In regions of the world where MDR tuber-
culosis is highly prevalent, it is recommend-
ed to replace standard treatment regimens
for non-responders to therapy by individu-
alised regimens based on (rapid) resistance
testing [28, 30].
Research also needs to be substantially in-
tensified in this area [10, 52]. Alongside
better diagnostic techniques for tuberculo-
sis, including techniques for the determina-
tion of drug resistance, there is an urgent
need for the development (or further de-
velopment) and testing of highly effective
anti-tuberculosis drugs. Over the long term,
there are high hopes that effective vaccines
can be developed through the improvement,
supplementation, or replacement of BCG
(Bacille Calmette-Guérin), a vaccine based
on an attenuated strain of M. bovis [53].
The ‘Global Stop TB Partnership’, founded
in 2000 and now with more than 700 pri-
vate and governmental partners, serves to
merge common interests and capabilities.
It receives major financial support from the
Global Fund to Fight AIDS, Tuberculosis
and Malaria, as well as other organisations.
Together with the WHO tuberculosis sec-
tion, it has recently published a revised ver-
sion of the ‘International Standards of Tu-
berculosis Care’ [54].
All of these approaches need to be continuous-
ly maintained and vigorously supported. Even
in low-prevalence countries,in which there are
adequate high-quality laboratory services and
all second-line drugs available, success rates
in the treatment of MDR- and XDR-TB re-
main unsatisfactory. It follows that the wors-
ening resistance situation together with the
HIV epidemic all over the world can only be
combated and alleviated through a common
effort. The political will of the industrialised
countries and their assumption of responsibil-
ity for health policy, which were expressed in
the ‘Berlin Declaration’by a WHO European
Ministerial Forum organised by the German
government and held in Berlin in 2007 [55],
must now be practically implemented through
support for research on the national and inter-
national levels,and through adequate financial
contributions.
66
Multidrug-resistant Tuberculosis
Conclusions
Although the incidence of TB in industria-
lised countries is now declining, the world
as a whole faces a threat of catastrophic di-
mensions that will also affect industrialised
nations. The main reason, aside from TB/
HIV co-infection,is the increase of resistant
TB strains. The situation is already serious
because of the spread of multidrug-resistant
TB, i.e.,TB that is resistant to the two most
important anti-tuberculosis drugs, and is
being further aggravated by resistance to
second-line drugs as well.
At present, there are an estimated half a
million cases of MDR-TB worldwide, and
so-called extensively resistant TB (XDR-
TB), with additional resistance to defined
second-line drugs, is now prevalent in more
than 58 countries.
An accurate assessment of the situation is
hampered by a widespread lack of labora-
tory capacity and/or proper surveillance.
The problem is mainly due to inappropri-
ate treatment, which may have many causes,
but is theoretically avoidable. Aside from
programmatic weaknesses, a lack of diag-
nostic and therapeutic tools causes difficul-
ties in many countries.
Only rapid and internationally concerted ac-
tion, combined with intensified research ef-
forts and the support of the affected nations,
will be able to prevent the development of a
situation that will no longer be manageable
even with 21st
century technology.
We thank the German Ministry of Health
for support.
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Raviglione MC, Uplekar MW. WHO’s new Stop48.
TB Strategy. Lancet 2006;367:952-5.
World Health Organization. Guidelines for esta-49.
blishing DOTS-Plus projects for the manage-
ment of multidrug-resistant tuberculosis (MDR-
TB). WHO, Geneva, Switzerland, WHO/CDS/
TB/200.278.
Gupta R, Cegielski JP, Espinal MA, et al. Increa-50.
sing transparency in partnerships for health – intro-
ducing the Green Light Committee. Trop Med Int
Health 2002;7:970-76.
Migliori GB, Sotgiu G, Jaramillo E, et al.: Deve-51.
lopment of a standardized multidrug-resistant/
extensively drug-resistant tuberculosis assessment
and monitoring tool. Int J Tuberc Lung Dis.
2009;13:1305-9.
Cobelens FGJ, Heldal E, Kimerling ME, et al.:52.
Scaling up programmatic management of drug-
resistant tuberculosis: a prioritised research agenda.
Plos Medicine 2008;5:1037-42.
Baumann S, Eddine AN, Kaufmann SHE. Progress53.
in tuberculosis vaccine development. Curr Opin
Immunol. 2006;18:438-48.
Tuberculosis Coalition for Technical Assistance.In-54.
ternational Standards forTuberculosis Care (ISTC).
The Hague: Tuberculosis Coalition for Technical
Assistance, 2006.
www.euro.who.int/tuberculosis/TBForum55.
/20070621_1
R. Loddenkemper, German Central
Committee against Tuberculosis
Stralauer Platz 34,10243, Berlin,Germany
e-mail: rloddenkemper@dzk-tuberkulose.de
S. Castell, German Central
Committee against Tuberculosis
B. Hauer, Robert Koch Institute
As the Medical Association of Thailand is
hosting the WMA Congress and General
Assembly in 2012, we would like to intro-
duce the overview to you in brief about
Thailand and some aspects of the works of
the Medical Association of Thailand.
Brief Introduction
of Thailand
Thailand is the world’s 50th largest coun-
try in terms of total area (slightly small-
er than Yemen and slightly larger than
Spain), with a surface area of approxi-
mately 513,000 km2
(198,000 sq mi), and
the 21st most-populous country, with
approximately 64 million people. About
75% of the population is ethnically Thai,
14% is of Chinese origin, and 3% is eth-
nically Malay; the rest belong to minority
groups including Mons, Khmers and var-
ious hill tribes. There are approximately
2.2 million legal and illegal migrants in
Thailand. Thailand has also attracted a
number of expatriates from developed
countries. The country’s official language
is Thai.
Thailand has a prevalence of Buddhism that
ranks among the highest in the world. The
national religion is Theravada Buddhism
which is practiced by more than 94.7% of all
Thais. Muslims make up 4.6% of the popu-
lation and 0.7% belong to other religions.
Thai culture and traditions are mainly in-
fluenced by Chinese, and to a lesser degree,
by Indian culture, along with Burma, Laos
and Cambodia. Thailand experienced rapid
economic growth between 1985 and 1995
and is a newly industrialized country with
tourism, due to well-known tourist destina-
tions such as Pattaya, Bangkok, and Phuket,
and exports contributing significantly to the
economy
Following the decline and fall of the Khmer
empire in the 13th–14th century, the Bud-
dhist Tai kingdoms of Sukhothai, Lanna
and Lan Chang were on the ascension.
However, a century later, the power of
Sukhothai was overshadowed by the new
kingdom of Ayutthaya, established in the
mid-14th century in the lower Chao Phraya
River or Menam area.
Ayutthaya’s expansion centered along the
Menam while in the northern valley the
Lanna Kingdom and other small Tai city-
states ruled the area.Thailand retained a tra-
dition of trade with its neighbouring states,
from China to India, Persia and Arab lands.
Ayutthaya became one of the most vibrant
trading centres in Asia. European traders
arrived in the 16th century, beginning with
the Portuguese, followed by the French,
Dutch and English.
After the fall of Ayutthaya in 1767 to the
Burmese, King Taksin the Great moved the
capital of Thailand to Thonburi for approxi-
mately 15 years. The current Rattanakosin
era of Thai history began in 1782, following
Host of the 2012 WMA Congress and
General Assembly
68
Regional and NMA news
the establishment of Bangkok as capital of
the Chakri dynasty under King Rama I the
Great.
Despite European pressure, Thailand is the
only Southeast Asian nation that has never
been colonized. Two main reasons for this
were that Thailand had a long succession of
very able rulers in the 19th century and that
it was able to exploit the rivalry and tension
between French Indochina and the British
Empire. As a result, the country remained
a buffer state between parts of Southeast
Asia that were colonized by the two powers,
Great Britain and France.
Western influence nevertheless led to many
reforms in the 19th century and major con-
cessions, most notably being the loss of a
large territory on the east side of the Me-
kong to the French and the step-by-step
absorption by Britain of the Shan (Thai Yai)
States (now in Burma) and the Malay Pen-
insula.
Geography of Thailand
Totalling 513,120 square kilometres
(198,120 sq mi), Thailand is the world’s
50th largest country in land mass, while it is
the world’s 20th largest country in terms of
population. It is comparable in population
to countries such as France and the Unit-
ed Kingdom, and is similar in land size to
France and California in the United States;
it is just over twice the size of the entire
United Kingdom, and 1.4 times the size of
Germany. The local climate is tropical and
characterized by monsoons.There is a rainy,
warm, and cloudy southwest monsoon from
mid-May to September, as well as a dry,
cool northeast monsoon from November to
mid-March.The southern isthmus is always
hot and humid.
Thailand is home to several distinct geo-
graphic regions, partly corresponding to the
provincial groups. The north of the country
is mountainous, with the highest point be-
ing Doi Inthanon at 2,565 metres above sea
level (8,415 ft).The northeast, Isan, consists
of the Khorat Plateau, bordered to the east
by the Mekong River. The centre of the
country is dominated by the predominantly
flat Chao Phraya river valley, which runs
into the Gulf of Thailand.The south consists
of the narrow Kra Isthmus that widens into
the Malay Peninsula.Politically,there are six
geographical regions which differ from the
others in population, basic resources, natu-
ral features,and level of social and economic
development. The diversity of the regions is
the most pronounced attribute of Thailand’s
physical setting.
The Chao Phraya and the Mekong River
are the sustainable resource of rural Thai-
land. Industrial scale production of crops
use both rivers and their tributaries. The
Gulf of Thailand covers 320,000 km² and is
fed by the Chao Phraya, Mae Klong, Bang
Pakong and Tapi Rivers. It contributes to
the tourism sector owing to its clear shal-
low waters along the coasts in the Southern
Region and the Kra Isthmus. The Gulf of
Thailand is also an industrial centre of Thai-
land with the kingdom’s main port in Sat-
tahip along with being the entry gates for
Bangkok’s Inland Seaport. The Andaman
Sea is regarded as Thailand’s most precious
natural resource as it hosts the most popular
and luxurious resorts in Asia.Phuket,Krabi,
Ranong, Phang Nga and Trang and their
lush islands all lay along the coasts of the
Andaman Sea and despite the 2004 Tsu-
nami, they continue to be and ever more so,
the playground of the rich and elite of Asia
and the world
Brief Introduction of
the Medical Association
of Thailand
The Medical Association of Thailand un-
der his Majesty the King’s patronage is a
nongovernmental non-profit making orga-
nization aiming at
2.1. Promoting and coordinating medical•
professions under ethical integrity.
2.2. Promoting relationship amongst•
members.
2.3. Promoting education, researches and•
medical services
2.4. Promoting member’s welfares.•
2.5. Coordinating and collaborating with•
other medical organizations in both gov-
ernmental and private sectors to improve
better standard of medical provision and
public health to meet the international
standard.
2.6. Advocating health promotion, pre-•
vention and medical services to public.
2.7. Collaborating with international•
health and medical organizations to keep
the global standard. The Medical Asso-
ciation of Thailand is an active member of
the Medical Associations of South East
Asian Nations (MASEAN), Confedera-
tion of the Medical Associations in Asia
and Oceania (CMAAO), and the World
Medical Association (WMA)
The Medical Association of Thailand is
practicing a great role in bringing all health
and medical providers from both govern-
mental and private sectors to work together
through the elective executive committee
which is composed of representatives from
various sectors. The Medical Association of
Thailand is also one of the three compo-
nents forming a collaborative body com-
posed of the Ministry of Public Health, the
Medical Council and the Medical Asso-
ciation to oversee the problems within the
medical profession and allies as well as to
discuss and solve the problems which may
arise together.
The Medical association of Thailand is also
taking roles in providing compromises in
69
Regional and NMA news
the conflicts between medical providers and
consumers.
The Journals of the Medical Association
of Thailand is a worldwide class accepted
media in distributing educational and aca-
demic know-how as well as researches.
The Medical Association is not only ex-
tending its professional consultation to
doctors in the remote areas but also support
them with the life insurance.
CMAAO ‘S Activities on Tobacco
Control in the Region
On February 25th
-28th
.2010, the Medical
Association of Thailand had hosted the “ 1st
.
International Summit on Tobacco Control
in Asia and Oceania Region” at the Rose
Garden Riverside Hotel in Sampran dis-
trict, Nakhonpathom Province, Thailand.
The event was assigned by the CMAAO
Congress and Assembly in Bali, Indonesia,
November 5-7, 2009.Tobacco Control Pro-
gramme was decided and approved to be a
flagship programme of the Confederation
of the Medical Associations in Asia and
Oceania starting this year and the progress
will be reported annually at the Conference
and General Assembly to share experiences
of success and barriers amongst member
countries.
The Summit was participated by 12 coun-
tries in the region comprised of Hong Kong,
India, Indonesia, Japan, Korea, Malaysia,
Myanmar, Philippines, Singapore, Taiwan,
Vietnam and Thailand. The programme
consisted of presentations from experts,
current situation in countries with the evi-
dence -based health hazards from tobacco
smoking and it’s effects on second handed
smokers as a preventable epidemic, group
discussion and production of Statement and
declaration on Tobacco control in Asia and
Oceania Region with recommendations for
member countries to practice and collabo-
rate at three levels ie. Medical Association,
individual physician and National. All par-
ticipating NMAs had also undersigned the
Proclamation that they will unite and work
together towards developing the regional
network on tobacco control and contribute
to make tobacco control one of the highest
priorities.
The Medical Association of Thailand is in
good relationship with the government as
well as the private sector. The monthly ex-
ecutive board meeting is a platform for
discussion and recommendation for stake-
holders to join hands together in practices
for the benefit of the consumers in general.
Many practical initiatives have been created
by the committee and practiced nationwide
since members of the committee are elected
from various fields of medical profession.
For more information please visit our web-
site at http:/www.mat.or.th
Contact persons are
Police Lt. General Dr. Jongjate
Aojanepong President
Dr. Wonchat Subhachaturas
President Elect
Prof. Dr. Somsri Pausawasdi
Past President
Assoc. Prof. Dr. Prasert Sarnvivad
Secretary General
Naval Lt. Dr. Manopchai Thamkhantho
International Relations
e-mail: math@loxinfo.co.th
Tel: +66 2314 4333, +66 2318 8170
Fax: +66 2314 6305
Wonchat Subhachaturas MD,
President Elect of the MAT
The Medical Association ofThailand has a big role in theThai Health Professionals Alliance against
Tobacco Consumption Project (THPAAT) to create the free environment, smoke-free hospitals
and etc.
70
Regional and NMA news
I. Establishment of CMAAO
Currently comprised of 18 member National
Medical Associations (NMAs), the Confed-
eration of Medical Associations in Asia and
Oceania (CMAAO) has now marked more
than 50 years of history. CMAAO’s estab-
lishment was proposed in 1956 by Dr. Rod-
olfo P. Gonzalez, President of the Philippine
Medical Association. The Japan Medical
Association (JMA) began participating in
process of establishing CMAAO as one of
its first international activities,after receiving
recognition from the international commu-
nity1
. In 1959, CMMAO was inaugurated at
the 1st Congress and Council Meeting was
held at the Imperial Hotel in Tokyo [1, 2, 3].
There were 11 member NMAs at the time of
inauguration,of which six were present at the
first meeting (Japan, Australia, Burma (now
Myanmar), Republic of China (Taiwan), In-
1 With Occupation Policy guidance, in 1951 the
Japan Medical Association was granted approval
for membership by the World Medical Association
following notification of member countries world-
wide and on the condition that the JMA was “an
organization representing the physicians of Japan”
and “operated independently of the government”,
receiving legitimacy as a medical organization.
donesia, and Philippine). The remaining five
who could not be present were the Republic
of Korea, Iran, Pakistan,Thailand, and India.
The complete list of current membership is
shown in Table 1.
The Asian Medical Journal, published in Eng-
lish by JMA since 1958, played an important
role in reporting CMAAO activities and
served as a forum for information exchange.
The article contributed by Dr. Albert Sch-
weitzer in 1959 [4] represented the spirit
and enthusiasm of everyone involved in the
journal.This Asian Medical Journal has since
been succeeded by Japan Medical Associa-
tion Journal (JMAJ), which continues to be
published bi-monthly by the JMA to this
day. In collaboration with World Medical
Journal (WMJ), JMAJ continues to present
CMAAO activities to the world and also
introduce English translations of articles
and papers from Journal of Japan Medical
Association (the Japanese language journal
of JMA) to the world. As part of the JMA’s
international mission, the JMA Interna-
tional Affairs Division cooperated with the
Takemi Program in International Health
at the Harvard School of Public Health in
2008, researching the theme “the potential
for national medical associations to con-
tribute to global healthcare through com-
munication of information,” by conducting
surveys among World Medical Association
(WMA) and CMAAO member organiza-
tions [5,6] . The role and contents of JMAJ
is hoped to expand further into the future.
II. History of CMAAO Activities
Since its inauguration in 1959, CMAAO
has held regular congresses and mid-term
council meetings – and today, it is an orga-
nization that is recognized by the WMA a
collaborating partner representing Asia and
Oceania. From the very beginning, it al-
ways has been the aim of CMAAO to pro-
mote friendship and information exchange
among member NMAs. The late Dr. Taro
Takemi, a former JMA President and 2nd
President of CMAAO, who for many years
continued to strive to enhance CMAAO,
also proposed strategic concepts like the
“proactive concept of building a system that
advantageously expands medical associa-
tion activities within international treaties,
considering that international controls exist
… no matter how free medical association
appear to be to conduct their activities.”
He also suggested that “when the Asian
CMAAO, Over Fifty Years of History and
Future Outlook
Table 1. CMAAO Members (18 National Medical Associations)
Australian Medical Association, Bangladesh Medical Association, Cambodian Medical
Association, Hong Kong Medical Association, Indian Medical Association, Indonesian
Medical Association, Japan Medical Association,Korean Medical Association, Macau
Medical Association, Malaysian Medical Association, Myanmar Medical Association,
Nepal Medical Association, New Zealand Medical Association, Philippines Medical As-
sociation, Singapore Medical Association, Sri Lanka Medical Association, Taiwan Medi-
cal Association, Medical Association of Thailand
Masami Ishii, Hisashi Tsuruoka
71
Regional and NMA news
and Pacific Region come together, we can
voice our opinions more strongly within the
World Medical Association” [7]. Under the
latter concept, the aim of CMAAO was to
build cooperative relationships as an inter-
national government organization modeled
after the ILO and WHO. In that sense,
the establishment of CMAAO was even
called the “creation of a new world”[8]. Dr.
Takemi’s visions to foresee the needs for so-
cioeconomic discussion within WMA and
establishment of organization like the JMA
Research Institute also show timeless wis-
dom, even from today’s perspective.
The CMAAO Secretariat, which was origi-
nally with Philippines Medical Association,
has moved among Malaysia, Thailand, New
Zealand. Since 2000, it has been in Japan,
with the JMA International Affairs Division
providing the Secretariat support. The role
of CMAAO Secretary General was passed
to the JMA simultaneously, of which I
(Dr. Ishii) assumed the position since 2006.
III. Directionality and Roles
of Recent CMAAO
In addition to the annual council meetings,
CMAAO holds a congress every two years
where officers are appointed and bylaws are
amended in accordance with the issues dis-
cussed at council meetings. Also at a con-
gress meeting, participating NMAs present
annual country reports of the current status
of their activities, as well as giving lectures
at symposium on the specific theme of the
year, generating lively discussions.
Congress activities in recent years include
the presentation of the “Taro Takemi Me-
morial Oration” that was established by the
Takemi family’s fund since 1991, where
a theme that reflect the time (Table 2) is
discussed. At the 2008 Mid-term Coun-
cil Meeting held in Manila, Philippine,
Dr. Keizo Takemi was invited as a special
speaker to present a memorial lecture com-
memorating CMAAO’s 50th anniversary
from the standpoint of global health. Com-
bining both experiences in Japan and the
results of research carried out at the Har-
vard School of Public Health, Dr. Takemi’s
lecture provided a visionary outlook for the
next 50 years. His lecture was tremendously
inspiring for the audience and lead to seri-
ous discussions to strengthen and revitalize
CMAAO activities toward the year 2010.
In 2006, at the suggestion of WMA, JMA
and WMA jointly hosted the 1st WMA
Asian-Pacific Regional Conference in To-
kyo, with CMAAO being the main organiz-
er. The two main themes of this conference
were; 1) disaster preparedness (natural disas-
Table 2. Taro Takemi Memorial Oration
Year Congress Theme, Lecturer
1991
17th
Hong
Kong
Congress
“Directions for Health care in the 1990’s”
Dr. Haruto Haneda, President, Japan Medical Association
1993
18th
Malacca
Congress
“Use of Environment Friendly Technology in the Health
Industry” Dr. M.K. Ralakumar, Past President, Malaysian
Medical Association
1995
19th
New
Delhi
Congress
“Diabetes and Circulatory Diseases- Asian Drama”
Prof. J.B. Bajaj, Member, Planning Commission in the rank of
Minister of State, Government, India
1997
20th
Bangkok
Congress
“Environmental Health: UNEP’s Perspective”
Dr. Suvit Yodmani, Director for Asia and the Pacific United
Nations Environment Programme
1999
21st
Wellington
Congress
“Managed Care and the Future of Health Professions”
Prof. Sir. John Scott, University of Auckland and South
Auckland Health, Middlemore Hospital
2001
22nd
Taipei
Congress
“Medical Education in 21st Century”
Dr. Ming-Liang Lee, Minister, Department of Health,Taiwan,
R.O.C.
2005
24th
Seoul
Congress
“Progress and Problems of Health Insurance Program in Korea”
Dr.Tai Joon Moon, President Emeritus, Korean Medical
Association
2007
25th
Pattaya
Congress
“60 years of Thai Healthcare under H.M. King Bhumibol”
Dr. Prinya Sakiyalak, Professor Emeritus, Mahidol University
2009
26th
Bali
Congress
“The roles of primary physician in achieving the MDGS”
Dr. Azurul Azwal, Professor, University of Indonesia
Dr. Taro Takemi
72
Regional and NMA news
ters such as earthquakes and tsunamis, and
infectious disease), and 2) the present state
and future of the medical profession. Simul-
taneous interpretation services were provided
for the representatives of prefectural medical
associations in Japan who also attended.The
special public lectures by international guest
speakers were also held concurrently, and the
details of the conference and special public
lectures were published in the 50th
anniver-
sary issue of the JMAJ[9]. Considering the
current situation of earthquakes, tsunamis
caused by earthquakes, and outbreaks of in-
fectious disease that that have been occurring
repeatedly since, it was a timely academic
meeting on an extremely meaningful theme.
IV. Positioning of CMAAO
in the World
At the 2009 CMAAO Congress, a proposal
for cross-regional anti-smoking action was
adopted.The expansion of these activities is
currently under consideration.
Looking at the common symposium themes
in the past (Table 3), each theme chosen re-
flected the times. In particular, we can see
that the 2009 “World Medical Association
Delhi Declaration” theme represents the
fruit of the past several themes, namely
the 2006 Symposium “Medical Ethics,”
the 2008 WMA “Seoul Declaration,” 2009
WMA “Madrid Declaration,” and 2008
Philippines Symposium “Climate Change.”
Reports on the advancement of social ag-
ing and declining birthrates in many Asian
countries, as if following Japan, were also
presented at the Thailand/Pattaya Congress
in 2007. This topic is truly a current theme
and was regarded extremely useful in consid-
ering the future forms of healthcare systems
and health policies. In addition, at the 2009
Indonesia/Bali Congress with the theme of
“Impact of Global Financial Crisis to the
Health System,” it was reported that, from
the standpoint of health management for
the general public, the economic crisis had
had very little impact in countries such as
Japan, Korea, and Taiwan where a national
universal healthcare system was already es-
tablished. This suggests that, in an unfore-
seen economic crisis,a nation-wide universal
healthcare system can act to minimize the
damage to the general health of the public,
reconfirming the necessity and significance
of such universal healthcare systems.
In recent CMAAO debates, problems re-
lated to collective capacity-building appear
to be clearly improving. The social structures
of countries in the Asia and Oceania region
Table 3. CMAAO Symposium – Recent themes
Year Congress Title of the Symposium
1999 21st
Wellington Congress Health care system
2000 36th
Tokyo Mid-term
Council Meeting
Infectious Disease Control Measures in Asian and
Oceania Regions
2001 22nd
Taipei Congress The Impact of Health Care Reform on the Health
Care Delivery System
2002 38th
Thai Mid-term
Council Meeting
Roles of Traditional Medicine in Asia and Oceania
Countries
2004
40th
Kuala Lumpur Mid-
term Council Meeting
Medical Risk Management: Improving Patient Safety
& Quality of Service by Controlling Medical Error
2005 24th
Seoul Congress
Present Status of National Health Insurance in Asia
& Oceania Region
2006
42nd
SingaporeMid-term
Council Meeting
Continuing Development in Ethics and
Professionalism
2007 25th
Pattaya Congress Arts and Science of Healthy Longevity
2008
44th
Philippines Mid-
term Council Meeting
Global Warming An Alarming Phenomenon, What
Shall We Do?
2009 26th
Bali Congress
Impact of the Global Financial Crisis on the Health
System
Table 4. Office Bearers of CMAAO 2009-2011
President Fachmi Idris Indonesia
President-Elect Ming-Been Lee Taiwan
Immediate Past President Somsri Pausawasdi Thailand
1st Vice President David Kwang-Leng Quek Malaysia
2nd Vice President Dong Chun Shin Korea
Chair of Council Wonchat Subhachaturas Thailand
Vice-Chair of Council Peter Foley New Zealand
Treasurer Yee Shing Chan Hong Kong
Secretary General Masami Ishii Japan
Assistant Secretary General Hisashi Tsuruoka Japan
Adviser Tai Joon Moon Korea
Yung Tung Wu Taiwan
73
Regional and NMA news
are tremendously rich and variable in terms of
politics,religion,and ethnicity.However,over-
coming these differences,nations have worked
together to resolve problems and undertaken
cooperative activities within the region in
many aspects, and some results are already
being achieved. Amidst this, CMAAO has
promoted deeper understanding amongst the
member NMAs through group presentations
at annual meetings for more than 50 years,
proposing meaningful themes to be discussed
in global scale, which have led the way for
global discussions in other forums. The Asia
and Oceania region is not only important as
the center of the world population – its geopo-
litical position has improved remarkably with
the invigoration of the economy. Thus, the
existence and significance of CMAAO have
gained even greater weight in recent years.
In the recent WMA activities, 2008 General
Assembly was held in Seoul,Korea; the 2009
General Assembly was held in New Delhi,
India; and the 2012 General Assembly is to
be held in Thailand.The WMA President for
2006-2007 was Dr. Arumugam of Malaysia,
and the 2010-2011 term will be Dr. Desai of
India.These trends illustrates that the role of
the CMAAO region is becoming more im-
portant on the global stage.
Furthermore, the efforts of CMAAO are in-
spiring other parts of the world, too. In Af-
rica,a movement to establish a confederation
of medical associations gained momentum,
which lead to the formation of the African
Medical Association (AFMA) in 2006, with
South Africa taking a central role in its in-
auguration. So far, there have been intermit-
tent talks between CMAAO and AFMA for
international exchange and cooperation –
which surely will grow to more specific dis-
cussions, given the opportunity in future.
V. CMAAO’s Board Structure
and Future Activities
The composition of the CMAAO Board,
determined at the 2009 Indonesia Con-
gress, is shown in Table 4. In order to further
strengthen information sharing that been
growing consistently among member NMAs
and to facilitate prompt actions when neces-
sary, it has been agreed to undertake strategic
revisions with a view to the next 50 years.The
significance of the JMAJ,which uses the com-
mon language in the region, is bound to in-
crease further. Urgent issues also include pro-
moting better information exchange through
enhancing of information platforms on the
internet and preparing online networks.There
is also a need to establish more effective means
to disseminate information, such as declara-
tions and other policy papers. These reforms
will likely call for examinations of the style
and format of congress meetings as well as
the constitution itself, for which exchange of
opinions online has already begun.
VI. Conclusion
With more than 50 years of history, the
CMAAO’s role within the WMA has re-
cently begun expanding. The purpose of this
brief history of CMAAO and summary of
its recent activities is to familiarize all WMA
members of the current status of CMAAO
as we begin to focus on our next 50 years.
References
Ishii M, Tsuruoka H. History and recent ac-1.
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TaroT.The government of Japan in the World Me-
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glish/journal/index.html
Masami Ishii, MD, Executive Board Member
of JMA, Secretary General of CMAAO,
Vice-Chair of Council of WMA
Hisashi Tsuruoka,
International Manager of JMA
e-mail: tsuruoka@po.med.or.jp
Dr. Rodolfo P. Gonzalez
74
Regional and NMA news
Samoa is a small, peaceful nation in the
South Pacific with a population of ap-
proximately 200,000. It experiences a se-
vere shortage of doctors and faces serious
obstacles in attaining sufficient numbers
of doctors to meet its health needs in the
decades ahead. The Samoa Medical Asso-
ciation (SMA) was founded in 1948 and is
one of the oldest professional associations
in Samoa.
Although the SMA has provided its mem-
bers with continuing medical education
opportunities, annual scientific conferences
and weekly CME meetings since its foun-
dation, it was felt that more could be done.
For many years, the Association dreamed of
having its own journal and holding interna-
tional conferences, but the relatively small
scale of medical and health care in Samoa
and excessive workloads of doctors meant
that, until recently, this dream could not
be realised. In 2009, through collaboration
among the Oceania University of Medi-
cine (OUM), the SMA, and the National
Health Service, the SMA achieved one of
its aspirations with the launch of the Samoa
Medical journal (SMJ), the online version
of which can be read without subscription
at www.oceaniamed.org. In April 2010, the
same collaborative group will launch the
first Medical Conference on Heart Disease
in Samoa with speakers from Samoa and
New Zealand.
Oceania University of Medicine was es-
tablished in Samoa in 2002 to serve the
national and regional interests in terms of
medical workforce needs. In addition to
offering a four-year graduate entry medi-
cal programme and a new five year MBBS
programme, OUM supports, encourages
and provides a range of opportunities for
practising doctors and emerging research-
ers to carry out medical and health-related
research. This includes working with the
NHS, Ministry of Health and SMA to
provide continuing medical education and
to develop a research infrastructure and
provision of postgraduate training and re-
search pathways, such as diplomas in key
clinical areas and a masters’ and doctoral
programme in clinical and health sciences.
The university shared the same conviction
as the SMA: that it was time to have a lo-
cal medical journal as part of the support
mechanisms and linkages for local practi-
tioners. The University, through its faculty,
has been instrumental in bringing together
its partners, the SMA and NHS, through
the medical doctors to work collaboratively
in the planning and implementing of the
new journal.
The journal is intended to support and en-
courage medical and healthcare research in
Samoa and the Pacific, providing a source
of current medical and health information
to practicing physicians and other health
professionals in the region. The journal has
a focus on the many healthcare workers in-
volved in delivering healthcare and not just
on a tiny minority of clinical researchers.
This interprofessional focus will facilitate
shared learning across and between health
disciplines and services. With a focus on
the South Pacific and reflecting health is-
sues common to the region (such as chronic
disease and infections), the journal covers
areas such as epidemiology, public health,
original basic science and clinical research,
interesting case reports, reviews of endemic
or emerging diseases, focal and regional
medical news, research methodology, pol-
icy, and innovations in medical education.
Reviews of relevant articles and books
published elsewhere will also be welcome.
There is a wealth of local health and medi-
cal information that needs to be shared and
made known that not only will contribute
to knowledge sharing but also ultimately
lead to providing a health service and clini-
cal care that is informed and evidence based.
As they say, if it is not published, it does not
exist!
The SMJ publishes 3 issues annually includ-
ing both online and printed copies. Sub-
missions for the journal are welcome from
medical health professionals and others
who are interested in health issues affecting
Samoa and the South Pacific.The first issue
was warmly received with articles covering
such diverse topics as diabetes mellitus, in-
testinal infections and respiratory muscle
testing. Challenges remain in the Samoan
medical community to engage its members
Partnership Initiatives Herald a New Phase
for the Samoa Medical Association
Judy McKimm Monalisa Punivalu Ben Matalavea Tia Vaai Surindar Cheema
75
Regional and NMA news
to conduct clinical research and publish
the findings, however the launch of a local
journal, plus support from OUM and other
educational providers will help to develop
and drive local research capacity in Samoa
and the region instead of relying on over-
seas researchers. International researchers
who have an interest in tropical medicine in
the South Pacific can look forward to col-
laboration with OUM and the energised
SMA to engage the international research
community by publication of the data in the
Samoa Medical Journal and other interna-
tional publications.
Organizing and holding medical confer-
ences is another opportunity to further sup-
port the SMA and the university’s objective
of promoting and developing medical re-
search,and updating and sharing of medical
and health information. Such conferences
will highlight the health challenges and
priorities of Samoa and the region but also
present a platform for both local present-
ers and invited regional and international
experts to share research findings and clini-
cal practice and become better informed on
current,evidence-based medical knowledge.
A medical conference with the theme Heart
Disease in Samoa is planned for 23rd
and 24th
April 2010. The second issue of the Samoa
Medical Journal is scheduled to be pub-
lished alongside the conference.
Judy McKimm, Professor of Oceania
University of Medicine
Dr. Monalisa Punivalu , Associate Professor
of Oceania University of Medicine
Dr. Ben Matalavea, Editor in
Chief, Samoan Medical Journal
Dr. Tia Vaai, President Samoan
Medical Association
Surindar Cheema, Professor of
Oceania University of Medicine
Triana Darmayanti Akbar
Indonesia faces the same health problems as
other developing countries, which are cur-
rently fighting against infection, malnutri-
tion and perinatal problems, not to mention
natural disasters such as tsunami and earth-
quakes. Malnutrition is still a major issue in
Indonesia, even in its capital city, Jakarta.
Common diseases such as dengue fever,
tuberculosis, malaria, food poisoning and
malnutrition still exist in varying degrees in
different provinces.
At a national level, in 2007 there were 4.1
million cases related to nutrition and mal-
nutrition issues. Alongside the high preva-
lence of communicable diseases such as
tuberculosis, malaria, dengue hemorrhagic
fever and measles, Indonesia is also facing
non-communicable diseases (NCD) such as
cardiovascular disease (CVD), diabetes and
hypertension. In 2007 the Indonesian Insti-
tute of Health Research and Development
indicated that 31.7% of Indonesians suffer
hypertension (the most common NCD)
and 7.2% suffer CVD.
Indonesian health levels are still below
those of other Southeast Asian countries
according to basic health indicators, such
as Infant Mortality Rates (IMR) and Ma-
ternal Mortality Ratio (MMR). In 2007,
Indonesia’s IMR was 34 per 1,000 live
births, and its MMR was 228 per 100,000
live births. Meanwhile, Indonesia’s Hu-
man Development Index (HDI) ranking
was 107—below Thailand (78), Malaysia
in (63), Vietnam (105) and the Philip-
pines (90). Even though the trends for
both indicators are improving, the figures
have not changed significantly. In terms
of communicable diseases, Indonesia
ranks third for tuberculosis after India
and China. This disease should have been
eradicated.
A more significant issue is Indonesia’s
health budget. Health expenditure in In-
donesia was equivalent to 2.8% of its GDP
in 2003 which was considerably less than
that of Thailand (3.5%) or Malaysia (4.2%).
There have been no major changes in these
figures since.
The Indonesian Medical Association (IMA)
plays a very important role in improving
health status in Indonesia. The Indonesian
Doctors bond was founded in 1911, sur-
vived the period of Japanese occupation
(1943-1945), and has evolved into its cur-
rent national organization. Led by Dr. Prijo
Sidipratomo, the newly-elected President,
the IMA organizational structure also con-
sists of an advisory board and a number of
committees and agencies through which
specialists’ associations in Indonesia can
join.
Having a vision of making IMA a national
medical professional organization which
could play a very important role in the Asia
Pacific region by 2020 and missions:
1) endeavouring ethical professional capa-
bilities;
A Glance at Indonesian Health and the
Indonesian Medical Association
76
Regional and NMA news
2) developing a meaningful role in im-
proving health status of the Indonesian
people;
3) forwarding aspirations, seeking the
welfare and providing protection to all
members;
4) developing professional service stan-
dards,ethical standards and the fight for
professional freedom which are capable
of aligning the professional develop-
ment of science and medical technol-
ogy with the demands and needs of the
community.
IMA has as its main goal integrating all the
potential of Indonesian doctors, enhanc-
ing dignity and honour of themselves and
the medical profession, developing science
and medical technology, and improving the
health of the people of Indonesia to become
a healthy and prosperous society.
In order to fulfill the IMA’s vision, mission
and goals,there are a number of changes that
must be implemented in Indonesia. First,
the low levels of health spending should
be increased because of rapid population
growth, the need for poverty alleviation and
an aging population. The 2009 Indonesian
Health Ministry budget was approximately
Rp 18 trillion (approximately $1.96 mil-
lion). Of this total, 48.5% was allocated for
curative and medicine operational costs,
15.8% for public health, and only 7.7%
for communicable and non-communicable
disease programs. Indonesia needs to shift
the focus of the health platform from cura-
tive programs toward health promotion and
prevention; therefore, the IMA has been
endorsing the empowerment of general
practitioners and family doctors to practice
active health promotion, the management
of integrated referral systems, the accel-
eration of National Social Security System
implementation,and a range of other health
and medical efforts,including much-needed
improvements to disaster management.
Triana Darmayanti Akbar, MD,
Vice Secretary General II
Indonesian Medical Association
Jacques de Haller
Currently in its 110th year of existence, the
Foederatio Medicorum Helveticorum (FMH),
or Swiss Medical Association,has continued
to show foresight in its advocacy on behalf
of physicians practising in Switzerland. It
fosters collaboration among all stakehold-
ers in the Swiss healthcare system and has
consistently, energetically, and successfully
defended physicians’ rights to the freedoms
necessary to practice of their profession. For
instance, in the summer of 2008 the FMH
resolutely opposed the proposed article in
the Swiss constitution “for more quality
and cost-effectiveness in medicine,” which
threatened patients’ freedom to choose
their physician and would have resulted in
health funds being managed exclusively by
health insurance companies.With the cam-
paign “NEIN zum Kassendiktat” (“NO to
healthfund supremacy”), and thanks to the
overwhelming support of its members and
a broad alliance of political parties, profes-
sional medical organisations, patients, and
consumers, voters soundly rejected this
proposal, to the benefit of both Swiss physi-
cians and patients.
Sound arguments – strong
community of physicians
Reliable statistical data are of paramount
importance, which is why physicians’ de-
mography has been a key priority of the
FMH from the outset. FMH statistics on
physicians provide information on more
than 30,000 doctors practising in Switzer-
land (status: March 2010). For many years,
statistics on physicians focused exclusively
on social attributes and qualifications; how-
ever, the working conditions of the Swiss
healthcare system have changed in recent
years – for example, many physicians no
longer work exclusively in a practice but
also part-time in a hospital. In addition,the
proportion of physicians with family com-
mitments is growing.
Accordingly, the FMH revised its annual
statistics and since 2008 has conducted dif-
ferent surveys among its members according
to their outpatient and/or inpatient activity.
As a result, the statistics now provide more
details and convey important distinctions
regarding place of work, full-time equiva-
lency and the content of the activities. This
enables actors in the healthcare sector to
monitor developments more closely, re-
spond in good time to shortages of supply,
and offset surplus capacities.
Setting the agenda for
SwissDRG and for eHealth
The FMH does more than just provide
planning instruments; for example, it also
supports projects such as SwissDRG and
eHealth. Swiss hospitals have until the
end of 2011 to convert their billing for
patient hospitalisation to the SwissDRG
FMH – Faithful to its Motto:“No Healthcare
Policy without the FMH!”
77
Regional and NMA news
diagnosis-based system. The organisation
responsible for setting up and managing
this system is SwissDRG AG, a non-profit
company co-founded by FMH. By the end
of 2009, FMH had worked with medical
associations and experts to solicit sugges-
tions for improvements to the system and
develop a concept for clinical research to
accompany SwissDRG’s launch: early
evaluation is necessary in order to identify
false incentives and introduce corrective
measures rapidly. In accordance with this
principle, an initial concrete, practicable
proposal for related research is now in
place.
The Swiss Confederation’s eHealth strategy
articulates ambitious healthcare objectives:
“By the end of 2010, secure authentication
and a legally valid electronic signature will
be available for all service providers […]
By the end of 2012 the electronic trans-
fer of medical data between members of
the healthcare system will be structured
[…].” Consequently, FMH activities over
the past two years have been dominated
by the development of eHealth concepts.
In this regard, FMH has positioned itself
as an essential partner and has channelled
its concerns to various actors in the health-
care sector so as to ensure that the needs
of physicians are taken into consideration.
Moreover, by issuing a Health Professional
Card to all physicians, it made an impor-
tant contribution to the national eHealth
strategy and set a national standard, suc-
cessfully asserting the independence of
physicians within the national eHealth
infrastructure. Thanks to close ties with its
members and good relations with policy
makers, the media, and other actors in the
healthcare sector, it remains a confident
advocate of its members’ interests in all ar-
eas of Swiss healthcare.
Dr. Jacques de Haller,
Président of the Swiss Medical Association
Mikuláš Buzgó
The Slovak Medical Chamber (SMC) is an
independent medical professional organiza-
tion whose objective is to meet the needs of
its members. It also supervises professional
and ethical performance of physicians in
Slovakia. Seventy-five percent of all doc-
tors in Slovakia (15,384 doctors) from all
branches of medicine are members of the
SMC.
The historical roots of the SMC go back to the
Austro – Hungarian Monarchy where a law
on the establishment of medical chambers was
issued in 1891. Later on, after the establish-
ment of the Czechoslovak Republic in 1918,
activities continued until the beginning of the
communist regime. However, communists in
Eastern Europe did not tolerate any non-gov-
ernmental self-regulation so they suspended all
Chambers’activities. They were restarted after
major political and social changes in Czecho-
slovakia in 1989. The Slovak Medical Cham-
ber was then re-established by law in 1990.
The SMC is a corporate body that is inter-
nally subdivided into eight Regional Medi-
cal Chambers – each in one of the eight
self-governing territorial units. The Central
Secretariat of the SMC is located in Brat-
islava. It is led by Secretary General, Mrs.
Daniela Resutikova. The eight Regional
Secretariats are an integral part of the Cen-
tral Secretariat.
The SMC is responsible for registration of
all physicians who wish to practice medi-
cine in Slovakia. At the moment there are
21,586 (12,466 female and 9,120 male)
doctors registered by SMC. From this
number, 2,671 are not currently practicing
in Slovakia (due to retirement, maternity
leave, working abroad).
The SMC acts also as a licensing body and
disciplinary body. It supervises continuing
medical education (CME) which is obliga-
tory in Slovakia for all doctors, who must
accrue 250 CME credits during a five-year
period. One of the major recent tasks of the
SMC is the E-Learning for Doctors Project
supported by European Social Fund. The
aim of this project is to make continuing
medical education easier and more acces-
sible for all doctors.The SMC is an advisory
body for all its members in legal, economic,
and professional issues. Moreover, the orga-
nization is involved in the process of eco-
nomical negotiations with health insurance
bodies and comments on legislative propos-
als.The SMC does not act as a trade union.
According to its statute, the highest body of
the SMC is the General Assembly, which
determines SMC policies. Other impor-
tant elected structures are: the board, the
council, controlling committee and disci-
plinary committee. The members of these
organs are elected for a four- year period.
The SMA also elects a president and two
Slovak Medical Chamber
(Slovenská lekárska komora)
78
Regional and NMA news
vice-presidents. In the most recent election
in 2008, Prof. Milan Dragula was re-elected
as the president.
International activities of the SMC include
the membership in WMA, the Standing
Committee of European Doctors (CPME)
and the European Association of Senior
Hospital Physicians (AEMH). There is in-
tensive and fruitful communication espe-
cially with medical organizations in neigh-
bouring countries.
Slovakia with 5.3 million inhabitants be-
came an EU member state in 2004. Since
then the Slovakian health system has been
facing new tasks and challenges. Consid-
erable migration of doctors to other EU
countries has resulted in workforce shortage
in some specialties. Hence the SMC has a
great interest in creating a quality profes-
sional environment for doctors in order to
enhance attractiveness of the medical pro-
fession in Slovakia. It is the basic condition
for increasing the quality and safety of Slo-
vak health care and thus the EU level.
Mikuláš Buzgó, Vice-president
Slovak Medical Chamber
The National Medical Association of the Re-
public of Kazakhstan was established in Feb-
ruary 1990. Entitled the Association of Physi-
ciansandPharmacistsofKazakhstan(KzMA),
it is voluntary, self-governing, professional,
public nongovernmental organization, uniting
physicians. It has more than 60 branches and
representatives in oblast (regional) centers and
many large cities of Kazakhstan.
The main purposes of the association are:
to promote the recognition of the medical
profession based on the highest levels of
professionalism, humanism, and charity; to
participate in medical science development
and practice to ensure the health of the
population; to support development of the
nongovernmental health sector; and to or-
ganize and implement charitable programs.
Full membership is open to the physicians
of Kazakhstan. Honorary members include
physicians of Europe and CIS countries.
Students of medical institutions of Kazakh-
stan are welcomed as “joining members”.
During its 20-year history, the National
Medical Association has implemented the
following activities:
Interacted with different ministries and•
governmental bodies
Represented the interests of the members•
of the NMA in governmental,internation-
al and nongovernmental organizations
Protected the rights and interests of their•
members experiencing conflict situations
and legal proceedings
Implemented publishing activities, in-•
cluding issuing the medical magazine
“Ave Vitae” – a collection of conferences
materials
Prepared and executed weekly pro-•
gramme “Densaulyk” (Health) on TV for
from 1996-2000
Initiated establishment of the Almaty Cura-•
tive Centre, institute of post-graduate edu-
cation for psychologists and physicians
Served as Chairs of “Medical psychology”•
and “Medical Rights and Bioethics” to-
gether with the Almaty Medical Institute
of Advanced Studies
Conducted local, national, and interna-•
tional conferences on health issues
Actively introduced independent exper-•
tise in the health system
created Committee on Ethics and-
Rights in 1995
created database of independent ex–
perts in 2000
passed accreditation of the Ministry of-
Health (MoH) of the Republic of Ka-
zakhstan in 2008
Founded the avenue “Ave Vitae” in Al-•
maty, devoted to the memory of physi-
cian-solders
Development of Ethical Code of Phy-•
sicians of the Republic of Kazakhstan,
hymn and oath
Established awards:•
The best physician of the NMA (Altyn-
Deriger)
The best clinic of the year-
NMA representatives are members of the
National Coordination Council on Health
Care under the government of the Repub-
lic of Kazakhstan, the MoH’s Board and its
Commission on Attestation, Conflict Situ-
ations, Awards and Commissions of Local
Executive Bodies. They are also members
of the Akimat’s Commissions on Narcoma-
nia and Narcobusiness Control, Family and
Women, and Support of Small Business.
International collaboration
In addition to maintaining close contact
with National Medical Associations of Eu-
rope and Asia,our organization is a member
of several international groups:
Member of the European Forum of•
Medical Associations (since 1994)
Member of the Eurasian Forum of Medi-•
cal Associations (since 1997)
Member of the World Medical Associa-•
tion (since 2003)
Member of the• European Forum for
Good Clinical Practice (since 2003)
The 2010 General Assembly of National
Medical Association of the Republic of Ka-
zakhstan, on the theme “Right for Health,”
will take place in Almaty, 12-14 May, a date
commemorating the 65th
Anniversary of the
Second World War.
Dr. Aizhan Sadykova,
President of National Medical Association
of the Republic of Kazakhstan
The National Medical Association of the
Republic of Kazakhstan
79
Regional and NMA news
Heikki Pälve
The European Union (EU) has 27 member
states that have common legislation in many
areas and cooperate closely in many others.
The core principle of EU is to create a func-
tioning internal market and enhance the
free movement of persons, goods, services
and capital. In the health field, the mandate
of the EU has substantially increased over
the last two decades.Nevertheless,the man-
date is still limited, taking into account the
subsidiarity principle according to which
matters ought to be handled by the smallest,
lowest or least centralized competent au-
thority, i.e. by sovereign countries. All in all,
many decisions on public health and health
services are made at the EU level, and have
effect on national health systems.
In this context, the significance of Europe-
an medical organisations (EMOs) is greater
than ever.There are various topics of EU co-
operation that influence medical profession.
Free movement of health care personnel is
already regulated at the EU level. Currently
there are discussions on the EU legislation
on free movement of patients, safety of or-
gan donations, and better collaboration on
medicinal products, just to mention few.
Increasing EU level cooperation in the
health sector emphasises the importance of
a unfied voice of physicians.Common views
have more power and influence on the de-
cision making of the EU. The European
Commission consults widely with different
stakeholders when considering new initia-
tives. It is important for the Commission to
know who to contact if it wants to hear the
opinion of European doctors.
For many years, that contact point has been
the Standing Committee of European Doc-
tors (CPME),which is an international,not
for profit association and represents the Na-
tional Medical Associations (NMA) of all
those EU member states who are members.
The CPME aims to promote the highest
standards of medical training and medi-
cal practice in order to achieve the highest
quality of health care for all patients in Eu-
rope. The CPME is well recognised by the
EU institutions.
In addition to the CPME, however, there
are numerous specialised European medi-
cal organisations where the member states´
representation is more varied. National
Medical Associations are not always rep-
resented in the specialised EMOs. In sum-
mary, NMAs are represented in the EMOs1
in the following way:
CPME (Standing
Committee on Eu-
ropean Doctors)
27
(NMAs)
/27
(coun-
tries)
100 %
PWG (Permanent
working group of
European Junior
Doctors)
10/20 50 %
1 Only full membership is taken into account in
this table.
UEMO (European
Union of General
Practitioners)
16/21 76,2 %
UEMS (European
Union of Medical
Specialists)
23/29 79,3 %
CEOM (Confé-
rence Européen
des Ordres des
Médecins)
Mem-
bership
cannot
yet be
defined
FEMS (European
Federation of Sala-
ried Doctors)
3/10 30 %
AEMH (Euro-
pean Association
of Senior Hospital
Physicians)
10/15 66,7 %
EANA (European
Working Group of
Practitioners and
Specialists in Free
Practice)
5/14 35,7 %
Lately, the relationship among the different
European medical organisations has been
under intense discussion, especially in the
context of how best to come together to
most effectively influence EU law and policy.
Like the majority of National Medical As-
sociations in Europe, the FMA’s approach
to this objective on the national level is to
obtain the views of different groups, such
as specialists, general practitioners, young
and senior doctors, etc., and then develop a
consensus position to represent to the gov-
ernment. It will be a challenge to replicate
this approach at the EU level, however it is
a crucial effort we must undertake.
Currently we face the threat that EU de-
cision-makers are able to poll the various
groups individually, select the response that
best suits their purpose, and then claim to
have incorporated the physicians’ viewpoint
into their decisions–even if that viewpoint
does not represent the majority perspective
of the NMAs but rather a subgroup of doc-
Challenges of the European Medical
Organisations
80
Correspondence
In the October 2009 issue of World Medical
Journal there was a long article by Dr. Na-
riman Safarli entitled “Ethical, Moral, and
Legal Responsibilities of Physicians: an
Islamic Perspective.” I wonder if I am the
only reader who was dumbfounded that the
editors chose to print this article. I found it
to be woefully silent on the ways in which
Islamic law contradicts basic human rights,
(never mind the responsibilities of physi-
cians), inaccurate and condescending in its
characterization of secularized medicine/
physicians, a thinly veiled attempt at reli-
gious proselytizing, and xenophobic.
Dr. Safarli writes that “Islamic Law (Sha-
riat) is comprehensive and encompasses
moral principles directly applicable to med-
icine.”What he doesn’t mention is that Sh-
ariah law prescribes barbaric punishments
like amputation of the hands, blinding,
flogging and stoning to death for “crimes”
as varied as homosexuality, thief drinking
alcohol, and extra-marital sexual relations.
Indeed, in this same issue of the World
Medical Journal, under Human Rights, we
are told of two physicians who were sen-
tenced in Saudi Arabia to 1500 and 1700
lashes (and prison terms of 15 and 20 years)
for allegedly facilitating the addiction of a
patient who was prescribed morphine for
pain after trauma. Attention is also drawn
to an Iranian man who was sentenced to be
blinded in both eyes with acid – “a process
that would involve medical professionals.”
What “moral principle” could possibly jus-
tify such unspeakable cruelty, never mind
the involvement of physicians?
Shariah law perpetuates the oppression of
women. Under Shariah law a husband has
the moral and religious right to beat his
wives and children for disobedience or for
perceived misconduct. A woman’s testimo-
ny in court is accorded half the value of a
man’s.
Dr.Safarli writes:“I know that the most im-
portant thing for a Muslim doctor is to be
interested in the basic values and principles
of Islam…” He contrasts this with “secular
ethics”which “are framed by a society which
is fickle, inconsistently ruled by a majority
vote and devoid of religious restrictions.”
He posits that “secularized medicine has no
consistent set of ethics regarding malprac-
tice, fraud, and bias in research.”
He writes that a secular physician turns “a
blind eye to the moral and social issue of
the day”. Has he never heard of Drs. Lown
and Chazov, two secular physicians who ac-
cepted the Nobel Peace Prize on behalf of
International Physicians for the Prevention
of Nuclear War? These men, one Ameri-
can, one Russian, organized hundreds of
thousands of physicians to oppose nuclear
weapons and to educate the public about
the horrors of nuclear war.
Contrast the good which these secular phy-
sicians accomplished with the deeds of the
Muslim physician Ayman al-Zwarahiri who
masterminded the slaughter of thousands of
civilians on September 11, 2001. Contrast
them with another Muslim physician,Nidal
Malik Hasan, who opened fire on a group
of unarmed individuals at an army base in
Texas, killing 13 and wounding 28.
Dr. Safarli ends his article: “To conclude,
the role of the Muslim doctor is briefly to
put his or her profession in service of the
pure religion Al-Islam…” (emphasis mine).
Here Dr. Safarli implies that other religions
are somehow not pure, or are less pure than
Islam. I find this offensive in the extreme,
and blatantly xenophobic. I remain puzzled
as to why the editors thought this article
was appropriate for the World Medical
Journal which is read by people of multiple
faiths and no doubt by many who have no
religious faith at all. I know I am not the
only reader who was offended by many of
the statements in this article and I would
be most interested in hearing Dr. Safarli’s
response.
Barbara H. Roberts, MD, FACC Director,
The Women’s Cardiac Center at The Miriam
Hospital Contributing Editor, Women’s
Heart Health, ProCOR Associate Clinical
Professor of Medicine Warren Alpert
Medical School of Brown University
Author’s response
It is was very annoying, at this time of con-
structive and harmonious exchange of thoughts
and dialogue for human welfare, to encounter
such unbalanced attacks against freedom of
expression of though and culture. Dr. Roberts
confused between issues in a non-scientific and
non-logical manner. She has mixed ethical
guidelines of genuine Islamic Law (Shari’ah),
Letters to the Editor
“Ethical, Moral and Legal Responsibilities of Physicians:
An Islamic perspective.” World Medical Journal. 2009; 55(3): 107-8.
tors represented only by some individual
countries. We must, therefore, strengthen
the position of the NMAs on the European
level and develop an organizational model
for EMOs that has a formalized structure
and the objective of creating a unified voice
for physicians. It is through such a collabo-
rative structure that we will to be able to
most effectively leverage our collective in-
fluence at the EU level.
Heikki Pälve, CEO
Finnish Medical Association
81
Correspondence
which she describes as barbaric, with other con-
temporary practices in some Muslim countries,
women’s issues, polygamy, September 11….
etc, issues that can be dissected and discussed
separately in a clam, scientific and constructive
manner.
It is amazing how an associate clinical profes-
sor in a respectable medical institution allows
herself to tackle major issues of ethics and cul-
ture in this narrow mended, non-scientific ap-
proach. Not only she allowed her self to contra-
dict freedom of expression of views and values,
which may differ from her’s, using a language
loaded with dogma and hatred, she also harshly
attacked the editorial board of the Journal twice
in her Letter!.
Our published article tried to present the broad
concept of Islamic bioethics,which was practiced
during many centuries of Islamic medical civi-
lization. A code of medical conduct that looked
at the medical profession as the most noble of
all professions, in view of its intimate relations
with human health, diseases, life and death.
Physicians from other faiths could present any
available systems of bioethics, in an effort to
discuss, harmonize and improve on the status
of bioethics which needs care and improvement.
All those contributions should be looked upon
with respect and should not be ridiculed or at-
tacked.
When we study the history of bioethics in past
and contemporary eras, it becomes clear that
people have always cared about bioethical de-
viations. Ethical codes have been designed and
modified in efforts to combat ethical deviations
and professional misconduct. The Declaration
of Helsinki, for example, was modified many
times since its adoption by the World Medical
Association. But with all these efforts, bioethi-
cal deviations continued, and proliferated un-
abated.
In front of me, there is a multitude of many,
many examples of unethical deviations. One
example took place for almost 40 years in the
city of Tuskegee-Alabama, where black patients
suffering from syphilis, were intentionally left
without treatment from the early 1930s to the
late 1970s, in order to study the natural course
of the disease in its various stages.
The Worldwide proliferation of medical in-
ventions and breakthroughs that took place
over the past several decades, have raised wide
hopes and expectations, but at the same time,
they have posed major dilemmas from ethical,
religious, social and legal points of view, which
should receive attention and efforts to improve
ethical codes.
In my article, I have tried to outline the concept
of combining scientific medical education togeth-
er with proper upbringing on faith and values.
Past Islamic Medical Civilization was successful
in doing so,with a remarkable record in combat-
ing ethical deviations.
Such medical deviations usually stem from the
materialistic outlooks of physicians that mar-
ginalize spiritual and ethical aspects of medical
care.
The influence of globalization and big busi-
ness on the medical profession always pushes
towards materialistic gains, waste and cost.
Such ethical and behavioral aberrations have
their roots in neglecting faith and accountabil-
ity in the hearts and minds of physicians and
researchers.
This is the message from the article, which was
written in good faith, to improve the current
status of bioethics. We stand for human values
and look for harmony and collaboration be-
tween cultures and other ideas.
Sincerely yours, Dr. Nariman Safarli
President, Azerbaijan Medical Association
The world medical and health games are a
gathering for health professionals that al-
low them to compete in various sports in a
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You have all been waiting for this for a
long time: the World Medical and Health
Games are finally going to Croatia!
From the 3rd till the 10th of July, we will
take you to the heart of the beautiful region
of Istria.
Sportsmen or not,with friends or family,we
promise that you will experience an unfor-
gettable stay!
Do not waste any more time and come and
register online on www.medigames.com!.
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The World Medical and Health Games
82
WMA news
The financial crisis has affected economies
on a global scale. While some countries
have experienced no more than a tempo-
rary decline, other countries are still in deep
recession leading to practical insolvency.
Despite the crisis many national health care
systems have maintained their stability and
have been only moderately affected, while
others have experienced direct budgetary
cuts of up to 30 % which jeopardize essen-
tial health care services in some areas.
In order to discuss the implications of the
financial crises on health World Medical
Association in cooperation with Latvian
Doctor’s Association is planning to hold a
two days’ conference “The Financial Crisis –
Implications for Health Care. Lessons for the
future”. The Conference will take place in
Riga, Latvia on 10th and 11th, September,
2010.
Objectives
How severely are different health care sys-
tems affected by the crisis? (Regional expe-
riences from different countries)
How do health care and economy interact
during a crisis? (Are health care systems no
more than an economic burden,or may they
be seen as playing a stabilizing role?)
What can we learn from the crisis? What
makes health care systems immune against
economic crisis? (Are there best practices/
solutions to keep health care systems per-
forming?)
What are the consequences for health care
reforms? How can health care systems be
structured and managed to be less sensi-
tive to crisis and play a stabilizing role in
economy?
Participants
The Conference is open to National Medi-
cal Professional organizations and. Health
Care Management Staff. It is expected to
convene between 300 and 400 profession-
als from Europe, Asia and America. The
Conference representing the views of health
experts and health professionals will pro-
vide an overview of the major threats and
challenges for health systems caused by the
economic crisis based on evidence drawn
from international experience and research.
Key problems and challenges faced by the
health systems in Europe and globally will
be identified and responses that countries
so far have developed in addressing these
problems and challenges will be outlined.
The Conference participants will look into
some priority areas to assess the impacts of
economic recession and to explore effective
policies in resolving the major problems
created. The aim of the conference is to
serve as a learning tool for finding the best
possible solutions in order to lead health
care systems out of the crisis and achieve
better progress in improving public health
and faster recovery of economies.
More information about the conference will
be available at www.riga-wma.lv .
We are looking forward to meeting you in
Riga and we promise you a great seasonal
experience in Latvia.
Welcome to Riga!
Financial Crisis – Implications for Health
Care Lessons for the Future
Conference of the World Medical Association
September 10–11, 2010, Riga, Latvia
83
In memoriam
Dr. Jo Asvall, former WHO Regional Di-
rector for Europe, died on 10th
February
2010.
Dr. Asvall had a long and distinguished
career qualifying in medicine in 1956, and
very early in his career, headed up WHO’s
malaria team in Benin, Cameroon and
Togo. Returning to Norway in 1963, he
took up a hospital post, becoming increas-
ingly engaged in clinical management and
hospital administration, in 1973 becaming
director of the Hospital department in the
Norwegian Ministry of Social Affairs He
joined the WHO European Regional Of-
fice in 1976 as Officer for Country Health
Planning, becoming Director Programme
Management in 1979 he was appointed
Regional Director in 1985,serving in this
post for the next 15 years.
Dr. Asvall particularly recognised the im-
portance of engaging the medical profes-
sion in understanding and implementing
the “Health For All” initiative. The initia-
tive to engage the profession started in
1984 with a meeting in Copenhagen un-
der Dr. Caprio his predecessor. In the fol-
lowing months when he became Regional
Director in 1985 Dr. Asvall pursued this
initiative, although in the initial years it
was greeted with some scepticism by a
few western European National Medical
Associations’(NMAs) leaders . This was
substantially due to misunderstanding and
failure to recognise the political constraints
within which the RD worked at that time.
However, it ultimately led to a mutual un-
derstanding, respect and to increasingly
fruitful engagement between EURO and
NMA’s in meetings right across the region
defined as the European Forum of Medical
Associations and European Region office
of WHO( EFMA/WHO) Subsequently
similar bodies were created for Nurses
and Midwives, and for Pharmacists, all of
which still are active.
Through these meetings NMA’s not only
learnt and clarified their knowledge of
WHO policies agreed at Regional Com-
mittee Meetings by regional member
states governmental representatives,as well
as their relevance to physicians at national
level. This also led to a better understand-
ing of various aspects of the “Health for
All”aims in the Regional plan and to some
successful collaborative efforts. The other
great benefit derived from the EFMA/
WHO meetings were that especially in
the,1980’s and early 1990’s they provided
an opportunity for physicians from both
east and west of the European Region to
meet and understand the strengths and
weaknesses of their various health care
systems and their problems,While Dr.As-
vall’s remarkable dynamism, genuineness
and enthusiasm which were always clear in
his presentations at the Forum, sometimes
they led to differences of opinion, strongly
expressed by both parties. However this in
no way diminished the respect in which
he was held by even the most critical of
his opponents and often differences were
resolved by positive compromise and sup-
port. His approach to engaging National
Medical Associations was but one example
of his foresight in pursuing the aims of
WHO in the region, not only in devising
and pursuit of policies by also informing,
educating and engaging doctors and other
health professionals.,both individually and
collectively in their application…
Unsurprisingly, his retirement was a no-
tional one and he continued to be very
active in many fields not only in public
health and health policy, but also as Direc-
tor of the Rehabilitation of Torture Vic-
tims in Copenhagen and many other areas
of activity The European Region,its medi-
cal and other health professions are greatly
in his debt and will miss the qualities of
leadership ,inspiration and the personality
of this physician.
Dr. Alan J. Rowe
In memoriam
Jo E. Asvall (1931-2010)
WMA news
100th
-anniversary-festivities of the Finnish Medical Association
Sports at all ages – for a healthy population . . . . . . . . . . 43
Exploring Sustainable Systems to Document Torture –
the Role of Health Professionals . . . . . . . . . . . . . . . . 44
Physicians Call for Elimination of Female Genital Mutilation 46
Health Professions Consider the Future of Regulation . . . . 46
Revolutionary Transplant in University College London –
a world first. . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Pfizer Launches Speaking Book in China
on Dangers of Smoking . . . . . . . . . . . . . . . . . . . . 49
Accountability and Transparency: Two Pillars
of the Health Professions in the 21st
Century . . . . . . . . . 50
Placebo Controls in Clinical Trials . . . . . . . . . . . . . . 53
The Climate Crisis, Global Health,
and the Medical Response . . . . . . . . . . . . . . . . . . . 56
Keeping the Lines of Communication Open –
and Patient Safety First . . . . . . . . . . . . . . . . . . . . 59
End Water Poverty. . . . . . . . . . . . . . . . . . . . . . . 59
Multidrug-resistant Tuberculosis:Problems and Responses . . 60
Host of the 2012 WMA Congress and General Assembly . . 67
CMAAO, Over Fifty Years of History and Future Outlook . . 70
Partnership Initiatives Herald a New Phase
for the Samoa Medical Association . . . . . . . . . . . . . . 74
A Glance of Indonesian Health
and the Indonesian Medical Association. . . . . . . . . . . . 75
FMH – Faithful to its Motto:
“No Healthcare Policy without the FMH!” . . . . . . . . . . 76
Slovak Medical Chamber (Slovenská lekárska komora) . . . . 77
The National Medical Association
of the Republic of Kazakhstan . . . . . . . . . . . . . . . . . 78
Challenges of the European Medical Organisations . . . . . . 79
Discusion about the article. . . . . . . . . . . . . . . . . . . 80
The World Medical and Health Games . . . . . . . . . . . . 81
Financial Crisis – Implications for Health Care
Lessons for the Future . . . . . . . . . . . . . . . . . . . . . 82
In memoriam . . . . . . . . . . . . . . . . . . . . . . . . . 83
Contents