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COUNTRY
• Research Ethics Committees:
Identifying and Weighing Potential Benefit and Harm
from Clinical Research
• What is “Deontological Ethics”?
vol. 58
MedicalWorld
JournalJournal
Official Journal of the World Medical Association, INC
G20438
Nr. 1, February 2012
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1
The current year began with remarkable problems for many phy-
sicians and their organizations. In Poland, the parliament tried to
hold physicians financially responsible for the management of non-
transparent entitlements of their patients. This is interesting in a
country where the health insurance system is run by the state – the
entity best positioned to fix the problem in the first place. Fortu-
nately it appears that the actions might be reversed soon.
At the end of the year in the Slovak Republic, the government put
the hospitals in a state of emergency, which placed hospital physi-
cians under a kind of martial law, prohibiting them from going on
strike. Do they really believe physicians waived all their rights upon
entering the profession? Of course it is easy to save money at the
expense of others, especially when you can “gag”them with the help
of the police. This is yet another bitter attempt of a government to
compensate for their financial problems by taking from those who
serve most and work hardest.The fact that physicians in the Slovak
Republic are already severely underpaid makes the situation even
more deplorable.
But the worst situation has been the attempt by the Turkish gov-
ernment to dismantle physician self-governance, despite the fact
that this responsibility was granted by law to the Turkish Medical
Association. Through a government order, the Turkish government
is attempting to take key self-regulatory functions away from the
TMA and empower a government-controlled organization with
oversight of all health professionals. This is a blatant attack on civil
society and defies the principles of parliamentary democracy, in
which laws made by the parliament must not be changed by the
executive branch.
Letters of solidarity have come to the Turkish Medical Association,
supporting them in their fight for self-governance, civil engage-
ment, and the maintenance of basic democratic rules. The World
Medical Association will have a presence in Ankara and Istanbul on
April 16th
and 17th
to help the Turkish Physicians regain their rights
of self-regulation.
Attacks on physician self-governance have not been limited to these
very recent situations. We have seen this several times in the past
years, with some efforts more successful and some less so.The com-
mon thread among these situations is the objective of “command
and control”of the profession. In most affluent societies, health care
is by far the largest identifiable sector of economy.To steer this sec-
tor holds strong appeal for all governments. Physicians, with their
highly influential structures designed to maintain and develop
health care systems, are the most targeted group in this changing
environment because cutting entitlements for medical and health
care is most easily accomplished when this group is disempowered.
And in the end, it matters very little whether control of the profes-
sion is exercised by a government body, an insurance company, or a
managed care company.
The profession has a lot to lose. Being regulated by a bureaucratic
administration that does not understand medicine and the work of
physicians is difficult. Being regulated by an administration that is
not only disconnected from medicine and care but that has only
cost-savings on its radar is even worse. And while these frustrations
and difficulties are not to be underestimated, the ultimate threat is
to be downgraded from a respected profession to a technical service.
Professional self-governance is not merely a means for physicians
to exercise control to serve their own interests; it serves a critical
patient-centered purpose and we must make that understood to
all stakeholders. In health care, the objective of self-governance is
to provide better medical care to the patients and services to our
people, to protect the dignity of patients, and to improve public
health in our communities. We must be able to demonstrate to our
societies that it is to their advantage to have physicians who can
freely exercise their duties according to professional standards and
ethical rules rather then to be under the control of a government,
or an insurance or a managed care company. When physicians are
forced to follow third party orders, the interests of the patients will
always come last.
Dr. Otmar Kloiber
A Difficult Start Into the Year
Editorial
2
GERMANYClinical Research
1. Introduction1
Identifying, assessing, and weighing poten-
tial benefit and harm from clinical research
is one of the central though most difficult
tasks of any research ethics committee
(REC). Article 15 of the World Medi-
cal Association’s Declaration of Helsinki
(Seoul 2008) explicitly states:
“The research protocol [of every medical
research study involving human subjects]
must be submitted for consideration, com-
ment, guidance and approval to a research
ethics committee before the study begins.”
And (according to Article 18) every study
“must be preceded by careful assessment
of predictable risks and burdens to the in-
dividual and communities involved in the
research in comparison with foreseeable
benefits to them and other individuals or
1 We thank Prof. Elmar Doppelfeld for helpful
comments on an earlier version of the manuscript
communities affected by the condition un-
der investigation.”
In addition, biomedical research and the
role of RECs are governed at the European
level by several legally binding instruments:
One is the Directive 2001/20/EC relating
to the conduct of clinical trials on medicinal
products for human use. Article 3.2 states:
…”A clinical trial may be initiated only if
the Ethics Committee … comes to the con-
clusion that the anticipated therapeutic and
public health benefits justify the risks”…
The Council of Europe’s Convention on Hu-
man Rights and Biomedicine [1] and its Ad-
ditional Protocol concerning Biomedical Re-
search [2] are binding only in States where
they were ratified. The Convention states:
“Research on a person may only be under-
taken if … the risks which may be incurred
by that person are not disproportionate to
the potential benefits of the research” (ar-
ticle 16).
The Additional Protocol explicates:
“In addition, where the research does not
have the potential to produce results of
direct benefit to the health of the research
participant, such research may only be un-
dertaken if the research entails no more
than acceptable risk and acceptable bur-
den for the research participant” (Article
6.2) and “Research on a person without the
capacity to consent to research may be un-
dertaken only if … the research entails only
minimal risk and minimal burden to the in-
dividual concerned” (Article 15).
The task of the “risk-benefit analysis” pri-
marily addresses researchers and secondly
the relevant REC (and later i.a. monitoring
committees, industry, politicians, regulators,
providers, purchasers, guideline producers;
[13] and finally individual doctors and pa-
tients: Communicating Risks and Benefits:
an evidence-based users guide [6].
In 2004 the German Drug Law (Medicinal
Products Law, in German: Arzneimittel-
gesetz = AMG) incorporated the norma-
tive framework of the European Directive
2001/20/EG, transforming the role of Ger-
many’s more than 50 RECs considerably.
In the case of assessing clinical trials of
medicinal products they had to change
from an intra-professional advisory to an
approving body.The changes intensified the
professionalisation of RECs and influenced
the assessment of all study types. They gave
RECs both a stronger position and an in-
creased responsibility.
Over the last years the bioethical literature
have been proposing different approaches to
risk-benefit assessment [11]. The two best
known are the component analysis [15, 16,
17] and the net risk test [18, 19], the latter
being further developed into a seven-step
framework by Rid & Wendler [12].A recent
overview of relevant problems and literature
is provided by King and Churchill [10].
Since 2006 we have been developing and
testing an own systematic approach to the
Heiner Raspe
Research Ethics Committees:
Identifying and Weighing Potential Benefit
and Harm from Clinical Research
Angelika Hüppe
3
GERMANY Clinical Research
ethical analysis of risks and potential ben-
efits from clinical research [8]. A prelimi-
nary version was applied to study protocols
presented (in 2006) to the REC of our
medical faculty [9]. The text below gives a
brief description of the method – against
the background of the normative situation
of our country.
2. Evaluating potential benefit
and harm: a stepwise approach2
Step 1: Identifying potential benefi-
ciaries and victims of possible harm
Principal beneficiaries are a) patients or
healthy volunteers (probands) as study par-
ticipants, b) patients or healthy volunteers
outside the study with the same charac-
teristics as defined by its in- and exclusion
criteria, and c) a very broad range of other
persons, organisations, communities, (seg-
ments of) public health or “the” economy,
society, or environment. The same distinc-
tions are to be used to classify potential vic-
tims of possible harm (“maleficiaries”).
A study implies potential individual benefit
if each and every participant has a priori a
chance to benefit directly from the diagnos-
tic or therapeutic intervention under study;
this is the case if the benefit can be expected
as an effect of the specific intervention (as
its cause) and not via the mere inclusion in
the study (by e.g. early access to novel treat-
ment, careful monitoring, financial rewards;
“collateral benefit”). Participation in a well
planned double-blind randomised placebo-
controlled trial (RCT) convincingly hy-
pothesising superiority of the experimental
condition satisfies the criterion.
A study offers group benefit if its results
can be more or less directly utilised in fa-
2 The following focuses (paradigmatically) on clini-
cal evaluative studies of diagnostic and therapeu-
tic methods.
vour of patients/probands with characteris-
tics identical to those of the study members
exposed. One or few further – replicative
or corroborative – studies may be necessary
and acceptable. The first group to benefit
from the results of a “positive”RCT may be
the then unblinded control group followed
by other prevalent or incident cases with
identical characteristics. We thus referred
to group benefit as a form of “delayed direct
benefit” [8]. Note that we propose a de-
liberately narrow definition of group ben-
efit – a category which is being discussed
in Germany highly controversial, especially
when loosely defined (as e.g. in Article 17.2
of the Oviedo Convention: “… other per-
sons in the same age category or afflicted
with the same disease or having the same
condition”).
A study is said to have external benefit (or
harm) if c) applies. This category includes
a wide and heterogeneous spectrum of po-
tential bene- and maleficiaries: it runs from
less well defined future patients/probands
with similar ailments and their relatives
and other healthy persons to researchers,
providers and purchasers and further to
pharmaceutical companies, clinical medi-
cine, biomedical science,“the”national eco-
nomy or “the” community, society or envi-
ronment.3
We therefore propose to define three types
of possible benefits and beneficiaries – in
contrast to prominent German ethicists
and Members of the Parliament who cling
to the dichotomy individual vs. external
benefit. If they accept group benefit as an
additional category at all, they regard it
only as another subtype of external benefit.
And external benefit is seen as insufficient
3 “External benefit”is an incomplete and imperfect
translation of German “Fremdnutzen”, which
means benefit not for the study participants
themselves or the respective group but for unde-
fined others. “Fremd” is the (German) antonym
to “selbst” (Englisch: self) and indicates a wide
distance, even an opposition between individual
and external benefit.
for justifying the inclusion of patients into
studies and totally unacceptable where a
trial addresses adults being “incapable of
comprehending the nature, significance
and implications of the clinical trial and
of determining his/her will in the light of
these facts” (§ 41 (3) AMG). This position
still prevents Germany from ratifying the
Convention on Human Rights and Bio-
medicine [1] and led our country to add an
“explanation of vote” to the Universal Dec-
laration on Bioethics and Human Rights
[2].
The position poses particular difficulties for
medicine as an evidence-based pragmatic
science. Medicine has to rely, for example,
on evidence-based diagnostic strategies
and tests to be developed and evaluated
in a series of diagnostic studies, be it in
decisionally capable or incapable subjects
(e.g. newborns, young children, demen-
tia patients, stroke or accident victims).
One indispensable early step in the series
is the diagnostic accuracy study; it applies
a new test to two groups separated on the
outcome of an established “gold standard”
test: subjects definitely with vs. definitely
without the disease in question. Imagine
the evaluation of a novel blood test pre-
sumably specific for adult Alzheimer’s dis-
ease. An early low-risk phase 2 diagnostic
study (case-referent approach) would start
with advanced cases and ask whether the
results of the new test differ between the
cases and a group of non-diseased subjects.
Its results are evidently of no direct benefit
for any of the study participants but imply
potential benefit for 1. the preparation and
conduct of a phase 3 study (cohort type in
the clinical environment followed by phase
4 and 5 studies4
and 2. – when again and
again “positive” – for further prevalent
and incident clinical cases (group benefit).
An analogous example from the world of
therapeutic studies is given by the strictly
4 A phase 4 study analyses therapeutic impact, of-
ten in a before-after design, a phase 5 study is a
diagnostic RCT.
4
GERMANYClinical Research
non-interventional cohort study assessing
favourable and unfavourable effects of e.g.
a certain drug under ordinary practice con-
ditions, another by some non-inferiority
RCTs. Again, one cannot expect a direct
benefit for any of the study participants but
possible benefit for equal patients outside
the study, when for instance therapeutic al-
ternatives have to be considered.
We can’t discuss here in detail the ethics of
group-beneficial studies but would like to
state that if patients, clinicians, purchasers,
legislators and regulators demand evidence-
based diagnostic testing (and treatment)
independently from the patients’ decisional
capacity then studies such as the men-
tioned above have to be conducted. If this
is accepted it is inacceptable to outlaw such
studies. We hope that our narrow defini-
tion of group benefit (as a third category)
may help building a bridge between so far
incompatible positions5
.
Step 2: Realising country-
specific legal norms
Though – at least in the European con-
text  – a further convergence of legally
binding norms can be expected, there are
still national peculiarities (see for instance
footnote 4). Hence it is necessary to realise
and recognise all relevant country-specific
norms and directives. Some address cer-
tain groups of beneficiaries, others require
certain types of benefit or define upper
limits for risks and burdens. All this serves
the purpose of harm minimisation, an
ethical requirement which is relevant not
only when legally prescribed. It has to be
observed whenever and wherever a study
is planned and conducted. RECs should
propose how to minimise study-associated
potential harms.
5 The German situation is all the more incompre-
hensible as the law accepts group-beneficial stud-
ies in children (§ 41 (2) AMG) but not in deci-
sionally incapable adults (§ 41 (3)).
Step 3: Assessing equipoise
This step involves two assessments: The
first evaluates whether any study group or
individual subject is at risk of substandard
care as defined by relevant clinical practice
guidelines (“external equipoise”).This ques-
tion is difficult to answer especially when
“routine or usual care” serves as a compara-
tor in a controlled study. Does the actual
care meet relevant professional standards?
For uncontrolled studies such standards
provide a benchmark for the evaluation of
the experimental condition (or the actual
care in purely observational studies).
The second assessment addresses the po-
tential benefit/harm relations between
two or more arms within controlled stud-
ies (“internal equipoise”). We ask whether
the different exposures imply comparable
risks, potential benefits and harm-benefit
relations – in the light of the current best
available evidence as critically appraised by
the respective expert community.If a certain
clinician deliberately participates in a study
he or she agrees, at least implicitly, with
what was accepted as being “in equipoise”.
Confusion sometimes arises from study
hypotheses which take a relevant clinical
benefit already for granted and do not leave
room for doubt and so far imperfect knowl-
edge (i.e. for further research).
Step 4: Identifying, measuring,
and assessing single potential
benefits and harms
The following distinctions apply to the
analysis of both potential benefits and
harms again: we assess their type/qual-
ity and relevance (e.g. mortality, morbidity,
symptoms, quality of life) – magnitude/size
(given e.g. as high relative risk, absolute risk
difference, effect size) – likelihood of their
occurrence (absolute risk,number needed to
treat/harm) – time of onset and duration/
sustainability of any favourable or unfavour-
able effect (minutes to years). We propose
to express the degree of relevance, size, and
likelihood of any benefit/harm by means of
simple trichotomous scales (at least: high –
medium – low6
). Finally, a similar rating of
the certainty of each single estimate and of
the aggregated benefit and harm is required
(based on e.g. confidence intervals of point
estimates). An open question addresses the
degree of (un)certainty (bias potential) of
the total body of evidence regarding pos-
sible benefits and harms: Germany’s Drug
Law (§ 5 (2)) requires not more than “rea-
son to suspect” that a certain drug is un-
safe – a standard nobody would accept for
“proving” potential benefit. In view of the
central role of RECs (to protect study par-
ticipants) a lower standard of proof thus
seems acceptable when risks and burdens
are to be considered.
Step 5: Analysing, comparing, and
assessing summary benefits and harms
Summary statistics (rates, means, relative
risks, effect sizes etc.) are more or less blind
to underlying distributions: take, for ex-
ample, a head-to-head comparison of two
drugs, novel vs. standard; assume the RCT
results in equal success rates (in %).Can you
be sure (without additional data and analy-
ses?) that the benefit is equally stochastical-
ly distributed within the two groups? Could
it be that the interventional product favours
females (one half of each sample) whereas
the comparator favours males (the other
half)? You can’t be sure, even though the re-
searchers started the trial under the (in the
light of all current knowledge) justifiable as-
sumption of stochastic effectiveness within
both groups. A similar question arises when
statistics for central tendencies (mean, me-
dian) are to be analysed (who benefits with-
in a sample?) and compared (equal benefi-
ciaries across samples?). These uncertainties
6 Wider ranging scales may be used, e.g. for ex-
pressing the potential frequency (fivefold between
very frequent and very rare) or severity (fivefold)
of harms:
5
GERMANY Clinical Research
require both a close inspection of individual
data and subgroup analyses.
Other problems are encountered where
multiple and/or complex outcome measures
are included such as a range of heteroge-
neous endpoints (e.g. clinical, laboratory,
patient related), health related quality of life
scales or – even more opaque – quality ad-
justed life years (QALYs). The widely used
instrument SF36, for instance, comprises 8
components (vitality, physical functioning,
bodily pain etc.) each made up by more than
one item. All separate results can be sum-
marised in two measures (physical/men-
tal subscale summary) and a single over-
all score. Thus equal sum scores may well
hide differences at the item, component or
subscale level and/or different mixtures of
positive and negative effects and thus may
well have different meaning in the light
of different patient preferences. The use of
QALYs adds merely another incommen-
surable dimension (lifetime) to a measure
already non-transparent. Similar problems
result from the use of so called composite
endpoints.
Though these considerations relate more
to situations where completed studies have
to be appraised they are not irrelevant for
RECs. To get an estimate of potential ben-
efit and harm RECs have to rely on the re-
sults of former evaluative (e.g. phase 1 and
2 drug) studies, besides case reports, lab and
animal research, and preclinical human ex-
periments.
Step 6: Weighing all
benefit against harm
Nevertheless, different approaches to the
assessment of “net benefit” have been
proposed (European Medicines Agency
20117
) – mathematical (aiming at an aggre-
7 EMA`s considerations refer to the evaluations of
completed studies but seem useful in our context
as well.
gate statistic expressing the balance between
all benefits and harm),“algorithmical”(aim-
ing at a structured stepwise assessment and
summary), and purely judgemental. We
prefer and recommend the multidimen-
sional judgement approach to be guided
initially by the stepwise identification and
assessment of every potential benefit and
harm as mentioned above [8, 9].The judge-
ments then have to be worked out in a thor-
ough discussion among all REC members.
Though this may end up with only incon-
sistent “capricious” results, depending on
numerous situational factors, the proposal
takes into account the singular nature of
each study, the fundamental incommen-
surability of different types of benefit and
harm (see above) and the (to our opinion)
indispensable exchange of various profes-
sional and lay perspectives.
However, before starting any discussion,
it has to be made clear whether individual
(potential) benefit always (or only in certain
cases?) has to exceed harm,balance it,has to
be only loosely related or may in some situ-
ations even be sacrificed for a greater good,
e.g. “the anticipated significance of the me-
dicinal product for medical science8
(§ 40
(1) 2 AMG) or public health.
It is surprising that virtually every REC in
the world faces the task of “balancing ben-
efits and risks” 9
and seems to cope with it
successfully on an everyday basis – in the
absence of any formal concept, advice and
training. We are learning by doing and
training on the job.The Guide for Research
Ethics Committee Members designed to
assist RECs and based on a number of Eu-
ropean Conventions and Protocols [3] of-
fers some help, for example it outlines key
8 In German: “Heilkunde” which means “clinical
medicine” and is to be distinguished from “medi-
cal science”.
9 Which is eo ipso either impossible or trivial:
“risk” refers to the probability of an unfavourable
outcome within a defined period of time whereas
“benefit”refers to a factually given but further un-
specified advantage.
questions which RECs should consider
when reviewing a research protocol.
Is this an unsatisfactory situation? We think
it is, but at present we are unable to offer a
more complete solution. Nevertheless: our
descriptive and evaluative taxonomy com-
bined with the conceptual framework for
comparing and balancing potential research
benefit and harm should increase transpar-
ency of eventual judgements and facilitate
the communication between and within
research groups and RECs. It may help to
standardise and harmonise ethical review,
advice, and approval procedures.
References:
1. Council of Europe: Convention for the Protec-
tion of Human Rights and Dignity of the Hu-
man Being with regard to the Application of
Biology and Medicine: Convention on Human
Rights and Biomedicine. Oviedo, 4.IV.1997
http://conventions.coe.int/Treaty/en/Treaties/
Html/164.htm (accessed February 14th
).
2. Council of Europe: Additional Protocol to the
Convention on Human Rights and Biomedi-
cine, concerning Biomedical Research. Stras-
bourg, 25.I.2005 http://conventions.coe.int/
Treaty/en/Treaties/Html/195.htm (accessed
February 14th
).
3. Council of Europe (2011): Steering Committee
on Bioethics (CDBI) Guide for Research Ethics
Committee Members. Strasbourg, 7th
February
2011. http://www.coe.int/t/dg3/healthbioethic/
source/INF(2011)_en.pdf (accessed February
14th
).
4. European Communities: Directive 2001/20/EC
of the European Parliament and of the Council
of 4 April 2001 Official Journal of the European
Communities L 121/34. http://eur-lex.europa.
eu/LexUriServ/LexUriServ.do?uri=OJ:L:200
1:121:0034:0044:EN:PDF (accessed February
14th
).
5. European Medicines Agency (EMA) 2011
Benefit-risk methodology project: Work pack-
age 2 report –Applicability of current tools and
processes for regulatory benefit-risk assessment.
http://www.ema.europa.eu/docs/en_GB/docu-
ment_library/Report/2010/10/WC500097750.
pdf (accessed February 14th
).
6. Fischhoff B, Brewer NT, Downs JS, PhD, edi-
tors. Communicating Risks and Benefits: An
Evidence-Based User’s Guide. Food and Drug
Administration (FDA), US Department of
Health and Human Services, Silver Spring
6
BELARUSMedical Ethics
August 2011. http://www.fda.gov/downloads/
AboutFDA/ReportsManualsForms/Reports/
UCM268069.pdf (accessed February 14th
).
7. Gesetz über den Verkehr mit Arzneimitteln
(Arzneimittelgesetz – AMG): http://www.ge-
setze-im-internet.de/bundesrecht/amg_1976/
gesamt.pdf (accessed February 14th
).
8. Hüppe A, Raspe H (2009) Analyse und Abwä-
gung von Nutzen- und Schadenpotenzialen aus
klinischer Forschung. In J. Boos, R. Merkel, H.
Raspe, B. Schöne-Seifert (Hrsg.) Nutzen und
Schaden aus klinischer Forschung am Men-
schen. Deutscher Ärzteverlag, S. 13-52.
9. Hüppe A, Raspe H (2011) Mehr Nutzen als
Schaden? Nutzen- und Schadenpotenziale
von Forschungsprojekten einer medizinischen
Fakultät – eine empirische Analyse. Ethik Med
23: 107-121.
10. King NMP, Churchill LR (2008) Assessing and
comparing potential benefits and risks of harm
In: EJ Emanuel, Grady C, RA Crouch, RK Lie,
FG Miller, D Wendler (eds.) The Oxford text-
book of clinical research ethics. Oxford Univer-
sity Press, 514-526.
11. Rid A, Wendler D. (2010) Risk-benefit assess-
ment in medical research – critical review and
open questions. Law, Probability and Risk, 9,
151-177.
12. Rid A, Wendler D. (2011) A framework for
risk-benefit evaluations in biomedical research.
Kennedy Inst Ethics J. 21:141-79.
13. Sawaya GF, Guirguis-Blake J, LeFevre M Har-
ris R,Petitti D (2007) Update on the methods of
the U.S.Preventive Services Task Force: estimat-
ing certainty and magnitude of net benefit. Ann
Intern Med.; 147:871-875.
14. United Nations Educational, Scientific and
Cultural Organization (UNESCO): Universal
Declaration on Bioethics and Human Rights.
Adopted by acclamation on 19 October 2005
by the 33 rd session of the General Confer-
ence of UNESCO. http://unesdoc.unesco.org/
images/0014/001461/146180E.pdf (accessed
February 14th
).
15. Weijer C (2001) The Ethical Analysis of Risks
and Potential Benefits in Human Subjects Re-
search: History, Theory and Implications for
U.S. Regulation. In: National Bioethics Advi-
sory Commission: Ethical and Policy Issues in
Research Involving Human Participants. Vol. 2,
1-29.
16. Weijer C, Miller PB (2004) When are research
risks reasonable in relation to anticipated ben-
efits? Nature Medicine, 10, 570-573.
17. Weijer C (2000) The Ethical Analysis of Risk.
Journal of Law,Medicine & Ethics,28,344-361.
18. Wendler D, Miller FG (2008) Risk-benefit
analysis and the net risk test. In : Emanuel EJ
et al. (Eds.) The Oxford Handbook of Clinical
Research Ethics. New York: Oxford University
Press. p 503-526.
19. Wendler D, Miller FG (2007) Assessing re-
search risks systematically: the net risks test.
J Med Ethics, 33, 481-486.
20. World Medical Association (2008) Declaration
of Helsinki: Ethical Principles for Medical Re-
search Involving Human Subjects, 59th
WMA
General Assembly, Seoul.
MD, PhD Prof. Heiner Raspe,
Dr. Angelika Hüppe,
Centre for Population Medicine
and Health Services Research and
Research Ethics Committee,
University at Luebeck
Ratzeburger Allee, D 23538
Luebeck, Germany
E-mail: heiner.raspe@uksh.de
It is known that deontological ethics means
a set of ethical and moral standards for
health professionals when they perform
their professional duties.These notions were
derived from Latin word “ethica”, Greek
word “ethice” – ethics and morality study,
and Greek word “deon” – duty.
First records about medical ethics and
deontology appeared in ancient sources:
“The Code of Hammurabi” (Babylonian
law code, XVIII BC), “On the Physician”,
“Hippocratic Oath” and “Hippocratic Cor-
pus” (V–IV BC), Indian “Book of life” –
“Ayurveda” (V–IV BC). Term “ethics” as a
criterion for human morality and ethics was
set forward by Aristotle (384-322 BC).The
notion of deontological ethics as “…a study
of proper human conduct in order to reach
his/her goal” was introduced in XVIII by
English philosopher, jurist and priest Jer-
emy Bentham.
Today medical ethics includes the following
aspects: scientific, which is studying ethical
rules of health professionals’ activity, and
practical which is development and appli-
Vladimir Krylov
And Still, What is “Deontological Ethics”?
Pavel Mikhalevich
7
BELARUS Medical Ethics
cation of ethical rules in professional activ-
ity. Being a criterion for personal qualities
of a health professional it studies and de-
termines solution to different interpersonal
issues between colleagues, with patients,
their relatives, junior and senior personnel,
administration.
The quality of performance of deontologi-
cal rules by health professionals depends
directly on political, economical and social
condition of the states, which influence the
level of ethical views of contemporary soci-
ety. Currently global capitalization is hap-
pening in the world and its peak is about
to reach heights. Population of economi-
cally developed countries is consistently
increasing consumption of resources, which
peter out tragically fast. Unstoppable con-
sumption, especially when humans use for
themselves much more than they create by
their labor, is per se an immoral action.This
attitude to life leads to tension in society,
which causes social and political tempests,
which in their turn intensify demonstration
of immorality.
This is the picture we’ve observed in recent
decades in CIS countries,including Belarus.
Certainly, in circumstances like these the
principles of ethical life of a society change
and this concerns medical deontological
ethics despite its somewhat traditional pro-
fessional resistance to difficulties of life in
society.
Hippocratic Oath is rarely remembered in
today’s society. Commercialization, which
affected all levels of social life, firmly settled
down in medicine as well.Profit in this once
grand and genuine area of social life pushed
moral principles aside from priority posi-
tion, replacing them with economic effi-
ciency of rendering medical aid, its substan-
tiation of application effectiveness. Material
significance began to replace not only ethic,
but moral principles as well.
However the reasons of it aren’t only in so-
cial and economical tempests of contempo-
rary social and political system. Disparity
of obeying to deontological rules is based
in the nature of human development. To
understand that it’s necessary to remember
fundamental provisions of ethical notions,
which humanity created in course of many
thousands of years. Peculiarity of ethics as
the code of human conduct in society and
definition of duty we have to each other is
in the fact that it wasn’t created by separate
individuals, but was formed by community
in the process of making of humanity. It is
a reflection of our life, expectations and ac-
tions of every one and each of us.
Ethics lies in the following. Development
of humanity happens in two ways. One of
them is materialistic, the other one is ideal-
istic. The first one implies utilitarian, selfish
and pragmatic character of mutual relations
whereby the mindset is formed on the basis
of principles of material priority in our life,
the other one is altruistic, sacrificial, extra
terrestrial spirituality is in its basis.
Contact of these two ways is across two no-
tions: morality (formal duty of every person
to other people) and ethics (heartfelt atti-
tude to the formal duty, when duty to each
other isn’t based on principles “you do this
for me and I’ll do that for you” but when it
is based on deep respect and love to people
who are people just like you are). Human
moral principles are secured by legislation
(Constitution, codes, regulations, instruc-
tions and others) by a certain community
and are binding. Ethical principles are not
declared by laws, but are determined by
each person’s conscience, and they are dem-
onstrated in mercy and sacrifice towards
other people and it all is aimed at spiritual
development.
Failure to obey moral principles, i.e. civil
laws adopted by us,is called immorality,and
their complete neglect is called degradation.
On the contrary, idealistic way provides
for further ethical development in order
to reach spirituality and holiness. When a
person loses ethical criteria it brings him/
her back to pragmatic way of development.
Therefore, materialistic (pragmatic) way of
development is determined by moral, im-
moral and degradation criteria. And ideal-
istic way is determined by ethics,spirituality
and holiness. Based on humanity develop-
ment it is clear that humans make a way
from primitiveness to high ethical stan-
dards.
The basis for these ethical rules is Moses’
Decalog.His first three commandments be-
came the grounds for formation of idealistic
way of development by humanity, and oth-
ers – of pragmatic. On the border between
them there are so called good people. They
follow moral principles, they don’t violate
them, and to a certain extent they are self-
less and they tend to respect others. This
condition is the basis for transition to ideal-
istic way. At the same time it is necessary to
clearly understand, that the way of develop-
ment isn’t chosen for a certain person but
the person chooses it himself or herself.
Numerous studies showed that even in
more simple biological life two thirds of so-
ciety show characteristics of selfishness and
one third sacrifice themselves to secure life.
The same way in human society, two thirds
of people follow pragmatic (naturalistic)
way of life (development), and idealistic is
followed only by one third. That said most
of “idealists”are in the zone of ethical crite-
ria because it is extremely difficult to reach
spirituality and holiness.Therefore they may
periodically stray away from moral stands to
elements of pragmatic or utilitarian ambi-
tions. However mobilization of efforts in
development of altruism and mercy give
them opportunity to harden at this ethical
level.
It should be noted that there’s a belief that
the mentioned ratio 66.6 percent and 33.3%
percent reflect biblical thought. In the Bi-
ble number 666 is mentioned as the devil’s
number. And it is logical to match it with
the rating 66.6 percent, which reflects self-
ish attitude to life with utilitarian and mer-
8
BELARUSMedical Ethics
cenary interests. Lucifer is considered to be
the prince of this world. On the contrary in
the Bible there’s crucifixion of 33 years old
Jesus Christ, symbolizing sacrifice for the
sake of others and characterizing idealistic
and altruistic attitude to life.
Therefore the majority of the population
prefers utilitarian needs as the basis of their
life interests, and these needs mainly de-
termine the way of interpersonal relations.
Sacrifice for the sake of others, selfless serv-
ing to interests of other people are more rare
events in our real life.
This proportion is destroyed when the ma-
jority of people abandon moral stands. Im-
morality is a serious evidence of disease of
society; it draws the people who are near
into greedy rush of chasing after additional
profit.When that happens it’s impossible to
talk about mercy or require from the per-
son who hasn’t grown to follow moral, not
to mention ethical criteria, to be an altruist,
to be selfless and sacrificial. These qualities
should mature in a person, they don’t just
come from somewhere but they are the re-
sult of persistent seeking in everyday life for
beautiful and genuine things which are love
and mercy.
It is impossible to deny that many people
go into medicine because of their calling,
at the heart’s dictation or because of intu-
ition, so they are prone to mercy, serving
others, sharing their pain and sufferings.
However the experience has shown that
among health professionals there are lots of
those who either lost these genuine qualities
or they have never had them and got into
medicine accidentally or on opportunistic
grounds.
What can you require from them? Can you
require that they act genuinely and merci-
fully? They know how to do that in their
minds but not in their souls. That is why
they will adapt to these requirements, re-
maining self-centered in their souls,and not
being able to share the sufferings of their
patients. Among them there can be spec-
tacular professionals, who really do good for
the patient but remain cold-hearted in their
actions.
So here in this surrounding of health pro-
fessionals,who live on the grounds of unsta-
ble moral criteria, where there are no moral
principles in life, deontological problems
arise. And furthermore it is necessary to
clearly understand that it is connected with
weak moral basis of an individual.
It’s been known for a long time, and that is
why at the beginning of making of nation-
ality the rules of work for health profession-
als already existed and they governed their
attitude towards patient despite absence of
morality. Even Ibn Sina required treating
patients in a special way: “You should know
that every individual has special character,
native personally to him/her.It is very rarely
or never for someone to have the same char-
acter as somebody else’s”. In ancient Indian
treatise the doctor told his disciples: “Now
you should leave your passions, rage, greed,
foulness, vanity, pride, jealousy, rudeness,
fooling, falseness, laziness and any wrong
behavior. From now on you will have your
hair and nails close-cut, you will wear red
clothes and live pure life”
However health professionals by no means
always obey to moral requirements, not to
mention ethical aspect, that it why in prac-
tice the main rule was formed: do no harm!
Gradually in different countries very similar
legislation was formed which was aimed at
regulation of work of health professionals,
which should stop ethical violations and er-
rors in treatment of patients.
However in healthcare professionals’ activ-
ity there may be not only errors but medical
offence as well.That is why abiding to moral
and ethical standards by health profession-
als means not only fulfilling one’s duties but
also being held liable for failure to fulfill or
non-professional performance of one’s du-
ties.
Depending on the degree of seriousness
of committed offence health professional
is subject to administrative punishment
(admonition, severe admonition, transfer
to a less paid job, and etc.) or is subject
to punishment in accordance with appli-
cable legislation. Thus work with patients
apart from accurate fulfillment of duties by
health professionals assumes abiding to the
principles of medical deontology and legal
liability.
When mutual relationships were capital-
ized the concept of moral was substantially
changed not to mention ethical grounds of
medical treatment. It deprived of halo all
sorts of activities which before that were
considered honorable and were treated with
reverence. Doctors, lawyers, priests, poets,
scientists became paid salaried employees,
which lead to decrease in the level of cri-
teria of moral responsibility among them.
Yet many famous doctors in the world have
urged and urge today not to turn people’s
diseases into means of gaining profit.
There is not doubt that the main deonto-
logical and standard work offences in the
field of medicine are driven by weak morals.
Patients’ sufferings form even deeper feel-
ings of compassion and mercy only in deep-
ly ethic employees. In these events patient
say: “doctor, medical assistant or nurse with
a God-given talent”. In case of immoral
view of life someone else’s sufferings don’t
affect the soul of a medical employee, and
this leads to an even bigger obduracy.This is
the trouble of many employees. And it’s im-
possible to change that with orders. That’s
where delicate work with them is needed,
the work aimed at upbringing ethical stan-
dards.
Work of a health professional is hard work.
The main problem is connected with con-
siderable psycho emotional load. It is es-
pecially hard on responsible employees in
connection with demonstrating by them the
feelings of compassion and mercy. In this
situation ethical upbringing and support of
9
Regional and NMA newsCOLOMBIA
a health professional can not only preserve
his or her psycho emotional status but also
increase his or her spiritual qualities.
That is why it is important for the state
to take care of social conditions and psy-
chological climate of medical personnel.
Support for health professionals may be
in attention to them from administration,
restriction from unneeded administra-
tive tasks, the feeling of care and delicacy
which will correspond to moral and maybe
even ethical criteria of the manager. Work
with personnel not only concerning profes-
sional issues but also studying the basics of
medical ethics can bring up good results in
treating patients and upbringing spiritual
qualities specifically in every individual em-
ployee.
It is a difficult task, which can’t be done by
means of administrative actions only. Of
course testing for compliance to working
with patients could be introduced but it is
not possible because it is very hard to orga-
nize it and there may be serious shortage in
health professionals. At the same time team
strategy has never lead people to ethics and
moral standards as our life shows it’s very
hard for it to contain either.
We need a structural element which in its
nature would be to a much lesser extent
connected with administration. We have a
nonprofit volunteer organization like that.
It is Belarusian Association of Doctors. In
it the work is based on volunteer principle
of assisting each other within the frame-
work of legislation of the state. Special role
has Ethical Commission of the Association,
the aim of which is to support and pro-
tect honor, dignity and professionalism of
health professionals. The basis of work of
this Commission must be moral and ethical
principles.
Belarusian Association of Doctors, remain-
ing an open nonprofit organization, has to
keep to priority membership of best spe-
cialists, employees who adhere to moral and
ethic criteria. The main direction of it work
must be ensuring rights, honor and dignity
protection of its members in the framework
of legislation and ethical rules, support of
improvement of their professional level,
help to the population concerning issues of
mutual relationships between patient and
health professional.
Coordination of work with the Health
Ministry is necessary. For that it is reason-
able to conclude an official agreement with
it concerning format of joint venture stat-
ing clear dividing functions of work with
health professionals in the form of mutual
assistance and support to determine the
structure of contact mechanism and the
rules of its operation. For the purposes of
Association popularization it is advisable
to prepare the organization brochure stat-
ing rights, obligations and main directions
of its activity.
MD, Prof. Vladimir Krylov
MD, Pavel Mikhalevich
According to recent press releases, in 2012
the General System of Social Security
in Health (SGSSS) in Colombia will re-
ceive nearly $43’000.000’000.000 COP
(US $22,052,000,000). In January 2011,
the Congress of the Republic of Colom-
bia passed Law 1438 on Health and So-
cial Security. Under the aegis of this law,
the Colombian government presented the
new POS or Benefits Plan that takes ef-
fect as of 2012 and about which President
Santos stated: “This benefit plan will be uni-
versal, fair, inclusive and comprehensive and
will not exclude any illnesses, meaning that
all Colombians will receive care for all types of
medical conditions since the system that exists
today does not provide care for certain types of
illnesses”. Thus, in his own words, the Presi-
dent recognized the inequity of the current
SGSSS.
Nonethless, and despite the Benefits Plan,
that inequity will continue as long as profit-
based financial intermediaries continue to
manage the private EPS (Health Promot-
ing Entities), which over the past 18 years
have failed in their mission and are unnec-
essary for the operation of the system.Three
examples that clearly demonstrate this fail-
ure are:
• The government handed over
$1’000.000’000.000 COP (US
$513,000,000) to a section of the pub-
lic hospital network to save them from
bankruptcy due to money owed them by
the EPS;
• The government promised but did not
deliver $120.000’000.000 COP (US
$62,000,000) to the national EPS
(Health Promoting Entities) under theSergio Isaza
Is the Colombian Health System
Equitable?
10
Medical Education CZECH REPUBLIC
The unbelievable progress in new technolog-
ical developments represents an important
factor in medical education at all levels.Med-
ical students and young doctors are naturally
amazed by these new technologies. This,
however, may contribute to a certain ten-
dency to dehumanise medicine. The condicio
sine qua non for a good medical educator is to
protect the humanitarian character of medi-
cine. The physician must remain a doctor of
medicine and not an engineer of medicine.
Personalised care should remain the basis of
the patient-to-doctor relationship. In other
words, these new techniques, however es-
sential they may be for the patient, must not
distract physicians from this basic obligation,
which is expected by their patients.
The doctor-to-patient attitude is also
changing in the sense that patients are be-
coming more and more informed and re-
quire more solid information about diseases,
diagnostics and therapeutic measures.These
patients’ needs must be taken into account
in medical education at all levels.
Reforming pre-graduate medical educa-
tion is a continuous process. These reforms Jaroslav Blahos
The Education of Medicine in the
Czech Republic
Subsidized Regime (CAPRECOM) and
directly paid some hospitals in the pub-
lic network part of what the EPS owed
them, for fear that the money would dis-
appear,as had already happened.Thus,the
Department of Health will hand over the
money directly to the hospitals through a
mandated trustee;
• Since the start of Law 100, social security
in health care for the Colombian Con-
gress, national military forces, Ecopetrol,
and the public school teachers is provided
through a special regime that works di-
rectly, without discriminatory plans and
without using the EPS as an intermedi-
ary.
With the eruption of the bankruptcy scan-
dal of the SGSSS,it came to light that many
private EPS were misappropriating a large
part of the health funding to increase their
revenues and using these funds for profit-
making activities other than health care
(private building projects, luxury hotels, golf
courses, sports teams, capital export and in-
vestment, support for political campaigns,
etc.).Furthermore,the public EPS under the
Subsidized Regime has been used to sup-
port political campaigns for local politicians.
Despite all this, the government persists in
maintaining the intermediary system.
In terms of the medical profession, article
105 of Law 1438 defines medical autonomy
as “the guarantee that a health professional
may freely issue his professional opinion
in regard to the quality care and treatment
of his patients,applying the standards,prin-
ciples and values that govern the practice
of his profession, and the right to give his
opinion on medical conditions and their
respective treatments”. By definition,
therefore, medical professional autonomy
implies the capacity to act and resolve med-
ical problems based on scientific knowl-
edge and is not in any way limited solely
to stating an opinion. Clearly, the medical
professional autonomy of Colombian doc-
tors has disappeared by operation of the law
and therefore,the very decisions and actions
of the medical profession have also become
subject to the whim of the financial entities
of the SGSSS.
Colombian doctors have advocated for the
need to change the Health System and to
structure it in order to guarantee the pa-
tient the Fundamental Right to Heath. The
current system is designed on the basis of
economic production and profit-seeking
private financial intermediation. As long
as this structure continues, the intention of
Law 1438 to develop a basic health care sys-
tem will only result in another failure.
Given that this deficient structure under-
mines the development of proper training,
skills and professional education, we sup-
port work stability without intermediaries
and continuing education for members of
the system to provide comprehensive and
quality care and ensure the security of pa-
tients.
Let us remember: the “Benefit Plan” is not
the health care system; it is only one of its
components. The equity of the system is
ensured by the structure of the system to-
gether with all of its components.
Dr. Sergio Isaza,
President, FMC (Federacion
Medica Colombiana)
11
Medical EducationUZBEKISTAN
include organisational as well as structural
changes. In some of the medical schools in
the Czech Republic, a new curriculum sys-
tem has been introduced to combine the ba-
sic and clinical sciences. This system seems
very logical yet requires very detailed coor-
dination of teachers and departments. It is
uncertain whether this integrated system
leads to better results than the “classical”
system,which was based on a separation be-
tween the basic sciences, taught in the first
two years, and the clinical sciences, which
were taught afterwards.
However, new educational methods and
techniques, like the use of telemedicine
and the Internet, may shed a new light on
and broaden educational horizons. What-
ever system is used, new knowledge will
have to be incorporated in the curriculum,
such as new systems based on evidence,
new methods of medical statistics, socio-
economic factors, legal aspects of medical
practice and a basic knowledge of health-
care systems in other countries.
An integral part of pre-graduate education
should be research that will ensure that
the student is acquainted with this kind of
emerging medical work and learns to deal
with medical literature, publication tech-
niques and related issues.
Continuing Medical Education (CME)-
life-long learning-is mandatory in the
Czech Republic. This is understandable
given that 50% of medical science and tech-
nology changes every five to seven years. As
mentioned above,CME includes both parts
of medicine, from knowledge, techniques
and skill to ethical and personal attitudes.
A  30-year-old specialist without CME is
no specialist at 50.
CME in the Czech Republic is managed
and supervised by the Medical Associa-
tion, the Medical Chamber, the Ministry
of Health and the Institute for Postgradu-
ate Medicine Education. The system of
credit points has been taken as a model for
assessment. The CME in the future will
have to reflect the enormous explosion of
knowledge. It will not be easy to find the
most suitable method to educate physi-
cians, as it will have to enable them to gain,
retain and use new knowledge rapidly. The
courses led by teachers will be comple-
mentary to Internet education, rather than
the other way around. The same will prob-
ably happen with seminars, symposia and
congresses. The era of telemedicine is ap-
proaching, with all its unforeseeable tech-
nical advances. A good doctor, however,
must always find adequate time to main-
tain a personal, friendly and relaxed atti-
tude towards his patient.
The next WMA Council will meet in
Prague, April 26–28, 2012. One of the top-
ics proposed by the CzMA will be to co-
ordinate the activities of The World Health
Professions Alliance (www.whpa.org) in the
Czech Republic, namely targeting tobacco
smoking, the need for a holistic approach
to health care, and the social determinants
of health and other cultural, environmental
and economic factors, with special attention
to the elderly.
Professor Jaroslav Blahos,
President Czech Medical Association
former President World Medical
Association (WMA)
In modern society physicians’ skills upgrading
through continuous education has become es-
sential. Consequently, it is a topical issue for
public health service in the whole world. We
analyse the situation in professional skills im-
provement and describe the latest developments
in Uzbekistan where for the first time the mod-
ern form of distance learning for physicians has
been introduced.
Introduction. Acquisition of medical
knowledge and professional development
should be an ongoing process with any prac-
tising physician and done through continu-
ous medical education (CME). Alongside
with improvement of professional skills and
self-education of physicians CME includes
raising of patients’ health awareness [1, 3].
Fast changes in medical practice demand
from physicians a constant improvement of
their professional skills. Some North Amer-
ican research has revealed the expressed in-
verse relationship between the medical expe-
rience and the level of knowledge, as well as
the diagnostic and the medical skills. Physi-
cians possess the best clinical skills right af-
ter the internship [5, 6]. Attending courses
on improvement of professional skills have
proved to be relatively ineffective and ac-
tually does not prevent gradual decrease in
professional qualification of physicians [7].
In the developed countries paid short-term
courses within the framework of the sys-
tem for continuous medical education are
offered to physicians for training them to
pass examinations required for granting
a license. A widespread form of improv-
ing physicians’ skills with subsequent li-
censing is training by using the so-called
transcription programmes which are pub-
lished in journals of various medical as-
Continuous Medical Education: Physicians’ Professional Skills
Improvement by Distance Learning
12
Medical Education UZBEKISTAN
sociations, accredited for CME. The given
programmes are a kind of distance learning
[4] described, for example, in the Journal
of the American Academy of Dermato-
logy. In Uzbekistan improvement of profes-
sional skills of medical workers is possible
in two ways – by means of direct training
(through educational programmes), and in-
direct training (no educational programmes
involved as a rule).
Direct training includes a programme for
general and thematic improvement of pro-
fessional skills (upgrading). The indirect
way embraces the following forms: on-the-
job training; distance learning; self-educa-
tion; exchange of experience; participation
in seminars, congresses and conferences;
courses on the development of information
technology [2].
Distance learning as an indirect form of
professional skills upgrading is based on
information-communication technologies,
applied for in-service training in various
forms (case studies, on-line asynchronous
and synchronous media, etc.). Distance
learning can be carried out as an indepen-
dent form of improving professional skills
according to the respective programme or
bringing it closer to the customary face-to-
face learning. Duration of a course and its
structure depend on the programme and the
respective tutor; the course duration might
exceed the academic term. Acquiring of
new knowledge is monitored by TashIUV,
TashFarMI and a certificate is issued after a
successful completion of the distance learn-
ing course; a sample of it in [2].
Distance learning of physicians is a per-
spective method for professional training
and improving professional skills in medi-
cine [3]. Participants in CME and distance
learning are practicing physicians as this
method features a number of advantages,
e.g. they needn’t leave their families and
home, their medical institutions and pa-
tients [8].
Research objective: Study effective and
approved methods of post-degree medical
education in the developed countries of the
world and introduce them in Uzbekistan.
Materials and methods: More than 70 000
physicians work in the Republic of Uzbeki-
stan. Every five years each of them has to
participate in a qualification upgrading
course,covering 288 hours,and be conferred
a respective sertificate. Implementation of
Resolution of the Cabinet of Ministers of
the Republic of Uzbekistan No 319 “On
Improvement of the Retraining System
and Professional Skills of Medical Doctors
in the Republic of Uzbekistan” of 18 De-
cember, 2009, is assigned to the Tashkent
Institute of Qualification Improvement of
Physicians.
Analysing the reasons for physicians in Uz-
bekistan neglecting the traditional methods
for upgrading professional skills the follow-
ing factors can be singled out: unwillingness
to leave the family and home, as well as the
medical institutions and patients, shifting
the workload to the colleagues, the travel
expenses, accommodation and sustenance
costs in another city.
To introduce modern training methods in
2010 an agreement was made for physicians
becoming readers of the periodic journal
“Bulletin of the Medical Association of
Uzbekistan”; the certificate form has been
approved as well.
The Medical Association of Uzbekistan
together with the Tashkent Institute of
Qualification Improvement of Physicians
develop curricula of distance learning. In
2010–2011 in the “Bulletin of the Medi-
cal Association of Uzbekistan” nine cur-
ricula on the following themes have been
published: the public health situation in
Uzbekistan; stenocardia; current problems
in oncology; valueology, the study on the
formation of a healthy person; discirculato-
ry venous encephalopathy: diagnostics and
treatment problems; dysphagy; changes in
the organism and uncomfortable sensations
of the woman during pregnancy; modern
approach to food for children in the first
year of life; the basic directions for improv-
ing the outpatient clinic performance in
the Republic of Uzbekistan. The curricula
are developed taking into account the latest
achievements in medicine and targeted at
specialists in various fields.
Results and analysis. Each curriculum
contains in paper format 16–20 tests of
Abdulla Khudaybergenov Zokhid Abdurakhimov
13
GEORGIA Palliative Care
different complexity and three choice
answers for the task. After completion
of the tests they are sent to the “Bulletin
of Medical Association of Uzbekistan”
within 6 months after the publication of
the respective Bulletin edition. In case
correct answers exceed 60% a certificate
on distance learning (18 hours course) is
conferred.
In 2010 the certificate was conferred to 140
physicians, in 2011 – to 112 physicians for
doing the tests published in three issues
of the Bulletin. In total in 2010–2011 the
Medical Association of Uzbekistan received
302 completed tests, 252 physicians re-
ceived the certificate, it making 83 % of all
the submitted tests.
Thus, the physicians’professional skills have
been improved without leaving home and
interest in the “Bulletin of Medical Asso-
ciation of Uzbekistan” has been growing as
its circulation increased twice in 2011.
Conclusions. In the present-day situation
we should develop effective methods of
postgraduate education that have already
been approved in the developed countries
of the world.
Improvement of professional skills through
distance learning allows knowledge upgrad-
ing and retraining of physicians without leav-
ing their medical institutions and patients,as
well as saves the incurred expenses of travel,
accommodation and sustenance costs.
References
1. Order of the Ministry of Health of the Repub-
lic of Uzbekistan No 505 “On Improvement of
the Retraining System and Professional Skills of
Medical Doctors in the Republic of Uzbekistan”
of 14 November, 2006 .
2. Resolution of the Cabinet of Ministers of the
Republic of Uzbekistan No 319 “On Improve-
ment of the Retraining System and Professional
Skills of Medical Doctors in the Republic of Uz-
bekistan” of 18 December, 2009.
3. Tselujko VJ. The form of postgraduate medi-
cal education – distance learning via journal is
something new. Liki Ukraini 2010; 5 (141): 6–7.
4. Korotkov Y, Stuleva T. About certification and
licensing abroad. Physician. 1995; 4: 2–3.
5. Evans CE,Haynes RB,Gilbert JR et al.An edu-
cational package on hypertension for primary
care physicians: Older physicians benefit most.
Can Med Assoc J. 1984; 130: 719.
6. McCauley RG, Paul WM, Morrison GH et al.
Results of 5 years of peer assessment of physi-
cian’s office practices by the College of Physi-
cians and Surgeons of Ontario. Can Med Assoc
J. 1990; 84:162.
7. Davis DA, Thomson MA, Oxman AD, Haynes
RB.Changing physician performance.A system-
atic review of the effect of continuing medical
education strategies. JAMA. 1995; 274: 700-705.
8. Grant J. The Flexible Use of Distance Learning
in a Professional Context: the Medical Experi-
ence. In:Distance Education Futures, ed. Ted
Nunan, 1993, pp. 309-329.
Dr. Abdulla Khudaybergenov,
Dr. Zokhid Abdurakhimov,
Medical Association of Uzbekistan
Georgian Experience in Palliative Care Development –
From Pilot Programs to International Collaboration
Tamar Lobzhanidze Gia Lobzhanidze Zaza Khachiperadze Dimitri Kordzaia
Approximately 42,000 deaths are registered
annually in Georgia, which has a population
of 4.5 million. Based on international data,
approx. 60% of these terminal patients (or
25,000) require palliative care and pain relief.
Given that at least two family members are
involved in caring for each terminal patient,
palliative care services can significantly im-
pact approximately 75,000 people each year,
including both patients and caregivers  [1].
During recent years in Georgia, through
collaboration between Governmental In-
stitutions and NGOs (including Interna-
tional Organizations), the basis for the de-
velopment of Palliative Care as an integral
14
Palliative Care GEORGIA
part of the National Healthcare System
was created. All activities were performed
in accordance with WHO experts’ recom-
mendations for the integrated develop-
ment of “Education”, “Drug Availability”
and “Services Implementation” under the
united umbrella of “Governmental Policy”
(Figure 1).
In the period between 2002 and 2011 the
following results were achieved:
• Establishment of Palliative Care educa-
tional materials in the Georgian language;
• Creation of Palliative Care educational
programs and their implementation
in Medical Universities and Nursing
Schools;
• Preparation and implementation of Pal-
liative Care CME accredited programs;
• Training of medical professionals expe-
rienced in Palliative Care, including two
international fellows (experts);
• Preparation of Video/TV and printed
materials for public education and aware-
ness;
• Improvement of legislative/normative
standards regulating Palliative Care and
Drug Availability, and promotion of the
incorporation of Palliative Care in the
National Healthcare system;
• Organization of hospices (in-patients
units for Palliative care) and their finan-
cial support from the governmental bud-
get;
• Organization of Home-Based Palliative
Care Teams and their financial support
from the governmental budget;
In 2009-2010 under the leadership of the
Georgian National Association for Pallia-
tive Care, a group of authors developed the
Georgian National Program for Palliative
Care [2].The Program was approved by the
Georgian Parliament’s Healthcare and So-
cial Issues Committee in July 2010.
Despite of the fact that current palliative
care services cover less than 15 % of the
needs of the population, and geriatric and
pediatric palliative care are still absent (Fig-
ure 2), given the relatively short history of
its development, the Georgian experience is
evaluated by international experts as one of
the most successful Palliative Care models
among post-Soviet countries.
To share Georgia’s knowledge and expe-
rience in Palliative Care, site trainings of
foreign healthcare professionals in Geor-
gia’s capitol, Tbilisi, began in 2011. The
first request for cooperation was received
from the former Soviet countries of Ta-
jikistan and Kyrgyzstan.The trainings were
conducted by the support of Open Society
Foundations (OSFs) – the New York office
(Ms.  Mary Callaway) and the Open So-
ciety Georgia Foundation (Irma Khabazi,
Nino Kiknadze) – and the Soros founda-
tions in Tajikistan (Nigora Abidjanova)
and in Kyrgyzstan (Aibek Mukambetov).
The Palliative Care Service of the National
Cancer Center (PCSNCC), which in-
cludes an in-patient unit with 15 hospital
beds, home-based Palliative Care services,
and consulting services, was selected as the
site for the international training programs.
PCSNCC provides emotional support to
patients and family members, guides and
advises them during cancer treatments,
and continues to support them after treat-
ment. PCSNCC also provides home care
services in Tbilisi, as well as Kutaisi, Telavi
and Zugdidi. All physicians of the PC-
SNCC are well-trained to identify and re-
S
i
t
u
a
t
i
o
n
O
u
t
c
o
m
e
s
Policy
Education
Drug
Availability
Implementation
Figure 1.
Palliative
Care
Pediatric Geriatric
Cancer AIDS TBNeurology
< 15% Figure 2. 15 Palliative CareGEORGIA lieve physical and psychological symptoms of disease, and provide psychological and spiritual support. PCSNCC collaborates with numerous national and international organizations working in the fields of practice, education and research related to palliative care and clinical oncology. It is also the clinical af- filiate of the Iv. Javakhishvili Tbilisi State University (TSU), actively working with medical students, nursing students, resi- dents, and general practitioners. Since 2011, the PCSNCC has been accredited as a Pal- liative Care and Oncology integrated centre (ESMO designated centre). PCSNCC cooperates closely with the Palli- ative Care National Coordinator’s Office of the Parliament of Georgia in advocating for the development of a national strategic plan for palliative care throughout the country, according the above-mentioned Georgian National Program for Palliative Care [2]. An educational/training program for healthcare professionals from Middle Asia was led by Georgian Academy of Pallia- tive Care – Educational Training Resource Centre (GAPC). GAPC was branched from the Georgian National Association for Palliative Care (GNAPC) for better coor- dination of educational/training programs and research activities in different fields of palliative care on the national and/or inter- national levels. The two-week pilot programs (bedside training courses) were conducted for four colleagues from Tajikistan in July 2011 and two colleagues from Kyrgyzstan in Au- gust 2011. These programs included the key topics in Palliative Care: essence of pain, evaluation of pain in advanced can- cer patients, pain management by opioids administration, evaluation and manage- ment of delirium, nausea, vomiting, ascities, breathlessness, etc. All participants worked with experienced medical staff under the supervision of Dr. Rukhadze – the head of PCSNCC and founder of GAPC, who at- tended three years of specialty training at the Institute of Palliative Medicine & San Diego Hospice (California, USA). After successfully passing exams at the end of the training courses, participants received cer- tificates confirming their skills and knowl- edge. The trainings were considered a suc- cess and at the end of 2011, it was decided that the project would be continued in 2012 and include 18–20 participants from Mid- dle Asian Countries. As illustrated in the model provided by J. Stjernsward (Figure 3), we can offer fully sufficient education and training programs in Palliative Care for GPs and Oncologists from post-Soviet countries. At the same time we are realizing that the optimal ap- proach to training in Palliative Care is should occur across the broad spectrum of stakeholders. References: 1. Jan Stjernsward. Georgia National Palliative Care Programm, Report, 2005 2. http://www.parliament.ge/files/619_8111_ 336972_Paliativi-Eng.pdf 3. Georgian National Program for Palliative Care (Action Plan – 2011-2015), 2010 http://www.parliament.ge/files/janmrteloba/ paliatiuri/pc-nat-2011-2015-en.pdf 4. Jan Stjernsward: Ind.J.PallCare, 2005, Decem- ber 2005 ,11,2: 52-58, and June 2005 MD, PhD Tamar Rukhadze, Georgian National Association for Palliative Care ; MD, PhD Gia Lobjanidze, President of Georgian Medical Association; MD Zaza Khachiperadze, Georgian Medical Association; MD, PhD Dimitri Kordzaia, Georgian National Association for Palliative Care; Tbilisi, Georgia PC specialists (experts) Oncologists GPs Society Figure 3. The Community Approach-Necessary to Achieve Palliative Care for All 16 BELGIUMEvidence Based Medicine When Claude Bernard and others intro- duced experimental medicine, they did not fundamentally upset the knowledge of the time from one day to the other; neither did they reform the way to take care of patients. What they brought in is a method which allowed reaching a better level of certainty in the matter of knowledge and,above all,to get the information in a faster way. But the acquisition of knowledge was still based on former data, since they were verified by ex- perimentation. A huge step had been taken, though, and progress was on its way. Experimental research allows going further and deeper into the understanding of pro- cesses, finding remedies which have a more and more accurate effect on them while re- straining their consequences on vital phe- nomena which are not concerned (side ef- fects). The action on identified risk factors has been clearly evidenced. Yet, our societies have added other require- ments to efficiency: security, which is very legitimate, and one more which we have to deal with: the relationship between the cost of treatment and the expected benefit for a group of patients (the individual patient has never been taken into account). From this point of view, researchers have been lead to ask themselves two questions: • Does the correction of one factor really have the expected effect on, on one hand, reducing the risk and, on the second hand, the chances to survive? • Doesn’t a preventive or curative treatment of a given pathology cause more dreadful complications? Large studies have been launched. The re- sulting knowledge has been summarized and EBM arose from it. The promoters of that synthesis imagined they would come up with a helping tool for medical deci- sions. Collective experience adds itself as a tool to personal experience and medi- cal experimentation. The instigators of the project never imagined that they brought in a change of paradigm for financiers. Since the very beginning, physicians have always taken their decisions in a state of uncertain- ty. EBM was meant to reduce the degree of uncertainty.Besides,its developers have also established levels of evidence according to the degree of certainty. Now one could believe, though, that what bears the EBM trademark is secure, the only medication to be authorized for pre- scription and that what doesn’t belong to EBM is definitely discarded. Those who prescribe non-EBM medications should thus be strongly disapproved. Such a dualistic attitude is not acceptable for a scientific mind. The highest degree of evidence in EBM is meta-analysis. By col- ligating all the studies that were undertaken on a given subject, it really does have the benefit of reducing uncertainty, but with- out granting the degree of evidence. In the Middle-Ages, three hear-says were consid- ered an evidence. Will we now admit that three studies amount to evidence? The questions these studies try to answer are different most of the time.The conditions of the studies, the surveyed patients and, most of all, the results are not homogeneous. How is it possible to make certainties when, most of the times, they rely on facts that stand no comparison? The resulting agreements have two short- ages: • Sometimes they do not stand for any- body’s opinion but are the mean of dif- ferent opinions. • They are an instant picture of a constantly evolving knowledge on a given subject. They can become obsolete as soon as they are established. As for experts’recommendations,EBM itself places them at the lowest level of the scale. They can be useful but only if there exist no more evidential elements. Yet, it is on the base of experts’ opinions that the authorities produce guidelines for prescription which have nothing to do with a help for making decisions but are imposed like some sort of revelation which,when not followed,exposes a practitioner to disciplinary measures. The Church itself has no longer such power. Conclusions : It is obvious that EBM reduces uncertain- ty and provides a helping tool for making medical decisions. But it is absolutely not a revolution which implies to sweep away individual experience, which remains an important element of the decisional process. EBM has not yet proven that individual experience and experimental medicine are tools that belong to the past. EBM is based on statistics.These are estab- lished by discarding bad cases like multiple Roland Lemye EBM (Evidence Based Medicine), not an Absolute Reference but a Help for Making Decisions 17 Antimicrobial ResistanceSWEDEN Recently I met my president-colleagues from the other Nordic medical associations. We meet twice a year to discuss current is- sues relating to political and professional developments in the Nordic countries. It is staggering to realize how dependent we are on international cooperation when it comes to issues such as the spread of infections, pharmaceutical chemicals in the environ- ment, and political trends. In our informa- tion-intense societies, healthcare trends are rapidly moving across borders and will be observed and also used by our governments. It is therefore essential to share experiences with colleagues across borders. One such issue we discussed is antimicro- bial resistance, which is climbing on the EU-agenda. Antimicrobial resistant bacte- ria does not respect borders between profes- sions nor does it recognize national borders. In Sweden there is a network called Strama (the Swedish strategic programme against antimicrobial resistance), which coordinates activities across sectors to maintain antibi- otics as a strong tool both for humans and animals. In November 2011 the EU-commission revealed an action plan for antimicrobial resistance with 12 actions for the next five years. A basic requirement for preventing antimicrobial resistance is monitoring and surveillance of the use of antibiotics in hu- man and animal medicine. Since Denmark holds the Presidency of the Council of the European Union during the first half of 2012, they will prepare a common strat- egy on preventing antimicrobial resistance. There will be a conference the 14-15 of March in Copenhagen on the issue, with the hope that conclusions from the confer- ence will be adopted by the Council of the European Union. The Danish Medical Association, which is working closely with the Danish Vet- erinary Association, would like to see two main conclusions from the conference. The first one is that all antibiotics used should be prescribed by a doctor or a veterinarian. The second one is that neither doctors nor veterinarians should be allowed to sell an- tibiotics, as this ability creates the wrong incentive. They would also like to share the Scandinavian model on combating antimi- crobial resistance with other EU-countries. Since about two-thirds of the antibiotics in Denmark are used in the agricultural sector, strong cooperation with the veterinarians is crucial. Antimicrobial resistance is a growing health problem. The EU-commission states that about 25,000 patients die per year in the EU from infections caused by drug resis- tant bacteria. We need to create awareness among patients and doctors about the risk of using antibiotics and the actions that must be taken. Doctors and veterinarians must show professionalism and present a common strategy for the use of antibiot- ics – a strategy that should include ethical considerations. If doctors and veterinarians fail to lead the development in the right direction on issues such as antimicrobial resistance, pharma- ceutical chemicals in the environment, and the health effects of climate change, we face an overwhelming risk of losing our best tools for treatment as well as the trust of the general public. Dr. Marie Wedin, The Swedish Medical Association Marie Wedin Combating Antimicrobial Resistance pathologies, which means most of the cases general practitioners see every day. Statistics appeal to populations, GPs to individuals. While EBM does give some answers, these are two few compared to the infinite field of questions. A physician has to help a pa- tient even if EBM provides no answer. A physician has to keep on looking for solu- tions if a patient has been treated according to EBM and the treatment failed. EBM is always outdated when it comes to medical field knowledge. Until now, EBM has failed to obtain a better care for all risk popula- tions like diabetics, people with overweight, high blood pressure, hypercholesterolemia etc, which grow exponentially and are un- dertreated. EBM has diverted from its purpose of being a help for making decisions and became a rationing and control instrument. EBM’s greatest achievement has been to help governments control their expenses. EBM has in no way fought against “ magic thinking  “. Some social insurances, while advocating prescriptions submitted to EBM, do not mind refunding homeopathic prescriptions which have never been vali- dated by EBM. Dr. Roland Lemye, des Syndicats Medicaux President Association Belge 18 Public Health Public health strives to put into place con- ditions in which people can live healthy and productive lives. The cornerstones of these efforts are disease/injury prevention and health promotion and protection. In- deed, the steps necessary for people and their communities to be healthy, productive, and resilient starts long before they require medical treatment. Public health begins in the places where people live, learn, and work; in other words, in their families and communities. It takes into account that the health of a population is influenced by more than the health care system. The structural and social determinants of health encom- pass a wide range of factors,including polit- ical, social, economic, physical and techni- cal environments, personal health practices, individual capacity, coping skills, human biology, genetics, early childhood develop- ment, life circumstances, income, education, gender and ethnicity. Public health seeks to mitigate preventable disease burdens along with their associated financial and social costs. The World Federation of Public Health Associations (WFPHA) is the global civil society organization representing the inter- ests of the world’s public health community. Created in 1967, the WFPHA currently counts as a member of over 60 national and regional public health associations, as well as regional associations of schools of public health and several academic, health-orient- ed institutions/organizations that share the Federation’s mission and values (the right to health for all; social justice; diversity and inclusion, partnership and ethical conduct). Cumulatively, the WFPHA represents a voluntary membership community of over 250,000 public health professionals, re- searchers and practitioners. The WFPHA advocates for a strong civil society voice, the active participation of national public health associations, allied groups in national and global discussions and decision-shaping around public health policy and practice. Over the past 44 years, the WFPHA has played a leadership role in global public health. In terms of global health advocacy, the Federation has produced over 40 reso- lutions, declarations and position papers. These policy statements cover a variety of topics, including the relationship between climate change and environmental health, conflict/peace and health, globalized trade and public health, as well as tobacco con- trol, health systems sustainability, univer- sal and equitable access to primary health care services, health human resources, and the prevention of infectious and non-com- municable diseases. In 2010, the WFPHA passed an innovative resolution calling for a comprehensive and equitable approach to the health of people incarcerated in prisons and other detention centers. The Federa- tion has used these position statements to educate and advocate for stronger, more effective public health policies and strate- gies at the global level, through the World Health Organization and other multilateral organizations. Many WFPHA member as- sociations have used these positions as in- struments to support public health policy advocacy efforts in their own countries. They have also formed the evidence base for presentations and statements by WF- PHA representatives at international and national conferences. In recent years, the Federation has focused its advocacy on health equity. At its trien- nial World Congress on Public Health held in 2009 in Istanbul (Turkey), the WFPHA highlighted its commitment to the issue of Health as a Human Right for All. Through the Istanbul Declaration, the Federation re- affirmed the definition of health as a pub- lic good and the principles of solidarity, sustainability, morality, justice, equity, fair- ness and tolerance as fundamental under- pinnings of all public health policies and practices. Global health equity is the theme of the Federation’s 13th World Congress The World Federation of Public Health Association Representing the Global Civil Society Voice for Public Health and Health Equity James Chauvin Laetitia Rispel Deborah Klein Walker Bettina Borisch 19 Public Health on Public Health, which takes place April 23–27, 2012 in Addis Ababa (Ethiopia), hosted by the Ethiopian Public Health As- sociation. The Federation has helped to build the ca- pacity of national and regional public health associations around the world. Over the past 25 years, through the efforts of several WFPHA member associations, such as the Canadian Public Health Association, the European Public Health Association and the American Public Health Association, the organizational and programmatic ca- pacity of new and emerging public health associations in low- and middle-income countries and countries in political transi- tion have been strengthened. Over the past quarter century, over 30 national public health associations have been created and become active members of the WFPHA and, in turn, have acted as mentors to other emerging national PHAs. This growing number of public health associations has enhanced the Federation’s effectiveness as a global health advocate. One of the more recent testaments to the growing importance of the public health movement was the establishment in August 2011 of the African Federation of Public Health Associations, through the combined efforts of over two dozen national PHAs on the African continent. The WFPHA collaborates closely with the AFPHA, as it does with the European Public Health As- sociation and the emerging networks of na- tional PHAs in the Asia Pacific region and Latin America, to advance action on prior- ity global public health issues and build a strong collective civil society voice for pub- lic health. The policy influence and public health pro- gramming impact of national public health associations is impressive. Several PHAs have played leadership roles in tobacco con- trol by influencing the decisions of national governments to ratify and apply locally the Framework Convention on Tobacco Con- trol (FCTC), which was the world’s first public health treaty. Others have focused their efforts on public health education and training, the expansion and quality of access to public health services, such as immuni- zation, water supply sanitation, maternal- newborn and child health services, the pre- vention and control of both infectious and non-communicable diseases, the prevention and treatment of HIV and AIDS, and ac- cess to essential medicines. Some of the PHAs have become strong advocates for a social determinants approach to achieving health and health equity. The WFPHA looks forward to contribut- ing, in an effective and productive manner, to achieving health equity for all. Over the next few years, the Federation will review and refine its organizational strategic plan to advance public health practice,education, training and research and help facilitate and support efforts to improve the organization- al and programmatic capacity of national PHAs. The WFPHA intends to expand and strengthen its partnerships with orga- nizations such as the World Medical As- sociation and other civil society movements that share our values. It will also enhance its advocacy capacity to shape global public health policies and strategies through more pro-active participation in future World Health Assemblies, the development and dissemination of bold position statements on issues that affect the public’s health and visibility through participation in global and regional conferences and events. In partnership with other global federations and associations and in support of a strong leadership role for the World Health Or- ganization, the World Federation of Public Health Associations will continue to make its mark helping put into place the condi- tions and opportunities for people and their communities to be healthy, productive and resilient. James Chauvin, Director of Policy/Canadian Public Health Association and Vice-President & President-Elect/World Federation of Public Health Associations (WFPHA) Laetitia Rispel, Dean/Witwatersrand University School of Public Health (South Africa) and member of WFPHA Executive Board and Global Health Equity Working Group Deborah Klein Walker, Vice-President and Senior Fellow/ Abt Associates (USA) and member of WFPHA Advisory Board and Global Health Equity Working Group Bettina Borisch, Professor, Department of Social Medicine/University of Geneva and Head of the WFPHA Geneva Office and member of WFPHA Global Health Equity Working Group Ulrich Laaser, Professor, School of Public Health/ University of Bielefeld (Germany) and WFPHA President Ulrich Laaser 20 Regional and NMA news The global context For any professional association working in the medical field, it is very important to be globally present and make sure that the in- terests of the profession, and in particular the interests of the public, are well repre- sented, promoted and defended at an inter- national level. The reason that associations and institu- tions federate locally, nationally, regionally and internationally is that they believe that joining forces with like-minded associations at each level gives them a better chance of achieving their goals. It means they can dis- cuss, debate, sometimes dispute, and gener- ally arrive at some kind of compromise to move forward. For our colleagues, it is sometimes difficult to understandthereasonsbehindtheexistenceof certain international organizations and what they do beyond that which a regional,national or even local organization can achieve. Dentistry and dental medicine have always been one of the best organized professions around the world at the national level. World Dental Federation (FDI) was set up over 110 years ago as a forum for dentists globally to share views and experiences to- gether. Its continued existence today implicitly recognizes that the profession needs an in- ternational voice to defend its positions and promote its views. Let me give you three examples: 1) A focus on prevention As we all know, teeth have a vital function in the human body: healthy teeth are a vital part of human health. Caring for teeth and oral health is essential for a healthy popu- lation. Tooth decay and periodontal (bone and gum) disease currently affect 90% of people around the world. With limited funds available for restorative care in many countries, an essential part of FDI’s work is to raise awareness of the im- portance of oral health and focus its proj- ects and activities on prevention strategies. This, for example, is the key message of the landmark Global Caries Initiative, GCI for short. The GCI vision is to improve oral health through the implementation of a new para- digm for managing dental caries and their consequences – a paradigm that is based on our current knowledge of the disease pro- cess and its prevention, so as to deliver op- timal oral and thus general health and well being to all peoples. In practice, the goal is to achieve a paradigm shift from the restor- ative to the preventive model of oral care. FDI launched the GCI in 2009, with some very concrete priorities and actions: • Eradicate very early childhood caries in children 0–3 years of age by 2020 • Carry out primary and secondary preven- tion and health promotion activities • Achieve consensus on terminology FDI was joined in its efforts by founding partners Colgate, GlaxoSmithKline, Proc- tor and Gamble Oral health, Unilever and Wrigley. The aim was to establish a broad alliance of key influencers and decision- makers from research, education, clinical practice, public health, government and industry, partnering in a common goal: to to achieve the 2020 goal by effecting funda- mental change in health systems and indi- vidual behaviour. The GCI’s first task was to design and de- velop a prevention-oriented caries classifi- cation and management system (CCMS), thereby laying the foundation for the pre- ventive model of caries management. It is now in the process of developing an over- arching Global Oral Health Improvement Matrix (GOHIM) to integrate oral health into health, thereby establishing a collab- orative, prevention-oriented model of oral health care. It is precisely this preventive model of care that FDI is advocating, along with professional partners, within the con- text of the global fight against noncommu- nicable diseases. 2) Oral health and noncommunicable diseases (NCDs) It is now time to admit that viewing oral health as somehow separate from general health is truly obsolete, and nowhere is the indisputable relationship between the two better illustrated than in the area of NCDs, or chronic diseases as they are sometimes known. NCDs, which include cardiovascular disease, cancer,chronic respiratory disease and diabe- tes, among others, are responsible for 60% of deaths worldwide: in 2008,36 million people died from NCDs, around 80% of them in low to medium income countries. Orlando Monteiro da Silva A Globalized World – and a Unified Global Approach for Health Professions 21 Regional and NMA news With this in mind,FDI undertook a project to develop a practical tool to help in the fight against NCDs, the NCD toolkit. It carried out the work on behalf of the WHPA World Health Professions Alliance-representing well over 20 million health professionals worldwide, including dentists, physicians, physical therapists, pharmacists and nurses The Toolkit was funded by the International Federation of Pharmaceutical Manufactur- ers and Associations. The Toolkit focuses on common risk fac- tors-poor diet, physical inactivity, smoking and alcohol abuse-and includes a ‘Health Improvement Card’ for the individual to assess personal risk, in consultation with a health professional. The Toolkit also con- tains support materials for the health pro- fessional as well as for the patient, together with advice on how to reduce or eliminate certain risk behaviours. Naturally, some people have asked why FDI and ‘dentistry’ agreed to lead the WHPA project: after all, oral diseases do not ac- count for high death rates. There are two main reasons: • Neglected NCDs such as tooth decay and periodontal disease affect more than 90% of the world’s population and have an enormous impact on health; • There is increasing association and sci- entific evidence between the presence of oral conditions (especially periodontal disease) and systemic diseases, including cardiovascular and cerebrovascular dis- eases, adverse pregnancy outcomes, dia- betes mellitus, pulmonary infections and different forms of cancer. Furthermore, it is my view that that the dental profession, and dental medicine in general, should have a much broader am- bition. Within the medical sphere, the various fields of education, prevention, diagnosis, treatment and rehabilitation are becoming increasingly interrelated. Equal- ly, relations between dental medicine and medicine in general, as well as other fields such as nutrition, psychology and sociol- ogy, are growing. Indeed, dental practitioners are in a unique position when it comes to detecting risk factors. They are one of the few medical professions to see patients who are not ac- tually ill but just there for a check-up. Fur- thermore, many behaviours are immediately visible during the course of a dental check- up, so dentists are well positioned to initiate discussion on risks. FDI’s next move will be to field test the WHPA Toolkit in one or two key develop- ing countries to assess how well it integrates into health strategy and its methods of use by health professionals. On a wider level, FDI is now looking to establish the Global Oral Health Partner- ship (GOHP). This is envisaged as a multi- stakeholder partnership to address the NCD burden with a special responsibility for oral diseases: dental caries, periodontal disease and oral cancer.The GOHP’s objec- tive is to provide strategic leadership to co- ordinate and synergize policy, strategy and programmes within a common stakeholder framework. This will enable the implemen- tation of a model of oral health care based on health promotion,disease prevention and preventive disease management worldwide. 3) Oral health and development The major contribution to the NCD Toolkit and the associated WHPA NCD campaign project allowed FDI-along with a number of other agencies and groupings working in the field of oral health-to achieve an impor- tant goal: to have oral disease specifically referenced in the Political Declaration of the United Nations Summit on NCDs held in New York in September 2011. In practical terms, Summit Declarations contain principles to guide development strategy and projects. Having oral health mentioned within the context of NCDs and primary health care means that dental medicine is now officially linked with gen- eral health policy. This is certainly what many developing countries would wish for. This was clearly illustrated by an event I attended during the course of the Summit entitled ‘Putting the teeth into NCDs’ and by the Republic of Tanzania. It highlighted the importance of oral health in health strategy. In fact, one speaker, Helen Clark, Administrator of the United Nations Development Programme (UNDP), called oral diseases “obstacles to development”. I am gratified to see how FDI is so much in tune with concepts of development: it is in- deed time to face the fact that viewing oral health as somehow separate from general health is truly obsolete. And also obsolete is approaching health without a political and public understand- ing of health inequities and social determi- nants of health: it is necessary to take ac- tion simultaneously on the broader factors that influence people’s health behaviour; the conditions in which they are born, grow, live, work and age; and the influence of so- ciety. Together with its coalition members, WHPA is in a unique position to raise awareness on this approach at a global level, in light of the scope of the recent WHO World Conference on Social Determinants of Health in Rio de Janeiro. Conclusion We at FDI have recently intensified our dialog, with the aim of encouraging gov- ernments to prioritize and promote oral health and consider it as a citizens’ right. It is essential that we continue to stress the fundamental point: “Good oral health is a primary factor in general health”. Orlando Monteiro da Silva, FDI President E-mail: orlando@orlandomonteirodasilva.com 22 Regional and NMA news THAILAND Standing and domestic Activities • Continuous Medical Education and re- search promotion. • Provision of scholarships for postgraduate study and research in Japan in collabora- tion with the Takeda Science Foundation. • Provision of the Research Grants to member. • Lecture tours on Special topics: Con- tinuous Medical Education and Medical Ethics. • Monthly Publication of the Journal of Medical Association of Thailand. • Launching of E-Journal to Members and public. • Supply Accommodation for members at the club house. • Provide consultative support for members with professional legal problems. • Organize charity golf tournament for the fund raising. • Organize Post congress tours to study Health Care abroad. • Performing Medical Advocacy through social Medias: Radio, Television and Newspaper. International Activities: Participation at the International congresses and medi- cal association meetings as invited and as a member  – WMA; CMAAO; MASEAN; National Medical Associations in Asia, Aus- tralia,Europe,North and South America etc. Special Events. • Hosting the 1st International Summit on Tobacco Control in Asia and Oceania Region on February • 25,2010 at Rose Garden Riverside Hotel, Sampran, Thailand resulting in Sampran Declaration. • At the WMA Congress and General Assembly 2010 in Vancouver, Canada, Dr.  Wonchat Subhachaturas, the Presi- dent Elect of the MAT, was elected at the General Assembly to be the 61st Presi- dent of the World Medical Association for period of 2010–2011,the ninth from Asia and the first from Thailand • Organizing the 90th Anniversary Cel- ebration of the MAT on September, 27–30, 2011. • Exchange visit with the Chinese Medi- cal Association on August 4–8, 2011 in Beijing. • Promotion of community Tobacco Ces- sation Programs through the Thai Health Alliance Against Tobacco Network (THPAAT) • Setting up health and rehabilitation visit- ing teams for the flood victims in collabo- ration with the Thai Health Professionals against Tobacco (THPAAT). • Organizing the robes presentation to the priests at the temple with donation. Contact Persons of the Current Executive Board of the MAT: President: Dr.  Won- chat Subhachaturas; President Elect: As- soc.  Prof.  Dr.  Prasert Sarnvivad; Vice President: Prof.  Dr.  Teerachai Chantraro- janasiri; Secretary General: Prof. Dr. Sara- natra Waikakul; Treasurer: Group Captain Dr. Paisal Chantarapitak; International Re- lations: Lt.General Dr. Nopadol Wora-urai; CEO: Prof. Dr. Somsri Pausawasdi The Medical Association of Thailand committed itself to host the 2012 Gen- eral Assembly of the World Medical As- sociation during October 10–13, 2012 in Bangkok. The Medical Association of Thailand Flood in Thailand 2011 The flood in Thailand this year, 2011 was the heaviest and the worst in the history of the country. Twenty- six provinces out of seventy-seven were affected mostly in the north and the central basin with the loss of 540 lives mostly from land slide, drowning and electric shock. More than 2 millions of the population have been the victims of the flood and more than 300,000 people were evacuated from their home places to the higher evacuation grounds. The estimated loss of the country could reach 1,000 billion Baht (31 Baht = 1US$) in total. However, with the superb collaboration of the governmental and nongovernmental health organizations and institutions and massive health volun- teers, no epidemics were detected so far. Wonchat Subhachaturas 23 Regional and NMA newsNEW ZEALAND The New Zealand Medical Association (NZMA) is the largest medical professional organisation in New Zealand. We are pan- professional, representing doctors from all disciplines within medicine and at every stage of their career. The pan-professional focus differentiates our organisation from the other medical bodies in the country and gives us the mandate to advocate on issues that influence the medical profession as a whole. It was with significant pride that the NZMA celebrated its 125-year anniversary in 2011. NZMA Chair Dr. Paul Ockelford, speaking at a function late last year which showcased and celebrated 125 years of the NZMA, said that the Association had a long and proud history but continued to be proactive by anticipating emerging health sector issues impacting on doctors and pa- tients. He referred to the Role of the Doctor Consensus Statement, recently published in the New Zealand Medical Journal, as an example of the NZMA taking a lead- ership role. The NZMA hosted medical leaders from throughout New Zealand at a two-day seminar to develop the statement, which highlights the key skills and personal attributes required by doctors to ensure pa- tient care is not compromised in a health sector undergoing significant change. It re- flects the greater role of the patient in mak- ing decisions about their health care and also considers the role of the doctor within the wider healthcare team.  The statement reinforces the role and the responsibility of doctors as leaders in the healthcare team, and as public health advocates. The state- ment, endorsed by the medical colleges, will serve as the foundation for ongoing discus- sions with government and the wider health sector to deliver optimal healthcare to New Zealanders. The NZMA’s direction is driven by our mission statement: to provide leadership of the medical profession; to promote profes- sional unity and values, and the health of all New Zealanders. We have developed a strategic plan for the next five years which will build on these principles and shape the Association’s future work.The six priorities in the plan provide a strategic focus to ad- vance the health of New Zealanders and leadership of the profession in the context of a rapidly changing health sector. Key themes include improving the health sta- tus and health outcomes of all New Zea- landers; proactively advocating on behalf of the profession; being one profession with one vision and one voice; targeting both national and global health issues; be- ing responsive to concerns raised by mem- bers and championing quality in health policy and systems. The NZMA is highly respected for its knowledge, reasoned commentary and robust evidence based positions. It has a strategic programme of advocacy with politicians and officials at the highest lev- els of government and works consistently to maintain strong relationships within the health sector and other government agen- cies, including the Ministry of Health, Accident Compensation Corporation, De- partment of Labour, and Ministry of Social Development.The Association is influential in shaping health policy and it has a grow- ing membership which reflects increasing recognition among doctors that a strong, unified voice for the profession is essential, especially in a time of rapid health sector changes. The NZMA also advocates on a wide range of issues, with the medical workforce and health equity being two major areas of ac- tivity. Medical workforce At the forefront of NZMA advocacy is the medical workforce. New Zealand is fac- ing shortages of doctors (and other health professionals), and there are challenges in recruiting and retaining staff. The com- petitive global health market means many local graduates choose to work in other countries often for higher salaries. New Zealand has an over-reliance on overseas trained doctors  – around 45 percent of doctors working in New Zealand did not train here. After years of little progress, with governments not even acknowledging a problem existed, we are beginning to see real progress. Health Workforce New Zealand (HWNZ) has been formed to lead and coordinate the planning and development of our country’s health workforce to achieve a self-sufficient, fit for purpose workforce that meets the healthcare needs of New Zealanders. This new agency has implemented a number of initiatives, including: increases in medi- cal student numbers, a voluntary bonding Paul Ockelford Celebrating 125 Year Anniversary – NZMA Challenges and Opportunities 24 Prior to independence, the Primary Health Care (PHC) System in Estonia was based on the Soviet Semashko model. Prima- ry care services were mainly provided in polyclinics at first-level patient contact. Polyclinics were staffed by clinicians, gyne- cologists, surgeons, pediatricians and other specialists. There was no specialist training in family medicine, thus the specialty did not exist.The health centers were owned by municipalities [1, 2]. Following independence, PHC reforms were introduced in 1991.The reforms aimed to develop a family medicine-centered PHC system and to establish family medicine as a medical specialty and academic discipline. In 1993, Estonia was the first post-Soviet country to designate family medicine as a medical specialty. New postgraduate train- ing programs were introduced, including a three-year residency program for new grad- uates and an in-service retraining program Regional and NMA news ESTONIA scheme and interest free loans for medical students who stay in New Zealand. The NZMA is generally supportive of HWNZ’s goals and has forged a good working rela- tionship with the organisation. We are nevertheless concerned about some of the initiatives, particularly those that have been undertaken with little wider policy analysis and without adequate consultation with doctors and medical students. The NZMA will continue to voice these concerns to HWNZ and work with the organisation to provide input into its projects. High quality training for our doctors is an- other issue crucial for NZMA’s workforce advocacy. Many of our doctors in training members are concerned there is excessive emphasis on service delivery at the expense of training. Ensuring that trainee doc- tors have sufficient learning time, mentor- ing and supervision is essential to effective health workforce development. New Zealand’s medical workforce has many challenges  – an increasing demand for health services, especially in light of our ageing population, the ageing doctor workforce which is not being adequately replenished, doctor dissatisfaction and morale, doctors leaving New Zealand for overseas and optimal scopes of practice. Well-informed and determined advocacy can make a discernable difference towards improving these and other workforce is- sues. Health equity The NZMA has taken a leadership role in raising awareness of health inequity and the correlation between social factors and health outcomes. In our Health Equity Position Statement we have recommended a whole of government, inter-agency ap- proach to address the social determinants of health (such as housing, education and em- ployment) to help bridge health inequities. The NZMA has urged the Government to invest more in preventive care, particularly in early childhood, and supports invest- ment into disorders such as Rheumatic Fever that disproportionately affect Maori and Pacific communities. There appears to be a growing willingness from throughout the political spectrum to address health inequity and certainly increased recogni- tion of the key actions required such as a minimum income for healthy living and in- vesting in housing and education to achieve health outcomes. 2012 Commemorating 125 years of the NZMA has provided a platform to celebrate the As- sociation’s achievements and reflect on the major milestones. It has also been an op- portunity for the NZMA Board to consider and evaluate the NZMA’s future direction. The NZMA is anticipating another active year advocating on a range of issues facing the healthcare sector. These include pro- posed changes to medicines management, enhancing clinical leadership and gover- nance, delivering electronic health records for all New Zealanders, and the passage into law of the Medicines Amendment Bill which seeks to align the prescribing frame- work for health professionals. The NZMA is concerned that there has been a shift in the general approach to change in the health sector with less being debated at a policy level and more being introduced in an experimental way. Challenges therefore lie ahead but also opportunities, as we strive to attain a health system which maintains New Zealand as a world leader in quality healthcare delivery. Dr. Paul Ockelford, Chairman, New Zealand Medical Association Development of Family Medicine in Estonia – from Nothing to Modern Specialty Katrin Martinson 25 Regional and NMA newsESTONIA for specialists who were working in PHC. Courses were formed on voluntary bases mainly by clinicians and district pediatri- cians. In 1997, significant health reforms were introduced in primary health care, which required citizens to register with the list of family doctors (FDs). The economic sta- tus changed for family doctors and they became independent contractors. As in- dependent contractors, family doctors had to establish contracts with the Estonian Health Insurance Fund (EHIF) to pro- vide primary health care services to their registered populations and be remunerated by according to a new mixed payment sys- tem comprising basic payment for practice and capitation payment (now 79.9% from income), and fee-for-service (now 18.2% from income) [5]. In 2006 a pay-for-performance (P4P) sys- tem was introduced by initiating incentives to promote clinical quality in family medi- cine. The system was developed in collabo- ration with the Estonian Society of Family Doctors (ESFD) and EHIF. The system’s development remains an ongoing process. While physician participation in the pro- gram is voluntary, in 2011, 95% of family doctors were participating in clinical quality assessment (EHIF 2011). The clinical quality assessment system con- sists of three parts: 1. Prevention (vaccinations and follow-up of preschool age children, prevention of cardiovascular diseases at the age of 40–60) 2. Management of chronic diseases (type 2 diabetes, arterial hypertension, myocar- dial infarction and hypothyreosis) 3. Professional competence and CME (recertification and competence of the family doctors and nurses), follow-up for pregnancies, gynecological and sur- gical activities. When family doctors meet 80% or more of the criteria, they are paid on the basis of P4P.The P4P maximum level is 1,2% of the family doctor’s income. In 2009, ESFD defined standards for good practice, publishing the Quality Guide for Estonian Family Doctor Practices (photo added). The manual describes how best to organize work in a family medicine practice. The book was published in the Estonian and Russian language and is also translated and digitally available in English. Contents of manual: 1. Availability of family doctors and ac- cess to the practice (Standards: access to practice, patient information) 2. Organisation of the practice (Standards: working order of the practice, managing medical information, work-rooms and access to them, medical accessories and devices, clinical supporting processes). 3. Quality of the treatment/therapy (Stan- dards: promoting health and preventing diseases, diagnosing and solving indi- vidual health problems, consistency of medical care, cooperation with the pa- tient, safety and quality, education and training) 4. Practice as an educational/scientific base (Standards – practice as an educa- tional base, practice as a base for scien- tific work) Picture 1. The Quality Guide for Estonian Family Doctor Practices Appendices to the document are the ques- tionnaire for patients feedback and a table of indicators. Eret Jaanson Ruth Kalda Anneli Rätsep Madis Tiik 26 Regional and NMA news ESTONIA On the basis of The Quality Guide for Es- tonian Family Doctor Practices, the devel- opment of a practice accreditation system was launched. The ESFD uses an intranet SVOOG as a tool for digital practice ac- creditation assessment. Family doctors complete the table regarding quality indica- tors for the practice and receive a score from A (maximum) to C (minimum).This is vol- untary and open only to doctors who are members of ESFD. (Of 805 Estonian fam- ily doctors, 787 are the members of ESFD). In the first year (2009/2010) 79 practices performed this self-analysis. The number rose to 109 in 2010/2011.The total number of family practices in Estonia is 468. The board of ESFD has decided to audit the best practices (A-level) through site vis- its to these practices by volunteer auditors. The auditing protocol was agreed by both sides (the auditor and the practice represen- tative). As our system is unique – bottom to top or- ganized, voluntary, without any P4P quality incentives – the only motivation for par- ticipants is recognition and positive pub- lic attention. In 2011, the President of the Estonian Republic Toomas, Henrik Ilves, specifically acknowledged the A- level prac- tices. ESFD also provided a beautiful pen- nant (Picture 2), designed by textile artist, Ene Pars. ESFD is also very proud of our digital dis- tance learning environment for family doc- tors. Our SVOOG (intranet) system now includes approximately 400 different lec- tures. Learner can listen to the online lec- ture, view slides, and answer the questions about the issue. SVOOG also assists fam- ily doctors in meeting continuous medical education requirements, through links to different educational centers’ homepages and the possibility of collecting educational points for recertification. As mentioned above, SVOOG also facilitates practice ac- creditation. Another very important development in Estonian health care is a nationwide e-health system. The idea of national e-health information system (EHR) emerged in 2002, with the purpose of de- veloping a nationwide database of different medical documents in digital format to fa- cilitate the exchange of health information. Beginning on January 1, 2009, care provid- ers have been obliged to forward medical data to the health information system. Patients have the right to set restrictions regarding access to their data. Patient take full responsibility for consequences that may occur from banning access to their medical data [3]. Also part of the e-health system is the e-prescription program, launched on Janu- ary 1,2010.Within a year more than 80% of prescriptions were made digital. Both doc- tors and patients have been satisfied with the development. The Estonian e-health system is unique. It encompasses the whole country, registers virtually all residents’ medical history from birth to death, and is based on a compre- hensive state-developed basic IT infrastruc- ture [4]. The biggest problems are the lack of doctors and nurses in primary care (and in special- ist care as well), and trained staff leaving for Europe to earn larger salaries. The system for temporary substitution in time of vaca- tion or illness of regular staff is underdevel- oped. In addition, payment for primary care is unbalanced in comparison with specialist care. In conclusion, a lot has happened within 20 years of family medicine in Estonia. Start- ing from scratch, there are now 486 family medicine practices, led by 805 family doc- tors. Family medicine, as the widest medical specialty, has became the most logical and well-functioning base for Estonian health care. References 1. Lember M. A policy of introducing a new con- tract and funding system of general practice in Estonia. Int J Health Plann Manage 2002; 17: 41–53. 2. Lember M. Re-evaluation of general practice/ family medicine in Estonian health care system. Eur J Gen Pract 1996; 2:72-74. 3. Tiik, Madis (2010). Rules and access rights of the Estonian integrated e-Health system. Medi- cal and Care Compunetics 6 (245 - 256). IOS Press. 4. Tiik, M., Ross, P. (2010). Patient opportunities in the Estonian Electronic Health Record Sys- tem. Medical and Care Compunetics 6 (171 - 177).IOS Press. 5. Ruth Kalda, Euract Newsletter, nov. 2010,vol 1, issue 1. Katrin Martinson, Eret Jaanson, Ruth Kalda, Anneli Rätsep, Madis Tiik, Estonian Society of Family Doctors Picture 2. The ESFD award for A-level practices 27 Regional and NMA newsTURKEY The Turkish Medical Association was con- stituted by Law No. 6023, enacted in 1953. The managing and auditing bodies of the Association are elected by its members (medical doctors) under the supervision of a judge. The mission of the Association is to ensure that the profession of medicine is practised so as to promote the benefit of the public in general as well as individuals, and to protect the rights of physicians. How- ever, recent arrangements by the Govern- ment are but negative interventions both to the autonomy of the profession and to the duties of the Association in this regard. Government Decree no. 663, in Force of Law on the Organization and Duties of the Ministry of Health and its Associated Or- ganizations, reorganizes the field of health in a way that creates many legal and social problems. In fact, under the present Con- stitution, the authority to introduce pri- mary legislative arrangements rests with the Turkish Grand National Assembly as the legislative body of the Republic. However, by means of an authorization act,the Coun- cil of Ministers was equipped with authori- ties that should actually belong to the leg- islature. Consequently, new arrangements were unconstitutionally introduced in some domains where the Council of Ministers is normally denied the authority establish rules or codes. Now we want to share with you the nature of these arrangements that destroy the univer- sal values of the profession and require your support and solidarity to find a solution. 1. A new board, the “Board for Health Professions” which was previously non- existent was recently formed and equipped with authority pertaining to a large spec- trum of health affairs, including physicians themselves and their work. The Board comprises 14 members desig- nated by the Government plus one mem- ber from the Turkish Medical Association which, according to its laws of constitution, is supposed to form and express opinions regarding the profession.  Hence the Board is composed of members whose profession- al and scientific freedom and autonomy is highly questionable. Duties assigned to the Board are as follows: • Providing opinions on such matters as educational curricula and training in health; identification of professional areas and branches and planning for the em- ployment of health workforce, • Establishing ethical codes and principles in health profession, • Deciding on procedures to be followed in such issues as testing professional competencies of health workers, training of health workers in ethics and patient rights, as well as content and duration of trainings, • Deciding on bans to practising the pro- fession on grounds of health problems, and • Deciding on temporary or permanent ex- clusion from the profession. As such, the Board assumes the authorities of medical schools,the Turkish Medical As- sociation,and even the legislative body itself by introducing new offences and penalties. There are over 30 health professions in Turkey and both the respective functions of these professions and the conditions of recruitment are prescribed by law. There are nearly one hundred fields of specialization and sub-specialization solely in the field of medicine.  Thus, the members of the Board appointed by the Minister will exercise au- thority concerning fields in which they may have no competence. The Board will be in charge of assessing competence in all health professions, set- ting codes of professional ethics, handing down decisions for exclusion from the pro- fession,measuring professional competence, and developing curricula! In short we face a situation not compatible with any demo- cratic society. Meanwhile, for 58 years, the Turkish Medi- cal Association has been setting the rules of professional deontology, investigating and applying sanctions for practices not in line with deontology, and organizing trainings to support advancements in the profession. The latest arrangement by the Government virtually eliminates the established duties and authorities of the Turkish Medical As- sociation and other professional associa- tions and undermines the autonomy of the profession and its guarantees by delegating full authority to a board whose members are to be appointed by the Ministry of Health. 2. The expression “ensuring that medical profession is practised and promoted in line with public and individual well-being Eriş Bilaloğlu Turkish Medical Association (TTB) 28 Regional and NMA news TURKEY and benefit” in Article 1 of the Constitut- ing Law of the Turkish Medical Associa- tion has been deleted from the text. This amendment is tantamount to exclud- ing from the mandate of a professional as- sociation the task of practising and pro- moting medicine for public and individual well-being and benefit. The new arrangements taken as a whole de- prive the medical profession of the means to be managed and supervised autonomously by its own professionals within the frame- work of values specific to the profession itself. They also completely disregard the principle of exemption from the control of any Governmental office or agency, which is a precondition for being a constituent member of the World Medical Association. As the Turkish Medical Association, we urge all Medical Associations to support us in the fight against this unacceptable action taken by the Government. We request that you use your strong and important influence to assist us in this regard.The Turkish Med- ical Association kindly asks for the solidar- ity of your Medical Association in stating its position on this issue. In defence of universal values of the profession of medicine and rights of the physician is Turkey While the TTB was founded back in 1953 with its present name, its background dates back to Etibba Chambers of 1929. Its his- tory runs parallel to the history of the Re- public of Turkey founded in 1923 and the development of democracy. The TTB was originally a professional orga- nization with compulsory membership for all physicians. However, after the military coup of 12 September 1980, which violent- ly eliminated democratic organization and introduced constitutional arrangements for preventing the flourishing of democracy,the requirement for compulsory membership was lifted, except in the case of freelance doctors. Turkey started with 700 physicians in 1923, reaching over 7,000 in 1953, and at present has over 120,000 physicians. The first president of TTB was also the head of the World Medical Association in 1957-58.The 11th World Medical Congress was held in İstanbul in October 1957 and the “Attitude of Doctors in Conflict Situa- tions” was adopted at that meeting. The TTB has 65 local chambers throughout the country and their executives are elected every two years. The TTB is engaged in all problems in the field of medicine and car- ries out its activities with its members work- ing on voluntary basis. Under the umbrella of TTB, students of medicine, general prac- titioners and associations of specialists are organized as autonomous bodies. The TTB is in close contact with the European Union of Medical Specialists (UEMS). The fol- lowing are among specific activities that the TTB is engaged in: • Organizing Workshops for developing professional ethics (1998) and ethical guidelines • dealing with disciplinary actions relating to the profession • developing and presenting draft legisla- tion about the rights of physicians, cases of malpractice, and medical practices • supporting and participating in such pro- cesses as planning for the health work- force, training and education in medicine, life-long professional development, cred- iting and National Medical Education Accreditation • developing and annually publishing guides for medical examination fees • delivering health services in emergencies • conducting work in such areas as the rights of patients, women’s issues, and fe- male physicians • categorization of medical services • drawing attention to problems and issues such as public health, abuse of children and elderly people, and the health status of persons in prisons • protesting against human rights viola- tions, smoking, and nuclear plants and hydraulic power plants that harm envi- ronmental health • standing against wars and defending peace in all circumstances. Of the above activities, the personal rights of employed physicians and medical educa- tion/training enjoy special priority and im- portance. • During its more recent history follow- ing 1980, the TTB became the focal point in defending the personal rights of employed physicians. Particularly after 2003, its struggle against the dominant attitude, “knowing the price but not the value of everything”, devaluation of the work of the physician, and countrywide practices of sub-contracting and lack of secure employment were recognized even in the official statements of the Minis- try of Health as “TTB’s intensive and noisy opposition”. In addition to present- ing draft laws and opinions on personal rights and benefits for the health work- force and associated initiatives, the TTB also organizes demonstrations and other actions including temporarily stopping work. • Due to top-to-down approaches imposed by the Government,Turkey is among the leaders in the number of new schools of medicine opened. In 2006 there were 50 medical schools. There are 83 today. In 2011, approximately 9,000 new students enrolled in these schools. A large pro- portion of these newly enrolled students eventually graduate. However, despite the full commitment of the academic staffs, these schools were launched without con- sideration of the necessary infrastructure and standards, leading to the problem of poorly qualified graduates. The TTB also has a legal affairs board com- posed of professional lawyers. This body manages a large work burden, since the 29 Regional and NMA newsTURKEY government’s arbitrary acts outside of the legal framework are rather frequent. Publi- cations of the Association are prepared by editorial boards composed of persons work- ing voluntarily, and include “Continuous Education in Medicine” targeting primary level health services; “Occupational Health and Safety Journal”targeting those engaged in this area; the periodical “Community and Physician” that contains articles in medi- cine and politics; and the bulletin “World of Medicine” providing information about centrally organized activities and other is- sues and events of interest. Unfortunately, the TTB has had signifi- cant experience in very difficult and un- desirable issues. Mushrooming events of torture, cruel and degrading treatment and human rights violations-particularly after the military coup of 1980-bought to the forefront the unity of medical profession- als in terms of spotting and reporting such cases and the actions required by medical ethics in the face of such events. It is based on this experience that the TTB was able to significantly contribute to the Guide- book to the Istanbul Protocol on the Ef- fective Investigation and Documentation of Cases of Torture and other Cruel, In- human and Degrading Treatment or Pun- ishment, which was also approved by the United Nations. The Board Members of the TTB have been charged and prosecuted twice, in 1985 and again in the 2000s, with the ob- jective of their removal from positions to which they were elected. In the first case, it was for TTB’s objection to capital pun- ishment on the ground of professional ethics and its insistence that physicians be excluded from executions although it was legally obligatory. The second case was TTB’s stance on the attitude of physicians in regard to widespread hunger strikes go- ing on in prisons at that time. In both cases and beyond, in defense of the right to life and health, the TTB insistently stood for peaceful and democratic solutions to en- vironments of conflict and associated as- saults and killings. In short, the TTB promotes and defends the universal values of the profession of medicine in Turkey and stands for the rights of physicians on the basis of profes- sional values and the right to health. The TTB is committed to protecting the pro- fession from established government poli- cies that create dilemmas regarding both physicians’ and patients’ rights. The TTB evaluates its responsibilities in the context of the overall situation in any given peri- od-in Turkey or in the world-to develop suggestions about health policies and de- termine its stance with regard to the right to health. The TTB is the representative of an approach that refutes negative medical practices of the past and strives to maintain and promote its accumulated knowledge and experience by upholding the principles of public health. Turkey is endowed with a strong legacy in the medical profession. The history of the young Turkish Republic has witnessed strenuous efforts of physicians in diverse areas and particularly in combating conta- gious diseases. However, in spite popular support and prestige, physicians and the TTB wrestle with many difficulties, mostly created by the government. In this context, two periods deserve special mention. The first was the practice and discourse of the military junta following the coup of 12 Sep- tember 1980 and the second is the period that began in 2003 and continues today. Pressure on and harassment of physicians in the present period of civilian Government have assumed dimensions one might ex- pect to see in satire magazines. For example, regulations and instructions determine even the door and window measurements and heights of stairs in facilities where physi- cians receive their patients. At present, the policy pursued by the Government aims at creating disrespect for the profession of medicine and physicians. This policy is ac- companied statistics, such as one of every three patients visit the emergency service when at a hospital, and “efficiency” is de- fined as a physician examining over 100 patients a day. The rights of patients are re- duced to ordinary consumer rights in terms of satisfaction, while the demand for health services is transformed into “customer de- mand”. Further provoked by irresponsible and hostile discourse by politicians, this sit- uation instigated physical violence against physicians. In the face of this threat, the TTB created a “Group for Zero Tolerance to Violence” to combat violence targeting health workers. The Ministry of Health, on the other hand,just ignored a parliamentary investigation proposal on this issue lodged by some deputies. The stance of the TTB vis á vis govern- ment policies and practices is subject to defamation by describing it as “raising op- position”, “engaging in politics”, or “acting with ideological motives”. Another policy being pursued is geared toward ending TTB’s connection with and representation before the Government, and the Ministry of Health in particular. There are initia- tives to position the TTB as a hierarchical subordinate of the Ministry. And finally, there is the Government Decree in Force of Law on which the WMA circulated its letter dated 11 January 2011 informing its members. We should be proud that in the face of all difficulties, Turkey still has physicians dedicated to their profession and there is the turkish medical association! Dr. Eriş Bilaloğlu President of Turkish Medical Association 30 SERBIARegional and NMA news The Serbian Medical Chamber is an inde- pendent, professional, self-governing and self-financing organization of Serbian medi- cal doctors based on mandatory membership. Founded according to the Law on Health Care Professionals Chambers, the Serbian Medical Chamber was created to improve the medical profession’s working conditions, protect its professional interests, and actively participate in developing and managing the healthcare interests of citizens,particularly in attaining their healthcare protection rights. The Republic of Serbia assigned to the Serbian Medical Chamber the following authorities: • To adopt the Code of Professional Ethics • To register medical doctors and to keep an index of all members • To issue, renew and revoke medical li- censes and to keep records on them • To mediate disputes among its members or between its members and patients • To organize the Courts of Honor for in- vestigation of alleged breaches of profes- sional duties and to apply penalties, main- taining a separate index on these issues • To issue the official records, certificates and confirmations from the directories • To establish membership and license fees • To issue identification cards and license numbers to its members At the same time, the Serbian Medical Chamber represents and protects the pro- fessional interests of its members, and pro- motes and defends the reputation of the profession and health care services provided according to the Code of Professional Eth- ics. It responds to illegitimate and unfound- ed public statements in media for the sake of protection of its members. The Serbian Medical Chamber was origi- nally founded in 1901 and remained active until 1945, when it was cancelled by the Com- munist Decree. Its work was restored in Decem- ber 2006. The Serbian Medical Chamber has exercised its given au- thority and has become one of the most impor- tant stakeholders in the health care system of Serbia. There are approx- imately 30,500 medical licenses issued in Serbia, today, which are required for medical doctors to practice. The Main Working Principles of the Ser- bian Medical Chamber are: • Serbian medical chamber indepen- dence. The Serbian Medical Chamber is self-governing professional organization that is financially autonomous, since it is financed by membership fees and not from the state budget of the Republic of Serbia • Legality of the assigned authorities. Among the most important authorities assigned by the State are licensing and re- licensing of medical doctors • Protection of the medical profession, and promotion of the honor and repu- tation of medical doctors and medical profession. • Absolute equality of private and public practice. • Decentralization and regional organi- zation of the serbian medical chamber. • Transparency. The Serbian Medical Chamber Mission: As a specialized organization, the Serbian Medical Chamber protects the medical profession, the honor and reputation of physicians, and the overall health profession and, at the same time, actively works to re- inforce public and individual patient trust in medical doctors. The Serbian Medical Chamber Vision: The Serbian Medical Chamber strives to be an important factor in medical problem resolution and to influence the outline, scope and contents of all medical- ly-related laws, including the Medical Law itself. Based on the professional potential of its members and its professional bod- ies, the Serbian Medical Chamber has the vision to move from the margins of the Serbian health care system (where it cur- rently stands despite of all its efforts), and to actively participate in core dialogue and de- cision-making within the health care system of Serbia. We can. We know how. We will. We are responsible and we act exclusively according to the law. Serbian Medical Chamber Plan for the Following Period 1. Developing a strategic and sustainable five year business plan 2. Improving the Serbian Medical Cham- ber IT system in terms of communica- tions networking 3. Expanding its assigned public authority in the area of medical expert supervision 4. Introducing clinical protocols as a man- datory segment of the Serbian Health Care System 5. Outlining the national strategy for minimizing professional and medical mistakes 6. Introducing clinical audit and peer re- view as part of the licensing process 7. Outlining the national anti-corruption strategy Dr. Tatjana Radosavljevic, General Manager, Lekarska Komora Srbije Tatjana Radosavljevic Serbian Medical Chamber 31 CYPRUS Regional and NMA news The Cyprus Medical Association was estab- lished in 1967 and represents all practicing physicians in Cyprus. The main aims of the Association are to unite all members of the medical profession who are practicing in Cyprus and to safeguard their interests. Ac- cording to the Cypriot Law, membership to the CyMA is compulsory to all physicians that are practising in Cyprus. Furthermore, the CyMA provides advice and assistance to its members in their mutual relations, and in their relations with the State or other authorities and organisations. In addition, the CyMA cooperates with other national and international bodies in order to foster its aims. The Cyprus Medical Association is not only a professional body but also acts in various ways for the benefit of patients and the pub- lic in general. Objectives of the Association include protecting medical ethics; devel- oping the health care system so that every patient enjoys the right to adequate treat- ment; offering its members professional training and advancement opportunities; introducing new legislation and regulations governing health issues; and managing the members’ pension fund and life insurance schemes. The Association administers its authority through five regional medical associa- tions: 1) Nicosia- Kyrenia, 2) Fama- gusta, 3) Larnaca, 4)  Limassol and 5) Paphos. The Cyprus Med- ical Association has an administrative board of 24 members. It meets once a month and appoints its nine sub-committees. These sub-committees are the Ethics Committee, the Continu- ing Medical Education Committee, the Bioethics Committee, the Scientific Com- mittee, the Law and Regulations Com- mittee, the Pension Fund Committee, the Communication Committee, the National Health Insurance Scheme Committee and the International and European Affairs Committee. According to the new General Charter of the CyMA, its administrative board has been constituted as follows: 1. The Presidents of each regional Medical Association (Nicosia-Kyrenia, Fama- gusta, Larnaca, Limassol and Paphos.) 2. Representatives of each Regional Asso- ciation according to the number of its members (Nicosia-Kyrenia = 5, Limas- sol = 4, Famagusta = 2, Larnaca = 2, and Paphos = 2) and 3. Four members elected from the General Assembly of the CyMA In total, the CyMA has 2584 active mem- bers, of which 36% are women and 64% are men. Currently, the Cyprus Medical Association participate in various regional, European and international medical bodies such as: • The Standing Committee of European Doctors (CPME) • The European Union of Medical Special- ists (UEMS) • The European Forum of Medical Asso- ciations (EFMA) • The World Health Organization (WHO) • European Accreditation Council for Continuing Medical Education (EAC- CME) • Conference Europeene des Ordres de Medecins (CEOM) • GIPEF – Regional Medical Association of Mediterranean countries • Conferenza degli Ordini dei Medici Euro Mediterranei (COMEM) • World Medical Association (WMA) • Commonwealth Medical Association (CMA) • Balkan Medical Association (BMA) Among other events, for 2012 the Cyprus Medical Association will host the annual meetings of the CPME and the UEMS in the second half of the year. Two other Medical Associations are ac- tive in Cyprus, besides CyMA. The first one is the Cyprus Government Physicians Union, whose members are also members of CyMA. The second one is the Turkish Cypriot Medical Association, which is reg- istered under the illegal regime in the oc- cupied northern part of Cyprus and thus has no legal validity. Moreover a number of Turkish Cypriot physician that are practic- ing in the north are also members of the CyMA. Dr. Andreas Demetriou, President of the CyMA, Dr. Alkis Papadouris, Secretary of the CyMA Andreas Demetriou Cyprus Medical Association (CyMA) A Glance to the Past, the Present and the Future Alkis Papadouris 32 TAIWANRegional and NMA news Humanity, professional innovation, and medical quality are the three core values that guided the work of Taiwan Medical Asso- ciation (TMA) in 2011. Some noteworthy activities in the past year include: promoting medical malpractice civil liability, establish- ment of a Medical Specialty Think Tank, revising the standards of medical establish- ments, promoting safety medical practice, organizing long-term care training course, reviewing clinic-based global budgeting, improving patient-centered care at the pri- mary level, advocating holistic care to ensure safety and quality, and hosting the 27th Con- federation of Medical Associations in Asia and Oceania (CMAAO) Congress and 47th Council Meeting.Key agenda items for 2012 include international participation, the na- tional health insurance program,medical ser- vices audit, medical care act reform, continu- ing medical education and member welfare. International participation and exchange The TMA encourages and recommends that physicians and experts attend inter- national professional meetings. In addi- tion, the TMA sends goodwill delega- tions to visit national medical associations or medical societies around the world in order to strengthen ties and facilitate professional exchange on various issues, such as medical administration, drug ad- ministration, the healthcare environment and other health affairs. In particular, the TMA hopes to play an active role in the operation, document revision and activi- ties of the World Medical Association. By close interaction and participation with international non-governmental organiza- tions, the TMA enhances its capacity and performance. National health insurance Being a key stakeholder in the health care system, the TMA studies policies and op- erations related to the National Health In- surance (NHI) financial system. By ensur- ing full understanding of the systems, the TMA is able to provide solutions to achieve fair resource allocation. At the same time, the TMA maintains regular communica- tions with the Bureau of National Health Insurance (BNHI) to improve people’s health and to assist members in carrying out projects commissioned by the Bureau. The TMA also monitors development of pilot projects under the NHI and provides suggestions. Of course, establishing a com- prehensive global budget implementation methodology is also a continuous effort of the TMA. Clinic-based medical service audit The TMA has been commissioned by the BNHI to design and implement a mecha- nism that performs clinic-based medical service auditing. This mechanism aims to increase efficiency, and ensure regulatory compliance and effective management. Coping with the global budget system The TMA stresses the importance of self- management by the medical community and the existence of a fair and objective audit mechanism in the global budget sys- tem. To this end, the TMA will participate in setting reasonable practice guidelines. While the global budget payment system incorporates external auditing, it is the re- sponsibility of the TMA to take part in the negotiation process and uphold the inde- pendence and dignity of the medical com- munity. Medical Care Act revision To address the increasingly complex issues involving medical malpractice, the TMA has been working since last year to revise the Medical Care Act to specify crimi- nal malpractice and its consequences. The TMA will continue promoting the revision in 2012 by approaching government agen- cies for better understanding, mobilizing its members to lobby for consent, and submis- sion of the draft to parliament for endorse- ment. Violence in the healthcare setting To prevent violent episodes in healthcare facilities, the TMA requests medical soci- eties to collect information and investigate the causes of such occurrences. The TMA also demands that local chapters protect physicians’ rights when they are threatened or injured, and requires that they follow up existing cases.Furthermore,for the safety of patients and medical staffs, the TMA ap- Mission 2012 – Taiwan Medical Association Ming-Been Lee 33 FRANCE Regional and NMA news peals to the authorities to increase punish- ments for these offenses and will formulate a standard operating procedure dealing with workplace violence. Improved continuing medical educa- tion for higher quality medical care The TMA coordinates among professional groups to organize continuing medical education (CME) for general practitioners. CME comes in multiple formats, includ- ing the Taiwan Medical Journal and TMA’s online program. Course announcements are updated on a regular basis on the TMA homepage. The TMA, along with local and regional academic institutions, offers video conferences to provide CME for members in the remote areas. Member benefit program development To improve member benefits,the TMA will offer favorable options for its members by having several insurance companies design policies that meet members’ needs, specifi- cally malpractice insurance. In the public sphere, the TMA will also appeal to the government to reaffirm the contribution of physicians and pass legislation protecting physicians’ welfare. Dr. Ming-Been Lee, President of TMA and CMAAO. France has been represented at the WMA by the French Medical Association (AMF), of which the French Medical Council (CNOM) is a member.The year 2012 is im- portant for French representation since the French Medical Council and the French Medical Association have decided to submit to the WMA the French Medical Council’s application for membership. The French Medical Council, an indepen- dent and autonomous institution, recog- nized to be of public utility by the French legislation, manages the recognition of the professional qualifications, the registration to the Register of the Order, the authori- zation to practice and the discipline of the profession. The French Medical Council’s opinion is regularly sought before any draft- ing of a law in the field of public health in France. At the international level,the French Medi- cal Council has a permanent office in Brus- sels in order to be as close as possible to the European legislature. It also serves as the Secretariat of the European Council of Medical Orders (CEOM), chaired by the Belgian Medical Council, in close coopera- tion with all the other Orders. The CEOM adopted on June 10, 2011 the European Charter of Medical Ethics. The French Medical Council also provides the Secretariat for the Conference of the Francophone Medical Councils (CFOM), chaired by the Gabonese Medical Order; The CFOM brings together many Euro- pean and African francophone states. As we are facing the revision of several Eu- ropean Directives (notably in 2012, the re- vision of the Directive on the recognition of professional qualifications, but also the Di- rective on protection of personal data) and French bioethics laws, we understand that deontology can differ, depending on the legislation in force in each country, but we remain convinced that there is a single and universal ethic since Hippocrates. This ethic must be fully respected by any doctor, whatever the country of practice. It is essential that each government respect the independence of the physicians and comply with this right to ethic. This, is one the principal reasons why we wish to strengthen our presence in the WMA in collaboration with the French Medical Association, indispensable partner. For more information: www.conseil-national.medecin.fr, www.assmed.fr , www.ceom-ecmo.eu. Dr. Xavier DEAU, CNOM Vice-president, AMF Secretary General, CFOM Secretary General French Medical Association (AMF) Xavier Deau 34 Regional and NMA news KAZAHSTAN ALTYN DARIGER is the highest public recognition award for physicians’ contribu- tion to the development of national public health, selfless work in protecting people’s health and an active involvement in social activities,established by the National Medi- cal Association (NMA) of the Republic of Kazakhstan. ALTYN DARIGER, translated from the Kazakh language,means a golden physician, implying the high evaluation of the physi- cian’s merits. The Association established ALTYN DARIGER in 2009, the year when the Association of Doctors and Pharmacists of Kazakhstan celebrated its 20th anniver- sary and, accompanied by re-registration, it was renamed as the National Medical Association. We have always focused on moral encouragement. I believe that many people will share my opinion that we all feel gratified if our work has been appre- ciated and when putting one’s heart and soul into the work it is rewarded not only financially, but also morally in the form of letters of appreciation, badges, medals and titles. The members of the Association are award- ed not only letters of appreciation, but also badges of several categories: the ALTYN DARIGER badge,the NMA golden badge, the NMA diamond badge, as well as the title of Honorary Member of the National Medical Association.For organizations pro- viding a high quality health care, the merit award Public Recognition of High Quality Health Care has been established. More- over, people and organizations involved in charity work, aiding patients, clinics or doing philanthropy work are awarded the title Mayirim that means mercy. To com- memorate our colleagues who died, provid- ing medical assistance to people during the Great Patriotic War, as well as in peacetime, in 2000 in the 28 Panfilov Heroes Memo- rial Park in Almaty a memorial stone was erected and trees planted in the avenue Ave Vitae. Doctors of the South-Kazakhstan region followed suit and in 2010 in Turkistan city a memorial was unveiled and an avenue set up, financed by medical professionals and supported by H. Yasavi International Kazakh-Turkish University. L. T. Tashimov, President of the University, already at the 2010 commencement ceremony conferred diplomas to young doctors at this sacred place. Why is the place sacred? In 2008 in Turkistan city three doctors died, try- ing to save the life of a young woman. Struggling for her life and attempting to stop the bleeding, they were infected by a deadly contagious disease. All of them were awarded posthumously the honor- ary title together with five other doctors of Kazakhstan. Besides, according to the Resolution of the Central Council of the National Medical Association the ALTYN DARIGER badge shall be awarded to doc- tors of other countries for great contribu- tion to the health protection system of our country. Members of WMA, WHO and other international organizations have promoted the development of our organi- zation and Kazakhstan, and the following distinguished persons have been awarded the ALTYN DARIGER: • Dr. Joe Asvall, former Director General, WHO EUROPE • Dr. Allan Rowe, WHO EUROPE • Dr. Rene Salzberg/European Forum of Medical Association and WHO • Dr. Yoram Blachar, President, Israel Medical Association • Dr. Andrey Kehayov, SEEMF President, Bulgaria. NMA has over 60 branches (regional and specialty-specified), Individuals, various of- ficial institutions and public organizations may apply for membership. To become a candidate member to our Organization at least five-year experience is required, and what is most important – the candidate should meet the requirements set for the high rank of ALTYN DARIGER. The NMA golden badge and the NMA diamond badge were established in honour of the 15th anniversary of our Organization. ALTYN DARIGER is awarded twice a year – during the NMA General Assembly held on the eve of the Medical Workers Day and when celebrating independence of the Republic of Kazakhstan. Each As- sociation branch may nominate only one candidate for ALTYN DARIGER, there- fore the candidates undergo a rigorous se- lection. Dr. Aizhan Sadykova President of National Medical Association of the Republic of Kazahstan Award for Physicians in The Republic of Kazahstan Aizhan Sadykova 35 NEPAL Regional and NMA news Established on March 4th , 1951, the Ne- pal Medical Association is the largest and oldest professional organization of medical doctors in Nepal.The goals of the NMA are increased coordination, efficiency improve- ments and advocacy related to the needs and deeds of our medical doctors. The as- sociation has been regularly publishing an indexed medical journal and organizing scientific workshops, seminars and confer- ences to keep our medical professionals fully up-to-date with the advances in medi- cal science. Basic health care has been en- shrined as a fundamental right under the Interim Constitution of Nepal. With this important recognition in the Constitution paving the way, we are working closely with our government to provide basic health ser- vices to the people of Nepal. The NMA has granted affiliation under our constitution to 25 specialty societies work- ing in Nepal. All of these societies are in- volved in professional and academic activi- ties and include the Society of Surgeons of Nepal, the Society of Internal Medicine of Nepal, the Nepal Orthopedic Association and many others.The NMA, itself, operates 14 zonal branches spread across Nepal and has a total of 4,171 life members, to date. The NMA is an affiliate of the World Med- ical Association, the Indian Medical Asso- ciation and the Confederation of Medical Associations in Asia and Oceana. Aims and Objectives • Maintain a Code of Conduct to protect the medical profession. • Facilitate the formulation of health poli- cies with the government. • Protect and advocate for human rights and medical ethics. • Encourage its members to maintain the highest professional standards. To achieve these objectives,the NMA is spe- cifically focused on the following categories Professional Activities: Rights, Regulations, Ethics, and Advocacy of Medical Professionals. Academic Activities The NMA has published a peer reviewed medical Journal since 1963 and an indexed in PubMed/MedLine since 2005. Continuing Medical Education (CME) Programmes conducted include: • National Consultative Meeting on Un- dergraduate vs. Postgraduate’s Seats: Ra- tionale, Challenges and Future Prospec- tive in Nepal (June 28, 2009) • Review of Kidney Transplantation Chal- lenges, Recent Trends and Future Per- spectives in Nepal (Sep 21, 2009) • Malaria Diagnosis & Treatment Guide- line of Nepal (November 1–3, 2010) • Various other CME programmes CME Programmes Proposed: • Capacity building for Nepal Medical As- sociation members • Training for Medical Journal Editors, Author and Peer Reviewer • One-day workshop to implement the Health Professional Protection Act in Medical Institutions. • One-day medical conference entitled “The Importance of District Coverage and Primary Health Care Services” • A medical wastes management workshop Institutional Activities 1. NMA has actively participated in and chaired the Professionals’ Alliance for Peace and Democracy in the country 2. NMA has a small guest house with 12 beds available only to NMA Life Mem- bers who are visiting. 3. NMA has some scholarship programs for undergraduate and post graduate medical students. 4. NMA has some provisions to provide scholarships for the children of de- ceased Life Members. 5. NMA has plan to a construct a new building for official as well as commer- cial purposes. 6. Submission of a proposal on “Digitali- zation of the Journal of Nepal Medical Association”. The present day world, especially in under- developed countries like ours, is experienc- ing a difficult phase of uncertainty. Perform- ing our respective duties efficiently, honestly and sincerely in such an insecure atmosphere of instability and mismanagement is some- what risky. As a result, the working situation is deteriorating in the field of health services. The proposed forum seeks to address the ob- stacles a doctor in a developing country is encountering. With the cooperation of the Ministry of Health, our population and dif- ferent health agencies like the WHO, the Nepal Medical Association is working to- wards better health for our people and a bet- ter working environment for medical profes- sionals in our country. Dr. Bhupendra Kumar Basnet, General Secretary, Nepal Medical Association Bhupendra Kumar Basnet Nepal Medical Association 36 Regional and NMA news A lunch debate held at the European Par- liament in Brussels EPF, CPME, PGEU and EFPIA brought together perspectives of patients, doctors, community phar- macists and the research-based pharma- ceutical industry presenting examples of best practices on adherence to therapies and demonstrating how a coordinated, multi-stakeholder and patient-centred ap- proach  – involving patients, their carers/ families, health professionals, industry, and the public, is a key factorin improving pa- tient safety and the quality of healthcare tailored to patients’ needs. Hosting MEPs Linda McAvan (S&D), ChristoferFjellner (PPE) and CristianS- ilviuBusoi (ALDE) opened the event by emphasising the vital importance of adher- ence to therapies “In the EU alone 194,500 deaths each year are due to misdose of and non- adherence to prescribed medication. Poor ad- herence carries a huge cost, both in terms of pa- tient safety and quality of life. It also presents a serious problem for health systems, both in terms of inferior health outcomes, unnecessary treatments and hospitalisations” said Linda McAvan. “The World Health Organization has stressed that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments” added ChristoferFjellner. “When long-term medication is prescribed, 50% of patients fail to adhere to the prescribed regimen” said Prof. PrzemyslawKardas from the Medical University of Lodz, Poland, who gave an overview of facts and figures on non-adherence. “Adherence-enhancing in- terventions should be adopted as a routine part of normal care, and provided to every patient”. The patients’ perspective was presented by Christos Sotirelis, who said: “Adherence sup- port and concordance are key components of good quality care. We believe that concordance in healthcare decision-making will lead to higher adherence by the patient. Health pro- fessionals should engage with patients as equal partners in the prescribing process, really lis- tening to and taking account of their views. We need to empower patients and educate health professionals in order to create such an environment and promote meaningful dia- logue.” “Doctors believe that much can be done from the communication point of view in order to improve medical adherence. eHealth tools could be used on a more regular basis in order to fa- cilitate easy and fast communication, particu- larly between doctors and pharmacists, under the condition that data protection and privacy is safeguarded” added Dr.Lemye,Vice-Pres- ident of CPME, who presented the role of doctors in a health care team with patients and pharmacists. Raj Patel from the National Pharmacy Association of UK, member of PGEU, il- lustrated how pharmacists in the UK con- tribute to a better medicines management through the Medicines Use Review service. “Pharmacists´ interventions to improve adher- ence – such as medicine use reviews – have been shown to be effective, both in terms of patient outcomes and cost efficiency.The need for new approaches to counselling patients on medicine use will only grow as our population ages, and more of our fellow citizens take a number of different medicines at the same time. But to re- ally make an impact we need to develop such initiatives on a large scale. Partnership with patients and other health professionals is cru- cial for this. The opportunities are there – we cannot afford to miss them” said John Chave – Secretary General, PGEU. Speaking at the conference today Mr Richard Bergström – Director General of EFPIA-explained how the pharmaceuti- cal industry can contribute: “EFPIA and its member companies are committed to improve adherence to therapies. This will contribute to better health outcomes and support sustain- able healthcare systems in times of economic constraints. EFPIA wishes to encourage more data gathering and evaluation, encourage best-practice sharing and involve all relevant stakeholders. A medicine that is sold but not taken is a waste for everyone – only cost and no benefit”. Finally, in his closing speech, MEP CristianSilviuBuşoiadded: “There is still a lack of coordination between health profes- sionals, patients and the industry.The Steering Group of the European Innovation Partner- ship on Active and Healthy Ageing, which is a pilot flagship initiative within the EU “Inno- vation Union” has recognised the importance of addressing treatment adherence and polyphar- macy. The Partnership will be an excellent op- portunity to explore potential innovative solu- tions that can support individual patients and carers, improve data sharing and communica- tion between health professionals, and improve the integration of care”. EPF, CPME, PGEU and EFPIA called for a concrete EU-level action on adherence, for example through: • Prioritising adherence and concordance in the future EU Health Programme, in the Steering Group of the Euro- pean Innovation Partnership on Active and Healthy Ageing and the Research Framework Programmes • Setting up information and awareness campaigns targeted to patients and the public,as part of an EU strategy for health literacy and information to patients • Using the Structural Funds to implemen- tadherence intervention EU Umbrella Organizations Call for a Concrete EU-level Actionfor Better Adherence to Therapies 37 Order of Physicians of Albania (OPA) Rr. Dibres. Poliklinika Nr.10, Kati 3 Tirana ALBANIA Dr. Din Abazaj, President Tel/Fax: (355) 4 2340 458 E-mail: albmedorder@albmail.com Website: www.umsh.org Col’legi de Metges C/Verge del Pilar 5, Edifici Plaza 4t. Despatx 11 500 Andorra La Vella ANDORRA Dr. Manuel González Belmonte, Presidente Tel: (376) 823 525 Fax: (376) 860 793 E-mail: coma@andorra.ad Website: www.col-legidemetges.ad Ordem dos Médicos de Angola (OMA) Rua Amilcar Cabral 151-153 Luanda ANGOLA Dr. Carlos Alberto Pinto de Sousa, President Tel. (244) 222 39 23 57 Fax (244) 222 39 16 31 E-mail: secretariatdormed@gmail.com Website: www.ordemmedicosangola. com Confederación Médica de la República Argentina Av. Belgrano 1235 Buenos Aires 1093 ARGENTINA Dr. Jorge C. Jañez, Presidente Tel/Fax: (54-11) 4381-1548 / 4384- 5036 E-mail: comra@confederacionmedica. com.ar Website: www.comra.health.org.ar Australian Medical Association P.O. Box 6090 Kingston, ACT 2604 AUSTRALIA Dr. Steve Hambleton, President Tel: (61-2) 6270 5460 Fax: (61-2) 6270 5499 E-mail: ama@ama.com.au Website: www.ama.com.au Osterreichische Arztekammer (Austrian Medical Chamber) Weihburggasse 10-12 - P.O. Box 213 1010 Wien AUSTRIA Dr. Walter Dorner, President Tel: (43-1) 514 06 64 Fax: (43-1) 514 06 933 E-mail: international@aerztekammer.at Website: www.aerztekammer.at Armenian Medical Association P.O. Box 143 Yerevan 375 010 REPUBLIC OF ARMENIA Dr. Parounak Zelvian, President Tel: (3741) 53 58 68 Fax: (3741) 53 48 79 E-mail: info@armeda.am Website: www.armeda.amt Azerbaijan Medical Association P.O. Box 16 AZE 1000 Baku REPUBLIC OF AZERBAIJAN Dr. Nariman Safarli, President Tel: (99 450) 328 18 88 Fax: (99 412) 510 76 01 E-mail. info@azmed.az Website: www.azmed.az Medical Association of the Bahamas P.O. Box N-3125 MAB House - 6th Terrace Centreville Nassau BAHAMAS Dr.Timothy Barrett, President Tel. (242) 328-1858 Fax. (242) 328-1857 E-mail: medassocbah@gmail.com Bangladesh Medical Association BMA Bhaban 15/2 Topkhana Road Dhaka 1000 BANGLADESH Prof. Mahmud Hasan, President Tel: (880) 2-9568714 / 9562527 Fax: (880) 2 9566060 / 9562527 E-mail: info@bma.org.bd Website: www.bma.org.bd Association Belge des Syndicats Médicaux Chaussée de Boondael 6, bte 4 1050 Bruxelles BELGIUM Dr. Roland Lemye, Président Tel: (32-2) 644 12 88 Fax: (32-2) 644 15 27 E-mail: absym.bvas@euronet.be Website: www.absym-bvas.be Colegio Médico de Bolivia Calle Ayacucho 630 Tarija BOLIVIA Tel: (591) 6 227 256 Fax: (591) 6 122 750 E-mail: secretario@ colegiomedicodebolivia.org.bo Website: colegiomedicodebolivia.org.bo Associaçao Médica Brasileira R. Sao Carlos do Pinhal 324 - Bairro Bela Vista Sao Paulo SP - CEP 01333-903 BRAZIL Dr. Florentino de Araújo Cardoso Filho, President Tel. (55-11) 3178 6810 Fax. (55-11) 3178 6830 E-mail: rinternacional@amb.org.br Website: www.amb.org.br Bulgarian Medical Association 15, Acad. Ivan Geshov Blvd. 1431 Sofia BULGARIA Dr. Cvetan Raychinov, President Tel: (359-2) 954 11 81 Fax: (359-2) 954 11 86 E-mail: blsus@mail.bg Website: www.blsbg.com Canadian Medical Association P.O. Box 8650 1867 Alta Vista Drive Ottawa, Ontario K1G 3Y6 CANADA Dr. Jeffrey Turnbull, President Tel: (1-613) 731 8610 ext. 2236 Fax: (1-613) 731 1779 E-mail: karen.clark@cma.ca Website: www.cma.ca Ordem Dos Medicos du Cabo Verde (OMCV) Avenue OUA N° 6 - B.P. 421 Achada Santo António Ciadade de Praia-Cabo Verde CAPE VERDE Dr. Luis de Sousa Nobre Leite, President Tel. (238) 262 2503 Fax (238) 262 3099 E-mail: omecab@cvtelecom.cv Website: www.ordemdosmedicos.cv Colegio Médico de Chile Esmeralda 678 - Casilla 639 Santiago CHILE Dr. Pablo Rodríguez, Presidente Tel: (56-2) 4277800 Fax: (56-2) 6330940 / 6336732 E-mail: rdelcastillo@colegiomedico.cl Website: www.colegiomedico.cl Chinese Medical Association 42 Dongsi Xidajie Beijing 100710 CHINA Dr. CHEN Zhu, President E-mail: intl@cma.org.cn Federación Médica Colombiana Carrera 7 N° 82-66, Oficinas 218/219 Santafé de Bogotá, D.E. COLOMBIA Dr. Sergio Isaza Villa, Presidente Tel./Fax: (57-1) 8050073 E-mail: federacionmedicacolombiana@ encolombia.com Website: www.encolombia.com Conseil National de l’Ordre des Médecins du RDC B.P. 4922 Kinshasa, Gombe CONGO, DEMOCRATIC REPUBLIC Dr. Antoine Mbutuku Mbambili, President Tel: (243-12) 24589 Fax: (243) 8846574 E-mail : cnomrdcongo@gmail.com WMA Directory of Constituent Members 38 Unión Médica Nacional Apartado 5920-1000 San José COSTA RICA Dr. José Federico Rojas Montero, President Tel: (506) 290-5490 Fax: (506) 231 7373 E-mail: junta@unionmedica.com Ordre National des Médecins de la Côte d’Ivoire Cocody Cite des Arts, Bâtiment U1, Escalier D, RDC, Porte n°1, BP 1584 01 Abidjan CÔTE D’IVOIRE Dr. Florent Pierre Aka Kroo, President Tel: (225) 22486153/22443078/ 02024401/08145580 Fax: (225) 22 44 30 78 E-mail: onmci@yahoo.fr Website: www.onmci.org Croatian Medical Association Subiceva 9 10000 Zagreb CROATIA Dr. Željko Metelko, President Tel: (385-1) 46 93 300 Fax: (385-1) 46 55 066 E-mail: tajnistvo@hlz.hr Website: www.hlk.hr Colegio Médico Cubano Libre 717 Ponce de Leon Boulevard P.O. Box 141016 Coral Gables, FL 33114-1016 CUBA Dr. Enrique Huertas, Presidente Tel: (1-305) 446 9902/445 1429 Fax: (1-305) 4459310 E-mail: info@sirspeedy5551.com Cyprus Medical Association (CyMA) 14 Thasou Street 1087 Nicosia CYPRUS Dr. Andreas Demetriou, President Tel. (357) 22 33 16 87 Fax: (357) 22 31 69 37 E-mail: cyma@cytanet.com.cy Czech Medical Association Sokolská 31 - P.O. Box 88 120 26 Prague 2 CZECH REPUBLIC Prof. Jaroslav Blahos, President Tel: (420) 224 266 201-4 Fax: (420) 224 266 212 E-mail: czma@cls.cz Website: www.cls.cz Danish Medical Association 9 Trondhjemsgade 2100 Copenhagen DENMARK Dr.Mads Koch Hansen, President Tel: (45) 35 44 82 29 Fax: (45) 35 44 85 05 E-mail: er@dadl.dk Website: www.laeger.dk Egyptian Medical Association Dar El Hekmah 42 Kasr El-Eini Street, Cairo EGYPT, ARAB REPUBLIC Prof. Ibrahim Badran Tel: (20-2) 27 94 09 91 Fax: (20-2) 27 95 78 17 E-mail : ganzory@tedata.net.eg Colegio Médico de El Salvador Final Pasaje N° 10, Colonia Miramonte San Salvador EL SALVADOR Dr. Rodolfo Alfredo Canizález Chávez, President E-mail: marnuca@hotmail.com juntadirectiva@colegiomedico.org.sv Website: colegiomedico.org.sv Estonian Medical Association Pepleri 32 51010 Tartu ESTONIA Dr. Andres Kork, President Tel: (372) 7 420 429 Fax: (372) 7 420 429 E-mail: eal@arstideliit.ee Website: www.arstideliit.ee Ethiopian Medical Association P.O. Box 2179 Addis Ababa ETHIOPIA Dr. Fuad Temam, President Tel: (251-1) 158174 Fax: (251-1) 533742 E-mail: ema.emj@ethionet.et ema@eth.healthnet.org Fiji Medical Association 304 Wainamu Road G.P.O. Box 1116 Suva FIJI Dr. Ifereimi Waqainabete, President Tel: (679) 3315388 Fax: (679) 3315388 E-mail: fma@unwired.com.fj Finnish Medical Association P.O. Box 49 00501 Helsinki FINLAND Dr.Timo Kaukonen, President Tel: (358-9) 393 091 Fax: (358-9) 393 0794 E-mail: riikka.rahkonen@fimnet.fi fma@laakariliitto.fi Website: www.medassoc.fi Association Médicale Française 180, Blvd. Haussmann 75389 Paris Cedex 08 FRANCE Dr. Elie Chow-Chine, President Tel: (33) 2 99 38 55 88 Fax. (33) 2 99 38 15 57 E-mail: deletoile.sylvie@cn.medecin.fr Website: www.assmed.fr Georgian Medical Association 7 Asatiani Street 0177 Tbilisi GEORGIA Prof. Gia Lobzhanidze, President Tel. (995 32) 398686 Fax. (995 32) 396751 / 398083 E-mail. georgianmedicalassociation@ gmail.com Website: www.gma.ge Bundesärztekammer (German Medical Association) Herbert-Lewin-Platz 1 10623 Berlin GERMANY Dr. Frank Ulrich Montgomery, President Tel: (49-30) 4004 56 360 Fax: (49-30) 4004 56 384 E-mail: international@baek.de Website: www.baek.de Ghana Medical Association P.O. Box 1596 Accra GHANA Dr. Kwabena Opoku-Adusei, President Tel. (233-21) 670510 / 665458 Fax. (233-21) 670511 E-mail: gma@dslghana.com Website: www.ghanamedassn.org Association Médicale Haitienne 1ère Av. du Travail #33 - Bois Verna Port-au-Prince HAITI Dr. Claude Surena, President Tel. (509) 2244 - 32 Fax:(509) 2244 - 50 49 E-mail: secretariatamh@gmail.com Website: www.amhhaiti.net Hong Kong Medical Association, China Duke of Windsor Social Service Building 5th Floor, 15 Hennessy Road HONG KONG Dr. Gabriel K. Choi, President Tel: (852) 2527-8285 Fax: (852) 2865-0943 E-mail: hkma@hkma.orgoui Website: www.hkma.org Association of Hungarian Medical Society (MOTESZ) P.O. Box 200 H-1364 Budapest HUNGARY Dr.Tibor Ertl, President Tel: (36-1) 312 2389 - 311 6687 Fax: (36-1) 383-7918 E-mail: nagy.dora@motesz.hu Website: www.motesz.hu Icelandic Medical Association Hlidasmari 8, 200 Kópavogur ICELAND Dr. Birna Jonsdottir, President Tel: (354) 864 0478 Fax: (354) 5 644106 E-mail: icemed@icemed.is Website: www.icemed.is 39 Indian Medical Association Indraprastha Marg 110 002 New Delhi INDIA Dr. G. K. Ramachandrappa, National President Tel: (91-11) 23370009/23378819/23378680 Fax: (91-11) 23379178/23379470 E-mail: imawmaga2009@gmail.com Website: www.imanational.com Indonesian Medical Association Jl. Samratulangi No. 29 10350 Jakarta INDONESIA Dr. Prijo Sidipratomo, President Tel: (62-21) 3150679 / 3900277 Fax: (62-21) 390 0473 E-mail: pbidi@idola.net.id Website: www.idionline.org Irish Medical Organisation 10 Fitzwilliam Place 2 Dublin IRELAND Dr. Ronan Boland, President Tel: (353-1) 6767273 Fax: (353-1) 662758 E-mail: imo@imo.ie Website: www.imo.ie Israel Medical Association 2 Twin Towers, 35 Jabotinsky St. P.O. Box 3566 52136 Ramat-Gan ISRAEL Dr. Leonid Eidelman, President Tel: (972-3) 610 0444 Fax: (972-3) 575 0704 E-mail: michelle@ima.org Website: www.ima.org.il Japan Medical Association 2-28-16 Honkomagome 113-8621 Bunkyo-ku Tokyo JAPAN Dr. K. Haranaka, President Tel: (81-3) 3946 2121/3942 6489 Fax: (81-3) 3946 6295 E-mail: jmaintl@po.med.or.jp Website: www.med.or.jp/english National Medical Association of the Republic of Kazakhstan 117/1 Kazybek bi St. Almaty KAZAKHSTAN Dr. Aizhan Sadykova, President Tel. (7-327 2) 624301 / 2629292 Fax. (7-327 2) 623606 E-mail: doktor_sadykova@mail.ru Korean Medical Association 302-75 Ichon 1-dong 140-721 Yongsan-gu Seoul KOREA, REPUBLIC Dr. Man Ho Kyung, President Tel: (82-2) 794 2474 Fax: (82-2) 793 9190/795 1345 E-mail: intl@kma.org Website: www.kma.org Kuwait Medical Association P.O. Box 1202 Safat 13013 KUWAIT Dr. Abdul-Aziz Al-Enezi, President Tel. (965) 5333278, 5317971 Fax. (965) 5333276 E-mail. kma@kma.org.kw / alzeabi@hotmail.com Latvian Medical Association Skolas Str. 3 Riga 1010 LATVIA Dr. Peteris Apinis, President Tel: (371) 67287321 / 67220661 Fax: (371) 67220657 E-mail: lma@arstubiedriba.lv Website: www.arstubiedriba.lv Liechtensteinische Ärztekammer Postfach 52, 9490 Vaduz LIECHTENSTEIN Dr. Remo Schneider, Secretary LAV Tel: (423) 231 1690 Fax. (423) 231 1691 E-mail: office@aerztekammer.li Website: www.aerzte-net.li Lithuanian Medical Association Liubarto Str. 2 2004 Vilnius LITHUANIA Dr. Liutauras Labanauskas, President Tel./Fax. (370-5) 2731400 E-mail: lgs@takas.lt Website: www.lgs.lt Association des Médecins et Médecins Dentistes du Grand- Duché de Luxembourg (AMMD) 29, rue de Vianden 2680 Luxembourg LUXEMBOURG Dr. Jean Uhrig, Président Tel: (352) 44 40 33 1 Fax: (352) 45 83 49 E-mail: secretariat@ammd.lu Website: www.ammd.lu Macedonian Medical Association Dame Gruev St. 3 P.O. Box 174 91000 Skopje MACEDONIA, FYR Prof. Dr. Jovan Tofoski, President Tel: (389-2) 3162 577/7027 9630 Fax: (389-91) 232577 E-mail: mld@unet.com.mk Website: www.mld.org.mk Society of Medical Doctors of Malawi (SMD) Post Dot Net, PO Box 387, Crossroads Lilongwe Malawi 30330 Lilongwe MALAWI Dr. Douglas Komani Lungu, President E-mail: dlungu@sdnp.org.mw Website : www.smdmalawi.org Malaysian Medical Association 4th Floor, MMA House, 124, Jalan Pahang 53000 Kuala Lumpur MALAYSIA Dr. Mary Suma Cardosa, President Tel: (60-3) 4041 1375 Fax: (60-3) 4041 8187 E-mail: info@mma.org.my Website: www.mma.org.my Ordre National des Médecins du Mali (ONMM) Hôpital Gabriel Touré Cour du Service d’Hygiène BP E 674, Bamako MALI Prof. Alhousseïni AG Mohamed, President Tel. (223) 223 03 20/ 222 20 58/ E-mail: cnommali@gmail.com Website: www.keneya.net/ cnommali.com Medical Association of Malta The Professional Centre Sliema Road, Gzira GZR 06 MALTA Dr. Steven Fava, President Tel: (356) 21312888 Fax: (356) 21331713 E-mail: martix@maltanet.net Website: www.mam.org.mt Colegio Medico de Mexico Adolfo Prieto #812 Col. Del Valle D. Benito Juárez Mexico 03100 MEXICO Dr. Ramón Murrieta González, Presidente E-mail: colegiomedicomexico. federacion@gmail.com Website: www.colegiomedicodemexico. org Associação Médica de Moçambique Avenida Salvador Allende, n° 560 1 andar, Maputo MOZAMBIQUE Dr. Rosel Salomao, President Tel: (258) 843 050 610 Fax: (258) 213 248 34 E-mail: associacaomedicamz @gmail.com Medical Association of Namibia 403 Maerua Park - POB 3369, Windhoek NAMIBIA Dr. Reinhardt Sieberhagen, President Tel. (264) 61 22 4455 Fax. (264) 61 22 4826 E-mail: man.office@iway.na Nepal Medical Association Siddhi Sadan, Post Box 189 Exhibition Road Katmandu NEPAL Dr. Kiran Prasad Shrestha, President Tel. (977 1) 4225860, 4231825 Fax. (977 1) 4225300 E-mail: mail@nma.org.np Website: www.nma.org.np 40 Royal Dutch Medical Association P.O. Box 20051 3502 LB, Utrecht NETHERLANDS Prof. A.C.Nieuwenhuijzen Kruseman, President Tel: (31-30) 282 32 67 Fax: (31-30) 282 33 18 E-mail: j.bouwman@fed.knmg.nl Website: www.knmg.nl New Zealand Medical Association P.O. Box 156, 26 h e Terrace Wellington 1 NEW ZEALAND Dr. Paul Ockelford, Chairman Tel: (64-4) 472 4741 Fax: (64-4) 471 0838 E-mail: nzma@nzma.org.nz Website: www.nzma.org.nz Nigerian Medical Association National Secretariat 8 Benghazi Street, Off Addis Ababa Crescent Wuse Zone 4, FCT, PO Box 8829 Wuse Abuja NIGERIA Dr. Prosper Ikechukwu Igboeli, President Tel: (234-1) 480 1569, 876 4238 Fax: (234-1) 493 6854 E-mail: info@nigeriannma.org Website: www.nigeriannma.org Norwegian Medical Association P.O.Box 1152 sentrum 0107 Oslo NORWAY Dr.Torunn Janbu, President Tel: (47) 23 10 90 00 Fax: (47) 23 10 90 10 E-mail: ellen.pettersen @legeforeningen.no Website: www.legeforeningen.no Asociación Médica Nacional de la República de Panamá Apartado Postal 2020 Panamá 1 PANAMA Dr. Rubèn Chavarria, President Tel: (507) 263 7622 /263-7758 Fax: (507) 223 1462 E-mail: amenalpa@cwpanama.net Colegio Médico del Perú Malecón Armendáriz N° 791 Miral ores Lima PERU Dr. Julio Castro Gómez, President Tel: (51-1) 213 1400 Fax: (51-1) 213 1412 E-mail: prensanacional@cmp.org.pe Website: www.cmp.org.pe Philippine Medical Association 2/F Administration Bldg. PMA Compound, North Avenue Quezon City 1105 PHILIPPINES Dr. Oscar D.Tinio, President Tel: (63-2) 929 63 66 Fax: (63-2) 929 69 51 E-mail: philmedas@yahoo.com Website: philippinemedicalassociation. org Polish Chamber of Physicians and Dentists (Naczelna Izba Lekarska) 110 Jana Sobieskiego, 00-764 Warsaw POLAND Dr. Konstanty Radziwill, President Tel. (48) 22 55 91 300/324 Fax: (48) 22 55 91 323 E-mail: sekretariat@hipokrates.org Website: www.nil.org.pl Ordem dos Médicos (Portugal) Av. Almirante Gago Coutinho, 151 1749-084 Lisbon PORTUGAL Dr. José Manuel Silva, President Tel: (351-21) 842 71 00/842 71 11 Fax: (351-21) 842 71 99 E-mail: intl@omcn.pt Website: www.ordemdosmedicos.pt Romanian Medical Association Str. Ionel Perlea, nr 10, Sect. 1 Bucarest ROMANIA Prof. Dr. C. Ionescu-Tirgoviste, President Tel: (40-21) 460 08 30 Fax: (40-21) 312 13 57 E-mail: amr@itcnet.ro Website: www.ong.ro Russian Medical Society Udaltsova Street 85 119607 Moscow RUSSIA Dr. Sergey Bagnenko, President Tel: (7-495) 734 12 12 Fax: (7-495) 734 11 00 E-mail. info@russmed.ru Website: www.russmed.ru/eng/who. htm Samoa Medical Association Tupua Tamasese Meaole Hospital Private Bag - National Health Services, Apia SAMOA Dr. Viali Lameko, President Tel. (685) 778 5858 E-mail: viali1_lameko@yahoo.com Ordre National des Médecins du Sénégal Institut d’Hygiène Sociale (Polyclinique) BP 27115 Dakar SENEGAL Prof. Lamine Sow, President Tel. (221) 33 822 29 89 Fax: (221) 33 821 11 61 E-mail: lamsow@orange.sn Website: www.ordremedecins.sn Lekarska Komora Srbije (Serbian Medical Chamber) Serbian Medical Chamber Kraljice Natalije 1-3 Belgrade SERBIA Dr.Tatjana Radosavljevic, General Manager E-mail: lekarskakomorasrbije@gmail. com Singapore Medical Association Alumni Medical Centre, Level 2 2 College Road 169850 SINGAPORE Dr. Chong Yeh Woei, President Tel. (65) 6223 1264 Fax. (65) 6224 7827 E-mail. sma@sma.org.sg Website: www.sma.org.sg Slovak Medical Association Cukrova 3 813 22 Bratislava 1 SLOVAK REPUBLIC Prof. Peter Krištúfek, President Tel. (421) 5292 2020 Fax. (421) 5263 5611 E-mail: secretarysma@ba.telecom.sk Website: www.sls.sk Slovenian Medical Association Komenskega 4 61001 Ljubljana SLOVENIA Prof. Dr. Pavel Poredos, President Tel. (386-61) 323 469 Fax: (386-61) 301 955 E-mail: matija.cevc@trnovo.kclj.si Somali Medical Association 7 Corfe Close, Hayes Middlesex UB4 0XE, United Kingdom SOMALIA Dr. Abdirisak Dalmar, Chairman E-mail: drdalmar@yahoo.co.uk The South African Medical Association P.O. Box 74789, Lynnwood Rydge 0040 Pretoria SOUTH AFRICA Dr. Ed J. Coetzee, President Tel: (27-12) 481 2036 Fax: (27-12) 481 2100 E-mail: GM@samedical.org Website: www.samedical.org Consejo de Médicos de España Plaza de las Cortes 11, 4a Madrid 28014 SPAIN Dr. Juan José Rodriguez-Sendin, Presidente Tel: (34-91) 431 77 80 Fax: (34-91) 431 96 20 E-mail: internacional@cgcom.es Website: www.cgcom.es Swedish Medical Association (Villagatan 5) P.O. Box 5610 SE - 114 86 Stockholm SWEDEN Dr. Marie Wedin, President Tel: (46-8) 790 35 01 Fax: (46-8) 10 31 44 E-mail: info@slf.se Website: www.slf.se Fédération des Médecins Suisses (FMH) Elfenstrasse 18 - C.P. 170 3000 Berne 15 SWITZERLAND Dr. Jacques de Haller, Président Tel. (41-31) 359 11 11 Fax. (41-31) 359 11 12 E-mail: info@fmh.ch Website: www.fmh.ch Taiwan Medical Association 9F, No 29 Sec.1 An-Ho Road 10688 Taipei TAIWAN Dr. Ming-Been Lee, President Tel: (886-2) 2752-7286 Fax: (886-2) 2771-8392 E-mail: intl@tma.tw Website: http://www.tma.tw/EN_tma Medical Association of Tanzania P.O. Box 701 255 Dar es Salam TANZANIA Dr. Namala Nkopi, President E-mail: kajuna2010@gmail.com Website: www. mat-tz.org Medical Association of Thailand 2 Soi Soonvijai New Petchburi Road, Huaykwang Dist. Bangkok 10310 THAILAND Pol.Lt.Gen.Dr.Jongjate Aojanpong, President Tel: (66-2) 314 4333/318-8170 Fax: (66-2) 314 6305 E-mail: math@loxinfo.co.th Website: www.mat.or.th Trinidad and Tobago Medical Association The Medical House, #1 Sixth Avenue Orchard Gardens Chaguanas TRINIDAD AND TOBAGO Tel: (868) 671-5160 Fax: (868) 671-7378 e-mail: medassocS@tntmedical.com Website: www.tntmedical.com Conseil National de l’Ordre des Médecins de Tunisie 16, rue de Touraine 1002 Tunis TUNISIA Dr. Mohamed Néjib Chaabouni, President Tel: (216-71) 792 736/799 041 Fax: (216-71) 788 729 E-mail: cnom@planet.tn Website: www.ordre-medecins.org.tn Turkish Medical Association GMK Bulvari, Sehit Danis Tunaligil Sok. N° 2 Kat 4 Maltepe 06570 Ankara TURKEY Dr. Eris Bilaloglu, President Tel: (90-312) 231 31 79 Fax: (90-312) 231 19 52 E-mail: Ttb@ttb.org.tr Website: www.ttb.org.tr Uganda Medical Association Plot 8, 41-43 circular rd. P.O. Box 29874 Kampala UGANDA Dr. M. Mungherera, President Tel. +256 772 434 652 Fax. (256) 41 345 597 E-mail. mmungherera@yahoo.co.uk Ukrainian Medical Association 7 Eva Totstoho Street PO Box 13 Kyiv 01601 UKRAINE Dr. Oleg Musii, President Tel: (380) 50 355 24 25 Fax: (380) 44 501 23 66 E-mail: sfult@ukr.net British Medical Association BMA House,Tavistock Square London WC1H 9JP UNITED KINGDOM Mr.Tony Bourne, Secretary General Tel: (44-207) 387-4499 Fax: (44-207) 383-6400 E-mail: vnathanson@bma.org.uk Website: www.bma.org.uk American Medical Association 515 North State Street Chicago, Illinois 60654 UNITED STATES Dr. Peter W. Carmel, President Tel: (1-312) 464 5291 / 464 5040 Fax: (1-312) 464 2450 E.mail: ellen.waterman@ama-assn.org Website: www.ama-assn.org Sindicato Médico del Uruguay Bulevar Artigas 1515 CP 11200 Montevideo URUGUAY Dr. Martin Rebella, President Tel: (598-2) 401 47 01 Fax: (598-2) 409 16 03 E-mail: secretaria@smu.org.uy Website: www.smu.org.uy Medical Association of Uzbekistan Str. Parkenentskay 51 Tashkent City UZBEKISTAN Prof. Abdulla Khudaybergenov E-mail: info@avuz.uz Website: www.avuz.uz Associazione Medica del Vaticano Stato della Citta del Vaticano 00120 Città del Vaticano VATICAN STATE Prof. Renato Buzzonetti, President Tel: (39-06) 69879300 Fax: (39-06) 69883328 E-mail: servizi.sanitari@scv.va Federacion MedicaVenezolana Av. Orinoco con Avenida Perija Urbanizacion Las Mercedes Caracas 1060 CP VENEZUELA Dr. Douglas Leon Natera, President E-mail: sgeneral@saludfmv.org Website: www. federacionmedicavenezolana.org Vietnam Medical Association 68A Ba Trieu-Street Hoau Kiem District Hanoi VIETNAM Dr.Tran Huu Thang, Secretary General Tel: (84) 4 943 9323 Fax: (84) 4 943 9323 E-mail: vgamp@hn.vnn.vn Zimbabwe Medical Association P.O. Box 3671 Harare ZIMBABWE Dr. Billy Rigawa, President Tel. (263-4) 791553 Fax. (263-4) 791561 E-mail: zima@zol.co.zw www.zima.org.zw iv Contents Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Research Ethics Committees: Identifying and Weighing Potential Benefit and Harm from Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 And Still, What is “Deontological Ethics”? . . . . . . . . . . . . 6 Is the Colombian Health System Equitable? . . . . . . . . . . . 9 The Education of Medicine in the Czech Republic . . . . . . 10 Continuous Medical Education: Physicians’ Professional Skills Improvement by Distance Learning . . . . . . . . . . . . . 11 Georgian Experience in Palliative Care Development – From Pilot Programs to International Collaboration . . . . . 13 EBM (Evidence Based Medicine), not an Absolute Reference but a Help for Making Decisions . . . . . . . . . . . 16 Combating Antimicrobial Resistance . . . . . . . . . . . . . . . . . 17 The World Federation of Public Health Association . . . . . 18 A Globalized World – and a Unified Global Approach for Health Professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 The Medical Association of Thailand . . . . . . . . . . . . . . . . . 22 Celebrating 125 Year Anniversary – NZMA Challenges and Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Development of Family Medicine in Estonia – from Nothing to Modern Specialty . . . . . . . . . . . . . . . . . . . . . . . 24 Turkish Medical Association (TTB) . . . . . . . . . . . . . . . . . 27 Serbian Medical Chamber . . . . . . . . . . . . . . . . . . . . . . . . . 30 Cyprus Medical Association (CyMA) . . . . . . . . . . . . . . . . 31 Mission 2012 – Taiwan Medical Association . . . . . . . . . . . 32 French Medical Association (AMF) . . . . . . . . . . . . . . . . . 33 Award for Physicians in The Republic of Kazahstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Nepal Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . 35 EU Umbrella Organizations Call for a Concrete EU-level Actionfor Better Adherence to Therapies . . . . . . 36 WMA Directory of Constituent Members . . . . . . . . . . . . 37