WMJ 03 2013

COUNTRY
• The Future of Global Health
• Physicians in Turkey
vol. 59
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
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Nr. 3, June 2013
Editor in Chief
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Latvian Medical Association
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81
Instead of Editorial
June is graduation month and approximately 700,000 young doctors
throughout the world will receive diplomas. These medical degrees
may be quite variable. In some countries non-traditional practitio-
ners, local medical specialists and dentists are counted as doctors,
whereas in others, physicians must undergo six years of rigorous
medical education before they get medical doctorates. Nonetheless,
they will all join the pool of doctors in the world and will become
serious players in the medical field within ten years.
Most of these doctors will greet the turn of the next century. In 2100
life expectancy is expected to be much longer than it is today.Continu-
ing population growth will add further stress to the healthcare system,
though eventually continued population growth will not be sustainable.
The number of old people, many of whom will have chronic ill-
nesses, will grow exponentially and the burden to society will be
tremendous. Most countries will be unable to support all the re-
tirees, so the retirement age will increase faster than the lifespan.
Doctors who graduate this year will probably have to work until
they are 80 to 85 years old. Just a century ago, no one thought that
it would be normal to be working at age 70, as is common today.
During these years, medicine will change so dramatically that much of
what graduating students have learned in medical school will be obsolete.
The rate of change is increasing, and there are projections that in the
21st
century the philosophy of medicine will change completely every
20 years.In the beginning of the 20th
century a sick patient was commit-
ted to bed rest and fed a calorie-diet rich.In the beginning of the 21st
cen-
tury,the same sick patient is mobilized and the calories may be restricted.
If aging genes or cancer-predisposing genes are discovered in the
next 20 years, medicine will go in a completely new direction. The
most important questions in medical ethics will be related to busi-
ness issues – expensive medications, gene therapy and cell trans-
plantation will not be accessible to everyone.While it might be pos-
sible to extend life indefinitely, this will no be available to everyone.
Welcome,young doctors,to the medical profession.Welcome to the
World Medical Association.
Editor in Chief, WMJ
Dr. Pēteris Apinis
On May 30, in the third and final reading the Latvian Parlia-
ment unanimously adopted amendments to the law “Protection
of the Rights of the Child” which among other things contain the
following:”Physical abuse is intentional application of force that
threatens the health or life of a child in contacts with the child,
including deliberate exposure of a child to the effects of harmful
factors, including tobacco smoke.”
Latvia has become the first country in the world where smoking in the
presence of a child regardless of the environment, a street or a private
apartment,is a violation of the law and will be considered a criminal act.
In Europe, 700 000 people every year die of direct effects of smok-
ing, but tens of millions of smokers die prematurely of cardiovas-
cular diseases, cancer or lung diseases. More than 60% of smokers
in Europe acquired the habit because their parents were smokers,
smoked in the presence of children and left the cigarettes unattend-
ed. Moreover, when smoking in the presence of their children, par-
ents send an implied message that smoking is not to be condemned
as mom or dad does it.
Recent studies reveal that the foetus can become addicted to nico-
tine if a pregnant woman smokes or has to breathe in tobacco smoke
regularly.
Unfortunately, children are dependent on their parents or other
adults and do not have sufficient information and life experience to
assess the dangers of smoking. Similarly, disabled people and those
who do not possess decision making capacity should be protected
from smoking in their presence.
The Ministry of Health of Latvia together with the Latvian Medi-
cal Association put forward further legislative proposals to reduce
smoking,especially among children and youth.Currently the Latvian
Parliament is reviewing amendments to the law “On Restrictions Re-
garding Sale, Advertising and Use of Tobacco Products”. Latvia aims
at legislation providing that any non-smoker has the human right
to breathe clean air instead of smokers having the right to smoke.
Hence, the next amendment to the Law will stipulate that in Latvia
smoking in the presence of other people (on the street,in a park,pub-
lic places, private territories) is permissible only after receiving their
consent. In Latvia smoking is already prohibited in cafes, restaurants,
clubs,sports stadiums and halls,workplaces and public premises.Now
balconies, terraces, staircase and many other places where smoking
can inconvenience other people will be added to the list.
Latvia supports designing plain cigarette packets like in Australia,
namely, 100% of the packet’s design informs about the harmful ef-
fects of cigarettes.However,understanding the different experiences
of European countries,Latvia’s proposal is a draft law providing that
75% of the packet’s design carries information on the dangers of
smoking, and calls on all European countries follow suit. Latvia’s
proposition: Smoke free Latvia in 2020, smoke free Europe in 2025.
Dr. Ingrida Circene,
Minister of Health of Latvia
Dr. Pēteris Apinis,
President of Latvian Medical Association
82
AUSTRALIAGlobal Health
The future of global health depends far more
on fundamental ecological and social determi-
nants than on progress for health technologies,
whether surgical, pharmacological or immu-
nological. There is a growing gap between the
optimism in official forecasts of development
and global health and the trend of the most
important health determinants. Without fun-
damental change to these, in turn requiring
a global shift in culture and measurements of
progress, the prospects for global health look
bleak. “Peak health” in the past has generally
referred to humans in their prime of fitness; in
the future it may be seen to refer to the time
when global life expectancy reached its maxi-
mum. That time may be within a decade –
but, if we can change sufficient practices, then
we might still improve global health through
this century.
“The prospect for the human race is sombre be-
yond all precedent. Mankind is faced with a
clear-cut alternative: either we shall all per-
ish, or we shall have to acquire some slight
degree of common sense. A great deal of new
political thinking will be necessary if utter
disaster is to be averted.” Bertrand Russell,
1945 [1].
Introduction
It is a truism within public health circles,
in contrast to much of the common un-
derstanding of health, that underlying
“determinants” are more important than
health technologies in explaining phenom-
ena such as life expectancy. For example,
mortality from infectious diseases such
as tuberculosis decreased, decades before
antibiotics, in industrialising countries of
Europe from the second half of the 19th
century. This has been widely credited to
improvements in housing and nutrition
[2]. More recently, however, there has been
increased appreciation that some medical
factors, especially smallpox vaccination,
also contributed to better health outcomes
[3, 5].
In the 18th
century, in the UK, civil society
also generated an expanded number of hos-
pitals, a trend which abated in the early 19th
century, when life expectancy declined in
England, the leading industrialised country
in the world,during a time when an extreme
form of capitalism often called laissez faire
dominated [5]. In this period, before wide-
spread labour organisation, inequalities and
squalor increased along with industrialisa-
tion. In Glasgow, faith in market forces also
contributed to a decline in state-supported
smallpox vaccinations from about 1820
[4, 6]. Ironically, this was just as Glasgow
was becoming known as the “second city of
the British empire”.
The surge of technical developments in re-
cent centuries is very impressive; from elec-
tricity to satellites and the internet. Most
of them have health applications. Tech-
nologies specific to health have also been
revolutionised, and the ambition of human
health interventions has greatly expanded.
A global highly organised campaign led to
the eradication of smallpox, and insecticides
and good public health have greatly reduced
the burden of malaria [7]. For patients with
funds, organ transplants are routinely avail-
able in some countries, if needed. The list
of such medical contributions to improved
health is very long,and their cumulative im-
pact is a powerful reason for the general be-
lief that technology is now more important
than deeper health determinants – and will
continue to do so.
However, while antibiotics have been dis-
covered, synthesised and used in great
quantities, resistance to them is also in-
creasing. Increased resistance to insecticides
also looms.Optimism for important vaccine
breakthroughs, from malaria to dengue, far
exceeds reality, though some progress has
been made, such as with a partly effective
defence against rotavirus [8].
But problems far worse than antibiotic
and insecticide resistance shadow future
global health. Especially fundamental are
ecological and social determinants, the se-
verity of which underpin the growing gap
The Future of Global Health.
Reasons for Alarm and a Call for Action
C. D. Butler P. Weinstein
83
AUSTRALIA Global Health
between the optimism in official forecasts
of development and global health and our
concern.
Because of these determinants, an increas-
ing number of scientific papers declare
openly that civilisation is at risk [9–12].This
article focuses on these underlying ecologi-
cal and economic determinants, and then
links them to future health prospects.
We assert that, without fundamental re-
form, associated with a shift in global cul-
ture and measurements of genuine progress,
the prospects for global health look bleak.
“Peak health” in the past has generally re-
ferred to humans in their prime of fitness;
in the future it may be seen to refer to the
time when global life expectancy reached
its maximum [13].That time may be within
a decade – but, if we can change sufficient
practices,then we might still improve global
health through this century.
Hubris, Economics
and Recession
Much of southern Europe is in severe re-
cession, and unemployment also remains
high in the U.S. Tent cities sheltering the
homeless have appeared in the most mili-
tarily powerful nation on Earth [14].These
are the modern equivalent of “Hoover-
villes” – shanty towns common in the
1930s, named after U.S. President Herbert
Hoover, who was in power on Black Friday,
October 29, 1929, at the onset the Great
Depression.
There are disturbing similarities between
the 1930s and the present time, and we
should not forget that earlier decades saw
the nurturing of fascism in Europe and cul-
minated in an even bloodier conflict than
the “War to End Wars”. Perhaps the most
important similarity between the time
leading to the Great Depression and our
own is the economic and cultural hubris of
those in power [15]. The U.S. stock market
boom of the 1920s was considered by the
herd of bankers, investors and politicians
in control at that time to be never-ending.
Sceptics who recalled the long history of
booms and busts, the best known of which
may be the Tulip Mania of 1636–37 [16].
were disregarded in what became a stam-
pede to lock in profits, and then a rout, as
people were left holding near-worthless
bulbs, when they had formerly possessed
a house.
For a while, the series of global catastro-
phes and tragedies that unfolded between
1914 and 1945 – two World Wars and the
Great Depression – seemed to offer hope
of a new, fairer world order [17]. Interna-
tional idealism was evident at high levels,
fostering the birth of the United Nations
institutions and declarations, including
for Universal Human Rights, a new ideal
for which former U.S. First Lady, Eleanor
Roosevelt, had been instrumental [18].
Post war U.S. President Harry Truman,
who had ordered the atomic attacks on
Japan, quickly became troubled by the aw-
ful potential of nuclear weapons and took
steps to reduce their control by the U.S.
military.. Truman is said to have recoiled
from their further use, argued by some to
be justified by the Korean War [19]. Yet,
within another few years the U.S. adminis-
tration was openly contemplating the con-
ventional use of tactical nuclear weapons
(including in limited wars) and the Cold
War was heating up [19].
About this time, the Canadian-born econo-
mist JK Galbraith was warning of the likeli-
hood of future speculative financial bubbles:
No one can doubt that the American people
remain susceptible to the speculative mood–to
the conviction that enterprise can be attended
by unlimited rewards in which they, individu-
ally, were meant to share. A rising market can
still bring the reality of riches. This, in turn,
can draw more and more people to participate.
The government preventatives and controls are
ready. In the hands of determined government,
their efficacy cannot be doubted. There are,
however, a hundred reasons why a government
will determine not to use them [20].
Galbraith wrote this in 1955. Although
numerous economic bubbles burst in the
following decades [20], the next great
global economic crash was delayed until
2008, more than fifty years later. This pre-
cipitated today’s Great Recession, which
to date has persisted for five years, with
no end yet in view. Soon after the crash,
English Queen Elizabeth II visited the
London School of Economics, where she
asked why so few experts had predicted
this second great financial crash it. A re-
sponse stated in part:
“Financial wizards” managed to convince
themselves and the world’s politicians that they
had found clever ways to spread risk through-
out financial markets – whereas “it is difficult
to recall a greater example of wishful thinking
combined with hubris” [21].
Developmental and
Environmental Hubris and
the 2015 Hunger Targets
Even less well-recognised than the risks of
economic hubris, civilisation today faces
dangers grounded in the interaction of
planetary environmental and social factors
[22–24]. Nevertheless, living conditions,
and life expectancy for the more privileged
global middle class or “second claste” [17]
may be protected for some decades, even if
these trends remain unaltered.
There are many components to this risk (see
box), and many ways that these dimensions
can be described. Importantly, the risks to
global health extend far beyond climate
change [25]. Above all, it is their systemic
nature which is the most troubling. For ex-
ample, an important response to the grow-
ing scarcity of cheap oil has been to convert
food crops to ethanol and biodiesel. Almost
84
40% of the U.S. maize crop (and over 16%
of the global crop) is now used for ethanol
[26,  27]. A non-trivial fraction of other
foodcrops are also used for fuel, from palm
oil to sugar cane and cassava.This diversion
of food to fuel adds appreciably to global
food prices, and José de Silva, the newly
appointed head of the FAO, has recently
called on the US to lower the percent-
age of maize diverted to ethanol, so as to
lower global food prices [28]. The diversion
of food to fuel also threatens biofdiversity
(because of the associated replacement of
native forest with monoculture, for example
oil palm), and as we shall see below a loss of
biodiversity in itself poses serious threats to
human health.
Only a few of these elements can be dis-
cussed in any detail in this article. Funda-
mental to most analyses, however, is the
principle common to all currently dominant
economic systems, whether based on redis-
tribution (i.e. leftist or socialist) or market
forces (i.e. rightist), which is the failure to
properly account for two forms of hazards.
These hazards are the depletion of natural
resources (both non-renewable and renew-
able) and the accumulation of waste. The
failure to measure either harm is especially
pronounced when the damage accrues to
people who are far away,whether in physical
distance, culture, or time, including future
generations.
Depletion of non-renewable natural re-
sources, such as oil and other fossil fuels
impacts directly on global health. The ris-
ing cost of energy not only lifts the price
of food, but also makes it harder and more
costly for civilisation to develop the infra-
structure which may one day free us from
dependency on these dangerous and pol-
luting fuels. Depletion of renewable natu-
ral resources, especially biodiversity and
intact forests is also problematic. We are
dependent on healthy, sustainable ecosys-
tems for food, water, fibre, and fuel. While
provisioning ecosystem services (such as
for food and fuel) continue to increase, this
is at the expense of regulating ecosystem
services [29], which are vital for a stable
climate, for adequate fresh water, and to
reduce runaway growth of unwanted spe-
cies population increases, such as jellyfish
swarms [30].
It is also becoming increasingly clear that
indirect effects of biodiversity decline in-
clude epidemics of emerging infectious
diseases: When biodiversity is lost, the
likelihood is increased of disease vectors be-
coming increasingly prevalent [31–33].
The second problem – the failure to account
for waste – may result from the long evo-
lutionary human experience as “patch dis-
turbers” [34]. For millennia, humans were
migratory,and our numbers small compared
to the resources and landscape. Our species
could disrupt its local environment and
then move on. Even after the development
of settlements, local pollution was generally
manageable; most wastes were organic, and
quickly broke down – though the failure to
safely dispose of human faeces and in some
cases urine did contribute to various infec-
tious diseases, including cholera, hookworm
and schistosomiasis. The close proximity of
humans and animals living together also re-
sulted in a number of ‘host jumping’ events,
wherein animal pathogens crossed into hu-
man populations.
Economic systems are fundamental, be-
cause they supply incentives, operant at
multiple levels, including global in the form
of price signals, to act in ways that either
hinder or facilitate the sustainability of ci-
vilisation and thus the chance of reasonable
global health. Today, most financial incen-
tives operate to deliver short-term benefit
for those who are privileged, but to pile on
disadvantage and risk to those who are al-
ready poor and vulnerable.
The complacency and misunderstanding
which are generating these risks is re-
Major under-appreciated risks
and solutions to global health
– A global lack of leadership, bolstered
by a retreat from aspirations of global
civilisation by the first and second
“clastes”.
– Climate change, especially its impact on
food security, migration and conflict.
– Rising energy costs.
– Impending phosphate scarcity.
– Limits to yield growth of major crops
in Europe, the U.S., China, and India.
– Biodiversity loss.
– Diminishing returns to increasing
complexity.
– Youth bulges and the risk of con-
flict and declining governance on the
“front-line”.
– The awakening of “sleeping” infectious
disease pandemics in the threatened
new milieu of chaos.
Potential solutions
– New technologies, especially solar,
which make fossil fuel uncompetitive.
– Revived global leadership, especially a
re-awakening of aspirations for educa-
tion and health for all.
– Improved human rights, especially for
women.
– Better treatment of parasitic and other
neglected diseases.
– Less wastage of food, pre and post-
harvest.
– Greater care to recycle phosphate and
reduce its waste.
– The ascendancy of ecological economic
systems.
AUSTRALIAGlobal Health
85
vealed by global attitudes towards hunger
targets. At the time of the World Food
Summit in 1996, great progress had been
made in reducing the fraction of the world
population classed as chronically under-
nourished. The proportion of hungry peo-
ple globally almost halved between 1970
and 1996, due to the success of the Green
Revolution (see Figure). At that summit,
it was announced that the hunger target
for 2015 would be to reduce the number
of people classed as chronically hungry in
1990 (850 million) by half (to 425 mil-
lion) [35]. This number represents 6% of
an estimated global population of 7.2 bil-
lion in 2015.This promise will not be kept;
its failure cannot principally be attributed
to climate change, though that is now of
growing importance.
Full discussion of this little-noticed failure
to reduce global hunger are complex and
is not possible here. One factor includes
the intransigence of Catholic teachings on
contraception; a ruling whose power seems
inversely proportional to the distance from
Rome. Slowing population growth enhanc-
es economic growth, and makes the prob-
lem of food distribution easier [37].
Many commentators on the political Left,
certainly since Karl Marx (a trenchant critic
of Malthus) [38] have argued that the prob-
lem with food-poverty is primarily one of
distribution, rather than supply. However,
the decline in hunger between 1970 and
1996 coincided with a large increase in per
person food supply, especially of grain [39].
In recent years, total food supply, when ad-
justed for biofuels (food which cannot be
eaten), has been either static or in decline
[36]. Irrespective of the wishes of idealists,
world hunger is unlikely to be substantially
solved by redistribution, though reduced
food waste in low-income countries, espe-
cially India, could surely reduce rural hun-
ger.
The 2015 hunger targets could have been
on track (and could still be reached, even
starting from today) by sufficient redis-
tribution of food and the other resources
needed to enable secure food entitlement
[40]. However, to argue that the failure of
the hunger goals lies primarily in the fail-
ure of redistribution is very unrealistic. It
is also very unlikely that the framers of the
1996 World Food Summit goals thought
that their target could be thus achieved
by redistribution. Rather, they most likely
believed that the progress made between
1970 and 1996, in greatly expanding food
supply per person, could simply continue.
But the chance of such additional food was
in reality no more likely at possibility had
no more credibility than that stocks would
keep rising, predictions made by econom-
ic pundits at the height of stock market
booms.
This statement may sound too harsh,but not
to those who signed or studied the World
Scientists Warming to Humanity, now two
decades old [41]. Signatories included more
half of the Nobel Prize laureates for natural
science then alive.The list included Norman
Borlaug, who had been awarded the Peace
Prize in 1970, for his work in developing
the Green Revolution. The collective state-
ment warned:
We the undersigned, senior members of the
world’s scientific community, hereby warn all
humanity of what lies ahead. A great change in
our stewardship of the earth and the life on it is
required, if vast human misery is to be avoided
and our global home on this planet is not to be
irretrievably mutilated.
The reasons for the failure of the 1996
and 2000 food targets (for 2015) lie far
more with wishful thinking and a failure
to understand limits to growth than with a
failure of redistribution. The success in re-
ducing hunger in the heyday of the Green
Revolution was not primarily because of
redistribution, but because food supply per
person expanded dramatically in that pe-
riod.
Probably the single most important reason
for the failure to reach the 2015 hunger
goals is that the crop and technological
improvement which led to the enormous
1970 1980 1990 2000 2010 2020
30
25
20
15
10
5
0
World Food Summit target
Percenthungry
Global financial crisis
MDG
target
Green revolution
failed trend
Figure. From 1960 until about 1996 great progress was made in reducing global hunger. A
failure to understand the reality of limits to growth led to wildly optimistic targets for
2015. Raw data FAO, to 2011. FAO data in 2012 revised these data, making the target
look less out of reach [36].
AUSTRALIA Global Health
86
increase in yield facilitated by the Green
Revolution (albeit dependent on energy-
intensive fertilisers, pesticides and water)
had largely been achieved by about 1990.
Yields continued to increase, but at di-
minishing rates. In some cases, including
rice in China, wheat in India, and irrigated
maize in the U.S, they have entirely flat-
tened [42]. Indeed, Borlaug broadly fore-
cast these developments in his Nobel Peace
Prize acceptance speech, in 1970, in which
he also called for the kerbing of population
growth [43].
Since about 1990 considerable effort has
gone into trying to replicate the Green
Revolution’s success, using genetically mod-
ified crops. The effort in promoting GMOs
has not been well spent [44]. Much this
research has been to improve weed control
through the development of crops such as
canola and corn modified to be resistant to
the herbicide glyphosate. But, as predicted
at least as early as 1996 [45], selection pres-
sure has driven the evolution of glyphosate
resistant weeds [46].
Some work has attempted to develop ge-
netically modified crops for use in the Third
World that are resistant to drought and dis-
ease; however, the results have so far fallen
far short of their promise. At the same time,
complex factors have prevented the Green
Revolution from penetrating far into Africa
[47]. The Millennium Development Goal
(MDG) for hunger, set in 2000, was slightly
less ambitious than the 1996 target [48].
Neither has much progress been made to-
wards it.Furthermore,since the onset of the
Great Recession, little noticed by wealthy
populations, famines have returned to the
African countryside, to Somalia, Sudan
and Niger. At least some of the causation
for the famine in the Horn of Africa is due
to human-induced climate change [49, 50].
There is also increasing recognition that the
chronic food insecurity in Niger is related
to that nation’s high population growth.
Half of the people in Niger are aged under
15 [51].
Economics, Energy
and Recessions
Our dominant economic systems, whether
capitalist or communist, evolved and be-
came dominant in the last two centuries, at
a time when global resources were abundant
and generally increasing, even on a per-
person basis. The price of energy was his-
torically low in most of this period, as was
the price of food [52]. Despite the warning
of one of the most eminent fathers of eco-
nomic theory, John Stuart Mill [53],“steady
state” systems, which preferred qualitative
to quantitative growth were scorned.
The discipline Mill helped establish, most
commonly called ecological economics
[54,  55], remains as marginalised today
[56]. as the analysis of the rare critics who
(correctly) questioned the wisdom of mak-
ing “sub-prime”loans to impoverished U.S.
house buyers in 2007. This is the case even
though a major component of the seem-
ingly intractable global recession is the
persistently high price of energy. Despite
claims disputing the reality of “peak oil”
[57]. energy prices remain very high glob-
ally, even during the current deep recession
[58]. The former U.K. chief scientist, Sir
David King, recently co-authored a paper
in Nature which pointed out that consum-
ers in the European Union and the U.S.
each spend $1 billion dollars per day im-
porting energy, greatly reducing the money
circulating in the local economy. These
funds could stimulate domestic employ-
ment [59].
Optimists have predicted that the discov-
ery of large supplies of shale gas and new
technologies that allow increased recovery
of “tight” oil mean that a new global en-
ergy glut is unfolding with a consequent
impending price drop. Others dispute this,
including the Post Carbon Institute [60].
A major report underlying this optimism
[57]. completely ignored the concept of
“net energy”, or “energy return on energy
investment” [61]. One way to conceptual-
ise this is by thinking of stocks and flows.
The total stock of fossil fuel has expanded,
but the rate at which it can be withdrawn
has altered little, so that total annual supply
remains constrained. A medical analogy is
the birth of twins. A uterus may have two
fetuses, but they can only be delivered one
at a time, even by Caesarean.
A major reason for this is that much “un-
conventional oil” is extremely energy-in-
tensive to extract, such as the Canadian tar
sands. At least a fifth of the energy con-
tained in these fields is required to extract
the remaining energy, giving an energy
return, at the best case, of 4:1[61]. Off-
shore wells from Brazil are so remote that
helicopters must be refuelled in mid-air in
order for drillers to reach their platforms
[58]. These discoveries and new technolo-
gies may mean that the world oil produc-
tion experiences a “bumpy plateau” rather
than a sharp peak, and it seems also likely
to delay really steep price rises (e.g. above
$200/barrel), partly because high prices
generate a deepened recession, temporarily
lowering demand [61].
A sustained decline in the price of liq-
uid fossil fuels appears unlikely. But even
if fossil fuel prices fall substantially, relief
to the global economy is likely to be only
temporary, unless that energy bonus can be
used to build the technological and energy
revolution that is so badly needed, which
can wean civilisation from “Earth poisons”
such as coal and radioactivity. But without
greatly improved leadership, humanity is
likely to squander that chance. High energy
prices may in fact be the best way to drive
the creation of new technologies (such as
new-generation photovoltaic), because the
constrained supply acts as a de facto carbon
price, applicable globally except in those
few countries which export abundant oil,
and which continue to heavily subsidise the
price of fuel, often at the same time creating
high traffic density and localised air pollu-
tion.
AUSTRALIAGlobal Health
87
Moving from Social to Eco-
Social Health Determinants
Recently there has been a welcome revival
of interest in the “social determinants” of
health. In short, this thinking points out the
impossibility of good health when people
are poor, either materially or relatively. In-
equality appears to be an important health
determinant, perhaps rivalling undernutri-
tion in some societies. The core solution to
inadequate social determinants is either to
redistribute the existing “cake” or to bake a
bigger cake, perhaps preferentially distrib-
uting the increment to those who are only
receiving crumbs.
However laudable these approaches are,
they do not contribute sufficiently to solv-
ing the problem of limits to growth. The
case of energy and food has been extensively
discussed above.While redistribution of ex-
isting energy supplies would alleviate fuel
poverty for many, it would neither lower the
price of electricity nor increase the supply of
oil.The same analysis applies for phosphate,
an essential element which must be mined
or recycled and which like oil is declining in
quality and quantity [62].
Therefore, there needs to be commensurate
awareness of the environmental health de-
terminants, including ecological ones.These
may be renewable – such as fish stocks, bio-
diversity and fresh water – or non-renew-
able, such as fossil fuels, phosphate and ar-
able land.
Also necessary is a greater recognition of
the links between social and environmen-
tal factors,such as between conflict,migra-
tion and resource scarcity. The co-mingled
causation of many eco-social phenomena
is contested, sometimes bitterly. For ex-
ample, the Rwandan genocide of 1994–
together with many other conflicts in
Africa and elsewhere – are often analysed
as purely social events rather than inter-
actions between ecological events. This is
especially true for resource scarcity, most
often of land and social factors. An excel-
lent rare exception was published in the
Journal of Economic Behaviour and Organi-
zation [63].
Most wars concern the struggle for re-
sources, but this purpose is often disguised.
The invasion of Iraq in 2003 had much to
do with the struggle to control that nation’s
oil supplies. Rupert Murdoch forecast that
oil would fall to $20 per barrel [64]. How-
ever, the link to oil was vigorously denied
by the leaders of the U.S., U.K. and Aus-
tralia.
A more recent example is the displacement
of about 400,000 people in the northeaster
Indian state of Assam in 2012 [65]. This is
generally characterised as a clash between
Muslims and the indigenous people, the
Bodo, who are largely Christian or animist.
Depending on their bias, pundits discuss
different events as triggering factors. How-
ever, too few analysts, including academics,
consider that the problem is one of insuffi-
cient land and other resources for the wants
and needs of the population. True, some
people in such areas could voluntarily live in
more extreme poverty,thus enabling a high-
er population density. But that strategy be-
comes self-defeating, because such poverty
leads to increased weakness and vulnerabil-
ity, creating the potential for displacement
by more powerful groups or populations. In
practice, each of the main groups in Assam
has sought to increase its living standard by
means such as improved technology, better
fertiliser, remittances and also by utilising
all available resources, including fertile land.
This competition creates dry tinder, requir-
ing only a small spark for violence to catch
fire.
An increasing number of social scientists
recognise the links between earth system
limits (including planetary boundaries)
and human well-being [66,  67]. At the
same time, a slowly increasing number of
health workers also recognise these links
[22, 24, 68, 69].
Migration
Migration, including the seeking of politi-
cal asylum,has recently been most frequent-
ly characterised as having an “economic”
causation, that is, purely social; in the sense
that the economic problem could be solved
by enough social cleverness. However, eco-
nomic factors are associated with elements
that are both material (food, shelter) as well
as social (freedom of association and speech,
psychological security).
Despite growing understanding of the in-
teractions,wealthy populations are reluctant
to accept this argument. In countries such
as Australia the fiction of purely econom-
ic refugees is used widely in the media to
reduce feelings of guilt and responsibility,
including about climate change, with its
spectre of rising sea levels and other con-
tributory drivers of migration.
Australia, a signatory to the refugee con-
vention, does eventually settle – usually after
years of confinement – most people who
seek asylum and who are able to reach an
Australian territory. However, the entre-
preneurs who are paid by asylum seekers to
bring them to Australia (a lawful act) are
universally vilified as “people smugglers”.
Would a sympathetic German helping
someone escape from Auschwitz to Swit-
zerland be denigrated this way?
Health
We have written here much more about
the determinants of health than health it-
self. Clinicians are familiar with the art
and science of diagnosis and treatment, but
rarely consider why their patients may suf-
fer a chronic disease or engage in such risk-
taking behaviour as smoking. If clinicians
do start to ponder this, then they venture
into public health territory, a field in which
practitioners routinely consider population-
scale factors that influence health, such as
calorie intake and cigarette advertising. In
AUSTRALIA Global Health
88
this paper we have only sketched the nu-
merous links between the planetary envi-
ronmental determinants mentioned and
health.
The most important mechanism is unlikely
to be a sudden ecological catastrophe that
ends food production, though an intensi-
fied loss of pollinators, vital for food, is oc-
curring [70]. More plausibly, as limits to
growth tighten, competition among people
and between human groups will increase,
leading to intensified regional scarcity, con-
flict and misery.
A recent spate of self-immolations in Bul-
garia has been driven by poverty and in-
equality. Conflict over resources in Chech-
nya can have ramifications in Boston.Rising
prices of food and oil in Egypt threaten to
deepen unrest there. Globalisation links di-
verse populations via trade; but unless the
wealth it creates is shared equitably – at
least to a minimum standard, then resent-
ment and occasional terror will also be ex-
changed [71].
Climate change is expected to impact on
human health in numerous ways, classified
by Butler and Harley as primary, secondary
and tertiary [25, 72]. In brief, these include
direct (“primary”) effects (such as from
heatwaves or extreme weather events),
less direct “secondary”effects such as from
changes in insect vector populations or the
rate of growth of parasites within vectors
in warmer environments, and “tertiary”
effects. These occur when climate change
acts as a “risk multiplier” for events such as
conflict, famine and large-scale migration.
Some analysts think that the Syrian con-
flict has been worsened by climate change
[73].
Even without conflict, rising food prices
increase the risk of undernutrition and
(perhaps paradoxically) also of obesity, as
populations strive to conserve calories at
the expense of micronutrients. Chronic
under- or unemployment can be devas-
tating for self-esteem and mental health.
Resultant poverty can stress families and
reduce the intergenerational transmission
of love and nurturing that is essential for
population health to flourish. Although
we have not argued that health care is the
major health determinant, it is a factor.
Recessions make it harder for the poor to
pay for health care. In many locations ill-
nesses are an important cause of impov-
erishment.
From Describing the
Problem to Outlining
the Solution
These problems may seem intractable but
solutions exist. The mainstream approach
has two main prongs. The first strategy is
to deny the existence of any fundamental
problem, such as a limit to growth or con-
sumption, and trust that ingenuity, invest-
ment and market forces will find a solution.
This approach has had isolated success,
most notably the “Green Revolution” de-
scribed above. Today, civilization is like a
man falling to Earth without a parachute,
regarding his velocity as the chief indicator
of progress.
The second strategy is scarcely discussed.
That is to fortify the walls, moats and elec-
tronic surveillance mechanism that sepa-
rate and try to protect wealthy populations
from the masses. This approach can be seen
at the border between Europe and North
Africa, the U.S. and Mexico, and Australia
and Asia. It also is evolving between India
and Bangladesh, which can now be called
the world’s “biggest human cage”, due to
the fence that India has been constructing
along most of its border.
Neither of these solutions is tenable over the
long run. The solution instead must lie in
an intellectual and social revolution which
overturns our dominant ways of thought.
We must collectively develop the new ways
of thinking called for by such visionaries
such as Bertrand Russell, Albert Einstein
and Martin Luther King.
Some of these visionaries have worked in
health, including Albert Schweitzer, René
Dubos and Frank Fenner. Health organ-
isations including The International Phy-
sicians for the Prevention of Nuclear War
(IPPNW), Physicians for Social Responsi-
bility (PSR) and the International Society
of Doctors for the Environment (ISDE)
exist,and collectively can work to reduce the
threats we face. Perhaps the leading medical
aid group, Médecins Sans Frontières, will
also take a more active role in calling for
improved health determinants.
Another, alternate, solution has emerged:
the accelerating power of the internet. An
example of how it can be used as a force
for change is the use of low-cost mobile
phones for internet access in Kenya, which
could provide a model for other African
countries [74]. Many traditional authori-
ties lament the demise of print media, but
some optimists think that the rise of social
electronic media may be more democratiz-
ing than newspapers have been in recent
years,controlled by oligarchs such as Rupert
Murdoch.
Academics can contribute by greater recog-
nition of the dangers that exist and by writ-
ing about solutions. A recent special issue
in The Lancet was devoted to human popu-
lation numbers and health [75]. Melinda
Gates has also recently spoken of the need
to slow global population growth [76, 77].
A meeting to commemorate the 350th
an-
niversary of the Royal Society accepted the
peril we face is real, and warned of the risk
of pessimism as a response [68]. The Royal
Society report People and Planet will also
serve to relegitimise discussion of family
planning and limits to growth [51].
The fact that such reports are seen as
groundbreaking shows how far we have to
come.These themes were widely recognised
AUSTRALIAGlobal Health
89
in the 1970s, a decade which experienced
the first Earth Summit in Stockholm, pub-
lication of the report to the Club of Rome
called The Limits to Growth [78] and the
coining of the phrase “development is the
best contraceptive” [79]. It still is.
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C. D. Butler
Faculty of Health, University of Canberra,
Bruce, ACT 2601, Australia
E-mail: colin.butler@canberra.edu.au
P. Weinstein
Barbara Hardy Institute,
University of South Australia,
Adelaide, SA, Australia
The 66th
session of the World Health As-
sembly (WHA) took place in Geneva from
20–28 May. It was attended by many rep-
resentatives from the World Medical As-
sociation.
In the days leading up to the Assembly, the
WMA had joined organisations from the
Safeguarding Health in Conflict Coalition
in sending a letter to Dr. Margaret Chan,
Director General of the World Health Or-
ganisation, urging her to use her opening
address to the Assembly to condemn the
continuing violence against health person-
nel in Syria.
So when the Assembly was opened on the
Monday by Dr. Chan, the WMA leaders
welcomed her words condemning violence
against health personnel.
Director General’s
Opening Address
Dr. Chan declared: ‘WHO is aware of re-
ports of assaults on health personnel and
health care facilities in conflict situations.
We condemn these acts in the strongest
possible terms. Conflict situations sharply
increase the need for health care. I cannot
emphasize this point enough. The safety of
facilities and of health care workers must be
sacrosanct.’
In other issues referred to in her address
Dr.  Chan spoke about two new diseases
currently facing the world, human infec-
tions with a novel coronavirus and the first-
ever human infections with the H7N9 avian
influenza virus. ‘These two new diseases re-
mind us that the threat from emerging and
epidemic-prone diseases is ever-present’,
she said.
She went on to talk about the place of
health in the post-2015 development
agenda and the need to ensure that health
occupied a high place on the new develop-
ment agenda.
World Health Assembly Week
91
WMA news
‘Investing in the health of people is a smart
strategy for poverty alleviation. This calls
for inclusion of non-communicable dis-
eases and for continued efforts to reach the
health-related MDGs after 2015.’
She talked of the success in treatments for
HIV and encouraging progress on tubercu-
losis and malaria. The past two decades had
seen dramatic improvements in health in
the world’s poorest countries, but she added
that WHO would never be on speaking
terms with the tobacco industry. However,
she did not exclude cooperation with other
industries that had a role to play in reducing
the risks for NCDs.
Junior Doctors Network
The WMA leaders who travelled to Ge-
neva for the Assembly began by attending
a highly successful meeting held by the As-
sociation’s Junior Doctors Network. This
discussed the issues likely to be raised at the
Assembly as well as the various projects be-
ing pursued by the JDN, including a white
paper on physicians’ wellbeing, a policy pa-
per on the ethical aspects of global health
education and an environmental scan of
post-graduate medical education examining
conditions for junior doctors in training in
countries around the world.
WHPA Luncheon
On the first day of the Assembly, the World
Health Professions Alliance held a lun-
cheon at which it issued a major new state-
ment on collaborative practice.
The global bodies for the five leading health
professions, representing more than 26 mil-
lion health professionals worldwide, called
for a new emphasis on collaborative prac-
tice.They said that health professions work-
ing together around the world can lead to
improved health services and a more effec-
tive use of resources.
The Alliance,bringing together the Interna-
tional Council of Nurses, the International
Pharmaceutical Federation, the World
Confederation for Physical Therapy, the
World Dental Federation and the World
Medical Association, informed that health
service users around the world can experi-
ence duplication, gaps and discontinuity in
the health system. Yet, effective collabora-
tion between different professions and ser-
vice can prevent this and lead to improved
access to services, more user involvement in
decision-making, more responsive services,
better use of resources, reduced incidence of
disability and increased job satisfaction of
health professionals.
WHPA called on governments to fund
structures which supported interprofes-
sional collaborative practice (ICP). The
structures of health systems around the
world should enable ICP, educational sys-
tems should promote shared learning, and
health professionals needed to respect each
other’s expertise.
Dr. Cecil Wilson, President of the WMA,
underlined that once the individual contri-
butions of all professionals are recognised,
there is more likely to be appropriate refer-
ral and a good matching of competencies to
a person’s needs. ‘High quality patient care
is most likely to be achieved when health
professionals work together as a team. In
an increasingly complex and fast-moving
medical world, it is safer and more efficient
when health professionals collaborate to the
full extent of their training and experience.’
Rosemary Bryant, President of the Interna-
tional Council of Nurses, said: ‘Health pro-
fessionals strive to deliver high quality ser-
vices within their scope of practice and with
respect for the expertise of other members
of the team. This is a challenge that health
professions can address positively together
and with other agencies.’
Michel Buchmann, President of the Inter-
national Pharmaceutical Federation, said:
‘Evidence shows that effective interpro-
fessional collaborative practice leads to a
comprehensive, coordinated and safe health
system that better meets the needs of people
and their communities.’
Marilyn Moffat, President of the World
Confederation for Physical Therapy, stated:
‘Effective interprofessional collaborative
practice brings benefits in every area of
health services – from health promotion,
through injury prevention to condition
management. Working together, profes-
sionals can effectively address pressing
societal health needs such as the growing
burden of non-communicable diseases and
their risk factors.’
Orlando Monteiro da Silva, President of
the World Dental Federation, assured: ‘The
World Health Professions Alliance will
promote interprofessional collaborative
practice through advocacy, by example and
by promoting educational, legislative and
health system changes that bring about and
strengthen interprofessional collaborative
partnerships.’
WMA Luncheon
Seminar
The following day the WMA held its an-
nual luncheon seminar on the theme ‘Influ-
enza: We can do better!’
Dr. Cecil Wilson highlighted the unaccept-
ably low level of immunization rates among
health care professionals. He said that sea-
sonal flu might seem a harmless infection
that people got every year and then got over
it within a week or so. But, in fact, it was a
significant global health threat that was fre-
quently overlooked.
‘Flu is harmless only at first glance. Ac-
cording to the World Health Organization,
influenza outbreaks cause about 250,000 to
500,000 deaths per year globally. The US
Centers for Disease Control and Prevention
92
WMA news
(CDC) estimate that an average season of
influenza results in tens of thousands of
deaths and as many as 200,000 hospitaliza-
tions due to influenza-related causes in the
US alone.’
Dr. Wilson stressed that the risk of com-
plications associated with influenza is the
highest among older persons, young chil-
dren, patients with underlying medical
conditions and pregnant women. These are
the populations that frequently are around
health professionals by virtue of attending
clinics, hospitals and doctors’ offices. 
He added: ‘Therefore, healthcare profes-
sionals play an important role in both trans-
mitting and preventing the virus. The good
news is that a safe and affordable vaccine
is available against influenza. But the bad
news remains that healthcare professionals’
immunization rates are unacceptably low,
even in developed countries.’
According to the CDC, the healthcare
workers’ vaccination coverage used to be
around 40 per cent in the US.However,that
changed in 2010 when the Veterans Health
Administration healthcare facilities vacci-
nated 64 per cent of employees through the
system-wide “Infection: Don’t Pass It On”
campaign. 
‘We have peer-reviewed evidence that as
the percentage of immunized healthcare
professionals goes up, healthcare-associated
influenza goes down. We also know that
educational campaigns in immunization
work.’ 
Dr.Wilson said that with the support of the
International Federation of Pharmaceutical
Manufacturers and Associations the WMA
had launched a global campaign to promote
influenza immunization among physicians
as a means of protecting their health and
the health of their patients. Before launch-
ing the campaign, the WMA had surveyed
its member associations, representing 102
countries worldwide, and all the respon-
dents had stressed the need for more infor-
mation and global advocacy on the need for
immunization of healthcare professionals.
Seventy seven per cent of respondents had
asked for toolkits with facts and figures as
the most useful advocacy material, followed
by web-based resources and draft letters to
governments. 
He said that getting a flu shot is a rou-
tine task that every healthcare professional
should be performing every year. Physician
vaccination practice also has the extra ben-
efit of encouraging patients to follow their
doctors’ lead, as physicians are the best role
models for healthy behaviours.
‘Immunizing physicians against influenza
represents a standard of quality care. We, as
an organization speaking on behalf of more
than 9 million physicians globally, are say-
ing today that we can do better!’
The first guest speaker introduced by Dr.
Wilson was Dr. Ingrida Circene, Minister
for Health of the Republic of Latvia. The
title of her speech was ‘ Influenza: The poli-
cies on immunization and health systems’
role in ensuring health workers vaccination’.
She said that illness from influenza result-
ed in hospitalisations and deaths, mainly
among high risk groups. There were three
to five million cases worldwide of severe ill-
ness. But among healthy adults, influenza
vaccine could prevent between 70 to 90 per
cent of influenza-specific illness. Among
the elderly, the vaccine reduced severe ill-
ness and complications by up to 60 per cent
and deaths by 80 per cent.
Dr. Circene continued about the situation
in Latvia and the legislation requiring mon-
itoring, investigation and response plans.
Referring to influenza prevention among
health care professionals, she said that
monitoring was not carried out, awareness
was low and there was low immunization
take up as a result of poor communication
globally.
She concluded by saying that wider, care-
fully planned and well communicated im-
munization campaigns at a national level
would promote vaccination.
The final guest speaker was Dr. Cornelia
Betsch, a psychologist from the University
of Erfurt in Germany. She began her ad-
dress starkly: ‘Imagine you visit your doctor
with your new-born child or grandchild and
the doctor can’t stop sneezing and coughing
during the whole consultation. Imagine a
friend with cancer who has to go to hospital
to undergo the next chemotherapy. And the
nurse,just after she took blood samples,gets
diagnosed with influenza. Imagine that you
are unsure if you should get the flu shot and
so you ask your doctor if she is vaccinated
against influenza. And she says ‘no’.
‘These are situations that many people have
to face because vaccination rates are low
among health care workers.’
Dr. Betsch asked why many health care
workers refused vaccination? She remind-
ed that a 2009 overview study summarized
the most important reasons. ‘Isn’t it sur-
prising to learn that across a large number
of studies HCWs’ most important reason
against vaccination was their fear of side
effects?’
She said that the other reasons included low
perceptions of risk of infection and a lack of
concern, potentially because they believed
that the risk to transmit influenza to their
patients was low. But this was wrong.
Dr. Betsch shared her belief that the more
people get immunized in society, the more
difficult it gets for a disease to spread.People
who are too young or ill to get vaccinated
will be protected by a firewall of immunized
individuals around them. With a sufficient
number of people immunized, diseases can
be eradicated.
She said that in the Global Vaccine Action
Plan, which was endorsed during the last
93
Health Profession
World Health Assembly, immunization is
recognized as a core component of the hu-
man right to health. Mandating vaccination
would be like forcing people to drink clean
water. Thus, if we do not want to mandate
vaccination, health care workers need to be
better educated. They need to know where
there is a risk and where there isn’t. They
need to know that they can infect their pa-
tients and their families. They need to be
aware that they are role models and highly
trustworthy sources of information for their
patients.
Side Events
Palliative care was among the side events
jointly supported by the WMA during the
week of the World Health Assembly. The
meeting was sponsored by the permanent
missions to the UN of Panama, Uganda
and the United States, and organised by the
WMA together with the African Palliative
Care Association,
Asociacion Latino Americana de Cuidados
Paliativos, Hospice Africa Uganda, Human
Rights Watch,International Association for
Hospice and Palliative Care, Kenya Hos-
pice and Palliative Care Association, Open
Society Foundations and the Union for In-
ternational Cancer Control.
Among the speakers was Dr. Mary Car-
dosa, a Malaysian consultant anaesthesiolo-
gist and pain specialist and Immediate Past
President of the Malaysian Medical Asso-
ciation. She spoke about the prejudice and
fears of healthcare professionals about us-
ing morphine to relieve pain which she said
were causing millions of patients to suffer
unnecessarily.
She stressed that tens of millions of people
around the world suffer from significant
pain and other debilitating symptoms re-
lated to illnesses such as cancer, advanced
diabetes, heart disease, other non-commu-
nicable diseases and HIV and TB. 
‘These patients require palliative care, a
health service that can restore or maintain
their quality of life and allows them to live
with dignity. Despite this great need, pal-
liative care services remain sparse in much
of the world,’ Dr. Cardosa told the meet-
ing.
Dr. Cardosa went on: ‘Apart from having
national policies on pain and palliative care,
efforts must include education of the public
and of healthcare professionals in order to
overcome barriers to effective pain manage-
ment and palliative care. 
Among the big challenges are the prejudices
and fears of healthcare professionals regard-
ing the use of morphine which is the main-
stay of pain relief in patients with acute pain
as well as those with advanced cancer and
other painful conditions. 
Morphine provides cheap and effective
analgesia to such patients, but is often
not accessible because of legal barriers or,
worse still, because of healthcare profes-
sionals’ fear of addiction and side effects
as well as lack of knowledge on the ap-
propriate prescription of morphine and
morphine-like substances for pain relief in
these patients.’
Dr. Cardosa told that the Worldwide Pal-
liative Care Alliance estimates that about
one hundred countries worldwide do not
have any palliative care services available,
while in another 74 countries such ser-
vices are limited to isolated locations and
reach only a small proportion of patients
in need.
She said the Executive Board of the World
Health Organization (WHO) and the
World Health Assembly (WHA) are ex-
pected to discuss palliative care needs and
barriers next year.The present WMA meet-
ing, organised with other bodies, including
the Human Rights Watch and the African
Palliative Care Association, was designed
to discuss successful palliative care models
from different world regions and exchange
views on how a potential WHA resolution
could most effectively promote palliative
care. 
Dr. Cardosa suggested that building a glob-
al coalition for palliative care was a means to
ending unnecessary suffering from treatable
symptoms for the millions affected, espe-
cially those in the countries where palliative
care services were not readily available.
Mr. Nigel Duncan,
Public Relations Consultant,
WMA
The politicians of the European Member
States spend a lot of time and resources
on health services, planning, controlling
the medical profession and revising in-
frastructure, issueing laws and regulations
instead of trusting doctors to continue
developing the services patients need.
For example, on the European level there
has for years been a lot of work on cross
border health care, and then it turns out
that only about 1% of medical services
actually are cross border. Patients like to
be treated near to where they live. I am
not saying that cross border health care
shouldn’t have been looked at, and CPME
certainly has been an active stakeholder,
but wouldn’t it have been more beneficial
for all that effort to be put into coming
How Much Independence is Necessary?
94
Health Profession
to grips with the financial world and the
banks?
The medical profession is in my opinion
to be trusted. There are fewer bad apples
to be found in medicine than in any other
field that I know. The patients know this
too. Therefore there is a relationship be-
tween doctors and patients unlike any
other. At present, trust in the Icelandic
Parliament is less than 10% and no one
trusts the banks!
There are not many professions that have
a background of 10–15 years of study and
specialist training as we have and there-
fore it is not surprising that doctors prefer
to have a say in the structure and running
of their own work. Our closest ally is the
patient and to my mind it is the right of
each patient to have a well trained doctor in
times of illness.
In many countries the relationship be-
tween doctors and politicians is based on
trust. On the other hand there are visible
trends in some of our countries for the
politicians to think they know better. I re-
alised this rather late in my professional
life, after having spent time myself as a
politician.
What is Professional Autonomy?
A multitude of terms is used to discuss
professional autonomy, all of which con-
tribute to the description of the framework
of doctors´professional practice. These de-
rive from a wide range of sources: national
and EU laws, ethics codes, regulations of
professional bodies, societal expectations
and medico-technical requirements. While
some concepts can be seen to overlap in
meaning, others can also be considered as a
balance to each other.
Professional autonomy is applicable both
to the medical profession as a whole and
to each professional individually. In both
concepts, the right of autonomy implies a
freedom to practice without interference
(be it administrative, political or other)
counterbalanced by the obligation and re-
sponsibility for those actions. With relation
to the profession as a whole, professional
autonomoy is closely linked to the concept
of “liberal professions”. This concept is also
acknowledged at EU level, e.g. in the Pro-
fessional Qualifications Directive 2005/36/
EC. On an individual basis, professional
autonomy is closely linked to clinical inde-
pendence.
As a principle, the compliance with
clinical guidelines is seen as one of the
fundamentals of high quality medi-
cal practice; CPME policies uphold this
principle continuously. They enshrine an
evidence-base for effective and efficient
clinical treatment decisions and provide
a reference point for demonstrating the
decision-making process both to patients
and peers. However, in certain situations a
guideline´s application would not help to
achieve the best possible outcome for that
specific patient. It is in these situations
that the concept of clinical independence
becomes a tool to comply to comply with
the objective of delivering the best possi-
ble care for the individual patient. Clinical
independence is therefore directly linked
with professional autonomy insofar as this
“ dictates that a doctor shall deviate from
a a guideline whenever she/he feels that
is in the best medical interest of the pa-
tient”. Professional autonomy is however
necessarily counterbalanced by the need to
ensure accountability for a decision. Pro-
fessional responsibility brings professional
autonomy to an equilibrium. This respon-
sibility is not only relevant in terms of its
relation to guidelines, but in particular as a
tool of accountability to patients. In addi-
tion to this, it also is relevant in relation to
accountability towards peers, professional
bodies and in a further step towards the
legal framework of professional practice,
as regards professional liability.
Professional responsibility therefore acts as
as safeguard for the exercise of professional
autonomy. As such it is important to ensure
a coherent and sound framework for its ex-
ercise.
The Framework
The framework therefore must ensure that
autonomy and responsibility are in bal-
ance. In a CPME position paper of No-
vember 2009, it is stated that “ professional
autonomy, properly defined and used, can
help to preserve a balance between needs,
demands and responsibilities of the par-
ties involved with a priority for patients
needs”.
To achieve the best possible coherence for
this framework, self-regulation is a pre-
ferred policy tool. With the EU compe-
tences on the organisation of healthcare,
including the organisation of the profes-
sion’s practice, limited by the Article 168
TFEU, the principle of subsidiarity applies
to give Member States the power to al-
locate self-regulatory competences to the
professions.
Across the various Member States, the
degree of self-regulatory competence var-
ies, as does the legal context the profession
Katrin Fjeldsted
95
Health Profession
may act in. In some cases self-regulation is
complemented by significant governmen-
tal regulation to create a situation of co-
regulation.
For CPME the safeguarding of profession-
al autonomy and the self-regulation of the
profession are two sides of the same coin.
In the 2009 position paper it is recalled that
“rules drawn up by the medical profession
and instruments to enforce their application
have always served to ensure medical care of
the highest possible professional and ethi-
cal standards.”It is this objective that shows
that essentially professional autonomy is
not primarily a professional privilege, but
rather a patient right.
As can be seen, the patient and the pos-
sibility to make a decision in a patient´s
best interest is the ultimate consequence of
professional autonomy and therefore sub-
stantiates the need to safeguard the prin-
ciple.
Working With Patients
If departing from the point of view of the
patient, the right to high quality health-
care, as enshrined in national and Europe-
an laws, is dependent on the best possible
quality of medical training and practice, an
objective which lies at the core of CPME’s
mission. In order to achieve this, the prin-
ciple of professional autonomy is essential.
The element of trust in the patient-doctor
relationship is directly related to profes-
sional autonomy: If professional autonomy
in making clinical decisions is undermined
and quality healthcare outcomes are not
achieved, trust diminishes. Conversely the
exercise of clinical independence also pre-
necessitates a degree of trust between pa-
tient and doctor.
A trustful patient-doctor relationship is
therefore one of the pillars of professional
autonomy. The importance of reciprocal
trust and committment to the patient-
doctor relationship, the shared interest
and value of safeguarding the relation-
ship is recognised by both patients and
doctors. Indeed in the Joint Principles
CPME adopted in 2008 with the Euro-
pean Patients´ Forum (EPF), both par-
ties highlight patient empowerment and
professional autonomy as key areas for
cooperation by declaring: “..information
to patients, medical ethics, Information
Communication Technology and health,
continuous professional development,
patient´s empowerment and physician´s
autonomy (are) identified by both EPF
and CPME as significant areas where our
joint work at EU level could make an im-
pact”.
The commitment to cooperation between
patients and doctors also reflects the chang-
ing environment of the patient-doctor re-
lations. This relationship is very much a
dynamic one and the changing role particu-
larly of the patient entails also a changing
environment for the delivery of healthcare,
In order to indeed achieve a model of pa-
tient-centered healthcare, professional au-
tonomy is a vital tool to ensure quality of
care for each patient.
Recent years have seen the parallel devel-
opments of increased patient empowerment
and health literacy. This is in part due to a
more active participation of patients in the
management of their condition, especially
in the case of chronic diseases. CPME is
very supportive of the empowerment of pa-
tients, as enshrined in the Joint Principles
adopted with the European Patients’ Fo-
rum. It must therefore be made clear that
clinical independence is a complementary
rather than contradictory tool in achieving
the best patient care.
Technology
The rapid developments in health technol-
ogy contribute significantly to the changing
environment of professional practice.
Developments in pharmaceutical care, both
as regards organisation of care and scientific
progress resulting in technological innova-
tions, offer many examples of situations in
which professional autonomy is challenged,
The issue of decision-making on generic
substitution has been debated for some
time: in 2000 CPME recommended that
“prescribing doctors must have the right
not to allow pharmacists to dispense a dif-
ferent generic from that prescribed, or a
generic instead of a branded pharmaceuti-
cal prescribed, where they judge it in their
patients´ interests to do so “. The more re-
cent discussion on biosimilars has included
similar questions.
The increased use of telemedicine and
eHealth technologies has changed the
clinical decision-making process and con-
sequently redefined the context of pro-
fessional autonomy. CPME is closely in-
volved in EU-level policy initiatives and
projects on eHealth and telemedicine
technologies, in recognition of their vast
potential to improving access to an deliv-
ery of care. One of CPME´s priority prin-
ciples in eHealth is however safeguarding
the trust and confidentiality of the patient-
doctor relationship regardless of the medi-
um through which healthcare is delivered.
As stated in the “ CPME guidelines for
telemedicine”, adopted in 2002: “The use
of telemedicine must not adversely affect
the individual patient-doctor relationship
which, as in all fields of medicine, must be
based on mutual respect, the independence
of judgement of the doctor, autonomy of
the patient and professional confidential-
ity”. Therefore innovative eHealth tech-
nologies should only be used if these prin-
ciples are respected. An even more recent
technological development is the creation
of computer-programmes which assis
clinical decision-making. Their potential
impact on clinical independence is vast,
a discussion on the status of professional
autonomy and professional responsibility
in light of such technologies therefore of
significant interest.
96
Health Profession
Changes in healthcare systems as such also
have significant implications for profes-
sional autonomy. The organisation, regula-
tion and training of the health workforce
is subject to constant policy changes in all
Member States. These changes are driven
as a response to budgetary pressures, short-
ages and changing requirements as to the
skills and knowledge of professionals as
well as new systemic models of care, the
defintion of the different healthcare pro-
fessions’ tasks, the influence of other ac-
tors, such as payers and administrators.
The process for clinical decision-making
and therefore also the status of clinical
independence and professional respon-
sibility is often affected. One example is
task-shifting, especially when motivated
by reasons other than improving quality of
care. In its policy on task-shifting adoped
in 2010, CPME recommends that “ In
order to guarantee the safety of patients,
(task -shifting) should always take place
under the condition that the responsibil-
ity for diagnosis and therapeutic decisions
cannot be divided and remains with a doc-
tor, even if (s)he has shifted a task as de-
scribed above”.
The Budget
Cost-effectiveness drives are one of the
most direct challenges to professional au-
tonomy. CPME fully recognises the need
to respect budgetary restraints and take
into account not only the effectiveness but
also the efficiency of treatments and has
acknowledged this repeatedly. However,
the patient´s best interest must be the main
criterion for the decision taken, be it policy
or treatment related. Challenging or disin-
centivising the exercise of professional au-
tonomy as cost-containment policy must
therefore be opposed. Examples for such
action can be found i.a.in the incentivising
of generic prescriptions through financial
rewards to doctor; this was discussed by
CPME in 2006 on the basis of a case in
the Netherlands.
Patient Mobility
Patient mobility has now been codified in
the Directive 2011/24/EY on the appli-
cation of patients´ rights in cross-border
healthcare. This legislation also addresses
the importance of transparent safety and
quality standards to ensure access for
well-informed patient decisions. CPME
very much welcomed the clarification of
patients´rights in accessing healthcare ser-
vices outside their home Member State and
repeatedly highlighted the need to establish
“a clear framework of safe, high quality and
efficient heathcare throughout the EU-
which will be beneficial both to patients
and to physicians”. The need to be able to
demonstrate and be accountable for qual-
ity, must however not be seen as eliminating
professional autonomy, neither at an organ-
isational nor individual level.
Government Regulation
Lastly trends in government regulation can
undermine the basis for professional au-
tonomy by challenging the self-regulaton
of the profession.This may be motivated by
poitical preference for centralised regulation
or taken with a view ot cost-containment.
In many Member States developments can
be observed in which the legislative frame-
work shift decision-making competences
from professional bodies to the government
thus eradicating the substance of autono-
my. CPME has lent support to number of
members which have faced challenges by
their governments and confirmed its belief
of the importance of professional autonomy
also at organisational level for the best in-
terest of the patient.
The Future
The future holds new technologies for cer-
tain. The financial crisis has reinforced and
renewed pressure for cost containment in
health workforce and services in general.
We must always bear in mind that the pa-
tient-doctor relationship must be central
to the introduction of new technologies.
There are also some moves towards stan-
dardisation at EU level and the possible
increase in cross-border healthcare makes
demands on greater harmonisation of
clinical practice and may seek to constrain
professional autonomy.
Conclusions
Professional autonomy both at organisa-
tional and individual level is a vital tool for
the achievement of high quality health-
care and as such a patient right. So as to
retain its place in medical practice, pro-
fessional autonomy msut strike a balance
between safeguarding its core values, such
as the observance of ethical codes and the
trustful patient-doctor relationship, and
the evolving environment of professional
practice and healthcare systems.This could
include better communication of the regu-
latory framework, in which professional
autonomy is exercised, in order to provide
better information to patients and other
stakeholders. It must also include a con-
tinuous review of professional guidelines
to safeguard an adequate response to the
changing environment of healthcare deliv-
ery and scientific progress.The existing and
new challenges arising from governmental
regulation, but also societal and commer-
cial developments must be addressed sus-
tainably. Support should be lent to those
whose governance model is challenged to
the detriment of professional autonomy
and thus patient care.
Katrin Fjeldsted,
President of CPME
97
Prison Health
In a previous publication1
, various actions
have been suggested for the physician to
implement during this quality time with the
hunger strikers. The initial encounter with
the hunger striker, for the history and exam,
and initial evaluation, is the starting point.
It is essential that the physician conveys
from the start that he is not there as a prison
official to try to convince them to stop their
protest. He is there as their physician, to see
to their health, to answer any questions they
may have, to explain how fasting and me-
tabolism work, but above all he is there to
listen and maintain a constant line of com-
munication with them. The physician has
to convey genuine concern for health, and
for providing professional care.This in most
cases should counterbalance any qualms or
legitimate fears the hunger striker may have
about the doctor’s role.
Without respect for the dignity of the pa-
tient,any medical practice is severely handi-
capped. In the case of a hunger strike, the
physician should see to it that the patient
is not placed automatically in a bleak or
1 Allen S., Reyes H. Clinical and Operational Issues
in the Medical Management of Hunger Strikers. In:
Interrogations, Forced Feedings, and the Role of
Health Professionals; ed. Ryan Goodman and
Mindy Roseman, Harvard University Press, Feb-
ruary 2009.
demeaning environment by the authority
wanting to punish him. This is an aspect
often neglected by doctors. If there is to
be communication, and this is the key to a
positive way forward, the patient has to be
treated with respect. At the very least, the
physician should clearly demarcate himself
from any abusive attitude by the custodial
staff and hierarchy. This is particularly im-
portant in settings where torture is occur-
ring or is likely to occur.
The physician has to ensure his own clini-
cal independence and autonomy. He has to
firmly establish, with the custodial hierar-
chy, that he must have a free hand in deal-
ing with all matters relating to health,in the
broad sense of the term,as well as any medi-
cal interventions. If he is to try to influence
the hunger strike so that extreme situations
are not reached, he cannot be taking orders
that go against medical common sense, let
alone medical ethics.
This is easier said than done in many con-
texts. It is beyond the scope of this paper
to examine the issue of “doctors, serving the
state first and their patients second”, as this
easily spills over into “cultural”, “traditional”
and “political”discussions.The status quo of
hunger strikes and forced feeding will likely
continue unless there are deliberate steps to
ensure respect of medical ethics2
. National
medical associations need to provide sup-
port for physicians confronted with such
ethical dilemmas, and if necessary appeal to
supra-national entities such as the WMA
for guidance.
During the initial history, often a key mo-
ment for establishing the role he wants to
play, the physician must ensure confidenti-
ality, as in any doctor-patient relationship.
This means there should be no presence
of a guard during the discussion in private
between the hunger striker and the doctor.
This is easier said than done, and in recent
situations, this was out of the question from
the start because of “SOPs” not allowing
such privacy. This has to be accepted. If
security is a non-negotiable concern, then
a guard should be at the very least out of
earshot, so that privacy of exchanges be-
tween the hunger striker and the doctor
are guaranteed. If there are microphones
or other devices to monitor conversations,
the physician should be transparent and tell
the hunger striker that he, the doctor, is not
in a position to impose their removal. Such
communication can be achieved, if there is
a common language, if necessary by scrib-
bling on a pad.
Once this trust has been, however pre-
cariously, established, it is then up to the
physician to use the four weeks ahead of
them to asses the seriousness of the situ-
ation. How resolute exactly is the hunger
striker? How determined is he to push his
protest through? Can he accept a compro-
mise solution that would allow the fasting
to stop? What is behind the protest? Is
2 Annas, G.  J. ‘Dual Use,’ Prison Physicians, Re-
search, and Guantánamo”;, American Vertigo:,
Case Western Reserve J. International Law 2011;
43: 631-650.
Physicians and Hunger Strikes in Prison: Confrontation,
Manipulation, Medicalization and Medical Ethics (part 3) (part 1, 2 vol. 59 N 1, 2)
Hernán Reyes George J. AnnasScott Allen
98
Prison Health
there some misunderstanding that could
be easily corrected so as to defuse the situ-
ation? Is there peer pressure from other
prisoners? …Or from within the group
of hunger strikers themselves when it is a
collective action?
During these first few weeks, a physician
dedicated to his task should have sufficient
time to determine whether the hunger
striker is alone in his decision, or whether
he is under pressure. For public consump-
tion the solution the hunger striker wants
to find may be a political statement, often
a realistically impossible proposal… How-
ever, and this is what the physician should
be able to pin down, the hunger striker will
often be prepared to accept a fall back po-
sition, accepting much less than initially
asked for. If he somehow, however indi-
rectly, admits he does not really “want to
die”then the door is open for the physician
finding a solution. What solution, depends
on a multitude of factors. It may be to con-
vince the hunger striker to lower the bar
of contention so that a compromise can
be reached with the hierarchy. It may be
to persuade the hunger striker to take vi-
tamins and perhaps other nutrients, so as
to allow plenty of time for negotiations. In
extreme cases, which are rare, the hunger
striker may agree to receive artificial feed-
ing – thus allowing him not to lose face
(by quitting the hunger strike) while get-
ting him out of danger while a solution
is found. If the patient is under pressure,
moral or potentially physical from his
peers, the physician may simply arrange for
the hunger striker to being transferred to
the sick bay, where (voluntary) “therapeutic
feeding” may be undertaken. In most cas-
es, this feeding will simply mean that the
hunger striker quietly starts to eat again.
In a collective hunger strike, the situation
may be more complex, a small number of
“hard liners”, or sometimes even just one
leader, making it impossible for any other
hunger striker to get out of line. The group
may adopt an intransigent position – and
the individual hunger striker may not be
in a position to back out individually, even
though he would like to.The key here is for
the physician first to get to talk to each hun-
ger striker individually.If the relationship of
trust has been attained, some at least of the
group will admit in confidence that they do
not want to “go all the way”. If the physi-
cian can get to know this, it is most of the
time half the battle won. The next step will
be to separate the hunger strikers from one
another.This does not mean isolating them,
putting them in solitary confinement, let
alone punishing them actively or worse hu-
miliating them (as has been the case these
recent years in a well-known hunger strike.)
Once the peer pressure relieved, the road to
reconciliation is open.
Perhaps even more important, the physi-
cian has to strive to avoid the development
of a clash between the custodial or judicial
authorities and himself or his medical su-
periors. This will be over untoward medical
intervention, and ultimately about force-
feeding. In the first stage of a hunger strike,
he has to calm things down so that there is
no “hasty” decision to force a naso-gastric
tube down the hunger striker’s throat when
there is absolutely no need for any medi-
cal intervention.The hunger strikers should
be informed, officially, or perhaps “less of-
ficially” in some contexts, that the doctor is
not going to force a naso-gastric tube into
their throat. The physician should persuade
the authorities that there is no risk before
at least four weeks of total fasting. If the
situation is one of non-total fasting, this
limit can be pushed back even further. He
has to convince the non-medical authori-
ties, sometimes “itching for a fight” with
the “hostage takers”, that he will do his best
to reach a way out well before that limit is
reached. It may be at this stage counter-
productive for the physician to brandish
his ethical banner and declare that he will
refuse to force-feed whatever the authori-
ties decide. The physician knows his duty,
and when the moment comes, he will know
what to do, In the meantime, the point is
not to push the “trigger-happy” custodial/
judicial authorities to pull the force-feeding
trigger. An open clash is also to be avoided
at all times.
All the high publicity hunger strikes in the
recent years have been very badly managed
in this respect.Physicians have found them-
selves to be the instruments of the high-
spirited and interventionist non-medical
authorities. Some physicians, not having a
solid ethical education, have simply “obeyed
orders”. Others, thinking to help the situ-
ation, have loudly protested and clashed
openly with the non-medical authorities,
which has poisoned the general atmosphere
and often provoked a crack-down, with
subsequent orders being given to force-feed,
when there was no medical need whatso-
ever, thus dashing any hopes for a compro-
mise.
The first month of a hunger strike elimi-
nates all the “food refusers”, and becomes
premium time for the physician to genu-
inely play his role and to try to preserve life
and dignity, and find the best solution for
compromise. He has to have the trust of the
hunger strikers, and also that of the custo-
dial authority. He has to persuade the latter
not to be hasty, and above all not to make
decisions that are unwarranted, unsound
and unethical. Prison Governors have been
known to up the ante by taking decisions, or
implementing new constraints that make it
much more difficult for a prisoner to reflect
and stop fasting, by withholding medical
care for example. There have been concrete
cases of physicians themselves knowingly
giving out false “medical” information, so
as to frighten prisoners into stopping their
fast. In one specific case, a medical officer
of a prison in the Middle East “let it be
known” that going on hunger strike “caused
impotency in the young male, which could
be long-lasting.”This was obviously deceit-
ful information, and the use of medical au-
thority in such a way obviously undermines
any trust with the prisoners, already so dif-
ficult to obtain.
99
Prison Health
The physician has to stretch out a hand to
the hunger striker, to allow him to confide
in the doctor, and in the majority of cases
find a way out of what should never become
an inextricable situation.
In the very rare event of a hunger strike in a
Bobby Sands-type situation, where intran-
sigence on both sides is impossible to break,
the physician must know when to back off
himself. As clearly stated and explained in
“Malta 2006” and its comprehensive back-
ground paper, it is never ethically acceptable
to force-feed anyone. The physician should
never lend himself and his medical skills to
such abusive practice. In the specific case of
Guantánamo Bay, Navy reservist physicians
were “vetted” before being sent to the Base.
Any doctor strongly against force-feeding
was not sent there1
.
Conclusions: Medical Ethics
In managing hunger strikes,no one seems to
realise exactly how counter-productive the
confrontation between the custodial/judi-
cial authorities and the medical doctors can
be towards the goal of resolving the hunger
strike. By shining the spotlight of public-
ity on this clash between professionals, both
sides are helping to paint the hunger striker
into a corner. They also prevent the physi-
cian from playing a crucial role during the
first weeks of the strike, when there is time
and no danger.The hunger striker thus finds
himself in the limelight, which may “force
his hand”. The hubbub around his case, the
fact that his “determination” becomes com-
mon knowledge, the fact he is placed on the
pedestal of “heroism” or “martyrdom,” may
well end up pushing him into actually want-
ing to become one.
Management of fasting, possibly taken to
its extreme limits, will seem to involve a
conflict between the duty of health profes-
sionals to preserve life and the right of the
1 Okie S. op. cit.
patient to make an informed refusal of a
medical intervention2
. The main point we
have tried to make here is that there has
been far too much focus on the “Endgame”3
,
and “saving lives”, when in the vast major-
ity of cases, hunger strikers do not intend
to get that far and most often need only to
obtain some of their goals. Time is wasted,
and, worse, radical positions are taken and
hunger strikers can be thus “painted into
corners” when it becomes extremely diffi-
cult to get out of.That there are many weeks
before a situation warranting any medical
intervention will arise, is just not grasped by
most physicians, let alone the non-medical
authorities.
The Declaration of Malta does not cat-
egorically forbid resuscitation. There may
be room for some legitimate debate in indi-
vidual cases when the health of the hunger
striker is so critical that death is imminent,
and the individual’s real intentions are not
clear.But this is a decision for the physician,
not the prison officials. Policies, however, of
force-feedings of groups of hunger strikers
en masse before clinically indicated for rea-
sons of intimidation or punishment, as have
been reported at Guantánamo, is without
question in violation of basic human rights,
including the provisions against cruel and
inhuman treatment in the Geneva Conven-
tions.
The use of emergency restraint chairs for
force-feeding can never be ethically, legally,
or medically justified. A patient who must
be forcibly restrained in such a device to be
fed is certainly strong enough to be in little
or no health danger from continuing a fast.
The primary justification for the use of this
device for force-feeding would seem to be
for punishment, control and humiliation
rather than for legitimate medical care.
2 Allen S., Reyes H., op. cit.
3 Doctors attack US over Guantánamo; BBC NEWS;
http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas
/4790742.stm, accessed March 2012.
The main conclusion is that medical ethics
is consistent with a type of ethical pragma-
tism in dealing with the vast majority of
hunger strikers.This means doctors treating
each one as a patient and finding a way to
establish at least a minimum of trust in the
context of what will always be a difficult and
confining the doctor-patient relationship.
To this end, we have drawn up here a series
of practical recommendations which would
most certainly “calm things down” and en-
courage an ethical, pragmatic and humane
way to defuse the vast majority of difficult
hunger strikes. The WMA “Malta 2006” is
very clear in its prohibition of any form of
force-feeding of a competent patient, but it
gives generous leeway for the bedside clini-
cian, and only that physician, to address the
situation and take the final best decisions
for the patient.
Finally, in the specific case, again of Guan-
tánamo Bay, President Barack Obama’s
Executive Order (EO) of March 7, 2011,
unfortunately makes it at least likely that
the detention facility there will remain
open indefinitely. The EO ignores the
whole hunger strike issue and the ongo-
ing force-feedings of at least some pris-
oners. Solutions and approaches based on
the patient trust in the military clinicians
are by now impossible because of the past
practices. For the reasons stated, the issue
is not, at the present time, how to end the
on-going force-feeding, but rather how
our suggestions and observations could
be useful to prevent another Guantánamo
force-feeding scenario in the future, there
or elsewhere.
Recommendations
→ Conform to established medical ethics
The WMA’s Declaration of Tokyo very
clearly anticipates the exact scenario of
hunger strikes undertaken at places like
Guantanamo Bay, and the declaration rep-
resents the established ethical guidelines for
100
Prison Health
physicians. The use of torture during inter-
rogations, or in cases where the very con-
ditions of confinement constitute a form
of torture, were envisaged when writing
up “Tokyo”, as a central and direct cause
for the initiation of the hunger strikes. As
mentioned, it was this that ultimately led
the WMA to specifically condemn force-
feeding itself. In 2006 in an editorial ex-
plaining the AMA’s endorsement of the
WMA’s Declaration of Tokyo, Duane M.
Cady, MD, chair of the AMA’s Board of
Trustees quoted from the WMA itself “…
where a prisoner refuses nourishment and
is considered by the physician as capable of
forming an unimpaired and rational judg-
ment concerning the consequences of such
a voluntary refusal of nourishment, he shall
not be fed artificially.”1
In addition, efforts to circumvent medi-
cal ethics by pre-deployment screening of
health professionals to exclude those who
might object to the policy of force-feeding
at Gtmo does not excuse ethical misconduct
by either the health professionals or the de-
taining authority.2
Physicians deployed to provide detainee
and prisoner care should be appropriately
trained in the ethical management of hun-
ger strikes,as well as international standards
of medical care for detainees and prisoners.
Credentialing for work in detention facili-
ties should emphasize and address humane
treatment and familiarity with the accepted
standards of care in prison and detention
facilities.
→ Don’t undermine detainee trust in physi-
cians
The foundation of effective medical prac-
tice is trust between the doctor and the
1 O’Reilly, Kevin B. Physicians Speak out on Prisoner
Force-feeding http://www.ama-assn.org/amed-
news/2006/04/03/prsc0403.htm; April 3, 2006.,
last accessed March 2012.
2 Okie S, op. cit.
patient. This is especially true in the sce-
nario of hunger strikes where the doctor’s
ability to engage with the patient to find an
acceptable resolution to the hunger strike
is entirely dependent on the patient’s abil-
ity to trust the physician. For that reason,
practices that may undermine the trust be-
tween the patient and the physician must
be eliminated. These include the practice
of assigning some health professionals
to support the interrogation procedures.
These health professionals quite obviously
did not act in the detainee’s interest (that
wasn’t their assignment), and their pres-
ence in support of interrogation clearly
undermined any detainee’s trust in the cli-
nicians working outside of the interroga-
tion setting. In a 2005 Memo, DoD Assis-
tant Secretary for Health Affairs William
Winkenwerder established differential
ethical duties for “clinical”, as opposed to
“non-clinical”, medical personnel. This
goes against the very essence of medical
ethics: a physician is a physician is a physi-
cian! In addition, the use of medical per-
sonnel or even psychologists for activities
such as identifying psychological vulner-
abilities so as to advise interrogators, con-
stitutes a serious breach of medical ethics.3
Moreover, failures of health professionals
to document and report evidence of abuse
and torture undoubtedly undermined the
trust between the detainee and the health
professionals.4
Trust between health pro-
fessionals and patients in custodial settings
is unavoidably challenging from the outset.
Effective correctional health professionals
overcome structural barriers to trust slowly
by developing trust with the patient over
time largely by the integrity of their ac-
tions in treating the patient. Policies that
ask health professionals to undermine
3 http://www1.umn.edu/humanrts/OathBetrayed/
Winkenwerder%206-3-2005.pdf
4 Iacopino, V., Xenakis, S. Neglect of Medi-
cal Evidence of Torture in Guantánamo Bay: a
case series.In: PLoS Medicine. 8(4): e1001027.
doi:10.1371/journal.pmed.1001027. Available at:
http://www.plosmedicine.org/article/info%
3Adoi%2F10.1371%2Fjournal.pmed.1001027
their own credibility and integrity must be
avoided. Making physicians force-feed de-
tainees destroys any possible trust between
the doctor and the patient.
→ Respect clinician autonomy (clinical deci-
sions to be made by clinicians)
Key clinical interventions such as whether
or not to use forced naso-gastric feeding
must be left exclusively to the treating cli-
nician. While there will unavoidably be a
role for non-medical chain of command
and courts, the clinical approach must be
determined by the treating clinician within
the frame of accepted ethics and clinical
practice.
→ Minimize coercive practices that infringe
on patient autonomy
From a psychological perspective, it is im-
portant to understand the act of a hunger
strike as an act by the patient to assert his
or her autonomy over the basic act of eat-
ing. This is not only an act of autonomy as
an ethical issue, but as a practical issue. The
reason food refusal is often chosen as the
act of assertion of autonomy is that often all
other areas of autonomy have been removed
as options. In the case of Guantanamo, the
development of widespread hunger strikes
cannot be separated from the authorization
and widespread application of practices that
infringed on the autonomy of the prisoners
and have now been recognized as ill-treat-
ment and torture.
→ Develop alternative means of addressing
grievances
“Indefinite detention” as applied in Guan-
tánamo Bay is the major grievance, and as
has been stated, one of major reasons the
internees initiated hunger strikes there – a
situation that hopefully will not be repeated
in most hunger strike cases. Fundamental-
ly, the act of hunger striking is a form of
stating a grievance. It is more likely to be
employed as a means of stating a grievance
101
Prison Health
when alternatives to resolution of griev-
ances are not available. Here it should be
noted that the custodial authorities hold “all
of the cards,” so to speak. The non-medical
officials have the power and authority to ne-
gotiate, address and where possible resolve
all prisoner grievances (and do not require a
medical intervention to do so).
→ Individualize care
Develop emphasis on individualized reso-
lution of the hunger strike before clinical
deterioration occurs. The rapport estab-
lished between the bedside clinician and
the hunger striker can be a crucial element
starting to resolve the conflict and develop-
ing a dialogue between the authorities and
the prisoner- patients.
→ De-medicalize the early stage
Hunger strikes are predicated on the as-
sumption that the assertion of autonomy by
the detainee will result in a response from
the authority. In societies where it is known
that the authority will not intervene, hun-
ger strikes are rare to non-existent. One
way to reduce incentive to a hunger strike
is to avoid intervening too early.The earliest
hours and days of a hunger strike pose little
or no health risk in the patient without sig-
nificant underlying health problems.In fact,
from a clinical perspective, there is little or
no justification to monitor or intervene in
any way during the first 72 hours of a hun-
ger strike. Accordingly, in the case of the
U.S., its Department of Defense Standard
Operating Procedures should be redrafted
to emphasize clinically appropriate care.
Health professionals must not be exploited
to assert control over the patient even for
national or prison security purposes.
→ Reduce peer pressure
In settings such as Guantanamo, the po-
tential for a prisoner to undertake a hunger
strike as a result of peer pressure from other
prisoners is a genuine concern. Ideally, peer
pressure must be reduced or eliminated.Re-
moval or transfer of the prisoner to a health
setting may provide some mitigation of peer
pressure issues. Allowing access to family
and community supports would, of course,
be another.
→ Don’t punish or further limit other areas of
autonomy
Efforts by the detaining authority to limit
and control other areas of personal au-
tonomy make it all the more likely that the
detainee will use food refusal as a means of
asserting some autonomy and as a form of
grievance. In this equation, the detaining
authority actually has almost all the control
over the other areas of autonomy and must
not lose sight of that fact. Such broad con-
trol provides options for creating alternative
paths for the detainee to food refusal. Ac-
cordingly, routine use of the restraint chair
cannot be justified and must be discontin-
ued.
→ Improve conditions of confinement
Conditions of confinement are often a lead-
ing cause for grievance. Indefinite detention
and prolonged social isolation often are the
drivers of the kind of desperation that pro-
duces hunger strikes.
→ Employ outside expert clinicians
No matter how good the facility medical
staff is at establishing trust with the de-
tainee, access to a doctor who can offer im-
partial and independent expert advice to the
patient is essential in developing options for
resolving a hunger strike. There should be
no prison in the world that does not permit
a prisoner to be seen and examined by an
outside medical consultant at their request
or the request of their family.
→ Involve family, clergy, and community
Outside community supports can be effec-
tive in providing support needed to achieve
a successful resolution of a hunger strike. In
addition to dissipating a sense of isolation
and entrenched conflict, community and
family influences can counter-balance peer
pressure from fellow detainees.
→ Develop honest informed consent proce-
dures and advance directives
It is essential for the clinician to know the
intentions of the hunger striker. To formal-
ize it early on in a written declaration, how-
ever, may be the start of painting him into
a corner. More important is the reverse of
the coin, which leaves the final decision in
the hands of the bedside clinician, who is to
act ethically (and not follow any diktat from
Judges, prison authorities or any others) but
also take into account the situation he has
assessed in his bedside care of the patient.
Knowing this, and it is carefully spelled out
in “Malta 2006”, the clinician can devote all
his time and efforts to find the proper, in-
dividual, ethical solution best suited to the
patient, including death.
Dr. Hernán Reyes,
MD, Medical coordinator for the
International Committee of the Red Cross,
specializing in medical and ethical aspects
of Human Rights, Prison Health, and in
the field of MDR TB in prisons. Observer
for the ICRC on issues of medical ethics.
Prof. George J. Annas,
Chair of the Department of Health
Law, Bioethics & Human Rights of
Boston University School of Public
Health; Prof. Boston University School
of Medicine, and School of Law.
Scott A. Allen, MD, FACP, School of
Medicine,University of California, Riverside
E-mail: manzikert@gmail.com
102
GERMANYHealth Profession
Generally one does not like to talk about
addictive diseases and in particular if it con-
cerns physicians. The Intervention Program
of the Hamburg State Chamber of Physi-
cians breaks this taboo and assists physi-
cians with addictions in therapy, organi-
zation of the doctor’s office and postcare.
Addiction to alcohol is still underestimated
in our society as a whole.
The percentage of apparent addiction to
alcohol in the general population ranges –
depending on the source – between 3 to 5%,
i.e. 2.5 to 5 million people in Germany. As-
suming the frequency of addiction among
doctors to be the same as in the total popu-
lation these are small figures. We have 15
thousand members in the Hamburg State
Chamber. If you estimate that 2% suffer
from addiction the Intervention Program
should be offered to 300 Doctors. We treat
about 10 doctors a year.
Although we started the Program 20 years
ago and have gained some experience we
are still at the beginning. All over the pe-
riod the main slogan of the Program has
been: “Support rather than punishment”
and it still sails under this flag. Let us now
examine the specific conditions that could
be the cause of physicians’addictive diseases
and the specific problems existing before
intervention.
1. Among the causes are
• unfavorable work conditions
– great demands from hierarchical struc-
tures
– irregular and too long working hours
– unfavorable working contents
– high emotional stress due to frequent
involvement in patients’ fates
– pharmacological practice as a catalyst
for addicted behavior
The usage and availability of drugs act in
synergy with the professional everyday life
and the doctor’s supposedly precise knowl-
edge about the risks often lead to a faulty
estimation in the “self-experiment”or “use “.
2. Among the problems prior to the treat-
ment are
– the idealized self-image of the doctor.
Basically the doctor has to be an invul-
nerable helper who himself does not
become sick. Hence, the doctor never
loses his self-control, and he excludes
all possibilities of doubt in every situ-
ation about the fact that his consump-
tion of addictive substances is no longer
manageable by himself. Moreover, the
effect of the substance increases the
inability to think critically. The high
doctor’s ideal contrasts with the real
medical personality, which is exhaust-
ible.The so far unselfish helper requires
help for himself;
• the fear of the consequences of the addic-
tive disease’s disclosure. This fear has two
components:
– the immediately felt distress because
of the possible loss of the professional
existence (by revoking of the license or
other arrangement by the authority);
– the shame and fear of stigmatizing
in the personal and professional sur-
roundings;
• another disadvantageous effect for the
affected person: the repression of the
problem by his surroundings. We often
find an extensive and misunderstood col-
leagueship of medical and also paramedi-
cal employees concerning not only the
legally established addictive drugs, which
are tolerated up to a certain threshold val-
ue, but also with drugs and opiate abuses.
It is often accompanied by a like-minded
private-familial tolerance. Ignoring the
addicted colleague’s weakness and grow-
ing illness leads to co-dependency and for
the addicted to a chronic disease.
What makes physicians so vulnerable? We
should be aware that many factors work to-
gether.
1. Hierarchy-pressure
2. Extended working time
3. Fatal destinies of patients, they have to
cope with
4. Easy access to substances
5. Professional experience that leads to the
misapprehension that he could control
the risk he takes by consuming addictive
substances.
The Intervention Program is mostly initi-
ated in the following way. First of all the
Chamber is informed about the suspicion
of an existing addictive disease. Different
sources are considered.
We get information from
1. affected physicians,
2. their patients,
3. their partners or spouses,
4. their colleagues – usually rather late be-
cause of co-dependency,
5. pharmacies, telling us about suspicious
prescriptions,
6. media as we saw it at the beginning,
Intervention Program for Addictive Diseases.
Hamburg State Chamber of Physicians
Klaus Beelmann
103
GERMANY Health Profession
7. the court about criminal cases – this in-
formation is regulated by law and is re-
ceived if matters of professionalism are
touched upon;
8. anonymous advice.
The physician is directly confronted with the
fact if the suspicion is serious enough and if it
seems to be proven that the physician suffers
from an addictive disease. If the addiction is
not obvious and the physician agrees with
the evaluation, it is possible to discuss the
different necessary rehabilitation measures.
The Chamber itself becomes a kind of
Emergency Room. It offers
• First examination
• Crisis intervention
• Possibility to change the treatment
• Accompaniment of the cured “patient
doctor”.
The path from the willingness to change
is exhausting and usually needs a clinical
hospitalization (initial) therapy to show the
drastic results.The regeneration and conser-
vation of the doctor’s health and the protec-
tion of the patient’s interests are essential.
In the beginning we often have to face con-
flicts and resistance against the diagnosis.
It is not so easy to verify the suspicion of an
existing addictive disease We start by refer-
ring the member to a specialist for further
examination. If the physician does not agree,
the Chamber informs him that the docu-
ments are to be forwarded to the competent
supervising authority. There is also informa-
tion included if the physician does not take
part in the agreed plans for the protection of
his medical activity without drugs.
Reporting on the addicted Chamber mem-
ber to the authority is mandatory, even if
the Chamber member is cooperative. So
transparency and compliance are essential
for the Program.
According to the agreement with the su-
pervising authority the implementation of
the Intervention Program is approved and
judicial steps regarding the revoking of the
license to practice are not initiated in case of
positive improvement. This creates a stable
base for the attempt of co-operative rein-
tegration of addicted doctors into the daily
medical routine. Informing of the authori-
ties does not cause any disadvantage for the
doctor who trustfully contacts the Chamber.
The conversation with the affected doctor
takes place immediately after informing the
Chamber, possibly also on the ground,e.g.in
the doctor’s practice. Usually the physi-
cian is in a desolate, often also in an in-
toxicated condition. Often the employees
of the Chamber face reactions of protective
behavior and denial. In spite of the initial
aggression we mostly succeed in clarifying
the purposes and contents of the Program,
such as help and necessary support. It also
includes providing room for cooperation
and maneuver to be used constructively for
decontamination and rehabilitation.If there
is no cooperation in the cases of clear addic-
tive diseases, the physician is informed that
the existing documents are to be forwarded
to the competent supervising authority
within the next day. Notwithstanding the
partly emotional and aggressive atmosphere
it is nearly always possible to reach coopera-
tion with the addicted person at the begin-
ning of such an intervention.
In case of doubt concerning the existence of
an addictive disease an examination is car-
ried out by a doctor experienced in rehab
medicine, if necessary with a recommenda-
tion for a therapy.
So the Intervention Program consists of
three major steps.The first step: clarification,
starting with a conversation with the doctor
concerned, usually an examination by an ex-
pert. The second: usually in-patient therapy
for two months. The third: the follow-up
program running for two years, including
• curricular post care – usually offered by
the clinic
• psychotherapy
• participation in self-help-groups
• laboratory tests
• meetings at the Chamber with physicians
If the addictive disease is not to be doubted,
a stationary withdrawal therapy paying at-
tention to the person’s habits will usually
follow. It takes about 6 to 8 weeks aver-
age. The problems that often appear in the
clinic involve the acceptance of the patient’s
role by the addicted physician, the capac-
ity to understand and emotionally accept
the disease and the relapse management.
The Chamber of Physicians helps with the
choice of an adequate institution, finding
replacement in the affected physician’s prac-
tice and also with the clarification of costs
to make the therapy in the clinic possible.
After the decision on treatment is made the
Intervention Program is carried out based on
a yearlong support. If a relapse occurs within
the period, the time line of the curriculum is
adapted accordingly and the need of another
stationary therapy will be evaluated.
The postcare follow-up program – as men-
tioned above – is laid down in a “volunteer’s
agreement”. It begins after the discharge on
the basis of the agreement reached with the
addicted person. This usually contains five
items and initially covers a period of two
years:
1. Implementation of a monthly examina-
tion including the psychopathological
results and objective lab parameters. We
try to arrange an alternative regular con-
trol in case the clinic offers no curricular
postcare.
2. Weekly sessions of psychotherapy on
which the Chamber is only informed
in case of missing appointments (in re-
spect of secrecy obligations).
3. Regular visits of self-help groups (e.g.
Alcoholics Anonymous) once a week.
4. Random abstinence controls by the
Chamber (hair-/blood/urine and field
sobriety tests). The frequency differs in
relation to the type of test and the rec-
ommendation of the involved expert. So
104
Health Profession TURKEY
it could be three times a week for breath
tests or once in a half year for hair analy-
sis. To obtain valid results the Chamber
arranges these controls which are per-
formed under the supervision of the lo-
cal forensic institute.
5. A fixed appointment as a follow-up in
the Chamber to discuss the situation
and the results once a month to com-
plete the Program.For this interview we
claim a monthly record of the proceed-
ings.
The Chamber of Physicians is committed
to the fact that participation in a structured
treatment is to be a success. It is important
to involve the addicted person in therapy
and at the same time to protect his patients
in the phase of the disease against possible
negative consequences of the treatment.The
rate of effective abstinence throughout the
Program is about 70–80%, the dropout is
10%.
The legal framework for the Intervention
Program in Germany is as follows – the
Chamber of Physicians is supported by
the local Ministry of Health that provides
our members with the license to practice
medicine. As a result of a long persuading
process our Ministry of Health supports the
Program explicitly.
Usually untreated addiction leads immedi-
ately to the loss of license. Due to the Inter-
vention Program there is a chance offered to
continue working after the treatment.
In general our addicted doctors have a lot of
emotional stress. The practice is usually in
a deplorable economic state. Therefore it is
very important to clarify the financial situ-
ation first. The decontamination and with-
drawal is financed by the health insurance
and in Hamburg the retirement fund joined
in to bear the costs for the weaning.
So what is the key message? Looking closer
instead of looking away is in the interests of
the concerned, both: doctors and patients.
To conclude we want to encourage to act
when people may have an addiction. In this
situation we are a partner of the patients
and a partner of the doctor as a patient to
support his successful restart.
Dr. Klaus Beelmann,
Ärztekammer Hamburg
E-mail: klaus.beelmann@aekhh.de
The Greatest Motivation: Assurance of Practicing the Profession
with Dignity. Motivational State of Physicians in Turkey
Feride Aksu Tanik Eriş Bilaloğlu Ziynet Özçelik Uğur Okman
This article will try to illustrate the motiva-
tional state of physicians inTurkey based on the
well known Guidelines “Incentives for Health
Professionals”.
The main data sources are three separate web
based researches carried out by the Turkish
Medical Association.
The fixed income of physicians is below the pov-
erty line. Physicians are not happy with Pay
for Performance. They are not able to use their
rights to rest sufficiently. Their reasonable fi-
nancial expectations focus on providing them-
selves with modest human life.
The health care environment starts to destroy
the autonomy of physicians and the professional
values alienate from the practice of medicine.
In the last decade not a single law has been ad-
opted to ensure professional autonomy.
Physicians consider the managerial structure
of their work places as a stress factor. They are
working long hours. Physicians demand secure
work and secure future.
There is not an effective, participative man-
agement of occupational health and safety. The
violent atmosphere of health care in Turkey
tremendously demotivates physicians and other
health care staff.
105
Health ProfessionTURKEY
The status of the Association concerning its
freedom is reflected in the ILO reports and
unfortunately it is in the black list. There is
no paid leave for Continuous Medical Educa-
tion.
Physicians’ sense of belonging has weakened
and the expectation of future decrease. Phy-
sicians in Turkey as honorable members of a
profession dedicated to the good of society do
not want to be actors in a commercialized
health care.
Introduction
What motivates a health care worker or a
physician? What ensures that physicians
perform at their best all the time? What
is the driving force of physician’s efforts
for the wellbeing of the individual and so-
ciety? What should it be? Have the moti-
vating factors for physicians been the same
since the past up to nowadays? How can we
achieve and maintain motivation?
Does the quality of health care differ ac-
cording to the motivating factors? What
is it especially under the hegemony of the
pharmaceutical industry? If everything is a
commodity, can we expect from physicians
to work only for the wellbeing of the indi-
vidual and society? What physicians’ mo-
tivation do people expect to provide good
health care? Which motivating factor is the
most reassuring for the patient who is ex-
pecting a qualified health care? Is it making
more money or the value associated with
health and physicians and the privilege this
value provides?
The health of individuals and society is
something very special. In the capitalist and
neoliberal world and in the era of trivializa-
tion and commodification of health, how
can we talk about a trustable health care?
Turkey is a laboratory…The annual number
of admissions increased fourfold in the ten
year period 2002–2012. What is the moti-
vating power behind this increase? What
is the main reason of this “success” in the
era of increased violence against physicians,
including killing? Is this a real success in
terms of a qualified health care?
Maybe the reader could find these questions
unnecessary, confusing, meaningless.
We will try to illustrate the motivational
state of physicians in Turkey based on the
well known Guidelines “Incentives for
Health Professionals” [1]. By closing our
eyes to the recent health care, we hope for
the situation described in the guidelines,
knowing that such a World is possible.
Method
This article is based on the data of three
separate web based researches carried out by
the Turkish Medical Association (TMA) in
2007–2008, 2009 and 2010.
The first research was carried out by the
TMA Ethics Committee and evaluated
the attitude of the physicians towards Pay
for Performance (PFP). The Questionnaire
was on the website in 2007/2008 for seven
months. Random sampling method was
used. The total number of participants was
Table 1: Types of incentives
Financial incentives Non-financial incentives
Terms and conditions
of employment
• Salary/wage
• Pension
• Insurance (e.g. health)
• Allowances (e.g. hous-
ing, clothing, child
care, transportation,
parking)
• Paid leave
Performance payments
• Achievement of per-
formance targets
• Length of service
• Location or type of
work (eg. remote loca-
tions)
Positive work environment
• Work autonomy and clarity of roles and responsibilities
• Sufficient resources
• Recognition of work and achievement
• Supportive management and peer structures
• Manageable workload and effective workload management
• Effective management of occupational health and safety
risks including a safe and clean workplace
• Effective employee representation and communication
• Enforced equal opportunity policy
• Maternity/paternity leave
• Sustainable employment
Support for career and professional development
• Effective supervision
• Coaching and mentoring structures
• Access to/support for training and education
• Sabbatical and study leave. Access to services such as
• Health
• Childcare and schools
• Recreational facilities
• Housing
• Transport
Intrinsic rewards
• Job satisfaction
• Personal achievement
• Commitment to shared values
• Respect of colleagues and community
• Membership of team, belonging
106
1567. Due to missing data 98 respondents
were excluded, 1469 respondents were eval-
uated and reported on [2].
The second research focused on the working
conditions of physicians and their approach
to insecure modes of working.This crosssec-
tional study was carried out in 2009 when
the government was preparing new legisla-
tion on the working conditions of physi-
cians.2224 physicians participated,16 of the
respondents were excluded due to repetitive
entries. The answers of 2208 physicians
were used [3].
The third research had the title “Consen-
sus on the working conditions, workload
and labor force of physicians, 2010”. 4354
physicians participated in this web based re-
search. The report was based on the entries
of 2316 physicians since they had filled in
all the compulsory items for the evaluation.
This corresponds to 2.6% of the physicians.
Factors Affecting the
Motivation of Physicians
According to the Guidelines “Incentives
for Health Professionals” the incentives are
classified into two main groups: financial
and non-financial incentives [1].
Incentive mechanisms as a whole have a mul-
tidimensional content and structure. One of
the most important features of this approach
is the combination of financial and non-
financial incentives. Literature on the ap-
plication of incentive schemes in health care
acknowledges that financial incentives alone
are not sufficient to retain and motivate staff.
Research has confirmed that non-financial
incentives play an equally crucial role.
While the importance and potential of
non-financial incentives is widely recog-
nized, it is important to note that there are
limitations to what can be achieved with
non-financial incentives alone.
Effective incentive schemes share the fol-
lowing characteristics: they have clear ob-
jectives, are realistic and deliverable, reflect
health professionals’ needs and preferences,
are well designed, strategic and fit-for-pur-
pose, are contextually appropriate, are fair,
equitable and transparent, are measurable
and incorporate financial and non-financial
elements.
Results
1. Financial Incentives
Salary/wage
In general, salaries are low for all kind of
personnel. In 2011 the minimum net wage
was € 291.73. For a family of four the food
poverty line was € 365.03, while the poverty
line was € 1189.06 [5].
In 2011 the fixed income for physicians
working in the public sector was € 803
for specialists and € 643 for GPs. The
fixed income is the salary which will af-
fect what they receive after retirement and
is guaranteed to be paid every month. In
addition to the fixed income physicians
get PFP which is variable, not guaranteed.
The fixed income of physicians is below
the poverty line. The expectations of phy-
sicians are very clear concerning their sal-
aries. 94.8% of the physicians request an
income that does not require doing extra
job, 99.3% expect that their salary should
affect what they receive after retirement.
97.6% claim that the unpredictable, vari-
able income policies affect their future
plans negatively [3].
Physicians demand 6000 Turkish Lira
which makes € 2921.56 per month if it
does affect what they receive after retire-
ment.But they demand 10 600 Turkish Lira
which makes € 5161.42 per month if it does
not affect what they receive after retirement
[4]. It shows that the financial expectations
of the physicians are not very high, they are
reasonable in order to provide themselves
with modest human life.
Pension
Nowadays a retired physician would get
1600 Turkish Lira or € 779.08 per month
in Turkey. This level of income is below
the poverty line. Under this condition a
physician cannot live modest human life
and cannot survive without doing anoth-
er job. For that reason 67% of the GPs,
77% of the specialists stated that under
these conditions they do not want to re-
tire [4].
Paid leave
The right to rest is of vital importance in or-
der to prepare for another productive work-
ing day. Only 27% of the physicians admit-
ted that they can afford spare time to spend
with their families. Physicians are not able
to use their right to rest sufficiently. Only
19% of the physicians stated that they can
afford a break from work. The majority of
the physicians could not use the one month
vacation time [4].
Performance payments
PFP started in 2004 in public hospitals and
in 2011 in university clinics in Turkey [6,7].
PFP is not an incentive, it is rather a princi-
pal way of payment in Turkey. It is paid for
the active working days only. Illness, preg-
nancy, holiday leaves are not paid, it does
not affect what they receive after retirement
and related social rights.
90.1% of the physicians find the criteria of
PFP insufficient. 64.6% consider that PFP
increases the cost of health care and 83.3%
think that PFP damages the work environ-
ment [3]. 54.9% of the physicians believe
that PFP destroys their relationships with
their colleagues, 56.1% – that professional
solidarity has been damaged. 52.7% stated
Health Profession TURKEY
107
that the doctor – patient relationship was
negatively affected [2].
Since PFP is based on individual evalua-
tions it has a negative effect on team work
and the quality of care and makes physi-
cians compete with one another [8].
Educational activities are very badly affect-
ed by PFP. The training time has been re-
duced – 70.9% of the physicians underlined
the time decrease for skills training,66.6% –
for bedside training, 69.6% – for theoretical
training of RA’s and 64.4% – the time for
Continuous Medical Education (CME)[2].
Thus, preconditions for professional devel-
opment are not met in Turkey.
According to the report of the Turkish Sur-
gery Association in specialty training the
balance between educational activities and
health care is destroyed. Training hospitals
have lost their educational functions. The
number of clinical meetings, seminars and
case discussions has decreased. In order
to use time efficiently operations are per-
formed by specialists [9].
2. Non-financial Incentives
Work autonomy
In Turkey the Social Security Institution
intervenes seriously in professional au-
tonomy of physicians through changes in
regulations on reimbursement of health
care services. The reimbursement rules af-
fect the PFP rules.The reimbursement rules
indirectly determine in what way physicians
will carry out their professional activities. In
the determination of reimbursement rules
no participative mechanism is involved ei-
ther in the form of specialty associations or
the Turkish Medical Association. Therefore
health care environment starts to destroy
the autonomy of physicians and the values
of profession alienate from the practice of
medicine.
Job security
Job security is vital for professional auton-
omy and elimination of job security makes
physicians open to the influence of political
authority. In the last decade two approaches
were used systematically eliminating the job
security of the health care workers. Legisla-
tion was amended in the following way:
• secure employment was replaced with
contract based, insecure modes of em-
ployment, such as subcontracting [10,
11], contract based working [12,13,14];
• limitations to the freedom of physicians’
work in terms of fields and places; limit-
ing the number of physicians in private
hospitals [15], promoting the opening of
private clinics [16], compulsory service
[17], obstructing the independent self-
employment [18], work bans [19, 20, 21],
licence auctions [22], free trade zones for
health [23, 24].
In the last decade no single legislation has
been adopted to ensure professional au-
tonomy. On the contrary, the public and
private health care institutions have been
reorganized according to the expectations
of the sector.
The report of the UK House of Commons
reveals that in the Queen Alexandra hospi-
tal 700 health workers, including the physi-
cians,were fired in order to overcome the fi-
nancial difficulties [25].We can assume that
the health workers in Turkey will be forced
to work longer, harder under the threat of
unemployment.
Access to literature and new technologies
It is hard to believe that 71% of the GPs,
54% of the specialists, 20% of the RAs do
not have access to literature in their work
places. 95% of the physicians stated that
they are under stress trying to keep their
knowledge up to date and 91% of the phy-
sicians are under stress caused by access to
new technologies [4].
Supportive management
Supportive management is one of the criti-
cal elements in motivation. 45% of the GPs,
30% of the specialists and 37% of the RAs
admitted that they do not have supportive
management in their workplaces [4]. 92%
of the physicians evaluated the managerial
structure of their work places as a stress fac-
tor. On the other hand, 41% of the physi-
cians experienced oppression, even violence
from their managers [4].
Manageable workload and effective work-
load management
According to the laws in Turkey the
working time is 40 hours per week in the
public, 45 hours in the private sector. But
there is not an upper limit of the work-
ing hours. Physicians are working for long
hours.
Figure 1 shows the working hours of phy-
sicians. Most of the physicians are work-
ing more than 40 hours per week. Nearly
one third of the RAs admitted that they
work more than 95 hours per week [4].
They stated that they work nonstop 33
hours which is a threat to public health.
RAs demand limitation of working hours
to 56 hours per week and 220 hours per
month and leave of absence after the night
duties [26].
51% of the physicians have compulsory du-
ties. In addition to the compulsory duties
physicians have on-call duties – 26% of the
physicians in the public sector and 41% in
the private sector [4].
Physicians demand secure work and secure
future. 90% of the physicians demand the
right to strike and collective bargaining
agreements. As concerns contract based
work, 71.2% consider that it decreases con-
trol over work, 72% – that it does not im-
prove productivity, 79.3% – that it leads to
job insecurity [3].
Health ProfessionTURKEY
108
Effective management of occupational
health and safety risks
There is not an effective, participative man-
agement of occupational health and safety.
The most important issue is violence against
health care personnel and physicians. 28%
of the physicians are exposed to violence
from other health care staff, 36% – from
their colleagues, 41% – from their manag-
ers, 66% – from their patients [4]. The vio-
lent atmosphere of health care in Turkey
has tremendously demotivated physicians
and other health care staff. Unfortunately,
one surgeon was stabbed to death in 2011.
Physicians’ suicides have not been the sub-
ject of scientific research yet, but it cannot
be ignored. In Erzurum in 14 months three
young physicians committed suicide. The
TMA committee has prepared a prelimi-
nary report:
“It is hard to establish a connection between
deaths but there is an increase of depression,
psychological disorders, physical problems due to
very heavy work load and even the substance use.
There is a social pressure on physicians. Compul-
sory service creates broken families. Physicians
have worries about future. These cases cannot be
defined as individual cases” [26].
Effective employee representation and
communication
The status of freedom of the Association is
reflected in the ILO reports and unfortu-
nately it is in the black list. Only the trade
unions close to the government are sup-
ported,while being a member of other trade
unions is a serious risk.The long detentions
in prison and penalties have been reflected
in the European Commission Progress Re-
port on Turkey in 2012 [27].
Maternity/paternity leave
Women physicians have 4 months of paid
leave after delivery. But PFP is cut dur-
ing this period. Since the fixed income
is around the poverty line physicians are
having difficulties in using maternity
leaves.
Women physicians have a nursing leave for
one year.They are relieved of shift work and
duties during this period, but they face dif-
ficulties in the unions of private hospitals
and public hospitals in terms of restrictive
interventions.There are not enough well or-
ganized nursery and day care units for the
children of health care workers.
Access to/support for training and educa-
tion
There is no paid leave for CME activities.
95% of the GPs, 68% of the RAs and 33%
of the specialists state that they cannot af-
ford time for CME [4]. The total time de-
voted to CME is extremely negligible – 24
hours by the GPs, 36 hours by the special-
ists and 31 hours by the RAs per year [4].
75% of the GPs, 65% of the specialists and
66% of the RAs stated that their managers
are not aware of the importance of CME
and educational activities are not paid for
[4]. 75% of the GPs, 64% of the special-
ists and 74% of the RAs stated that their
requests for further training resulted in
cuts from their earnings [4]. This is limit-
ing the participation of physicians in the
CME activities. On the other hand, since
participation in the educational activities is
not supported financially, physicians might
have unethical financial relationships with
pharmaceutical firms.
Intrinsic rewards
In the WHO report “Successful health sys-
tem reforms: the case of Turkey”, the dis-
content of the health professionals has been
highlighted: “The SABIM telephone hot-
lines have significantly empowered patients
and resulted in a considerable change in the
power relationship between doctors and pa-
tients. This led to discontent among health
professionals.” [28] The investigations trig-
gered by SABIM became another form of
violence against physicians and resulted in
suicide of one young RA in 2012.
Conclusion
In addition to the health policies of the last
30 years, the last decade created a wreck of
health professionals and physicians. Physi-
cians’ sense of belonging has weakened and
the expectation of future decreased.This sit-
uation has been reflected even in the publi-
5% 9%
31%
2%
2%
8%
3%
5%
14%
6%
11%
12%
10%
16%
15%
26%
25%
7%
31%
19%
10%17% 12%
4%
0%
20%
40%
60%
80%
100%
General practitioner Specialists Resident
Less than 40 hours
41–45
46–55
56–65
66–75
76–85
86–95
More than 95 hours
Distribution in specialty status, %
Figure. Weekly working hours including duty and overtime. Consensus on the working condi-
tions, workload and labor force of physicians, 2010
Health Profession TURKEY
109
cations of the Ministry of Health. The gov-
ernment has lost physicians.This is tangible
and visible. The profession is falling into an
ordinary status. This needs serious, radical,
sincere precautions and interventions [26].
Physicians in Turkey as honorable members
of a profession which is dedicated to society,
do not want to be an actor in a commercial-
ized health care.
We would like to conclude with a quotation
from what Dr. Otmar Kloiber, Secretary
General of the World Medical Association,
has said in relation to the Turkish govern-
ment’s attack to dismantle physician self-
governance.
“…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 underestimat-
ed, 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 criti-
cal 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 pa-
tients and services to our people, to protect
the dignity of patients, and to improve pub-
lic 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 than 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” [29].
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23. Uzay N, Tıraş H. Economic results of Free
Trade Zones: Kayseri Free Trade Zone. Journal
of Erciyes University Social Sciences Institute.
2009:26:1: 247-277
24. Kocaman ÇB. Evaluation of macroeconomic
results of Free Trade Zones: Case of Turkey,
AÜHFD. 2007: 56: 3 :99-135
25. House of Commons. 2011: 22
26. Turkish Medical Association. Problems of phy-
sicians. 2012 http://www.ttb.org.tr/kutuphane/
hekimsorunlari.pdf
27. European Commission. Turkey 2012 Progress
Report
28. WHO. Successful Health System Reforms. The
Case of Turkey. 2012
29. Kloiber O. A difficult start into the year. World
Medical Journal. 2012, 58/1
MD Feride Aksu Tanik,
the member of Advisory Board of
Turkish Medical Association
MD, Eriş Bilaloğlu,
the member of Advisory Board of
Turkish Medical Association
Ziynet Özçelik,
lawyer, Legal Advisor of Turkish
Medical Association
Uğur Okman,
city planner, IT Specialist of
Turkish Medical Association
Health ProfessionTURKEY
110
BOSNIA and HERZEGOVINAMedical Publications
Introduction
Scientific publishing is the end product of
the scientific work. The number of publica-
tions and their citations are measures of sci-
entific success, while unpublished research-
ers are invisible to the scientific community
and as such are non-existent. Researchers in
their work rely on precedents, so the use of
works of other authors is the verification of
their contribution to the growing knowl-
edge of mankind. If the author published
an article in a scientific journal, this article
should not be published in any other jour-
nal, with little or no modification without
quoting parts of the first article [1,2,3,4,5].
Why do scientists publish? Apart from the
already mentioned, there stand out three
main reasons [1]:
• Profit, money incentives, grants;
• Personal promotion, fame, recognition of
society;
• Quest for sponsors.
According to K. Gowrinath [3], plagiarism
is one of the ways of scientific misconduct,
besides there is also data fabrication, falsifi-
cation, and specifying nonexistent references
or literature references. Plagiarism is defined
as “intentional or unintentional use of other
people’s thoughts, words, or ideas as their
own without clear attribution to their source“.
Stealing someone else’s intellectual work and
its appropriation is cheating of the public.
Violation of copyright occurs when the
author of a new article, with or without
mentioning of the author whose work has
been used, is using parts of previously pub-
lished articles, including tables and figures.
In accordance with the principles of good
scientific practice (GSP) and Good Labora-
tory Practices (GLP) scientific institutions
and universities should have a center for
monitoring, security, promotion and devel-
opment of quality research. Setting rules
and abiding by the rules of good scientific
practice are obligations of each research
institution, university and each individual
researcher, regardless of the field of science
that is being investigated. In this way, inter-
nal quality control ensures that the research
institution, such as a university, is respon-
sible for creating an environment that will
promote standards of achievement, intellec-
tual honesty and legality.
Common reasons of intellectual dishonesty
are as follows:
• Persisting “publish or perish” mantra;
• The personal ambitions of poorly edu-
cated individuals;
• Vanity;
• Financial pressure.
Therefore, all the reasons could be classified
into two categories: a) human nature (the
desire for status, power and glory without
the ability to perform the research in a
proper way), or b) a feverish competition
among researchers, under the pressure for
better results and lack of proper supervi-
sion at the workplace (“publish or perish”
culture).
As mentioned above, the worst forms of
scientific misconduct and intellectual dis-
honesty are:
• Falsification of information obtained;
• Fabrication of data;
• Plagiarism of ideas and words (stealing
other people’s ideas, data, texts).
Although the truth should be the goal of sci-
entific research,it is not a guideline for all sci-
entists.The best way to reach the truth in the
study and to avoid methodological and ethical
mistakes is a constant application of scientific
methods and ethical standards in research.
Plagiarism – Terms
and Definitions
The term “plagiarism” originates from the
Latin word plagium which means “to kid-
nap a man”.Literally it means “stealing,tak-
ing someone else’s work and presenting that
material as the work of someone else”[1, 2].
Plagiarism of words and ideas can be un-
intended and deliberate. It is “the tendency
of literary theft and illegal appropriation
of spiritual ownership of other people”, or
generally “presenting someone else’s work as
own”. According to Miguel Roig (St. John’s
University, USA), “Plagiarism can take
many forms,from the presentation of some-
one else’s work as the own work of the au-
thor, to copying or paraphrasing substantial
parts of another’s work without attributing
the results to a survey conducted by others”
[1]. In all its parts, plagiarism includes un-
ethical behavior and it is unacceptable.
According to the World Association of
Medical Editors (WAME), plagiarism is
repetition of 6 consecutive words, or over-
lapping of 7–11 words in a set of 30 words.
Although variously defined, plagiarism is
basically a method that is intended to mis-
lead the readers about one’s own scientific
contribution [1].
Plagiarism in Scientific Publishing
Izet Masic
111
BOSNIA and HERZEGOVINA Medical Publications
Types of Plagiarism
There are distinguished different forms
of plagiarism. The most common ones are
given below [1]:
1. Plagiarism of ideas: the inclusion of
others’ ideas, methods and results in
one’s own work without acknowledging
the original author.
2. Text plagiarism: copying materials from
other researchers and its inclusion in the
own work without any acknowledgment
or quotation. Inclusions comprise:
a. Not quoting the sources: the inclu-
sion of the text, or any material by
other authors without accurate cit-
ing of the sources.
b. Para plagiarism: inclusion of the text
of other authors with minor changes
or additions to someone else’s text
without recognizing the source text.
c. Pure copying: not using quotation
marks when the exact wording is
copied from other authors, even if
the source is indicated.
d. Incorrect paraphrasing: the text of
other authors is used with small
changes, but using the same word
or sentence structure, even if the
source is indicated.
e. Violation of copyright: exact copy-
ing of others’ words is a violation of
copyright.
3. Self-plagiarism
a. Duplicate publication: publishing
the same article with similar con-
tent to that which has already been
published.
b. “Salami” publication: publishing
several papers based on the results
of one study. However, the num-
ber of papers that can be published
based on the results of a study has
not yet been fixed.
c. Recycling texts: publication of the
same paper in different journals or
in different languages.
Adverse effects of plagiarism include un-
necessary utilization of space in journals,
spending time of reviewers and editors, the
risk of professional liability and infringe-
ment of copyright, inflating the importance
of research subject and awarding lies.Today
the availability of abundant materials of the
same or similar subject through a simple
internet search results in an increase in the
incidence of plagiarism. At the same time
the internet makes the detection of plagia-
rism easier with the help of detection soft-
ware [3].
Plagiarism Prevention
According to M. Roig [4], since 2005 un-
til today the number of published articles
containing the word “plagiarism” is higher
than in all the years up to 2004. The author
also argues that plagiarism is manifested in
various forms and describes self-plagiarism
and its other forms.
There is no general regulation of control
for scientific research and intellectual hon-
esty of researchers that would be absolutely
applicable in all situations and in all re-
search institutions. In the case of substan-
tial plagiarism (copying more than 25% of
the published sources), the redundant text
should be withdrawn from the publication
and measures should be taken to inform the
respective institutions. If plagiarism is de-
tected only after publication, editors should
withdraw the article and inform readers
about the abuse.
According to the Office of Research Integ-
rity USA (ORI), plagiarism is on the top of
the list of the three largest research fraud of-
fenses. In Bosnia and Herzegovina, plagia-
rism is not yet listed in the law as a criminal
offense and therefore appropriate penalty
for plagiarism is not defined.
The ethical aspect of publishing is especially
important for small and developing coun-
tries. The participation of scientists from
Bosnia and Herzegovina in the global sci-
entific communication implies the obliga-
tion of accepting international standards for
citing the sources used.
The authors should:
• Always follow the proper rules of citation
references, acknowledging that the ideas
were heard at conferences and in formal
or informal discussion;
• References must contain full bibliograph-
ic information;
• Each source cited in the text must be
listed in the bibliography;
• Quotation marks should be used if more
than 6 consecutive words are copied;
• Obtain permission of other authors/pub-
lishers for reproduction of protected fig-
ures or text.
K. Gowrinath [3] recommends the follow-
ing steps to prevent plagiarism:
• All data that have already been published
by other researchers should be quoted
with appropriate references and all the
sources of information used in the prepa-
ration of the document should be recog-
nized in the appropriate format;
• Provide footnotes and use inverted com-
mas whenever necessary;
• Written approval of other authors should
be obtained prior to the incorporation of
their figures or tables in the article.
Specific form of plagiarism is self-pla-
giarism. Scientists need to take into ac-
count this form of plagiarism, because at
the moment there is an attitude that their
own words can be used without fear of
plagiarism. If an author cites his/ her own
article that has already been published,
then this should be listed as a quote and
cite the source in which the article is pub-
lished.
Conclusion
Science should not be exempt from dis-
closure and sanctioning of plagiarism. In
the struggle against intellectual dishonesty,
education on ethics in science has a signifi-
112
Health Care and Pharmaceutical Industry BELGIUM
cant place. General understanding of ethics
in scientific research and in all its stages had
to be acquired during undergraduate studies
and is to be improved further in later years.
The ethical aspect of publishing industry is
as important, particularly in small and de-
veloping economies, because the publisher
has an educational role in the development
of the scientific community that wants to
enjoy it.
References
1. Masic I. Plagiarism in Scientific Publishing.
Acta Inform Med. 2012 Dec); 20(4): 208-
213. doi:10.5455/aim.2012.20.208-213 
2. Masic I. Ethical Aspects and Dilemmas of Pre-
paring, Writing and Publishing of the Scientific
Papers in the Biomedical Journals. Acta Inform
Med. 2012 Sep; 20(3): 141-148.  doi:10.5455/
aim.2012.20.141-148 
3. Gowrinath K. Plagiarism in Scientific Research.
NMJ. 2012; 1(2): 49-51. 
4. Roig M. Avoiding unethical writing practic-
es. Food and Chemical Toxicology. 2012; 50(10):
3385-3387. (doi: 10.1016/j.fct.2012.06.043)
5. The insider’s guide to plagiarism. Nature Medi-
cine. 2009; 15: 707. doi:10.1038/nm0709-707
http://www.nature.com/nm/journal/v15/n7/
full/nm0709-707.html
Dr. Izet Masic,
Bosnia and Herzegovina
Like every industry, pharmaceutical indus-
try develops a product, medication in this
case, which purpose is to draw the best pos-
sible benefit.
To do that, it aims for the highest possible
prices in accordance with the purchasing
power in each country it targets.
As much as possible, pharmaceutical indus-
try avoids the reentry of a medication from
a country where it has a low price to another
where its price is high.
Pharmaceutical industry attempts to extend
the duration of patents by introducing ga-
lenic or chemical improvements of some-
times low usefulness.
It tries to increase demand by raising the
conscience of a need or by creating a need
where there is none.
To achieve that, it works on:
• General public by publishing something
which is not always an advertisement but
is related to information;
• The prescribing practitioner.
And, indeed, what makes pharmaceutical
industry different from other industries,
is the fact that it is not the customer who
pays or chooses his product (at least for pre-
scribed medications). That is why pharma-
ceutical industry creates a relationship with
the prescribers.
Pharmaceutical industry needs doctors who
will prescribe its products.
Therefore, a doctor must be well informed
about a pathology. That is why pharmaceu-
tical industry spends substantial money in
continuous medical education of doctors.
It also makes tremendous efforts to inform
about its products.
On the other hand, competition between
firms which develop related medications for
the same pathologies and the ineluctable
deadline of the end of patent protection
incite the firms to develop a high research
activity because innovation only allows
growth and durability.
The firms need the cooperation of doc-
tors to do that. The use of new molecules
cannot, actually, happen without periods
of trial combined with an intense moni-
toring of the patients who undergo these
tests.
The policy of pharmaceutical industry
is not guilty in itself. Search for profit
is the driving force of progress and pro-
vides us, doctors, in therapeutic means
which allow us to relieve or heal our
patients more often than before. What
other product could be more useful to
mankind?
That remains true as long as these thera-
peutic means are used advisedly in the pa-
tients’ only interest and in complete trans-
parency towards them.
Yet, the boom of expenses in the field of
medications, the accidents, sometimes
caused by an excessive use, too much pro-
motion from the firms, the taboo on their
unwanted side-effects and the bad results of
research have led to mistrust from general
public towards the industry as well as to-
wards the prescribers.
Cooperation Between Medical Profession
and Pharmaceutical Industry
Roland Lemye
113
Health Care and Pharmaceutical IndustryBELGIUM
How was it possible to come as far as sus-
pecting WHO to have been swindled or
bribed by pharmaceutical industry about
the risk of a H1N1 pandemic and the ne-
cessity to vaccinate the world’s population?
The reason is quite simple: in public view,
pharmaceutical industry seemed to have
unlimited abilities and doctors were entirely
compliant to its messages.
How many abuses made this possible?
The most visible part was conviviality, fes-
tive invitations, presents, which amount
grew exponentially because they found
place in a climate of competition.
Doctors did not feel like they were being
bought without being aware of it, since
they cared most for the content of com-
munications from those who had made up
the atmosphere of conviviality.
So it was about time to restore a climate of
credibility for both parts.
Speaking for medical ethics, medical or-
ganizations have defined, in statements,
what was acceptable and what was not in
the context of relationship between prac-
titioners and industry.
The Standing Committee of European
Doctors (SCED) has taken it further
by negotiating a charter with the Euro-
pean Pharmaceutical industry (EFPIA).
Its advantage is, as long as it is signed
by all parties, to impose on doctors as
well as on firms. Many countries have
done the same or even preceded these
measures.
It must be said that the pharmaceutical
industry has hesitated for a long time be-
fore it decided to commit itself but finally
did so when it was confronted to two un-
avoidable outcomes of its policy:
• The exponential cost of conviviality and
• The receding decision-making power of
doctors to the benefit of pharmacists.
For all that, all problems are not solved yet
even if progress is evident.
The problem which is currently focused on
is that of transparency and conflict of inter-
est.
Everybody knows now how tobacco indus-
try has fought against medical efforts to
eradicate that plague, by corrupting famous
scientists so that they wrote articles which
minimized or denied some of tobacco’s
harmful effects. That strategy was particu-
larly used against the idea of passive smok-
ing in public places.
Methods used by pharmaceutical industry
are not always very different.
A spokesman, chosen by the firm (prefer-
ably a pacesetter in his field) makes a sci-
entific speech, using the firm’s slides, to a
public invited by the firm itself.
Industry sponsors medical reviews which
are sent for free to the practitioners, in
which professors claim the benefits of a
given product.
Conflicts of interests are obvious in this
case, but what about those who exist in
decision-making instances (Drug Agen-
cies, Repayment Commissions, and so on)?
It appears clearly that a doctor who has
taken part in clinical tests about a given
medication can only be influenced by his
knowledge of the medication itself, which
he gained during the tests (is that a bad
thing?), but also by the fact that he is often
offered clinical tests and that he does not
want to lose that source of income.
If doctors who have that knowledge were
by-passed, would a medication be consid-
ered with more impartiality by people who
do not know it?
Conflict of interest can also occur in the
opposite way. Is the person in charge of ex-
penses more neutral, who has to decide over
the conditions of repayment of a medica-
tion which is useful but expensive?
The problem is complex but must be solved.
The Platform on Ethics & Transparency,
which has recently published a list of guid-
ing principles promoting good governance
in pharmaceutical sector, is dedicated to
that.
The intention is that the patient, finally, re-
ceives the most appropriate treatment with
relevant information that goes with it.
In order to achieve that, all parties must es-
tablish relationships based on mutual trust
and transparency.
Transparency implies that all parties reveal
all their relationships and potential conflicts
of interests. As for companies, they must
provide complete information, particularly
to the competent authorities.
By introducing all partnerships, not only
industry and practitioners but also patients’
associations, caregivers, consumer associa-
tions, society, hospitals and competent au-
thorities of all levels into debates, the Plat-
form on Ethics & Transparency has given
the discussion a new dimension which al-
lows hope in a better future.
Dr. Roland Lemye,
President of Association Belge
des Syndicats Médicaux
114
Medical Education
Medical education has evolved beyond
the traditional didactic way of teaching.
Dr. William Osler put into practice a learn-
ing process that extended beyond the class-
room and to the patient’s bedside. From
the first day of medical school, students are
quickly exposed to the experiential concept
of “see one, do one, teach one,” and all can
agree that a considerable amount of learn-
ing in medicine happens through observa-
tion. Nonetheless, we need to be innovative
in changing the way we learn and teach as
the quantity of material has significantly in-
creased in recent decades.
Will sitting through numerous lectures
throughout medical training and attending
scientific meetings implicitly make one an
expert in designing lectures? Will it enable
future physicians tooptimize the transfer of
knowledge, and will it aid in understanding
the true meaning of Bloom’s Taxonomy and
fundamental theorists of pedagogy and an-
dragogysuchasBeinstein,Freire,orKnowles?
What are the principles of medical educa-
tion in relation to learning and teaching?
Many efforts have been made to advance
residency education such as the develop-
ment of the CanMEDS roles which are
meant to promote “better standards, better
physicians, better care.”These were formally
adopted by the Royal College of Physicians
and Surgeons of Canada in 1996 and are
in place to help guide educators to better
define the competencies of well-rounded
physicians should possess at the end of his
training. The CanMEDS Scholar role en-
compasses the role of physician as a teacher.
Additionally, the imperative to teach oth-
ers is intrinsic to most descriptions of the
constituents of professionalism in medicine.
Physicians must not only be lifelong learn-
ers, but also lifelong educators; however,
there is a paucity of formal training prepar-
ing them for either role. A greater emphasis
should be placed on the manner and context
in which these competencies are attained
within atraining program to ensure resi-
dents and trainers are adequately equipped
with the fundamentals of education in order
to properly acquire them.
Physicians are trained as medical profes-
sionals and generally do not receive formal
pedagogy training. There is a gap in the
medical community between knowledge
and understanding contemporary, effective
strategies of delivering the material.The ed-
ucator is a facilitator of learning; they need
to have some understanding of how people
learn as wellas how to teach. As an effect,
the trainer does not drive the curriculum,
but facilitates it for proficient and efficient
learning.
Communicating the science can be very dif-
ficult in a multifaceted and humanistic field
such as medicine where a plethora of factors
continuously shape the psychology of edu-
cation. Basic principles of education should
be further explored, integrated, and rein-
forced within post graduate medical educa-
tion. Furthermore, in order to see a change
in its culture,a stress on faculty development
is vital and an auditing of the education and
teaching should be imperative, particularly
in the delivery of material.A high-ranking
measurable is the transfer of knowledge and
skills to equip physicians with a certain ca-
pacity for critical thinking. Consequently,
learners would be given a greater sense ovf
inquiring about the material being deliv-
ered, especially with the relevance of their
socio-political context.
There is a call for a culture of continuous
quality improvement in medical education.
This would allow physicians to not only
identify weaknesses and strengths in their
scholars, but to guide them on how to act in
response. Increasing awareness forthe im-
portance and need of adult education must
be a priority among stakeholders as it has a
direct impact on patient care. Globally and
in itself, medical educationis a fragmented
system with a lack of commitment to excel-
lence from many political leaders. Recogni-
tion from the latter for the aforementioned
competencies could translate into higher
standards in medical education with the
aim of increasing the quality assurance and
preventing harm to patients.
The World Medical Association encour-
ages the highest possible standards not
only in medical ethics, but also in medical
education by way of “helping physicians to
continuously improve their knowledge and
skills.”Through its declarations, resolutions,
and statements, the World Medical As-
sociation and their partners and alliances,
have the potential to positively impact how
medical competencies are being transferred.
Medical education is an ongoing and dy-
namic process. In modern medicine, it is es-
sential that efforts are made to provide both
junior physicians and senior faculty with the
skills to evolve into educationalists.
Jean-Marc Bourque,
Deputy Chair of the Junior Doctors Network
A Call for Quality Improvement
in Medical Education
Jean-Marc Bourque
115
Healthy Ageing
Introduction
The Standing Committee of European
Doctors (CPME) represents national med-
ical associations across Europe. CPME is
committed to contributing the medical pro-
fession’s point of view to EU and European
policy-making through pro-active coopera-
tion on a wide range of health and health-
care related issues.
• CPME believes the best possible quality
of health and access to healthcare should
be a reality for everyone. To achieve this,
CPME promotes the highest level of
medical training and practice, the safe
mobility of physicians and patients, law-
ful and supportive working conditions for
physicians and the provision of evidence-
based, ethical and equitable healthcare
services. CPME offers support to those
working towards these objectives when-
ever needed.
• CPME sees the patient-doctor rela-
tionship as fundamental in achieving
these objectives and are committed
to ensuring its trust and confidential-
ity are protected while the relationship
evolves  with healthcare systems. Patient
safety and quality of care are central to
our policies.
• CPME strongly advocates a ‘health in
all policies’ approach to encourage cross-
sectoral awareness for and action on the
determinants of health, to prevent dis-
ease and promote good health across
society.
CPME’s policies are shaped through the
expertise provided by our membership of
national medical associations, representing
physicians across all medical specialties all
over Europe and creating a dialogue be-
tween the national and European dimen-
sions of health and healthcare.
CPME’s involvement in healthy ageing
goes back to the 1960s with policies ad-
dressing demographic change and the el-
derly including recommendations on health
care for the ageing population. In 2010 a
statement on Mental health in older peo-
ple/healthy ageing was adopted (CPME
2010/105), in 2011, a statement regarding
the European Innovation Partnership on
Active and Healthy Ageing (EIPAHA)
(CPME 2011/066). The latter, EIPAHA is
coordinated by the European Commission,
which gives high priority to initiatives in
this area. Three European Commissioners
strongly support EIPAHA which aims to
add two extra healthy life years to citizens
by 2020 and adopted in this sense a Stra-
tegic Implementation Plan in November
2010. Within the implementation plan,
CPME committed itself to Prevention,
early Diagnosis of Functional and cognitive
decline.
Doctor’s role in Healthy
Ageing
The role of doctors in healthy ageing is to
tackle both the physical and cognitive com-
ponents of frailty/functional decline, to
contribute to raising awareness within the
medical profession as well as partner with
patients and citizens and their social di-
mension for a life-long approach to health.
This includes maintaining functional ca-
pacity, participation and social inclusion,
independent living and caring environment
as well as a healthy work environment and
leadership.
Healthy ageing will be one of the most
important topics for European doctors
in the coming decade(s) with a specific
focus on maintaining, restoring and im-
proving the functional capacity of patients
and citizens. Hence, the role of doctors
can be seen in two components. One is
the physical component in which expert
knowledge is needed on physical fitness,
on nutrition and on chronic conditions
management including polypharmacy and
overmedication followed by functional
capacity assessment and evaluation. Im-
portant to mention here, is to concentrate
not only on the disabilities of patients but
above all on the existing abilities. (ability
vs. disability). Wrong judgments in this
area can easily lead to social exclusion of
people. Next is the psychological compo-
nent in which expert knowledge on social
and psychological well-being is needed,
including knowledge on a healthy lifestyle.
Patients and citizens should be engaged in
meaningful activities and get physical sup-
port and easy transportation when neces-
sary.
Very important is the need for a health lit-
eracy program in which dissemination of
knowledge is channelled into the capillaries
of the population through doctors and oth-
er stakeholders, also through educational
programmes, e-learning modules, web
Healthy Ageing.
A Socio-Medical Perspective
The role of European doctors
Jacques van der Vliet
116
Healthy Ageing
based applications, all of which must be
focused on the caregiving network and the
patients and the public.
Important Elements
of Healthy Ageing
Maintaining functional capacity can be
achieved through healthy eating and physi-
cal activity also including a healthy work
environment and lifestyle, a proper work-
life balance and smoking cessation. Avoid-
ance of drugs and controlled drinking are
also part of this topic. Avoidance of drugs,
alcohol and smoking cessation have the
most significant impact when introduced at
an early stage of one’s life. Healthy child-
hood habits will bring health profits 40
years later. Finally, coping skills and resil-
ience to live with daily pressure and stress
are needed as well as one must furthermore
respect heterogeneity, autonomy and differ-
ences in people.
Functional capacity assessment and evalu-
ation can be reached through use of tools
that measure subjectively and objectively a
person’s functional condition. In the objec-
tive tool a doctor looks at personal and so-
cial functioning and at adaptation to physi-
cal demands. This leads to an outcome in
which the result is either normal, limited or
limited to a certain extent. The Workability
Index is a subjective judgment by an indi-
vidual (see figure). As the figure above illus-
trates, the subjective judgement engages the
individual in a progressive follow-up ob-
tained from answering a set of 10 questions
that, dependent on the score, indicate either
the need to intervene and redress functional
capacity or assures the individual of his/her
functional capacity. The functional capacity
status may be observed through yearly eval-
uations done by the occupational physician
at the workplace.
Participation and social inclusion can be
realised through staying active in society,
either in work or in a social environment.
One should be well protected from get-
ting in an isolated position or facing the
loneliness which can be a threat for many
people in the later stage of their lives. The
position of family, relatives, social workers
or even neighbours is of key importance.
People are entitled to a meaningful place in
society and most people want to continue
to contribute having a lifetime of knowl-
edge and experience. One must keep older
people stimulated and engaged through
employment or through learning and pro-
mote fiscal benefits and cheap transporta-
tion to prolonge flexibility. A basic idea of
how to extend the social residency of the
elderly is through increasing their literacy
in technologies (computer skills, special
phones with bigger screens or buttons and
phone applications for caregivers) Further-
more courses and social clubs for the older
members of society could include musical
and artistic activities.
Independent living and caring environ-
ment is implemented by promoting in-
dependence and offer support where nec-
essary. One should stay in his/her own
environment as long as possible and create
a network of formal and informal carers,
such as family, social workers, GPs. Physi-
cal support (like vacuuming the house or
doing repairwork and or cooking meals)
will help people stay in their original set-
ting. Also organising shopping services
with transportation and support can be of
immense help.
Good Working conditions are important
since demographics show that in an ageing
population people will have to work lon-
ger. Evidence shows that work is good for
your (mental) health, provided that proper
working conditions are in place. A healthy
working environment is implemented
through a stimulating and inspiring lead-
erships or management style. There is a
need for a special focus on senior employ-
ees, providing them with a stable psycho-
social environment and good working
atmosphere including clear communica-
tion and clarity about goals and objectives,
changes and results in the organisation.
Training on IT and increasing the tech-
nological literacy, as mentioned previously,
could aid not only in making the older
employee stay integrated in the team but
also giving them a constant intellectual
stimulus. Human resources management
must be active, enabling senior employees
to use their potential to the full and con-
tribute to their ability including perma-
nent education.(and task shifting) Skills
and experience should be passed on to the
next generation with seniors as coaches or
mentors.
Likeable Organisations
In order to optimize the working environ-
ment for individual employees, employers
should promote likeable organisations. David
Kerpen, CEO of two companies (Likeable
Local and Likeable Media) and author of two
books, (Likeable Social Media and Likeable
Business), describes a likeable organisation
Workability Index
Subjective
judgment by
individual
10 questions
addressing
present and
future health
situation
Score leads to
assurance intervention
Yearly
evaluation
to measure
trend
117
Healthy Ageing
in 11 elements in a triangle (see figure). Key
elements would include:
• Listening: “When people talk, listen
completely. Most people don’t listen”, Er-
nest Hemingway;
• Storytelling: “Storytelling is the most
powerful way to put ideas into the world
today”,Robert McKee and “if you tell me,
it is an essay, if you show me, it is a story”,
Barbara Greene;
• Authenticity: “I had no idea that being
your authentic self could make me as rich
as I’ve become, if I had, I’d have done it a
lot earlier”, Oprah Winfrey;
• Transparancy: “ As a small businessper-
son you have no greater leverage than the
truth”, John Whittier;
• Teamplaying:” individuals play the game,
but teams beat the odds”, SEAL team
saying;
• Responsiveness: “Life is 10% what hap-
pens to you, and 90% how you react to
it” Charles Swindell and “your most un-
happy customers are your greatest source
of learning”, Bill Gates
• Adaptibility: “When you’re finished
changing, you are finished”; humility and
willingness to adapt mark a great leader,
Ben Franklin
• Passion: “The only way to do great work is
to love the work you do”, Steve Jobs
• Surprise and delight: “ A true leader
always keeps an element of surprise
up his sleeve, which others cannot
grasp but which keeps his public
excited and breathless” Charles de
Gaulle; likeable leaders underpromise
and overdeliver.
• Simplicity: “ Less isn’t more, just enough
is more” Milton Glaser
• Gratefulness: I would maintain that
thanks are the highest form of thought,
and that gratitude is happiness doubled
by wonder” Gilbert Chesterton
• The Golden Rule: “Above anything else,
treat others as you ‘d like to be treated”
Source: David Kerpen. Likeable social media
and likeable business. http://www.likeable-
book.com/
Blue Zones
Maintaining functional capacity, social in-
clusion and a stimulating working environ-
ment are crucial to healthy ageing,acknowl-
edging the potential of the older person.
Research has shown that where all these
elements are in place, people live longer and
happier.
Healthy Ageing
Blue zones (adapted from Dan Buettner,
USA):
• Still at work
• Physical activity
• Healthy nutrition
• Participation and social inclusion
• Porpose in life
• It starts with goed genes of course
For example, Dan Buettner, a journalist/
researcher from the USA and connected
to the National Geographic Journal de-
scribes 5 areas in the world where people
reach-on average- a higher age. What do
all these people have in common? Firstly,
it starts with good genes, of course. Then,
they are still at work most of the time.
Thirdly, they are engaged in some kind of
physical activity. They eat healthily. Never
cease being well integrated with a group.
They participate one way or another in so-
cial activities. Last but not least, they have
a very well –marked purpose in life (a rea-
son to get up in the morning; In Japan: iki-
gai). What we also see here is that a basic
thought is to avoid the disease instead of
curing it. Moreover, in our society we see
that people tend to be preoccupied about
a lot of issues, very often worrying solely
about themselves. Let us find out what we
can do for someone else who might be in
need. This could mean looking at our clos-
est environment including family, friends,
and neighbours. A small piece of advice
could be to try a change in attitude by be-
ing kind to other people and smile at one’s
neighbour. People in most societies work
GRATEFULNESS
ADAPTABILITY
AUTHENTICITY
&TRANSPARENCY
SIMPLICITY
SUPRISE
&DELIGHT
RESPONSIVENESS
LISTENING STORYTELLING PASSION
TEAM
PLAYING
Helthy
workplaces are
likeable
organisations
Figure. Adapted from David Kerpen. Likeable social media and likeable business. http://
www.likeablebook.com/
118
Speaking Books
Background
The Health Extension Program (HEP) is
an important institutional framework de-
veloped to achieve the goals of the Health
Sector Development Program (HSDP) at
community level [1]. It aims to improve
access and equity of services by provid-
ing health interventions at kebeles and the
household level, with a focus on sustained
preventive health actions and increased
awareness [2] by covering all rural kebeles
with the HEP. The HEP focuses on four
key areas: (1) Hygiene and Environmen-
tal Sanitation, (2) Disease Prevention and
Control,(3) Family Health Services,and (4)
Health Education. These packages address
proper and safe water/waste management
and disposal systems; HIV/AIDS, malaria
or tuberculosis prevention and control; first
aid; maternal and child health, family plan-
ning and reproductive health.The Speaking
Book is used as an additional health promo-
tion tool particularly for community health
promoters with low levels of literacy and for
health extension workers (HEW) to use
for existing projects related to community-
based maternal, newborn, child and family
health. As such, the research study has the
following objectives:
• Assess use and effectiveness of MNCH
Speaking Book in selected kebeles by
HEWs and HDA.
• Understand care-takers’perception of the
Speaking Book and the potential impact
of this initiative on caretakers’ knowledge
and practice.
• Assess effectiveness of Speaking Books as
a health promotion tool in general and for
future initiatives.
Speaking Books
The first Speaking Book in Ethiopia was
developed in 2010 by the Federal Minis-
try of Health (FMoH) in partnership with
United Nations International Children
Fund (UNICEF), the Integrated Fam-
ily Health Program (IFHP), and the Last
Ten Kilometers /JSI. The Speaking Book
is an educational tool containing 16 key
messages on community based maternal
and new born health presented through
text, pictures, and a recorded soundtrack in
Amharic.
Health extension workers (HEWs) and the
health development army (HDA) utilize
the books as a supplement to the Family
Health Card during interactions with the
community (mothers, fathers, grandparents,
aunts, care-takers and others) regarding
Rapid Qualitative Assessment of Maternal and Newborn
Health Care (MNHC) Speaking Book in Two Districts
in the Amhara Region, Ethiopia
towards retirement as a purpose in life, for
people in blue zones the word pension of-
ten does not exist in their language.
In conclusion 11 steps towards healthy
ageing are worth mentioning.
Here they come:
• “take the stairs,
• drink more water,
• eat a big breakfast,
• snack on fruit,
• have a cup of coffee every now and then,
• breathe more deeply,
• exercise your eyes,
• stretch regularly,
• take a walk after lunch,
• take a powernap,
• be more optimistic ………and
• smile at your neighbour”
References
1. CPME Statement on the European Innovation
Partnership Ageing Healthy Ageing,April 2011.
CPME 2011/066
2. CPME Statement on Mental Health in
the Older People, November 2010. CPME
2010/105
3. Dan Buettner, Blue zones. http://www.bluez-
ones.com/about/dan-buettner/
4. David Kerpen, Likeable social media and like-
able business, New York Times best selling
author, 2013. http://www.davekerpen.com/
books
Jacques van der Vliet,
(with the kind support
of Anamaria Corca (CPME)
and Olga Rostkowska, (EMSA))
119
Speaking Books
antenatal care, safe delivery, postnatal and new-born care (includ-
ing early and exclusive lactating), recognition of danger signs, care-
seeking and immunization.
Process
The aim of the study was to assess the effectiveness, acceptability
and relevance of the Speaking Book as a health promotion tool. As
the use of Speaking Books as a communication tool is still in the de-
velopment phase in this region,the pool of potential participants for
this study was too small to fill both the intervention and the control
group. However, the study can be valuable by providing:
• Information on who is being served by this program.
• Information that suggests whether anticipated changes are oc-
curring.
• Information on whether anticipated changes are occurring in
some subgroups and not others [3].
A total number of 1500 Speaking Books were distributed to the
Amhara region during March, 2012. The field research was con-
ducted between May and July 2012. Structured interviews, focus
group discussions (FDGs) and observations (use of book during
home visits, outreach and at health posts) in the woredas of Dem-
bia (North Gondar) and Dembecha (W/Gojjan) were conducted
to provide qualitative reports on the appropriateness, contribution,
and challenges of the Speaking Books. Interview participants in-
cluded:
• 18 health extension workers (HEWs),
• 29 health development army members (HDA),
• 27 care-takers (10 breast feeding mothers and 17 pregnant wo-
men),
• 4 focus group discussions with 21 pregnant and 15 lactating
mothers.
Transcripts were prepared for analysis through: (1) transcription
from voice recorder to paper, (2) translation from Amharic to Eng-
lish, and (3) manual test analysis.
Findings
In some locations, it was found that both HEWs and HDAs were
using the Speaking Book as a job aid on daily basis in health
posts, for home visits and during outreach programs. It was also
found that HDAs were using Speaking Books once a week during
home visits, local meetings, market days and local holidays. The
book was also used for health promotion during local gatherings
including coffee ceremonies, pregnant women’s conferences and
in churches.
120
Speaking Books
HEWs and HDA made the following ob-
servations:
• The book was a good communication
tool to strengthen messages of the Family
Health Card.
• The book helped HDA and HEWs gain
community acceptance.
• The book enabled health workers to pro-
vide essential MNCH information in an
organized, structured and creative format
suitable for small groups.
• The book assisted and simplified health
education efforts of health workers and
made more efficient use of health workers
time and energy.
• The intended audiences trust the mes-
sages and consider the Speaking Book
information as ‘expert advice or as a pro-
fessional delivering the message’.
• Mothers claimed to learn new informa-
tion including the importance of avoiding
harmful traditional practices and impor-
tance of calling HEWs to attend delivery.
• The book is a good communication tool
for the illiterate – the majority of the in-
tended audience.
The following are key takeaways from inter-
views with health workers:
• Showing pictures followed by hearing
sound messages was an effective way to
deliver the message.
• Speaking Books were useful during con-
ferences for pregnant women, home-vis-
its, outreach programs, and at church.
• It is worth noting that the number of new
attendees in antenatal care in April and
May 2012 were double that of February
and March, 2012.
Interviews with care-takers revealed that:
• The Speaking Book is a good tool to de-
liver full information.
• The voice was clear and understandable
and was the most informative aspect of
the Speaking Book.
• They trust the messages from the Speak-
ing Book.
• They appreciated the commitment of the
responsible parties for the provision of
Speaking Book and hoped such programs
will continue.
• Women showed interest in having fre-
quent and repeated learning through the
Speaking Book and preferred to have
available at least one book at household
or community level during their pregnan-
cy and lactation period.
Focus groups with pregnant/lactating
mothers, none of whom could read or write,
revealed that:
• All FGD participants claimed to learn
something new. Information found to be
particularly useful included: importance
of antenatal care visits; danger signs dur-
ing pregnancy and labor; birth prepara-
tion; attending a health facility; delivery;
new born colostrum feeding; breast feed-
ing; not washing a new born before 24
hours post-delivery; and feeding of infant
after 6 months.
• Participants claimed the book provided
the opportunity to ask HDA questions
during book use for additional informa-
tion (i.e. availability of delivery service in
the health posts; stretcher to carry labor-
ing women from home to health post;
solution to those infant with throat and
tooth problem if it is not extracted or cut;
and type of complementary food they
need to give to their children, etc.).
• The voice was the most informative as-
pect of the book and the pictures were
also found to be clear and understand-
able.
There were very few challenges or obstacles
in using the Speaking Books. Some chal-
lenges that were identified included failing
battery/replacing the battery, un-adjustable
volume and protecting the book from wa-
ter/rain damage.
Recommendations
Due to the limited availability, rotating
Speaking Books between HEWs and HDA
would result in more efficient use and in-
creased exposure in the community. As
suggested by pregnant and lactating moth-
ers and HDA/HEWs, it would be highly
beneficial to create Speaking Books to cover
other health areas such as: malaria, sanita-
tion, and hygiene. Speaking Books can be
used in someone’s home, in community and
social gathering forums, church programs,
development forums and even during in-
formal meetings. Clear training by instruc-
tors should be provided on how to replace
the battery of the Speaking Book. Alter-
natively, instructions to replace the battery
could be added to the Speaking Book in a
picture format. Adding adjustable volume
to the Speaking Books would make it use-
ful to distribute to larger groups or in larger
venues. Finally, advocacy for resource mo-
bilization at federal and regional levels is
needed to provide communities with effec-
tive health promotional tools.
Investigators:
Endale Engida,Tesfaye Simireta.
Advisors:
Luwei Pearson, Shalini Rozario
References
1. FMOH, HSDP IV document, Ethiopia, 2012
2. FMOH. Health Extension Implementation
Manual, Ethiopia. 2005
3. Kristin Anderson Moore, Ph.D. QUASI-EX-
PERIMENTAL EVALUATIONS Part 6 in a
Series on Practical Evaluation Methods, Publi-
cation #2008-04
Brian M. Julius
E-mail: bj@speakingbooks.com
III
TURKEY
4 June 2013
I am writing to you on behalf of the World
Medical Association (WMA), the global
federation of National Medical Associa-
tions representing millions of physicians
worldwide. Acting on behalf of patients
and physicians, the WMA endeavours to
achieve the highest possible standards of
medical care, ethics, education and health-
related human rights for all people. As such,
the WMA plays a key role in promoting
good practice, medical ethics and medical
accountability internationally. The Associa-
tion supports doctors at risk worldwide.
The purpose of this letter relates to the
current demonstrationsthatstarted peace-
fully in Gezi Public Park in Taksim
Square-İstanbul on 27 May. The Turkish
Medical Association (TMA) has draw-
nour attention to alarming violence with
excessive force used against protestors.
TMA reports hundreds of cases of injury
and detention following police confron-
tations with protestors in Ankara as well
as in other provinces including Adana,
Eskişehir and Gaziantep. According to
our sources, the majority of the injuries
were caused by the use of water cannon
and tear gas.
The WMA condemns strongly crowd con-
trol or riot prevention technology – such as
tear gar and water cannon – that is misused,
including to perpetrate human rights abuses
or that is used in a manner out of propor-
tion with the need, or against populations
with particular vulnerabilities.
We therefore call on you to immediately end
the excessive use of force against peaceful
protestors and to ensure the right to free-
dom of expression and assembly. We also
urge initiation of an independent and im-
partial investigation into the excessive use
of force and bringing to justice law enforce-
ment officials found to have ill-treated dem-
onstrators or other members of the public.
I thank you for your attention.
Dr. Cecil Wilson, President
World Medical Association
Letters to Prime Minister of Turkey
RecepTayyip Erdoğan
11 June 2013
I am writing to you on behalf of the World
Medical Association (WMA), the global
federation of National Medical Associa-
tions representing millions of physicians
worldwide.
We sent you last week a letter expressing
our deep concerns on the use of excessive
force against protestors in Ankara as well
as in other provinces including Adana,
Eskişehir and Gaziantep.
The Turkish Medical Association, one of
WMA members, reported cases of violence
these last days that were directed at health-
care workers and medical students taking
care of wounded people in houses, restau-
rants, and mosques that were converted
into temporary infirmaries. Mobile clinics
were disrupted and 13 doctors and students
were detained in Ankara.
The WMA notes with serious concern
that health-care services are threatened,
violating the principle of medical neu-
trality. According to this principle – de-
riving from international human rights
law, medical ethics and humanitarian
law  – health professionals must be al-
lowed to care for the sick and wounded,
regardless of their political affiliations.
All parties must refrain from attacking
and misusing medical facilities, transport,
and personnel.
We therefore urge you to ensure that medi-
cal neutrality is fully respected and that all
health personal is protected regardless of
whom they help.
Furthermore, we reiterate our call to imme-
diately end the excessive use of force against
peaceful protestors and to ensure the right
to freedom of expression and assembly.
I thank you for your attention.
Dr. Cecil Wilson, President
World Medical Association
Contents
Instead of Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
The Future of Global Health . . . . . . . . . . . . . . . . . . . . . . . 82
World Health Assembly Week . . . . . . . . . . . . . . . . . . . . . . 90
How Much Independence is Necessary? . . . . . . . . . . . . . . 93
Physicians and Hunger Strikes in Prison: Confrontation,
Manipulation, Medicalization and Medical Ethics . . . . . . . . . 97
Intervention Program for Addictive Diseases.
Hamburg State Chamber of Physicians . . . . . . . . . . . . . . . 102
The Greatest Motivation: Assurance of Practicing
the Profession with Dignity. Motivational State
of Physicians in Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Plagiarism in Scientific Publishing . . . . . . . . . . . . . . . . . . . 110
Cooperation Between Medical Profession
and Pharmaceutical Industry . . . . . . . . . . . . . . . . . . . . . . . 112
A Call for Quality Improvement in Medical Education . . . 114
Healthy Ageing. A Socio-Medical Perspective . . . . . . . . . 115
Rapid Qualitative Assessment of Maternal and Newborn
Health Care (MNHC) Speaking Book in Two Districts
in the Amhara Region, Ethiopia . . . . . . . . . . . . . . . . . . . . 118
Letters to Prime Minister Erdoğan . . . . . . . . . . . . . . . . . . III
Since May 31st
2013 the peaceful and legitimate demonstrations
are tried to be suppressed by the police.The police forces are using
chemical gases savagely on the unprotected civil masses.
Before complete blockage of health assistance to the injured peo-
ple and the preclusion of the functioning of health services by the
police attacks, that took place once more again on the night of
June 15th
, Turkish Medical Association was started a web based
survey in order to disclose the dangerous health effects of these
gases targeted at defenceless people and in one week period, over
11 thousand of people declared that they have been effected by
the gas.
65% of the repliers were between 20–29 years of age and profes-
sional protecting mask usage was only 13%. The total duration of
exposure was evaluated among 11.164 replies. 53% declared that
they have exposed to the chemical gases 1–8 hours where 11%
exposed more than 20 hours. Exposing the chemical gases more
than one day increases the prevalence of the systemic symptoms,
especially cardiovascular symptoms.These data shows the dimen-
sions of the problem.
Before the 15th
of June disaster the total number of injuries were
788 (7%). These data shows that the gas bombs were targeted the
people. Many of them were the injuries of head, face, eyes, thorax
and abdomen which could be fatal. 20% of the injuries were open
sores and fractures.
Only 5% of the people were admitted to hospitals. The tagging of
the people who are admitting to the hospitals is preventing people
from going to the hospitals in order to ask medical assistance.Min-
istry of Health opened an investigation about Istanbul Chamber of
Medicine which is organizing the volunteer physicians’ work. In
Istanbul one physician an done medical student handcuffed and
detained.There are many other information about the detaining of
health care staff.These data shows the witch-hunt in Turkey.
Turkish Medical Association making calls to the government to
act responsibly and stop the barbaric violence immediately. As
Turkish Medical Association it is our responsibility to inform the
international community. We urgently call the international com-
munity to act against brutal suppression of democratic demands.
Turkish Medical Association
Urgent Call FromTurkish Medical Association