WMJ 01 2014

COUNTRY
• Reconstruction of the Radiation Emergency
Medical System in Japan
• On the Road to Tobacco-Free Finland
vol. 60
MedicalWorld
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Official Journal of the World Medical Association, INC
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Nr. 1, February 2014
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1
Let me begin by congratulating you all on
your achievements and successes this year.
My special thanks to the Secretariat for
all the ways they continue to support the
WMA.
As we move into the New Year, as physi-
cians, we must continue to play our role in
advocating for the right to health for the
communities we serve and especially the
most disadvantaged. Regardless where we
live, there are those among us who do not
have access to quality health and health
care. We have a responsibility to play the
advocacy roles required to ensure that our
health systems are strengthened enough to
achieve universal health coverage. An im-
portant area for advocacy is the conditions
under which people are born, grow up, live and work also known
as the Social Determinants of Health.
The basic principles underlying medical ethics continue to be com-
passion, competence and professional autonomy. Every physician
therefore must become involved in advocating for quality medical
education, the highest possible ethical standards and evidence based
care. As we end the New Year, our hearts go out to those physicians
working in countries like Syria,Somalia,Israel,Palestine,Turkey and
others who struggle to ensure access to healthcare in such difficult
circumstances, at times risking their lives and those of their families.
In this regard, the WMA is partnering
with others in the Health Care in Danger
Project of the International Committee
of the Red Cross (ICRC)’s to advocate for
protection of health facilities and health
workers in areas of armed conflict and
other emergencies.
As physicians and NMAs, we must be-
come part of this community of concern.
We must ensure we adhere to our ethi-
cal principles, document and report inci-
dents, support our colleagues whose lives
are threatened and to work with others
in ensuring that health facilities, ambu-
lances and health workers are protected
in cases of armed conflict and other
emergencies.
The WMA will continue to play its role of advocating for the right
of physicians to exercise their professional autonomy and the right
to provide the quality of health care that their patients and com-
munities require.
Finally, as we end the year, I wish you and your families an enjoy-
able holiday season and a new year 2014 full of good health and
success.
Dr. Margaret Mungherera
President, World Medical Association
New Year Message from the President, World Medical Association
Margaret Mungherera
2
The radiation emergency medical system in
Japan ceased to function as a result of the
accident at the Fukushima Daiichi Nuclear
Power Plant, which has commonly become
known as the “Fukushima Accident.” In this
paper, we review the reconstruction processes
of the radiation emergency medical system
in order of events and examine the ongoing
challenges to overcoming deficiencies and re-
inforcing the system by reviewing relevant
literature, including the official documents of
the investigation committees of the National
Diet of Japan, the Japanese government,
and the Tokyo Electric Power Company, as
well as technical papers written by the doc-
tors involved in radiation emergency medical
activities in Fukushima. Our review has re-
vealed that the reconstruction was achieved in
6 stages from March 11 to July 1, 2011: [1]
Re-establishment of an off-site center (March
13), [2] Re-establishment of a secondary ra-
diation emergency hospital (March 14), [3]
Reconstruction of the initial response system
for radiation emergency care (April 2), [4]
Reinforcement of the off-site center and sta-
tioning of disaster medical advisors at the
off-site center (April 4), [5] Reinforcement
of the medical care system and an increase in
the number of hospitals for non-contaminated
patients (From April 2 to June 23), and [6]
Enhancement of the medical care system in
the Fukushima Nuclear Power Plant and the
construction of a new medical care system, in-
volving both industrial medicine and emer-
gency medicine (July 1). Medical resources
such as voluntary efforts, academic societies, a
local community medical system and univer-
sity hospitals involved in medical care activi-
ties on 6 stages originally had not planned. In
the future, radiation emergency medical sys-
tems should be evaluated with these 6 stages
as a basis, in order to reinforce and enrich both
the existing and backup systems so that mini-
mal harm will come to nuclear power plant
workers or evacuees and that they will receive
proper care. This will involve creating a net-
work of medical resources becoming involved
across the country.
Introduction
The nuclear disaster measures in Japan have
been developed by the prefectures with nu-
clear power plants, based on lessons learnt
from nuclear power plant accidents in the
past, including Three Mile Island (1979),
Chernobyl (1984), and the JCO Co., Ltd.
accident (Ibaraki, Japan: 1999) [1]. In those
prefectures, the government funded the
construction of an off-site center for deci-
sion-making and coordination relating to
radiation emergency medical responses to
be built around nuclear power plants. The
radiation emergency medical system estab-
lished by the prefectures consisted of 3 lev-
els of hospital care: initial, secondary, and
tertiary radiation emergency hospitals. The
prefectures designated the initial and sec-
ondary radiation emergency hospitals,while
the government designated the National
Institute of Radiological Sciences (NIRS)
and Hiroshima University as the tertiary
radiation emergency hospitals.
In Fukushima Prefecture, the off-site center
was located about 5 km from the Fukushima
Daiichi Nuclear Power Plant (hereafter re-
ferred to as FNPP1). Five initial radiation
emergency hospitals (Fukushima Prefec-
tural Ono Hospital, Futaba Kosei Hospital,
Imamura Hospital, Fukushima Rosai Hos-
pital, and Minamisoma City General Hos-
pital) and 1 secondary radiation emergency
hospital (Fukushima Medical University
Hospital) had also been designated (Fig-
ure 1).
After the nuclear accident at FNPP1,which
occurred as a result of the Great East Japan
Earthquake on March 11, 2011, the off-site
center and the radiation emergency hospi-
tals in Fukushima became non-functional.
Emergency Medical System JAPAN
Reconstruction of the Radiation Emergency Medical System from
the Acute to the Sub-acute Phases After the Fukushima Nuclear
Power Plant Crisis
Mayo Ojino Masami Ishii
3
JAPAN Emergency Medical System
The earthquake caused an emergency shut-
down of the reactors and a loss of the exter-
nal power supply, the tsunami caused sev-
eral of the reactors to lose all AC power,and
the water injection system for emergency
core cooling failed. Hydrogen explosions
occurred at Unit 1 on March 12 and at Unit
3 on March 14, and radioactive materials
were subsequently released into the envi-
ronment.This accident later became known
as the “Fukushima Accident.”
Residents who lived within a 20 km ra-
dius of the power plant had to be evacu-
ated, and residents within a 20–30 km
radius had to stay indoors on March 15.
Due to the earthquake damage, limited
satellite connection was the only means
of communication left for FNPP1’s off-
site center, and information such as the
plant’s situation or radiation levels (eg.,
SPEEDI), could not be obtained. Disap-
pointingly, there was very little scope for
assembling relevant organizations such as
national and local governments and plant
operators, meaning that it was extremely
difficult to examine the radiation protec-
tion that was available for residents or the
transportation system that was in place for
radiation-contaminated patients [2]. At
5:44 on March 12, the off-site center had
to be evacuated because everything within
a 10 km radius from FNPP1 was desig-
nated an evacuation zone by government
order. The facility that was previously des-
ignated as an alternate location was un-
suitable because the radiation level in the
area was increasing. Moreover, there was
insufficient space available, as the facil-
ity was already used for disaster manage-
ment for earthquakes and tsunamis [13].
At 18:25 on the same day, 3 out of 5 of
the initial hospitals also had to be evacu-
ated when the evacuation zone expanded
to a 20 km radius from the plant, again
by government order. The inpatient ward
of the Minamisoma City General Hos-
pital was also closed because the hospital
was located within the designated indoor-
sheltering zone [3]. The Fukushima Acci-
dent Hospital and the Fukushima Medi-
cal University Hospital are located outside
the 30 km zone, but the earthquake dam-
aged their essential utilities, leading to a
marked functional decline  [3]. The mal-
functioned medical systems were recon-
structed in order to respond to the much-
needed medical care for the plant workers
who were attempting to contain the acci-
dent, as well as about 78,000 residents and
850 inpatients.
In this paper, we have systematically clas-
sified the reconstruction of the radiation
emergency medical system in Fukushima in
order of events and examined the problems
and the future challenges.
Results
We have classified the reconstruction of the
radiation emergency medical system in Fu-
kushima into the following 6 stages.
Stage 1: Re-establishment of an off-site
center (March 13).
Stage 2: Re-establishment of a second-
ary radiation emergency hospital
(March 14).
Stage 3: Reconstruction of the initial re-
sponse system for radiation emer-
gency care (April 2).
Stage 4: Reinforcement of the off-site
center, and stationing of disaster
medical advisors at the off-site
center (April 4).
Stage 5: Reinforcement of the medical
care system, and an increase in the
number of hospitals for non-con-
taminated patients (from April 2
to June 23).
Stage 6: Enhancement of medical care
system at the Fukushima Nuclear
Power Plant, and the construc-
tion of a new medical care sys-
tem, involving both industrial
medicine and emergency medi-
cine (July 1).
Figure 1. Location of nuclear power plants and Radiation Emergency Hospitals in
Fukushima (Figure 1 was created by the authors using Google maps)
10km20km30km50km
Fukushima Medical University Hospital
4
Stage 1: Re-establishment of an off-site
center (March 13)
On March 13, the Fukushima Prefecture
Radiation Emergency Medical Coordina-
tion Council was established in the Fuku-
shima Prefectural Government Building
[3]. This council was voluntarily organized
by members of NIRS team, physicians from
the Fukushima Medical University Hospi-
tal, and prefectural government officers to
substitute the radiation emergency medi-
cal system, as the off-site center’s function
had failed. The members of the council had
knowledge and skills relating to radiation
emergency medicine, as well as personal
networks through the radiation emergency
medical training that had previously been
conducted by the government. This council
served in the decision-making regarding
the radiation emergency medical system,
such as transportation of contaminated pa-
tients, the screening of contamination, and
decontamination work, and coordinated
these tasks.
Stage 2: Re-Establishmentofasecondary
radiation emergency hospital (March 14)
On March 14, the Fukushima Medical
University Hospital (FMUH), a designated
secondary radiation emergency hospital lo-
cated 57 km from FNPP1 (Figure 2) started
accepting radiation emergency patients. It
takes 2.5 hours by car or 15 minutes by he-
licopter to travel from FNPP1 to FMUH.
Although there were other hospitals nearer
to FNPP1, they were not equipped to pro-
vide radiation emergency care.
At 11:00 on the same day, a hydrogen ex-
plosion occurred in Unit 3 of FNPP1, in-
juring 11 people [4], and FMUH accepted
4 of them. While 1 out of these 4 patients
was transported directly to FMUH, the
remaining 3 patients were brought into
the FMUH about 20 hours after the ex-
plosion [3] because their injuries were ini-
tially thought only to be minor trauma. On
March 16, a worker suspected of having
trauma to the right of his chest was trans-
ported to FMUH by a Japan Self-Defense
Force (SDF) helicopter [3]. He had more
than 10,000 cpm of contamination on his
head [3]. On March 24, 3 workers who
were laying cables on the first floor and the
first basement level of the turbine building
of Unit 3 submerged their feet in the con-
taminated water, resulting in external ex-
posure of over 170 mSv [2].They also were
accepted at FMUH. At this point, the ini-
tial radiation emergency care system near
FNPP1, which was supposed to provide
unsophisticated decontamination and first
aid, was extremely weak. Medical treat-
ment for radiation for the evacuated resi-
dents was supposed to be provided mainly
by the local hospitals and clinics; however,
many medical teams from various orga-
nizations across the country were provid-
ing the care. Disaster Medical Assistance
Team (DMAT) members, dispatched by
the national government, essentially pro-
vides medical assistance for natural disas-
ters, and specializes in providing emer-
gency care in affected areas [15]; it was
not intended to address a nuclear disaster.
The available information on the status of
FNPP1 and radiation were sketchy, and
experts disagreed in their opinions. The
evacuees who had been forced to flee from
their homes with nothing but the clothes
they wore were concerned about their
lives at shelters, and the impact of radia-
tion exposure on their health [16]. The Ja-
pan Medical Association also dispatched
medical assistance teams (called JMAT) to
the disaster area and supported community
health with the help of local medical as-
sociations [5; 6].
Stage 3: Reconstruction of the initial ra-
diation emergency care system (April 2)
On April 2, a facility for initial radiation
emergency medicine was established in
J-Village [7]. J-Village is a sports train-
ing center in Naraha Town, located 20 km
from FNPP1 (about 40 minutes by car)
(Figure 3). It was used by workers from
Tokyo Electric Power Co. (TEPCO; the
company that owns and operates FNPP1)
and other companies engaged in control-
ling the accident as a place to assemble,
put on protective clothing, and for moni-
toring radiation levels. The SDF and fire
departments also used J-Village as a front-
line base. Emergency physicians were also
available here: they would accompany the
emergency firefighting support team to the
accident site to provide health manage-
ment, medical care, and radiation protec-
tion, including the administration of stable
iodine tablets [8].
On March 24, at J-Village, an emergency
physician dispatched from a fire depart-
ment examined the aforementioned 3
workers who had their feet submerged in
the contaminated water during the cable-
laying work [2], and ordered them to be
transported to FMUH [8]. This incident
served as the turning point in the rebuild-
ing of the area’s radiation emergency medi-
cal system. The local headquarters of the
Government Nuclear Emergency Response
asked the Japanese Association for Acute
Medicine (JAAM) to dispatch emergency
physicians, and the reconstruction of the
radiation emergency medicinal system for
Fukushima, including J-Village, became
fully operational [8].This is when the initial
and secondary levels of radiation emergency
care system regained their function (Fig-
ure 2).
Stage 4: Reinforcement of the off-site
center, and the stationing of disaster med-
ical advisors at the off-site center (April 4)
The Government Nuclear Emergency Re-
sponse’s local headquarters also requested
that JAAM dispatch disaster medical ad-
visors to the medical team at the FNPP1’s
off-site center in order to supplement its
insufficient manpower: this dispatch began
on April 4 [8]. Disaster medical advisors
selected by JAAM were specialists in emer-
gency and disaster medicine with excellent
coordination capabilities, the ability to co-
Emergency Medical System JAPAN
5
operate, and leadership skills [8]. Their role
included giving proper advice to the head
of the medical team regarding emergency
and overall disaster medicine, formulating
response plans for cases where there were
multiple patients with injuries and/or high-
dose radiation exposure, and ensuring effec-
tiveness in the patient response, including
the status of medical facilities and patient
transport [8].
Stage 5: Reinforcement of the medical
care system, and an increase in the num-
ber of hospitals for non-contaminated pa-
tients (from April 2 to June 23)
Emergency hospitals in Fukushima pre-
fecture could not accept trauma patients
from FNPP1, because of these patients
might have contamination [3). From April
2 to June 23, a total of 8 hospitals were
prepared to provide general medical care
for non-contaminated patients. Specifi-
cally, on April 2 [7), Ohta General Hospi-
tal and Aizu Chuo Hospital were added to
the list of hospitals able to accept patients.
Fukushima Rosai Hospital, Iwaki Kyoritsu
General Hospital, Mito Medical Center,
and Ibaraki Prefectural Central Hospital
(secondary radiation emergency hospitals in
Ibaraki Prefecture) were also added to this
list on April 22 [9], and Tohoku University
Hospital and Sendai Medical Center (sec-
ondary radiation emergency hospitals in
Miyagi Prefecture) were added on June 23
[10] (Figure 3).
At this point in the reconstruction process,
patients with high-dose exposure or heavy
contamination were transported to the
designated radiation emergency hospital
(FMUH, NIRS, or Hiroshima University),
whereas patients in a severe condition with
moderate,minor,or no exposure were trans-
ported to other hospitals [11]*
.
* External full-body exposure of at least 1 Gy (with
prodromal symptoms such as vomiting) is consid-
ered high-dose exposure; heavy contamination is
100,000 cpm or higher.
Figure 2. The Radiation Emergency Medical System in Japan rebuilt after the Fuku-
shima Accident
Figure 3. Locations of the Fukushima Daiichi Nuclear Power Plant, J-Village and
hospitals (Figure 3 was created by the authors using Google maps.)
10km
20km
30km
50km
JAPAN Emergency Medical System
6
Stage 6: Enhancement of the medical
care system within the Fukushima Nucle-
ar Power Plant, and the construction of a
new medical care system, involving both
industrial medicine and emergency medi-
cine (July 1)
From May 29 onward, physicians who had
been dispatched from Fukushima Rosai
Hospital and the University of Occupa-
tional and Environmental Health were
permanently stationed 24 hours a day at
the Critical Based Isolated Building within
the plant to provide initial care and health
consultations for injured workers [12]. In
addition, the medical facility “5/6ER” was
established in the service building, located
between Units 5 and 6[12], and physicians
with a good knowledge of radiation medi-
cine were stationed around the clock in or-
der to strengthen the emergency medical
care. On July 1, TEPCO organized an in-
plant emergency medical system network
for FNPP1 to enhance preventive medi-
cine, industrial medicine, and emergency
medicine within the plant facility.
Discussion
The world has experienced nuclear di-
sasters several times, including the Three
Mile Island (1979), Chernobyl (1984),
and JCO (1999). Japan has learned lessons
from these past nuclear crises and devel-
oped plans that incorporated international
trends [1]. Nonetheless, a drastic review of
the Emergency Preparedness Guide has not
been carried out, because of the blief that
a Chernobyl type nuclear accident could
not occur in Japan [2]. Furthermore, the
general disaster management training for
nuclear disasters, which is annually con-
ducted by the national government, did
not take into account severe accidents or
compound disaster, and in a sense existed
merely as titular training [2]. In other
words, the national preparation for a nucle-
ar disaster never went beyond the “formu-
lation of plans” or the “execution of plans.”
We believe that the biggest problem with
the radiation emergency medical system in
Japan lies in the vulnerability of the back-
up system when the system that had been
planned proved dysfunctional. On this oc-
casion, it took 3 weeks to compensate for
the failed radiation emergency medical
system (Stage 1 to 3) and almost 4 months
to reinforce the system (Stage 4 to 6).None
of these stages was planned ahead; they
were created in accordance with the needs
of the accident sites. This suggests that the
6 stages revealed here can serve as a prac-
tical and effective backup system, as they
were obtained from real experience. The
Fukushima Accident, as a compound di-
saster involving a natural disaster, a nuclear
disaster, and a mass evacuation, surpassed
the level of disaster that any previous plans
had anticipated.
Immediately after the accident (March
13 and 14: Stage1 and 2), the voluntary
efforts of willing doctors contributed the
most to the reconstruction of the radia-
tion emergency medical system in the
area. For example, the doctors who vol-
untarily gathered launched an organiza-
tion at the Fukushima Prefecture Jichi
Kaikan building to serve as a substitute
off-site center with regard to medical
provision in the affected areas. These
doctors had knowledge of and skills in
emergency radiation care and personal
networks of colleagues: this allowed
smooth communication and prompt re-
sponses in the decision-making process
at sites [3].Various medical teams across
the country also gathered to assist with
the care and health management of the
evacuees. JMA dispatched JMAT teams
to shelters and other places to provide
medical care and health management
with the help of local medical associa-
tions [17]. JMA also created a map of ra-
diation levels in the air and posted it on
the website [18; 19]. Fulfilling this social
mission required not only collaboration
within JMA and its affiliated medical
associations, but also collaboration with
various medical organizations and dif-
ferent professions [6].By nature, doctors
are guaranteed their right to freely exer-
cise own professional judgment [20]. We
would suggest that the ability of doctors
in the field to think for themselves cre-
ated resilience in overcoming many dif-
ficulties that they faced.
In the aftermath of the Fukushima Ac-
cident, many suffered injuries as well as
radiation contamination, and required
emergency care. From March 11 through
December 16, 2011, there were 118 cases
of injuries, 44 cases of heat illnesses, 5 cas-
es of acute coronary syndrome or arrhyth-
mia, and 2 cases of cerebral strokes among
the plant workers alone [11].
Japanese Association for Acute Medicine
( JAAM) dispatched doctors to the facil-
ity for initial radiation medicine ( J-Vil-
lage) and the off-site center (April 2 and
4: Stage3 and 4). In particular, disaster
medical advisors enhanced the quality of
medical care that was provided by mak-
ing full use of the limited transportation
means and selecting appropriate care fa-
cilities based on the urgency and sever-
ity of a patient’s needs [11]. Neither the
basic disaster management plan nor the
nuclear emergency guidelines established
by the nation stipulated the involvement
of academic societies [23; 24]. In the fu-
ture, it will be essential to clearly estab-
lish the position of disaster medical ad-
visors in response plans in advance. The
involvement of academic societies will
also be indispensable in establishing dis-
patch systems and in fostering and train-
ing advisors.
From April 2 to June 23 (Stage 5), the
radiation emergency system cooperated
with local community medical system. In
this accident, emergency care, including
decontamination management and sim-
ple decontamination, were much needed,
while professional medical treatment for
severe exposure that requires tertiary ra-
Emergency Medical System JAPAN
7
diation emergency hospitals was in less
demand. The designated initial and sec-
ondary radiation emergency hospitals
were unable to respond to patients who
required emergency radiation care. The
link between initial, secondary, and tertiary
care was severed, leaving only 2 tertiary
hospitals a long distance away: the Na-
tional Institute of Radiological Sciences
in Chiba Prefecture (approx. 215 km by
air) and Hiroshima University Hospital
in Hiroshima Prefecture (approx. 840 km
by air).Tertiary radiation emergency hos-
pitals were supposed to treat the patients
in need of emergency radiation care if the
initial or secondary radiation emergency
hospitals were incapable of treating them
[21].The means of transporting patients to
a tertiary radiation emergency hospital, the
last safety net, were very limited. Seeking
and securing means of transport took time,
and so did the actual transport. Therefore,
prompt treatment was not easily available
for patients in need of emergency care.
We submit that tertiary radiation emer-
gency hospitals alone were insufficient as a
backup for initial and secondary radiation
emergency hospitals. We propose moving
beyond the conventional continuity con-
cept of initial, secondary, and tertiary care,
and encourage the establishment of a na-
tional network that involves local clinics
and hospitals for emergency care, as well as
the Disaster Base Hospitals.
On July 1(Stage 6), the in-plant medical
system was enriched from both the “pre-
ventative” viewpoint of industrial medicine
and the “treatment” viewpoint of emer-
gency medicine. According to the medi-
cal records of the FNPP1’s workers from
March 2011 to June 2012 [22], the number
of cases was highest in the month of the
accident (March 2011), with 67 patients.
The number decreased from June 2011 (45
patients). This underlines the importance
of stationing both industrial physicians
and emergency physicians through an or-
ganized dispatch of manpower in collabo-
ration with university hospitals.
Various medical resources such as vol-
untary efforts, academic societies, a local
community medical system and university
hospitals provided as much support as pos-
sible under extremely limited circumstanc-
es. They originally had not planned to in-
volving in radiation emergency medicine.
The radiation emergency medical system
should be reevaluated and further enriched
for the future by incorporating the per-
spectives of these 6 stages, so that nuclear
power plant workers and evacuees who re-
quire emergency radiation care may suffer
minimal harm and receive proper care. In
the future, radiation emergency medical
systems should be evaluated with these 6
stages as a basis, in order to reinforce and
enrich both the existing and backup sys-
tems so that minimal harm will come to
nuclear power plant workers or evacuees
and that they will receive proper care. This
will involve creating a network of medi-
cal resources becoming involved across the
country.
Conclusions
The conventional radiation emergency
medical system of Japan was proved insuf-
ficient after the Fukushima Accident, and
the vulnerability of the backup system in
the plan that existed previously became
evident at a time of major disaster. In this
paper,we have systematically classified the
actual reconstruction process into 6 stag-
es. These 6 stages were not the result of
established procedures by planning ahead;
they were born from the actual experience
and have substantial significance.We con-
clude that the radiation emergency medi-
cal system should be reevaluated for the
future, and further enriched by incorpo-
rating the perspectives of these 6 stages,
in order to minimize radiation damage
and enable proper care for nuclear power
plant workers and evacuees. It’s important
to create a network emergency medical
resources and organizations across the
country.
Acknowledgements
The authors would like to express to sincere
thanks to Mr. Takayoshi Ozaki, Chief Senior
Researcher from JMARI , Mr. Kazutaka Sato,
Researcher from JMARI and Ms. Fumiko
Kanekawa, translator.
References
1. Akashi M, Tominaga T, Goto T (2011) The ra-
diation emergency medicine in Japan. Hoken no
Kagaku. 53(12). pp.804-809.
2. The National Diet of Japan Fukushima Nuclear
Accident Independent Investigation Commis-
sion (2012) The official report of The Fukushima
Nuclear Accident Independent Investigation
Commission.
3. Tanigawa K, Hosoi Y, Terasawa H, Kondo H,
Asari Y, Shishido H, Tase C, Tominaga T, Tat-
susaki H, Iwasaki Y, Hirohashi N, Makoto A,
Kamiya K (2011) Lessons learned from the
Fukushima Daiichi nuclear power plant acci-
dent; the initial 5 days medical activities after the
accident.The Journal of Japanese Association for
Acute Medicine. 22(9), pp.782-791.
4. Japanese Association for Medical Management
of Radiation Accident (2012) Lessons Learned
from the Fukushima Daiichi Nuclear Power
Plant Accidnt. Iryokagakusha.
5. Ishii M(2011) Japan Medical Association
Team’s(JMATs) First Operation: Responding
to the Great Eastern Japan Earthquake. World
Medical Journal. 57(4), pp.131-140.
6. Ishii M, Nagata T, Aoki K (2011) Japan Medi-
cal Association’s Action in the Great Eastern
Japan Earthquake. World Medical&Health
Policy.
7. Local Nuclear Emergency Response Head-
quarter (2011) The response guidelines in the
event of multitudinous injury victims, April 2,
2011.
8. Sakamoto T, Yamaguchi Y, Koido Y, Yokota H,
Aruga T (2012) Emergency medical response
for Fukushima nuclear power plant accident
by Japanese Association for Acute Medicine.
The Journal of the Japan Medical Association.
141(1), pp.66-70.
9. Local Nuclear Emergency Response Head-
quarter (2011) The response guidelines in the
event of multitudinous injury victims, April 22,
2011.
10.Local Nuclear Emergency Response Head-
quarter (2011) The response guidelines in the
event of multitudinous injury victims, June 23,
2011.
JAPAN Emergency Medical System
8
In 1847 the American Medical Associa-
tion (AMA) revolutionized medicine in
the United States. Members of the newly
formed organization, meeting in Philadel-
phia as the first national professional medi-
cal organization in the world, dedicated
themselves to establishing uniform stan-
dards for professional education, training
and conduct. They unanimously adopted
the world’s first national code of profession-
al ethics in medicine.For the more than 165
years since then, the AMA’s Code of Medical
Ethics (www.ama-assn.org/ama/pub/physi-
cian-resources/medical-ethics/code-medical-
ethics.page) has been the authoritative ethics
guide for practicing physicians.
The Code articulates the enduring values
of medicine as a profession. As a statement
of the values to which physicians commit
themselves individually and collectively, the
Code is a touchstone for medicine as a pro-
fessional community. It defines medicine’s
integrity and the source of the profession’s
authority to self-regulate.
At the same time, the Code of Medical Eth-
ics is a living document, evolving as changes
in medicine and the delivery of health care
raise new questions about how the profes-
sion’s core values apply in physicians’ day-
to-day practice. The Code links theory and
practice, ethical principles and real-world
dilemmas in the care of patients.
At the end of 2008, the AMA Council on
Ethical and Judicial Affairs launched a multi-
year project to critically review and update the
Code of Medical Ethics. This project represents
the most thoroughgoing effort to update the
Code since 1957. The council hopes to com-
plete a draft of this work for deliberation by
the AMA House of Delegates in 2014.
By promoting physician professionalism
and accountability, the AMA’s work around
the Code of Medical Ethics strengthens trust
in the medical profession. This core com-
mitment to ethics is critical to the founda-
tion on which physicians are trained and
empowered to uphold the highest standards
in promoting health and in delivering qual-
ity patient care.
UNITED STATES OF AMERICAMedical Ethics
11. Members of the Japanese Association for Acute
Medicine, Emergency, Task Force on the Fuku-
shima Nuclear Power Plant Accident (2012).
Emergency and disaster medical support for the
Fukushima nuclear power plant accident repair
work. The Journal of Japanese Association for
Acute Medicine. 23(3), pp.116-129.
12. Tokyo Electric Power Company (2012) Fuku-
shima Nuclear Accidents Investigation Report,
June 20, 2012. http://www.tepco.co.jp/en/nu/
fukushima-np/interim/index-e.html
13. Investigation Committee on the Accident at
the Fukushima Nuclear Power Station of To-
kyo Electric Power Company (2011) Interim
Report.
14. Ministry of Land, Infrastructure, Transport and
Tourism (MLIT) (2012) MLIT’s activities for
the Great East Japan Earthquake. https://www.
mlit.go.jp/common/000208803.pdf.
15. Ministry of Health, Labour and Welfare (2012)
Japanese DMAT’s Action Guide.
16. Mayo O (2012) The report of Japan Medical
Association Research Institute: Reviewing ra-
diation emergency medicine – The future radia-
tion emergency medicine from lessons learned
the Fukushima Daiichi Nuclear Power Plant
Accident.
17. Ishii M(2011) Fukushima Nuclear Power Plant
Accidents Caused by Gigantic Earthquake and
Tsunami-Healthcare Support for Radiation Ex-
posure. World Medical Journal. 57(4), pp.141-
144.
18. Ishii M (2011) Japan Medical Association
Team’s (JMAT) First Call to Action in the
Great Eastern Japan Earthquake. Japan Medical
Association Journal. 54(3), pp.144-154.
19. Nagata T, Kimura Y, Ishii M (2012) Use of a ge-
ographic information system (GIS) in the medi-
cal response to the Fukushima nuclear disaster
in Japan. Prehospital and Disaster Medicine.
27(2), pp.213-215.
20. WMA Declaration of Seoul on Professional Au-
tonomy and Clinical Independence.2008.http://
www.wma.net/en/30publications/10policies/
a30/
21. Aoki Y(2011) Construction of radiation emer-
gency medical system. Journal of Clinical and
Experimental Medicine. 239(10), pp.973-976.
22. Tokyo Electric Power Company(2012) The
medical records of the FNPP1’s workers from
March 2011 to June 2012.
23. Central Disaster Prevention Council (2012).
The Basic Plan for Emergency Preparedness in
Japan. September.2012.
24. Nuclear Regulation Authority (2013) The
Emergency Preparedness Guide in Japan. Sep-
tember 5, 2013.
Mayo Ojino
Researcher,
Japan Medical Association
Research Institute,
Tokyo, Japan
E-mail: ojino@jmari.med.or.jp
Masami Ishii
Executive Board Member,
Japan Medical Association,
Tokyo, Japan
E-mail: jmaintl@po.med.or.jp
History of AMA Ethics
Ardis Dee Hoven
9
Medical EthicsUNITED STATES OF AMERICA
AMA Ethics Timeline:
1952 to 2012
1952
The AMA House of Delegates adopted a
council report condemning fee splitting in
health care.
1954
AMA establishes the Committee on Geri-
atrics to outline basic problems of aging.
1957
After two years of debate, the Principles
of Medical Ethics is revised, eliminat-
ing regulations on specific conduct with
broad, fundamental ethical principles.
This change gives the Judicial Council
broad rule-making authority, allowing
them to issue ethical pronouncements
without securing House of Delegates ap-
proval.
1971
AMA adopts report to the Board of Trust-
ees that states a need exists for more women
physicians and reviews specific changes
necessary to increase the number of women
physicians.
1974
AMA presents recommendations to ensure
adequate protection of individuals used in
human experimentation.
1975
AMA adopts resolution opposing sex dis-
crimination in medical institutions.
1976
AMA encourages handicapped access to
public facilities.
AMA adopts resolution seeking an increase
in participation of women physicians in or-
ganized medicine.
1978
AMA develops national policy endorsing
hospice care to enable the terminally ill to
die in a more homelike environment.
1980
James S. Todd, MD, eloquently defends his
ad hoc committee’s new Principles of Medi-
cal Ethics at the Annual Meeting of the
House of Delegates.This new version of the
Principles addressed changing ethical issues
in the field of medicine.
1982
AMA adopts a resolution calling for in-
creased representation among women and
minority physicians.
1985
AMA’s Judicial Council becomes the Coun-
cil on Ethical and Judicial Affairs.
1986
AMA passes resolution opposing acts of
discrimination against AIDS patients and
any legislation that would lead to such cate-
gorical discrimination or that would involve
patient-physician confidentiality.
AMA adopts policy prohibiting investment
of AMA funds in tobacco stocks and urging
medical schools and parent universities to
eliminate investments in corporations that
produce or promote use of tobacco.
1987
In School Board of Nassau County v. Gene H.
Arline, the U.S. Supreme Court rules that
individuals with infectious diseases are con-
sidered “handicapped” under anti-discrim-
ination laws, and decisions as to whether
they are “otherwise qualified” for employ-
ment should be based on “reasonable medi-
cal judgments”made on a case by case basis,
as outlined in a friend-of-the-court brief
provided by the AMA.
1989
AMA develops National HIV Policy reit-
erating physicians’ ethical responsibilities
to treat HIV patients whose condition is
within the physicians’ realm of compe-
tence.
AMA files brief on behalf of Cruzan fam-
ily in U.S. Supreme Court case Cruzan
v. Missouri Department of Health. AMA
holds that the guardian has a right to re-
fuse medical treatment for a patient in a
persistent vegetative state. Court later rules
that states have the right to regulate food
withdrawal.
1990
AMA adopts guidelines governing gifts to
physicians from industry.
1993
AMA passes resolution declaring physi-
cian-assisted suicide is fundamentally in-
consistent with the physician’s professional
role.
1994
AMA drafts the Patient Protection Act.
Elements of the act were included in ev-
ery health system reform bill reported out
of committee in both the House and Sen-
ate.
1995
The Journal of the American Medical Associa-
tion (JAMA) publishes an issue examining
the tobacco industry through corporate
documents of Brown and Williamson To-
bacco Company.
1996
AMA drafts the Patient Protection Act II
bill with two goals: protection for patients
through increased disclosure requirement
and managed care fairness; and physicians
need to have defined rights and protections
from arbitrary separation from managed
care plans.
1997
In conjunction with the AMA’s sesquicen-
tennial observance, “Ethics and Modern
Medicine,” the AMA’s first ethics confer-
ence, is held in Philadelphia, the city of the
AMA’s founding.
AMA renews its emphasis on medical eth-
ics by establishing the Institute for Ethics.
The Institute’s mission is to provide a fo-
rum for the timely exploration and discus-
sion of the tough decisions now affecting
10
UNITED STATES OF AMERICAMedical Ethics
physicians and their patients. The Institute
provides practical physician outreach and
guidance as well as scholarly research for
end-of-life issues, genetics, professionalism
and managed care.
1998
The AMA’s Task Force on Association/
Corporate Relations develops definitive
standards that guide the conduct of corpo-
rate relationships involving the AMA and
produces a report on such principles, stan-
dards and guidelines.
Named after the co-writers of the original
Code of Medical Ethics, the AMA selects its
first recipient of the Isaac Hays, MD, and
John Bell, MD, Leadership in Medical
Ethics Award.
1999
Through an educational grant from the
Robert Wood Johnson Foundation, the
AMA Institute for Ethics’ Educating Phy-
sicians on End-of-Life Care project provides
training to practicing physicians on the core
skills needed to provide quality end-of-life
care.
The AMA founds the Virtual Mentor, an
online ethics journal. The journal is open-
access and advertisement-free, and explores
the ethical issues and challenges that stu-
dents, residents and other physicians are
likely to confront in their training and daily
practice. For this reason, the journal is a
valuable teaching resource for medical edu-
cators at all levels as well as for doctors and
doctors-to-be.
2001
AMA revises its Principles of Medical Eth-
ics to emphasize a physician’s responsibility
to the patient as paramount during the care
of that patient,and a physician’s responsibil-
ity to support access to medical care for all
people.
The AMA Council on Ethical and Judicial
Affairs drafted the Declaration of Profes-
sional Responsibility: Medicine’s Social
Contract with Humanity. The declaration,
adopted by the House of Delegates at the
2001 Interim Meeting, serves as a reaf-
firmation of professional standards by the
world community of physicians.
The AMA launches a new national ini-
tiative “The Communication of Ethical
Guidelines for Gifts to Physicians from In-
dustry” as a means to urge physicians and
industry representatives to adhere to AMA
ethical guidelines regarding gifts.
2003
The AMA House of Delegates approves
recommendations from the Council on
Ethical and Judicial Affairs, which state
that cloning for biomedical research is con-
sistent with medical ethics.The recommen-
dations also include the critical importance
of appropriate oversight and safeguards for
subjects involved in such research.
The AMA’s Ethics Resource Center se-
lects 10 U.S. and Canadian medical school
partners for its Strategies for Teaching and
Evaluating Professionalism (STEP) pro-
gram, which encourages the design of in-
novative methods for teaching professional
competencies and for evaluating the success
of those methods.
2004
The Ethical Force Program® releases “En-
suring Fairness in Health Care Cover-
age Decisions: A Consensus Report on
the Ethical Design and Administration of
Health Care Benefits.”The report indicates
five general criteria to be used in health care
coverage decisions in addition to providing
more than 70 recommendations to enable
organizations to fulfill these criteria.
The AMA House of Delegates set new
ethical guidelines for physicians provid-
ing retainer services, sometimes known as
“boutique care.” The guidelines ensure that
physicians who provide additional care or
special services in return for retainer fees
deliver the same standard of care to all pa-
tients.
2005
The AMA issues new ethical guidelines ad-
dressing quarantine and isolation treatment
to help physicians adequately balance public
health goals with the interests of individual
patients during epidemics.
2006
The Ethical Force Program, led by the
AMA’s Ethics Resource Center, releases a
consensus report, “Improving Communi-
cation–Improving Care: How health care
organizations can ensure effective, patient-
centered communication with people from
diverse populations.”
2008
A group convened by the AMA’s Institute
for Ethics publishes “African American
Physicians and Organized Medicine, 1846-
1968.” Appearing in the July 16 edition of
JAMA, the piece investigates the associa-
tion’s relationship to and positions on race.
Following publication of the article, AMA
issues an apology for its historical role in
discrimination against African Americans
in organized medicine.
2009
At its 2009 Interim Meeting, the AMA’s
House of Delegates reaffirms policy that
unequivocally states that physicians “must
oppose and must not participate in torture
for any reason.”
2011
AMA updates ethical guidelines on physi-
cian relationships with industry.
2012
AMA issues new ethical guidelines on phy-
sicians’ responsibilities to be prudent stew-
ards of health care resources.
Dr. Ardis Dee Hoven,
President of American
Medical Association
11
Medical ProfessionLATVIA
Summary
The Congress of Latvian Physicians and
the 25th
anniversary of the Latvian Medi-
cal Association was the right moment to
analyze what has been done, define the cur-
rent status and make conclusions regarding
physicians work in Latvia on the whole, as
well as the role of governmental and non-
governmental institutions, the achieve-
ments and setting tasks and goals for the
future.
To find out how doctors feel in Latvia at
the current moment, their own assessment
of their profession and the public opinion
regarding doctors, the Latvian Medical As-
sociation commissioned the survey Medi-
cal Profession in Latvia Today to the public
opinion research centre SKDS.
This survey was organized by carrying out
two questionnaires  – one for doctors and
the other for the population of Latvia. Both
were carried out in August 2013.Invitations
to participate were sent to those physicians
whose addresses were available in the data
base of the Latvian Medical Association
(LMA). Responsiveness was high and the
questionnaire was filled out by 2274 doctors
representing various fields. Not all respon-
dents were members of LMA.Consequent-
ly, it may be assumed that the results repre-
sent not only the opinion of the Association
members, but they might be referred to the
physicians of Latvia on the whole.
The questionnaire addressed to the people
of Latvia embraced in total 1,005 perma-
nent residents of Latvia aged 18 to 74 ac-
cording to quota sampling. The question-
naire was carried out in the Internet while
the respondents were selected to make a
national representation as well.
To formulate the goals, research themes and
questions to be asked, the LMA formed a
working group. Later the issues were dis-
cussed and supplemented by the LMA
Board members. After the discussions six
themes were chosen to be included:
• prestige of medical profession, satisfac-
tion with professional choices;
• motivation;
• professional burnout;
• habits of doctors and their attitude to
personal health;
• the system of health care in Latvia;
• assessment of the activities of the LMA,
governmental and non-governmental in-
stitutions concerning health care.
The survey results had been reported dur-
ing 7th
Congress of Latvian Physicians by
the sociologist Arnis Kaktiņš. All graphs
and tables were published in the journal
Latvijas Ārsts (Physician of Latvia) . Now
here we are going to highlight the most im-
portant data and outcomes. Mostly the re-
search confirmed what was already known
and suspected. The results could have been
more optimistic, but bitter truth is better
than sweet lies.
The doctors assessment of the organizations
makes interpreting of the data possible.The
survey covers more than one fourth of doc-
tors working in Latvia, so their opinion is
fairly comprehensive. The assessment was
done using the scale from 1 to 10. The ac-
tivities of the LMA were evaluated as very
good (9 or 10, according to the scale) by
20% of the respondents, while 37% admit-
ted it was good (7 or 8), which altogether
makes 57%. It is also essential that 12%
of the doctors have no opinion about the
LMA activities. To compare – 51% of the
doctors have no opinion about the Latvian
Hospital Association. Another compari-
son – the Ministry of Health was evaluated
as very good by 2%, or good – by 8% of the
doctors.
At any rate the data give evidence that the
Trade Union of Health and Social Care
Employees, the Hospital Society and gov-
ernmental health structures have more
room for improvement than the Medical
Association.
Undoubtedly, the questionnaire for our col-
leagues contained a question on what they
consider to be good points of the Latvian
Medical Association.And particularly posi-
Medical Profession in Latvia Today
Pēteris Apinis Arnis Kaktiņš
12
Medical Profession LATVIA
tive is the fact that 83% of the respondents
evaluated the journal Latvijas Ārsts as very
good (36%) or good (47%). This is a really
positive evaluation which decisively makes
the Latvian Medical Association to im-
prove even more! Interdisciplinary confer-
ences organized by the LMA were evalu-
ated as very good or good by 73% of the
respondents,thematic conferences – by 68%
and likewise the process of certification – by
53% of the respondents. In many opinions
the thematic conference What do Latvian
Children Eat? was the year’s best.
Moreover, the survey revealed that doctors
are not informed well enough about every-
day work of the LMA, e.g. the concerns of
the activities of Ethics Committee or Pro-
fessional Court
The colleagues had evaluated the work of
the LMA and LMA, in our turn, could
evaluate doctors work. The survey revealed
that a doctor works average in 1.93 work
places. More work places are common for
male doctors, younger people as well as ra-
diologists, surgeons, neurologists. Latvian
doctor’s income usually is from medical
activities in 1.73 work places average. The
remaining 0.2 work places usually are con-
nected with pedagogical or organizational
work while a number of colleagues get in-
come from business, scientific research or
dividends.
More than 34% of the doctors work directly
with patients more than 40 hours a week
(which means more than 8 hours in a work-
ing day). More than 50 hours are worked
by 15%, while more than 60 hours – by 7%
of the doctors. Please, note that these hours
are spent in direct contact with patients,
not including the time spent on settling
bureaucratic formalities. In general, more
than the official hours for direct contact
with patients are worked by doctors in in-
patient clinics as well as anaesthetists, re-
animatologists, specialists in obstetrics and
gynaecology. Bureaucratic formalities take
more than 5 hours a week for 67% of the
doctors, but 13% of the doctors spend on it
20 hours a week.
91% of the doctors believe that the health
care system should be better financed, 88%
think that the care giving system and man-
agement should be improved, 85% con-
sider that the population awareness about
health issues should be raised. Regarding
the question whether health care provided
by government should be tied to taxes paid
by a respective patient, 49% answered posi-
tively while 29% opposed it. We can add
here that 35% of the doctors admitted that
their income decreased during the last year,
while only 15% reported increase of in-
come. Only 12% of the colleagues consider
that their work is sufficiently rewarded fi-
nancially. Only 33% of respondents think
that non-financial rewards like apprecia-
tion from patients and colleagues, prestige
of the profession etc. are sufficient. 80% of
the colleagues are of the opinion that fi-
nancial reward is not sufficient while 45%
also think that non-financial rewards are
scarce.
These conditions cause the burnout syn-
drome that is felt by 88% of the colleagues
(moreover,31% of them suffer from it often,
only 8% have never felt it). Burnout can be
caused by many different reasons, however,
the answers provided by the doctors reveal
that mostly burnout is connected with the
never-ending reforms of the health care
system, permanent uncertainty about the
future, excessive bureaucracy, low salaries
and too much time spent at work leaving
too little for self-improvement.
59% of the doctors feel positive and opti-
mistic about their own health while only
55% of them feel well mentally and emo-
tionally. To be a good doctor while feeling
emotional discomfort is a difficult task. Still
in our survey we mostly focused on physical
health and habits that support healthy life-
style. So we recommend everyone to look
closer into the graphs that show the doc-
tors smoking habits and what they recom-
mend to their patients concerning giving up
smoking; the doctors sports activities, over-
weight,vaccinations,following one’s choles-
terol level and blood pressure, PSA estima-
tion, mammography or blood in faeces in
connection with their recommendations for
patients.
Despite all the above mentioned, most of
the doctors still love their profession. 75%
of the respondents are sure that they would
choose to become a doctor again if they
could turn the time back,59% would choose
the same speciality they are working in at
the moment, 58% would prefer the work
place they have now.
Description of the survey
The survey was carried out by the public
opinion research centre SKDS.
The working group: Arnis Kaktiņš, Margita
Otto, Andrejs Solopenko, Laila Bīriņa, Ilze
Grase, Saiva Brežinska and Ieva Strode.
Doctors questionnaire
Time period: 25 July, 2013 – 15 August,
2013.
Respondents: Latvian doctors according to
the data base supplied by the client. Valid
and unique e-mail addresses in the data
base: 4804. Reached sampling: 2274 re-
spondents. Method of the questionnaire:
Internet questionnaire (CAWI).
Population questionnaire
Time period: 2 August, 2013 – 7 August,
2013.
Respondents: permanent residents of Lat-
via aged 18 to 74. Reached sampling: 1005
respondents.
Method of sampling: quota sample. The
data were weighed in accordance with
the Population Register of the Office of
13
Medical ProfessionLATVIA
Citizenship and Migration Affairs of the
Ministry of the Interior as of 21 January,
2013. Geographical coverage: the whole
territory of Latvia. Method of the question-
naire: Internet questionnaire (CAWI).
The following graphs reveal the data ob-
tained according to Net Promoter assess-
ment index that is often used by companies
to estimate the customer loyalty level.
Net Promoter system is based on the prin-
ciple that customers can be divided into
3 categories:
• promoters (the possibility to recommend
the company is 9 or 10) – loyal and en-
thusiastic customers who will continue to
use the company services and will recom-
mend them to other people;
• passive ones (the possibility to recom-
mend the company Is 7 or 8) – satisfied
customers who could be tempted away by
rival companies;
• detractors (the possibility to recommend
the company is 1 to 6) – dissatisfied cus-
tomers who could damage the brand with
their negative references.
To calculate Net Promoter index, the per-
centage of detractors should be subtracted
from the percentage of promoters.Theoreti-
cally Net Promoter index could range from
–100 (everyone is a detractor) to +100 (ev-
eryone is a promoter).
Source: Fred Reichheld, Rob Markey. The Ul-
timate Question 2.0: How Net Promoter Compa-
nies Thrive in a Customer-Driven World,
To estimate the statistical measurement er-
ror it is necessary to know the number of
respondents in the corresponding group
and the outcome in per cent.Based on these
characteristics, the table shows limits of sta-
tistical measurement error in +/– per cent
with 95% probability.
For example, if the survey data show that
55% of all respondents (the number of re-
spondents n=1005), taking into account the
information available about doctors and their
salaries, believe that doctors work in Latvia
is not sufficiently rewarded financially, then
we can assume with 95% probability that
the statistical measurement error is within
+/– 3.1%. It means that 51.9 to 58.1% from
the target group believe that doctors work in
Latvia is not sufficiently rewarded financially.
Figure 1. Prestige of the doctor’s profession (Doctors’ view)
Please, estimate the prestige of the following professions in Latvia
today
29
17
18
17
10
9
3
17
4
3
1
25
23
22
22
14
12
9
11
7
7
1
1
1
20
23
21
23
20
15
15
11
14
14
3
3
2
1
1
11
16
17
15
18
14
18
8
18
18
8
6
6
3
2
8
14
16
15
22
26
31
17
33
33
37
31
32
22
19
5
4
5
5
15
21
19
31
23
23
51
57
57
71
76
2
3
2
3
2
4
5
5
1
3
1
1
1
2
1
Lawyers
Entrepreneurs
Bank employees
Architects
Judges
Civil servants
Military
Politicians
Doctors
Engineers
Teachers
Police
Nurses
Drivers
Shop assistants
Very prestigious (10) (9) (8) (7) Average (5-6) Not prestigious (1-4) No opinion
8.2
7.9
7.8
7.8
6.9
6.4
6.2
6.1
6.0
5.9
4.4
4.2
4.1
3.5
3.3
0 5 10Index*
Basis: all respondents, n=2274 * Index – average estimation from
1 (not prestigious at all) to 10 (very prestigious)
1. Occupational prestige, satisfaction with the chosen profession
Figure 2. Prestige of the doctor’s profession (People’s view)
Please,estimate the prestig of the following professions in Latvia today
according to public opinion
Basis: all respondents, n=1005 * Index – average estimation from
1 (not prestigious at all) to 10 (very prestigious)
25
14
15
15
14
16
8
13
6
17
3
2
2
1
1
20
16
15
15
12
13
11
8
9
7
3
2
3
2
1
17
21
19
17
20
17
16
12
11
7
5
5
4
3
2
12
14
17
17
17
13
16
10
14
6
10
12
8
5
3
13
17
20
21
22
18
26
24
29
16
35
36
35
27
22
9
9
10
12
12
17
19
28
25
41
40
41
45
58
68
3
8
4
3
3
5
6
5
6
5
3
3
2
4
3
Lawyers
Architects
Entrepreneurs
Bank employees
Doctors
Judges
Engineers
Civil servants
Military
Politicians
Nurses
Teachers
Police
Drivers
Shop assistants
Really prestigious(10) (9) (8) (7) Average (5-6) Not prestigious (1-4) Hard to say
7.8
7.4
7.3
7.1
7.0
6.9
6.4
6.0
5.9
5.3
4.9
4.8
4.6
4.0
3.5
0 5 10Index*
14
Figure 5. Whom to trust? (People’s view)
Please, estimate the prestige of the following professions in the eyes of
Latvian society. In your opinion, what might be the trust level in the
following professions on the whole?
Basis: respondents who have given
the responding estimation
Data ranked according to trust data.
* Index – average estimation according to scale
from 1 (cannot be trusted/not prestigious at all)
to 10 (can be trusted/really prestigious)
6.9
6.8
6.5
6.3
6.3
6.0
6.0
5.9
5.5
5.2
5.1
5.0
5.0
4.1
2.3
6.4
7.4
4.8
7.0
4.9
4.0
5.9
7.1
7.8
7.3
3.5
6.9
4.6
6.0
5.3
0 5 10
Engineers
Architects
Teachers
Doctors
Nurses
Drivers
Military
Bank employees
Lawyers
Entrepreneurs
Shop assistants
Judges
Police
Civil servants
Politicians
Index*
Trust Prestige
Figure 6. Would you advise your child to choose your own profession?
Taking into account everything you know about your profession and
your practical experience, would you recommend your child to become a
doctor?
Basis: all respondents, n=2274
Definitely
would
recommend
12%
Sooner would
recommend
39%
Sooner would
not
recommend
31%
Definitely
recommend
9%
No opinion
9%
Figure 3. Prestige of the doctor’s profession
Please, estimate the prestige of the following professions in
Latvia today
Basis: respondents in respective groups
(see “n =” in the graph)
* Index – average estimation from 1 (not prestigious at all)
to 10 (very prestigious ). Data ranked according
to characteristics in doctors’group
7.8
7.3
7.1
7.4
6.9
6.0
5.9
5.3
7.0
6.4
4.8
4.6
4.9
4.0
3.5
8.2
7.9
7.8
7.8
6.9
6.4
6.2
6.1
6.0
5.9
4.4
4.2
4.1
3.5
3.3
0 5 10
Lawyers
Entrepreneurs
Bank employees
Architects
Judges
Civil servants
Military
Politicians
Doctors
Engineers
Teachers
Police
Nurses
Drivers
Shop assistants
Index*Population Doctors, n=2274
Figure 4. Whom to trust? (People’s view)
In your opinion, can representatives of the following professions
be trusted?
Basis: all respondents, n = 1005 * Index – average estimation according to scale
from 1 (cannot be trusted) to 10 (can be trusted)
6
5
3
4
4
3
5
4
2
1
2
1
1
13
14
9
9
9
7
9
7
7
3
3
5
2
1
20
18
20
17
15
13
14
17
11
8
8
11
10
5
1
18
17
22
22
20
17
14
16
15
14
14
13
15
9
2
23
24
29
29
34
33
27
29
29
36
34
28
33
28
10
9
10
14
15
15
18
20
23
29
30
34
36
34
50
82
12
13
4
4
4
8
11
5
7
7
5
6
4
6
4
Engineers
Architects
Teachers
Doctors
Nurses
Drivers
Military
Bank employees
Lawyers
Entrepreneurs
Shop assistants
Judges
Police
Civil servants
Politicians
Can be trusted (10) (9) (8) (7) Average (5-6) Cannot be trusted (1-4) Hard to say
6.9
6.8
6.5
6.3
6.3
6.0
6.0
5.9
5.5
5.2
5.1
5.0
5.0
4.1
2.3
0 5 10Index*
Medical Profession LATVIA
15
Figure 7. Satisfaction with your own choice
Are you sure that you
would choose to become
a doctor again if you
could turn the time
back?
Are you sure that you
would choose the same
doctor’s speciality
again if you could turn
the time back?
Are you sure that you
would choose the same
work place you are
working in now again
if you could turn the
time back?
Figure 8. Income changes over the last year
Taking into account all the income you get from your medical activities,
can you estimate the changes during the last year?
Basis: all respondents, n=2274
“Decreased by
more than 10%”
21%
“Decreased by
up to 10%”
14%
Not changed
44%
“Increased by
up to 10%”
10%
“Increased by
more than 10%”
5%
Hard to
estimate
6%
Basis: all respondents, n=2274
Yes
75%
No
10%
No
opinion
15%
Yes
59%
No
8% Would not
become a
doctor
10%
No
opinion
23%
Basis: all respondents, n=2274
Yes
58%
No
20%
No
opinion
22%
Basis: all respondents, n=2274
Figure 9. Satisfaction in doctor’s work
In your opinion, is your work in medical area evaluated sufficiently?
Basis: all respondents, n=2274
12
33
80
45
9
22
Financially (salary and other income
related to professional activities)
Non-material (recognition by patients and
colleagues, prestige of the profession etc.)
Evaluated sufficiently Not evaluated sufficiently
Figure 10. Satisfaction in doctor’s work
Please, identify the most rewarding moment in your doctor’s job.
Basis: all respondents, n=2274
37
22
21
5
4
5
1
4
0 20 40
To be a skilled practician able to
find answers and state diagnoses
Patients’ gratitude/
relationship with patients
The feeling that I can make the world
a better place, save people’s lives, help them
Possibility to feel proud
about being a doctor/medic
Possibility to earn what I need
Something else
There is nothing rewarding
Hard to say
2. Professional burnout
Figure 11. Burnout in work
Sometimes doctors’ professional activities are associated with the burn-
out syndrome, which means emotional and physical problems, loss of in-
terest concerning one’s work, cynical attitude, and feeling of no personal
achievements. Do you ever feel like that?
Basis: all respondents, n=2274
Often
31%
Sometimes
58%
Never
8%
Hard to say
3%
Medical ProfessionLATVIA
16
Figure 14. Satisfaction with different aspects of life
How satisfied are you in general with …
Basis: all respondents, n=2274
(10) I am absolutely satisfied (9) (8) (7) Average (5-6) (1-4) Not at all Hard to say
10
6
15
9
20
16
20
24
20
32
13
11
1
1
your life outside
your doctor’s job
your professional life
6.98
6.60
0 5 10Index*
Index* – average value according
to scale from 1 (I am not satisfied at all)
to 10 (I am absolutely satisfied)
How would you evaluate in general …
Basis: all respondents, n=2274
3
4
12
10
22
20
22
21
26
28
13
17
1
1
your state
of health
your emotional
feelings
6.65
6.42
(10) It is excellent (9) (8) (7) Average (5-6) (1-4) Not at all Hard to say 0 5 10Index*
Index* – average value according
to scale from 1 (it is really bad)
to 10 (it is excellent)
3. Doctors’ habits and caring for their health
Figure 15. Smoking
Do you smoke?
Basis: all respondents, n=2274
Yes
12%
No
87%
Hard to
say
1%
Figure 16. Overweight
Are you overweight?
Basis: all respondents, n=2274
Yes
46%
No
50%
Hard to say
4%
Figure 12. Burnout intensity
Please, using the 7 point scale, estimate the level of your professional
burnout
8 9
12
18 18
15
10
5
5
0
5
10
15
20
25
No feeling
of “burn-out”
1
I do not feel
bothered by it
2 3 4 5 6 7
It is so serious
that I am considering
the possibility
to leave medical
profession
Hard to say
Basis: all respondents, n=2274
Figure 13. Burnout causes
Please, evaluate the importance of the following factors that might
enhance your feeling of burnout, according to the 7 point scale.
Basis: respondentis that feel ”burn-out”, n=2009
52
39
31
24
30
18
18
18
10
10
7
6
7
3
13
13
16
15
12
14
14
13
11
10
5
7
6
3
11
11
16
14
10
15
13
12
13
15
8
8
7
4
7
10
13
14
9
15
15
11
16
14
11
9
8
8
6
10
10
12
7
15
13
12
17
15
13
13
13
13
5
11
7
11
11
12
14
15
18
17
22
21
21
26
5
5
5
9
17
10
11
17
13
16
32
35
37
41
1
1
1
1
4
1
2
3
2
3
2
1
2
2
Never-ending reforms of the health
care system/continuously unclear future
Too many bureaucratic
duties and procedures
Not sufficient income/salary
Too much time spent at work
Problems in taking sick leave
to become completely healthy
Not enough time and energy to improve
professional knowledge and qualifications
There is no possibility to ensure
that patients get quality service
Feeling like a tiny gerar
wheel in a huge system
Too many heavy and complicated cases
Lack of professional satisfaction
Increasing computerization of practice
Feeling of loneliness, there is nobody
to change professional advice with
Problems in co-operating
with authorities/employer
Problems in co-operating with
colleagues and other employees
7 – really important 6 5 4 3 2 1- not important at all Hard to say
Medical Profession LATVIA
17
Figure 17. Going in for sports
How many hours a week do you spend on physical activities/sports,
intensive enough to make you sweat?
Basis: all respondents, n=2274
10
15 13
9
7
10
3
10
22
67
57
42
29
20
13
0
20
40
60
80
1 h and less 1.1–2 h 2.1–3 h 3.1–4 h 4.1–5 h 5.1–10 h More than
10 h
I don’t do any
sports
Hard to say
Cumulative
Figure 18. Cholesterol index
Do you know what your cholesterol index is/do you follow your level of
cholesterol?
Basis: all respondents, n=2274
Yes
62%
No
37%
Hard to say
1%
Yes
38%
No
57%
Hard to say
5%
Basis: all respondents, n=1005
Doctors’ answers People’s answers
Figure 19. Blood pressure
Do you know what your blood pressure is/do you follow your blood pres-
sure?
Basis: all respondents, n=2274 Basis: all respondents, n=1005
Doctors’ answers People’s answers
Yes
84%
No
15%
Hard to say
1%
Yes
66%
No
31%
Hard to say
3%
Figure 20. Vaccination (Doctors’ answers)
Have you been vaccinated against the following infections?
18
36
38
77
79
63
60
23
3
1
1
1
Diphteria
Tick-borne encephalitis
Hepatitis
Influenza (last 3 years)
No Yes Hard to say
Basis: all respondents, n=2274
Do you recommend your patients vaccination against the following
infections?
Not recommend I recommend Hard to say
Basis: respondents contacting patients, n=2161
19
20
32
45
70
69
49
32
11
11
19
22
Tick-borne encephalitis
Diphteria
Hepatitis
Influenza (last 3 years)
(People’s answers)
There are different opinions about vaccination against infections.
Please, identify the infections everybody should be vaccinated
against:
66
64
60
19
7
9
0 20 40 60 80 100
Hepatitis
Diphteria
Tick-borne encephalitis
Influenza
Neither of the mentioned
Hard to say
Basis: all respondents, n=1005
Medical ProfessionLATVIA
18
Figure 23. Attitude towards clinical guidelines
Doctors differ in their attitude towards evidence based medicine. Part
believes in accurate following the guidelines, performing the indicated
activities, the sequence of their application and the tactics in the treat-
ment. Others consider that such guidelines cannot substitute the doctors’
experience, intuition and individual approach to each patient. Where
will you place yourself in the 7 point scale?
Basis: all respondents, n=2274
3
11 11
23
19
13
16
5
0
20
1- Guidelines 2 3 4 5 6 7 – Experience Hard to say
In my opinion, practical usage of clinical
guidelines in practice is limited,
so I usually act by my experience
I usually follow clinical guidelines exactly
25% 48%
Figure 24. Passive euthanasia
In case, you would get into a situation when you are unconscious and
cannot make any decisions, and your life would be maintained in termi-
nal condition without any medical solutions to improve the situation,
would you wish to have passive euthanasia performed??
May be
permissible
48%
Must not be
permissible
16%
Hard to say
36%
Basis: all respondents, n=2274
In case, you would get into a situation when you are unconscious and
cannot make any decisions, and your life would be maintained in termi-
nal condition without any maedical solutions to improve the situation,
would you wish to have passive euthanasia performed?
Basis: respondent of respective groups, (see “n=” in the graph)
54
84
11
33
13
1
58
8
33
15
30
59
ALL RESPONDENTS, n=2274
ATTITUDE TOWARDS PASSIVE EUTHANASIA
May be permissible, n=1082
Must not be permissible, n=362
Hard to say, n=830
Would wish Would not wish Hard to say
Figure 21. Early diagnosis of oncologic diseases
(Doctors’ answers)
Have you had prostata specific antigen (PSA) timely determined
according to guidelines? Have you had mammography done timely
according to guidelines? Have you had hemoplus in faeces timely
determined according to guidelines?
61
70
19
34
28
78
5 2 3
0
25
50
75
100
Male, 50+, n=261 Female, 50+, n=913 Respondents, 50+, n=1174
Hard to say No Yes
Basis: respondents at least 50 years of age, (see “n=” in the graph)
Figure 22. Recommendations for patients
Doctors’ attitude to their patients can be different. Some of them give
advice on healthy lifestyle while others do it rarely or never. Do you
recommend your patients the following actions?
Basis: all respondents, n=2161
66
53
48
48
28
38
40
40
5
6
10
9
1
3
2
2
To give up smoking – for
smoking patients
To take care about their
emotional well-being
To lose weight – for
overweight patients
To practise sports regularly
I often recommend
I don’t recommend
I sometimes recommend
Hard to say
Medical Profession LATVIA
19
Figure 26. Core values of health care system
Which two of the mentioned values should be the most important in
Latvian medical care system, in your opinion?
Basis: respondents of respective groups, (see “n=” in the graph)
57
50
31
18
5
56
62
38
18
4
0 20 40 60 80
Doctors, n=2274 Population, n=1005
Holistic approach –
the patient is examined as a whole,
not only particular illnesses are cured
Equality of chances –
timely and equal availability of health care
services not dependidng on patient’s income,
state and location
Real effectiveness –
fast and effective treatment
Efficiency of costs –
medical decisions based on costs efficiency
criteria, avoiding extra and overlapping costs etc.
Hard to say
5. Evaluation of the performance of the Latvian Medical Association
Figure 28. Evaluation of the Association’s performance
How do you evaluate activities of the following institutions?
20
3
4
7
4
2
37
12
13
17
16
8
30
35
46
54
57
78
12
51
37
22
22
12
Latvian Medical Association
Latvian Hospital Association
Trade Union of Latvian Health and Social Workers
Health Inspection
National Health Service
Ministry of Health
Excellent (9–10) Good (7–8) Average and poor (1–6) Hard to say
–10
–32
–42
–47
–53
–76
–100 –80 –60 –40 –20 0
Evaluation index*
Basis: all respondents, n=2274 Evaluation index* – (excellent (9–10)) – (average and poor (1–6))
Figure 27. Health care system in the future
Thinking about future development of health care in Latvia which two
theses do you agree with?
Basis: all respondents, n=2274
91
88
85
77
67
57
50
32
7
10
13
19
28
30
39
58
1
1
0,5
1
2
3
4
4
1
2
1
3
3
10
6
6
Health care system needs more funding
Management and organisation
of health care should be improved
People’s knowlwdge about
health should be improved
Health care system should improve
quality of people’s survival
Health care system should
provide more prevention
Public resources should be involved into
doctos’professional development
Health care system should be more
individualised concerning each patient
Health care system should
be more innovation oriented
I agree completely I agree partly I don’t agree Hard to say
4. Health care system in Latvia
Figure 25. Available services and tax payment
In your opinion, should the health care paid by the state
be connected with the taxes paid by respective patients?
Basis: all respondents, n=2274
Yes
49%
No
29%
Hard to say
22%
Medical ProfessionLATVIA
20
Figure 31. Contacts with patients
On average for how many hours a week do you contact your patients directly?
Basis: all respondents, n=2274
5 5 5
9 11 10 14 10 8
4 4
7 5
1
94
88
83
78
69
58
48
34
24
15
11
0
20
40
60
80
100
Less
than10
11–15 16–20 21–25 26–30 31–35 36–40 41–45 46–50 51–55 56–60 More
than 60
No direct
contacts
Cumulative %
More than 40 hours per week are usually worked by doctors in hospitals,
as well as anesthesiologists, reanimatologists, specialists in obstetrics and gynecology
In how many work places do you currently get income from medical
activities?
51
29
11
4 1 0.4 3
96
46
17
5
0
20
40
60
80
100
1 2 3 4 5–7 I am not working
at the moment
I cannot say
Cumulative %
Basis: all respondents, n=2274
Earnings of a Latvian doctor from medical practice come average from 1.73 work places
Figure 30. Number of work places
How many paid work places do you currently have?
42
31
15
5 3 0.4 2
97
55
24
8
0
20
40
60
80
100
1 2 3 4 5–8 I am not working
at the moment
I cannot say
Cumulative %
Basis: all respondents, n=2274
A Latvian doctor works average in 1.93 work places. Several work places are
common for men, doctors of younger age group, as well as radiologists, surgeons, neurologists
Figure 29. Evaluation of the Association’s performance
Please, evaluate the following events and activities organized by the Latvian Medical Association:
42
35
10
6
21
31
33
14
10
32
14
13
14
13
30
13
19
62
71
17
Interdisciplinary conferences by LMA
Specialized conferences by LMA
Work done by Ethics commission of LMA
Work done by Occupational court of LMA
The process of certification and work
done by the Certification Council of LMA
28
22
–4
–7
–10
–20 0 20 40
Basis: all respondents, n=2274 Evaluation index* – (excellent (9–10)) – (average and poor (1–6))
Evaluation index*
Excellent (9–10) Good (7–8) Average and poor (1–6) Hard to say
6. Statistics on the doctors-respondents
Medical Profession LATVIA
21
Figure 34. Statistics on the doctors-respondents
In what medical area do you work?
0.4
16
4
13
22
33
43
Hard to say
Other area
Rehabilitation
Diagnostics
Primary care
Stationary care
Ambulatory care
Basis: all respondents, n=2274
Doctor’s speciality
23
15
12
11
7
5
5
5
4
4
3
3
3
3
2
2
2
16
0.04
Family doctor (GP)
Internist
Pediatrician
Dentist
Occupational doctor
Alcohol narcotic and psychoactive
substances checking doctor
Surgeon
Gynaecologist, birth specialist
Anaesthetic, reanimatologist
Cardiologist
Neurologist
Psychiatrist
Radiologist diagnostic
Health care management doctor
Ophtalmologist
Otolaryngologist
Psychotherapist
Other
Not stated
Basis: all respondents, n=2274
How many patients do you contact on average per week?
Hard
to say
3
7 7 8 9 6
4 6 3
8 5
20
76
73
66
59
51
42
36
32
26 23
15
0
20
40
60
80
100
1–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91–100 101
and
more
No
contacts
Basis: all respondents, n=2274
Cumulative %
Figure 32. Time spent on bureaucratic and administrative work
How many hours on average do you spend filling out documents and
reports and doing administrative work?
18 19
11
10
6 3
33
67
50
31
20
10
0
20
40
60
80
100
Less than 5 h
(incl.)
5.1–10 h 10.1–15 h 15.1–20 h 20.1–30 h More than 30 h Hard to say
Cumulative %
Basis: all respondents, n=2274
Figure 33. Total length of service
For how many years have you been in a medical profession?
Basis: all respondents, n=2274
12
24
34
23
7
0.4
100
88
64
31
0
20
40
60
80
100
1–10 years 11–20 years 21–30 years 31–40 years 41 years and more Hard to say
Cumulative %
Medical ProfessionLATVIA
22
Figure 38. Statistics on the people-respondents
How many medical institutions did you visit as a patient
last year at least once?
How many doctors did you visit last year (including family doctors,
dentists etc.)?
Basis: all respondents, n=1005
18
21
18
8
6
4
1
16
9
0
10
20
1 2 3 4 5 6–9 10 and more None Hard to say
12
18
16
11
9 9
4
14
8
0
10
20
1 2 3 4 5 6–9 10 and more None Hard to say
Basis: all respondents, n=1005
Figure 37. Requirements for the doctor
How important for you is that your doctor …
79
69
58
49
42
15
3
-25
-50 0 50 100
0.4
1
2
3
4
11
15
22
3
6
10
27
30
41
33
37
42
48
45
37
39
23
63
54
44
32
31
21
14
8
1
1
1
4
3
4
3
7
Has good reputation
Has long practical working experience
Has enough time to talk to you
Regularly improves his/her professional knowledge
Is healthy
Is possible to contact via Internet
Has professional certificates exposed in his/her surgery
Is a university lecturer, teaches students and young doctors
Not important at all Sooner not important Sooner important Really important
12
17
Hard to say
Basis: all respondents, n=1005 * Index scale from – 100 (not important at all) up to +100 (very important)
Index*
7. Data from the population questionnaire
Figure 35. Adequate remuneration for doctors
Taking into account everything you know about doctors and their
salaries, do you think that doctors in Latvia are sufficiently financially
rewarded?
Basis: all respondents, n=1005
Yes, they do
24%
No, they
don’t
55%
Hard to say
21%
Figure 36. Ideas on doctors’ remuneration
What is in your opinion an average Latvian doctors monthly earnings
after taxes?
1
4
16
22
19
12
8
5 5 3
5
0
5
10
15
20
25
30
285
or less
From 286
to 427
From 428
to 569
From 570
to 712
From 713
to 854
From 855
to 996
From 997
to 1139
From 1140
to 1280
From 1281
to 1423
From 1424 Hard to say
The population believes the average doctors’
remuneration to be about EUR 800 net per month
EUR
Basis: all respondents, n=1005
Dr. Pēteris Apinis, President of Latvian Medical Association
Arnis Kaktiņš, sociologist, executive director of the public opinion research centre SKDS
Medical Profession LATVIA
23
TobaccoFINLAND
Background
Tobacco use leads to high morbidity and in-
creased mortality, shortening the user’s life
expectancy by 7–15 years. It accounts for
one in 10 deaths among adults [1]. Every
day 80,000–100,000 young people around
the world become addicted to tobacco. If
the current trends of tobacco use continue,
250 million children and young people alive
today will die from tobacco-related diseas-
es [1].Tobacco remains a major health issue.
Finland was one of the first countries to
introduce a comprehensive Tobacco Con-
trol Act (TCA, adopted in 1976. came into
force in 1977) [2]. The TCA restricted mar-
keting, banned advertising, and set an age
limit to sales. It also allocated resources,
0.5% of tobacco tax revenue, for preven-
tion, monitoring and development. Smoking
was prohibited in schools, public transport
and public indoor areas, and allowed only
in specially designated places. The Finnish
TCA was the toughest act in its time, and
over the decades it has been developed due
to improved knowledge of tobacco-induced
health hazards. Workplaces and public areas
are smoke-free, and environmental tobacco
smoke (ETS) was classified by law as a car-
cinogenic substance.Overall,the Finnish ex-
perience demonstrates a remarkable process
from new medical knowledge to compre-
hensive action and public policy. Adult male
smoking prevalence has decreased from 60%
to 21% in a few decades (Figure). This has
encouraged the Finnish tobacco policy mak-
ers to adopt an ambitious goal:Tobacco-Free
Finland by 2040.This was set as the objective
in the TCA in 2010 (Table).
Successes and Challenges of
Tobacco Control in Finland
The impact of the TCA has been monitored
over the years and there are several achieve-
ments that have genuinely increased health
at the population level. Cardiovascular mor-
tality was high in the 1970s when the North
Karelia project was launched to improve
health behaviours in the Eastern province
of Finland [3]. By the 1990s, male CVD
mortality had decreased by 68 %, with an
estimated 10% of which was due to declin-
ing smoking rates [4]. Exposure to ETS was
shown conclusively to be a health hazard,
and in 1995 workplaces became smoke-free;
currently 1–2% of non-smokers are exposed
to ETS (AVTK 2012) [5]. The health ben-
efits deriving from smoking bans have been
well documented in the UK, for instance,
where there is a marked decrease in CVD
mortality [6]. Tobacco use is responsive to
the cost of tobacco, and the World Bank has
recommended price elasticity as one of the
most effective measures of prevention [7].
Finland used this tool successfully in the
early 1980s and then again in the 2010s,
which has contributed to the declining
smoking initiation rate,together with health
education, cessation support and measures
to limit tobacco use in the public space [8].
On the Road to Tobacco-Free Finland
Kristiina Patja
Figure. Tobacco Control time – of Finland 1950–2010
–10
0
10
20
30
40
50
60
70
1950 1960 1970 1980 1990 2000 2010
change % of GDP
Men
Women
Consumption in100xtons
per 15-year old/100
Expenditure on tobacco
products in relation to
disposable income %
TCA 2010:
Endgame 2040
TCA 1995: Smoke-free
workplaces
TCA 1976+1978
24
Tobacco FINLAND
Table. Proposed actions from Framework Convention for Tobacco Control (FCTC) and how and when they have been implemented in
Finnish Tobacco Control Acts between 1977 and 2012. In italics the new initiatives from Tobacco Free Finland in 2013
Framework Convention for Tobacco Control
(FCTC)
Finnish TCA 1977–2012
New initiatives from Tobacco Free Finland in 2013
Taxation and duty-free sales:
Tax policies reducing tobacco consumption 
Tobacco tax has increased with direct mechanism since 2009. In the 1980s tax
increased nearly annually, but then the real price actually decreased due to good
economic growth in the early 2000s as tobacco tax was not increased.
Duty-free sales are discouraged: Countries may
prohibit/restrict duty-free sales and import
Duty-free allowed in airports and ferries, but import of snuff allowed only for
personal use. Restrictions on sales in some ferries to Estonia.
Any sale of snuff is forbidden. Ordering snuff, e.g. via the Internet, will also
be forbidden. A maximum of 30 packets, each containing 50 grams snuff, may,
however, be imported for one’s own use. It will be forbidden to import snuff as a
gift.
Setting a new insurance system for covering costs of tobacco induced diseases funded by
insurance payment from tobacco industry.
Second-hand smoke (Article 8): Non-smokers must be protected from exposure to tobacco smoke:
Indoor workplaces
ETS classified as carcinogenic substance since 1995 at work sites and smoke free
workplaces since 1995, restaurants from 2007.
Public transport
Smoking not allowed in public transport in 1977, totally smoke-free airplanes since
1995 and trains since 2012.
Indoor public places Smoke-free since 1977.
Other public places: schools, kindergartens,
libraries a.o.
All public facilities have been smoke-free since 1977. In 2010 TCA the prohibitions
against smoking were extended, outdoor (e.g. outdoor facilities used by children and
young peole) used by children and young people, the common facilities of apartment
house companies, events organised outdoors and hotel rooms. 
Obligation to protect from second-hand smoke for the housing association or the owner of
the house.
Banning smoking in cars, when minors in a car.
Communities and other public organisations have a right to ban smoking and use of
tobacco products at their premises indoors and outdoors.
Product regulation and ingredient disclosure (Articles 9 and 10):
Countries shall adopt and implement measures for
such testing, measuring and regulation
TCA includes guidelines for testing and measuring, currently the EU-legislation as
well.
Ingredients are to be disclosed Ingredients are partly disclosed within the EU.
Manufacturers and importers shall disclose to
governmental authorities information on contents
and emission
Ingredients are partly disclosed within the EU.
Measures for public disclosure of information
about toxic constituents and emissions
Information available, not fully implemented with campaigns.
Tobacco products will be classified as unusual consumer products and can be regulated
more: any chemical formulation of pH or addictiveness of nicotine will be banned as well
as sugar.
New tobacco products, tobacco and tobacco imitations offsets the import, sale or
other transfer is prohibited but cessation products regulated by medical agency.
Limiting availability of tobacco products in reducing points of sales to 500 in 2020.
25
Framework Convention for Tobacco Control
(FCTC)
Finnish TCA 1977–2012
New initiatives from Tobacco Free Finland in 2013
Packaging and labelling (Article 11): Large health warning labels are required:
Warnings Since 2003 text warnings; pictorial warnings the latest in 2016 with a new EU directive
Large, clear, visible and legible Since 2003.
Should be 50% or more of the principal display
areas (shall not be less than 30%)
Not applied in the EU.
Deceptive labels must be prohibited False/mislead-
ing term, description, trademark or any other sign
shall be prohibited (e.g. mild, low tar, light)
Applied in 1977.
Plain packaging planning with a health warning over 90 % of the package.
Packages have information on the environmental hazards.
Tobacco waste contains hazardous chemicals for environment: the manufacturer
responsible for collection and disposal (compare electronic waste).
Education, communication, training and public awareness (Article 12): Each party shall
promote and strengthen public awareness of tobacco control issues:
Broad access to effective and comprehensive
educational and public awareness programmes on
Since 1977 TCA separate finding from tobacco tax within TCA.
health risks of tobacco consumption;
Since 1977 TCA separate finding from tobacco tax within TCA and special health
education, including on tobacco, for all minors at schools
risks of exposure to tobacco smoke; Included in 1995 TCA.
risk of addiction; Added in 2012 TCA for grounds of TCA.
benefits of tobacco cessation; Since 1977 TCA, strengthened with the national current care guidelines in 2003.
public access to a range of information on the
tobacco industry.
New text added after this: Public health associations provide information on
TI actions.
Training or sensitization and awareness pro-
grammes to various stakeholder groups on the
health, economic and environmental consequences
of tobacco production and consumption.
In Finland,for decades there is a long tradition of the involvement of non-governmen-
tal organisations (NGO),like public health associations and patient organisations,in
tobacco control.Government funds can be applied for public health programmes and
collaboration with public services.Majority of campaigns are carried out by NGOs.
Advertising, promotion and sponsorship (Article 13): A comprehensive ban is required:
No point of sales advertising, brands hidden at sales since 2012.
Sellers of tobacco products must be at least 18 years of age since 2010.
Minimum package of measures prescribed Since 2012 TCA.
Direct and indirect advertising and promotion
covered
Since 1977 direct and indirect since 1995.
Cross-border advertising subject to ban and penalty Since 1995, joining the EU.
Banning movies with smoking from minors
Tobacco dependence and cessation (Article 14):
Designing and implementing effective tobacco
cessation programme in such establishments as
educational institutions, health care facilities.
Since 1977.
Including diagnosis and treatment of tobacco
dependence and counselling services on cessation
of tobacco use in national health and education
programmes, plans and strategies
Formally from the late 1990s, but initiated since the 1972 North Karelia Project.
National Current Care Guideline published in 2003.
Establishing tobacco cessation programmes in
health care facilities and rehabilitation centres
From the 1990s.
TobaccoFINLAND
26
Framework Convention for Tobacco Control
(FCTC)
Finnish TCA 1977–2012
New initiatives from Tobacco Free Finland in 2013
Facilitating accessibility and affordability for
treatment of tobacco dependence, including
pharmaceutical products
Nicotine replacement therapy over counter sales in 2005.
Tailored cessations programs, e.g. pregnant smokers.
Smuggling (Article 15): Action is required to eliminate tobacco smuggling:
Origin and final destination must be indicated on
the packaging
Applied by customs and manufacturers.
Developing a practical tracking/tracing regime. Applied by customs and manufacturers.
Confiscating products and proceeds of illicit trade Applied by customs.
Mutual cooperation in anti-smuggling, law
enforcement and litigation efforts
Applied by customs and the Ministry of Internal Affairs.
Sales to and by minors (Article 16): Prohibition of the following is required: 
Parties shall prohibit the sale of tobacco products
to persons under the age set by national law or
eighteen years of age
Since 1977 TCA (first 16, then 18 years in 1995).
Parties shall prohibit or promote the prohibition of
the distribution of free tobacco products
Since 1977 TCA.
Curbs on or prohibition of tobacco vending
machines
Will be applied in 2015.
Prohibition of sale by minors, as per national law.
Since 1977 TCA, even selling one cigarette or fetching a packet of cigarettes from
a shop to a minor person should be interpreted as a tobacco selling violation, for
which the person can be fined or sentenced to prison for a maximum of six months. 
Challenges exist. The less-educated seg-
ment of the population still suffers more
severely from tobacco-induced health haz-
ards. Smoking prevalence among men is
three times higher in the lowest education
group compared to the highest, and the ra-
tio is similar for women [8]. Smoking dur-
ing pregnancy remains common in the less
educated group as well, with every third
child of these mothers being exposed to to-
bacco chemicals prenatally. And if ETS has
been defeated in the workplace, the same
cannot be said for the home: 17% of the
population report domestic exposure every
year [8].These challenges need to be met in
a new phase of tobacco control.
From Reduction to Endgame
At the National Conference on Tobacco
in 2006, the Speaker of the Parliament,
former Prime Minister Paavo Lipponen,
asked the audience what their ultimate goal
was: to cut down tobacco use or end it. He
suggested that Finland should aim at To-
bacco-Free Finland within a timeframe of
35 years, the goal being set for 2040. This
was received with some bewilderment, but
soon researchers, public health advocates
and health professionals organised a meet-
ing for establishing a new network, which
all stakeholders could join in. By 2009, the
network had formulated the first roadmap
and gave a proposal for a new TCA that
emphasised the need to move ahead toward
an eventual total prohibition of tobacco use:
the endgame had begun.
New alliances were formed that had new
approaches, such as child protection asso-
ciations or municipalities. The Government
acted timely, and in 2010 the new TCA
was adopted, with the aim of legislating a
Tobacco-Free Finland in 2040. This year
the network has provided a detailed, gradu-
ated roadmap for Finland to achieve this
goal. Although the term endgame did not
exist in Finland in 2006, in actuality it was
launched at the time.
The Endgame Policy Today
There are four pathways in combat-
ing tobacco-related health harms at the
population level: preventing the initiation
of tobacco use, promoting and support-
ing tobacco use cessation, protecting the
population from ETS, and the treatment of
tobacco induced diseases.These are all cov-
ered in the Finnish tobacco policy (Table).
In implementing the TCA, multiple part-
ners are needed. They include tobacco-free
cities/municipalities (220 out of a total of
300 smoke-free), smoke-free hospitals,
Tobacco FINLAND
27
HONG KONG NMA and Regional News
smoke-free schools, universities and vo-
cational schools, doctors against smoking,
health educators, trade unions and sports
associations. Finland has adhered to most
of the FCTC implementation guidelines
and is strongly supporting the European
Union in its efforts to set ambitious health
targets for its tobacco policy. Unfortunately,
negotiations have been influenced by the
tobacco industry, and Finland will have to
keep to the strict aim without full support
from the EU.
What has Changed?
The new Finnish approach has changed the
target from reducing to ending tobacco use
altogether.The language and the image have
both become more positive: tobacco control
is an investment and a proactive measure,not
just a cost.We now have a clear new roadmap
for the endgame, and it has already led to
new alliances that deepen the engagement of
civil society [9].The social climate in Finland
is generally rather favourable to tobacco con-
trol owing to a steady process that has lasted
over four decades.The self-image of tobacco
control community has reversed, which may
be the key feature in the success.The tobacco
control community has a vision of victory in
the struggle to defend human life.The target
is simple and measurable. We do not need
any proof to justify our actions. We have a
positive message and no need to defend our
actions.Obviously there will be struggles,but
with forty years of experience, these can be
solved.One lesson has been learned: no com-
promises with the tobacco industry.
References
1. WHO Global Report. Mortality attri-
butable to tobacco. 2012. http://whqlibdoc.
who.int/publications/2012/9789241
564434_eng.pdf (accessed 2.12.2013)
2. Leppo K. Letter from Finland. Smoking
control policy and legislation. BMA: 11;
1(6109): 345–347. 1978.
3. Puska P, Tuomilehto J, Salonen J et al.
Evaluation of a comprehensive community
programme for control of cardiovascular dis-
eases in North Karelia,Finland 1972–1977.
World Health Organization,Regional of-
fice for Europe,Copenhagen 1981.
4. Puska P, Vartiainen E, Tuomilehto
J,  Salomaa, V, Nissinen A. Changes in
premature deaths in Finland: success-
ful long-term prevention of cardiovascu-
lar diseases. Bull World Health Organ.
76(4): 419–425. 1998.
5. Tobacco statistics Finland 2012. http://
www.thl.fi/en_US/web/en/statistics/
topics/tobacco (accessed 2.12.2013).
6. Lin H, Wang H, Wu W, Lang L, Wang
Q, Tian L. The effects of smoke-free leg-
islation on acute myocardial infarction:
a systematic review and meta-analysis.
BMC Public Health. 13: 529. 2013
7. Warner K. The economics of tobacco: myths
and realities. Tob Control. 9(1): 78–89.
2000.
8. S Helakorpi, T Martelin, J Torppa,
K  Patja, E Vartiainen, A Uutela. Did
Finland’s Tobacco Control Act of 1976
have an impact on ever smoking? An ex-
amination based on male and female cohort
trends. J Epidemiol Community Health.
58(8): 649–654. 2004.
9. Tobacco Free Finland – http://www.
savutonsuomi.fi/en.php (accessed 2.12.2013)
Kristiina Patja,
MD PhD, Adjunct Professor
Scientific Advisory Board
of Tobacco-Free Finland 2040
E-mail: Kristiina.patja@promedico.fi
Founded in 1920, the Hong Kong Medi-
cal Association brings together all medi-
cal practitioners practicing in and serv-
ing the people of Hong Kong, with the
objective to promote the welfare of the
medical profession and the health of the
public. With the continuous efforts of our
colleagues, the Association’s membership
has grown steadily over the past year with
currently over 9,000 members from all
sectors of medical practice. We speak col-
lectively for our members and aim to keep
our members abreast of medical ethics
and issues around the world. “To safe-
guard the health of the people” is the motto
we proudly display in the Association’s
emblem, and it could not be achieved in
vacuum. We tried as much as we could to
work with the Government for the bet-
terment of public health. As representa-
tives of doctors, our supervisory role on
the Government is irreplaceable. We ad-
The Hong Kong Medical Association
The Hong Kong Medical Association Council 2013-2014
28
NMA and Regional News HONG KONG
vise, and we criticize as the case demands
us to, and we have been unwavering in so
doing.
There has been a public-private imbal-
ance in the provision of medical services
in Hong Kong for long. The Hong Kong
Medical Association tries its best to voice
our concern, and urges for a revamp or
even overhaul of the Hospital Authority of
Hong Kong. The jump of doctors, juniors
and seniors, from public to private sector,
has created a shortage of manpower in
some public hospitals in recent years. The
ever-increasing chronic medical cases fur-
ther expose the shortage of manpower in
the specialist outpatient service. Partner-
ship between the public and private sector
in the caring of these chronic cases would
improve public health efficiency, and after
all benefit both patients and doctors. We
look forward to an all-win proposal from
the Government in the near future.
The Hong Kong Medical Association has
also established a close relation with all
doctors’ groups in the society, as well as
with the Chinese Medical Association.
The 15th
Beijing/Hong Kong Medical Ex-
change on “Recent Advances in Cancer
Medicine” was successfully held in Beijing
in 2013. Exchange visits to China were
also organized for young doctors and med-
ical students.
In the support of life-
long medical educa-
tion, we accredited
522 continuous medi-
cal education (CME)
events in 2013, of
which we organized
345. We are the CME
administrator for 1,065
doctors. Thanks to our
Community Networks
which are instrumental
in providing members
with CME lectures.
For many years we organize exercise for
health training courses to teach participants
a number of exercises for different chronic
diseases for them to apply in daily practice.
These are extended to various Community
Networks.
To help doctors face adversities in the daily
practice, and to go around avoidable pit-
falls, the Hong Kong Medical Association
jointly published a Clinical Risk Manage-
ment Handbook with the Medical Protec-
tion Society in late 2013. A two-day train-
ing course was organized in September the
same year to help doctors become expert
witness for inquiries, courts and tribunals.
We have a Duty Council Member Scheme
to constantly answer to members’ queries
month-to-month, year-to-year. Our Pa-
tient Complaints Mediation Committee
handles cases with care, with resolution
between interested parties most of the
time.
We observe work-life balance as an im-
portant component of our lives. The Hong
Kong Medical Association organizes a
number of social and recreational activi-
ties for our members, from photo shooting,
charity concerts to professional choir and
orchestra performances and band shows.
We also arrange countless sports events
including ball games such as football, bas-
ketball, volleyball, badminton, tennis, table-
tennis, squash, bowling, snooker and golf, as
well as bench pressing, power-lifting, hik-
ing, and the annual dragon boat competi-
tion and Trailwalker event.
Patient’s well-being is in the heart of our
members whose welfare is in the heart of
the Hong Kong Medical Association. We
pledge to serve both the community and
the doctors, to safeguard the health of the
people of Hong Kong.
Dr. TSE Hung Hing,
President of the Hong Kong
Medical Association15th
Beijing/Hong Kong Medical Exchange
The HKMA Choir
29
NMA and Regional NewsREPUBLIC OF KOSOVO
On 10 November this year,134 elected phy-
sicians met in Pristina to celebrate the es-
tablishment of the Chamber of Physicians
of the Republic of Kosovo. In the presence
of the Kosovan Minister of Health and
international guests, the delegates of the
chamber assembly were sworn in and a new
President elected. Up until this point there
had been no representative organisation of
physicians in this emerging state, which has
so far been recognised by 105 countries in
the world since its declaration of indepen-
dence from Serbia in 2008. Although 90%
of its population is Albanian speaking,there
is a region in the northern part of the coun-
try with a large Serbian population. At the
European level, Serbia and Kosovo are cur-
rently negotiating solutions for the future of
this part of Europe.
Before the establishment of the Chamber
of Physicians, all matters concerning phy-
sicians and other healthcare professions in
Kosovo had been regulated by the Ministry
of Health. As is common practice in many
states of Central and Eastern Europe, this
chamber will not only be responsible for
representing the interests of physicians, but
will also take on regulatory and licensing
tasks.
The foundation of the Chamber represent-
ed the culmination of a process in which the
German Medical Association (GMA) has
been closely involved.
Over the past two years a legal framework
has been established and elections to the
chamber assembly took place on 17 Octo-
ber 2013, with the participation of 85% of
the roughly 4,000 Kosovan physicians.
During the inaugural celebrations, elections
were held for the Chamber leadership. The
only female candidate of the four presiden-
tial candidates, neuropsychologist Dr Zyl-
fije Hundozi, was chosen to represent the
physicians of Kosovo over the next four
years.
Involvement at the international and Eu-
ropean level is of great importance to the
physicians of Kosovo and their newly es-
tablished organisation as they do not yet
have many contacts with other physicians’
organisations abroad. A seminar was there-
fore organised by the German Medical As-
sociation following the inauguration of the
chamber during which examples were given
of international organisations of physicians’
self-governance including the World Medi-
cal Association (WMA) and the Standing
Committee of European Doctors (CPME).
Dr. Otmar Kloiber, Secretary General of
the World Medical Association, encour-
aged the physicians of Kosovo to live up to
their responsibilities and speak out on be-
half of their patients, even if this may not be
looked upon favourably by some politicians.
Along with a delegation from the GMA,
representatives of the medical chambers
of Austria, Albania, Bosnia-Herzegovina,
Croatia, Hungary, Macedonia (FYROM)
and Montenegro were guests of honour
in Pristina. CPME was represented at the
event by its Vice-President, Dr. Istvan Éger,
and Secretary General, Birgit Beger.
The GMA’s approach throughout was to
assist the physicians of Kosovo at the pro-
fessional level independent of political is-
sues, helping them to establish their own
organisation and thereby guarantee better
health care for all patients in Kosovo, re-
gardless of their ethnicity. It was therefore
a success that physicians from the Serbian
population also registered for the chamber
elections. In the end, four Serbian physi-
cians were among the elected delegates of
the new Chamber.
With the legal framework already in place,
the inaugural event on 10 November in
Pristina represented the beginning of the
work of the Chamber of Physicians in
Kosovo. It is now time to breathe life into
the new Chamber and welcome it into the
European and international community of
medical associations.
Domen Podnar
Policy Advisor, Department for International
Affairs
Bundesärztekammer/German
Medical Association
Official Advisor to the WMA
Committees for Finance and Planning
and Socio-Medical Affairs
E-mail: domen.podnar@baek.de
New Chamber of Physicians Established
in Kosovo
30
MONTENEGRONMA and Regional News
Medical Chamber of Montenegro was es-
tablished by the Decree of the Parliament of
Montenegro in 1994, within Changes and
Amendments of the Law on Health Care,
and based on the initiative of the Medical
Association of Montenegro. It was estab-
lished as a professional organization con-
sisting of medical doctors and dentists, with
the objective of improving professional-
ism, maintaining medical ethics, improving
quality of health care and protecting profes-
sional interests, with rights and obligations
established in the Law on Health Care.
After long preparatory procedures, the
Chamber was established at the Constitu-
tional Assembly held on June 21, 1995. Prim.
Dr. Djoko Jocic, specialist in internal medi-
cine-haematologist, was elected as the first
president of the Chamber in 1996, and he is
still the president of the Chamber. Pursuant
to the Law on Health Care, the Chamber is
responsible for maintain of the register, is-
suing, and renewal and revoking of licenses,
as well as education. Current Register of the
Chamber includes 2800 medical doctors and
dentist, whereof 650 are dentists. We are ex-
pecting that the Dental Chamber will be es-
tablished soon,as an independent profession-
al institution, based on the request of Dental
Association and approval obtained from the
Medical Chamber and Ministry of Health.
Medical Chamber has its bodies (Assembly,
Executive Board,Chamber’s Court,prosecu-
tor, barristers and Supervisory Board) and
commissions.President of Executive Board is
also the President of the Chamber.Chamber
has nine commissions, among which is the
Commission for International Cooperation,
headed by doc. dr Olivera Miljanović, who
has been delegated to participate in meetings
of international medical associations.
Pursuant to our Law and rulebooks, license
for work is obtained upon graduating the
Medical Faculty and passing of professional
exam and fulfilling of other requirements
established in our rulebooks. Employment
relation cannot be established without this
license. Limited validity of the license is not
prescribed by the Law.
Health Care Law stipulates license based
on practice that is obtained upon completed
specialization and other forms of profes-
sional training (additional education, pub-
lishing of professional and scientific works,
professional publications, and periodical
stays in institutions in the country and
abroad,etc.).Number of points is prescribed
for obtaining of this license, which is deter-
mined based on categorization of all forms
of professional training. This is the respon-
sibility of the Chamber’s Commission for
Continuous Education. Doctor that doesn’t
hold this license cannot be elected to profes-
sional and managerial positions and cannot
become member of professional. expert and
educational teams, and has to work under
control of licensed doctor, regardless of his
specialty.This license is valid for seven years
and after this period it can be extended. Li-
cense must be extended in order to retain all
the benefits arising from it.
Special activities of the Chamber include ed-
ucation of its members, conducted through
organizing of professional and educational
conferences and issuing of publication. Par-
ticipation in conferences are also basis for
awarding points to doctors to help them meet
the requirements for obtaining license based
on practice. Chamber has a relatively good
cooperation with line ministry – Ministry of
Health, and participates in development of
laws that are of interest for profession and
health care service as a whole. Chamber has
started the initiative for establishing of pro-
fessional trade union of physicians and has
conducted all the activities for its establish-
ing, which was done in June 2013.This is an
independent professional body that will be a
competent representative of the profession
together with the Medical Chamber.
We are making efforts to have greater com-
petencies, similar to other Chambers and to
have Law on Chambers and Law on Physi-
cians, since the existing legal solutions pre-
scribe only rights of patients and our obliga-
tions and we want to regulate our rights with
the new law. We are not satisfied with the
current status of profession which is exposed
to unargumented attacks and accusations
by different media and non-governmental
organizations. Chamber doesn’t tolerate
violations of professional ethics and super-
ficial and unprofessional work. However
this should be proven first and then sanc-
tioned. Therefore, it is our priority to pro-
tect doctors from potential mistakes, which
we are currently doing in cooperation with
newly-established professional trade union
of physicians and we are expecting to have
a better solution, as we didn’t have support
of domestic insurance companies in the past.
Prim. dr Đoko Jočić,
President of the Medical
Chamber of Montenegro
Medical Chamber of Montenegro
New Member of WMA
Đoko Jočić
31
IRLAND NMA and Regional News
The Irish Medical Organisation (IMO) is
the representative body for all doctors in
Ireland and is celebrating its 30th
anniver-
sary this year.The IMO was formed in 1984
following the amalgamation of the Irish
Medical Association and the Irish Medical
Union, to act as the national representative
medical organisation linking all branches of
the medical profession in Ireland.
The basic objective of the IMO is to fulfil its
Mission Statement:
“The role of the IMO is to represent doctors in
Ireland and to provide them with all relevant
services. It is committed to the development of
a caring, efficient and effective Health Service.”
The IMO is a registered trade union in Ire-
land and for three decades has been work-
ing to safeguard both the working condi-
tions of our doctors and the integrity of our
health services.
Recently we ran a successful campaign
calling for an end to 24 hour shifts and
the full implementation of the European
Working Time Directive (EWTD). This
culminated in the first strike action in a
generation by our junior doctors (Non-
Consultant Hospital Doctors – NCHDs)
on the 8th
October 2013. Many of our ju-
nior doctors were working shifts of over
24 hours and working weeks of up to
100 hours posing significant safety issues
to both patient and doctors. Since 2000,
the IMO has been engaged with govern-
ment bodies on the implementation of the
EWTD, however frustrated by continued
lack of progress, the IMO launched its
“24  No More” campaign early last year.
The IMO engaged with health service
management to produce proposals to ad-
dress the issues, however the NCHDs were
not totally satisfied that penalties would be
imposed on employers for non-compliance
and voted unanimously for strike action.
In November 2013, the IMO reached a
settlement agreement with the health ser-
vice management to achieve maximum 24
hour shifts and the implementation of an
action plan to achieve full compliance with
the EWTD.
Resources for General Practice have been
successively cut over recent years and
in early November last year the IMO
launched our “Help us to Help More”
campaign calling on the Government to
increase resources for General Practice.
The IMO are also continually engaged in
issues concerning our Consultant members
and our Specialists in Public and Commu-
nity Health.
While the core activity of the IMO is in-
dustrial relations, as the leading represen-
tative body for the medical profession in
Ireland, the IMO has an important role in
advocacy. The IMO has been particularly
concerned about growing inequalities in
health and access to health care. In recent
years the IMO have published position pa-
pers on Universal Health Coverage,Health
Inequalities and Child Health. At our
AGM in April this year, the IMO will be
celebrating 30 years and will be holding a
policy seminar and publishing a discussion
paper entitled Balancing a Strong Economy
and an Equitable Society. The IMO will aim
to create debate on the future of Irish So-
ciety as Ireland as the country returns to
economic growth.
Over the years the IMO has been and re-
mains at the forefront promoting public
health policy on Obesity, Tobacco, Alco-
hol and Road Safety and advocating for
resources for the provision of public health
services, including Mental Health Services,
Elderly Care Services and Acute Hospital
Services.
The IMO also promotes professionalism
and has developed a number of papers on
the Role of the Doctor in Ireland.The IMO
recently published papers on Social Media,
Doctor-Patient Confidentiality and the
Role of the Doctor as Advocate.
Vanessa Hetherington,
Assistant Director – Policy and
International Affairs,
Irish Medical Organisation
Irish Medical Organisation Celebrates
30 years
Vanessa Hetherington
32
UNITED KINGDOMMedical Ethics
Early in the life of the World Medical Jour-
nal one of my predecessors wrote about eth-
ics at the BMA. We have been providing
ethics advice to doctors in the UK for the
best part of a century, while campaigning
and advocating for legislative and regula-
tory change. The most recent change in our
activities was nearly 30 years ago when we
started to undertake an active role in pro-
moting and protecting human rights. In
this article I shall look at the current areas
of work and how we undertake a series of
tasks to support members.
One of the earliest ethics matters on which
the BMA lobbied was on the regulation of
the medical profession. In the 1840’s only a
minority of those in the UK calling them-
selves medical practitioners were medically
qualified  – either through an apprentice-
ship route or via universities and the medi-
cal Royal College examinations. The BMA
published an expose of quackery, leading
to the establishment of the UK’s General
Medical Council.This body regulates medi-
cine, including ensuring that the universi-
ties are training undergraduates properly.
For the last 25 years it has also produced
an increasingly complex set of advisory
booklets and other materials to help doctors
understand the expectations that the GMC
has of doctors, addressing among other ar-
eas some of the ethically complex matters
that doctors see whether every day, or at
least frequently.
The BMA also provides advice in the form
of published material for doctors.Fifty years
ago this amounted to a very slim volume
setting out some of the rules, and stressing
the avoidance of behaviours that might lead
to being erased from the medical register by
the GMC. But that has now transformed
into a serious text book of medical ethics
and medical law’ “Medical Ethics Today –
the BMA’s Handbook of Ethics and Law”*.
The current edition is over 900 pages, and
covers all aspects of health care ethics and
the relevant statute and case law (judge
made law) in the UK, including identifying
the differences in the four countries of the
UK. It is not designed to be a text that is
read through once, but is a reference work.
BMA members have free access to it on-
line in a fully searchable version accessed
through the BMA’s on-line library.
The book was written by the BMA staff
who write all our ethics guidance, work
with members to negotiate on legislative
changes, and answer the queries that come
in to the Association from members facing
decisions with difficult ethical aspects.They
are experts, but experts who can write in a
manner that is academically excellent and
also readable and readily intelligible.
Given that the books size alone militates
against wide readership we have also pro-
* Medical Ethics Today; The BMA’s Handbook
of Ethics and Law, Third Edition, BMA, Wiley-
Blackwell, ISBN 978-1-4443-3708-2, pub 2012
duced a pocket sized book,“Everyday Med-
ical Ethics and Law”** which covers the ar-
eas on which we receive the most queries. It
is based on the larger book,but at just under
300 pages is readily readable.
In addition we produce guidance docu-
ments and a series of small toolkits on
common problems such as consent and
confidentiality, or for groups with a need
for specific guidance such as doctors in the
armed forces, and doctors new to practice
in the UK.
But how does the advice the BMA offers
to members come about? And how do we
decide on our ethics stance on new devel-
opments in medical practice, before we put
those into words of explanation and exposi-
tion?
The BMA has had a committee looking at
matters of medical ethics for over 100 years.
While the committee has had different it-
erations its current shape has been fixed for
nearly 25 years. The majority of members
are doctors (and medical students) elected
annually at our annual meeting. They may
come from any area of medicine – general
family practice, hospital medical specialties,
academic medicine, public health, occupa-
tional health etc – and bring a rich variety
of clinical experience to committee discus-
sions.In addition the BMA’s ruling Council
appoints 8 extra members to the committee,
who are not doctors but who have specific
expertise in the ethics area. These may in-
clude philosophers, professors of medical
law, theologians, social scientists and other
disciplines. All these members, and the staff
who support the Association’s work on eth-
ics, then debate the issues of the day.
Usually committee debates start with a pa-
per written by the secretariat, and setting
out the area under consideration. These
** Everyday Medical Ethics and Law, BMA Eth-
ics Department, Wiley-Blackwell, ISBN 976-1-
1183-8489-3, pub 2013
Ethics at the BMA
Vivienne Nathanson
33
Medical EthicsUNITED KINGDOM
papers include questions which the author
has identified as ones on which we need a
debate to establish a policy position, but de-
bate is not limited to those question-points.
Sometimes the paper will then be rewrit-
ten and represented, on other occasions
it moves more quickly to publication as a
position statement, part of our evidence to
an enquiry or some other equivalent dis-
posal. As with everyone else much of our
published guidance goes straight onto our
web pages; we are exploring ways of making
such web based guidance more interactive.
If the matter under consideration is a gov-
ernment regulatory or legislative proposal
then the staff, working with members, will
start to lobby on legislative changes. In-
creasingly the committee looks at matters
before the government has decided on its
legislative direction and the discussions are
with civil servants to attempt to influence
legislation as it is being developed to ensure
it is ethically sound.
All this sounds very dry – the reality is far
from that. All of the staff in the depart-
ment teach, from undergraduates through
to CPD, and they draw on the real cases
they are presented with when answering
member queries to bring the issues alive, to
ensure they are relevant to clinicians in ac-
tive practice, and to help those in the audi-
ence see how the academic material relates
to their working environment. The UK has
very many experts on philosophy and eth-
ics; the BMA is very unusual in bringing
that academic expertise together with real
life clinical examples and relevance. Frankly,
members want the clinically relevant sup-
port rather than ivory tower excellence. The
fact that our advice is – as one of the “ivory
tower” experts says – also academically ex-
cellent is a benefit but arguably not essential.
From time to time we analyse what the
most commonly asked questions are – it was
essential to know before preparing the sec-
ond book cited above, but it also helps us in
considering whether there are other matters
that would benefit from additional guidance
and advice. It also helps us to see if there are
trends, for example in challenges, or in legal
uncertainty.
Issues under consideration at present in-
clude a number relating to the beginning
of life, including the operation of Abortion
legislation, communication about death and
the process of dying, including decisions to
terminate treatment, consent to treatment,
new technologies impacting on diagnos-
tics, including maternal plasma testing for
foetal genetic anomalies, resource alloca-
tion, research regulation, whistle-blowing
(informing on bad or dangerous working
conditions) and professionalism.
For decades the commonest issue has been
confidentiality. The law is extremely com-
plex  – and there are regular changes fol-
lowing from new legislation. There are also
regular challenges as government and oth-
ers seek to use rich medical and other health
care data for management of health care,for
medical research and – from time to time –
for other government purposes. Govern-
ments often, in our experience, fail to un-
derstand the simple truth that people give
health care workers, and especially doctors,
sensitive private information to aid them
in their role as their health care provider.
While repeated public opinion surveys have
shown willingness to share genuinely ano-
nymised, usually aggregated, data for pur-
poses such as medical research (population
based epidemiological research in particu-
lar) and better health services management,
it is also clear that they expect that such data
will not be shared with other government
departments or commercial companies.
One element of our role is ensuring that
government understands the guardianship
role we share in relation to patient data, and
do not exploit this data inappropriately. It
can be a very delicate line to tread when we
are also seeking to ensure medical research
has proper access to information; more re-
search is in our interests as doctors and also
as patients and families of patients.
In much the same way government pro-
poses legislative and regulatory changes
that will affect medical practice. Recently
attempts to diminish the number of Quasi
Autonomous Non Governmental Organ-
isations (QANGO’s) or “Arms-length bod-
ies” which regulate sensitive areas of public
life have led to substantial areas of work.
Examples in recent months include the
regulation of the use of Human Tissue
and of Assisted Reproductive Technol-
ogy. Our members will be affected by the
way in which the regulations affect their
daily work, and expect us to ensure that
they make ethical and legal sense as well as
clinical sense. So we work with government
and with arms-length agencies to attempt
to ensure that we can regulate properly,
keep public confidence, maintain the high-
est ethical standards and do so in ways that
work with rather than against good clinical
practices.
Frequently we develop short or medium
term alliances with other interested groups
and work together to try to ensure a better
outcome for patients, scientists and doc-
tors. One example of an informal alliance
relates to organ transplantation. The BMA
has run a campaign for a number of years to
encourage the UK governments to choose
a policy of presumed consent or opt out.
This would mean that when someone died
in the right clinical circumstances unless
they had previously registered a refusal to
be a donor their organs could be retrieved
for transplantation. We prefer what is often
called a soft opt out system, where organ
retrieval would not go ahead if the family
were opposed and would be seriously dis-
tressed.The basis of the BMA policy is that
the government would have to fund a major
publicity campaign over several years to give
people information about opting out and
the opportunity to do so.That would ensure
families had many chances to discuss their
wishes, preferences and fear. While we have
had a significant increase in investment in
the infrastructure for organ transplantation,
34
Healthy Life Style BRAZIL
pleasingly increasing the numbers of organs
retrieved, and lives saved, only the Welsh
Assembly Government has so far legislat-
ed as we would want. Wales will therefore
become a within-the-UK “pilot” for this
policy.
To get this policy adopted we got together
a coalition of many groups interested in in-
creasing the number of organs donated and
transplanted. Not all agreed with opt out,
but there was common agreement on many
other areas. We all supported each other
as research was released or policy papers
distributed, and that has in no small part
helped with the attaining the high levels of
public awareness that has procured the in-
crease in donation achieved so far. In other
areas of work similar loose coalitions have
worked in achieving tobacco control and are
beginning to work in alcohol control.
One large area of work undertaken within
our ethics team is on human rights. This
started over 25 years ago with a report that
made it clear that doctors and other health
care professionals were or had recently been
involved in torture in many countries. Since
then two other reports have followed. The
last – “The Medical Professional and Hu-
man Rights; Handbook for a changing
agenda”* is used as a core book by many en-
tering the human rights arena for the first
time. The book sets out traditional human
rights and explains what these mean, how
doctors can become involved in protecting
or otherwise defending them, and gives ex-
amples of abuse.
In writing this the BMA was aware that
many doctors, and their medical associa-
tions, see human rights as someone else’s
responsibility. The BMA has long taken the
view that doctors are often the people who
see the evidence of abuses – we examine the
patients who survive and we certify the death
of those who die.We can gather evidence,or
we can ignore and become part of a system
seeking to hide the abuses it perpetrates.
In addition to working with Human Rights
activists, seeking to achieve a world free
from torture, we also take up individual cas-
es of human rights abuses. We concentrate
especially on cases where there is a health
issue – for example when there are reports
of a prisoner being denied access to health
care, or with serious health problems being
* The medical profession and human rights; Hand-
book for a changing agenda, BMA, Zed Books
ISBN 1-85649-612-0, pub 2001
inadequately treated.We also act on all cases
where health care professionals are targeted,
especially where that links to their provision
of care. Currently we, like the WMA itself,
are involved in trying to help the Turkish
Medical Association get their government
to understand that when doctors offer care
to people injured in riots or demonstra-
tions they do as a part of their ethical duty
to proffer care to all who need it, and not
as supporters of a particular political view.
Doctors, as all other citizens, will have par-
tisan views. But when acting as doctors we
do not act in a partisan manner. And here
ethics and human rights sit closely together.
Fifty years ago this article would have
stressed trying to stop doctors from being
struck off the register, and trying to help
doctors understand their privileged posi-
tion – and not abuse patients or indeed the
power that they have. Today we are acting
as advocates for patients, working with their
representative groups, and ensuring that the
power doctors still retain is used for public
good as well as benefitting individual pa-
tients.
Prof. Vivienne Nathanson
Director of Professional Activities
British Medical Association
In the last decades men and women have
gained weight and the global prevalence
of obesity (defined as a BMI ≥30) doubled
between 1980 and 2008, to 9.8% among
men and 13.8% among women – equiva-
lent to more than half a billion obese people
worldwide (205 million men and 297 mil-
lion women)*. Another 950 million adults
* Finucane MM, Stevens GA, Cowan MJ, et al.
National, regional, and global trends in body-
mass index since 1980: systematic analysis of
health examination surveys and epidemiological
have a BMI of 25 to less than 30. The
United States has had the largest absolute
increase in the number of obese people
since 1980, followed by China, Brazil, and
Mexico.** Obesity and excess body weight
have been associated with increased total
studies with 960 country-years and 9.1 million
participants. Lancet 2011;377:557-67.
** Stevens GA, Singh GM, Lu Y, et al. National,
regional, and global trends in adult overweight
and obesity prevalences. Popul Health Metr
2012;10:22
mortality and increased risks of disease or
death from diabetes, coronary heart disease,
stroke,cancers,andchronickidneydisease,***.
*** Whitlock G, Lewington S, Sherliker P, et al.
Body-mass index and cause-specific mortality
in 900 000 adults: collaborative analyses of 57
prospective studies. Lancet 2009;373:1083-96.
Wormser D, Kaptoge S, Di Angelantonio E, et
al. Separate and combined associations of body-
mass index and abdominal adiposity with car-
diovascular disease: collaborative analysis of 58
prospective studies. Lancet 2011;377:1085-95.
Renehan AG, Tyson M, Egger M, Heller RF,
Zwahlen M. Body-mass index and incidence of
cancer: a systematic review and meta-analysis
of prospective observational studies. Lancet
2008;371:569-78.
Excess Weight and Obesity
35
Healthy Life StyleBRAZIL
Excess weight is responsible for about 3.8%
of the global burden of disease, implicating
in 3.4 million annual deaths, also account-
ing for diseases that have low mortality and
long periods of disability, such as diabetes
and musculoskeletal diseases.
In this scenario physical activity has become
an important way in reverse the burden of
weight gain. Studies of the beneficial health
effects of physical activity date back to the
1950s* and have been replicated in large co-
horts.** Regular physical exercise improves
the CV risk profile and is a robust recom-
mendation for primary and secondary pre-
vention, according to current current guide-
lines [1;2]. In addition, low-to-moderate
running reduces levels of the inflammatory
markers [3]. On the other hand, vigorous
exercise, such as marathon running, may
increase the short-term risk of coronary
events [4]. Coronary atherosclerosis is the
main underlying cause of exercise-related
coronary events not only among elderly
persons unaccustomed to exercise [5], but
also in adult athletes including marathon
runners [6;7]. Over the past decades, the
number of recreational marathon runners,
including those at older age, is constantly
rising.
In developed countries air pollution, strictly
related to industrialization, has become
a major public health concern in the last
years, specially because of it’s association
as a risk factor of many kind of common
diseases, such as respiratory and CVD. Cu-
trufello et. al. [8] in a recent review among
pollutant exposure on healthy individuals,
have noticed that, despite detrimental ef-
fects are still in question, the inhalation
* Morris JN, Heady JA, Raffle PA, Roberts CG,
Parks JW. Coronary heart-disease and physical
activity of work. Lancet 1953; 265:1053-7.
** Sattelmair J, Pertman J, Ding EL, Kohl HW
III, Haskell W, Lee IM. Dose response between
physical activity and risk of coronary heart dis-
ease: a meta-analysis. Circulation 2011;124:789-
95.
of particulate matter (PM) is linked to an
increased inflammatory status and adverse
myocardial and vascular functions. Con-
sequently, onset of higher blood pressure
levels, decreased heart rate variability and
myocardial ischemia follows, contributing
to higher morbidity and mortality. Oxida-
tive stress, through endothelial dysfunc-
tion, seems to be one of the most important
mechanisms by which pollutants affect CV
performance  [9]. Despite compensatory
mechanisms, chronic exposure to air pollu-
tion still leads to decreased pulmonary and
cardiovascular function and increased mor-
tality, as it is recurrently shown on traffic
related air-pollution studies [10].
Notably, studies indicate that the forceful
inhalation, as in intense exercise, of small
environmental particles may directly or in-
directly result in vascular damage, an early
feature of the atherogenic process [11; 12].
The mechanisms responsible for this vas-
cular dysfunction remain unknown. One
hypothesis is that the amplification of shear
and oxidative stresses, present during vigor-
ous running in air-polluted surroundings,
promote the activation of inflammatory and
thrombotic mediators as well as endothelial
injury [13; 14; 15]
Since the Los Angeles Olympics in 1984,
this issue has become a frequent global con-
cern, attracting inclusively media attention.
Several studies were designed to correlate
exposure to PM and other gases (i.e., O3,
CO and NOx) to its effects on athlete’s per-
formance. This particular population may
have higher risk of inhaling pollutants be-
cause of vigorous breathing [16]. Rundell,
in his 2012 review [17] on effect of air pol-
lution on athlete health and performance,
established that vascular dysfunction related
to pollution inhalation limits performance.
However, he empathically says that there
has been no research into the effects of
long-term exposure to air pollution on ath-
letic performance and a paucity of studies
that describe the effects of acute exposure
on exercise performance.
To date, little is known about the genetic
responses to human exercise [18]. Exercise
training induces numerous cardiovascular
changes in the cellular and molecular level,
including mitochondrial synthesis [19],
myocardial remodeling [20] and angiogen-
esis [21]. Although such adaptations and
their attendant impact on exercise capacity
and health outcomes have been well docu-
mented, the genetic mechanisms lead-
ing to these changes remain incompletely
understood. In addition, it is important
to point out that genetic susceptibility is
likely to play a role in response to air pol-
lution [22]. Hence, gene-environment in-
teraction studies can be a tool for explor-
ing the mechanisms and the importance
of the pathway in the association between
exercise, air pollution and a cardiovascular
outcome [23].
As seems above, many scientists around the
world dedicated their studies to the harm-
ful effects of pollutant inhalation restrict to
their own cities or countries, proving that
training or living close to major roads or to
industrial centers may assemble CV risks
and reduce exercise performance. But is the
burden of CVD attributed to outdoor air
pollution similar among different running
volumes? Has air pollution exposure any
implication on international competitions,
as training programs are developed in dif-
ferent cities and countries?
References
1. Smith SC Jr, Benjamin EJ, Bonow RO, Braun
LT, Creager MA, Franklin BA, Gibbons RJ,
Grundy SM, Hiratzka LF, Jones DW, Lloyd-
Jones DM, Minissian M, Mosca L, Peterson
ED, Sacco RL, Spertus J, Stein JH, Taubert
KA; World Heart Federation and the Preven-
tive Cardiovascular Nurses Association. AHA/
ACCF Secondary prevention and risk reduc-
tion therapy for patients with coronary and
other atherosclerotic vascular disease (2011 up-
date):a guideline from the American Heart As-
sociation and American College of Cardiology
Foundation. Circulation 2011;124:2458-73.
36
Healthy Life Style BRAZIL
2. Eckel RH, Jakicic JM, Ard JD, Hubbard VS,
de Jesus JM, Lee IM, Lichtenstein AH, Lo-
ria CM, Millen BE, Miller NH, Nonas CA,
Sacks FM, Smith SC Jr, Svetkey LP, Wadden
TW, Yanovski SZ. 2013 AHA/ACC Guide-
line on Lifestyle Management to Reduce
Cardiovascular Risk: A Reportof the Ameri-
can College of Cardiology/American Heart
Association Task Force on Practice Guide-
lines. http://circ.ahajournals.org/content/
early/2013/11/11/01.cir.0000437740.48606.
d1.citation.
3. Colbert LH, Visser M, Simonsick EM,Tracy
RP, Newman AB, Kritchevsky SB, Pahor
M, Taaffe DR, Brach J, Rubin S, Harris TB.
Physical activity, exercise, and inflammatory
markers in older adults: findings from The
Health, Aging and Body Composition Study.
J Am Geriatr Soc 2004;52:1098-104.
4. Albert CM, Mittleman MA, Chae CU, Lee
IM, Hennekens CH, Manson JE. Triggering
of sudden death by vigorous exercise. N Engl
J Med 2000;343:1355-61.
5. Mittleman MA, Maclure M, Tofler GH,
Sherwood JB, Goldberg RJ, Muller JE. Trig-
gering of acute myocardial infarction by
heavy physical exertion: protection against
triggering by regular exertion. N Engl J Med
1993;329:1677-83.
6. Thompson PD, Balady GJ, Chaitman BR,
Clark LT, Levine BD, Myerburg RJ. Task
force 6: coronary artery disease. J Am Coll
Cardiol 2005;45:1348-53.
7. Noakes TD, Opie LH, Rose AG, Kleynhans
PH, Schepers NJ, Dowdeswell R. Autopsy-
proved coronary atherosclerosis in marathon
runners. N Engl J Med 1979;301:86-9.
8. Cutrufello PT, Smoliga JM, Rundell KW.
Small things make a big difference: par-
ticulate matter and exercise. Sports Med
2012;42:1041-58.
9. Mills NL, Donaldson K, Hadoke PW, Boon
NA, MacNee W, Cassee FR, Sandström T,
Blomberg A, Newby DE. Adverse cardiovas-
cular effects of air pollution. Nat Clin Pract
Cardiovasc Med 2009;6:36-44.
10.Wilund KR, Tomayko EJ, Evans EM, Kim
K, Ishaque MR, Fernhall B. Physical activ-
ity, coronary artery calcium, and bone mineral
density in elderly men and women: a prelimi-
nary investigation. Metabolism Clinical and
Experimental 2008;57:584-91.
11.Miyata R, Hiraiwa K, Cheng JC, Bai N,
Vincent R, Francis GA, Sin DD, Van Ee-
den SF. Statins attenuate the development
of atherosclerosis and endothelial dysfunc-
tion induced by exposure to urban particu-
late matter (PM10). Toxicol Appl Pharmacol
2013;272:1-11.
12.Brucker N, Moro AM, Charão MF, Dur-
gante J, Freitas F, Baierle M, Nascimento S,
Gauer B, Bulcão RP, Bubols GB, Ferrari PD,
Thiesen FV,Gioda A,Duarte MM,de Castro
I, Saldiva PH, Garcia SC. Biomarkers of oc-
cupational exposure to air pollution, inflam-
mation and oxidative damage in taxi drivers.
Sci Total Environ 2013;463-464C:884-93.
13.Rich DQ, Kipen HM, Huang W, Wang G,
Wang Y, Zhu P, Ohman-Strickland P, Hu M,
Philipp C, Diehl SR, Lu SE, Tong J, Gong J,
Thomas D, Zhu T, Zhang JJ. Association be-
tween changes in air pollution levels during
the Beijing Olympics and biomarkers of in-
flammation and thrombosis in healthy young
adults. JAMA 2012;307:2068-78.
14.Möhlenkamp S, Lehmann N, Breuckmann F,
Bröcker-Preuss M, Nassenstein K, Halle M,
Budde T, Mann K, Barkhausen J, Heusch G,
Jöckel KH, Erbel R, Marathon Study Inves-
tigators, Heinz Nixdorf Recall Study Investi-
gators. Running, the risk of coronary events:
prevalence and prognostic relevance of coro-
nary atherosclerosis in marathon runners.Eur
Heart J 2008;29:1903-10.
15.Libby P. Mechanisms of acute coronary syn-
dromes and their implications for therapy. N
Engl J Med 2013;368:2004-13.
16.Smith SC Jr,Benjamin EJ,Bonow RO,Braun
LT, Creager MA, Franklin BA, Gibbons RJ,
Grundy SM, Hiratzka LF, Jones DW, Lloyd-
Jones DM, Minissian M, Mosca L, Peterson
ED, Sacco RL, Spertus J, Stein JH, Taubert
KA; World Heart Federation and the Pre-
ventive Cardiovascular Nurses Association.
AHA/ACCF Secondary prevention and risk
reduction therapy for patients with coronary
and other atherosclerotic vascular disease
(2011 update): a guideline from the Ameri-
can Heart Association and American Col-
lege of Cardiology Foundation. Circulation
2011;124:2458-73.
17.Rundell K.W. Effect of air pollution on ath-
lete health and performance. Br J Sports Med
2012;46:407-12.
18.Baggish AL, Hale A, Weiner RB, Lewis GD,
Systrom D, Wang F, Wang TJ, Chan SY.
Dynamic regulation of circulating micro-
RNA during acute exhaustive exercise and
sustained aerobic exercise training. J Physiol
2011;589:3983-94.
19.Kiessling KH, Pilstrom L, Karlsson J, Piehl
K. Mitochondrial volume in skeletal muscle
from young and old physically untrained and
trained healthy men and from alcoholics.Clin
Sci 1973;44:547-54.
20.Baggish AL, Wang F, Weiner RB, Elinoff
JM, Tournoux F, Boland A, Picard MH,
Hutter AM, Jr, Wood MJ. Training-specific
changes in cardiac structure and function:
a prospective and longitudinal assessment
of competitive athletes. J Appl Physiol
2008;104:1121-8.
21.Gute D, Fraga C, Laughlin MH, Amann
JF. Regional changes in capillary sup-
ply in skeletal muscle of high-intensity
endurance-trained rats. J Appl Physiol
1996;81:619-26.
22.Yang IA, Fong KM, Zimmerman PV, Hol-
gate ST, Holloway JW. Genetic susceptibil-
ity to the respiratory effects of air pollution.
Postgrad Med J 2009;85:428-36.
23.Zanobetti A, Baccarelli A, Schwartz J. Gene-
air pollution interaction and cardiovascu-
lar disease: a review. Prog Cardiovasc Dis
2011;53:344-52.
Prof. Carlos Vicente Serrano, JR,
Paulo O. Cardoso
Dr. Paulo O. Cardoso;
Prof. Carlos Vicente Serrano, JR,Director,
Atherosclerosis Clinic Unit,
Heart Institute;
School of Medicine,University
of Sao Paulo, Brazil
E-mail: cvserranojr@gmail.com
37
WMA Directory of Constituent Members
Order of Physicians of Albania
Rr. Dibres. Poliklinika Nr.10, Kati 3,
Tirana
ALBANIA
Dr. Din ABAZAJ,
President
Tel/Fax: (355) 4 2340 458
E-mail: albmedorder@albmail.com
Website: www.umsh.org
Col’legi de Metges
C/Verge del Pilar 5, Edifici Plaza 4t.
Despatx 11, 500 Andorra La Vella
ANDORRA
Dr. Manuel González
BELMONTE, President
Tel: (376) 823 525
Fax: (376) 860 793
E-mail: coma@andorra.ad
Website: www.col-legidemetges.ad
Ordem dos Médicos de Angola
Rua Amilcar Cabral 151-153,
Luanda
ANGOLA
Dr. Carlos Alberto Pinto DE
SOUSA, President
Tel. (244) 222 39 23 57
Fax (244) 222 39 16 31
E-mail:
secretariatdormed@gmail.com
Website:
www.ordemmedicosangola.com
Confederación Médica de la
República Argentina
Av. Belgrano 1235, Buenos Aires
1093
ARGENTINA
Dr. Jorge C. JAÑEZ, President
Tel/Fax: (54-11) 4381-1548/
4384-5036
E-mail: comra@
confederacionmedica.com.ar
Website: www.comra.org.ar
Armenian Medical Association
P.O. Box 143, Yerevan 375 010
ARMENIA
Dr. Parounak ZELVIAN, President
Tel: (3741) 53 58 68
Fax: (3741) 53 48 79
E-mail: info@armeda.am
Australian Medical Association
P.O. Box 6090, Kingston, ACT 2604
AUSTRALIA
Dr. Steve HAMBLETON,
President
Tel: (61-2) 6270 5460
Fax: (61-2) 6270 5499
E-mail: ama@ama.com.au
Website: www.ama.com.au
Osterreichische Arztekammer
(Austrian Medical Chamber)
Weihburggasse 10-12 – P.O.
Box 213,
1010 Wien
AUSTRIA
Dr. Artur WECHSELBERGER,
President
Tel: (43 1) 514 063000
Fax: (43 1) 514063042
E-mail: international@
aerztekammer.at
Website: www.aerztekammer.at
Azerbaijan Medical Association
P.O. Box 16, AZE 1000, Baku
REPUBLIC OF AZERBAIJAN
Dr. Nariman SAFARLI, President
Tel: (99 450) 328 18 88
Fax: (99 412) 510 76 01
E-mail. info@azmed.az
Website: www.azmed.az
Medical Association of the Bahamas
P.O. Box N-3125,
MAB House – 6th
Terrace
Centreville,
Nassau
BAHAMAS
Dr.Timothy BARRETT, President
Tel. (242) 328-1858
Fax. (242) 328-1857
E-mail: medassocbah@gmail.com
Bangladesh Medical Association
BMA Bhaban 15/2 Topkhana Road,
Dhaka 1000
BANGLADESH
Prof. Mahmud HASAN, President
Tel: (880) 2-9568714/9562527
Fax: (880) 2 9566060/9562527
E-mail: info@bma.org.bd
Website: www.bma.org.bd
Association Belge des Syndicats
Médicaux
Chaussée de Boondael 6, bte 4,
1050 Bruxelles
BELGIUM
Dr. Roland LEMYE, Président
Tel: (32-2) 644 12 88
Fax: (32-2) 644 15 27
E-mail: info@absym-bvas.be
Website: www.absym-bvas.be
Colegio Médico de Bolivia
Calle Ballivian Nro. 1266 2do. Piso
Murillo
BOLIVIA
Dr. Edgar Villegas GALLO,
President
Telfs. Fax: (591-2) 2203643 –
2203649 – 2113252
E-mail: secretario@
colegiomedicodebolivia.org.bo
Website: colegiomedicodebolivia.org.bo
Associaçao Médica Brasileira
R. Sao Carlos do Pinhal 324 – Bairro,
Bela Vista,
Sao Paulo SP – CEP 01333-903
BRAZIL
Dr. Florentino de Araújo
CARDOSO FILHO, President
Tel. (55-11) 3178 6810
Fax. (55-11) 3178 6830
E-mail: rinternacional@amb.org.br
Website: www.amb.org.br
Bulgarian Medical Association
15, Acad. Ivan Geshov Blvd.,
1431 Sofia
BULGARIA
Dr. Cvetan RAYCHINOV, President
Tel: (359-2) 954 11 81
Fax: (359-2) 954 11 86
E-mail: blsus@mail.bg
Website: www.blsbg.com
Ordre National des Médecins du
Cameroun
B.P. 15534
11111 Yaoundé
CAMEROON
Dr. SANDJON, Guy, President
E-mail: onmcam@yahoo.fr;
onmc.cam@gmail.com
Website: www. onmc.cm
Canadian Medical Association
P.O. Box 8650, 1867 Alta Vista
Drive,
Ottawa, Ontario K1G 5W8
CANADA
Dr. FRANCESCUTTI, Louis
Hugo , President
Tel: (1-613) 731 8610/2289
Fax: (1-613) 731 1779
E-mail: karen.clark@cma.ca
Website: www.cma.ca
Ordem Dos Medicos du Cabo Verde
Avenue OUA N° 6 – B.P. 421
Achada Santo António
Ciadade de Praia-Cabo Verde
CAPE VERDE
Dr. Luis de Sousa NOBRE LEITE,
President
Tel. (238) 262 2503
Fax (238) 262 3099
E-mail: omecab@cvtelecom.cv
Website: www.ordemdosmedicos.cv
Colegio Médico de Chile
Esmeralda 678 – Casilla 639,
Santiago
CHILE
Dr. Enrique PARIS, Presidente
Tel: (56-2) 4277800
Fax: (56-2) 6330940/6336732
E-mail: amisseroni@colegiomedico.cl
Website: www.colegiomedico.cl
Chinese Medical Association
42 Dongsi Xidajie, Beijing 100710
CHINA
Dr. Zhu CHEN, President
Tel: 86-10-85158143
Fax: 86-10-85158551
E-mail: intl@cma.org.cn;
siwen@cma.org.cn
Website: www.cma.org.cn/ensite
Federación Médica Colombiana
Carrera 7 N° 82-66, Oficinas
218/219
Santafé de Bogotá, D.E.
COLOMBIA
Dr. Sergio Isaza VILLA, President
Tel./Fax: (57-1) 8050073
E-mail:
federacionmedicacolombiana@
encolombia.com
38
Conseil National de l’Ordre des
Médecins du RDC, B.P. 4922,
Kinshasa, Gombe
CONGO, DEMOCRATIC
REPUBLIC
Dr. Antoine MBUTUKU
MBAMBILI, President
Tel: (243-12) 24589
Fax: (243) 8846574
E-mail: cnomrdcongo@gmail.com
Website: www.cnom-rdc.org
Unión Médica Nacional
Apartado 5920-1000,
San José
COSTA RICA
DR. Edwin Solano ALFARO,
President
Tel: (506) 290-5490
Fax: (506) 231 7373
E-mail: junta@unionmedica.com
Website: www.unionmedica.com
Ordre National des Médecins
de la Côte d’Ivoire
Cocody Cite des Arts,
Bâtiment U1, Escalier D, RDC,
Porte n°1, BP 1584, 01 Abidjan
CÔTE D’IVOIRE
Dr. Florent Pierre AKA KROO,
President
Tel: (255) 22486153/22443078/
02024401/08145580
Fax: (255) 22 44 30 78
E-mail: secretariat@medecins.ci
Website: www.medecins.ci
Croatian Medical Association
Subiceva 9, 10000 Zagreb
CROATIA
Dr. Zeljko METELKO,
President
Tel: (385-1) 46 93 300
Fax: (385-1) 46 55 066
E-mail: tajnistvo@hlz.hr
Website: www.hlz.hr
Colegio Médico Cubano Libre
717 Ponce de Leon Boulevard,
P.O. Box 141016,
Coral Gables, FL 33114-1016
CUBA
Dr. Enrique HUERTAS, President
Tel: (1-305) 446 9902/445 1429
Fax: (1-305) 4459310
E-mail: info@sirspeedy5551.com
Cyprus Medical Association
14 Thasou Street, 1087 Nicosia
CYPRUS
Dr. Andreas DEMETRIOU,
President
Tel. (357) 22 33 16 87
Fax: (357) 22 31 69 37
E-mail: cyma@cytanet.com.cy
Website: www.cyma.org.cy
Czech Medical Association
Sokolská 31 – P.O. Box 88
120 26 Prague 2
CZECH REPUBLIC
Prof. Jaroslav BLAHOS, President
Tel: (420) 224 266 201-4
Fax: (420) 224 266 212
E-mail: czma@cls.cz
Website: www.cls.cz
Danish Medical Association
9 Trondhjemsgade, 2100
Copenhagen
DENMARK
Dr.Mads Koch HANSEN, President
Tel: (45) 35 44 82 29
Fax: (45) 35 44 85 05
E-mail: er@dadl.dk
Website: www.laeger.dk
Egyptian Medical Association
Dar El Hekmah
42 Kasr El-Eini Street, Cairo
EGYPT, ARAB REPUBLIC
Prof. Ibrahim BADRAN
Tel: (20-2) 27 94 09 91
Fax: (20-2) 27 95 78 17
E-mail: ganzory@tedata.net.eg
Colegio Médico de El Salvador
Final Pasaje N° 10, Colonia
Miramonte
San Salvador
EL SALVADOR
Dr. Milton Dagoberto Ramón
BRIZUELA, President
E-mail: juntadirectiva@
colegiomedico.org.sv
Website: colegiomedico.org.sv
Estonian Medical Association
Pepleri 32, 51010 Tartu
ESTONIA
Dr. Andres KORK, President
Tel: (372) 7 420 429
Fax: (372) 7 420 429
E-mail: eal@arstideliit.ee
Website: www.arstideliit.ee
Ethiopian Medical Association
P.O. Box 2179, Addis Ababa
ETHIOPIA
Dr. Fuad TEMAM,
President
Tel: 251 115 521776/
251 115 547982
Fax: 251 115 151005
E-mail: info@emaethiopia.org
Website: www.emaethiopia.org
Fiji Medical Association
304 Wainamu Road,G.P.O.
Box 1116,Suva
FIJI
Dr. James Fong, President
Tel: (679) 3315388
Fax: (679) 3315388
E-mail: fma@unwired.com.fj
Website: fijimedassoc.webnode.com
Finnish Medical Association
P.O. Box 49, 00501 Helsinki
FINLAND
Dr. RAJANIEMI,Tuula,
President
Tel: (358-9) 393 091
Fax: (358-9) 393 0794
E-mail:
suvi.koljonen@laakariliitto.fi
Website: www.laakariliitto.fi/en
Conseil National de l’Ordre des
Médecins (CNOM)
180, Blvd. Haussmann,
75389 Paris Cedex 08
FRANCE
Dr. Patrick, BOUET Chair
Tel: (33) 2 99 38 55 88
Fax. (33) 2 99 38 15 57
E-mail: international@
cn.medecin.fr
Website:
www.conseil-national.medecin.fr
Georgian Medical Association
7 Asatiani Street, 0177 Tbilisi
GEORGIA
Prof. Gia LOBZHANIDZE,
President
Tel. (995 32) 398686
Fax. (995 32) 396751/398083
E-mail.
georgianmedicalassociation@gmail.com
Website: www.gma.ge
Bundesärztekammer
(German Medical Association)
Postfach 120 864
10598 Berlin
GERMANY
Dr. Frank Ulrich MONTGOMERY,
President
Tel: (49-30) 4004 56 360
Fax: (49-30) 4004 56 384
E-mail: international@baek.de
Website: www.baek.de
Ghana Medical Association
P.O. Box 1596, Accra
GHANA
Dr. Kwabena OPOKU-ADUSEI,
President
Tel. (233-21) 670510/665458
Fax. (233-21) 670511
E-mail: gma@dslghana.com
Association Médicale Haitienne
1ère Av. du Travail #33 – Bois Verna
Port-au-Prince
HAITI
Dr. Marie Ginette RIVIERE
LUBIN, President
E-mail: secretariatamh@gmail.com
Hong Kong Medical Association,China
Duke of Windsor Social Service
Building
5th
Floor, 15 Hennessy Road
HONG KONG
Dr.TSE Hung Hing,, President
Tel: (852) 2527-8285
Fax: (852) 2865-0943
E-mail: hkma@hkma.orgoui
Website: www.hkma.org
Hungarian Medical Chamber
Szondi utca 100
1068 Budapest
HUNGARY
Dr. Istvan, EGER President
Tel: +36 13020065
Fax: +36 13540463
E-mail: elnok@mok.hu
Website: www.mok.hu
Icelandic Medical Association
Hlidasmari 8, 201 Kópavogur
ICELAND
Dr.Thorbjörn JÓNSSON, President
Tel: (354) 864 0478
Fax: (354) 5 644106
E-mail: lis@lis.is
Website: www.lis.is
39
Indian Medical Association
Indraprastha Marg,110 002 New Delhi
INDIA
Dr. K. VIJAYAKUMAR,
National President
Tel: (91-11)
23370009/23378819/23378680
Fax: (91-11) 23379178/23379470
E-mail: inmedici@gmail.com
Website: www.ima-india.org
Indonesian Medical Association
Jl. Samratulangi No. 29, 10350 Jakarta
INDONESIA
Dr. Zaenal ABIDIN, President
Tel: (62-21) 3150679/3900277
Fax: (62-21) 390 0473
E-mail: pbidi@idionline.org
Website: www.idionline.org
Irish Medical Organisation
10 Fitzwilliam Place, 2 Dublin
IRELAND
Dr. Matthew SADLIER, President
Tel: (353-1) 6767273
Fax: (353-1) 662758
E-mail: imo@imo.ie
Website: www.imo.ie
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, 52136 Ramat-Gan
ISRAEL
Dr. Leonid EIDELMAN, President
Tel: (972-3) 610 0444
Fax: (972-3) 575 0704
E-mail: michelle@ima.org
Website: www.ima.org.il
Federazione Nazionale degli Ordini
dei Medici
Chirurghi e degli Odontoiatri
Piazza Cola di Rienzo 80/a
00192 Roma
ITALY
Dr. Amedeo BIANCO, President
Tel: +39 06 36203242
Fax: +39 06 3222794
E-mail: estero@fnomceo.it
Website: www.fnomceo.it
Japan Medical Association
2-28-16 Honkomagome,
113-8621 Bunkyo-ku,Tokyo
JAPAN
Dr.Yoshitake YOKOKURA,President
Tel: (81-3) 3946 2121/3942 6489
Fax: (81-3) 3946 6295
E-mail: jmaintl@po.med.or.jp
Website: www.med.or.jp/english
National Medical Association of the
Republic of Kazakhstan
117/1 Kazybek bi St., Almaty
KAZAKHSTAN
Dr. Aizhan SADYKOVA, President
Tel. (7-327 2) 624301/2629292
Fax. (7-327 2) 623606
E-mail: doktor_sadykova@mail.ru
Korean Medical Association
302-75 Ichon 1-dong
140-721 Yongsan-gu, Seoul
KOREA, REPUBLIC
Dr. Hwan Kyu ROH, President
Tel: (82-2) 794 2474
Fax: (82-2) 793 9190/795 1345
E-mail: intl@kma.org
Website: www.kma.org
Kuwait Medical Association
Jabriah, Blk,  2 Next To Blood Bank
KUWAIT
Dr. Ali Zaid ALMAKAIMI,
President
Fax: (965) 25333905/(965) 25333276
Tel:  1881181 Ext: 100/101
E-mail. doctorshehab@gmail.com
Website: www.kma.org.kw
Latvian Medical Association
Skolas Str. 3, Riga 1010
LATVIA
Dr. Peteris APINIS, President
Tel: (371) 67287321/67220661
Fax: (371) 67220657
E-mail: lma@arstubiedriba.lv
Website: www.arstubiedriba.lv
Liechtensteinische Ärztekammer
Essanestrasse 93 
9492 Eschen
LIECHTENSTEIN
Dr. Rainer DE MEIJER, President
T +(423)370 20 30 
20 31 F +423,370
E-mail: office@aerztekammer.li
Website: www.aerztekammer.li
Lithuanian Medical Association
Liubarto Str. 2, 2004 Vilnius
LITHUANIA
Dr. Liutauras LABANAUSKAS,
President
Tel./Fax. (370-5) 2731400
E-mail: lgs@takas.lt
Website: www.lgs.lt
Association des Médecins et
Médecins Dentistes
du Grand-Duché de Luxembourg
(AMMD)
29, rue de Vianden, 2680
Luxembourg
LUXEMBOURG
Dr. Jean UHRIG, President
Tel: (352) 44 40 33 1
Fax: (352) 45 83 49
E-mail: secretariat@ammd.lu
Website: www.ammd.lu
Macedonian Medical Association
Dame Gruev St. 3, P.O. Box 174,
91000 Skopje
MACEDONIA, FYR
Prof. Dr. Jovan TOFOSKI,
President
Tel: (389-2) 3162 577/7027 9630
Fax: (389-91) 232577
E-mail: mld@unet.com.mk
Website: www.mld.org.mk
Society of Medical Doctors
of Malawi
Post Dot Net, 387X,
Crossroads
Lilongwe
MALAWI
Dr. Douglas Komani LUNGU,
President
E-mail: smdmalawi@gmail.com 
Website: www.smdmalawi.org
Malaysian Medical Association
4th
Floor, MMA House,
124 Jalan Pahang
53000 Kuala Lumpur
MALAYSIA
Dr. Dato’ Dr. N.K.S.Tharmaseelan,
President
Tel: (60-3) 4041 1375
Fax: (60-3) 4041 8187
E-mail: info@mma.org.my
Website: www.mma.org.my
Ordre National des Médecins
du Mali
Area of the river Bamako
MALI
Dr. Lassana FOFANA,
President
Tel. (223) +223 20 22 20 58
E-mail: cnommali@gmail.com
Website: cnom.sante.gov.ml
Medical Association of Malta
The Professional Centre,
Sliema Road, Gzira GZR 06
MALTA
Dr. Steven Fava, President
Tel: (356) 21312888
Fax: (356) 21331713
E-mail: martix@maltanet.net
Website: www.mam.org.mt
Colegio Medico de Mexico
Adolfo Prieto #812, Col. Del Valle,
D. Benito Juárez, Mexico 03100
MEXICO
Dr. Ramon MURIETTA, President
E-mail: colegiomedicomexico.
federacion@gmail.com
Website:
www.colegiomedicodemexico.org.mx
Medical Chamber of Montenegro
Ul. Slobode 64/1
81000 Podgorica
MONTENEGRO
Dr. Djoko Jocic, President
E-mail: lkomcg@t-com.me
Website: www.ljekarskakomora.co.me
Associacao Medica de Mocambique
Avenida Salvador Allende, n. 560,
1 andar, Maputo
MOZAMBIQUE
Dr. Jorge ARROZ, President
Tel: (258) 843 050 610
Fax: (258) 213 248 34
E-mail: rsalomao@teledata.mz
Myanmar Medical Association
No. 249,Theinbyu Road
Mingalartaungnyunt Township,
Yangon Region
MYANMAR
Prof. Kyaw Myint Naing, President
Tel: +95-01-380899, 388097, 394141
Fax: +95-01-378863
E-mail: mmacorg@gmail.com
Website: www.mmacentral.org
Medical Association of Namibia
9 Bassingthwaighte Street
Klein Windhoek
P O Box 3369
Windhoek
NAMIBIA
Dr. Reinhardt SIEBERHAGEN,
President
Tel. (264) 61 22 4455
Fax. (264) 61 22 4826
E-mail: man.office@iway.na
Website: www.man.com.na
40
Nepal Medical Association
Siddhi Sadan, Post Box 189,
Exhibition Road, Katmandu
NEPAL
Dr. Anjani Kumar JHA,
President
Tel: +977 1 4225860/4231825
Fax: +977 1 4225300
E-mail: info@nma.org.np
Website: www.nma.org.np
Royal Dutch Medical Association
P.O. Box 2005, 3502 LB, Utrecht
NETHERLANDS
Dr. R.J. Van Der GAAG,
President
Tel: (31-30) 282 32 67
Fax: (31-30) 282 33 18
E-mail: info@fed.knmg.nl
Website: knmg.artsennet.nl
New Zealand Medical Association
P.O. Box 156, Level 13 Greenock
House, 39,The Terrace,
Wellington 1
NEW ZEALAND
Dr. Lesley CLARKE, Chief
Executive Officer
Dr. Mark PETERSON,
Chairman
Tel: (64-4) 472 4741
Fax: (64-4) 471 0838
E-mail: nzma@nzma.org.nz
Website: www.nzma.org.nz
Nigerian Medical Association
8 Benghazi Street,
Off Addis Ababa, Crescent,
Wuse Zone 4,
FCT, PO Box 8829,
Wuse Abuja
NIGERIA
Dr. Osahon ENABULELE,
President
Tel: (234-1) 480 1569, 876 4238
Fax: (234-1) 493 6854
E-mail: nationalnma@yahoo.com
Norwegian Medical Association
P.O.Box 1152 sentrum, 0107 Oslo
NORWAY
Hege GJESSING, President 
Tel: (47) 23 10 90 00
Fax: (47) 23 10 90 10
E-mail:
legeforeningen@legeforeningen.no
Website: legeforeningen.no
Asociación Médica Nacionalde la
República de Panamá
Apartado Postal 2020, Panamá 1
PANAMA
Dr. Alfredo MACHARAVIAYA,
President
Tel: (507) 263 7622/263-7758
Fax: (507) 223 1462
E-mail: amenalpa@cwpanama.net
Colegio Médico del Perú
Malecón Armendáriz N° 791,
Miraflores, Lima
PERU
Dr. Juan VILLENA VIZCARRA ,
President
Tel: (51-1) 213 1400
Fax: (51-1) 213 1412
E-mail: clunyd@hotmail.com
Website: www.cmp.org.pe
Philippine Medical Association
PMA Bldg.,
North Avenue, Quezon City 1105
PHILIPPINES
Dr. Modesto O. LLAMAS,
President
Tel: (63-2) 929 63 66
Fax: (63-2) 929 69 51
E-mail:
info@philippinemedicalassociation.org
Website:
philippinemedicalassociation.org
Polish Chamber of Physicians and
Dentists
(Naczelna Izba Lekarska)
110 Jana Sobieskiego, 00-764
Warsaw
POLAND
Dr. Maciej HAMANKIEWICZ,
President
Tel. (48) 22 55 91 300/324
Fax: (48) 22 55 91 323
E-mail: sekretariat@hipokrates.org
Website: www.nil.org.pl
Ordem dos Médicos (Portugal)
Av. Almirante Gago Coutinho 151,
1749-084 Lisbon
PORTUGAL
Dr. José Manuel SILVA, President
Tel: (351-21) 842 71 00/842 71 11
Fax: (351-21) 842 71 99
E-mail: omcne@omcne.pt
Website: www.ordemdosmedicos.pt
Romanian College of Physicians
Bulevardul Timisoara nr. 15,
061303 Sector 6, Bucarest
ROMANIA
Prof. Dr. Vasile ASTARASTOAE,
President
Tel: (40-21) 413 88 00
Fax: (40-21) 413 77 50
E-mail: office@cmr.ro
Website: www.cmr.ro
Russian Medical Society
Udaltsova Street 85,
119607 Moscow
RUSSIAN FEDERATION
Dr. Sergey BAGNENKO,
President
Tel: (7-495) 734 12 12
Fax: (7-495) 734 11 00
E-mail. info@russmed.ru
Website:
www.russmed.ru/eng/who.htm
Samoa Medical Association
Tupua Tamasese Meaole Hospital
Private Bag – National Health
Services,
Apia
SAMOA
Dr. Viali LAMEKO, President
Tel. (685) 778 5858
E-mail: viali1_lameko@yahoo.com
Ordre National des Médecins
du Sénégal
Institut d’Hygiène Sociale
(Polyclinique)
BP 27115 Dakar
SENEGAL
Dr. Sheikh A. Bamba Diop,
President
Tel. (221) 33 822 29 89
Fax: (221) 33 821 11 61
E-mail: lamsow@orange.sn
Website: www.ordremedecins.sn
Lekarska Komora Srbije
(Serbian Medical Chamber)
Kraljice Natalije 1-3, Belgrade
SERBIA
Dr.Tatjana RADOSAVLJEVIC,
General Manager
E-mail:
lekarskakomorasrbije@gmail.com
Website: www.lks.orgs.rs
Singapore Medical Association
Alumni Medical Centre,
Level 2
2 College Road 169850
SINGAPORE
Dr. Jing Jih CHIN,
President
Tel. (65) 6223 1264
Fax. (65) 6224 7827
E-mail. sma@sma.org.sg
Website: www.sma.org.sg
Slovak Medical Association
Cukrova 3, 813 22
Bratislava 1
SLOVAK REPUBLIC
Prof. Peter KRISTÚFEK,
President
Tel. (421) 5292 2020
Fax. (421) 5263 5611
E-mail: secretarysma@ba.telecom.sk
Website: www.sls.sk
Slovenian Medical Association
Komenskega 4,
61001 Ljubljana
SLOVENIA
Prof. Dr. Pavel POREDOS,
President
Tel. (386-61) 323 469
Fax: (386-61) 301 955
E-mail: matija.cevc@trnovo.kclj.si
Somali Medical Association
KPP, Wadnaha Street, Hodan
District
Mogadishu
SOMALIA
Prof. Osman Adan ABDULLE,
President
Tel: +615-777615/+699-999222
E-mail: drmumin@hotmail.com
The South African Medical
Association
P.O. Box 74789,
Lynnwood Rydge
0040 Pretoria
SOUTH AFRICA
Prof. Zephne VAN DER SPUY,
President
Tel: (27-12) 481 2037
Fax: (27-12) 481 2100
E-mail: online@samedical.org
Website: www.samedical.org
Consejo General de Colegios
Médicos de España
Plaza de las Cortes 11 4a,
28014 Madrid
SPAIN
Dr. Juan José RODRIGUEZ-
SENDIN, President
Tel: (34-91) 431 77 80
Fax: (34-91) 431 96 20
E-mail: internacional@cgcom.es
Website: www.cgcom.es
Sri Lanka Medical Association
Wijerama House, 6 Wijerama
Mawatha
Colombo 00700
SRI LANKA
Dr. Palitha Abeykoon,
President
Tel: +94-112-693 324
Fax: +94-112-698 802
E-mail: slma@eureka.lk
Website: www.slmaonline.info
Sudan Doctors Union
Post box : 1001 Khartoum
11111 Khartoum
SUDAN
Prof. Abdalzaeem M. KABALLO,
President
Tel: +(249-83)777617
Fax: +(249-83)778322
E-mail: azimkaballo@yahoo.com
Swedish Medical Association
(Villagatan 5)
P.O. Box 5610,
SE – 114 86 Stockholm
SWEDEN
Dr. Marie WEDIN,
President
Tel: (46-8) 790 35 01
Fax: (46-8) 10 31 44
E-mail: info@slf.se
Website: www.slf.se
Fédération des Médecins Suisses
Elfenstrasse 18,
C.P. 170, 3000 Berne 15
SWITZERLAND
Dr. Juerg SCHLUP,
President
Tel. (41-31) 359 11 11
Fax. (41-31) 359 11 12
E-mail: saqm@fmh.ch
Website: www.fmh.ch
Taiwan Medical Association
9F, No 29 Sec.1,
An-Ho Road,
10688 Taipei
TAIWAN
Dr. Ching-Chuan SU,
President
Tel: (886-2) 2752-7286
Fax: (886-2) 2771-8392
E-mail: intl@tma.tw
Website: www.tma.tw/EN_tma
Medical Association of Tanzania
P.O. Box 701,
255 Dar es Salam
TANZANIA
Primus Felician Saidia,
President
E-mail: kajuna2010@gmail.com
Website: www.mat-tz.org
Medical Association of Thailand
2 Soi Soonvijai, New Petchburi
Road, Huaykwang Dist.,
10320 Bangkok
THAILAND
Dr. Wonchat SUBHACHATURAS,
President
Tel: (66-2) 314 4333/318-8170
Fax: (66-2) 314 6305
E-mail: math@loxinfo.co.th
Website: www.mat.or.th
Trinidad and Tobago Medical
Association
The Medical House, #1 Sixth
Avenue,
Orchard Gardens, Chaguanas
TRINIDAD AND TOBAGO
Dr. Rohit DASS,
President
Tel: (868) 671-5160
Fax: (868) 671-7378
E-mail: medassocS@tntmedical.com
Website: www.tntmedical.com
Conseil National de l’Ordre des
Médecins de Tunisie,
16, rue de Touraine, 1002 Tunis
TUNISIA
Dr. Mohamed Néjib
CHAABOUNI,
President
Tel: (216-71) 792 736/799 041
Fax: (216-71) 788 729
E-mail: cnom@planet.tn
Website: www.ordre-medecins.org.tn
Turkish Medical Association
Chi GMK Boulevard. Danis
Tunaligil Sok. No: 2/17 to 23
Maltepe, Ankara
TURKEY
Ahmet Özdemir Aktan,
Chairman
Tel: (90-312) 231 31 79
Fax: (90-312) 231 19 52
E-mail: Ttb@ttb.org.tr
Website: www.ttb.org.tr
Uganda Medical Association
Plot 8, 41-43 circular rd.
P.O. Box 29874, Kampala
UGANDA
Dr. Margaret MUNGHERERA,
President
Tel. +256 772 434 652
Fax. (256) 41 345 597
E-mail:
mmungherera@yahoo.co.uk
Website: www.uma.co.ug
Ukrainian Medical Association
7 Eva Totstoho Street,
PO Box 13,
01601 Kyiv
UKRAINE
Dr. Oleg MUSIJ, President (2013)
Tel: (380) 50 355 24 25
Fax: (380) 44 501 23 66
E-mail: sfult@ukr.net
British Medical Association
BMA House,
Tavistock Square,
WC1H 9JP London
UNITED KINGDOM
Prof. Vivienne NATHANSON,
Director of Professional Activities
Tel: (44-207) 387-4499
Fax: (44-207) 383-6400
E-mail: vnathanson@bma.org.uk
Website: www.bma.org.uk
American Medical Association
515 North State Street,
60654 Chicago, Illinois
UNITED STATES
Dr. Ardis Dee HOVEN, President
Tel: (1-312) 464 5291/464 5040
Fax: (1-312) 464 2450
E-mail:
ellen.waterman@ama-assn.org
Website: www.ama-assn.org
Sindicato Médico del Uruguay
Bulevar Artigas 1565/1569,
CP 11200 Montevideo
URUGUAY
Dr.TROSTCHANSKY
VASCONCELLOS, Julio, President
Tel: (598-2) 401 47 01
Fax: (598-2) 409 16 03
E-mail: secretaria@smu.org.uy
Website: www.smu.org.uy
Medical Association of Uzbekistan
Str. Parkenentskay 51,
Tashkent City 100007
UZBEKISTAN
Prof. Abdulla
KHUDAYBERGENOV, President
E-mail: info@avuz.uz
Website: www.avuz.uz
Associazione Medica del Vaticano
Stato della Citta del Vaticano,
00120 Città del Vaticano
VATICAN STATE
Prof. Renato BUZZONETTI,
President
Tel: (39-06) 69879300
Fax: (39-06) 69883328
E-mail: servizi.sanitari@scv.va
Federacion MedicaVenezolana
Av. Orinoco con Avenida Perija,
Urbanizacion Las Mercedes,
1060 CP Caracas
VENEZUELA, RB
Dr.Douglas Leon NATERA,President
E-mail: info@saludfmv.org
Website:
www.federacionmedicavenezolana.org
Vietnam Medical Association
68A Ba Trieu-Street, Hoau Kiem
District, Hanoi
VIETNAM
Dr. Pham SONG, President
Tel: (84) 4 943 9323/943 1866
Fax: (84) 4 943 9323
E-mail: vgamp@hn.vnn.vn
Zimbabwe Medical Association
P.O. Box 3671, Harare
ZIMBABWE
Dr. Billy RIGAWA, President
Tel. (263-4) 791553
Fax. (263-4) 791561
E-mail: zima@zol.co.zw
Website: www.zima.org.zw
IV
Dr. Musij, an anaesthetist and President
of the Ukrainian Medical Association, has
represented his country at the WMA in re-
cent years.
Commenting on his appointment,
Dr. Musij said: „The Ministry of Health of
Ukraine faces many challenges that urgently
need solving.The country has a poor economy
and poor health care and to tackle these the
Ministry has to take a number of organiza-
tional measures to work efficiently. Its main
goal is to preserve and ensure the health of
the Ukrainian nation. Despite the difficulties
we face, health care reform must not stop”.
Dr. Otmar Kloiber, Secretary General of
the WMA, said: „We offer our friend and
colleague Dr. Musij our best wishes and full
support in the difficult tasks he faces. These
have been difficult months so far and it will
not be easy in the near future.”
Dr. Musij, who has studied in Poland, the
USA, Finland, Austria and Germany, has
been chairman of the Kiev Medical Asso-
ciation and Vice-President of the World
Federation of Ukrainian medical societies.
He is a board member of the international
medical organization – Southeast Euro-
pean Medical Forum (Southeast Euro-
pean Medical Forum, SEEMF, Bulgaria)
and has been involved in drafting many of
his country’s laws on health, professional
self-government and self-regulation of
markets.
Contents
The World Medical Association has offered its support to the newly
appointed Minister of Health in Ukraine, Dr. Oleg Musij 
Oleg Musij
New Year Message from the President, World Medical
Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Reconstruction of the Radiation Emergency Medical
System from the Acute to the Sub-acute Phases
After the Fukushima Nuclear Power Plant Crisis . . . . . . . 2
History of AMA Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Medical Profession in Latvia Today . . . . . . . . . . . . . . . . . . 11
On the Road to Tobacco-Free Finland . . . . . . . . . . . . . . . . 23
The Hong Kong Medical Association . . . . . . . . . . . . . . . . 27
New Chamber of Physicians Established in Kosovo . . . . . 29
Medical Chamber of Montenegro . . . . . . . . . . . . . . . . . . . 30
Irish Medical Organisation Celebrates 30 years . . . . . . . . . 31
Ethics at the BMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Excess Weight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . 34
WMA Directory of Constituent Members . . . . . . . . . . . . 37