wmj201503

COUNTRY
vol. 61
MedicalWorld
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 3, October 2015
Contents
Doctor in the World and Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Interview with Dr. Xavier Deau, President of the World Medical Association . . . . . . . . . . . . 82
Interview with Dr. Zsuzsanna Jakab, WHO Regional Director for Europe . . . . . . . . . . . . . . . 83
Interview with Dr. Jacques de Haller, Vice President, President Elect
2016–2018 (Switzerland) of CPME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
From Zoonosis to Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Health and Asylum Seekers in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
International Committee of the Red Cross activities for refugees/displaced persons
in the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Subjectivity and Narratives in Primary Care: A Person Centered Issue. . . . . . . . . . . . . . . . . . . 106
The Integration of Mental Health and Primary Care: A Person-centered Approach. . . . . . . . 109
The Road to Paris: What is at Stake for Health in COP21 Negotiations? . . . . . . . . . . . . . . . . . 114
More Good Days: Person-Centered Care at the End of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
BACK TO CONTENTS
81
Editorial
In the modern world, pharmaceutical business is an honorary sec-
ond runner-up among the most profiteering businesses, right after
trafficking in humans and in drugs. With the recent shipping of
refugees to Europe, the winner and the first runner-up have merged
into one.The pharmaceutical business mostly is a quite legal, trans-
parent and straight one,except for counterfeit medicines which take
up 10–15% of the market. For a medical doctor, global information
available in 2015 is interesting due to the following patterns:
(I) clinical research is becoming increasingly costly, new drugs are
getting discovered less,generics are taking up higher proportion and
even prevail in the market. Countries and regions happen to over-
look the letter and spirit of the Helsinki Declaration, particularly in
respect of the work of the Ethics Committees;
(II) the pharmaceutical industry is losing interest in small-size mar-
kets, production costs are increasing due to quality control require-
ments, whereas compensation systems in the countries fail to evolve
together with the changing market. The pharmaceutical business is
facing new challenges, which are shortages of production capacities
and limited availability of raw materials;
(III) the accessibility of medicines and counterfeit drugs is becom-
ing a global problem as a result of internet pharmacies chains, re-
export with the purpose of price arbitrage and parallel import;
(IV) refugee crisis in Europe (also the flows of refugees in Asia,
Australia,the Republic of South Africa and some countries in Latin
America) involve uncertainties about the immigrants’state of health,
infectious and parasitic diseases, vaccination against dangerous dis-
eases, e.g. poliomyelitis.With some countries failing financially (e.g.
Greece is unable to settle its payments for the delivered medicines
for quite a while), selected segments of the drugs market start pan-
icking, and a tendency emerges to stock up some medicines, instead
of placing them on the market;
(V) there is not enough research as to the dosages for senior patients
and children: it is still believed that patients, though dissimilar as to
age, gender or physical capacities, should get prescribed medicines
in equal dosages;
(VI) most of clinical trials are shifted to developing countries,which
leads to a mistrust in the trial results in developed countries;
(VII) resistance to drugs is increasing, and not exclusively to anti-
biotics. The body cells tend to develop biochemical dependency on
medicines, and dosages need to be raised;
(VIII) polypragmasia as a medical problem in industrial and devel-
oped economies.Both in Europe and America,the population in the
age group beyond 50 are taking more than six different drugs daily,
plus a number of food supplements and over-the-counter medicines.
For the time being, no proper research has been done, and there is
a lack of understanding how much food supplements and other
chemically active substances are being consumed along with medi-
cines (e.g. illegal psychoactive substances, sports drinks and powders
etc.). Advertising promotes unreasonable consumption of medicines
and food supplements, especially among senior citizens;
(IX) biomedicines – medicines of the future – and their biological
equals appear in the market without adequate knowledge and un-
derstanding on the part of doctors and pharmacists,they are scarcely
used due to the high price;
(X) medicines launched to the market at an early stage and having
heightened vigilance, which have been subject to less trials and who
may have more side effects, especially when taken with other medi-
cines. Individualised medicines are being released to the market as
well;
(XI) non-cooperating patients. 25–40% of patients are non-cooper-
ating when receiving treatment: they are neither willing nor moti-
vated to get well again.10–20% of population prefer to be treated by
charlatans, healers and witchdoctors, or by psychologists or psycho-
therapists without any medical education etc.. Alongside with the
drugs prescribed by the doctor, nature therapy, Ayurveda medicines
and other chemically active substances are used;
(XII) medicines are continuously being discarded in open environ-
ment and may end up into food; in most cases the non-used medi-
cines still do not get destroyed.
This list could be compiled in a different order and complemented
with other items. In global medicine, the influence of the pharma-
ceutical industry is increasing, people are ageing, funds from gov-
ernments or insurance are not sufficient to pay for medicines.
The World Medical Association has to analyse the developments in
the medicines market all over again.
Dr. Pēteris Apinis
President of the Latvian Medical Association
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
Phone +371 67 220 661
peteris@arstubiedriba.lv, editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design and
cover design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
The Latvian Medical Association, “Latvijas Ārstu biedrība”,
Skolas street 3, Riga, Latvia.
ISSN: 2256-0580
Dr. Xavier DEAU
WMA President
Conseil National de l’Ordre des
Médecins (CNOM)
180, Blvd. Haussmann
75389 Paris Cedex 08
France
Dr. Donchun SHIN
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
46-gil Ichon-ro
Yongsan-gu, Seoul 140-721
Korea
Prof. Dr. Frank Ulrich
MONTGOMERY
WMA Vice-Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Margaret MUNGHERERA
WMA Immediate Past-President
Uganda Medical Association
Plot 8, 41-43 circular rd., P.O.
Box 29874
Kampala
Uganda
Dr. Joseph HEYMAN
WMA Chairperson
of the Associate Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Masami ISHII
WMA Treasurer
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Sir Michael MARMOT
WMA President-Elect
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Heikki PÄLVE
WMA Chairperson of the Medical
Ethics Committee
Finnish Medical Association
P.O. Box 49
00501 Helsinki
Finland
Dr. Miguel Roberto JORGE
WMA Chairperson of the Socio-
Medical Affairs Committee
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ardis D. HOVEN
WMA Chairperson of Council
American Medical Association
AMA Plaza, 330 N. Wabash,
Suite 39300
60611-5885 Chikago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of The World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
Doctor in the World and Medicines
BACK TO CONTENTS
82 83
WMA News Public Health Care
Q.Global warming and emission gases are
among the world’s most essential public
health problems. What initiatives can we
expect from the WMA for the forthcom-
ing Paris conference as to fighting global
warming?
The WMA will be present in Paris at the
COP21, channelling the serious con-
cerns of physicians regarding the impact
of climate change on health. The health of
the planet is our health. This is the mes-
sage that I would like to bring forward.
The WMA has joined the Campaign “Our
Climate, Our Health”. It is a new campaign
created to mobilise the health profession in
the lead up to the 2015 climate change ne-
gotiations in Paris. The Campaign is led by
the World Health Organization in collabo-
ration with the Global Climate and Health
Alliance. It aims to reach out to all parts of
the health sector, communicating the links
between health and climate change, de-
manding a stronger international deal, and
building support around a common decla-
ration  – to be presented to negotiators in
Paris this December. We will participate in
the Climate and Health Summit which is
scheduled to take place on the 5th
of De-
cember in Paris in the framework of this
Campaign.
Q. Clean air, clean water and harmless
food are the most important health pre-
conditions for global population. Right
now, when the global oceans and seas are
being polluted with plastics and chemi-
cal products, it has an impact on each
single inhabitant on the Earth. We can
even call the polluting of the world with
chemicals a chemical war. What could
the WMA do in order to reduce the glob-
al pollution with chemicals? Shouldn’t
the WMA take a more radical position
against the use of heavy metals (mercury,
bismuth), against pesticides, herbicides,
mineral substances and other substances
which inhibit the development of hor-
monal system?
The WMA’s policies in the area of environ-
ment have been developing over the last
years with the expertise of its members. We
have a clear position on climate change,
mercury products, chemicals, and more
recently on air pollution. We have also set
up the environment caucus to promote ex-
change of good practices and experiences
between the members. We could certainly
work further on our policies. But most im-
portant, the challenge now is to make sure
that our voice is finally heard, that strong
commitments and actions are finally taken
by decision-makers. This is a matter of ur-
gency. Our planet is ill and we are all ac-
countable. Mobilisation of all is what is
needed today.
Q. Shouldn’t the WMA develop its own
strategy for fighting global warming
and use a variety of instruments, such as
strong criticism of global polluters,or cre-
ate a WMA award in recognition of the
most successful pollution treatment and
ecological projects?
The WMA has been increasingly active in
the area of climate change nationally and
globally through various means: the UN
process, the promotion of regular plat-
forms for discussion between NMAs and
also through partnerships with the WHO
and non-governmental organisations,
active in the area of health and environ-
ment. I do not believe that another award
will bring significant changes. Today we
need concrete actions nationally and lo-
cally, we need to raise awareness amongst
the health professionals, the public, the
decision-makers. I  nourish great hopes
that the young generation will continue
carrying that torch. As a matter of fact, the
Junior Doctors Network is extremely ac-
tive in putting health at the centre of the
climate negotiations, and I am proud that
the WMA embraces this new generation
of physicians.
Interview with Dr. Xavier Deau, President of the World Medical
Association
By Dr. Peteris Apinis. September, 2015
Xavier Deau
“Better Health for Europe: More Equitable
and Sustainable – That is What We Work for”
Q. The WHO Regional Office is a Euro-
pean leader in public health area. Could
you please update us on the progresses,
concerns and main goals of the Region?
During the past few years, the WHO Eu-
ropean Region made good progress in many
areas, but we must do more and we must
do better.
On key health indicators, such as life
expectancy, Europeans are living longer
and the differences between countries in
health outcomes are shrinking: a clear
sign that inequalities are declining and
Health 2020 – the WHO European pol-
icy framework developed and adopted by
all our 53 Member States – works. How-
ever, the gap between the countries with
the highest and lowest life expectancy is
still 11 years.
The Region is on track towards reduc-
ing premature mortality due to decline
in cardio-vascular diseases (CVDs), and
Europeans are reducing their health risk
behaviours. But people in Europe still
smoke and drink more than anywhere
else in the world, and are among the most
obese.
We are making progress in improving
women’s health, but wide inequities be-
tween and within countries remain.The use
of modern, effective methods of contracep-
tion is alarmingly low in many countries.
Some countries have the highest abortion
rates in the world. Effective perinatal care
resulted in the decrease in the major killer
of mothers – the severe obstetrical bleed-
ing. Now is the time to focus on pre-exist-
ing medical conditions – such as diabetes,
obesity, CVD and mental diseases – that
are exacerbated by pregnancy. More needs
to be done on sexual and reproductive
health and rights.
Transforming health services to match the
needs of the 21st
century is the strategic pri-
ority in our Region. Coordinated, integrat-
ed health-service delivery towards people-
centred care is the way forward.The Region
is scaling up efforts on strengthening health
systems and public health capacity in order
to improve health outcomes in an equitable
manner, ensuring financial protection, re-
sponsiveness and efficiency.
We are addressing health-systems barriers
for specific diseases and conditions, includ-
ing communicable diseases and NCDs,
which are then translated into policy deci-
sions and actions. We are now broadening
the focus to include environmentally sus-
tainable health systems.
An extensive area of work in the Region
relates to tackling public health emergen-
cies and crisis situations. Our aim is to en-
sure that our Member States are adequately
prepared to effectively detect and respond,
whenever and wherever an emergency with
health consequences strikes. The recent Eb-
ola outbreak in West Africa demonstrated
that the international community is not suf-
ficiently prepared to manage major health
hazards. This is a defining moment for
change.We are fully committed to taking all
necessary action.This is a global objective.In
the Regional Office, we take an integrated,
generic, all-hazards and multisectoral ap-
proach to preparedness for both humanitar-
ian and public health emergencies.
Let me stress: real improvements in health,
including the areas I just outlined, can be
achieved if we work across government. All
sectors, especially with those responsible for
social and fiscal policies, need to work in
partnership for better health for all.
Intersectoral action for health requires politi-
cal commitment.It should focus on key public
health priorities and upstream interventions
by addressing the determinants of health and
health equity,and strive for maximum impact
by creating win–win partnerships.
Development is impossible without better
health. Health is a precondition for alleviat-
ing poverty, and an indicator and outcome
of progress towards a sustainable society.
More decision-makers are making coherent
and interconnected government policies, with
a strong intersectoral component, and using
Health 2020 as the way forward. From 2010
to 2013, the proportion of countries with
national health policies aligned with Health
2020 almost doubled: from 38% to 70%. And
this is a great achievement so far.This progress
demonstrates what we can do if we are com-
mitted and work together, but it also shows
that we have many challenges ahead,confirm-
ing that the key strategic directions of Health
2020 remain more relevant than ever before.
Interview with Dr. Zsuzsanna Jakab,
WHO Regional Director for Europe
By Dr. Peteris Apinis. September, 2015
Zsuzsanna Jakab
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84 85
Public Health CarePublic Health Care
Only the governments that put health and
well-being high on their social,economic and
development agenda will be able to overcome
these challenges. Health is a political choice.
In essence, Health 2020 supports making the
right political choices for health.Our key role
is to protect health as a universal value and
to promote it as a social and political goal for
government and society as a whole.
The economic case for investment in health
is strong. Investing in health generates cost-
effective health outcomes and economic,
social and environmental benefits. The
health sector’s call on government to invest
in health will make this change happen. We
need to give this message loudly.
For example, current evidence suggests
that investment in reproductive, maternal
and child health has a potential return of
more than US$  20 for every dollar spent.
The argument for investing in the best-buy
interventions is equally clear for addressing
noncommunicable diseases (NCDs).
Current investments in health and public
health are not sufficient. We need to invest
more. It is alarming to see that, between 2007
and 2011, the health share of public spending
fell in 24 countries in Europe.By tapping into
new sources,improving efficiencies and giving
high priority to health, all countries can find
ways to raise sufficient funds for health.
Also, many countries are applying the life-
course approach in developing their na-
tional policies or improving collaboration
between sectors, which is a key strategic
direction of Health 2020.
On 25 September, world leaders gathered
at the United Nations summit to adopt the
Agenda for Sustainable Development, to
end poverty by 2030. The Agenda has uni-
versal goals that will apply to every nation –
not just to developing countries. Among
the 17 Sustainable Development Goals, the
one for health is central. It aims to “ensure
healthy lives and promote well-being for all
at all ages”. There is increasing acceptance
that the new health goal must also aim to
achieve universal health coverage in every
community, in every country of the world.
The formulation of the health goal is fully
aligned with Health 2020.
Focusing solely on the health goal would be
a missed opportunity. All the Sustainable
Development Goals will influence health,
because they all address the determinants
of health.The 2030 Agenda will link differ-
ent dimensions of development – including
health – to the environment, to prosperity
and to all actions and policies that people
need.
Now we have a historic political respon-
sibility to pursue the integration of health
and well-being into each and every goal.We
have the opportunity to put into practice
the whole-of-government and whole-of-
society approaches to which we subscribed
through Health 2020.
Better health for Europe: more equitable
and sustainable – that is what we work for.
Q. At present, there is an opposition to
vaccination in Latvia. The situation is
pretty similar in other European coun-
tries. What can the WHO Regional Of-
fice do in order to promote immunization?
Vaccination is one of the most cost-effective
health interventions available, saving mil-
lions of people from illness, disability and
death each year. Vaccines protect against
more than 20 serious diseases.
Although the WHO European Region
has made good progress in protecting more
people, vaccine-preventable diseases still
challenge Europe’s public health and con-
tinue to burden our Member States. The
loss of a child from diphtheria, the deaths
of children from measles complications,
alongside thousands of cases of measles,
represent solemn reminders of unfinished
business. Accepting the status quo is not an
option.
Our goal is to reach and maintain high levels
of immunization, particularly in vulnerable
groups, at the appropriate ages and recom-
mended doses. To achieve this goal, WHO/
Europe works with Member States, interna-
tional organizations and bilateral agencies to
help countries strengthen their programmes
for the control of infectious diseases. Cur-
rent major initiatives include: supporting
communication capacity of national immu-
nization programmes; introducing new and
underused vaccines; eliminating measles and
rubella and maintaining the poliomyelitis-
free status of the European Region.
In adopting the European Vaccine Action
Plan, our Member States committed them-
selves to eliminating measles and rubella by
2015.
While many countries are on track to do
this by the end of this year, the regional
goal continues to elude us,owing to the lack
of steadfast political commitment in some
countries. We need public health leaders to
stand by your commitments to eliminate
measles and rubella.
There is no stronger reminder of the need
for vigilance than the return of polio.The re-
port of two cases in Ukraine, in August this
year, is alarming, particularly given the large
pockets of susceptible populations who could
be exposed to this crippling, deadly disease.
It is imperative that Ukraine and all Euro-
pean countries continue to mitigate the risks
posed by polio by maintaining high immuni-
zation coverage and surveillance.
In the 21st
century, every child has the right
to live free from vaccine-preventable dis-
eases. Strengthening immunization is vital.
WHO/Europe leads and coordinates Euro-
pean Immunization Week (EIW). Since its
establishment 10 years ago, EIW has served
as a flexible platform for Member States in
the European Region to mobilize support for
immunization. From its humble beginning
in 2005 with eight pilot countries, EIW ex-
panded each year to become a truly Region-
wide campaign encompassing all 53 Member
States. Together with Immunization Week in
the Americas,EIW was a forerunner of World
Immunization Week, established in 2012.
Regional and national partners,including the
United Nations Children’s Fund (UNICEF)
and the European Centre for Disease Pre-
vention and Control (ECDC), support im-
plementation. EIW also benefits from high-
level support at the national level, including
ministers, ambassadors, first ladies and other
distinguished supporters. At the regional lev-
el, the initiative has the support of Her Royal
Highness Crown Princess of Denmark, who
is WHO/Europe’s patron. In April this year,
we celebrated the tenth anniversary of the
EIW initiative throughout the Region.
There is still a lot to be done in this area – our
vision is a European Region free of vaccine-
preventable diseases. We need Latvia’s full
support and commitment in reaching this goal.
Q. In the past two years, Latvia has made
good progress in adopting a range of to-
bacco control regulatory legal acts. In
Latvia smoking is absolutely prohibited
in public facilities, premises of central and
local government institutions, work plac-
es, and elsewhere where it can harm other
people’s health. How would you evaluate
our achievement and how could we attain
this in entire Europe?
You are right: Latvia is doing well in tobac-
co control. The country ratified the WHO
FCTC in 2005 and took a number of legally
binding obligations in tobacco control,from
smoke-free public places, high taxes on to-
bacco products, banning tobacco advertis-
ing to eliminating illicit trade in tobacco
products. Latvia is among only 33 countries
in the world that have sufficiently high tax
rates on tobacco, which are among the most
effective tools in reducing consumption.
However, a lot more needs to be done. Al-
though the smoking among the adult popula-
tion has gone down in recent years, 30% of
Latvian adults smoke and this is slightly high-
er than in the WHO European Region in av-
erage (28%). Over 17% of female and 45% of
male adult population smokes in Latvia­.
More needs to be done in stopping young
people to become addicted to tobacco and
start the use of tobacco at an early age. Data
on the current situation is grim: 70% of the
boys in Latvia initiated smoking at the age
of 15 years or younger (in comparison, in
UK and Ireland, it is around 30%); up to
72% of the girls in Latvia started smoking at
the age of 15 years or younger (in compari-
son, in UK and Ireland, it is around 40%).
The Region as a whole is striving towards
making tobacco a thing of the past. Last
week, WHO Regional Committee for Eu-
rope – Region’s governing body – adopted a
roadmap for tobacco control, setting an am-
bitious goal of full implementation of the
FCTC and the voluntary global target to
reduce tobacco use by 30% by 2025. We are
grateful to Latvia for its support in adopting
this roadmap and count on its support in its
implementation in the coming years.
Tobacco smoking among adults continues
to decline in the Region. Nevertheless, we
remain the region with the highest overall
rate of adult smoking.
In the year 2000, 250 million adult people
in Europe smoked,in 2015,200 million and
it is projected that in 10 years’time, in 2025,
180 million will continue to smoke. As of
2015, Europe has the highest number of its
people smoking, 28%, in the world. Glob-
ally, being born male has been the highest
predictor of smoking. However, European
women are smoking alarmingly more than
any other women around the globe.
19% of European adult women smoke and
this number will continue to rise in the
coming years while smoking among men is
stabilizing or going down.As a consequence
of women smoking like men in some coun-
tries, the breast cancer is not any more the
biggest killer but the lung cancer is. The
change in the rates of incidence and mor-
tality for lung cancer can be attributed to
smoking prevalence amongst females.
As a result of high levels of smoking, 16% of
Europeans die as a result of a tobacco related
disease while the global average is lower,12%.
Against this background, it is clear that Eu-
rope could and should do more to save health
and life of Europeans.We know what works;
we have an international health treaty – the
WHO Framework Convention on Tobacco
Control (FCTC), which is celebrating a de-
cade of action.At present,50 countries out of
53 in the WHO European Region have tak-
en the political commitment by ratifying this
Treaty but the actual implementation should
be scaled up. Since last year, four additional
countries in our Region have become parties
to the Protocol to Eliminate Illicit Trade in
Tobacco Products. This is a great achieve-
ment and we call on others to join.
Several countries in Europe are already
moving towards becoming tobacco-free:
such as Ireland by 2025, Finland by 2040,
UK Scotland by 2034. Tobacco free coun-
try is defined by less than 5% of adult
population­smokes. I am proud that our
countries are taking global leadership in
plain packaging for tobacco products.
The generation growing up now cannot
comprehend that people used to smoke on
airplanes, buses, in restaurants or in offices.
The achievements of the past 20 years show
that the dream of a Europe where tobacco
control has succeeded is not unrealistic.The
gains will be huge if tobacco control suc-
ceeds, but there is hard work ahead. Gov-
ernments must fully implement the mea-
sures in the WHO Framework Convention
on Tobacco Control and work toward the
implementation of a common goal: a Eu-
rope where tobacco is not a social norm.
BACK TO CONTENTS
86 87
GERMANY Infection DiseasesPublic Health Care
Q. Right now, there is quite an opposi-
tion to vaccination in Latvia. The situa-
tion is pretty similar in other European
countries. There are excellent lecturers,
nice-looking books and YouTube files
discouraging people from vaccination
and explaining about the dangers of vac-
cination. What could the European phy-
sician do in order to present the informa-
tion on the need of immunization in an
equally attractive manner from the visual
and informative aspect?
You are addressing a real problem in-
deed. In our European countries, many
seem to have forgotten how life and
death was before vaccination and, disre-
garding the immense progress medicine
has brought to all of us, and particularly
to our children, they show something
like a “spoiled child” attitude towards
vaccination.
I don’t think that this is only a question of
nice booklets and lively internet pages  –
the WHO for instance has produced an
abundance of both, and although it does
offer an important support, it is obviously
not enough of what is needed. I think that
the question relates much more to culture
and societal trends: as a reaction to the dif-
ficulties of our industrial world and to the
threats on health and the environment,
people see nature, “natural” medicines and
the rejection of “chemistry” as the way to a
“safer health”.
So what we have to do, as Doctors, and
that’s something I see as an ethical obliga-
tion for Doctors, is to convince, convince
and convince, without losing any opportu-
nity to discuss this with the patients, with
all the parents we see at our consultation.
We don’t have the right to give up!
Q.Maybe it is the time to have a single im-
munization calendar in Europe?This issue
is becoming more and more topical due to
the increasing labour mobility in Europe.
Children are moving along with their par-
ents. For example, a child is born in Lat-
via, three months later it is taken to his or
her father to Ireland, and a year later the
parents come to Brussels to work there.
Each single country in Europe has its own
vaccination calendar, which is the reason
why many children do not get adequate
vaccination and immunization. To start
with, perhaps we could declare as manda-
tory such vaccinations as against diphthe-
ria, poliomyelitis, tetanus and some more
and these to be administered according to
strictly defined time schedule all across
Europe, whereas the rest (rotavirus, Ger-
man measles, pneumococci) could be left
at the national level?
I understand the idea behind your question
very well, but I am not sure I completely
share your point of view.
We live in a time when the European Union
is a concept questioned by quite a few peo-
ple in all our countries, and it’s obviously
not a good time to go for mandatory uni-
formity; I’d suggest to concentrate on the
results – request a good immunisation cov-
erage of the children at the end of school,
for instance, and leave the “how”, the deci-
sions on the means to achieve this goal, in
the hands of the Member States.
Q. Isn’t it high time that we have a man-
datory requirement to vaccinate all immi-
grants from third countries, because their
earlier vaccination is unreliable? We are
aware that many countries in Africa are
short of vaccines, and people often have
fake vaccination documents.
I definitely think that it is an absolute ne-
cessity, and in fact a question of ethics and
dignity for all our European countries, to
offer proper healthcare to the refugees and
immigrants now arriving in Europe.
I don’t think though that we should make
any treatment mandatory in medicine, ex-
cept in very critical situations of health
emergencies, like epidemics for instance. In
all other circumstances, medical treatment
(and vaccination is one!) should be done
with the consent of the patient: patients,
irrespective of their situation at the given
moment, are partners of the health profes-
sionals for their own health!
Q. In Latvia, we conducted a survey
among medical doctors about vaccination.
The question we asked was: do you im-
munize and are you active in prescribing
immunization against the flu for infants,
pregnant women, patients with immuno-
deficiency, and the answer was “yes”. An-
Interview with Dr. Jacques de Haller,
Vice President, President Elect 2016–2018
(Switzerland) of CPME
By Dr. Peteris Apinis. September, 2015
Jacques de Haller
other question was: have you immunized
your own grandchildren, your daughter
or daughter-in-law who is expecting, in
most cases the answer was “no”. Still an-
other question to doctors was: have you
immunized yourself against the flu, and
the answers were evasive  – “a couple of
times”, “once”. The trust in vaccination
programmes has decreased in the doctors’
community. What can be done to recover
the prestige of vaccination among medical
professionals?
This is a terribly difficult question! We
have the same situation in Switzerland,
and not only for immunization: some sur-
gical procedures show the same pattern, for
instance.
I find it very positive that Doctors are in close
contact with society,share its concerns,and are
not isolated in an ivory tower, but at the same
time Doctors should definitely remain in close
contact with the academic world (permanent
medical education is the point, here!), and be
more willing and able to believe in what they
learned. “Do what I say and not what I do” is
not an option for us,Doctors!
The human-animal interface has devel-
oped from ancient times till today into an
arena with a complex pattern of interac-
tions, strongly affected by the constantly
evolving impact that humans have on
their local and global environments. Con-
sequently, many human pathogens have
evolved in the Neolithic revolution by
crossing the animal-human species barrier
and subsequent adaptation to the newly
invaded species. These include mumps
virus (of the Paramyxoviridae family),
smallpox virus, Corynebacterium diph-
theriae, and Bordetella pertussis  [1]. The
respective animal hosts of origin of these
pathogens, being domesticated, commen-
sal, or wild, have largely remained elusive.
While the phylogenetically closest spe-
cies of measles virus and smallpox virus
are rinderpest virus (infecting cattle), and
camelpox or gerbilpox viruses, respec-
tively, it is unknown whether these animal
host species were sources or recipients of
these human pathogens. A recent pan-
demic infectious disease outbreak fuelled
by a complex mix of predisposing factors
in our modern society was caused by the
emergence of HIV/AIDS in Africa some
30 years ago. Today, the virus claims more
than one million lives each year, with more
than 20 million deadly victims in total
since its emergence.
Fortunately, the ever-increasing range of
infectious diseases is largely paralleled by
the implementation of an almost equally
complex mix of intervention strategies.
The latter includes the coordinated and
timely use of the achievements of medi-
cal, molecular, mathematical, social, and
other sciences. In the past decade, this has
resulted in the timely identification of the
SARS coronavirus, allowing concerted
public health efforts to successfully control
the emerging epidemic before the newly
introduced pathogen could cause a full
blown pandemic. Although this will prove
much more difficult for more transmissible
pathogens, as was the case for the latest
influenza pandemic of 2009, the SARS
episode is unique in our recorded history.
Among other most successful achieve-
ments of modern medicine is the eradica-
tion of two long-time plagues: smallpox
and rinderpest that have devastated human
and animal populations for many centu-
ries. In both cases, a combination of well
coordinated mass vaccination campaigns,
intensive surveillance, and case contain-
ment, successfully brought these pathogens
to extinction, with last identified cases in
1977 and 2001, respectively [2]. Stimulated
by these successes, concerted public health
efforts for the eradication of measles and
polio are currently ongoing, which in prin-
ciple should be considered feasible in the
near future, however, with major obstacles
rather being of political nature than related
to technical feasibility.
Although these successful eradications
may represent victories over infectious
diseases, the dynamic nature of infectious
pathogens, in particular due to their epi-
demiological and evolutionary flexibility
and adaptability, call for caution. With the
eradication of pathogens and the waning
of immunity that had characterized ani-
mal and human populations for millennia,
we are facing new challenges by creating
niches for colonization by related patho-
gens lurking in the animal world. Mon-
keypox virus may be considered a loom-
ing threat at the global human-animal
interface, which one day could fully adapt
to more efficient human-to-human trans-
mission and fill the niche left empty by the
eradicated smallpox virus. Similar threats
to animals and humans may come from
From Zoonosis to Pandemic
A.D.M.E. Osterhaus
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88 89
Refugees and Health CareInfection Diseases GERMANY
­animal morbilliviruses­after the eradica-
tion of rinderpest or the future eradication
of measles [3].
Unexpected virus threats continue to
emerge, as is painfully demonstrated by the
increasing number of human MERS coro-
navirus (MERS-CoV) infections, partly
due to increase in nosocomial transmis-
sion, but also because of ongoing transmis-
sion from dromedary camels to humans.
The most prominent mode of camel-to-
human transmission is probably through
human contacts with respiratory excreta
although transmission via milk or urine
cannot be ruled out. An important break-
through was the identification of the re-
ceptor of the virus in humans and animals,
which already proved helpful in identifying
animal species susceptible to MERS-CoV
infection and may further help in identi-
fying intervention strategies. An attractive
option would be to develop a vaccine for
dromedary camels and tackle the problem
at the source.
Our new era characterized by a real explo-
sion of novel molecular technology leads to
the discovery of an avalanche of hitherto
unknown human and animal pathogens,
some of which are candidates to fill newly
emerging niches at the modern human–
animal interface. For instance, in 2013, we
examined sick harbour seals that had de-
veloped neurological signs. The seals were
suffering from meningo-encephalitis of an
unknown cause. After thorough examina-
tion, a novel parvovirus was discovered
that resembles the human B19 parvovirus
which among other manifestations has
been associated with neurological disease
in children. The human B19 parvovirus
had also been associated with meningo-
encephalitis, but it was never demon-
strated before that the virus can indeed
enter the brain tissue. By showing that
the newly discovered seal B19-like parvo-
virus is indeed present in brain tissue and
directly linked with neurological disease,
we provide evidence that infection with
this group of viruses may cause meningo-
encephalitis in animals and most probably
also in humans F [4].
Another group of infectious agents that
continues to cross animal-human species
barriers consists of influenza A viruses.
In the framework of several US and EU
funded projects, the minimal determi-
nants of H5N1 transmission through air
were identified: only a handful of amino
acid substitutions suffice for avian H5N1
virus to become airborne in mammals,
and these are associated with three traits:
efficient binding to human type recep-
tors, increased stability of the hemag-
glutinin, and increased polymerase activ-
ity in mammalian cells. In line with the
H5N1 research, similar experiments were
conducted with avian H7N9 virus, which
emerged in spring 2013. This virus was
found to already display certain traits of
airborne H5N1. The wild type H7N9,
without any experimental modifications,
is indeed already airborne transmissible in
ferrets, though not very efficiently [5]. It
is suspected that it lacks sufficient hem-
agglutinin stability to be efficiently trans-
missible, and needs to reduce binding to
avian receptors.
In conclusion, rather than investing in
trying to influence the complex mix of
predisposing factors of emergence at the
human–animal interface, which are largely
related to human behavioural issues, in-
vestment in newly emerging technologies
and intervention strategies may provide us
with the tools to prevent or limit disasters
caused by emerging infections. This will
not only allow us to win major battles, but
also to limit the impact of the apparently
never ending war between mankind and
its relentlessly emerging microbial foes.
We should do this in a multidisciplinary
One Health approach. After all, emerg-
ing and re-emerging infectious diseases
clearly demonstrate that human, animal
and ecosystem health are inextricably
linked. It is therefore good to see that new
One Health initiatives are taken, and in
this context I would like to highlight the
newly founded One Health Platform.This
international foundation brings together
key opinion leaders of the One Health
topic and provides them with a framework
for information-sharing, cooperation and
awareness raising activities.
References
1. Wolfe ND. Origins of major human infectious
diseases; Nature May 2007; 447.
2. Normile D. Rinderpest, Deadly for Cattle, Joins
Smallpox as a Vanquished Disease; Science Oc-
tober 2010; Vol 330 22.
3. de Swart R et al. Rinderpest eradication: lessons
for measles eradication? j.coviro 2012.
4. Bodewes R et al. Novel B19-like parvovirus in
the brain of a harbor seal; PLoS One. 2013 Nov
5;8(11)
5. Richard M et al. Limited airborne transmission
of H7N9 influenza A virus between ferrets; Na-
ture. 2013 Sep 26;501(7468):560-3.
Prof. A.D.M.E. Osterhaus,
Director Research Centre for
Emerging Infections and Zoonoses
(RIZ), Hannover, Germany
E-mail: albert.osterhaus@tiho-hannover.de
Authors’ foreword
Truth is “the first casualty of war”[1]. Many
refugees come from war zones, and there is
little independent and even less empirical
research into the emerging refugee situation
in Europe. The authors strongly feel that
available data should be presented without
bias so that readers may make their own
judgment.
First and foremost, the authors would like
to applaud the countless volunteers includ-
ing health professionals providing assis-
tance to refugees across Europe and beyond.
Many are going above and beyond the call
of their professional duty to provide health-
care to refugees. The main purpose of this
article is to describe the current refugee cri-
sis. However, those providing this valuable
assistance should be recognized.
Introduction
Each and every day, many individuals leave
their home countries, where instability, re-
pression, terrorism, forced labor, poverty
and civil wars pose a threat to their lives and
their families. Current instability in parts of
the Middle East, Northern and Sub-Saha-
ran Africa is driving the biggest movement
of refugees across Europe since the Balkan
wars in the 1990s [2, 3, 4].
Under the UN 1951 Convention and Pro-
tocol Relating to the Status of Refugees,
a refugee is defined as an individual who
“…owing to a well-founded fear of being
persecuted for reasons of race, religion, na-
tionality, membership of a particular social
group or political opinion, is outside the
country of his nationality, and is unable to,
or owing to such fear, is unwilling to avail
himself of the protection of that coun-
try” [5]. Refugee and asylum seeker are two
distinct legally defined terms often used as
synonyms in public and varying between
jurisdictions [6]. This article focuses exclu-
sively on health and, for this reason, will
not explore this legal nuance; therefore, the
terms are used synonymously unless other-
wise stated.
The current crisis began in the wake of the
Arab Spring when border crossings began to
rise in 2011. In addition, refugees originat-
ing in both Northern and Sub-Saharan Af-
rica who had previously migrated to Libya
began to flee the unrest of the post-Qaddafi
era [4]. However, numbers have increased
sharply in 2015.The latest data, gathered in
September 2015, indicate a total of 473,887
men, women and children have arrived in
Europe by sea. Just under 40% were from
Syria, fleeing the country´s civil war and the
threat posed by the self-styled Islamic State
(IS). In 2014, between 25-33% of those ar-
riving by sea were from Syria [2].
Turkey has an open door policy granting
“temporary protection status” to every Syr-
ian fleeing the conflict. Currently, Turkey
hosts the largest number of refugees in the
world, with around 2 million people, while
Lebanon has the highest quota of refugees
per inhabitant [7,8].According to UN High
Commission for Refugees (UNHCR), it
is estimated that Lebanon will have more
than 1.8 million refugees and asylum seek-
ers by the end of 2015 [9]. This condition
has become a severe economic challenge for
these countries’ economies. Approximately
260,000 refugees are located in refugee
camps,while the remaining live freely in the
cities [10]. The plight of children displaced
by the Syrian conflict is particularly dire;
Malta and Italy alone have received 10,000
separated or unaccompanied children this
year [11].
Refugees and migrants typically use one of
seven routes to reach Europe [7]:
• Western African
• Black Sea
• Eastern borders
• Western Mediterranean
• Central Mediterranean
• Eastern Mediterranean
• Western Balkan
In 2015, the Central Mediterranean, East-
ern Mediterranean and Western Balkan
route are most commonly used. Land bor-
ders within the Western Balkan region were
the main entry points for refugees with the
Hungarian-Serbian border being the most
frequently crossed border in the region. Mi-
grants entering Europe through this route
include Western Balkan nationals and Syr-
ians, followed by Afghans, Iraqis and Paki-
stanis [12]. Another highly popular route is
through Turkey, over the Eastern Aegean
Sea to the Greek islands. Refugees from
Syria, Afghanistan, Iraq, Pakistan and Pal-
estine, amongst others, often use this route.
They may arrive in Turkey by land or ferry
and continue on their way to Greece on car-
go ships or inflatable boats [7].The number
of asylum seekers arriving in Greece each
day typically reaches around 5000, with
peaks of up to 10,000 [8].
Crossing the desert
For Sub-Saharan African nationals, the
Central Mediterranean route is a primary
point of entry into Europe. Little data are
available describing events in the Saharan
desert.The United Nations Office on Drugs
and Crime (UNDOC) reports “only” 1691
confirmed deaths in the desert; however,
it has been suggested that these numbers
significantly underestimate the number of
those killed with actual numbers at least
three times higher [13].
Refugees are not only at risk due to heat
stroke,thirst or starvation,but also face oth-
er dangers. According to UNDOC, many
Health and Asylum Seekers in Europe
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90 91
Refugees and Health CareRefugees and Health Care
paid a ransom. However, it is hard to verify
this information. In a 2013 report, Reisen
et al. that there have been an estimated
25,000-30,000 victims of Sinai trafficking
with about 622 million USD in ransom
collected [17]. While the Egyptian govern-
ment’s efforts have been successful in reduc-
ing these crimes, exploitation of vulnerable
refugees may have simply shifted to other
lawless zones.
Crossing the Mediterranean
Almost daily, powerful photos are emerging
of refugees struggling to cross the Mediter-
ranean – and in some cases, losing their lives
in search of a better future. In 2015, an esti-
mated 2,812 people have died crossing the
Mediterranean Sea to date – an average of
eight fatalities per day [18].The Internation-
al Organization for Migration estimates that
about 75% of all refugee deaths worldwide
are occurring in the Mediterranean [19].
Many human smuggling networks operate
from the practically failed state of Libya,
smuggling migrants mainly from Gambia,
Senegal, Somalia, Syria, Eritrea, Ethio-
pia, Mali and Nigeria on wooden fishing
boats or inflatable boats with no naviga-
tion capacities and engines which often fail.
Usually a distress call is sent to the Italian
authorities about 6-7 hours after departure
from the Libyan coast [7].
Arriving in Europe
According to the International Organisa-
tion for Immigration, out of 430,000 refu-
gees and migrants who have reached West-
ern Europe since the beginning of 2015,
390,000 have passed from Greek territory.
Daily, more than 4000 refugees set foot on
the island of Lesbos having traveled across
on small boats from the Turkish coast. Most
refugees continue their journey via main-
land Greece, Macedonia, Serbia and Hun-
gary [20].
Germany and other neighboring Western
European countries are the primary desti-
nations for refugees. In absolute numbers
Germany has admitted most refugees of all
EU countries, resulting in multiple health-
care challenges [21].
Health of refugees
For most refugees, the journey to Europe is
fraught with a multitude of health threats,
although it is a common misconception
that refugees themselves constitute a sig-
nificant health risk [22]. In this context,
it is also important to emphasize that
stigmatization of refugees is never justi-
fied and only risks creating or exacerbat-
ing threats to health. Long and exhaust-
ing travel under unsafe conditions and the
interruption of health care can exacerbate
chronic diseases. Dangers specific to the
routes and border-crossings pose health
threats to young and healthy migrants
as well. People spend a long time hidden
in overcrowded trucks or boats. Injuries,
burns and dehydration are frequently oc-
curring health problems. Traumatizing
experiences in the country of origin or on
the journey, and exposure to violence and
the loss of family members, increase their
vulnerability to communicable and non-
communicable diseases. Children, preg-
nant women, elderly and immunocompro-
mised people are particularly susceptible to
health threats [8].
Food insecurity among refugees also creates
many additional potential health threats.
Starvation and malnutrition are a real-
ity for many refugees [23, 24]. In addition,
refugees may resort to trying to obtain food
wherever they can.In Germany,this has had
disastrous consequences where more than
thirty refugees have become seriously ill and
at least one refugee has died after ingesting
poisonous mushrooms. It is believed that
these mushrooms were consumed because
they look similar to common edible mush-
room in Syria [25, 26, 27].
Infectious Diseases
Due to poor hygiene conditions in transit
and in receiving facilities, diarrhea, acute re-
spiratory infections, skin infections, scabies
and head lice may occur [28, 29]. The sup-
ply of safe water and food may be limited
during the journey. Unsanitary conditions
can often be found at border points and in
receiving facilities, with a lack of safe drink-
ing water, shower facilities and regular re-
moval of waste. The result can be outbreaks
of food- and water-borne diseases such as
salmonellosis, shigellosis, campylobacterio-
sis and hepatitis A [8].
Communicable diseases are often associ-
ated with poverty. An efficient health sys-
tem, good housing, hygiene, vaccinations
and clean water reduce the prevalence of
diseases such as TB, measles, rubella, and
hepatitis.They still exist in the European re-
gion, independent of migration. The influx
of people from countries where infectious
diseases are more prevalent can change the
disease burden in Europe, although there is
no proven association between migration
and the importation of infectious diseases.
Experience shows that if cases of exotic in-
fections, such as the Ebola virus, occur in
Europe it affects regular travelers or health
care workers rather than migrants [8].
Other infectious diseases such as scabies
have also emerged as a public health chal-
lenge. In Germany, Hamburg, health au-
thorities declared a health emergency on
August 21st
due to an outbreak of scabies
in an emergency shelter for newly arrived
asylum seekers. At the time, only topical
anti-scabies therapies were available within
Germany (Permethrin and Benzylben-
zoate) [30]. Ivermectin, an antifilarial on
WHO’s list of essential medicines [31] and
the de facto oral therapeutic standard for
scabies [32], is publicly available in France
but only with indications for treatment of
strongyloidiasis and elefantiasis not scabies
[33]. On September 2nd
, the Federal Minis-
try of Health declared scabies a dangerous
die in traffic accidents,overcrowded vehicles
or by simply falling off of a vehicle and be-
ing left in the desert [13]. There are even
more shocking reports of abuse, torture and
other crimes against refugees. Until 2013,
when the Egyptian Government reinstated
the rule of law in the Sinai [14], many refu-
gees became victims of rape, torture – or
even homicide.
Physicians for Human Rights-Israel report
that 59% of asylum seekers treated at their
open clinic report being chained and/or
locked up with 52% also reporting physical
abuse [15]. A CNN crew visiting the Sinai
reported that the morgue was packed with
dead corpses daily [16] with refugees being
abducted and tortured until their families
BACK TO CONTENTS
92 93
that a person (migrant) will experience with
time: “family and friends, language, culture,
homeland,loss of status,loss of contact with
the ethnic group, and exposure to physical
risks” [46]. Reception in the intended des-
tination country can be very important for
completion of this grief process [46].
McColl et al. defined some pre-migration
and post-migration adversities in the con-
text of UK asylum applicants. Pre-migra-
tion adversities include war, imprisonment,
genocide, physical or sexual violence, trau-
matic bereavement, lack of healthcare, etc.,
while post-migration adversities are the
“seven Ds”: discrimination, detention, dis-
persal, destitution, denial of the right to
work,denial of healthcare,delayed decisions
on asylum applications [47].
It is important to emphasize that the ma-
jority of refugees and asylum seekers do not
suffer from a psychiatric condition [47]. In
this context, traumatic experiences should
be addressed without pathologizing normal
human reactions [48].
A meta-analysis by Porter and Haslam found
that,compared to non-refugees,refugees had
somewhat poorer outcomes in psychopa-
thology measures. They also found that the
mental health outcomes are influenced by
postdisplacement conditions, and that refu-
gees who are living in institutional accom-
modation, economically restricted, internally
displaced, persons who were repatriated, or
whose initiating conflict was unresolved had
worse outcomes. Worse outcomes were also
found in more educated, older, female, per-
sons with higher socioeconomic status and
rural residence before the migration [49].
Studies suggest that two thirds of refugees
experience anxiety and/or depression, and
have a higher incidence of post traumatic
stress disorder, panic disorder and agora-
phobia, in addition to depression and anxi-
ety [46]. Post traumatic stress disorder is
the leading mental health condition among
refugees and asylum seekers, probably con-
nected to the experiences in the country of
origin (persecution, conflicts, etc.) [46]. A
review by Fazel et al.in 2005 found that ref-
ugees placed in Western countries were 10
times more likely to have PTSD than the
general population [50]. There is also a dif-
ference between the group of migrants – for
example, a Norwegian study found asylum
seekers to have higher rates of PTSD than
refugees [51]
In addition, asylum interviews are shown
to have a stressful effect on asylum seekers,
especially when the asylum seekers were
already traumatized [52]. Apart from the
procedural difficulties in obtaining asylum,
access to healthcare also poses a major chal-
lenge for many refugees.
Undocumented migrants, or the migrants
without legal status, face obstacles to receiv-
ing adequate healthcare services – particu-
larly mental health services – in destination
countries. Many times healthcare access for
refugees is limited to emergencies curbing ac-
cessibility to mental health services and there-
fore influences the overall health of refugees.
It is important to protect and ensure ad-
equate treatment of persons who are already
suffering of a severe mental disorder. This
group of refugees is particularly vulnerable
and can be considered neglected in complex
emergencies, such as conflicts [53].
Some countries provide mental health ser-
vices to the refugees who enter their borders
(e.g. temporary protection status in Turkey
includes mental health services). However,
resource shortages limit these services to life-
threatening emergencies in many places­.
Women and LGBT Health
Refugee women face higher rates of ex-
posure to violence, sexual exploitation and
abuse than men [54].Risks increase on their
journey and can be exacerbated by lack of
access to emergency sexual assault treat-
ment and obstetrical care [55]. The stress
of the migratory process can also trigger or
intensify intimate partner violence [56, 57].
Sexual violence, abuse, trafficking and rape
by smugglers, officials, policemen and male
refugees are a common experience among
refugee women. Some may be forced into
prostitution [58, 59, 60].The selling of Syr-
ian brides has become a business in Turkey.
Unwanted pregnancies without access to
safe abortions and venereal diseases without
access to appropriate treatment may occur
as a result [61, 62].
In July and August of 2015, 36160 Syrian
males applied for asylum in the EU-28 only
10970 female Syrian refugees did so [63].
This is in sharp contrast to the 1:1 ratio
worldwide. [64] It is reported that many
families can only afford paying for one per-
son’s trip and will send young healthy males
as a pilot, hoping for their female family
members to be allowed to join them later
[65]. However, it should not be neglected
female refugees are an even more vulnerable
group [66, 67].
In Germany, emergency shelters are cur-
rently so overcrowded that males and fe-
males share sleeping space in gyms, as well
as toilets and showers [66]. Even though
authorities were not able to confirm, Ger-
man NGOs reported widespread cases of
rape and forced prostitution in an emer-
gency shelters for new arrivals in Gießen,
Hesse Germany [68].
According to a report from the German In-
stitute for Human Rights on refugees and
gender-specific violence,protection through
“restraining and protection orders”are avail-
able for refugees as well; however, refugees’
choice of accommodations and even move-
ment is limited by law. In many cases, only
the husband claimed reasons for asylum and
in that case under German law the partner’s
asylum will depend on continued marriage.
Legally violent partners may be separated
to different accommodations even against a
­communicable disease and authorized im-
portation of Ivermectin without prior mar-
keting approval [30].
The prevalence of HIV is low among people
from the Middle East and Northern Africa
[8]. Most HIV cases in migrants are found
in Sub-Saharan African nationals. About
40% of HIV cases in Europe are migrants.
There is also growing evidence that some
migrant populations acquire HIV after ar-
riving in Europe [34]. Antiretroviral treat-
ment can be interrupted for refugees liv-
ing with HIV with potentially devastating
consequences. In some European countries,
no HIV services are offered to people with
uncertain legal status [34].
The majority of tuberculosis (TB) cases are
detected in the native-born population in
Europe, with substantial variation across
European countries. People with severe
cases of TB are often not fit for travel and
therefore do not attempt the journey. TB is
not easily transmissible and active disease
occurs only in a small proportion of those
infected. However, crowded and humid
spaces such as those found in trucks and
ships may facilitate the transmission of TB
when an infected person is present [8]. The
overall incidence is declining, while it is on
the rise among migrants [34].
The mass influx of refugees increases the
risk of the reintroduction of vector-borne
diseases such as Malaria, Leishmaniasis and
to the European region.Tajikistan and Tur-
key are at particularly high risk at the mo-
ment [8, 34, 35].
Outbreaks of measles, rubella and other
vaccine-preventable diseases can occur in
the migrant population and spread to un-
vaccinated people of the receiving country.
There is still a gap in vaccination coverage
in European countries due to refusal to
vaccinate. In migrants’ countries of origin,
access to vaccinations is often considerably
lower than in EU countries, creating condi-
tions under which outbreaks may emerge.
The 2015 outbreak of measles in Berlin had
originated within a group of asylum seekers
from Serbia and Bosnia and Herzegovina
[36, 8].
In Turkey, registered refugees are provided
temporary protection status and are then
placed in provinces based on a national plan.
However, the rapidly increasing number of
refugees has made execution of this plan dif-
ficult and created new medical challenges.
According to an official field survey report
by AFAD in 2013, 26% of children in refu-
gee camps and 45% of children not living
in camps did not receive polio vaccination.
One in three children in camps and 41% of
the children out of the camps did not have
measles vaccination [37]. This situation in-
troduced the risk of polio to a country which
was polio-free for more than 15 years.There
has been also a rise in other infectious dis-
eases including measles,tuberculosis and cu-
taneous leishmaniasis [38, 39].
Many developing countries experience a
high burden of hepatitis B cases. Incidence
is higher among migrants than among na-
tive populations in most European coun-
tries. Chronic infections are particularly
increasing. In most cases, migrants acquired
the virus in their countries of origin or from
mother-to-child transmission [34].
In Lebanon, the sanitation conditions in
refugee camps are very basic and a surge
of diarrheal diseases has been observed in
2014 by the epidemiologic surveillance unit
of the Lebanese Ministry of Public Health.
Lebanon has seen an increase in the num-
ber of reported tuberculosis, hepatitis A
and measles cases [40]. In addition, a vec-
tor borne disease, cutaneous leishmaniasis,
which was not present in Lebanon before,
has made its appearance with 476 cases in
2014, all in Syrian Refugees.There is a con-
cern about the introduction of the sandfly
vector to Lebanon, but this has not been
proven with certainty yet. The community
physicians have faced a major challenge in
making a timely diagnosis of Leishmaniasis,
a condition they had not be accustomed to
evaluating and treating in the past[35]. Ma-
jor education efforts for healthcare workers
through tertiary care and academic medi-
cal centers in Lebanon, are undertaken to
spread the knowledge about the disease.
NCDs
Noncommunicable diseases are a significant
problem in the refugee population. Diabetes,
cardiovascular diseases, chronic lung diseases
and cancer are the most common of these.
The exhausting and demanding circumstanc-
es of the journey often lead to exacerbations
of chronic diseases.A common characteristic
is that these conditions require regular and
continuous treatment. The supply of drugs
and the access to necessary procedures and
care can be interrupted, resulting in poorer
health outcomes including unnecessary mor-
bidity and mortality [8, 41]. In the process
of uprooting and social marginalization, mi-
grants may lose self-esteem and feel power-
less to manage chronic illness. The situation
is exacerbated by linguistic barriers and a real
or perceived inability to seek health care [42,
18]. For many refugees fleeing the Syrian
civil war, access to non-communicable dis-
ease management and prevention may have
been limited for years as the Syrian health
care system has been “shattered” by the con-
flict with more than 75% of physicians hav-
ing fled the country [43, 44]. Numerous re-
ports have described attacks on health care
facilities in clear violation of international
humanitarian law [45].
Mental Health
The effect of migration on an individual
is pervasive – everything in person’s life
changes: diet, family, culture, social rela-
tions, status, etc [46]. Migratory experience
is essentially a psycho-social process of loss
and change, which can be labeled as a grief
process. This can be explained through a
model comprising of seven griefs of losses
Refugees and Health CareRefugees and Health Care
BACK TO CONTENTS
94 95
Conclusion
People travel with their health profiles, val-
ues, culture and beliefs. Health workers in
Europe and beyond need to be aware of this
and have the necessary knowledge to pro-
vide high quality care to refugees. Recipient
countries must be prepared to be responsive
in the event of a crisis, so as to deliver basic
services to migrants in recognition to their
basic human rights [28].
Large numbers of people moving between
countries may have implications for the
character and distribution of a country or
region’s disease burden. Acute conditions,
many of them infectious disease, psychiat-
ric illness or injuries sustained fleeing their
home countries might be the most obvious.
Many refugee lack access to mental health-
care and delayed treatment for mental
health problems may worsen refugees’prog-
nosis. Attention must be given to persons
with pre-existing psychiatric disorder as
well as other vulnerable groups.
However, host countries themselves are also
important factors for refugees’ health. Cul-
tural and language barriers can in worst case
cause innocent, yet deadly confusion. The
basic rules of hygiene and sanitation are an
important factor for today’s increased life
expectancy [84], ensuring these basic rules
for refugees should be of immediate concern.
However, we believe that after the acute
phase refugees and health care systems
will adapt to each other and chronic con-
ditions will set in. The social determinants
of health have been shown to be crucial for
health [85] and first and second generation
immigrants face many challenges, amongst
them often lower wages and less education
[86]. While today’s situation may seems to
be a crisis, it should not be forgotten that
refugees health challenges will not end
when an asylum decision has been made.
Like with any other human being, health
is a lifelong process even setting the course
for future generations. For this reason, it is
critical that governments, national medical
associations and health professionals ensure
a sustained,timely and appropriate response
to the health implications of refugee crises
[87, 88]. Refugee health is public health.
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violent partners wishes and women’s shel-
ters may be accessed, however, there are still
many bureaucratic hurdles. In the case of
violence, the Institute recommends either
lifting restrictions causing vulnerability for
victims or introducing fast track procedures
for victims to offer them different shelters
and making emergency accommodations
available. It further recommends making
refugee shelters safer places by ensuring
lockable rooms and sanitary facilities, in-
forming residents about their rights, setting
up women’s rooms, sensitizing staff, inte-
grating NGOs and ensuring there is female
as well as male security staff at shelters [69].
Pregnant women in refugee or migrant
communities can have limited access to an-
tenatal care or safe delivery facilities [70].
This can result in late diagnosis and some-
times life-threatening conditions for moth-
ers and their babies [8].
In addition, discrimination and violence
based on sexual orientation and gender
identity is an unfortunate reality for refu-
gees who identify as lesbian, gay, bisexual,
transgender, queer or intersex (LGBTQI).
Although data are limited, anecdotal evi-
dence suggests these refugees face addition-
al health threats including psychological
such as “humiliation” [71].
Implications for Health
Systems: Examples
European Union
According to the Fundamental rights of
migrants in an irregular situation in the
European Union – Comparative report
from 2011, in “19 out of 27 EU Member
States migrants in an irregular situation
are entitled to emergency healthcare only”
[72]. For example, Croatia’s law on asylum
(28th
member state of the European Union)
states that health care services for asylum
seekers include emergency medical services.
Turkey
In Turkey, registered refugees are offered
free primary healthcare services in public
hospitals for both emergency and elec-
tive procedures. Since the beginning of
the Syrian conflict, 4.383.907 outpatient
visits have occurred in the temporary shel-
ters and 4.914.920 polyclinic examinations
were performed in hospitals across the
country, while 389.837 of them ended up
with inpatient service. 62.022 deliveries
and 278.035 surgeries were performed ac-
cording to official numbers [10]. This put
the healthcare system of the country under
extra stress, which had already limitations
with the shortage of healthcare workers
[73, 74].
Lebanon
Since the beginning of the Syrian conflict
in 2011, Lebanon as one of the closest
bordering states has witnessed a contin-
ued influx of refugees to reach about 1.5
million in official numbers provided by the
UNHCR. This has propelled the country
into the pole position, having the high-
est refugee per capita in the world (232
refugees per 1000 inhabitants).The already
strained healthcare system is now stretched
very thin with the healthcare needs of the
refugee population [75]. The drop in vac-
cination rates in Syria has impacted the
reemergence of infectious diseases thought
to be close to eradication from Lebanon
such as measles [76, 43].
Greece
Greece faces an unprecedented economic
crisis that has led the country to a con-
tinuous depression since 2010. The current
refugee crisis creates therefore tremendous
problems in Greece, which the Greek state
cannot handle by itself. As a common point
of entry to Europe, lack of first recep-
tion and accommodation infrastructure in
Greece may exacerbate public health issues
and prove hazardous to refugee populations
and local societies.It is a humanitarian need
that healthcare services and infrastructure
in Greece, a country at Europe’s doorstep,
be financially supported by European funds
to ensure refugees have access to holistic
care upon arrival in Europe [77].
Germany
Upon arrival, refugees receive a preliminary
medical examination and are offered vacci-
nations according to German national rec-
ommendations. Due to this policy and the
sheer number of refugees, vaccine stocks for
many combination vaccines were exhausted
during the summer of 2015 [78].
Refugees are distributed throughout Ger-
many under a pre-agreed quota system [79].
Local authorities are required to provide
food and shelter for refugees, sometimes
with a few hours of prior notice [80]. In or-
der to meet the need,gyms,empty school or
stores and tents have been set up as make-
shift shelters with only basic sanitary ser-
vices available [21].
Overall, under German law, refugees are
entitled to free healthcare for alleviating
pain and acute disease. The only exception
being pregnant women, who are entitled to
the same health care standard as all pub-
licly insured women [81]. Until recently
refugees had to first go to public admin-
istration receive a written approval before
having their doctors visit for acute disease
covered. This has often been criticized as
discriminatory, especially as public officials
in charge of granting the visit had no for-
mal medical expertise [82]. Recently most
states changed statutes to issue refugees
standard German health insurance cards
[83]. They do not extend coverage, how-
ever, allow refugees to see doctors without
prior approval and for doctors to receive
reimbursement through standard health
insurance processes.
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respond-syrian-refugee-crisis
Isabel Tourneur,
DRK Kliniken Westend, Berlin,
Germany;
MD, MPH, DTMH Xaviour Walker,
Johns Hopkins Bloomberg School
of Public Health, USA;
MD, JD, MPH Elizabeth Wiley,
University of Maryland, USA;
MD Caline Mattar,
Washington University in St. Louis, USA;
MD Fehim Esen,
Turkish Young Doctors Association,
Devrek State Hospital, Turkey;
MD Goran Mijaljica,
Psychiatric Hospital Ugljan and University
of Split School of Medicine, Croatia;
MD, MSc Kostas Roditis,
National Kapodistrian University
of Athens, Greece;
MD, PhD Kostas Louis,
“Konstantopoulio-Patision”
General Hospital, Greece;
MD, MSc Ahmet Murt,
Cerrahpasa Medical Faculty,
Istanbul, Turkey;
MD Thorsten Hornung,
University of Bonn, Germany
E-mail: Thorsten.hornung@ukb.uni-bonn.de
Refugees and Health CareRefugees and Health Care
BACK TO CONTENTS
98 99
JORDAN, 2013-10-28,
© ICRC / REVOL, Didier
Mafraq Governorate. The ICRC and the
Jordan Red Crescent Society distribute
debit cards to vulnerable Syrian families liv-
ing in host communities.
The mechanism for the cash transfer is done
through ATM cards issued by a major bank.
The project will last until March 2014, with
one instalment per month. The amount
of cash assistance varies according to the
household size. To help Syrians withstand
winter, the amount will increase during the
cold season. The ICRC and Palestinian RC
helped around 1000 syrian families with
their cash transfer programme.
As the conflict continues unabated, Syr-
ians are fleeing their homes every day to
seek refuge in Jordan. With winter ap-
proaching, the ICRC and the Jordan Na-
tional Red Crescent Society are finding
new ways to help them cope with increas-
ing needs.
Many Syrians who have found refuge in
Jordan depend on aid provided by local and
international aid agencies. The vast major-
ity of the refugees have been taken in by lo-
cal communities in northern areas near the
Syrian border. Some have not received any
other kind of assistance since arriving in the
country.
“Between 200 and 500 people are arriving
daily. Most have endured a gruelling jour-
ney across the desert,” said Nana Chukhua,
ICRC delegate in Jordan. “As soon as they
arrive, they urgently need water, food and
shelter.”
“We were forced to travel dozens of kilo-
metres through the desert with scarcely any
food or water,” said Abu Yazan, a Syrian
refugee from Homs. “It was cold, and we
had to sleep on the ground.”
The majority have left all their belongings
behind and cannot meet basic needs such as
food,health care,house rent,water and elec-
tricity bills. Besides distributing relief items
to the refugees, the ICRC and the Jordan
National Red Crescent Society launched a
programme in October to provide cash as-
sistance for 1,000 families in Mafraq gover-
norate, northern Jordan, with the dual aim
of helping them and easing the burden on
local communities.
“The cash money will definitely help us
cover our basic needs, mainly house rent,”
said Um Anwar, a 32-year-old Syrian who
resides in Mafraq.“The money will also help
me obtain treatment for my 13-year-old
daughter,” the mother of five added.
An innovative cash transfer programme:
In Jordan, the vast majority of Syrian refu-
gees live in host communities and often
have problems meeting their basic needs.
To help them with expenses not covered
by other relief mechanisms, the ICRC and
the Jordan National Red Crescent Soci-
ety launched a cash assistance programme
in October in Mafraq governorate, in the
north of the country, which will be imple-
mented over a period of six months.
An initial group of 1,000 families have
started receiving debit cards issued by a ma-
jor bank that will allow them to withdraw
money directly from ATM machines. The
amount of money (from USD 70 to 310)
made available to each family depends on
the size of the household and will be in-
creased during winter months.
As the ICRC’s Hekmat Sharabi puts it, this
programme “is much more flexible than
just giving them assistance that they might
not consider suitable. It preserves people’s
dignity by giving them the opportunity to
determine on their own what they are most
in need of.”
IRAQ, 2013-09-25
© ICRC / MOHAMMAD, Flamerz
Dohuk governorate, Qsrouk sub-district,
Qsrouk transit camp. Distribution of ICRC
non-food assistance to Syrian refugees. A
young girl carries the thermos her family
received during the distribution.
In Qasrouk kits were distributed to a total
of 561 persons (99 families and 35 singles).
The kits consisted of basic hygiene and
household items (stove, bucket, kettle, tea
pot, thermoses and tarpaulin).
IRAQ, 2015-01-16
© ICRC / ACHKAR, Nora
Iraqi Kurdistan, Penjwin. ICRC assistance
operation.
On Friday 16 January, the ICRC provides
emergency aid to nearly 180 displaced per-
sons who are currently living in Penjwin, 46
km from Sulaymaniyah. Penjwin lies at an
altitude of 1500 m, where meteorological
conditions are harsh in winter.
A similar distribution operation took place
in December 2014,when the ICRC provid-
ed supplies for 660 people. The people that
the ICRC is helping have fled from Nayna-
wa, Salah al-Din, and Diyala governorates
in Iraq, and from Ayn al-Arab/Kobani.
Refugees and Health CareRefugees and Health Care
International Committee of the Red Cross activities for
refugees/displaced persons in the Middle East
BACK TO CONTENTS
100 101
JORDAN, 2013-10-29
© ICRC / REVOL, Didier
Ruwaishid area, assembly point in Bustana.
The ICRC distributes blankets, jerrycans
and hygiene items.
The ICRC has, since July 2013, equipped
three asssembly points and two transit sites
in the area with water tanks and drinking-
water coolers, sanitation facilities and waste
containers; it has also ensured temporary
accommodation for refugees fleeing Syria
As the conflict continues unabated, Syrians
are fleeing their homes every day to seek
refuge in Jordan. With winter approach-
ing, the ICRC and the Jordan National Red
Crescent Society are finding new ways to
help them cope with increasing needs.
Many Syrians who have found refuge in
Jordan depend on aid provided by local and
international aid agencies. The vast major-
ity of the refugees have been taken in by lo-
cal communities in northern areas near the
Syrian border. Some have not received any
other kind of assistance since arriving in the
country.
«Between 200 and 500 people are arriving
daily. Most have endured a gruelling jour-
ney across the desert,» said Nana Chukhua,
ICRC delegate in Jordan. «As soon as they
arrive, they urgently need water, food and
shelter.»
«We were forced to travel dozens of kilo-
metres through the desert with scarcely any
food or water,» said Abu Yazan, a Syrian
refugee from Homs. «It was cold, and we
had to sleep on the ground.»
The majority have left all their belongings
behind and cannot meet basic needs such as
food,health care,house rent,water and elec-
tricity bills. Besides distributing relief items
to the refugees, the ICRC and the Jordan
National Red Crescent Society launched a
programme in October to provide cash as-
sistance for 1,000 families in Mafraq gover-
norate, northern Jordan, with the dual aim
of helping them and easing the burden on
local communities.
JORDAN, 2013-10-30
© ICRC / REVOL, Didier
Growing numbers of families in search of
a safe haven are embarking on a danger-
ous journey across Syria to border areas
in eastern Jordan. Between 200 and 500
people arrive every day in this remote des-
ert area.
Refugees, iamong them the elderly and the
very young, walk long distances, mostly at
night, to cross the border.
Because of the intensity of the fighting on
the Syrian side, the usual entry points in
eastern Jordan are now harder to reach for
the refugees. The refugees are gathered by
the Jordan Armed Forces, first at assembly
points and then at transit sites.
As the conflict continues unabated, Syrians
are fleeing their homes every day to seek
refuge in Jordan. With winter approach-
ing, the ICRC and the Jordan National Red
Crescent Society are finding new ways to
help them cope with increasing needs.
Many Syrians who have found refuge in
Jordan depend on aid provided by local and
international aid agencies. The vast major-
ity of the refugees have been taken in by lo-
cal communities in northern areas near the
Syrian border. Some have not received any
other kind of assistance since arriving in the
country.
«Between 200 and 500 people are arriving
daily. Most have endured a gruelling jour-
ney across the desert,» said Nana Chukhua,
ICRC delegate in Jordan. «As soon as they
arrive, they urgently need water, food and
shelter.»
«We were forced to travel dozens of kilo-
metres through the desert with scarcely any
food or water,» said Abu Yazan, a Syrian
refugee from Homs. «It was cold, and we
had to sleep on the ground.»
The majority have left all their belongings
behind and cannot meet basic needs such as
food,health care,house rent,water and elec-
tricity bills. Besides distributing relief items
to the refugees, the ICRC and the Jordan
National Red Crescent Society launched a
programme in October to provide cash as-
sistance for 1,000 families in Mafraq gover-
norate, northern Jordan, with the dual aim
of helping them and easing the burden on
local communities.
Refugees and Health CareRefugees and Health Care
BACK TO CONTENTS
102 103
JORDAN, 2013-10-30
© ICRC / REVOL, Didier
Ruwaished area, assembly point in Bustana.
ICRC trucks regularly deliver blankets, jer-
rycans and hygiene items to refugees fleeing
Syria; twice a day, a local NGO distributes
meals paid for by the ICRC.
The ICRC has, since July 2013, equipped
three asssembly points and two transit sites
in the area with water tanks and drinking-
water coolers, sanitation facilities and waste
containers; it has also ensured temporary
accommodation for refugees fleeing Syria.
As the conflict continues unabated, Syrians
are fleeing their homes every day to seek
refuge in Jordan. With winter approach-
ing, the ICRC and the Jordan National Red
Crescent Society are finding new ways to
help them cope with increasing needs.
Many Syrians who have found refuge in
Jordan depend on aid provided by local and
international aid agencies. The vast major-
ity of the refugees have been taken in by lo-
cal communities in northern areas near the
Syrian border. Some have not received any
other kind of assistance since arriving in the
country.
«Between 200 and 500 people are arriving
daily. Most have endured a gruelling jour-
ney across the desert,» said Nana Chukhua,
ICRC delegate in Jordan. «As soon as they
arrive, they urgently need water, food and
shelter.»
«We were forced to travel dozens of kilo-
metres through the desert with scarcely any
food or water,» said Abu Yazan, a Syrian
refugee from Homs. «It was cold, and we
had to sleep on the ground.»
The majority have left all their belongings
behind and cannot meet basic needs such as
food,health care,house rent,water and elec-
tricity bills. Besides distributing relief items
to the refugees, the ICRC and the Jordan
National Red Crescent Society launched a
programme in October to provide cash as-
sistance for 1,000 families in Mafraq gover-
norate, northern Jordan, with the dual aim
of helping them and easing the burden on
local communities.
LEBANON, 2013-08-05
© ICRC / SPAULL, John
Bekaa Valley, close to the Syrian border,
near Bar Elias.Tal Sarhoun informal Syrian
refugee settlement. Children huddle around
a flimsy tent.
Several makeshift settlements of this sort
host hundreds of families, especially in the
Bekaa region.
The ICRC is working to help family mem-
bers separated by the conflict from their
loved ones to reestablish links. It has also
reminded the Lebanese government of its
responsibility to ensure respect for the prin-
ciple of non-refoulement.
LEBANON, 2013-08-05
© ICRC / SPAULL, John
Bekaa Valley, close to the Syrian border,
near Bar Elias.Tal Sarhoun informal Syrian
refugee settlement.
This informal refugee settlement hosts
around 500 families. Having fled their
homes, taking little of their belongings with
them, the refugees need essential assistance,
ranging from shelter, to food, water, hygiene
items and sleeping material.
Refugees and Health CareRefugees and Health Care
BACK TO CONTENTS
104 105
LEBANON, 2012-10-09, © ICRC / PARRISH, Paula
Tripoli. ICRC nurses visits a Syrian wounded.
SYRIA, 2012-06-22, © ICRC / GARCIA VILANOVA, Ricardo
Homs governorate, Qussayr. A doctor takes care of a child in a
field hospital.
SYRIA, 2012-08-24, © ICRC / GARCIA VILANOVA, Ricardo
Aleppo. A wounded man is tended to.
SYRIA, 2013-03-18
© ICRC / s.n.
Between Aleppo and Manbij. An ICRC
convoy on its way to deliver medical sup-
plies to Manbij an opposition held area.
Syria: Heavy fighting in Aleppo plagues
lives of hundreds of thousands
Damascus/Geneva (ICRC) – Humanitari-
an needs in Aleppo are enormous,according
to personnel from the International Com-
mittee of the Red Cross (ICRC) who have
just concluded a five-day visit to Aleppo
governorate together with the Syrian Arab
Red Crescent.
During the visit, they gauged the humani-
tarian situation and delivered much-needed
medical assistance.
«There are tens of thousands of displaced
people in the governorate with no income
and no savings who depend on assistance
to survive,» said Marianne Gasser, head of
the ICRC delegation in Syria, upon her re-
turn from the governorate. «Apart from the
pressing humanitarian needs, several roads,
hospitals, schools, other public facilities and
world heritage sites have been damaged.
Essential public services such as the distri-
bution of power and water have also been
disrupted as a result of the heavy fighting
that has plagued the governorate over the
past nine months.»
The ICRC has been unable to return to
Aleppo since July of last year because of
the ongoing fierce fighting. However, the
Syrian Arab Red Crescent never stopped
delivering food and household essentials,
with ICRC support. In addition, the ICRC
ensured that potable water was available
to the population. «Our trip to Aleppo is
an important step forward. It is a good ex-
ample of how continuous dialogue with all
parties concerned yields results, and makes
it possible to reach people in need, includ-
ing in opposition-controlled areas,» added
Ms Gasser.
Together with the Syrian Arab Red Cres-
cent, the ICRC visited a number of differ-
ent areas in the governorate, including op-
position-held territory in the eastern parts
of Aleppo city such as Bustan Al-Qasr and
Masaken Hanano, and Manbij in Rural
Aleppo. «During these visits, we assessed
humanitarian needs and spoke to people
suffering the effects of the violence to better
understand their needs as well as the situa-
tion,» said Ms Gasser.
Working with the Syrian Arab Red Cres-
cent and the local water boards, ICRC wa-
ter engineers surveyed the effect the fight-
ing has had on the supply of clean drinking
water in the city of Aleppo and surrounding
rural areas. «We are planning to go forward
with a number of upgrades and to provide
support that will help the Aleppo water
board solve some of the problems it is fac-
ing,» said Antonio Bolinches, an ICRC
water engineer who participated in the visit.
ICRC health personnel also visited the
governorate and checked on a number of
health-care facilities, where they provided
much-needed medical supplies and drugs
for chronic diseases.
The Syrian Arab Red Crescent branch in
Aleppo was highly involved in the activities
carried out during the visit. «These young
volunteers are doing tremendous work on
the ground,» said Ms Gasser. «I was moved
by their dedication and commitment to
helping everyone in need – irrespective of
where they are.»
SYRIA, 2012-07-08, © ICRC / GARCIA VILANOVA, Ricardo
Homs governorate, Qussayr. A wounded man is tended to at a
hospital.
SYRIA, 2013-04, © ICRC / CARRIN, Jeroen
Zabdani. Ambulance damaged.
SYRIA, 2014-02, © ICRC / KAS BARSOUM, Jack
Aleppo, Internally Displaced People Centre.The black buildings,
which are used by the internally displaced persons.
Refugees and Health CareRefugees and Health Care
BACK TO CONTENTS
106 107
FRANCEFRANCE Person Centered MedicinePerson Centered Medicine
It has been extensively shown that mental
health problems or symptoms are frequently
brought up in the context of primary care
either as the main reason to consult or as a
concomitant symptom. It is at the heart of
the WHO WONCA report “Integrating
mental health into primary care”[1] and also
extensively demonstrated by several well-
designed studies more or less in line with the
Alma Ata declaration on primary health care
(see for example) [2,3].Hence,it can no lon-
ger be disputed that primary care is the best
setting to ensure that people get the mental
health care they need, not only because “it
is accessible, affordable, acceptable and cost
effective” but also because while promoting
“early diagnosis, respect of human rights and
social integration”,“primary care also helps to
ensure that all people are treated in a holistic
manner, addressing both their physical and
mental health needs”[1].To the point that –
even if there is still a lack of evidence* – this
*  Mainly because there is a lack of criteria and met-
rics to evaluate these aspects
holistic ambition is fulfilled in this perspec-
tive, many countries have tried more or less
successfully to restructure their organization
based on these principles including practical,
rather than conceptual, adaptations to their
cultural and socio economic context.In many
cases their main objective is to find the most
cost effective and sustainable way to diagnose
a nosographic mental disorder using brief
evidence based screening for such conditions
[4].In this type of adaptation “holism”is lim-
ited to the integration of a somatic and men-
tal disorder centered appraisal of the health
status without real consideration of the per-
son as a whole including his values, expec-
tations and subjective aspects. An apparent
unanimity on benchmarked principles hides
a profound heterogeneity of their definitions
and, not surprisingly, a strong implicit ten-
dency to maintain the health organizations
in their usual biomedical type of approach to
physical and mental health: a disorder cen-
tered approach. Various indicators, and par-
ticularly criticisms and complaints coming
from users and stakeholders, show that this
perspective is far from satisfactory.
Towards a Person
Centered Perspective
One of the main problems health profes-
sionals have to face when dealing with
mental health or psychological issues is the
fact that – maybe more than other medi-
cal disciplines – Psychiatry and Mental
Health are exposed to the negative effects
of a disorder centered approach. Because of
the many competing theories about the very
nature of one’s mental life a disorder cen-
tered approach risks neglecting many of the
non-objective aspects of the person’s mental
health,including key aspects such as subjec-
tivity and psychodynamic dimensions. The
implicit or explicit tendency is to mimic the
paradigm based on the biomedical classifi-
cations in other medical disciplines.
The first stake of a person-centered per-
spective is to fight against this abusive re-
ductionism that leaves us “with half a sci-
ence” [5] and landmarks not well adapted
to clinical practice [6]. The objective of this
paper is to briefly consider and discuss the
process allowing a professional to access
subjective and psychodynamic dimensions
of the patient’s health status and consider
how this process could be integrated into
primary care.
In this perspective, the modernity and
originality of Person Centered Medicine
(PCM) resides in the fact that it does not
satisfy itself with asserting its principles
but strives to define conditions for effective
implementation of this ambition in each
medical situation. What counts the most
here is to meet real patients’ needs and not
those of more or less paradigmatic entities
defined by each medical speciality which
trigger the reductionist approach imposed
by the research methodology in a “classical”
Evidence-Based Medicine approach.
Three conditions must be met to reach this
goal [7,8]:
• To take into account the whole being of the
patient (I am myself and my context) [9].
• To consider the diagnosis and therapeu-
tic choices as a joint process involving the
person of the patient, the persons of the
carers (family and caregivers in general),
and the person of the clinician.
• To consider as essential the subjective as-
pects of the person’s health situation, and
not only the objective aspects of the ill-
ness.
This last condition is the focus of this brief
paper, starting with the idea that, in addi-
tion to the attention paid to the medico-
biological aspects of the person’s health
status, a person centred assessment needs to
give enough consideration to the patient’s
subjective feelings. Whether or not we sus-
pect a psychic or psychosomatic causality to
the disorder that a patient brings to us, it is
essential to keep in perspective the factors
involved in the patient’s health situation.
“Beyond reasserting this principle, we need
to utterly enhance the methodology for ac-
cessing these subjective dimensions among
different partners involved in the diagnos-
tic process and the therapeutic relation-
ship”[10]. For the professionals, the only
way to access these subjective dimensions is
through what the patient (and or his carers)
says in words or shows in acting, as long as
these words or acts can trigger in the pro-
fessionals enough empathy to approach the
patient’s subjective feelings to which these
expressions are related.
At first considered as the professional’s
ability to listen sympathetically to the
comments of the patient and to integrate
his wishes and needs, the notion of em-
pathy has gradually widened to include
representations that the physician (or the
health professional) makes of the clinical
situation in which the person in need of
care is involved. In short, these are repre-
sentations that the professional makes of
the health situation of the person suffer-
ing through his/her (the professional) own
empathy, triggered by the words and the
acts of the patients and their caregivers.
This mechanism is well described by the
concept of “metaphorizing-empathy” pro-
posed by Lebovici [12] from his work with
babies and their mothers. It is also close
to the notion of “narrative empathy” pro-
posed by Jacques Hochmann [13] based
on his work with autistic children and on
the philosophical ideas brought by Paul
Ricoeur, a famous French phenomenolo-
gist, in his book “Time and Narrative”[14].
It is also consistent with Kleinman’s as-
sumptions [15] on illness narratives. This
important development in PCM marked
the full recognition of the role of the phy-
sician’s subjectivity as a diagnostic and
treatment tool in the physician-patient
relationship.
To approach the subjectivity of the person (in
both its conscious and unconscious aspects)
[10] the physician has to use his personal
commitment in the relation with the patient
and his use of his metaphorizing empathy.
This perspective is very consistent with the
reality of medical practice that, in one form
or another, must deal with this vital dimen-
sion in every patient.Moreover,by establish-
ing the subjectivity of the physician as a tool
for understanding the patient and his disor-
der, the subjective involvement of the pro-
fessional regains positive status which was
lost with the progress of objective technical
medicine. In this perspective the subjectivity
of the professional can be properly included
in practice and training if enough space is
given to work it through. Rather than train-
ing the professionals to fight against their
subjective movements or to deny it and to
prevent them from getting closer to the
patient’s personal needs, Person Centered
Medicine (PCM) proposes to train them to
use these subjective movements as their best
tool to access the patient’s subjectivity.Thus,
PCM acknowledges relevance for clinical
practice of the clinician’s congruence in the
relationship, (i.e. his or her access to experi-
ences arising in resonance with the patient).
A required condition is, for professionals, to
be trained to work it through properly, and
develop enough reflexive capacities. This
would enable them to take subjectivity and
intersubjectivity as one of the bricks of the
therapeutic relationship, i.e. the interactive
construction they should build with the pa-
tient and for him or her, involving all those
who are contributing to their health care and
health status [10]. The teamwork and peer
supervision are crucial to enhance and sus-
tain this interactive process.
What about subjectivity and
narrative in primary care?
Obviously, subjectivity is of crucial impor-
tance in primary care, not only because a
primary care visit usually is the first contact
with health professionals but also because it
is the first step in a process transforming a
suffering or a distress into a medical disease
or disorder. In this complex process con-
tributing eventually to the transformation
of “pain into suffering” [16]*, the proximity
of primary care with the person’s every day
life can obviously be a major asset to take
into account the subjective feelings induced
by his/her health experience and status, and
potentially their subjective determinants. It
is generally considered and well document-
ed that this asset contributes to the acces-
sibility of care and their cost effectiveness
in most medical conditions. However, there
are emerging concerns that this asset could
become an obstacle to care when proximal
relations do not help the patient to address
the subjective aspects of his health in rela-
tion or not with his/her somatic condition.
Schematically, three reasons can transform
primary cares proximity and generality into
an obstacle for such subjective appraisal:
• The patient’s fear to disclose a stigmatiz-
ing situation to a health professional in-
tegrated in his every day life
• His difficulty to recognize subjective as-
pects and psychological distress related
to health questions (physical, mental or
both) due to the health problem itself,
either when this difficulty is one of the
symptoms of this condition (Alexithymia
as symptom of various health disorders**)
or when the pervasiveness of the somatic
issues tends to mask the psychosocial as-
pects of the disease
• In these various situations,the lack of time
and expertise of primary care’s profession-
als to recognize and overcome adequately
such obstacles in clinical situations
*  For Paul Ricoeur, there is a crucial difference
between Pain and Suffering. In Pain, physical or
psychical, painful experience suppresses all psychical
representations and reduces communication with
others, whereas in Suffering, the painful experience
triggers psychical representations and the need to
communicate with others [17].
**  It can be related to various health issues or dis-
orders: suffering Adolescents [18], Psychosomatic
conditions [19] , Personality disorders [20], or other
medical of psychiatric illnesses [21].
Subjectivity and Narratives in Primary Care:
A Person Centered Issue
Michel Botbol
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Person Centered MedicineUNITED STATES OF AMERICAFRANCEPerson Centered Medicine
In a person-centered perspective, these
obstacles should be addressed in the
situations in which they occur. While
in many cases, this could be achieved
through the better promotion of person-
centered medicine principles (given that
person-centeredness in medicine is not
only an ethical stance but also a techni-
cal advancement), we have to study more
closely if the current “WHO service or-
ganization pyramid for an optimal mix of
services for mental health” [1:16] is suf-
ficiently adapted to tackle the problem
raised by the integration of the subjective
aspects of health into health care. To do
so, there is an urgent need to elaborate rel-
evant metrics to evaluate more thoroughly
how this issue is tackled in the currently
recommended health service models. My
hypothesis is that, if we want to address
seriously the problem raised by the inte-
gration of subjective dimensions into pri-
mary health care, we may have to consider
amending this optimal model to make
sure that renouncing the integration of
subjective aspects of health into primary
care will not be the price to pay to the cost
effectiveness, affordability and transpar-
ency claimed by the model.
Conclusion
PCM has brought back the person of the
patient at the centre of medicine, allowing
integrating the subjective dimensions of
the patient’s mental health into the health
cares from where they have been generally
excluded by the disease-centered approach.
Because it involves the personal commit-
ment of the health professional and his
empathic capacities the approach of this
dimension needs time and specific training.
As first interface between the patients and
the health system, primary care is of cru-
cial importance for the implementation of
person-centered principles into the health
system. It is the reason why, after being the
focus of the International College for Per-
son Centered Medicine (ICPCM) last Ge-
neva Conference, it is going to be the topic
of the 2015 ICPCM International Con-
gress in London.The usefulness of the opti-
mal use of primary care is well documented
for its cost effectiveness and affordability; in
contrast, however, more studies are needed
to better know the conditions that primary
cares have to meet to be person-centered,
especially when it comes to integrating sub-
jective aspects of health. This paper claims
that, besides the well-demonstrated useful-
ness of the primary care oriented model,
there is still a long way to go to ensure that
this subjective dimension will not be lost in
primary care.
References
1. WHO and Wonca (2008) Integrating mental
health into primary care: a global perspective.
WHO Library.
2. Berkel H, Henderson J, Henke N, et al. Mental
health promotion and prevention strategies for
coping with anxiety, depression, and stress relat-
ed disorders in Europe (2001- 2003). Research
report 1001. Bremerhaven: Federal Institute for
Occupational Safety and Health 2004
3. Hickie I. Can we reduce the burden of depres-
sion? The Australian experience with beyond
blue: the national depression initiative. Austral-
ian Psychiatry 2004: 12, 38-46
4. Spitzer RL, Williams JB, Kroenke K, Linzer M,
de Gruy FV 3rd, Hahn SR, Brody D, Johnson
JG. Utility of a new procedure for diagnosing
mental disorders in primary care: The PRIME-
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5. Strauss JS. Diagnosis and reality: A noun is a
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Garrabe J, Golse B, Jeammet P, Plantade A,
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8. Botbol M. Du manifeste au subjectif: ce qu’est
la médecine de la personne [From objectivity to
subjectivity: What is Person Centered Medi-
cine] In SD Kipman (ed.) Manifeste pour la
médecine de la personne [Manifesto for Person
Centered Medicine]. Paris, Dunod, 2012
9. Laín-Entralgo P. El Diagn©stico Médico: His-
toria y Teoría [The medical diagnostic: history
and theory]. Salvat, Barcelona, 1982
10. Botbol M, Lecic-Tosevski D. Person-Centered
Medicine and Subjectivity. In: Jeffrey HD Cor-
nelius-White, Renate Motschnig- Pitrik, Mi-
chael Lux (eds) Interdisciplinary Applications of
the Person-Centered Approach. Springer, New
York, 2013
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subjectivity and Psychological Functioning, In
Person Centered Psychiatry. Springer, Heidel-
berg, in press, 2015
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chopathologie du bébé [The tree of life – Princi-
ples of infant psychopathology]. Eres, Toulouse,
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tory of empathy]. Odile Jacob, Paris, 2012
14. Ricoeur P. Temps et récit [Time and narrative].
Le Seuil, Paris,1983
15. Kleinman A.The Illness Narratives. Basic Book,
New York, 1988
16. Ricoeur P. La souffrance n’est pas la douleur
[Suffering is not Pain]. Psychiatrie Française,
Juin 1992
17. Botbol M, Hagmann V. Douleur ou souffrance?
A propos du point de vue de Paul Ricoeur. [Suf-
fering or Pain  ? on Paul Ricoeur perspective]
Nervure 2005; 17: 2
18. Loas G. L’Alexithymie [Alexithymia]. Annales
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therapy and Psychosomatics 1973; 22: 255-26
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sions. Cortex 2012; 49: 899-90
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Affect Regulation: Alexithymia in Medical and
Psychiatric Illness. Cambridge University Press,
1999
Prof. Michel Botbol,
Professor of Child and Adolescent Psychiatry
at University of Western Brittany,
Chief of the Child and Adolescent
Department of Brest University Hospital
Member of the Board of the International
College for Person Centered Medicine
Chair of the Psychoanalysis in
Psychiatry WPA Section
E-mail: botbolmichel@orange.fr
Introduction
Ancient as well as modern concepts of
“health” have highlighted the holistic un-
derstanding (emphasizing the importance
of the whole and the interdependence of its
parts) in medicine. Ancient Chinese medi-
cine used diagnostic indicators in a holistic
framework to provide an understanding of
the disease process. The Indian medicine
Ayurveda (or the knowledge of living),
viewed health as harmony between body,
mind and spirit. Ancient Greek philoso-
phers affirmed that “if the whole is not well,
it is impossible for the part to be well” [1, 2].
A modern articulation of this understand-
ing is expressed in the World Health Or-
ganization (WHO) constitution published
in 1946 which defined health as “a state of
complete physical, emotional, and social well-
being and not merely the absence of disease or
infirmity.” [3]
The extraordinary advances in medicine
post World War II, with its emphasis on
specialized care, resulted in the provision
of medical care unimaginable only a few
decades ago, especially for complex and ad-
vanced medical-surgical problems.This em-
phasis and the current progress has changed
our expectations of medicine and has in-
creased hope in prolonging life and improv-
ing the quality of life for people suffering
from these ailments, an obvious example
being the field of organ transplantation. On
the other hand, the focus on disease special-
ization has led to an unfortunate shift in
the practice of medicine away from a view
of health as an interdependent whole with
artificially parceling out care, resulting in
fragmentation, incoordination, and in some
instances decreased access to care.
Furthermore, the worldwide increased
prevalence of non-communicable chronic
diseases, the interconnectedness and ex-
ceptional burden of chronic diseases and
mental health conditions, along with the
key role of behavioral determinant of health
strongly demand models of care that ad-
dress the totality of health with emphasis
on disease prevention and health restora-
tion. In this paper, we will review the ra-
tional for integrating mental health within
primary care along with reported positive
experiences in the field. We will also discuss
the Person-centered Integrative Diagnosis
(PID) model, an emerging person- and pa-
tient-centered approach to care anchored in
person-centered medicine.The PID consid-
ers the person-in-context as the center and
goal of interventions and care [4, 5].
Why Integrate Mental Health
Care and Primary Care
The need for integrated care is almost uni-
versally appreciated and it has risen from
the recognition that specialized care often
leads to fragmentation of care, inadequacy
of addressing comorbid problems, limits ac-
cess to care and largely neglects preventive
efforts. In contrast to disease focused spe-
cialized and fragmented system approach
with clear barriers to care, integrated care
is the systematic coordination of care for
physical and mental disorders. It allows for
the provision of adequate care for the whole
person (addressing any presenting health-
related problems) facilitating a holistic ap-
proach to care.
Multiple lines of evidence point to the rel-
evance of this model for addressing mental
and physical disorders.There is a high prev-
alence of mental disorders among people
presenting to primary care settings. Like-
wise, people with mental disorders have
high rates of physical disorders.
Medical comorbidity is the most significant
cause of mortality in people with mental
disorders, and these disorders are less likely
to receive adequate attention in non-inte-
grated care systems. Patients with chronic
mental disorders such as major depression,
bipolar disorder, schizophrenia, alcoholism
and other substance use disorders have high
rates of physical disorders such as diabetes,
cardiovascular, chronic respiratory diseases,
human- immune deficiency virus (HIV) in-
Ihsan M. Salloum
The Integration of Mental Health and
Primary Care: A Person-centered Approach
Ladan Khazai
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Person Centered MedicinePerson Centered Medicine UNITED STATES OF AMERICAUNITED STATES OF AMERICA
the availability of unified support systems
such as shared medical information and
referral systems, the degree of shared goals
and vision among the health care teams and
the degree of shared financing streams.
Health services have been graded on a con-
tinuum of integration of care, from low to
fully integrated systems, based on the level
of collaboration between the various disci-
plines of health care providers. The lower
the level of care, the less being able to ad-
dress more complex conditions. Level one
identifies a low level of integration with
minimal collaboration between health pro-
fessionals. Level two identifies basic col-
laboration and loosely coordinated care,
with periodic communications between
health providers in separate systems of care
and separate locations. Level three refers
to closer collaboration among health pro-
viders who still are part of different teams
but share the same facility (co-located).The
co-location facilitates more frequent com-
munications,including occasional meetings.
Level four identifies close collaboration in
a setting where there is partial integration
between mental health and other medical
care. Providers are co-located at the same
sites and share other functions such as the
medical information system or scheduling.
There is more formal collaborative work
and meetings that may involve coordinated
treatment plans for certain cases. The most
integrated level is level five. There is close
collaboration in this fully integrated model
where health professionals operate as part
of the same team, with shared vision, and
using the same supportive system. There is
regular and systematic team meetings and
treatment planning with similar emphasis
and expectations on prevention and treat-
ment.
The Four Quadrant Model is a conceptual
population-based planning model for in-
tegrated care developed under the auspices
of the National Council for Community
Behavioral Healthcare (NCCBH) [29].
Health risk and complexity are considered
in each quadrant and used as a guide for in-
terventions and levels of services to meet the
individual patient’s need. Quadrants range
from low risk/low complexity (quadrant I)
to high risk/high complexity (quadrant IV)
on both mental health/substance abuse and
physical health. Quadrant II indicates high
risk/complexity on mental health/substance
abuse and low to moderate risk/complexity
on physical health; quadrant III indicates
low to moderate risk/complexity on men-
tal health substance abuse and high risk/
complexity on physical health. The Care
Model is another conceptual model de-
veloped for improving care for chronic ill-
nesses by refocusing the emphasis from an
illness-centered reactive model to a health-
centered preventative model. It addresses
key features for enhancing care at multiple
levels including community, organization,
practice and patient levels [29].
Models have been advanced for linking inte-
grated care to the processes of care through
systematic screening and identification of
mental and behavioral disorders. This pro-
vides targeted linkage to appropriate inter-
ventions within an integrated primary care
providers with the goals to enhance access
to care, reduce stigma, and enhance engage-
ment and adherence to care [30].
An example of systematic screening and
brief intervention highly relevant to prima-
ry care is the Screening, Brief Interventions,
Referral and Treatment (SBIRT) program
for unhealthy alcohol use [31]. The SBIRT
is an evidence-based practice aimed at iden-
tifying, reducing and preventing problemat-
ic alcohol use. The SBIRT has three major
components: Screening, using highly effi-
cient and practical standardized screening
tools such as the CAGE questionnaire, the
Alcohol Use Identification test (AUDIT)
or the three questions AUDIT-C [32–34].
Brief Intervention, providing feedback and
advice for patients with unhealthy alcohol
use. Referral to Treatment, for either brief
therapy or for additional more intensive
treatment. Similarly, interventions for the
highly prevalent depression in primary care
have been developed and extensively tested
[35]. Community friendly interventions
that could be incorporated into integrated
primary care programs for serious mental
disorders are less developed. Two examples
of integrated counseling interventions for
bipolar disorder with comorbid alcohol or
substance use that are designed to be simple
and easily adaptable to community settings
include a group therapy format [36] and
an individual counseling approach [37].
These interventions utilize integrated dis-
ease management and educational strate-
gies along with motivational enhancement
approaches that are practical and easily ap-
plicable in community settings.
The Person-centered Integrative
Diagnosis (PID) Model
The Person-centered Integrative Diagno-
sis model (PID) may provide a conceptual
approach to integrative care. The emerging
PID model aims at putting into practice the
vision of Person-centered Medicine affirm-
ing the whole person of the patient in con-
text as the center of clinical care and health
promotion at the individual and community
levels [4,5].The PID motto of “persons car-
ing for persons” recognizes that the person
of the patient and the person of the health
providers are in a respectful and empower-
ing partnership. The PID considers the to-
tality of the person’s health, including both
ill health and positive aspects of health with
primary emphasis on prevention and health
restoration. It is based on a holistic, contex-
tual and humanistic approach to care em-
phasizing recovery and wellbeing. It views
the process of care as a partnership (equali-
tarian) approach, including the patient,
family, care givers and other stakehold-
ers and the health professionals forming a
health support network.
The PID scheme could be easily incorporat-
ed into other models of integrated care, and
it provides a comprehensive and dynamic
fection, Hepatitis, sexually transmitted dis-
eases (STD), tuberculosis (TB) and trauma
with excess mortality. Factors that increase
risk for physical disorders in mental dis-
orders include high rates of smoking, sub-
stance abuse, and obesity [6]. Studies have
shown that those with serious mental illness
have 25 years less life expectancy compared
to the general population [7]. They are over
three times more likely to die from cardiac
diseases and over six times more likely to
die from respiratory ailments. These pa-
tients often suffer from multi-comorbid
problems. For example, patients with bipo-
lar disorder have high rates of cardiovascu-
lar and respiratory diseases, in addition to
substance use disorders which increase their
risk for chronic infectious diseases such as
viral hepatitis and HIV infection [8, 9].
Three or more chronic comorbid conditions
were found, on the average, among people
with bipolar disorder [10]. Additional co-
morbidity increases the risk for mortality.In
a study of mortality among Medicaid ben-
eficiaries, while the most common causes
of death were attributed to heart disease
and cancer, death by injury was found to
be twice as likely among the mentally ill
compared to the general population. Those
with mental illness and comorbid substance
abuse were 6-8 times more likely to die of
injury,primarily poisoning,than their coun-
terparts treated for medical conditions only
[11]. While that study did not look at the
trajectory of care for those patients, limited
access to appropriate care may have been a
key contributing factor for those with excess
mortality. Integrated care will substantially
facilitates access to care for patients with
severe mental disorders.
The need for integrated care stems from an
even more fundamental reason for a holistic
view of health. Studies have long reported
that psychosocial determinants generate
the majority of health care visits [12]. Psy-
chosocial distress or depressive disorders
often are expressed as physical distress seen
by primary care physicians. Likewise, de-
pression may develop as a consequence of
chronic physical disorder such as diabetes or
cardiovascular disorder [13]. Furthermore,
behavioral and life style factors are overrep-
resented among the preventable risk factor
for developing chronic diseases. The World
Health Alliance (World Medical Asso-
ciation, International Council of Nurses,
World Dental Federation, and Internation-
al Pharmaceutical Federation) has recently
identified through a Health Improvement
Card a number of key risk factors to pre-
vent chronic diseases. Among these are diet,
exercise, avoidance of alcohol and other
hazardous drugs, stress-control, adequate
rest and sleep, and participation in social
and creative activities [14]. Addressing be-
havioral health problems in primary care is
essential because of the prevalence of these
problems in primary care setting with re-
ported prevalence of smoking at 20%, obe-
sity at 30% and sedentary lifestyle at 50%.
Chronic conditions that require a behav-
ioral health component in a standard care
protocol include asthma, diabetes, cardio-
vascular disease, irritable bowel syndrome,
obesity and substance abuse. Alcohol abuse
is linked to over 60 medical disorders [15].
Primary care practices are de facto where
the overwhelming majority of patients with
mental health problems receive care [16].
There is mounting empirical evidence dem-
onstrating that integrated care improves
access to both mental health and physical
health services, decrease stigma of receiving
mental health care, improves outcome and
reduces health care costs [17–25].
The importance of integrating mental
health into general health and public health
practice has been recognized as a way for
promoting mental health [26]. Integration
of mental health and substance use disor-
ders treatment in primary care has been also
supported by legislative acts, such as the Pa-
tient Protection and Affordable Care Act of
2014 in the United States of America and
have been highlighted by the US Surgeon
General and the Institute of Medicine re-
ports [27, 28].
Levels and Models of
Integrated Care
Integration may need to be addressed at
multiple levels. At the systems’ level, major
factors such as financing of care and facili-
tating access to care need to be addressed
to facilitate integration. At the providers’
level­, training and commitment are es-
sential. For example, integrating mental
health and substance abuse treatment into
primary care there is a need for a three-
way enhancement of training. Medical care
providers need to have enhanced training in
mental health and substance abuse recogni-
tion and need for intervention. Likewise,
mental health and substance abuse provid-
ers need to have enhanced training in the
recognition and need for intervention for
medical, mental health or substance abuse
problems. At the interventions’ level there
is a need to identify, select, and develop in-
tegrated pharmacological or psychosocial
interventions that are most appropriate for
the patient. Repeated studies have high-
lighted the superiority of integrated inter-
ventions, tailored to the patient’s comorbid
conditions, compared to interventions that
are condition specific. These studies high-
light the importance of addressing the dy-
namic interplay between comorbid condi-
tions and their reciprocal negative impacts
on the overall outcome. Patients’ factors
is another crucial factor for integration of
care, especially with the increased patient’s
awareness and participatory, protagonist
role in the process of care. This involves
enhanced patients’ recognition of interrela-
tionship of health problems and enhanced
commitment to wellness maintenance and
health restoration [5, 8].
Integration of care between different service
providers is facilitated by addressing a num-
ber of features. These include the level of
communication between the services, their
physical proximity (co-located or not), their
accessibility to patients in terms of distance
and time for the appointment, the availabil-
ity of expertise and cross-trained personnel,
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Charns MP, Yano EM. Mental health provider
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for patients with serious mental illness. Adm
Policy Ment Health, 2012;39(6):448-57.
23. Lawrence D, Kisely S. Inequalities in healthcare
provision for people with severe mental illness. J
Psychopharmacol, 2010;24(4 Suppl):61-8.
24. Wittwer SD. The patient experience with the
mental health system: a focus on integrated
care solutions. J Manag Care Pharm, 2006;12(2
Suppl):21-3.
25. AHRQ. Integration of Mental Health/Sub-
stance Abuse and Primary Care. Structured Ab-
stract. Rockville, MD.: Agency for Healthcare
Research and Quality, October 2008.
26. Herman H, Saxena S, Moodie R. Promoting
mental health: concepts, emerging evidence,
practice. WHO, 2005.
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United States.
28. Report TIoM. Building a Better Delivery Sys-
tem: A New Engineering/Health Care Partner-
ship (2005). Washington, DC.
29. NASMHPD. Integrating Behavioral Health
and Primary Care Services: Opportunities and
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Alexandria VA: National Association of State
Mental Health Program Directors. Medical
Directors Council January, 2005 Contract No.:
Eleventh
30. Butler M, Kane RL, McAlpine D, Kathol RG,
Fu SS, Hagedorn H, et al. Integration of mental
health/substance abuse and primary care. 2008.
31. Madras BK,Compton WM,Avula D,Stegbauer
T, Stein JB, Clark HW. Screening, brief inter-
ventions,referral to treatment (SBIRT) for illicit
drug and alcohol use at multiple healthcare sites:
comparison at intake and 6 months later. Drug
Alcohol Depend, 2009;99(1-3):280-95.
32. Bohn MJ, Babor TF, Kranzler HR. The Alco-
hol Use Disorders Identification Test (AUDIT):
validation of a screening instrument for use in
medical settings. Journal of studies on alcohol,
1995;56(4):423-32.
33. Ewing JA. Detecting alcoholism: The cage ques-
tionnaire. JAMA, 1984;252(14):1905-7.
34. Bush K, Kivlahan DR, McDonell MB, Fihn
SD, Bradley KA.The audit alcohol consumption
questions (audit-c): An effective brief screen-
ing test for problem drinking. Ambulatory Care
Quality Improvement Project.. Archives of In-
ternal Medicine, 1998;158(16):1789-95.
35. deGruy FV. Treatment of depression in primary
care. Ann Fam Med, 2015;13(1):3-5.
36. Weiss RD, Griffin ML, Kolodziej ME, Green-
field SF, Najavits LM, Daley DC, et al. A ran-
domized trial of integrated group therapy versus
group drug counseling for patients with bipolar
disorder and substance dependence. American
Journal of Psychiatry, 2007;164(1):100-7.
37. Salloum IM, Douaihy AB, Daley DC, Kelly
TM, Cornelius JR, Kirisci L. Integrated individ-
ual therapy for bipolar disorder and alcoholism:
results from a randomized pilot study. Bipolar
Disorders, 2009;11:74-5.
38. Salloum IM, Mezzich JE. Person-centered di-
agnosis. Int J Integr Care, 2010;10 Suppl:e027.
39. Salloum IM,Mezzich JE.Outlining the bases of
person-centred integrative diagnosis. Journal of
evaluation in clinical practice 2011;17(2):354-6.
40. Mezzich JE, Snaedal J, van Weel C, Botbol M,
Salloum I. Introduction to person-centred med-
icine: from concepts to practice. Journal of Eval-
uation in Clinical Practice, 2011;17(2):330-2.
Ihsan M. Salloum, MD,
MPHProfessor of Psychiatry
University of Miami, Miller
School of Medicine
Executive Board Member, International
College of Person-centered Medicine;
Chair, Section on Classification, Diagnostic
Assessment and Nomenclature,
World Psychiatric Association
Ladan Khazai, MD, Master of Public
Health Graduate Candidate, 2016;
Department of Public Health
Sciences, Research Assistant,
Department of Psychiatry and
Behavioral Sciences,
University of Miami, Miller
School of Medicine
Corresponding address:
Ihsan M. Salloum, MD, MPH
1120 NW 14th
Street, suite 1449,
Miami, Florida 33136, USA.
E-mail: isalloum@med.miami.edu
assessment of the health status of the person
presenting for care. The PID is a multilevel
approach to assessing the health status. The
first level includes the assessment of health.
This includes the assessment of ill health,
such as any physical or mental disorders
along with assessment of functional abili-
ties. This level also includes the assessment
of positive aspects of health and wellbeing.
Positive aspects of health and wellbeing are
key to the recovery, health restoration and
health preservation efforts.The second level
in the PID is the assessment of contributors
to the health status. These contributors are
considered on a bio-psycho-social continu-
um. Contributors to health are divided into
health promoters and health risks.The PID
has incorporated the health contributors
included in the Health Improvement Card
developed by the World Health Professions
Alliance [14]. Health promoters include
diet, physical activity, creative activity, social
involvement,and other.Health risks include
overweight, elevated lipid, elevated glucose,
high blood pressure, alcohol and tabacco
use, family history, early trauma, significant
stress, and other. The third level of the PID
is the experience of health which includes
the experience of wellbieng and the experi-
ence of ill health. This provides assessment
of personal and cultural identity, suffering,
meaning of illness and expectations for the
health care encounter.These subjective con-
tributions to the process of diagnosis and
care provide idiographic narrative crucial
for the processes of empowerment, engage-
ment, partnership and recovery [38–40].
Future Directions
Integration of care has become a pressing
prerogative to provide an adequate response
to the growing pandemic of chronic diseas-
es and to the increase of the aging world-
population with substantial rise of the bur-
den of comorbid chronic conditions. The
integration of mental health into primary
care and general health responds to the
considerable evidence of the strong impact
of mental and behavioral health on physical
health, and also to the need for adequately
addressing ill physical health in people with
mental health problems. The dictate that
“there is no health without mental health” and
the goal of eliminating disparities in health
care are best served by integration of care.
Refocusing medicine from an essentially
disease-centered, “reactive” attitude to an
approach focusing on disease prevention
and health restoration with emphasis on
enhancing wellbeing and healthy living also
calls for integration of care.
The Person-centered Integrative Diagnosis
approach, embodying the vision of Person-
centered Medicine as expressed to a large
extent in the various Geneva Declarations
and proceedings of the International Col-
lege of Person-centered Medicine (ICP-
CM), provides an overarching conceptual
framework for integrated care converging
on the person in context as the center and
goal of care and public health.
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al. Person-centred integrative diagnosis: concep-
tual bases and structural model. Canadian Jour-
nal of Psychiatry, 2010;55(11):701-8.
5. Salloum IM, Mezzich JE. Conceptual appraisal
of the Person-centered Integrative Diagnosis
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tered Medicine, 2011;1(1):39-42.
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Bakmas M, Cohen D, Asai I, et al. Physical
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tients with Comorbid Substance Use Disorders.
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DM, Regier DA. Measuring need for mental
health services in a general population. Med
Care, 1985;23(9):1033-43.
13. Ducat L, Rubenstein A, Philipson LH, An-
derson BJ. A review of the mental health is-
sues of diabetes conference. Diabetes Care,
2015;38(2):333-8.
14. Seyer J. Development of the Health Improve-
ment Card developed by the World Health Pro-
fessions Alliance. (2012) In: Medicine ICoPC
(ed.) The 5th Geneva Conference on Person-
centered Medicine. Geneva, Switzerland,.
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psychiatry: official journal of the World Psychi-
atric Association, 2003;2(3):153-7.
16. Regier DA, Narrow WE, Rae DS, Mandersc-
heid RW, Locke BZ, Goodwin FK.The de facto
US mental and addictive disorders service sys-
tem. Epidemiologic catchment area prospective
1-year prevalence rates of disorders and services.
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17. Woltmann E, Grogan-Kaylor A, Perron B,
Georges H, Kilbourne AM, Bauer MS. Com-
parative effectiveness of collaborative chronic
care models for mental health conditions across
primary,specialty,and behavioral health care set-
tings: systematic review and meta-analysis. Am J
Psychiatry, 2012;169(8):790-804.
18. Kilbourne AM, Pirraglia PA, Lai Z, Bauer MS,
Charns MP, Greenwald D, et al. Quality of gen-
eral medical care among patients with serious
mental illness: does colocation of services mat-
ter? Psychiatr Serv, 2011;62(8):922-8.
19. Druss BG, von Esenwein SA, Compton MT,
Rask KJ,Zhao L,Parker RM.A randomized tri-
al of medical care management for community
mental health settings: the Primary Care Access,
Referral, and Evaluation (PCARE) study. Am J
Psychiatry, 2010;167(2):151-9.
BACK TO CONTENTS
114 115
Climate ChangeClimate Change
Climate change is considered one of the
greatest threats and/or opportunities for
(human) health [1, 2, 11, 13]. Although
the relationship between climate change
and health is complex, concrete examples
include extreme heat and weather events
[46], poor air quality exacerbating pulmo-
nary disease [47, 48], increased water-borne
and vector-borne infectious disease out-
breaks and food insecurity and malnutrition
caused by drought and crop failure.
Despite widespread recognition of the
numerous health implications of climate
change, evidence suggests that climate
change continues relatively unabated [15].
In this context, there is an imperative for
health professionals to be involved in the
discussion and act on this issue which
threatens to undermine public health ef-
forts worldwide [2, 34, 35]. This paper
provides a brief introduction to the United
Nations Framework on Climate Change
(UNFCCC), current climate change ne-
gotiations and health sector engagement in
global efforts to tackle climate change.
I.The Climate-Health Nexus
Broad scientific evidence shows that climate
change has and will continue to have pro-
found health implications [2, 4], primar-
ily driven by carbon and other greenhouse
gas emissions [16]. The effects of climate
change on health are diverse and complex;
some directly attributable to rising tem-
peratures and changes in precipitation pat-
terns, others are mediated through social
and ecological changes such as population
displacement, vector migration, conflict and
agricultural failure [7, 8, 14].
In 2014, the Intergovernmental Panel on
Climate Change (IPCC) highlighted some
of the most significant threats to human
health posed by climate change including
but not limited to:
• Spread of infectious diseases including ma-
laria,dengue fever,and water-borne diseases;
• Increased frequency and severity of natu-
ral disasters and flooding;
• Worsening food insecurity;
• Increased migration and conflict; and
• More than 7 million deaths annually at-
tributable to rising temperatures and air
pollution [2].
The Road to Paris: What is at Stake for
Health in COP21 Negotiations?
Mediating factors
Social infrastructureEnvironmental
conditions
CLIMATE CHANGE
• Precipitation
• Heat
• Floods
• Storms
HEALTH IMPACT
• Undernutrition
• Drowning
• Heart disease
• Malaria
Public health capability
and adaptation
• Warning systems
• Socioeconomic status
• Health and nutrition status
• Primary health care
• Geography
• Baseline weather
• Soil/dust
• Vegetation
• Baseline air/water
quality
• Food production distribution
• Mental stress
Via economic and social disruption
Mediated through natural systems:
• Allergens
• Disease vectors
• Increase water/air pollution
Indirect exposures
Direct exposures
• Flood damage
• Storm vulnerability
• Health stress
Figure 1. Diagram of the three exposure pathways through which climate change affects health [3]
Climate change has been recognized as one
of the many social determinants of health
[5, 6]. Not surprisingly, health implications
of climate change are inequitably distribut-
ed worldwide, excessively affecting popula-
tions in low-and-middle income countries
and vulnerable populations around the
globe [10, 18, 19, 49, 54].
Synergistic adaptation and mitigation
strategies are widely viewed as necessary
to address climate change broadly and,
more specifically, the resulting health ef-
fects. Mitigation strategies seek to prevent
or otherwise avert climate change, while
adaptation implies modifying systems in
response to the effects of climate change
[38]. Health impacts of climate change are
indeed mediated through the environmen-
tal conditions, the social infrastructure and
the public health adaptation [3, 49]. As a
result, mitigation and adaptation strate-
gies demand a multisectorial approach
which includes the health sector [9, 10, 12,
32, 33].
II.The Road to Paris/COP21
Adopted as part of the Rio Convention at
the Rio Earth Summit in 1992, UNFCCC
entered into force in 1994 and now includes
196 parties [37]. Each year, the Conference
of Parties (COP) is convened to review
UNFCCC progress.
In December 2014, COP20 was held in
Lima,Peru,and resulted in the Lima call for
climate action [20], a precursor to this year’s
much anticipated COP21 negotiations.The
Lima call for climate action represented the
first time parties revived the health effects
from Art. 1 of the Convention [37] and
recognized the need to further assess the
health co-benefits of climate change miti-
gation.
A new ambitious agreement on climate
change is anticipated this December at
COP21 (“2015 Paris Climate Conference”)
Figure 2. Diagram of the Road to Paris
World Conference Center Bonn (ADP 2.9, June 2015)
BACK TO CONTENTS
116 117
Climate Change Climate Change
[50] and is expected to be an important step
in addressing this huge challenge for hu-
manity. This agreement is meant to succeed
to the Kyoto Protocol [51, 52] in setting
very ambitious long-term goals for address-
ing climate change. High profile targets
may include limiting global mean tempera-
ture increase and carbon emissions. Current
long term goals under discussion are: a max-
imum of a two degree temperature increase
and carbon neutrality by 2050.
Since 2011, the Ad Hoc Working Group
on the Durban Platform for Enhanced Ac-
tion (ADP) has been meeting regularly to
discuss the post 2020 agreement as well as
the pre-2020 ambitions needed to reach
the long term goal(s). The mandate of the
ADP is set to conclude in December 2015;
thus, several ADP meetings are scheduled
in 2015.
The first ADP meeting of the year (ADP
2.8) took place in Geneva in February, 2015
where an early draft of the party-led negoti-
ating text was created, the so-called Geneva
Negotiating Text [21]. This text, essentially
a compilation of all possible components
parties would want to see in an agreement,
was the first time that health co-benefits
were recognized with preamble language
initially tabled by Switzerland. At the con-
clusion of ADP 2.8, all parties agreed that
this text would need to be streamlined in
the months to come.
In June 2015, ADP 2.9 convened at the
UNFCCC Headquarters in Bonn, Ger-
many. Although ADP 2.9 was a much an-
ticipated opportunity to refine the 90-page
Geneva Negotiating Text, little significant
progress was made to streamline the docu-
ment.Parties met and started the streamlin-
ing process but only managed to reduce the
negotiating text to 85 pages [22]; however,
progress was made in defining the way for-
ward and the Co-Chairs of the ADP will
produce a tool which will facilitate the work
at the next session at the end of the month
of July [23, 24].
Despite the lackluster progress at ADP 2.9,
G7 leaders concurrently announced a com-
mitment to “…a protocol, another legal in-
strument or an agreed outcome with legal
force” under the UNFCCC in Paris includ-
ing an explicit political commitment to the
“global goal to hold the increase in global
average temperature below 2°C” [25,  26].
However, this commitment was not reflect-
ed in concurrent negotiations at ADP 2.9
in Bonn.
In 2013, parties adopted a new approach
to climate change negotiations which in-
cludes submission of Intended Nationally
Determined Contributions (INDCs) , or
post-2020 climate commitments and plans.
INDCs are expected to be submitted by
all countries and are intended to shape the
anticipated COP21 framework.In anticipa-
tion of COP21 and a new comprehensive
international climate agreement, parties
will continue to unveil their INDCs in the
months to come [17]. At COP20, parties
agreed that INDCs would focus on reduc-
ing emissions, although little additional
INDC guidance for parties was agreed
upon [53]. The next INDC deadline is cur-
rently 1 October 2015 with a synthesis re-
port from the Secretariat anticipated by 1
November 2015.
III. Health Professionals and
Climate Change Negotiations
Health is included in the first article of the
UNFCCC as an requiring action: “Adverse
effects of climate change” means changes in
the physical environment or biota resulting
from climate change which have signifi-
cant deleterious effects on the composition,
resilience or productivity of natural and
managed ecosystems or on the operation
of socio-economic systems or on human
health and welfare.”[37] The grave and om-
nipresent threat of climate change demands
coordinated multisectoral action [27] and
the health sector has the potential to unite
actors behind a shared well understood and
tangible common cause [2].
Yet, the climate-health connection has not
been consistently recognized in UN process-
es including development of the post-2015
development agenda [38], and the health
sector  – and physicians more specifically  –
have only distantly been involved in climate
change negotiations. In the current stream-
lined and consolidated Geneva Negotiating
Text, health is highlighted only in the pre-
amble: “Recognizing that actions to address
climate change simultaneously contribute to
the attainment of the highest possible level
of health and that climate change policies
and health policies should be mutually sup-
portive.” [21] It is, however, generally recog-
nized that health sector interventions both
mitigation and adaptation and that financial
resources will be flowing through climate
dedicated funds to the health sector. At a
minimum, given the relationship between
climate change and health, the health sector
will need to be ready to anticipate the effects
of climate change on the natural history of
disease, distribution of illness and severity
of disease burden for vulnerable populations
[2]. It will be important to mitigate these ef-
fects while also working to change the fac-
tors leading to worse health outcomes and
supporting smart public policy decisions to
improve population health. Health care pro-
viders are uniquely positioned to assume a
leadership role through both education and
advocacy to advance mitigation and adapta-
tion [14, 29, 30, 31].
It is critical, however, that the health sec-
tor engages in development of the global
framework for climate change action  –
namely, the anticipated COP21 agreement.
As recommended by the recent Lancet
Commission report, this agreement should,
at a minimum, provide clear support and
direction for countries transitioning to a
low-carbon economy, a strong predictable
carbon pricing mechanism and ensuring ac-
cess to renewable energy [2].
Specific advocacy targets for health profes-
sionals and organizations could include [2]:
• Urging negotiators and national policy-
makers (both within and beyond Minis-
tries of Health) to ensure urgent, ambi-
tious binding action on climate change as
reflected in both national level commit-
ments (INDCs) and the COP21 Paris
agreement;
• Leveraging media to communicate the
health risks of climate change and health
co-benefits of mitigation and adaptation
as well as the need for emergent action;
• Investing in climate-health research to
more clearly define and measure the
health co-benefits of adaptation and mit-
igation; and
• Supporting integration of climate change
education into health professions curri-
cula.
Over the last several years, several interna-
tional health and health professions orga-
nizations [61] including the World Health
Organization (WHO) [62],World Medical
Association (WMA) [34-36, 60], Global
Climate & Health Alliance (GCHA) [31]
and International Federation of Medical
Students’ Associations (IFMSA) [57-9]
have been engaging in UNFCCC processes
and negotiations.
However, the urgency and severity of the
threat to health from climate change de-
mands further action and participation by
health professionals and organizations on a
local, national and global scale.
There are a growing number of successful
examples of health professional advocacy
for policy change that recognizes the health
co-benefits of climate change mitigation
and adaptation. The divestment movement
has been rapidly growing within the last
few years and seeks to support the transi-
tion to a low-carbon economy through
“disruptive innovation” [55]. Divestment is
generally defined to include the withdrawal
of all existing investments in fossil fuels and
a commitment not to make any new in-
vestments. In some cases, divestment may
be coupled with investment in renewable
energy or similar more socially responsible
industries. In 2014, the British Medical As-
sociation (BMA) passed a motion to divest
from the fossil fuel industry [40, 41, 13, 45].
Other national medical associations, aca-
demic institutions and other organizations
are increasingly considering and adopt-
ing similar divestment policies [42-44].
Similarly, Health Care Without Harm,
an international coalition of hospitals and
health care systems, professions and other
organizations, has developed and executed
numerous successful local, national and in-
ternational advocacy campaigns around en-
vironmental health and justice – including
climate change [56].
IV. Conclusion
Unchecked climate change will inevitably
have grave negative implications for health;
conversely, addressing climate change
through mitigation and adaptation presents
an extraordinary opportunity to protect
global health [2]. Without concerted global
action, climate change will continue to have
profound negative effects, both directly and
indirectly, on the patients and communi-
ties health professionals serve – and global
population health more broadly. Many
health sector interventions addressing cli-
mate change are no-regret policies which
even without accounting for the benefits for
climate change are valuable for the health
of population [2]: health professionals have
a role to play in illustrating that to policy-
makers.
In this context, the medical community has
a professional obligation to engage in an ef-
fective multisectoral global response to cli-
mate change and to ensure a strong climate
change agreement [34, 35]. The urgency
around this action and engagement by
health professionals could not be stronger
in the coming months as ADP/COP21 ne-
gotiations proceed down the “road to Paris”.
Keep up with upcoming COP21 negotiations
and the road to Paris on Twitter by following
@medwma and #COP21, #ADP2015, #Cli-
mateHealth.
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change/en/
MD, MIH Yassen Tcholakov,
McGill University, Canada;
MD, JD, MPH Elizabeth Wiley,
University of Maryland, USA;
MD Thorsten Hornung,
University of Bonn, Germany;
MD, MPH, DTMH Xaviour Walker,
Johns Hopkins Bloomberg School
of Public Health, USA;
MD Diogo Martins,
University of Beira Interior, Portugal;
MD Arthur Mello,
University of the State of Pará, Brazil;
MD Deborah Vozzella Hall,
University of Connecticut, USA
MD Caline Mattar,
Washington University in St Louis, USA;
MD, MSc, BSc Kimberly Williams,
University of Calgary, Canada;
MBE, MSW, Candidate
Donna Castelblanco, University
of Pennsylvania, USA;
MD Candidate Claudel P-Desrosiers,
University of Montreal
MBChB, BMedSci, Sudhvir Singh,
EAT Initiative, Norway;
MD Renzo Guinto,
Health Care Without Harm-Asia;
Reimagine Global Health, Philippines;
MD Candidate Skander Essafi,
University of Sousse, Tunisia;
MD Candidate Samantha De Leon,
University of Panama, Panama
E-mail: yassen.tcholakov@mail.mcgill.ca
Molly Mettler
More Good Days: Person-Centered Care
at the End of Life
“Modern medicine is good at staving off death
with aggressive interventions – and bad at
knowing when to focus, instead, on improv-
ing the days that terminal patients have
left” [1].
Are we asking the right question?
Is more care better than less care at end of
life? It’s a highly personal choice calling for
a person-centered response.
According to Pew Research Center polls,
Americans’preferences for end-of-life med-
ical treatment vary depending on the exact
circumstances they might face [2]:
• 57% would tell their doctors to stop treat-
ment if they had a disease with no hope
of improvement and were suffering a
great deal of pain;
• 52% would ask their doctors to stop treat-
ment if they had an incurable disease and
were totally dependent on someone else
for their care;
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Person Centered Medicine UNITED STATES OF AMERICA
• But about 35% (about a third) say they
would tell their doctors to do everything
possible to keep them alive – even in dire
circumstances, such as having a disease
with no hope of improvement and expe-
riencing a great deal of pain.
In light of this variation, as we strive to
make all care person-centered, perhaps we
need to expand, even change, the traditional
questions around end of life care.
In addition to asking what level of care pa-
tients want at the end of their lives-curative
care or comfort care, more care or less care,
in other words: “What is a good death for
you?” – perhaps we should be asking each pa-
tient: “What is a good life for you? What, for
you, is a good day? What can we do together
to ensure that you have more good days?”
Goals of care, then, can be refocused on
maximizing the number of “good days” that
the patient can enjoy, ensuring care that is
truly patient centered [2].
We are failing our
patients at end of life
Woody Allen, an American comedian, fa-
mously said, “I’m not afraid of dying, I just
don’t want to be there when it happens.”
Most of us are more realistic, and we still
hope for a good death.
In a narrative study of patients, physicians,
family members and others, several com-
mon themes about what constitutes a good
death emerge: freedom from pain, the sense
of a life well lived, and a sense of commu-
nity [3]. However, while people hope for a
“good death”, they don’t necessarily get one.
Instead, research shows that although 70%
patients want to die at home, approximately
60% die in hospitals, nursing homes or oth-
er care settings [4].
People are getting expensive high-tech
care when they prefer more conservative
treatment. Overtreatment in the form of
aggressive interventions-repeated hospi-
talizations, intensive care, cardiac resusci-
tation, multiple rounds of chemotherapy,
etc.-is costly. In the US, approximately
30% of Medicare funding goes to 5% of
beneficiaries who die. Acute care, not com-
fort care, accounts for 78% of costs in-
curred in the final year of life. One-third
of those expenditures are spent in the last
month of life [5].
Is Geography Destiny?
Even though patients often prefer more
conservative end-of-life care than they
actually receive, a patient’s wishes can be
less influential than the practice patterns
at the hospital where care is delivered. In
other words, the degree to which care at
the end of life is most closely aligned with
a patient’s values and preferences may de-
pend more on where one dies than on how
one dies [6].
Tracking these geographical differences,
the authors of the Dartmouth Atlas of
Health Care’s report on end of life care
suggest:
These findings underscore the importance of in-
novative approaches to care that help ensure
that patients and their families engage in dis-
cussions of their preferences before they become
seriously ill and that providers respect these
preferences [7].
Patient Preferences at End of
Life: Arriving at a Tipping Point
These hoped-for “innovative approaches to
care”include advanced care planning (ACP),
a series of actions to help care providers un-
derstand what a patient’s treatment pref-
erences would be if that patient could not
speak for herself. Driven in part by the mis-
match in goals between what patients want
and what they get in end of life care, and by
the desire to align care with outcomes that
matter to the patient, several patient educa-
tion and engagement programs have begun
to emphasize the importance of ACP. (See
the Resource List below for a small sample
of current programs.)
In years past, advance care planning was
a political “hot button” for physicians and
provider systems. However, changes are
afoot that indicate that embracing ad-
vanced care planning as a vital component
of person-centered care has reached a tip-
ping point.For example,in the US,two new
proposed Medicare billing codes for ad-
vance care planning would allow physicians
and other qualified health professionals to
be reimbursed for time spent explaining and
discussing advance directives during a visit.
Reimbursing clinicians for this use of their
time with their patients supports care deliv-
ery that is “high-quality,comprehensive and
person-centered” [8].
The Goal: More Good Days
We need to plan our lives to the end, be-
yond the administrative work of complet-
ing advance directives. We need to plan
to go even further than the very impor-
tant discussions about treatment choices
and documentation of health care proxies.
Equally important in making end-of-life
care person-centered is the exploration of
more good days.
A focus on more good days engages the
patient by asking: “What is a good day for
you?”
Each person’s “good day” is uniquely their
own. For some, any day alive is a good day.
For others, a good day may mean the op-
portunity to enjoy an activity or the com-
pany of loved ones. With this in mind,
questions about advanced care options help
patients discover how likely each proposed
treatment will create more good days than it
takes away. With the focus on good days, it
Person Centered Medicine
becomes easier to discuss which treatments
might result in the greatest net number of
good days.That can be a welcome shift from
answering the question of more care vs. less
care.
Perhaps truly person-centered care in ad-
vanced illness is not so much about how
we plan the end of our lives, but rather how
we want to live our lives to the end. (Focus
groups and provider interviews we’ve con-
ducted suggest that this approach can open
up communication among patients, families
and providers.)
Patients and families can help protect and
support “good days” by becoming well-
informed about treatment options and
their potential clinical outcomes, and by
becoming well-prepared for what is likely
to happen throughout the course of an ill-
ness. Framing care planning around more
good days would mean making decisions
that protect “good days,” that is, making
decisions based upon a balance of two
things:
• The chance that any proposed treatment
will extend the number of good days for the
patient.
• The chance that any proposed treatment
will reduce the number of good days for the
patient.
Using a person-centered approach focus-
ing on more good days, patients, families
and caregivers gain from each other these
benefits:
• Understanding of the patient’s treatment
and care options and each option’s likely
impact on remaining good days.
• Understanding of the patient’s options
for effective pain control either at home
or in care facilities.
• Emotional support and practical tips for
when the patient chooses to receive late
life care in their own home with family
and friends present.
• Consensus and acceptance among family
members for a chosen care plan or ad-
vance directive.
Conclusion
Good days become particularly precious
when one’s health is fragile and failing.
Choosing a more good days approach is to
seek to improve patient understanding and
to help them get care aligned with what
they prefer and want. In no way does it sug-
gest that patients be deterred from making
a choice to pursue life-extending treatment.
For some people, fighting for life every inch
of the way could constitute a day well-spent.
We, as care professionals, cannot judge any
patient’s choices if we seek to be person-
centered in our care.
Making it possible to gain clarity about
more good days and helping people express
their preferences to their families and care
providers will help make care, right up until
the end, truly person-centered.
Resource List: USA-based programs
that promote patient-centered
Advance Care Planning:
• ACP Decisions: www.acpdecisions.org
• Advanced Illness Management (AIM) ®:
http://www.sutterhealth.org/quality/focus/
advanced-illness-management.html
• Healthwise Advanced Care Planning
Assets: http://www.healthwise.org/docs/
DOCUMENT/8349.pdf
• Respecting Choices®: http://www.
gundersenhealth.org/respecting-choices
• The Conversation Project: http://thecon-
versationproject.org
References
1. Gawande A. 2010. Letting Go.The New Yorker,
August 2.
2. Kemper D. 2013. More Good Days. White Pa-
per, Boise: Healthwise.
3. Views on End of Life Medical Treatments. Pew
Research Center. 2013. www.pewforum.org.
November 11. Accessed April 10, 2015. http://
www.pewforum.org/2013/11/21/views-on-end-
of-life-medical-treatments/.
4. Facing Death.Facts and Figures.2015 www.pbs.
org. Accessed April 10, 2015. http://www.pbs.
org/wgbh/pages/frontline/facing-death/facts-
and-figures/
5. Zhang B. et al. 2009. Health care costs in the
last week of life. Arch Intern Med.2009; 169 (5):
480>-488
6. End-of-Life Care. Dartmouth Atlas of Health
Care. 2015. http://www.dartmouthaltlas.org.
Accessed April 10, 2015. http://www.dart-
mouthatlas.org/keyissues/issue.aspx?con=2944
“People with severe chronic illness who live in com-
munities where they receive more intensive inpa-
tient care do not have improved survival, better
quality of life, or better access to care than patients
who live in communities where they receive less
care. Patients’ experience of care, however, differs
dramatically; they receive a much more aggressive
brand of medicine, seeing medical specialists more
frequently, spending more days in the hospital, and
dying in an ICU more often than those in lower in-
tensity regions.”
7. Ibid. Dartmouth Atlas of Health Care. 2015,
8. C-TAC. C-TAC Applauds Landmark 2016
Medicare Physician Fee Schedule (PFS) Pro-
posed Rule on Advance Care Planning. The
Coalition to Transform Advanced Care 2015.
Accessed August 24, 2015. http://www.thectac.
org/2015/07/3912
Molly Mettler,
Senior Vice President, Mission
Healthwise
Boise, ID 83702
USA
E-mail: mmettler@healthwise.org
Healthwise is a not-for-profit consumer health infor-
mation organization whose mission is “to help people
make better health decisions.”
UNITED STATES OF AMERICA
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IV