WMJ 02 2011

UNITED STATES
vol. 57
MedicalWorld
Journal
Official Journal of the World Medical Association, INC
G20438
Nr. 2, April 2011
• Council Session in Sydney
• TaskD elegation Versus Task Shifting in the Indonesian
Health Service
• Infectious Diseases
wmj 2 2011 5CS.indd I 4/29/11 11:13 AM
Cover picture from Japan
ii
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
Dr. Alan J. Rowe
Haughley Grange, Stowmarket
Suffolk IP143QT, UK
Co-Editor
Prof. Dr. med. Elmar Doppelfeld
Deutscher Ärzte-Verlag
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Assistant Editor Velta Pozņaka
wmj-editor@wma.net
Journal design and
cover design by Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher
“Medicīnas apgāds”, President Dr. Maija Šetlere,
Katrīnas iela 2, Riga, Latvia
Cover painting:
The printing depicts the Ikaho Onsen
(hotspring) in Japan. It is said that the hotspring
was found in the 2nd
Century or 7th
Centry, good
to digestive diseases, rheumatism, neuralgia,
paralysis, bruises, etc. A westerner on the
right edge may be Dr. Erwin Von Baelz, a
German medical doctor, who was said to have
praised the Ikaho Onsen for its health benefits.
This printing was made by an ukiyo-e artist,
Kunichika Toyohara (1835–1900).
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ISSN: 0049-8122
Dr. Wonchat SUBHACHATURAS
WMA President
Thai Health Professional Alliance
Against Tobacco (THPAAT)
Royal Golden Jubilee, 2 Soi
Soonvijai, New Petchburi Rd.
Bangkok,Thailand
Dr. Leonid EIDELMAN
WMA Chairperson of the Finance
and Planning Committee
Israel Medical Asociation
2 Twin Towers, 35 Jabotinsky St.
P.O. Box 3566, Ramat-Gan 52136
Israel
Dr. Masami ISHII
WMA Vice-Chairman of Council
Japan Medical Assn
2-28-16 Honkomagome
Bunkyo-ku
Tokyo 113-8621
Japan
Dr. Dana HANSON
WMA Immediate Past-President
Fredericton Medical Clinic
1015 Regent Street Suite # 302,
Fredericton, NB, E3B 6H5
Canada
Sir Michael MARMOT
WMA Chairperson of the Socio-
Medical-Affairs Committee
British Medical Association
BMA House,Tavistock Square
London WC1H 9JP
United Kingdom
Dr. Guy DUMONT
WMA Chairperson of the Associate
Members
14 rue des Tiennes
1380 Lasne
Belgium
Dr. José Luiz
GOMES DO AMARAL
WMA President-Elect
WMA Chairperson of the Socio-
Medical-Affairs Committee
Associaçao Médica Brasileira
Rua Sao Carlos do Pinhal 324
Bela Vista, CEP 01333-903
Sao Paulo, SP Brazil
Dr.Torunn JANBU
WMA Chairperson of the Medical
Ethics Committee
Norwegian Medical Association
P.O.Box 1152 sentrum
0107 Oslo
Norway
Dr.Frank Ulrich MONTGOMERY
WMA Treasurer
Herbert-Lewin-Platz 1
(Wegelystrasse)
10623 Berlin
Germany
Dr. Mukesh HAIKERWAL
WMA Chairperson of Council
58 Victoria Street
Williamstown, VIC 3016
Australia
Dr. Otmar KLOIBER
WMA Secretary General
13 chemin du Levant
France 01212 Ferney-Voltaire
France
World Medical Association Officers, Chairpersons and Officials
Official Journal of the World Medical Association
Opinions expressed in this journal – especially those in authored contributions – do not necessarily reflect WMA policy or positions
www.wma.net
wmj 2 2011 5CS.indd Sec1:ii 4/29/11 11:13 AM
41
Council Down Under
For many years, the mid-year WMA Council session of the year
(held in April or May of each year) has been held in the Geneva
area, for reasons of economic prudence and the will to connect it
to the World Health Assembly (WHA). However the results have
been mixed. Yes, it has been more economic to stay close to the
WMA office in the Geneva area, but not substantially so – either in
terms of price or value for the money.The Geneva area is known for
its very high prices, and when it comes to meeting services, there is
ample room for improvement.The opportunity for WMA delegates
to take advantage of being in Geneva for the Council session in or-
der to attend the WHA has not generally been a huge success. Over
the last several years, not more than a handful of Council attendees
have stayed on for the WHA.
Most important,we have learned that remaining in the Geneva area
where dozens of associations and organizations are holding meet-
ings at the same time limits the amount of visibility of the WMA
Council session. Starting in 2007, the WMA ended the stationary
status of the Council Session, venturing back out into the world
again in alternating years, first to Berlin, then to Tel Aviv in 2009,
and this year to Sydney. These venues generated increased atten-
tion to the Council sessions,attracting more members and observers
than those held in the Geneva Area.
For a membership-based organization this active participation is
crucial. Returning the hosting role to our member associations has
raised their interest and commitment to our Council meeting and
has attracted public attention as well. The Australian Minister of
Health,Nicola Roxon,leveraged the occasion of the Council session
to launch her new law proposal on plain packaging of cigarettes –
and this on World Health Day, April 4th
. There was no better place
for this ambitious health initiative than a stage prepared by the
global organization of physicians.A brave new concept,and the first
effort to legally codify a requirement for plain packaging, the initia-
tive was immediately backed by the Council, which is recommend-
ing that General Assembly make this part of the WMA policy.
The Australian and the New Zealand Medical Association used the
meeting to stage a Leadership Day immediately before the Coun-
cil, taking advantage of the presence of a large number of medical
leaders from around the world who had come to attend the WMA
Council Session. And, last but not least, the Governor General is-
sued a rare invitation for a reception to WMA Council Members,
highlighting the importance Australia places on the work of its phy-
sicians.
Returning to Australia after 15 years was also a tribute to our col-
leagues in Australia, New Zealand and the Pacific. Despite the fact
that they must travel the farthest for most of our meeting venues,
they have proven among our most faithful, committed members,
with many delegates from the Pacific region serving the WMA as
Council members, officers, advisors and volunteers. The election in
his home country of Dr. Mukesh Haikerwal as WMA’s new Chair
of Council was a happy coincidence, and the natural result of his
exceptional engagement in the WMA during the past years.
Finally, the WMA got its junior doctors network going. With an
active group, strongly backed by young physicians from the region,
this is a promising initiative to keep the WMA inter-generational.
What has been missing – a global platform for doctors in training –
is now available within the Associate Membership of the WMA.
The WMA is proud to have this new platform under its roof.
Dr. Otmar Kloiber WMA Secretary General
wmj 2 2011 5CS.indd 41 4/29/11 11:13 AM
42
It gives me great pleasure to welcome you
to Sydney and to Australia and to address
your conference.
You’ve come to a wonderful country for this
council meeting and you’ve come at an ex-
citing time.  Australia is not just a beauti-
ful and welcoming country, it has a strong
health system too. 
But we acknowledge the strength of our
health system will not last, faced with the
challenges of demography and chronic dis-
ease without reforming key parts of the sys-
tem.
No doubt many of these challenges are
shared in your countries too, and will be
covered at length in your conference.
At the start of my second term as Austra-
lian Health Minister I can share with you
how the Gillard Government is facing these
challenges and how some of our reforms are
being implemented.
I’d like to focus first on three areas that pro-
vide a sample and flavour of our reforms:
(1) our determination to shift the centre of
gravity in our health system more heav-
ily to primary care;
(2) financing and accountability – particu-
larly in a federated country to benefit
consumers; and
(3) modernising health service delivery
through technology.
(1) Our Government has put a lot of focus
on heavily supporting our GPs,and primary
care more broadly.  We strongly believe this
is better for patients but also helps us better
manage the growing cost of high tech and
expensive interventions.
The OECD reports that Australia has an
overnight hospitalisation rate of 163.4 per
1,000 population compared to half that at 84
per 1,000 population in Canada, 137 in New
Zealand and 134 in the United Kingdom.
And in the decade to 2007–08, the number
of hospital admissions in Australia rose by
37 per cent – that is an unsustainable figure.
So doubling our GP training numbers,
incentivising general practice in commu-
nities that are undersupplied, providing
infrastructure funding through GP super
clinics and to existing practices to expand
multidisciplinary work and training in pri-
mary care are all part of our drive to boost
primary care.
Our next steps are establishing Medicare
Locals – to help co-ordinate disparate and
dispersed private practices and to identify
and fill gaps within those local communi-
ties.  Our vision is that primary care with-
in local communities will grow a voice to
match the strength and voice of local hos-
pitals.
(2) Another big area of our reform focuses
on better financing and better accountabil-
ity for health expenditure across all jurisdic-
tions – but also better information for con-
sumers that can flow from this. 
Whilst some of our financing problems are
unique to the Australian federal system  –
our determination to establish an national
efficient price and to have national perfor-
mance benchmarks are not. 
We already launched our “MyHospitals”
website which advises, hospital by hospital,
emergency department waiting time and
elective surgery waits.  These are two areas
where we are investing more to change the
way we do things and get improved and
timely access for consumers.
(3) Our Government has been very deter-
mined to unleash the potential of technol-
ogy – to become one of the world’s leading
digital economies by 2020.  Our national
broadband network will allow users internet
access at speeds the envy of the world.  This
network will enhance the care we can pro-
vide, especially in remote parts of the coun-
try or where our specialists are distant from
those who need their care.
We’ve committed to a personally controlled
electronic health record for all Australians. 
This will mean that patients won’t have
to tell their medical history to every new
health professional that they see when they
are travelling across the country or when
they move.  And, by the way, we’re pretty
mobile  – more than 331,400 Australians
moved interstate in 2009–10.
Public Health AUSTRALIA
Nicola Roxon
New Policy Against the Tobacco
Speech during World Medical Association Council Meeting,
Sydney 7th
April 2011
by The Hon. Nicola Roxon,
Australia’s Federal Minister for Health and Ageing
wmj 2 2011 5CS.indd 42 4/29/11 11:13 AM
43
Public HealthAUSTRALIA
With patient permission,health profession-
als that they consult will be able to access
their history – not just saving a lot of time
but also preventing errors and saving lives. 
For example, medication errors alone cur-
rently account for 190,000 admissions to
hospitals in this country each year. Avoid-
ing mistakes on medications, allergies and
reactions will be a huge benefit, especially
for older people.
In a similar vein, from 1 July this year we
will have a national after hours GP hot-
line – initially by phone,but with the poten-
tial to grow to an online video conference
from July 2012, talking to a doctor from
your own home. 
Also from 1 July 2011 Medicare rebates
will be payable for specialists consultations
across the internet  – for those unable to
access face to face consultations, this will
liberate them from the tyranny of distance. 
We want to tackle the brutal truth that too
many rural and regional Australians don’t
get the care they need if it involves hours, or
often days, of travel. 
I hope these few examples of our broad re-
forms are of interest and give you a sense of
the breadth and flavour of reforms that are
designed to significantly improve the health
of Australians and reinforce our system for
the future.
The main focus of my presentation today,
though, is on our Government’s passionate
determination to tackle preventable disease. 
This is a clear challenge of the future, and a
clear component of our need to help make
the health system sustainable.
As you know in this audience, many of the
major diseases – cancer, cardiovascular dis-
ease and diabetes – are potentially avoidable.
In fact it’s reliably estimated that risk fac-
tors contribute to more than 30 per cent
of Australia’s total burden of death, disease
and disability.
A particular challenge is that a vast and
rising proportion of our burden of illness
and mortality is due to conditions which
develop over some time and which could
be avoided or prevented, often by relatively
cheap and low-tech interventions.
It needs local and national initiatives to
educate the public about health risks and to
support healthy lifestyles and disease pre-
vention.
The Government is making the nation’s
largest investment in preventative health –
$872 million over 6 years.  These invest-
ments stretch from work in local commu-
nities such as cooking classes, community
gardens and walking groups that are par-
ticularly disadvantaged, to workplace ini-
tiatives, a focus on children, and our new
campaign “swap it, don’t stop it.”
As part of this work, I want to focus on one
area where Australia has made good prog-
ress, where we are committed to the long
haul and have important news to share.
The area is tobacco control
Smoking is one of the most damaging pre-
ventable causes of ill health and death in
Australia.
It causes a range of cancers and chronic dis-
eases well known to you all – because you
have to treat them.
It currently kills about 15,000 Australians
each year,and costs Australia’s economy and
society about $31.5 billion dollars a year.
Globally, the World Health Organisation
estimates that 5 million people die from
tobacco-related illness each year, most of
them in low- and middle-income countries. 
This is expected to reach 9 million by 2030.
As you all know the message is blatantly
clear: if we reduce smoking rates we can
radically reduce the burden of cancer and
chronic disease.
Australia has had success over the years.
Australia recognised the malign influence
of cigarettes early and has made signifi-
cant progress in reducing the smoking rate. 
Over the years the Commonwealth, State
and Territory Governments together have
prohibited advertising, removed sponsor-
ships, restricted point of sale displays, and
outlawed smoking in restaurants and many
public places.
Thanks to increasing efforts by govern-
ments, the proportion of Australians aged
14 years and over who smoke each day has
fallen from 30.5 per cent in 1988 to 16.6 per
cent today – one of the lowest in the world.
However about 3 million Australians con-
tinue to smoke every day – so there is more
that can and will be done.
Smoking is also more concentrated among
people in disadvantaged groups, and en-
trenches disadvantage by entrenching ill
health.  Naturally a Labor government
is concerned by the hard caused in these
groups.
For example, the adult daily smoking rate
among Australia’s Aboriginal and Torres
Strait Islander people – at 47 per cent – is
more than double the whole of population
smoking rate and is estimated to contrib-
ute 17 per cent of the large life expectancy
gap between Indigenous and other Austra-
lians.
When we first came to office our Govern-
ment committed to closing the gap in life
expectancy between Indigenous and non-
Indigenous, but we cannot do that without
reducing their smoking rates.
That’s why the government is making a re-
cord investment in helping Aboriginal and
Torres Strait Islander communities to tack-
wmj 2 2011 5CS.indd 43 4/29/11 11:13 AM
44
Public Health AUSTRALIA
le smoking  – through indigenous tobacco
workers and the first ever advertising cam-
paign for the indigenous community.
The daily smoking rate among other dis-
advantaged groups also remains unaccept-
ably high.  It is around 32 per cent among
unemployed people and a similar rate for
people with mental illness. 
Around 50 per cent of men in some cultur-
ally and linguistically diverse communities
smoke.  And tragically, over 40 per cent of
pregnant teenagers.
I am very strongly of the view that we in
government and you in the medical profes-
sion have a responsibility to do all that we
can to reduce smoking and reduce the pain
and suffering it causes.
That is why the Labor Government has
taken the lead, at home and internationally,
on this important issue.
We have set targets to reduce the national
daily smoking rate to 10 per cent or less of
the population by 2018 and halve the smok-
ing rate for Indigenous Australians.
We are approaching these targets by mov-
ing simultaneously on a comprehensive
range of fronts –
• In April last year we increased the excise
on tobacco products by 25 per cent, ef-
fectively increasing the price of a packet
of 30 cigarettes by over $2.
• We have legislation in the Parliament to
restrict internet tobacco advertising in
Australia, bringing it in line with restric-
tions on advertising in other media.
• We are making record investments in an-
ti-smoking social marketing campaigns,
including tough new advertisements
linking smokers’ cough with lung cancer
and the first ever national indigenous
anti-smoking advertisement.  These cam-
paigns are being extended to specifically
target high risk and hard to reach groups
including pregnant women, people with
mental illness, prisoners and people from
culturally and linguistically diverse back-
grounds.
• In February we provided heavy subsidies
for nicotine replacement therapies, as an
aid to quitting smoking, on the Pharma-
ceutical Benefits Scheme.
These are important initiatives to keep Aus-
tralians healthy, but there is more that we
can do.
Plain Packaging
So, today I am pleased to announce a world
first initiative.
Today I am releasing the world’s first plain
packaging laws.  I’m releasing a consulta-
tion paper and the exposure draft of the
government’s legislation on plain packag-
ing  – the world’s toughest legislation on
tobacco promotion.
Plain packaging will remove one of the last
remaining forms of tobacco advertising. It
will restrict tobacco industry logos, brand
imagery, colours and promotional text.
The packaging will be mandated to appear
in a standard dark olive brown colour which
has been chosen based on research for the
lowest appeal to smokers.
The only thing to distinguish one brand
from another will be the brand and product
name in a standard colour,standard position
and standard font size and style.
Most of the front of the package – 75 per
cent, up from the current 30 per cent – will
be covered with updated graphic health
warnings, adding to the current 90 per cent
coverage on the back of the pack.
As you see from these examples, all vestiges
of marketing messages have disappeared;
the pack now becomes a stark reminder of
the health effects of smoking.
Manufacturers will also be permitted to
include certain anti-counterfeiting design
features that do not run counter to the
public health objectives of the measure, to
minimise any impact on the illicit trade in
tobacco products.
There is strong evidence to support this
tough approach.
The National Preventative Health Task-
force, commissioned by the Australian
Government in 2008 as a key part of our
reform plans examined the growing body of
evidence on plain packaging and conclud-
ed – “there can be no justification for allow-
ing any form of promotion for this uniquely
dangerous and addictive product which it is
illegal to sell to children” – including on the
packaging.
The taskforce said plain packaging would:
• increase the impact of health warning
messages;
• reduce the ability of tobacco companies
to mislead consumers into believing that
some cigarettes are less harmful than oth-
ers;
• make cigarettes look less attractive – for
adults and children;
• and reduce the appeal and desirability of
smoking generally.
But it’s not just our national taskforce
which believes this. Plain packaging has
been discussed in various countries and fo-
rums over the past 25 years, and is backed
by the World Health Organisation.
Our legislation will give effect to commit-
ments under the WHO Framework Con-
vention on Tobacco Control, which was
adopted by the World Health Assembly on
21 May 2003 and entered into force on 27
February 2005.
The Framework Convention has since be-
come one of the most widely embraced
treaties in UN history. To date, more than
170 countries have ratified it.
wmj 2 2011 5CS.indd 44 4/29/11 11:13 AM
45
The Conference of the Parties to the Frame-
work Convention agreed in 2009 that plain
packaging should be considered as part of
comprehensive bans on tobacco advertising
and as a way of ensuring that consumers are
not misled about the dangers of smoking. 
Australia is the first signatory and the first
country in the world to commit to imple-
menting these recommendations on plain
packaging.
We intend the legislation to commence on
1 January next year, with the requirement
that all products on sale comply with the
new laws within six months.
To meet these timelines, I am today releas-
ing a consultation paper together with the
plain packaging design and an exposure
draft of the legislation for 60 days of public
consultation.
I will then introduce the Tobacco Plain Pack-
aging Bill 2011 during the winter sitting of
Parliament.
I expect Big Tobacco to fight these steps
tooth and nail.
They are already doing everything in their
power to fight the Government politically
and legally.This legislation will be no excep-
tion.
They have established a group to front their
activities – The Australian Retailer’s Asso-
ciation.
The Association ran a multi-million dol-
lar advertising campaign in the last Federal
election against the Government.
They claim plain packaging “won’t work” –
but if it won’t work, why would they pour
millions of dollars into opposing it?
It’s simple – a reduction in smoking rates
is a reduction in profits, a reduction in bo-
nuses.
Money is no object to them because they
are fighting to keep a very profitable global
front – hawking their killer products across
the developing world.
They know that if Australia is the first, we
will not be the last.
We might be breaking ground, but we are
on firm ground.  Others will follow.
Then tobacco companies will be forced to
scurry around the world targeting other
countries with their insidious products.
A global business, causing global hard de-
serves a global response.
I believe therefore that Governments and
the medical profession must continue to
work together to fight tobacco.
I believe there is an imperative on people
like me, in government, and people like you,
in the medical profession,to act to do what-
ever we can to reduce the smoking rate.
I therefore ask you when you return to your
own country, to urge your government to
act in the fight against tobacco  – to take
further steps to implement  commitments
under the WHO Framework Convention.
It’s true that our nation and the world have
other important health issues, all of which
require attention.
But reducing smoking – compared to most
of those problems – is relatively simple and
incredibly cost effective.
It doesn’t require a new workforce, huge in-
vestment of dollars or new health techno-
logy.
It does require a great deal of political will
and determination to withstand the tobacco
lobby.
I consider myself very fortunate to be part
of a government that has that determina-
tion.  But I can also assure you that it feels a
lot less lonely when you have strong support
from people like yourselves.
I hope that when your return home you will
press for plain packaging in your country
and for it to become commonplace around
the world.
Because tobacco smoking is one health di-
saster that we can stub out, if we have the
will.
Public HealthAUSTRALIA
wmj 2 2011 5CS.indd 45 4/29/11 11:13 AM
46
WMA news
Council Meeting
The 188th
Council session (7–9 April) was
opened by the Secretary General, Dr. Ot-
mar Kloiber at the Westin Hotel, Sydney,
Australia. He welcomed new members of
Council and said apologies had been re-
ceived from the Japanese physician mem-
bers,who were heavily involved in the after-
math of the Japan earthquake.
The first business was the election of the
Chair of Council, the Vice Chair and the
Treasurer. Dr. Mukesh Haikerwal (Aus-
tralia) was elected unopposed as Chair
of Council, replacing Dr. Edward Hill
(America) who stood down after four years
in the post. Dr. Masami Ishii (Japan) was
re-elected Vice Chair of Council and Dr.
Frank Ulrich Montgomery (Germany) was
elected Treasurer.
Dr. Wonchat Subhachaturas, the President,
gave a report on his activities and his vis-
its since October. He referred to the various
natural disasters around the world and the
work that medical professionals were doing
to treat the victims,and he asked delegates to
stand in silence in respect of those who had
lost their lives. He also spoke about attacks
on physicians in conflict zones and said that
medical professionals must be protected at
all times, although the profession must not
take sides or be part of these conflicts.
The WMA then welcomed the Hon. Nic-
ola Roxon, Australia’s Federal Minister for
Health and Ageing, to open the conference.
In her address, she spoke about the health
challenges facing the world and current
reforms being undertaken in Australia  –
shifting the centre of gravity to primary
care, addressing the issues of finance and
accountability and modernising the health
service through new technologies.
She then announced a major new policy
on tobacco control with proposed legisla-
tion for plain packaging for cigarettes. This
was the latest step in the fight to reduce the
number of smoking related deaths in Aus-
tralia,which currently totalled 15,000 lives a
year. She said this development was a world
first and the proposed new plain packs had
been designed to have the lowest appeal to
smokers. She appealed to WMA delegates
to urge their governments to take similar
action.
Dr. Kloiber then presented the secretariat’s
report on the WMA’s activities since the
last meeting.
Antimicrobial Resistance
Speaking on what was World Health Day,
with its theme of antimicrobial resistance,
Dr. Kloiber said that WMA policy on the
issue was far ahead of its time and every-
thing forecast in its 15-year-old Statement
had come true. The world was now facing a
disaster, dealing with resistance on a large
scale, killing many people round the world.
He announced that, together with the Cen-
ter for the Study of International Medical
Policy and Practices at the George Mason
University, USA, and the International So-
ciety for Microbial Resistance, an online
training course on antimicrobial drug resis-
tance had been set up and could be accessed
on the George Mason University website.
Non Communicable Diseases
As part of the WHO’s Global Action
Plan on Non Communicable Diseases
the WMA, together with the members of
the World Health Professions Alliance
(WHPA), had developed a campaign to
188th
WMA Council Meeting
Sydney, Australia 7th
–9th
April 2011
Rosanna Capolingua
Wonchat Subhachaturas
Dana Hanson
J. Edward Hill
Mukesh Haikerwal
Otmar Kloiber
Jose Luiz
Gomes Do Amaral
Frank Ulrich
Montgomery
Sir Michael Marmot
Jón Snædal
wmj 2 2011 5CS.indd 46 4/29/11 11:13 AM
47
WMA news
prevent NCDs by targeting the common
risk factors and the social determinants of
health.In the run up to the United National
Summit on NCDs in September 2011, the
WHPA would begin with an advocacy and
awareness raising campaign aimed at health
professionals, patients and government.
Multi Drug Resistant
Tuberculosis Project
As part of the Lilly MDR-TB partnership,
the WMA had printed a version of the TB
refresher course for physicians and trans-
ferred it into an interactive TB refresher
online course available free of charge from
the webpage.The course had been nominat-
ed by the United States Center of Disease
Control (CDC) as an educational highlight
and had received an award.To complete the
online tools two virtual patient cases on TB
and MDR-TB had been developed with
INMEDIA.
The WMA had also become a member of
the Stop TB Partnership Human Rights
Task Force.
Alcohol
In line with the WMA Statement on Re-
ducing the Global Impact of Alcohol on
Health and Society, the secretariat had
monitored the drafting process of the
WHO’s Global Strategy.
Counterfeit Medical Products
The WMA and the members of the World
Health Professions Alliance had stepped
up their activities on counterfeit medical
issues and developed an Anti-Counterfeit
campaign with an educational grant from
Pfizer Inc. and Eli Lilly. The basis of the
campaign was the ‘Be Aware’ toolkit for
health professionals and patients to in-
crease awareness of this topic and provide
practical advice for actions to take in case
of a suspected counterfeit medical product.
Two regional WHPA Counterfeit Medical
Products workshops had been organised in
Costa Rica and Nigeria.
Health and the Environment
On climate change, lobbying activities had
been undertaken following the Cancun
Summit in 2010, inviting medical associa-
tions to write to their governments to ask
that health be brought to the forefront of
the global warming debate.
Joint action was also being explored to pro-
tect human health and the global environ-
ment form the release of mercury.
Social Determinants of Health
Following the decision in Vancouver, a
Workgroup had been established to draw
up a draft policy on the initiative of the
British Medical Association. The group
was also monitoring the preparation of the
World Conference on Social Determinants
of Health organised by WHO in Rio de Ja-
neiro from 19 to 21 October 2011.
Health systems
An international conference to review the
effect of the global economic crisis had
been held in Riga, Latvia in September
2010. Entitled “Financial Crisis – Implica-
tions for Health Care – Lessons for the Fu-
ture”, the conference revealed, on one hand,
a staggering vulnerability of some health
care systems to the economic situation and
documented that it was the weakest mem-
bers of society that suffered the most when
a crisis hit the health care system. On the
other hand, examples demonstrated that
health care systems, when appropriately
protected, did actually support the overall
economy.
Hisashi Tsuruoka
Yoram Blachar
Robin J. Menes
Robert Ouellet
Dongchun Shin
Cecil B. Wilson
Paul-Emile Cloutier
Vivienne Nathanson
Torunn Janbu Heikki Pälve
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WMA news
The WMA had contributed to WHO ac-
tion in helping governments to monitor and
report about their health workforce and had
been represented at the World Economic
Forum’s Industry Partnership Strategists
Meeting for Health in New York in Sep-
tember 2010.
Prior to the OECD Health Ministerial
meeting in October, the OECD Forum on
Quality of Care took place and the WMA
was invited to present the physicians’ per-
spective on this issue.
Positive Practice Environment
Campaign (PPE)
The WMA continued its close involve-
ment in the Positive Practice Environment
Campaign, the global five-year campaign
spearheaded by WHPA members together
with the International Hospital Federation,
to ensure high-quality health workplaces
for quality care. The PPE Partners and sec-
retariat were working with national health
professional and hospital organisations in
Uganda, Morocco and Zambia to develop
country projects and improve their practice
environments. The campaign had organised
a workshop during the 2nd
Global Forum
on Human Resources for Health in Bang-
kok in January 2011 with participants from
more than 25 countries.
Migration & Retention
The WMA had taken part in drafting the
WHO Guidelines on Retention Strategies
for Health Professionals in Rural Areas,
aimed at attracting and retaining health
care professionals in rural areas. And in
January 2011, the Global Health Work-
force Alliance had organised the 2nd
Global
Forum on Human Resources in Health in
Thailand, where the WMA helped organise
a highly successful skills-building workshop
on Enhancing Personal Resilience for a
Sustainable Health Care Workforce.
Workplace Violence in
the Health Sector
The WMA had taken part in the planning
process of the Conference on Workplace
Violence in the Health Sector, held on
27–29 October 2010 in Amsterdam. Ms.
Leah Wapner, Secretary General of the Is-
rael Medical Association, presented a paper
on the issue.
Education & Research
The World Federation for Medical Educa-
tion had started a discussion process about
the future role of the physician, starting
with an expert panel in March that in-
cluded representatives of academia, WHO,
the WMA and international and regional
medical organisations.
Patient Safety
The WMA was a member of the WHO
reviewing committee to develop a Multi-
Professional Patient Safety Curriculum
Guide, after the WHO had defined patient
safety as a major global priority in health
care. To deliver safe health care, clinicians
required training in the discipline of patient
safety, which included an understanding of
the nature of medical error, how clinicians
themselves could work in ways that reduced
the risk of harm to patients, techniques for
learning from errors, and how clinicians
could harness quality improvement meth-
ods to improve patient safety in their own
organisations.
Caring Physicians of the World
Initiative Leadership Course
Invitations would be sent out to NMAs for
the fourth Leadership Course planned to
be held in Singapore on 20–25 November
2011. The curriculum included training in
decision-making, policy work, negotiat-
Ramin Parsa-Parsi
Fiona Davies
Alex Mark Well
David Mountain
Peter Foley
Roderick McRae
Michael Bonning
Mark Peterson
Ardis D. Hoven Julio Trotchansky
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WMA news
ing and coalition building, intercultural
relations and media relations. The courses
were made possible by an unrestricted edu-
cational grant provided by Pfizer, Inc. This
work has been supported by the WMA Co-
operating Center – the Center for Global
Health and Medical Diplomacy at the Uni-
versity of North Florida.
Speaking Book
The WMA launched the speaking book on
clinical trials during the General Assembly
in Seoul 2008, as part of a collaborative ef-
fort with the South African Medical As-
sociation, the SADAG (South African De-
pression & Anxiety Group) and the Steve
Biko Center for Bioethics in Johannesburg
and the publisher “Books of Hope”. The
speaking book on clinical trials in English-
Hindi & Telugu was launched at the 2009
General Assembly in India.The project was
made possible by an unrestricted education-
al grant provided by Pfizer, Inc. In March
2010, Books of Hope presented a speaking
book on the dangers of smoking, targeting a
low literacy community. Each of the books
was expected to be received by an average of
27 people as a study had shown. Thus the
first 5000 books had the potential to impact
50,000 to 100,000 people.
Human Rights
A seminar took place on 1–2 November
2010 in Turkey aimed at contributing to
the implementation of the right to health
and strengthening the independence of
the medical profession in Middle East
countries. The seminar was organised by
the Norwegian Medical Association, the
Human Rights Foundation of Turkey, the
Turkish Medical Association, the WMA
and the International Federation of Health
and Human Rights Organisations. Partici-
pants included representatives from health
organisations from Egypt, Iraq, Israel, and
Palestine together with the organisers of
the event. Issues raised during the event
were related to access to health care, such
as health care for undocumented migrants,
problems in accessing health care facilities
in occupied territories, lack of resources and
migration of health care personnel due to
violence.
During the year the WMA had written to
the Iranian authorities about the cases of
Dr. Arash Alaei and Dr. Kamiar Alaei who
were sentenced to six and three years’ im-
prisonment respectively, for “cooperating
with an enemy government”.
In February 2011, the WMA had sent let-
ters to the ministers of health and of inte-
rior in Bahrain expressing deep concerns
about attacks on health professionals that
were unprovoked and in breach of interna-
tional law enforcement standards.
Women and Children
and Health
The WMA had been invited to be involved
in a WHO initiative to develop “guidelines
for a health-care response to intimate part-
ner and sexual violence”. The overall aim
of this initiative was to elaborate a policy
framework intended to improve health sec-
tor responses to sexual violence by assisting
decision-makers to design health policy and
service measures that would provide com-
prehensive, sensitive and quality care to vic-
tims of sexual violence.
Medical Ethics
At the 2008 General Assembly, the Decla-
ration of Helsinki had been amended and
there was a debate on the use of placebo in
medical research. If a proven effective inter-
vention existed, the Declaration of Helsinki
allowed the use of placebo controls, though
only in very limited circumstances. How-
ever this opening raised some concerns.
In order to analyse the use of placebos in
Serafin Romero
Jose Manuel Silva
Luis Mazzuoccolo
Joel Hellstrand
Paul Ockelford
Marcos Gomez-Sancho
Ignacio Carrasco
De Paula
Ruben Tucci
Thomas Flodin
Kate Baddock
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WMA news
medical research a WMA working group
was formed. It was acknowledged that the
same ethical questions might arise with
any control group that received a treatment
less than the “best current proven interven-
tion” (which was currently required by the
Declaration). The overriding question of
the placebo controversy appeared to be: To
what extent and under which circumstances
was it ethically acceptable to provide a control
group with an intervention less effective than
the best current proven treatment in a clini-
cal trial? This included a placebo control as
well as a control with a second standard or
no treatment. The problem was aggravated
by the fact that in many circumstances it
was not conclusively known which was the
“best proven” treatment. Furthermore the
question remained, whether the different
economic circumstances in the different
parts of the world had to be considered in
the Declaration or not. Most prominent
were the questions: Whether the use of place-
bos, or interventions less effective than the best
current proven treatment had to be seen dif-
ferently on the existence of different economic
backgrounds? and What were the requirements
to post-trial access to care and how should they
be dealt with?
The workgroup would discuss these ques-
tions at a conference to be held in July 2011
in Sao Paulo, Brazil.
Medical and Health
Policy Development
The Center for the Study of International
Medical Policies and Practices, George-
Mason-University, one of the WMA’s Co-
operating Centers, had invited the WMA
to participate in the creation of a scientific
platform for international exchange on
medical and health policy development and
in 2009 the first issue of a scientific journal,
the World Medical & Health Policy was
published by Berkeley Electronic Press as
an online journal. It could be accessed at:
http://www.psocommons.org/wmhp.
World Health Professions
Alliance
After ten years of successful collaboration,
the four main health professions – physi-
cians,nurses,pharmacists and dentists – had
shown that working in collaboration instead
of along parallel tracks,benefited the patient
and health care system. Now the WHPA
was seeking to find best practice models of
similar inter-professional cooperation on a
national and local level. A working group
would research how a best practice model in
collaborative practice could be defined and
was looking for examples worldwide.
Medical Organisations in
Arabic Countries
The WMA was continuing to reach out to
medical associations in Arabic countries
and was pleased to have participation from
Egypt, Iraq and Palestine at its conference
“Right to Health as a Bridge to Peace in the
Middle East”.
Dr. Ramin Parsa-Parsi (Germany) reported
on discussions that had taken place in Bah-
rain, which were now on hold as a result of
the unrest in that country.The Council then
heard two oral reports about the natural di-
sasters in Japan and New Zealand.
Mr Hisashi Tsuruoka, a staff member from
the Japan Medical Association, reported on
the earthquake, tsunami and nuclear plant
accident in Japan. He said it was very dif-
ficult to obtain accurate information about
the disaster and its victims, as it was esti-
mated that about 240,000 evacuees were
staying in about 2,600 shelters over a wide
area. No-one knew how many people were
missing.The number of dead was estimated
at that time to exceed 30,000. In addition,
many medical institutions had collapsed.
He spoke about the work of medical disas-
ter teams and the help being offered by the
Japan Medical Association and teams from
many other countries.
Ming-Been Lee
Yung Tung Wu
Mads Koch Hansen
Cristina Lumby
Rasmussen
Marie Wedin
Chung-Shao Lin
Bente Fogh
Poul Jaszczak
Jeff Blackmer
Hakan Wittgren
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WMA news
The nuclear power plant accident in Fu-
kushima was aggravating the situation and
efforts to contain and resolve the problem
would be ongoing over the coming months
and years.
Mr Tsuruoka said, however, that he believed
Japan would recover in a much shorter pe-
riod that they were currently expecting.
Dr. Peter Foley (New Zealand) reported
about the earthquake which he said had
wiped out the core of Christchurch, New
Zealand. He thanked international col-
leagues for their help.
Medical Ethics Committee
Dr. Torunn Janbu (Norway) was re-elected
Chair of the committee.
Ethical Organ Procurement
Dr. Vivienne Nathanson (United Kingdom),
Chair of the Workgroup,gave an oral report
on work in progress. She said the group had
considered a first draft of possible principles
and had decided that the British Medical
Association would review existing policy to
see if it was up to date and fit for purpose,
and if there were gaps.
It hoped to present to the next meeting a
set of principles in terms of the ethical pro-
curement of organs and a background docu-
ment explaining the principles.
Other issues to be covered would include
commercialisation, trading in organs, pay-
ing donors, international transport of or-
gans, and sending patients abroad for treat-
ment that was illegal.
End-of-Life Medical Care
In a lengthy debate, the committee consid-
ered and amended a Proposed Declaration
on End-of-Life Medical Care and back-
ground document.
Dr. William Silvester (Australia), an inten-
sive care specialist and national director of
the Respecting Patient Choices Programme
in Australia, introduced the debate, speak-
ing about the importance of advance care
planning. He said this was not about eutha-
nasia but about giving patients a say about
their care, and advanced care planning em-
powered people.
The committee agreed to include in the
introduction to the document the phrase
‘palliative care at the end of life is part of
good medical care’ and in a discussion on
pain and symptom management, it agreed
to insert the words ‘the primary aim is to
maintain patients’dignity and their freedom
from distressing symptoms’.
Further amendments were agreed follow-
ing a detailed debate on the development
of care plans for patients approaching the
end of life and the way in which a patient’s
preferences should be initiated and han-
dled.
The committee approved the amen-
ded Declaration for consideration by
Council, which later agreed to for-
ward it to the General Assembly for
adoption.
It was decided to ‘file’the background docu-
ment to the policy.
The Ethics in Palliative Sedation
A Proposed Declaration on the Ethics
in Palliative Sedation was introduced by
the Spanish Medical Association (Consejo
General de Colegios Médicos de España)
exploring the boundary between palliative
sedation and active euthanasia. Following a
brief debate it was agreed to circulate the
document to NMAs for comment.
Bo Kyung Kang
W. Paul Rijksen
A.C. Nieuwenhuijzen
Kruseman
Ajay Kumar
Mervi Kattelus
Brendan Shaw
Deon Schoombie
Tatjanna
Radosavljevic
Prijo Sidipratomo
Jaroslav Blahos
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WMA news
The Ethics of Placebo Control
in Clinical Trials
Dr. Ramin Parsa-Parsi (Germany), Chair
of the Workgroup on Placebo in Medical
Research, gave a report from Workgroup
and said that the planned expert conference
(13–15 July) would now be relocated from
Tokyo, Japan to Sao Paulo, Brazil because
of the Japanese earthquake. The conference
would debate the general wording of para-
graph 32 of the Declaration of Helsinki, the
use of placebos in resource poor settings,the
positions of international organisations and
the ‘reasonable availability’ approach.
The Declaration of Tokyo
A proposal was discussed to revise the Dec-
laration of Tokyo on Guidelines for Phy-
sicians Concerning Torture to include the
development of a monitoring and reporting
mechanism to permit auditing states’ ad-
herence to the guidelines. Delegates sug-
gested that NMAs should offer support for
physicians in difficult situations, including
helping individuals to report violations of
patients’ health rights and physicians’ pro-
fessional ethics in custodial settings.
The committee approved the docu-
ment, which Council later agreed
to send to the General Assembly for
adoption.
Child Subjects
A Proposed Statement on Ethical Prin-
ciples for Medical Research on Child
Subjects, produced by Dr. James Appleyard
(UK), was considered and after a brief de-
bate it was decided to file the document.
Social Media
A Proposed Statement on the Profession-
al and Ethical Usage of Social Media, pre-
pared by Dr.Marianne Maman,an associate
member, was considered.
Dr. Kloiber said the WMA currently had no
policy on the use of social networks. Physi-
cians were using social networks, sometimes
for communicating with their patients.
Although everyone was in favour of using
technology to improve health care and com-
munications, social networks had a number
of problems. For instance, the information
being exchanged was being exploited for
commercial purposes.
So physicians had to take special caution.
Many NMAs were now using these social
networks to communicate with their mem-
bers. But the WMA had to examine these
issues more closely. He suggested that the
WMA should use the expertise of the new
junior doctors’ network to consider this is-
sue.
Dr. Michael Bonning, a junior doctor from
Australia,said that if they as doctors wanted
to be able to reach their patients and work
more effectively among themselves, then
the social media networks were some of the
challenges they had to deal with. He said
the junior doctors’ network would be happy
to help the WMA draw up a policy on this
issue.
Dr. Peteris Apinis (Latvia) said that in his
country pharmaceutical companies were
using these networks to approach doctors
about their products.
It was agreed to circulate the proposed
Statement and to set up a working party,
comprising members of the Committee and
the junior doctors’ network, to draft a new
policy. Council later approved this recom-
mendation.
Bio Banks
A Proposed Resolution on Physicians’
Ethical Responsibilities Regarding Bio
Miguel Roberto Jorge
Roberto Luiz d’Avila
Peter W. Carmel
Elie Chow-Chine
Pedro Barbosa
Way Oliveira
Michael D. Maves
Hernan Reyes
Gilbert Pioud
Trond Markestad
Alarico Rodriguez
de Leon
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WMA news
Banks was briefly considered and it was
decided to postpone the issue until the re-
vision of the WMA policy on health data-
bases.
Misuse of Drugs for Execution
An emergency Resolution expressing deep
concern about the misuse of drugs for the
purpose of capital punishment was pro-
posed by Dr. Ulrich Montgomery (Ger-
many).
He said this followed various approaches
that had been made to countries for the
export of thiopental to the USA for capital
punishment.
Dr. Peter Carmel (USA) said the Ameri-
can Medical Association had clear policy
preventing physicians from participating
in executions, but he suggested that this
specific matter concerning drugs be post-
poned until the AMA had investigated the
situation.
After a debate it was decided to postpone
consideration of the Resolution and estab-
lish a Workgroup to examine the question
of whether the WMA should develop a
policy statement opposing the use of capital
punishment.
Finance and Planning
Committee
After the committee had approved the
minutes of the last meeting, an election
for Chair took place to fill the vacancy
left by Dr. Haikerwal’s election as Chair
of Council. Two candidates were nomi-
nated – Dr. Leonid Eidelman (Israel) and
Dr. Robert Ouellet (Canada) – and after
a ballot, Dr. Eidelman was elected. How-
ever he was not able to be present because
of his leadership of a physicians’ strike in
Israel, and so the meeting was chaired by
Dr. Haikerwal.
Membership Dues
A report on Membership Dues Payments
for 2011 was tabled and agreed. Dr. Kloi-
ber proposed a new baseline of membership
dues to create a stable income situation and
to have a concrete means of determining
whether a constituent member was in good
standing.
The committee accepted the proposal and
recommended it to Council, which later
forwarded it to the General Assembly for
approval and adoption.
Financial Statement
Mr A. Hällmeyer, the Finance Advisor, gave
a detailed presentation on the pre-audited
financial statement for 2010,stating that the
positive trend of recent years had continued.
The audited Financial Statement was rec-
ommended for approval by Council, which
later also adopted it.
Strategic Plan
The committee received an oral report from
Dr. Ouillet, who led a Workgroup on the
format for a strategic plan for 2011–2015.
He emphasised how important it was for
members to respond to the survey sent out
to them and he also referred to surveys be-
ing sent to outside bodies.
WMA Meetings
The committee reviewed future meetings
and dates – Prague, Czech Republic for the
Council meeting in April 2012 and Bang-
kok, Thailand for the General Assembly in
October 2012. It was agreed that the theme
of the scientific session for the General As-
sembly in Bangkok should be ‘Megacity –
Megahealth’.This was later approved by the
Council.
Geir Riise Bjorn Oscar Hoftvedt
Steven Hambleton
Andrew Pesce
Nikolay Izmerov
Evgeny Achkasov
M W Sonderup
Evgeny Mashkovskiy
Sergey Puzin
Norman Mabasa
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WMA news
Network in Disaster Medicine
and Public Health
A proposed new Statement on Disaster
Preparedness and Medical Response was
considered. During the debate that fol-
lowed it was recognised that the role of the
WMA was not to provide or co-ordinate
practical assistance in the event of disasters,
which was complex work being done by
specialised relief organisations.
Rather it was to provide policy support and
opportunities for information exchange and
learning for national medical associations
and to engage in advocacy for disaster pre-
paredness on a national level.
Dr.Ardis Hoven (US) said the WMA should
build on the platforms already in place
around the world and perhaps use its web-
site to link to existing resources throughout
the world, while Dr. Janbu (Norway) said
the Workgroup should look at possibility
of facilitating a network, with information
about courses and existing organisations
that physicians might join.
Dr. Nathanson (UK) suggested the WMA
might put online a document to help doc-
tors understand the kinds of skill sets and
qualifications they needed for work in di-
saster zones. Often doctors were not sure
whether their skills would be useful. It was
agreed that the mandate of the Workgroup
should be extended to take these issues into
consideration and that the Statement be
circulated to NMAs for comment.
Greening of WMA Meetings
Dr. Mads Koch Hansen (Denmark), leading
a Workgroup on greening WMA meet-
ings, gave an oral report on the need for the
WMA to reduce its carbon footprint,saving
both money and human resources.
He suggested reducing the use of paper
by using the WMA website for accessing
documents, making more use of buses and
sharing taxis for travelling to conferences
and greening the WMA building with bet-
ter use of energy.
His report was supported by several speak-
ers and Dr. Nathanson (UK) said the British
Medical Association had saved a six figure
sum by reducing photocopying.
Dr. Kloiber said the time had come to go pa-
perless,but having both paper and web access
would not be a cost saving. It was decided to
ask Council to take action on the issue.
Membership
An application was received from the Trini-
dad and Tobago Medical Association to be
admitted into WMA membership and it
was decided to recommend this to Council,
which later agreed to forward the applica-
tion to the General Assembly for adoption.
Governance
The committee discussed further consolida-
tion of the bylaws, including issues such as
voting rights for the President, President-
elect and immediate Past President and the
termination of a President’s office.
Junior Doctors’ Network
Dr. Kloiber reported that the first draft had
been drawn up of terms of reference for set-
ting up a junior doctors’ network as part of
the Associate Membership. He said further
work on the terms of reference was required,
but he was pleased with the progress that
had been made.
Dr. Bonning said there was no current for-
mal process for junior physicians to interact
globally. He and his colleagues believed that
the WMA was the best vehicle for achiev-
ing this.
Annabel Seebhom
Lamine Smaali
Julia Seyer
Nigel Duncan
Sunny Park
Joelle Balfe
Elmar Doppelfeld
Roderic Dennett
Clarisse Delorme
Tania Goodacre
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WMA news
World Medical Journal
The editor of the Journal, Dr. Apinis, pre-
sented his report and said he had three pro-
posals – to promote and publicise the WMJ
to the members of NMAs,to be more active
in writing articles about the NMAs’ activi-
ties and to encourage Council members to
become involved in writing articles.
Socio-Medical Affairs Committee
The committee approved the minutes of
the last meeting, and then elected unop-
posed Sir Michael Marmot (UK) as the
new Chair.
Health and the Environment
The committee considered an oral report
from Dr. Ouellet (Canada), Chair of the
workgroup on health and the environment.
He said the group had consulted Dr. Larry
Frank, a Canadian expert on the area of
the built environment, based on a docu-
ment provided by the WMA office. The
group had decided that for the time being
the WMA was not in a position to draw
up policy in this specific area for lack of ex-
pertise. The document was based on North
American situations and did not meet the
international requirements of the WMA,
including in developing countries. The
group decided to send the document to the
Workgroup on social determinants for re-
view and incorporation in a broader social
context.The document would then be circu-
lated and posted on the website. It was then
decided that the group had accomplished
its work and should now be dissolved.
Declaration of Edinburgh
A Proposed Revision to the Declaration
on Prison Conditions and the Spread of
Tuberculosis and Other Communicable
Diseases was considered.
Dr. Janbu (Norway) asked whether the
phrase ‘physicians working in prisons have
a duty to follow national public health
guidelines, particularly concerning the
mandatory reporting of infectious and
communicable diseases’, could be a problem
where national guidelines were not in ac-
cordance with WMA policy. Dr. Nathanson
said the workgroup had assumed that any
NMA which believed their national guide-
lines were unacceptable would be lobbying
their government to get those guidelines
changed. The committee agreed that the
document should be amended and sent
to Council for forwarding to the General
Assembly for adoption.
Chronic Disease
The committee considered a Proposed
Statement on the Global Burden of
Chronic Disease, which Sir Michael Mar-
mot said was a hugely important issue.It was
on the WHO agenda and the UN General
Assembly would debate the issue later in
the year. Dr. Cecil Wilson (US), Chair of the
Workgroup, said this lent urgency to get-
ting the paper approved.
The paper had been circulated and includ-
ed solutions on prevention, primary care,
medical care and health infrastructure,
with recommendations for governments,
NMAs, medical schools and individual
physicians.
It was agreed to send the document to
Council, who later agreed to forward
it to the General Assembly for adop-
tion.
Violence in the Health Sector
A Proposed Statement on Violence in the
Health Sector was proposed by Dr. Yoram
Blachar (Israel), who said that violence
against physicians was becoming a real
problem.
This was caused in part by understaffing
problems, unreal expectations, dissatisfac-
tion with health services and the role of the
media and television in creating imaginative
expectations for the best medical result. He
said it was vital to adopt a policy of zero tol-
erance accompanied by relevant legislation.
Dr. Nathanson said that violence in the
health sector was a problem in all parts of
the world and she suggested expanding the
document to add in more areas to help less
developed parts of the world.
Dr. Janbu questioned the document’s pro-
posal that physicians should have the right
to refuse to treat previously violent patients,
except in emergency situations. She found
this a very difficult statement.
Dr. Nathanson said that the UK had a zero
policy to violence. But it was important that
alternative provisions were available before
physicians were able to refuse to treat a vio-
lent patient.
It was agreed to send the document to
Council.
Social Determinants of Health
A debate took place about the Proposed
Statement on Social Determinants, de-
scribed as the conditions in which people
are born, grow, live, work and age and the
societal influences on these conditions. Sir
Michael Marmot, Chair of the Workgroup
on the issue, said the World Conference on
Social Determinants, organised by WHO,
would take place in October in Rio de Ja-
neiro, Brazil. He was part of the organising
committee and the WMA would be part of
the conference.
It was agreed to send the document
to Council, which later agreed to for-
ward it to the General Assembly for
adoption.
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Armed Conflicts
The Norwegian Medical Association pre-
sented a Proposed Statement on the Pro-
tection and Integrity of Medical Personnel
inArmedConflicts.Dr.Janbu said the paper
highlighted the lack of a systematic reporting
of violent incidents concerning physicians.
This made it very difficult to know what
strategy to adopt to prevent attacks if they
did not know the extent of the problem. She
said she was surprised that no international
body had this responsibility. It was agreed to
circulate the document for discussion.
Tobacco-Derived Products
The American Medical Association brought
to the meeting a Proposed Revision of the
WMA Statement on Health Hazards of
Tobacco and Tobacco-Derived Products.
Dr. Ardis Hoven (US) said the tobacco in-
dustry were heavily marketing new forms
of tobacco-derived products with sticks,
mints and other nasty things to make their
products more appealing and acceptable.
Smokeless tobacco was also being aggres-
sively marketed and targeted towards young
people. There were also electronic cigarettes
available in convenience stores and on the
internet. The WMA had to address these
new forms of tobacco by revising its policy.
There needed to be a stronger statement
recommending banning the production,
distribution and sale of tobacco-derived
products that resembled candy.
She said that a separate policy statement
would be drafted by the American Medical
Association on electronic cigarettes follow-
ing further investigation about their status.
Dr. Nathanson wanted to see something
added on plain packaging following the an-
nouncement made that week by the Austra-
lian Government.
Dr. Peteris Apinis (Latvia) presented another
proposed revision to classify smoking in the
vicinity of children and pregnant women as
violence against children, as smoking sig-
nificantly reduced children’s life expectancy
and impaired their quality of life.
Dr. Rosanna Capolingua (Australia) said that
in her home state of West Australia they had
banned smoking in cars where children were
present, and the police actually policed that.
But several speakers were unsure about us-
ing the language of ‘violence against chil-
dren’ in the document and the Latvian
Medical Association was invited to come
back with a further proposal. It was agreed
to send the document to Council, which
later agreed to forward it to the General
Assembly for adoption.
Pain Relief
Dr. Nathanson presented a Proposed Reso-
lution on the Access to Adequate Pain
Treatment. She said that around the world
a lot of patients in pain were being denied
access to adequate pain killers because of
government policies and lack of availability.
She asked that the document drafted by the
British Medical Association and others be
sent out for consultation.This was agreed.
Ivory Coast
An emergency resolution on the situation in
the Ivory Coast was presented by Dr.Kloiber
at the request of the Ivory Coast Medical
Association. He said that as a result of civil
war in the country the European Union had
decided to implement sanctions which were
affecting the import of drugs leading to a
shortage. The Resolution (see separate box)
urged the EU to take steps immediately to
ensure the delivery of medical supplies to
the Ivory Coast in order to protect the life
and health of the population.
The committee agreed to forward the Reso-
lution to Council for approval.
Resumed Council Meeting
The Council considered the Medical Ethics
Committee report.
Social Media
It was agreed that the proposed Statement
on the Professional and Ethical Usage of
Social Media be referred to a Workgroup
comprising members of the Junior Doc-
tors’Network and two representatives of the
Medical Ethics Committee.
Capital Punishment
The Council agreed that a Workgroup be
set up to examine the question of whether
the WMA should develop a policy state-
ment opposing the use of capital punish-
ment. Included on the Workgroup will be
Dr. Haikerwal, Dr. Dana Hanson, Dr. Yor-
am Blachar, Dr. Cecil Wilson, Dr. Otmar
Kloiber and representatives from Denmark,
the UK and Uruguay.
Dr. Wilson (US) referred to the earlier de-
bate in the committee which indicated that
the US Government had solicited the drug
thiopental. On a preliminary investigation
his understanding was that the issue of thio-
pental used came to light because the US
Government’s drug enforcement agent had
seized supplies of thiopental from two states,
Tennessee and Kentucky, because of the as-
sumption they had been illegally obtained.
So these were supplies that were already in
the state and they had not been solicited.
They were just sold to these two states and
the US Government had not solicited their
import.
The Council approved the Medical Ethics
Committee report
The Council considered the Finance and Plan-
ning Committee report.
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WMA newsUNITED STATES
Disaster Medicine and Public Health
The Council agreed to expand the mandate
of the Workgroup.
Primary Care Conference
Dr. Rosanna Capolingua spoke about hold-
ing a conference on primary care to show-
case the primary care physician and empha-
sise the general practitioner being the leader
of the health care team.This was cost effec-
tive and efficient for the patient. Dr. Hanson
said that the term ‘primary care’ should go
wider than just family practice. Council
noted the comments.
Russian Conference
The Council debated a proposal by the Rus-
sian Medical Society for a WMA Confer-
ence to be held in Moscow in 2012 on the
relationship between physicians and the
pharmaceutical industry. Several speakers
questioned who would pay for the confer-
ence, while others expressed reservations
about the suggested topic and proposed
their own ideas.
The Council decided that the secretariat
should discuss the proposal further with the
Russian Medical Society and report back to
the General Assembly in October.
Georgian Medical Association Award
The Council debated a proposal from the
Georgian Medical Association to sponsor
an annual prize for outstanding physicians
internationally with the help of the WMA.
After several speakers expressed their
doubts about the proposal, the Council de-
cided not to pursue the proposal.The Coun-
cil approved the Finance Committee report
The Council considered the Socio-Medical Af-
fairs committee report.
Declaration of Edinburgh
Council agreed to amend the proposed re-
vision to the Declaration on Prison Condi-
tions and the Spread of Tuberculosis and
Other Communicable Diseases to read
‘physicians working in prisons have a duty
to follow national public health guidelines
where these are ethically appropriate’.
It was agreed to forward the docu-
ment to the General Assembly with
the recommendation that it be ad-
opted.
Violence in the Health Sector
A further debate took place about the docu-
ment’s proposal that physicians should
have the right to refuse to treat previously
violent patients, except in emergency situ-
ations. Several speakers questioned whether
this was the right approach and the Council
eventually decided to refer the document
back to the committee for further consid-
eration.
Global Health Data Charter
Dr. Haikerwal said that many groups were
involved in health with very little knowl-
edge about the subject, and they viewed
the issue as one of expense. The WMA had
been asked by the World Economic Fo-
rum to participate in the development of a
Global Charter on Health Data and then to
co-sign the Charter. But he had a number
of concerns about the Charter which was
not in line with WMA policies and was not
based on a patient-centred view of the is-
sues.
Having heard his comments, Council
agreed not to sign the Charter, but to fur-
ther engage with the World Economic Fo-
rum to advocate for an improvement of the
Charter, and to report back to Council if
changes occurred.
Tobacco-Derived Products
Dr. Apinis (Latvia) repeated the proposal he
put to the committee to classify smoking in
the vicinity of children and pregnant women
as ‘violence’. Dr Ardis Hoven (US) said she
was concerned about the use of the word ‘vi-
olence’. The objective should be not to pun-
ish but to educate people. They needed to
change the environment through parenting
information and in other ways and this op-
portunity would be better served by getting
away from using words such as ‘violence’.
After further debate, Council decided to
amend the proposed revision of the State-
ment on Health Hazards of Tobacco and
Tobacco-Derived Products to add that the
WMA should advocate the enactment and
enforcement of laws to ‘protect children
from passive smoking’.
Ivory Coast
Council voted to approve the emergency
motion reaffirming WMA policy on eco-
nomic embargoes and health (see box).
Advocacy Plan 2011/12
Dr. Hanson reported on the advocacy plan
for 2011/12 with its five headings – human
resources for health,health and the environ-
ment, individual health, human rights and
patient safety. The Council approved the
Socio-Medical Affairs Committee report.
World Health Assembly 2011
Ms Clarisse Delorme and Dr. Julia Seyer re-
ported on the forthcoming World Health
Assembly and highlighted several topics,
including climate change, the protection of
health personnel in armed conflicts,counter-
feit medicines, non communicable diseases
Nigel Duncan, WMA Public
Relations Consultant
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58
WMA news
Francis Sullivan
Ross Boswell
Richard H Osborne
Jane Halton
Brendan NelsonKatie Allen
Peter Flaming
George Margelis
Ron Trent
Mike Bainbridge
Council Resolution Reaffirming the WMA Resolution
on Economic Embargoes and Health
The World Medical Association is deeply concerned about reports of potential serious
health impacts resulting from economic sanctions imposed by the European Union
against Ivory Coast leader, Laurent Gbagbo, and numerous individuals and entities
associated with his regime, including two major ports linked to Gbagbo’s government.
The sanctions aim to severely restrict EU-registered vessels from transacting business
with these ports, which could inhibit the delivery of necessary and life-saving medi-
cines.
The WMA Council reiterates the following position from the WMA Resolution on
Economic Embargoes and Health:
All people have the right to the preservation of health; and, the Geneva Convention (Article
23, Number IV, 1949) requires the free passage of medical supplies intended for civilians.
The WMA therefore urges the European Union to take steps immediately to ensure
the delivery of medical supplies to the Ivory Coast, in order to protect the life and
health of the population.
Medical Leadership Seminar:The view from Down Under
On the Tuesday before the WMA Council opened, the Australian and New Zealand
Medical Associations held a joint seminar on Medical Leadership at the Westin Hotel,
Sydney.
Among the speakers were the BMA President, Professor Sir Michael Marmot, His
Excellency The Hon.Brendan Nelson,Australia’s Representative to NATO and WHO,
Dr Peter Foley, Chair of the New Zealand Medical Association, and Jane Halton, Sec-
retary of Australia’s Department of Health and Ageing.
Dr. Andrew Pesce, President of the Australian Medical Association, spoke about the
importance of doctors remaining at the centre of the debate on health reform and Sir
Michael Marmot spoke about social justice, which he said was right at the centre of
what they as doctors were doing. He said there was much current interest in well being
and happiness, but health was a better definition of well being than happiness. Health
inequalities began at the beginning of life and that’s where they had to start their in-
terventions.
He spoke about the impact of unemployment on young people, the need for a progres-
sive tax system and the importance of addressing the whole of society and not just
focusing on the most deprived.
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Why a GAPA Brief on NCDs?
In May 2010 the UN General Assembly
(GA) passed Resolution 64/265 which
called for the convening of a high-level
meeting of the GA in September 2011 in
New York on the prevention and control of
non-communicable diseases [1]. This reso-
lution and related documents have stressed
the need to recognise the primary role and
responsibility of governments to respond to
the challenges of NCDs, but also the re-
sponsibility of the international community
in assisting member states, particularly in
developing countries, to generate effective
responses [2]. Among the various NCDs,
cardiovascular diseases, cancers, chronic
respiratory diseases and diabetes have been
singled out for attention [2].
This resolution reflects the growing recogni-
tion of NCDs as a major threat to develop-
ment in developing countries. Furthermore,
the resolution is seen as having reframed
the global discussion about NCDs into em-
phasising broader social and environmen-
tal drivers of NCDs rather than unhealthy
choices made by individuals [3]. It comes
with the hope of garnering multi-sectoral
commitment and facilitating action on an
unprecedented scale to address NCDs.
What is the Brief ’s purpose?
1. To put forward the case that addressing
harmful use of alcohol is essential in mov-
ing forward the agenda to meaningfully im-
pact on NCDs by highlighting the strong
linkages between alcohol and several of the
main NCDs of interest and also to indi-
cate the availability of interventions that
have been documented to have an impact
on reducing the burden of alcohol on public
health.
2. To highlight the relevance of the call
made by the World Health Assembly in
2010 for countries to implement effective
responses to address harmful use of alcohol
and to urge that greater support be given
to the WHO to enable it to carry out its
mandate in terms of the Global Strategy to
Reduce the Harmful Use of Alcohol [4] and al-
lied WHO resolutions.
3. To specifically feed into a report being
prepared by the Secretary-General of the
UN (in collaboration with Member States
and WHO) by May 2011 that will serve
as input to the preparatory phase for the
September 2011 high-level meeting and
also feed into an informal interactive hear-
ing with NGOs, civil society organisations,
the private sector and academia that is to be
held no later than June 2011 and which also
aims to provide input into the September
meeting.
What is the link between
alcohol use and NCDs?
Alcohol has been identified as a leading
risk factor for death and disability globally,
accounting for 3.8% of death and 4.6% of
disability adjusted life years (DALYs) lost
in 2004 [5, 6]. Alcohol was found to be the
8th
highest risk factor for death in 2004 (5th
in middle-income countries and 9th
in high-
income countries). In terms of DALYs lost
in 2004, alcohol ranked 3rd
highest (1st
in
middle-income countries, 8th
highest in
low-income countries and 2nd
highest in
high-income countries). The role of alco-
hol (and particularly heavy alcohol use and
having an alcohol use disorder) in NCDs
has been given increasing recognition. For
example, at the recent NGO conference in
Melbourne on health and the Millenium
Development Goals (MDGs) during a ses-
sion on NCDs, along with tobacco, diet and
lack of exercise, alcohol was recognised as
one of four major common risk factors [7].
In terms of NCDs, alcohol has been partic-
ularly linked to cancer, cardiovascular dis-
eases (CVDs) and liver disease. Alcohol has
also been clearly linked to mental disorders
and in some systems mental health is seen
part of NCDs. However, for the purpose
of this Brief we shall not comment on this
linkage [5].
Cancer
• Nine leading environmental and behav-
ioural risks (higher body mass index, low
fruit and vegetable intake, physical inac-
tivity, tobacco use, alcohol use, and unsafe
sex, urban and indoor air pollution, and
unsafe health-care injections) have been
estimated to be jointly responsible for
35% of cancer deaths [6].
• In 2007 the International Agency for
Research on Cancer asserted that there
was sufficient evidence for a causal link
between alcohol and cancer of the oral
cavity, pharynx, larynx, oesophagus, liver,
colon, rectum, and female breast [8]. All
these cancers showed evidence of a dose-
response relationship, that is, the risk of
cancer increased steadily with greater vol-
umes of drinking [9].
• The strength of this relationship varies
for different cancers. For example, with
regard to female breast cancer, each ad-
Addressing Harmful Use of Alcohol is
Essential to Realising the Goals of the UN
Resolution on Non-Communicable Diseases
(NCDs)
Provided by Global Alcohol Policy Alliance
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ditional 10 g of pure alcohol per day
(roughly one standard drink*
*) is associ-
ated with an increase of 7% in the rela-
tive risk (RR) of breast cancer whereas
regular consumption of approximately
50g of pure alcohol increases the relative
risk of colorectal cancer by between 10%
and 20%, indicating that the association
is stronger for female breast cancer [9].
The relationship of average consumption
to larynx, pharynx and oesophagus can-
cer on the other hand would be mark-
edly higher than the relationship to both
breast and colorectal cancer (about about
a 100% to 200% increase for an average
consumption of 50g pure alcohol per day)
[8].
• Among the causal mechanisms that have
been indicated for some cancers is the
toxic effect of acetaldehyde which is a
metabolite of alcohol [9].
• Of all alcohol-attributable deaths in
2004, about 20% come from cancer, 19%
for males and 25% for females. When
considering both the burden from death
and disability,cancer is estimated to com-
prise approximately 9% of all alcohol-at-
tributable DALYs lost, 8% for males and
14% for females [5].
Cardiovascular diseases (CVDs)
• Eight risk factors (alcohol use, tobacco
use, high blood pressure, high body mass
index, high cholesterol, high blood glu-
cose, low fruit and vegetable intake, and
physical inactivity) jointly account for
61% of loss of healthy life years from
CVDs and 61% of cardiovascular deaths.
These same risk factors together account
for over three quarters of deaths from
ischaemic and hypertensive heart disease
[6].
* In the UK 1 standard drink is 7.9 g of eth-
anol, in Australia it is 10 g, in South Africa
12 g and in the USA 14g. 12 g is prob-
ably the most common mass for 1 standard
drink
• Chronic, heavy alcohol use has been as-
sociated with adverse cardiac outcomes
including ischaemic heart disease (IHD),
dilated cardiomyopathy, cardiac dysryth-
mias, and haemorrhagic strokes [10].The
detrimental effects of heavy drinking oc-
casions on IHD are consistent with the
physiological mechanisms of increased
clotting and a reduced threshold for ven-
tricular fibrillation which occur following
heavy drinking [9].
• Alcohol has been identified as the cause
of 30% to 60% of cases of patients with
new-onset atrial fibrillation, with several
causal mechanisms being put forward
to explain this association, including
increased intra-atrial conduction time,
impairment of vagal tone, hyperadren-
ergic activity during drinking and with-
drawal, and direct alcohol cardiotoxicity
[8]. Studies vary considerably in terms
of the amount of alcohol needing to be
consumed and the onset of cardiac dys-
rhyhmias, ranging from approximately 2
to 5 drinks per day [9].
• Of all alcohol-attributable deaths in
2004, about 22% come from CVDs, 23%
for males and 18% for females. CVDs are
estimated to comprise approximately 9%
of all alcohol-attributable DALYs lost,
10% for males and 8% for females [5].
These estimates do not take into account
any beneficial effects of alcohol on CVDs.
However, it has been estimated that the
detrimental effects of alcohol in terms of
CVDs outweigh the beneficial effects by
a factor of 2.4 (for deaths) and 3.5 (for
DALYs), and these benefits typically
only occur with low to moderate alcohol
consumption (less than 20 g per day) and
then only for selected cardiovascular out-
comes (e.g. ischaemic heart disease and
strokes) [5].
Alcoholic liver disease (ALD)
• Alcohol is associated with various kinds
of liver disease, with fatty liver, alcoholic
hepatitis and cirrhosis being the most
common. The likelihood of developing
ALD is a function of both the duration
and the amount of heavy drinking [11].
• For men drinking 30 g of absolute alco-
hol per day is associated with a RR of 2.8
of dying from liver cirrhosis (7.7 for fe-
males). Regarding morbidity, the RRs for
males and females for drinking the same
amount of alcohol per day were 0.7 and
2.4. For men drinking 54 g of alcohol per
day was associated with a relative risk of
2.3 for acquiring liver cirrhosis. For both
morbidity and mortality,the RR increases
with the volume consumed per day [12].
• Various mechanisms have been put for-
ward for how alcohol is associated with
liver disease, such as the view that the
breakdown of alcohol in the liver leads to
the generation of free radicals and acet-
aldehyde which individually damage liver
cells [13, 14].
• Of all alcohol-attributable deaths in 2004
about 15% come from liver cirrhosis, 15%
for males and 17% for females. CVDs
are estimated to comprise approximately
10% of all alcohol-attributable DALYs
lost, 9% for males and 13% for females.
Alcohol appears to have a greater impact
on cirrhosis mortality as compared to
cirrhosis morbidity due to the fact that
heavy drinking has detrimental effects on
the immune system [5].
Other disease
For pancreatitis a threshold of about 48 g
pure alcohol per day has been found, again
with increased volume of alcohol consumed
per day being associated with increased risk
[15]. With regards to diabetes the situa-
tion is more complicated. A recent meta-
analysis confirmed that there is a U-shaped
relationship between the average amount of
alcohol consumed per day and the risk of
type 2 diabetes [16]. There appears to be a
protective effect of moderate consumption
of alcohol, particularly among women. Fur-
ther research appears to be needed to make
stronger claims about the negative effects
of higher levels of consumption of alcohol
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Regional and NMA news
and the incidence of diabetes and to allow
for greater generalisability of the findings to
broader populations globally.
What response is required?
• As part of national efforts to address
NCDs countries need to give priority to
implementing the Global Strategy to Re-
duce the Harmful Use of Alcohol approved
by the WHA in Geneva in May 2010 [4].
Particular attention should be given to
implementing evidenced-based strategies
that have the potential to reduce the oc-
currence of heavy drinking episodes and
the prevalence of alcohol use disorders
that impact on NCDs.Such strategies are
likely to include regulating the availabili-
ty,price and marketing of alcohol and im-
proving the capacity of health services to
support initiatives to screen for risk and
conduct brief interventions for hazardous
and harmful drinking at primary health
care and other settings [17, 18, 19].
• While there is less evidence to support
the efficacy of health education on its
own, it nonetheless does seem appropri-
ate that alcohol consumers should be
made aware of the risk associated with
different levels of drinking and NCDs.
Consumers should, for example, be in-
formed that stopping or reducing alcohol
consumption will reduce cancer risks, al-
beit slowly over time [7].
• Countries must be urged to collect better
information on levels of alcohol exposure,
e.g. recorded adult (15 years+) per capita
consumption in litres of pure alcohol and
heavy episodic drinking among adults
(15+ years) and alcohol-related harm as-
sociated with NCDs (e.g. age-standard-
ized death rates for liver cirrhosis per
100,000 population) [20].
• At a global level support should be given
to the WHO to enable it to carry out its
mandate in terms of the Global Strategy
to Reduce Harmful Use of Alcohol and al-
lied WHO resolutions, in particular with
regard to providing technical assistance
to low- and middle-income countries to
develop and implement policies to reduce
the burden of alcohol-related problems;
seeing that public health interests regard-
ing alcohol issues are taken into account
in global trade agreements, the settle-
ment of trade disputes, and decisions by
international development agencies; and
ensuring that transnational marketing
or major international event marketing
does not act against national policies with
regard to alcohol advertising and promo-
tion. This needs to come in the form of
political support for action and concrete
resources to enable WHO to carry out its
mandate.
• Opposition from vested interest groups
such as the alcohol-beverage industry
and associated sectors (e.g. the advertis-
ing industry) that benefit from the status
quo must be anticipated and countered
[3, 7]. Addressing the social determinants
of NCDs will also require understanding
and combating the role of globalisation in
promoting such diseases [21].
Conclusion
Addressing NCDs in countries at all levels
of development is now seen as important in
ensuring the achievement of MDGs [21].
The way forward is to take concerted and
inclusive actions to address the common
causes of the most prevalent NCDs. Al-
cohol has now been recognised as one of
four major common risk factors for NCDs.
GAPA urges that this reality be factored
into documents being prepared for the UN
high-level meeting in September 2011.
Not only must the causal association be-
tween alcohol use and NCDs be acknowl-
edged, but responses that address the so-
cial and environmental drivers of problem
drinking must be included in interven-
tion packages that will be highlighted in
an Outcomes Statement to be produced
at the end of the UN high level meeting.
This Statement should be a declaration with
clear, binding commitments, measurable
targets and long-term agreements and pro-
grammes.It should form a clear programme
of action for governments, the UN system,
and civil society.
The Global Alcohol Policy Alliance (GAPA) is
a developing network of non-governmental
organizations and people working in public
health agencies that share information on al-
cohol issues and advocate evidence-based alco-
hol policies. 12 Caxton Street, London, SW1H
0QS. gapa@ias.org.uk. www.globalgapa.org
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(2009). Effectiveness and cost-effectiveness of
policies and programmes to reduce the harm
caused by alcohol. Lancet, 373, 2234-2246.
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tributable harm and societal responses: Valencia,
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INDONESIASocio-Medical-Affairs
Prior to 2001, the Indonesian government
conducted several programs to enchance
the quality of health services at health cen-
ters [1]. One of these initiatives was to im-
prove the skill of nurses and midwives in pro-
viding health services by using the Clinical
Algorithms (CAs). A CA is a step-by-step
problem-solving procedure for clinical ser-
vices that guides nurses/midwives to arrive
at a diagnosis and treatment.The Indonesian
government provides CAs because doctors
are used in managerial roles at government
health centers. As a result nurses and mid-
wives must provide most of the health ser-
vices. For that reason, the Indonesian Medi-
cal Association (IMA) and the Indonesian
Nurse Association (INA), in collaboration
with the Ministry of Health and Social Wel-
fare and with the support of the World Bank,
developed 15 CAs for nurses and midwives
to implement in government health centers
to improve the quality of services.
After the CAs were developed, the IMA
supported the program by issuing a letter
of agreement for the nurses and midwives
to conduct some restricted medical activi-
ties [2].Through that letter, nurses and mid-
wives had the authority to diagnose and treat
patients using the CAs for 15 symptoms
of diseases, i.e.: running nose and cough,
fever >4 days, fever <5 days, hearing prob- lem, itching of skin, rash on the skin, vagi- nal discharge, eye redness, diarrhoea, nausea and vomiting, muscle and joint ache, vaginal bleeding, headache, burning during urina- tion,sore throat,epigastric pain,and difficul- ty in breathing.The IMA letter of agreement meant that certain elements of doctors’ au- thority could be formally delegated to nurses and midwives. Of course, the letter of agree- ment also had terms and conditions for nurs- es and midwives to follow when conducting the doctor’s job. First, the authority to diag- nose and treat using CA guidelines applied only in government health centers during working hours. Second, the tasks delegated were given by the government health cen- ter doctor to the government health center nurses and midwives only. Third, the scope of tasks delegated was restricted to CAs with written guidelines.Lastly,the task delegation required nurses and midwives fully record all procedures in patients’medical records. Task delegation to be Task Shifting In the beginning,there were no major prob- lems in task delegation or implementing the CA guidelines.For five years, from 2001 until 2005, the program and relationship between doctors and nurses/midwives was Fachmi Idris Task Delegation Versus Task Shifting in the Indonesian Health Service wmj 2 2011 5CS.indd 62 4/29/11 11:13 AM 63 INDONESIA Socio-Medical-Affairs run well. By the end of 2005, however, the situation was out of control. The conditions in the letter of agreement allowing nurses and midwives to conduct these restricted medical activities were not properly met by nurses in one province of Indonesia. At that time, Indonesia had 33 provinces and the doctors In Central Java province, the sec- ond largest province in terms of total popu- lation, launched a protest to the IMA cen- tral executive board. They insisted the IMA Central Executive Board revise the letter of agreement [3]. The main reason for the protest was that the condition of the relationship between doctors and nurses/midwives had become chaotic,especially in Boyolali district,where the Health Authority of Central Java Prov- ince established the Village Health Clinic (VHC) [4]. The VHC was basically a com- munity health service effort with the nurses/ midwives serving independently as health service officers.It was very different from the spirit of the letter of agreement that allowed the nurses/midwives to conduct diagnoses and treatment in government health centers only. The conflict occurred between general practitioners and nurses/midwives in Boyo- lali when nurses/midwives campaigned to the community that they could conduct the doctor’s job because they were trained as well as a doctor using CA guidelines, which were recognized by IMA. nurses/midwives also felt secure doing the doctor’s job since the VHC was a formal institution licensed by the Central Java Health Office.Task del- egation evolved to task shifting at that time. Cancelled Task Shifting As a result, the Boyolali District IMA Branch office asked the IMA Central Ex- ecutive Board to take immediate action [5]. Since data showed that the total number of doctors in Central Java was relatively high in proportion to the population, and trans- portation was generally available if there was a need to find a doctor in another vil- lage, the need for task delegation in Central Java seemed less imperative. Fortunately, previous to that situation occurring in October 2004, the Indonesian Parliament and Government had enacted the Medi- cal Practice Law (Law No. 29/2004)  [6] which states, in articles 73 & 77, that any person who intentionally assumes the iden- tity of a registered doctor, or provides the impression to the public that he or she is a registered doctor, shall be punished with imprisonment of 5 (five) years or a fine of not more Rp 150.000.000. With this law in place, the Indonesian Medical Association finally cancelled the letter of agreement. After the IMA cancelled the letter of agree- ment,there was a need to find a way to meet health services needs when there were no doctors in a particular area. Therefore, the Indonesian Medical Association sent rec- ommendation letter on task delegation in 2008  [7]. In this letter, the IMA recom- mended that doctors delegate medical au- thority to nurses/midwives in remote areas with the following terms and conditions: the delegation mechanism includes ac- countability measures; the criteria of service is very clear; the time frame is restricted; only selected doctors in the area can dele- gate authority to nurses/midwives; medical authority to be delegated is clear; there is a limited list of drugs that can be dispensed by nurses/midwives; and nurses/midwives can perform these tasks in government health facilities only [8]. The main difference between the prior letter of agreement and the new letter of recom- mendation is in the scope of collaboration. In the letter of agreement, the Ministry of Health collaborated with the IMA Cen- tral Executive Board directly. The terms and conditions of collaboration were very general and it was difficult to control their implementation. In the letter of recommen- dation, the IMA Central Executive Board did not collaborate directly with the Minis- try of Health but instead gave full author- ity to IMA Branch offices at district levels to decide on collaboration with the district health office. The collaboration really de- pends on how severe the shortage of doctors in that area is and requires that doctors in that district accept the concept of delegat- ing their medical authority. The IMA Cen- tral Executive Board was involved minimal- ly only in determining the guidelines. Lessons Learned The World Medical Association describes “Task Shifting” as a situation where a task normally performed by a physician is trans- ferred to a health professional with a differ- ent or lower level of education and train- ing, or to a person specifically trained to perform a limited task only, without having a formal health education (World Medical Association) [9]. Within the World Health Organization (WHO), task shifting is a term that involves the rational redistribu- tion of tasks among health workforce teams. Specific tasks are moved, where appropri- ate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resourc- es for health [10]. Regardless of the differences between the WMA and WHO definition, the fact is that the Indonesian Medical Association formerly supported shifting some physi- cians’tasks to nurses and midwives, as com- municated through the letter of agreement. But, given the deteriorated professional relationship among physicians and nurses/ midwives, and the IMA’s assessment that the implementation of task shifting could be dangerous for patients, the Indonesian Medical Association cancelled the letter of agreement. References 1. Setyawati, B., et all. Development of Clinical Algorithm for Nurse and Midwife (Final Re- port). Indonesia Medical Association and In- wmj 2 2011 5CS.indd 63 4/29/11 11:13 AM 64 Georgia Georgia is situated in the South Caucasus, on the southern foothills of the Greater Caucasus mountain range. There is a short border with Turkey to the south-west and a western coastline on the Black Sea. The northern border with the Russian Federa- tion follows the axis of the Greater Cauca- sus. To the south lies Armenia and, to the south-east, Azerbaijan. Georgia has a rich history thanks to its stra- tegic location. Ionian Greeks colonized this area in the 6th century BC. At this time the western region of what is now Georgia was known as Kolkhida and the eastern region as Iberia.In the 4th century BC Georgia was united into a single kingdom, with Mtskhe- ta as its capital. Christianity was introduced in the 4th cen- tury AD. The Persian and Byzantine em- pires dominated the area until the Arab conquest in the 7th century.The region then came under control of the Seljuk Turks in the 11th century before their foray into Ana- tolia. A period of unification and indepen- dence in the 12th century, under King David IV, was swept aside by the Turco-Mongol invasion in the 13th century.Between the re- turn of Timur’s army to central Asia and the 18th century, control of Georgia oscillated between the Persian and Ottoman empires. A short-lived Georgian kingdom was pro- claimed in the mid-18th century, followed soon after by annexation by the Russian Empire.Initially,in 1783,this took the form of control of the kingdom’s foreign affairs. In 1801, with the abdication of the last Georgian king, Georgia was fully incor- porated into the Russian Empire. After the Russian Revolution, in 1917, Georgia briefly became an independent republic. This independence was short-lived, lasting only until 1921, when it was incorporated into the Union of Soviet Socialist Republics (USSR), where it remained for the follow- ing 70 years. During the Soviet era, Georgia was a rela- tively prosperous republic, supplying USSR with produce and services and exerting con- Medical History GEORGIA History of Georgia, Georgian Medicine and Medea Otar Toidze Nino Chikhladze Gia Lobzhanidze Zaza Khachiperadze donesia Nurse Association in collaboration with Ministry of Health and Social Welfare. 2001. 2. IMA Central Executive Board. The Agreement of Task Delegation of The Restricted Medical Service to Nurse and Midwives. The letter No. 380/PB/E.1/05/2001. 3. GP Boyolali Forum. The Position Statements of GP for Village Health Service Training. Aorta Magazine. January-March edition 2006, page: 26. 4. IMA Boyolali Branch Office. Village Health Service. Aorta Magazine. January-March edi- tion 2006, page: 21. 5. IMA Boyolali Branch Office. The proposal of Management of Medical Service Base on Health Provider Competency. 7 Agustus, 2006 6. The Government of Indonesia Republic. The Medical Practice Act, Law Number 29, year 2004. 7. IMA Central Executive Board. The Revocation of Agreement Letter of Task Delegation of The Restricted Medical Service to Nurse and Mid- wives.The letter No. 2032/PB/E.1/08/2006. 8. IMA Central Executive Board. The IMA Posi- tion on the Regulation of Medical Task Delega- tion.The letter No. 2392/PB/E.1/12/2008. 9. WMA. World Medical Association Resolution on Task Shifting from The Medical Profession. Adapted by WMA General Assembly, New Delhi, India, October, 2009. 10. WHO. World Health Organization: Task Shifting, Global Recommendation and Guide- line. Pefpar and UNAIDS. the WHO Docu- ment Production Services, Geneva, Switzer- land, 2008. Dr. Fachmi Idris, Dr (PH). President of CMAAO/Immediate President of Indonesian Medical Association and Lecturer in Public Health-Community Medicine of Medical Faculty of Sriwijaya University, Indonesia wmj 2 2011 5CS.indd 64 4/29/11 11:13 AM 65 Medical HistoryGEORGIA siderable influence over internal exchange and cultural networks. The country declared its independence from the USSR in April 1991[1]. Georgian Medicine (Christian period) Georgian medicine is one of the oldest in the world. Georgian medicine is created on the basis of two great traditions of East and West.There are more than 500 medical manuscripts in Georgian and foreign librar- ies. In the 1st century Greco-Roman medi- cine was closely bound to the ancient Pelas- gian, pre-Iberian world. The Georgians and the Caucasians were always close to the Hellenic world.It resulted from genetic,an- thropological, intellectual and cultural links between them [2]. The level of Georgian medicine is given in the literary monument of the 5th cen- tury “Martyrdom of Shushanic”, in which the author gives not only the methods of treatment and care of the patient, but also describes the direct and indirect causes of disease. In the work of Sabatsmindeli “Sin- anulisatvis Simdablisa” together with many interesting advises, the medical knowledge necessary for monks and nuns is imparted. An emergency situation with sending for a doctor is noted here as well. It denotes that the doctor’s profession has existed indepen- dently in the 6th century in Georgia. It is natural that the exceptional place of mon- astery medicine is especially underlined in religious literary sources. It is evident that monastery medicine is a significant part of the whole medicine. All saints are healers, and there are no excep- tions. Petre Iberi, Shushaniki (5th century AD), Thirteen Assyrian Fathers (6th cen- tury AD), and Grigol Khandzteli (8th –9th centuries AD) were the famous healers of their times. Ilarion Kartveli must be es- pecially mentioned. He was a worldwide known doctor treating patients without fee. The first medical book, “Ustsoro Karaba- dini”, which has reached our time, dates back to the 10th century. Last year we cel- ebrated the 1000th anniversary of the book. It was written by a doctor with encyclope- dic knowledge, who called himself Kanan- eli. Many scientific works are devoted to the Georgian golden period (11th –12th centu- ries AD). These favorable conditions were conducive to the early origin of remarkable Renaissance. Only after a few centuries Western European countries could enter the Renaissance. Medicine in particular achieved a high level of development. This time was an extraordinary period in Geor- gian history.Georgian medicine is known as Joanne Petrici’s and Arsen Ikaltoeli’s period. Arsen Ikaltoeli was recognized as the great- est anatomist of this period. He lived and worked in the same sociocultural environ- ment where the genius of Shota Rustaveli flourished. In the 10th –13th centuries many Georgian institutions were created in Geor- gia and abroad. Building of hospitals was leading among these activities. The ruins of these hospitals are still to be seen in Geor- gian cloisters in the western and eastern Georgia, southwestern part Tao-Klarjeti and at Georgian cultural centers abroad: Jerusalem, Khalkedon, Petrisioni, Sinai, and the Black Mountains. Some hospitals had rich libraries. In the 13th century Kojakopoli wrote the medical book “Tsigni Saakimoi”, which also corresponds with the “golden period” of Georgian history. The greatest Georgian doctor and philosopher, Zaza Panaskerteli- Tsitsishvili (15th century AD) was the first lay person, holding an especial place in the history of Georgian medicine. His most famous medical work was “Samkurnalo Tsigni (The Book of Treatment)”. It became extremely popular in the country. In the 16th century David Batonishvili (Bagrationi) wrote the medical book “Iad- gar Daudi”. The 17th –18th centuries were significant because of the expansion of Eu- ropean culture and knowledge in Georgian medicine. The king of Georgia, Vakhtang VI (18th century) took some young people to Russia, where they received univer- sity medical education. Among them, Ilia Gruzinov (Namchevadze) should be espe- cially mentioned as a talented person, who was sent to Europe, where he became well known in the scientific circles of Germany, France and England. He is considered as a pioneer neurophysiologist. The document of this period of King Erekle II shows that “Ekimbashi”– chief of doctors – trained his pupils for 20–25 years and only after at- tending his course, had they a right to con- duct independent practice and to have their own trainees. Medea and Medicine In the 18th century K. J. Sprengel’s classic of the history of medicine begins with Cura Mediana (Treatment by Medea) and thus recognizes the antiquity of Kolkh-Iberian medicine. There exists a well-founded ver- sion linking medicine with the name of the Kolkhetian ruler’s daughter – Medea,famed for her knowledge of various remedies. She was preparing remedies in different forms, for respiratory, internal and external usage, etc. There were many kinds of drugs in her arsenal of medicaments: curing different diseases, giving strength, poisoning, un- guents, magic, etc. One of the medical treatment manipula- tions, among the ones Medea knew, was the treatment of wounds quickly and effectively. The wounded Argonauts,who were fighting against the Kolkhs, were treated by Medea “in a few days with roots and some other herbs” (Diodorus the Sicilian). Medea also knew the treatments for steril- ity. The King of Athens – Egeos, who was “ill with sterility,” was told by the healer woman: “You do not even know how lucky wmj 2 2011 5CS.indd 65 4/29/11 11:13 AM 66 Medical History GEORGIA you are as you have come up to me, I know the medicine of infertility.” The Kolkh woman was quite educated in cosmetology, too. She is considered to be the first in creating coloring hair. She knew the secrets of skin caring. The healing woman during her medical functioning used to make blood transfusion, too. She used lamb as a donor. She cured Jason’s uncle in the same way. Medea was making poison with special processing – boiling, thermal, mechanic, or chemical influence, that means getting the poison by concentrating. The principle on which nowadays medicine exists and develops, is contraria contrariis curantur, or the allopathic maxim. The priority falls on this maxim now. This is the direction followed by the world’s modern medicine today. It is worth mentioning that this direction before Medea’s epoch was not developed in any other countries’ medicine. In the east- ern medicine the allopathic maxim is not emphasized as a dominant one. It originates from Greco-Roman medicine. The roots of it are in Mediterranean Pelasgic and Kolkh- Iberian medicine. The evidence to it is Ro- doseli’s “Argonautica”. Medea is special for her skills to find out curing merits in new plants. And later, she prepares the concentrates for creating drugs – poison. Seems that this is the basis of connection between “Satsamlavi” (poi- son) and “Tsamali” (drug) in Georgian. For effective influence of adversity on an- other adversity medicine needed drugs. As for the medicine, it was prepared by poison’s dilution. It became the basis of the allo- pathic mentality system. The aunts taught Medea the art of poison preparation. But she used this knowledge differently. As she got the active concentrate from plants, she diluted it in the dose, that this substance was used not as poison but as a drug. She knew the maxim that medicine is poison and poison is medicine. The difference is only in dosage. (Paracelsus.) Medea could determine dosage between dosis letalis mini- ma and dosis therapeutica. Medea’s skills are revealed in the myth about the Argonauts. Facts say that Jason arrived from Iolcus to Colchis (the old kingdom of Georgia) to claim his inheri- tance and throne by retrieving the Golden Fleece. In the most complete surviving ac- count, the Argonautica of Apollonius, Me- dea fell in love with him and promised to help him but only on the condition that if he succeeded, he would take her with him and marry her. Jason agreed. In a famil- iar mythic motif, Aeëtes promised to give him the fleece but only if he could perform certain tasks. First, Jason had to plough a field with fire-breathing oxen that he had to yoke himself. Medea gave him an un- guent with which to anoint himself and his weapons, to protect him from the bulls’ fiery breath. Figure 1. John William Waterhouse’s paint- ing “Jason and Medea” (1907) Source: http://kevinalfred- strom.com/art/v/paintings/ Foto+2_+Jason+and+Medea_+1907+2.jpg. html Figure 2. The statue of Medea in Batumi Source: http://4.bp.blogspot.com/_ h4G8qWVecRo/TFa7jmAh_2I/ AAAAAAAAAmg/vhSrs23GXl0/ s1600/100_9408.jpg Then,Jason had to sow the teeth of a dragon in the ploughed field (compare the myth of Cadmus). The teeth sprouted into an army of warriors. Jason was forewarned by Me- dea, however, and knew to throw a rock into the crowd. Unable to determine where the rock had come from, the soldiers attacked and defeated each other. Finally, Aeëtes made Jason fight and kill the sleepless drag- on that guarded the fleece. Medea put the beast to sleep with her narcotic herbs. Jason then took the fleece and sailed away with Medea, as he had promised [8]. Even nowadays Medea is highly respected in Georgian medicine. Georgian nation built a statue of Medea in Batumi. The monument is a symbol of Georgia’s Black Sea coast and is an attribute thereof. References 1. Chanturidze T., Ugulava T., Durán A., Ensor T., Richardson E. Georgia: health system review, 2009. 2. Verulava T. History of Georgian medicine, 2000. 3. Saakashvili M. History of Georgian medicine. Tbilisi, 1956. 4. Shengelia M. Georgian medicine in transition, 1801-1860.Tbilisi,1968. 5. Shengelia M. History of Georgian medicine. Tbilisi, 1984. 6. Shengelia M. Ancient Kolchian-Iberian medi- cine.Tbilisi,1979. 7. Shengelia R. History of Georgian medicine. Tbilisi, 1995. 8. http://en.wikipedia.org/wiki/Medea Dr. Otar Toidze MD, PhD, Head of the Healthcare and Social Issues Committee of the Georgian Parliame Prof. Gia Lobzhanidze MD, PhD, Chairman of Georgian Medical Association Nino Chikhladze MD, PhD, Associated Professor Ivane Javakhishvili Tbilisi State University Dr. Zaza Khachiperadze MD, Deputy General Secretary of Georgian Medical Association wmj 2 2011 5CS.indd 66 4/29/11 11:13 AM 67 Regional and NMA newsNETHERLANDS Introduction Palliative care has been the subject of consid- erable interest in the Netherlands since the late 1990s, partly because the government has actively promoted it. The past few years have witnessed a proliferation of expertise and skill in this area. The Netherlands now occupies the fourth place in the European ranking for palliative care.This ranking indi- cates the extent to which palliative care has been developed within a country [1]. Palliative sedation has also been discussed at great length in the context of these developments.This debate was triggered by the Public Prosecution Service in 2003. This year marked criminal and disciplinary proceedings against a physician due to the sedation of a terminally ill patient who was at risk of suffocating. Partly as a result of all the publicity that this story attracted,the govern- ment highlighted the importance of the drafting of a national guideline for palliative sedation by the profession.The guideline of the Royal Dutch MedicalAssociation(RDMA)forpalliativeseda- tion was published in 2005 and reviewed in 2009 [2–4]. Besides defining the professional standard, the guideline has also acquired legal significance. The Public Prosecution Service has stated that it sees no reason to prosecute physicians who keep totheguideline.Anyphysicianwhodeviatesfrom it,however,mustbearinmindthathisactionsmay be the object of a criminal investigation.Research has shown that the practice of palliative sedation has improved and that the RDMA-guideline is being followed [5–8].This article discusses the keypointsoftheguideline.Theguidelinehasbeen translated in full and is available on the website of theRDMA[2]. Relationship between palliative care, palliative sedation and patients’ rights Palliative sedation forms part of a palliative care process [9]. The decision-making pro- cess regarding whether or not to commence palliative sedation takes place in the Neth- erlands within the conditions for a palliative care approach, as described by the WHO: ‘Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threat- ening illness, through the prevention and relief of suffering by means of the early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’ [10]. The RDMA strongly agrees with this de- scription, as it centres on the needs of the patient and his or her family. This is crucial when caring for the terminally ill. The focus on the patient’s needs is also in line with the rights granted to patients in the Netherlands. The Dutch ‘Medical Treatment Contracts Act’ stipulates that except for in emergency situations, physicians must adequately in- form the patient and the patient must then grant consent before the physician can start the treatment, if possible. The starting point for every treatment is therefore informed consent. The consequence of this is that the patient may refuse the treatment, and the physician must respect this decision. Aside from this, however, the RDMA considers it important for the physician and patient to talk to one another in clear terms and in a timely manner about feasible and unfeasible care and treatment options in the last stages of life. Staff should be proactive in ensuring that consent is sought while the patient is still lucid. This means that the possibility should be discussed with the patient,if at all possible, well before the stage when palliative sedation is the only remaining option. The essence of this discussion is the quality of remaining life and the inevitable death of the patient. What does palliative sedation mean? The RDMA has defined palliative sedation as: ‘The deliberate lowering of a patient’s level of consciousness in the last stages of life’. It is a treatment administered to patients who are dying and experiencing unbearable suffering.The aim of palliative sedation is to alleviate this suffering. Lowering the level of consciousness is a means to that end.Pal- liative sedation can be administered in dif- ferent ways: deep or superficial, temporary/ intermittent or continuous. The RDMA considers it crucial that pal- liative sedation be applied proportionately and adequately, in response to the appropri- ate medical indications. It is the degree of symptom control rather than the degree to which consciousness must be reduced that determines the dose, combinations, and duration of the medication administered in palliative sedation. Interim evaluations and other decision-making processes must be geared towards adequately alleviating the patient’s suffering in order to create a tran- quil and tolerable situation. Eric van Wijlick Palliative Sedation in the Netherlands The Royal Dutch Medical Association Guideline Tries to Provide Clarity wmj 2 2011 5CS.indd 67 4/29/11 11:13 AM 68 NETHERLANDSRegional and NMA news The word ‘deliberate’ is included in the definition in order to exclude situations in which the lowering of the patient’s level of consciousness is a (possibly unintended) side effect of treatment,for instance the lowering of consciousness as a result of the adminis- tration of morphine to relieve pain. Physi- cians may use or increase the dose of opioids or other forms of medication not usually used primarily as sedatives with the implicit or explicit aim of palliative sedation. Empirical data The total number of deaths in the Nether- lands in 2005 where the patient underwent deep and continuous sedation prior to death was 8.2% [11].In the international literature, the reported incidence of palliative sedation of patients receiving clinical care (generally in hospices) ranges from 15% to 52%. The commonest indications for palliative seda- tion are delirium or agitation in the terminal phase (57%), followed by dyspnoea (23%), pain (17%) and vomiting (4%) [12–18]. Continuous, deep sedation until death is practised most often by medical specialists (45%), followed by general practitioners (34%) and nursing home physicians (19%). Of the cases in which continuous, deep se- dation was administered until the time of death in the Netherlands, 47% involved pa- tients with cancer,17% patients with cardio- vascular disorders, 6% pulmonary diseases, 4% diseases of the nervous system and 26% ‘other’ disorders. In about three-quarters of all cases, the patients were aged 65 years or over. The most common symptoms in 2005 in the last 24 hours preceding death were fa- tigue (55%), dyspnoea (48%), reduced level of consciousness (47%) and pain (42%). The vast majority of patients have virtu- ally ceased eating and drinking by the time that deep and continuous sedation needs to be initiated and most of them die within a few days of its initiation [14, 20]. Research shows that 47% of patients put into a state of continuous, deep sedation die within 24 hours,47% within one to seven days and 4% within one to two weeks [11, 21]. Indications for palliative sedation In the Netherlands, indications for pallia- tive sedation are present if the patient is suf- fering from one or more refractory symp- toms. A symptom is, or becomes,‘refractory’ if ‘none of the conventional modes of treat- ment is effective or fast-acting enough,and/ or if these modes of treatment are accompa- nied by unacceptable side-effects’. In practice, determining whether a symp- tom is refractory sometimes leads to dif- ficulties. It requires knowledge and skill to distinguish symptoms that are difficult to treat from symptoms that are untreatable. The physician will have to decide whether a symptom is treatable or not on the basis of accepted good medical practice, bearing in mind the specific circumstances of a patient in the last stages of life. Since the guideline was introduced, patients are increasingly be- ing involved in the decision-making process and at an earlier stage (from 72% before to 82% after the introduction). Determining whether there are indications for palliative sedation is a medical decision. The decision to administer palliative sedation is not based on a specific moment in time, but is a pos- sible outcome within the context of a pallia- tive care plan. Patient and physician (often a member of a multidisciplinary treatment team) have together arrived at a point where they find themselves, through a complex of problems, with their backs to the wall. The feelings of the patient are extremely impor- tant,especially as regards the discomfort and other side-effects of any possible mode of treatment. The decision-making is also in- fluenced by factors such as the views of the patient and the physician concerning a ‘good death’, the quantity and severity of symp- toms, the impact of the somatic complaints on feelings such as fear,the fear of death and the actual process of dying, powerlessness, uncertainty, grief, anger, sadness, the dura- tion of the illness, the burden on informal carers, and the strength and endurance of the patient and of his informal carers.Physi- cal exhaustion (intense fatigue) may also play a role at this stage, and may exacerbate suffering. It is one of the factors that help to determine the patient’s endurance.This may lead to the conclusion that there is no more scope for deploying any other reasonable interventions aside from palliative sedation. The decision to apply palliative sedation is made within the context of palliative care, which characteristically relies on a multidis- ciplinary approach. Nursing staff and other care professionals can provide input for drawing up the indications, and the RDMA advises physicians to consult the appropriate expert in good time if he or she is in any doubt as to whether medical indications are present. In the Netherlands, every physician can enlist the assistance of a regional pallia- tive care consultation team. The relationship between palliative sedation and action intended to terminate life Within the context of palliative sedation, the RDMA distinguishes between the fol- lowing two situations: • continuous sedation until the time of death; • temporary or intermittent sedation. We take the view that on the one hand, these are situations that must both be viewed against the wider background and the process of palliative care, but that on the other hand also differ from one another, for instance as regards the substance and word- ing of the preconditions for good medical practice. The discussions that have taken place over the past few years have focused on continuous, deep sedation until the time of death. This form of palliative sedation, which is sometimes also known as terminal sedation, and its relationship to action in- wmj 2 2011 5CS.indd 68 4/29/11 11:13 AM 69 Regional and NMA newsNETHERLANDS tended to terminate life has led to medical- ethical, legal, social and political debate. Palliative sedation is a normal medical proce- dure.The aim of palliative sedation,including continuous sedation until the time of death, is not to shorten or prolong life,but to allevi- ate suffering. When applied proportionately and adequately, palliative sedation does not hasten death [22–29]. The patient dies as a consequence of the underlying disease and not as a result of palliative sedation. Pallia- tive sedation is a way of stopping the patient from consciously experiencing symptoms and thereby preventing unbearable suffering prior to death. Based on the view that the patient’s remaining quality of life and death must be the key focus, the RDMA considers it essential for the physician and patient to talk to one another in clear terms and in a timely manner about feasible and unfeasible palliative care options, including palliative sedation. The guideline therefore places a strong focus on the decision-making process and dealing with the patient’s family. Intermittent palliative sedation can be initi- ated in consultation with the patient to re- store tranquillity and then allow the patient to return to consciousness,but in some situa- tions also provides the opportunity to estab- lish whether a symptom is permanently re- fractory. This gives the physician the chance to assess the situation with the patient and his or her family and if necessary to modify the management of the case. Another op- tion is continuous sedation. In this situation the RDMA considers that besides the pres- ence of one or more refractory symptoms, a second precondition is the expectation that death will ensue within one to two weeks. The RDMA feels that there should be no artificial administration of fluids and food in the case of continuous sedation.The artificial administration of fluids and food is viewed as medical treatment in the Netherlands.When a patient is in the last stages of life and a pal- liative care approach has been adopted, the artificial administration of fluids and food must be regarded as medically futile. There are indications that artificially administering fluids and food to a patient who is dying pro- longs life and exacerbates suffering (oedema, ascites, bronchial secretions etc.). In practice, however, most patients are no longer will- ing or able to take any fluids, because they are dying. Patients are frequently cachectic, tired and debilitated. Of all patients who are continuously sedated prior to death 47% die within 24 hours, 47% within one to seven days and 4% within two weeks. In 2% of pa- tients, it proved necessary to administer con- tinuous sedation for over two weeks [11, 21]. Palliative sedation differs from euthanasia in that its aim is not to shorten life.In this case too, the patient’s needs and wishes are para- mount. Palliative sedation is the first choice for patients who no longer want to experi- ence unbearable suffering, but who also do not want to end their lives. If the patient does not want to live any longer as a result of his or her unbearable suffering, euthana- sia is an option in the Netherlands. Eutha- nasia is not regarded as a normal medical procedure and is not accepted good medical practice. Euthanasia is subject to statutory requirements. The patient does not have a right to euthanasia and the physician is not under any circumstances obliged to comply with the patient’s request. Timely and clear communication about feasible and unfea- sible options is of course essential. Morphine and Midazolam In situations where continuous, deep seda- tion until the time of death is being consid- ered, morphine is often already being given to treat pain or dyspnoea. In these circum- stances, it may seem attractive to increase the dose of morphine substantially in the hope of expediting loss of consciousness and death. Research into medical decisions relating to the end of life has shown that 19% of specialists, 13% of general practitio- ners and 10% of nursing home physicians use morphine for this purpose [11]. Closer consideration reveals that its use in this way often has two different aims: first, to render the patient unconscious and second, to has- ten death. For neither of these aims, how- ever, is morphine the drug of choice. Exces- sively high doses of morphine frequently produce drowsiness, but not always loss of consciousness. Therapeutic doses of opioids (that is, doses tailored to the degree of pain or dyspnoea) are not at all likely to shorten life, even if they are high. Moreover, mor- phine has major side-effects. For instance, it can increase delirium or induce myoclonus. The RDMA regards the use of morphine for these purposes as bad practice. Morphine should only be given or continued (alongside sedatives) to relieve pain and/or dyspnoea. The dose should be calculated to relieve the actual or assumed extent of the pain and/or dyspnoea. If it is necessary to intentionally lower the patient’s level of consciousness in the last stages of life with the aim of allevi- ating suffering,the RDMA-guideline speci- fies Midazolam as the drug of choice. Record-keeping and evaluation Accurate record-keeping plays a very impor- tant role in helping to ensure the quality and continuity of care. Palliative care and seda- tion characteristically rely on a multidisci- plinary approach.This means that all relevant information about the patient and his or her situation must be recorded in his or her file. First and foremost, the file should contain the reasons why it was decided to adminis- ter palliative sedation and how sedation was administered. The problems and symptoms that prompted the decision to administer continuous sedation should serve as the basis for evaluation. The physician against whom criminal and disciplinary proceedings were brought in 2003 had failed to adequately update the patient’s file. The physician was therefore unable to demonstrate the patient’s symptoms, the aim of the treatment, which drugs were used and at what doses.The phy- sician was eventually acquitted.However,the disciplinary court found the physician guilty of failing to keep proper records. wmj 2 2011 5CS.indd 69 4/29/11 11:13 AM 70 Regional and NMA news NETHERLANDS Conclusion Practice has improved following the in- troduction of the RDMA-guideline for palliative sedation and is in line with the basic principles and recommendations in the guideline. The RDMA still considers patient involvement in the decision-making process to be a point that requires attention. The essence of palliative care and therefore also palliative sedation is the quality of re- maining life and the inevitable death of the patient.The RDMA-guideline clearly states that palliative sedation does not shorten life and must be clearly distinguished from eu- thanasia. The physician must include in the file information on the patient’s symptoms and complaints, the physician’s envisaged treatment objective, whether or not in- formed consent has been granted, the drugs administered and at what doses. It cannot be said enough that the main priority is the quality and continuity of care during the patient’s remaining life and death. There is no room for misunderstandings or miscon- ceptions. The RDMA-guideline provides clear and substantiated criteria that can be applied in practice in the Netherlands. Summary • In the last stage of life, palliative sedation consists always of continuous administra- tion of the sedatives. In this stage of life the patient is dying and experiencing un- bearable suffering. • Part of palliative care is that the physi- cian and patient talk to one another in clear terms and in a timely manner about feasible and unfeasible options in the last stage of life.The essence of this discussion is the quality of remaining life and the in- evitable death of the patient. • The decision to apply palliative sedation is made within the context of palliative care, which characteristically relies on a multidisciplinary approach. • Continuous sedation differs from eutha- nasia in that its aim is not to shorten life. Palliative sedation is a normal medical procedure, euthanasia is not. References 1. See www.eapcnet.eu 2. Royal Dutch Medical Association (KNMG). Guideline for Palliative Sedation 2009. Down- load: http://knmg.artsennet.nl/dossiers/Dossi- ers-op-thema/levenseinde/euthanasieenpallia- tievesedatie.htm 3. Verkerk M,Wijlick EHJ van, Legemaate J, Gra- eff A de. A national guideline for palliative seda- tion in the Netherlands. J Pain Sympt Manage 2007; 34: 666-670. 4. Legemaate J,Verkerk M,Wijlick EHJ van, Gra- eff A de. Palliative sedation in the Netherlands: starting-points and contents of a national guide- line. Eur J Health Law 2007; 14: 61-73. 5. Hasselaar GJ, Verhagen CAHHVM, Wolff AP, Engels Y, Crul JP, Vissers CP. Changed patterns in Dutch palliative sedation practice after the introduction of a national guideline. Arch Intern Med 2009; 169(5): 430-437. 6. Swart SJ, Brinkkemper T, Rietjens AC, Blanker H, Zuylen L van, Ribbe M, Zuurmond WA, Heide A van der, Perez SGM. Physicians’ and nurses’ experiences with continuous palliative sedation in the Netherlands. Arch Intern Med 2010; 170(14): 1271-1273. 7. Deijck HPD, Krijsen JC, Hasselaar GJ, Ver- hagen CAHHVM, Vissers CP, Koopmans TCM. The practice of continuous palliative se- dation in elderly patients: a nationwide explora- tive study among Dutch nursing home physi- cians.Journal American Geriatrics Society 2010. 8. Brinkkemper T,Klinkenberg M,Deliens L,Eliel M, Rietjens AC, Zuurmond WA. Palliative se- dation at home in the Netherlands: a national wide survey among nurses. Journal of Advanced Nursing 2011. 9. European Association for Palliative Care (EAPC): recommended framework for the use of sedation in palliative care. Palliative Medicine 2009; 23(7): 581-593. 10. World Health Organization. WHO Definition of Palliative Care 2002. 11. Rietjens JA, Delden JJM van, Onwuteaka- Philipsen BD, Buiting H, Maas P van der, Heide A van der. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. British Medical Journal 2008; 7648: 810-813. 12. Wein S. Sedation in the imminently dying pa- tient. Oncology (Huntingt) 2000; 14: 585-592. 13. Cherny NI, Portenoy RK. Sedation in the man- agement of refractory symptoms: guidelines for evaluation and treatment. Journal of Palliative Care 1994; 10: 31-38. 14. Cowan JD, Palmer TWP. Practical guide tot palliative sedation. Current Oncol Rep 2002; 4: 242-249. 15. Cowan D, Walsh D. Terminal sedation in pal- liative medicine – definition and review of lit- erature. Support Care Cancer 2001; 9: 403-407. 16. Chater S, Viola R, Paterson J, Jarvis V. Sedation for intractable distress in the dying – a survey of experts. Palliat Med 1998; 12: 255-269. 17. Cherny NI. Sedation: uses, abuses and ethics at the end of life. Jerusalem, Israel, 2003. 18. Voltz R, Borasio GD. Palliative therapy in the terminal stage of neurological disease. J Neurol 1997; 244 (Suppl 4): S2-S10. 19. Fainsinger RL, Landman W, Hoskings M, Bru- era E. Sedation for uncontrolled symptoms in a South African hospice. Journal of Pain and Symptom Management 1998; 16: 145-152. 20. Rousseau P.Terminal sedation in the care of dy- ing patients. Arch Intern Med 1996; 156: 1785- 1786. 21. Verhagen CAHHV. Incidence, methods and outcome of palliative sedation before and after publication of a specific guideline in the Neth- erlands. Aachen, EAPC 8–10 April 2005, P148. 22. Chiu TY, Hu WY, Lue BH, Cheng SY, Chen CY. Sedation for refractory symptoms of termi- nal cancer patients in Taiwan. Journal of Pain and Symptom Management 2001; 21: 467-472. 23. Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T. Sedation for terminally ill patients with cancer with uncontrollable physical distress. Journal of Palliative Medicine 2005; 8: 20-25. 24. Morita T, Tsuneto S, Shima Y. Proposed defi- nitions of terminal sedation. Lancet 2001; 358: 335-336. 25. Stone P, Phillips C, Spruyt O, Waight C. A comparison of the use of sedatives in a hospital support team and in a hospice. Palliative Medi- cine 1997; 11: 140-144. 26. Sykes N,Thorns A.The use of opioids ands sed- atives at the end of life. The Lancet Oncology 2003; 4: 312-318. 27. Ventafridda V,Ripamonti C, De Conno F,Tam- burni M, Cassileth BR. Symptom prevalence and control during cancer patients’ last days of life. Journal of Palliative Care 1990; 6: 7-11. 28. Wein S. Sedation in the imminently dying pa- tient. Oncology (Huntingt) 2000; 14: 585-592. 29. Maltoni M, Pittureri C, Scarpi E, Piccinini, Martini F, Turci P, Montanari L, Nanni O, Amadori D. Palliative sedation therapy does not hasten death: results from a prospective multi center study. Annals of Oncoloy 2009; 20: 1163- 1169. Eric van Wijlick, senior policy advisor Royal Dutch Medical Association E-mail: e.van.wijlick@fed.knmg.nl wmj 2 2011 5CS.indd 70 4/29/11 11:13 AM 71 Belgium’s current law on euthanasia was passed on May 28th , 2002, shortly after a secular government unseated the prevail- ing Social-Christian party, which had held power almost continuously since World War II. This law is very permissive since it allows euthanasia in circumstances where the death process has begun, as well as in cases of long-term, often terminal illness. The circumstances The law was passed in 2002 following a time when rationing, cost containment and the sustainability of social systems were the is- sues that largely filled political agendas. The extension of life expectancy and the prohibi- tive cost of the last six months of life often were arguments of weight in the debate. The philoso phical basisof the law The Belgian law has been very permissive from the very start and recently there has been a movement to consider extending the law to include the possibility of eu- thanasia for children. The current law is, to a large extent, founded on the patient’s autonomy. It is the patient who decides to submit to euthanasia as long as the condi- tions of eligibility are met. A constraining anticipated declaration can be made, or a person of trust can be appointed by pa- tients to represent themselves in the event they become unable to express their will. The practitioner may refuse to perform the euthanasia on the grounds of objection of conscience, but must tell the patient and offer to give way, immediately or when the moment has come, to one of their peers who is likely to comply with the patient’s wishes. The decision must not be made by the practitioner, nor may he submit it to a committee of ethics. These possibilities have been discarded by the legislator and it stands in the law. The autonomy of the patient has naturally been supported by advocating associations like « Mourir dans la Dignité » (To Die in Dignity) but often leaves the practitioner perplexed. It can be confusing for practi- tioners to witness more and more deaths by suicide and even more suicide attempts while trying to bring back to life and restore a joy of living to some patients while eu- thanizing others . What should be done in the numerous cases of depression in those suffering from incurable diseases? The situation prior to the law It cannot be denied that euthanasia was performed in Belgium before the law was passed, although in what numbers it is dif- ficult to assess. Most certainly, it was done in some terminal cases (irreversible coma, unrelieved pain) and maybe also when the death did not present itself imminently but life had become unbearable (locked-in syn- drome). Belgium did experience a famous trial at the end of the 1950’s regarding the euthanasia of an infant born without arms or legs, after the intake of Thalidomide by the mother while she was pregnant. The trial ended with acquittals and there were no more trials dealing with euthanasia in Belgium until the subject was debated in the parliament. Was there a need for a law? In the past, when charged with the crime of euthanasia or medically assisted suicide, practitioners could raise the argument of a state of necessity, which is the situation in which one has to act in opposition to the law because to obey it would lead to an even greater harm. However, the decision regarding the state of necessity belonged to a judge who would make it according to their own convictions.Therefore,in the past, a physician was quite vulnerable, as the le- gitimacy of their decisions were subject to the judgement of others. As a result, before the current law was passed, euthanasia was hypothetically legally available to Belgian society under exceptional and justifiable circumstances. However, there was little guarantee that even under these conditions, a practitioner could be found who was will- ing to risk the legal consequences if a judge were to disagree with the physician’s assess- ment of what constituted an exceptional and justifiable case. The current situation The current law sought to make the situa- tion more consistent with the actual situ- ation and, in doing so, it provided a very permissive framework within which eutha- nasia is permissible because patients with serious incurable diseases are eligible even if they are not threatened by imminent death. The patient is placed at the centre Regional and NMA newsBELGIUM Roland Lemye Opinion of the Belgian Medical Association About the Law Refering to Euthanasia wmj 2 2011 5CS.indd 71 4/29/11 11:13 AM 72 BELGIUMRegional and NMA news of the decision by his or her demand, an- ticipated declaration, or by the demand of the person of trust he or she has previous chosen, In addition, the family practitioner, if he or she accepts a request of euthana- sia, must have the eligibility of the patient checked by a second physician and follow an administrative procedure that becomes central to the process. If the procedure is respected, the practitioner must not be sued. Now the responsibility of the judge is to ensure that the procedural guidelines of the law are followed instead of to judge the legality of the performing practitioner’s in- tent.. The current position of the medical profession At the time the current law was passed, there was not a strong call from the medi- cal profession demanding a law to legal- ize euthanasia. Our association was in opposition to any such legal initiative. In the field, however, opinions were much more divided and varied. Flemish doctors, probably influenced by the example of the Netherlands, we more in favour of it than the French-speaking physicians who are culturally bound to a more Latin vision of things. Regardless, the law was voted and passed, taking advantage of the eviction of the Catholic parties.The law has now been implemented in Belgium for almost ten years and, as of yet, there is no evidence of the slippery slope of broadening eligibility that the Netherlands has experienced. On the contrary, an important opposition has been noted in the French-speaking part of the country, although the Dutch-speaking part of the country has remained stable in its support of the law. Despite the law’s history of non-revision, there is no guar- antee that changes to the law will not be called for in the future. Furthermore, the complexity of the administrative proce- dure and the uncertainty of the response to declarations of legal euthanasia suggest that, even under the law, not all cases of euthanasia are declared. The question is almost no longer mentioned in adminis- trative boards since it is well known that opinions are even more divided since the publication of the law. Our association has, however, refused to meet the request of some practitioners who, supported by mutual insurance companies and social se- curity, have proposed to create a fee for this medical act. Remaining questions 1. Is life the absolute value which physi- cians have to protect at any cost? 2. If there exists a hierarchy according to which life has to be sacrificed for more important values (sacrifice,suffering, ...), who is able to judge? A physician has his or her own hierarchy of values. His or her judgement may be altered by his own suffering or emotions. Society’s opinon is most certainly the one that has to be disregarded in the individual deci- sion because it is the most motivated by money savings. But is the patient really able to judge? Does the anticipated de- cision really allow people to predict how they will feel when faced with death? Couldn’t it be said that people at the end of their life are too vulnerable and likely to be swayed by the pressure of their entourage and society to be able to refuse such a decision? Who can ad- vocate for them better than their family practitioner in such a situation? Suicide and suicide attempts are such frequent events in our society that it is difficult for physicians who witness these situa- tions to leave the decision to die or not solely with the afflicted patient, even if the decision for suicide seems to be based on good reasons. 3. To put an end to a patient’s suffer- ing when he or she is agonizing or has reached a stage of unconsciousness with- out any hope of recovering is one thing, but to put an end to the life of an in- curable patient who is not at a terminal stage is something different. If that last statement is admitted, where is the bor- der? 4. On the other hand, did not the physi- cians themselves induce a distorted im- age with therapeutic harassment, not always misplaced. Here too, where is the line drawn? 5. Is the family in a better position to de- cide? The family may have interests which could sway their decision. Even if there was no ulterior motive to decide for euthanasia, is it right that the family bears the burden of such a decision? 6. Some say that the family practitioner could do that last duty to the patient, but is it really his or her role? Conclusion Civil society is evolving. The rights of the individual are growing while, at the same time, a will for transparency threads on ev- eryone’s private life.The countries that have legislated to allow euthanasia or medically assisted suicide have also, simultaneously, legislated to define patient care to which all patients are entitled. By doing so, they also define the patient care to which they are not entitled. According to the principle of equity, what is not affordable for every- body should not be affordable for anybody. Is it possible to infer from all this that the concepts of rationing, sustainability of pa- tient care, equity and euthanasia are bound together, whether the physicians accept it or not? Whatever may happen in society, phy- sicians always have to stand on the side of their patients. Dr. Roland LEMYE, President, Association Belge des Syndicats E-mail: roland.lemye@skynet.be wmj 2 2011 5CS.indd 72 4/29/11 11:13 AM 73 Infectious Diseases The Challenge of Infectious Diseases: A Historical Perspective /lead of the section Prof. Charles Savona Ventura/ It was made clear from the beginning of this conference that infectious diseases are still very much at the top of most of the world’s agenda. Malta’s strategic importance due to its geographical position in the centre of the Mediterranean has attracted a string of powers over the centuries, and with them, infectious diseases. In the Medieval ages it was well understood that the spread of disease resulted from a “corruption of the atmosphere” or, as it was known at the time, a “Miasma”. By the time the Knights of the Order of St John pre- sided over the archipelago, quarantine was strictly enforced. Punishments were harsh if regulations were infringed but Malta had been stung by repeated outbreaks of the Bu- bonic Plague and every effort was made to stem the deaths. Bishop Island (now Manoel Island) was the site for the temporary accommodation of sailors entering Malta’s harbours during the British Period. John Howard described the fumigation process, or “perfuming”, that took place there. The worst plague to ever the hit the island occurred in 1675, claiming the lives of 20% of the population. Gozo, however, was spared. It was not un- til 1894 that the causative bacterium was identified and the last outbreak of plague took place during the Second World War, the Government setting a price on rats’ heads. Hepatitis C: Current Standards of Care /lead of the section Dr. James Pocock/ The 6 genotypes of the Hepatitis C virus were identified and described, as was the screening process for their respectable anti- bodies. Hepatitis C is a chronic disease that leads to cirrhosis and liver failure in 30% of patients, with the attendant risk of Hepato- cellular Carcinoma. The virus may be transmitted through the bloodstream, through contact of mucous membranes, or vertically during childbirth. 72% of cases in Malta are drug addicts. Drugs include PEGylated Interferon and Ribavirin. There are numerous adverse af- fects of PEGylated Interferon, including an Influenza-like syndrome, bone-marrow suppression and autoimmune diseases. Rib- avirin also has serious side effects, namely teratogenicity and a tendency to induce haemolysis. Contraindications for the use of these drugs include co-morbidities, preg- nancy and decompensated liver failure. The Markov Model, constructed from co- hort studies, predicts the course of Hepa- titis C in different patients, the possible outcomes being a breakthrough, relapse or a sustained virological response. The im- portance of achieving an early virological response (EVR) is recognized. The aim is for a 50% reduction in vRNA by the 12th week of treatment. Genotypes 2 and 3 are classified as dose-independent patients whilst genotypes 1 and 4 are dose-depen- dent patients. A single letter genetic varia- tion of the IL 28B Gene on chromosome 19, coding for interferon λ3, seems to be responsible for the genotypic variation. Studies have shown that prolonged treat- ment for 24 weeks are beneficial for geno- types 2 and 3. Treatment should be terminated after 72 weeks for patients who fail to respond. Protease inhibitors are used after trying a PEGylated interferon and Ribavirin com- bination. There is also an ethnic variation in the degree of response to treatment, with Asians reacting well but Africans poorly. Challenges in Prosthetic Joint Infections /lead of the section Dr. Charles Mallia-Azzopardi/ The main sites vulnerable to developing prosthetic joint infections were outlined, with special emphasis on the hip and the knee, as well as revision arthroplasties. Advanced age, obesity and diabetes were mentioned as predisposing factors and Coagulase-negative Staphylococci were identified as the most important causative pathogens. Gordon Caruana-Dingli Report from Infectious Diseases Conference, Malta 2010 Stephen Micallef-Eynaud wmj 2 2011 5CS.indd 73 4/29/11 11:13 AM 74 Infectious Diseases Prosthetic joint infections may be classified according to their time of onset into early, middle and late. The former occur within 3 months of the operation and are generally caused by more virulent organisms.They are characterized by an inflammatory response around the suture line. The latter may arise 2 years after the operation, are generally caused by less virulent organisms and are often the result of haematogenous spread from a urinary tract infection, pulmonary infection or any other primary locus. The “Arthroplasty Effect” was described. Macrophages are known to take up debris from the prosthesis. An increase in osteo- clast activity then follows, possibly due to inflammatory mediators. Bone resorption ultimately leads to mechanical dysfunc- tion. A key element in the pathogenesis is the development of a biofilm. This impreg- nable surface offers protection to the mi- crobes beneath, where they exist in a highly organized community and exhibit quarum signaling and the development of complex water channels. Correct diagnosis involves the measurement of inflammatory markers: CRP and ESR. A high white blood cell count and procalci- tonin level are less sensitive tests. There are various means of imaging the joint. X-rays often prove to lack sensitivity. MRI and CT scanning are of limited use. Nuclear imag- ing is not ideal. Sinugrams may be more helpful in visualizing the site of infection. Microbiological culture and sensitivity test- ing requires organisms to be retrieved from the peri-prosthetic area and not the sinus, where the flora will correlate poorly with that found at the surgical site. The joint is removed and placed in a vor- tex container. This removes the biofilm and allows proper investigation of the joint, in- cluding careful sampling and debridement of necrotic tissue. The patient receives long term antibiotic therapy before undergoing a joint replacement. An antibiotic-impreg- nated cement is used for this procedure. Infections in an Intensive Care Unit /lead of the section Dr. Sundaram Arulrhaj/ Ventilator-associated pneumonias (VAPs), catheter-associated urinary tract infection (CAUTIs), and catheter-related blood- stream infection (CRBSIs) are just a hand- ful of the enormous list of infectious dis- eases encountered in an ICU environment, where pathogens may invade the patient “from the floor to the roof ”. Several factors contribute to the high in- cidence of these infections in the ICU and the associated poor patient outcomes. Compared to patients in the general hos- pital population, patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements. The use of certain drugs, such as sedatives and muscle relaxants also predisposes to infection. The high frequency of indwelling catheters among ICU patients provide a portal of entry of organisms into the bloodstream. The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens. Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus au- reus (MRSA) and vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs. Infections caused by these resistant pathogens are dif- ficult to treat effectively. mHealth /lead of the section Dr. Michael Chamberlain/ mHealth is the practice of medical and public health, supported by mobile devices. Whilst it certainly has a role for industrial- ized nations, the field has emerged in recent years as a major application for developing countries, stemming from the rapid rise of mobile phone penetration in low-income nations. mHealth is a useful means of pro- viding greater access to larger segments of a population in developing countries, as well as improving the capacity of health systems in such countries to provide quality health- care. The motivation behind the development of the mHealth field arises from two factors. The first factor concerns the myriad con- straints felt by the healthcare systems of de- veloping nations. These constraints include high population growth, a high burden of disease prevalence, low health care work- force, large numbers of rural inhabitants, and limited financial resources to support healthcare infrastructure and health infor- mation systems.The second factor is the re- cent rapid rise in mobile phone penetration in developing countries to large segments of the healthcare workforce, as well as the population of a country as a whole. With greater access to mobile phones, the po- tential of lowering information and trans- action costs in order to deliver healthcare improves. The combination of these two factors have motivated much discussion of how greater access to mobile phone technology can be leveraged to mitigate the numerous pres- sures faced by developing countries’ health- care systems. Trinidad and Tobago /lead of the section Dr. Soloiman Juman/ The talk focused on the main infectious dis- eases crippling this twin island state. HIV remains at the forefront of the popula- tion’s health burdens. The incidence of new cases has remained fairly constant in recent years, with a 3.2% prevalence. Only 6,000 of the 18,000 people infected with HIV are receiving treatment. HIV has received increasing attention over the past five years with the introduction of the National AIDS Coordinating Committee and the Medical Research Foundation in the capital, Port of Spain. wmj 2 2011 5CS.indd 74 4/29/11 11:13 AM 75 Infectious Diseases Dengue has spread relentlessly through the Caribbean in the past 2 years.There is some discrepancy in identifying ‘true cases’. Tu- berculosis, which had been rampant up un- til the early 1980s, has reared its ugly head again in concordance with the rise in HIV/ AIDS and a trend in antibiotic resistance. 5 deaths due to H1N1 infection were also noted in the country. In 1983 only 60% of children one year of age and younger had been immunized against measles, poliomyelitis, diphthe- ria, pertussis, and tetanus. The implication of the deficient inoculation programs was evident in the 4.7% of total deaths result- ing from infectious and parasitic diseases; this was significantly higher than on other English-speaking Caribbean islands.Today, the pneumococcal polyvalent vaccine is only available privately. Nigeria /lead of the section Prof. Oluwole Ayoola Atoyebi and Dr. Chris Piwuna/ The immensity of the impact that infectious diseases have had and continue to have on Africa’s most populous country, with a pop- ulation of 151 million, was outlined from the beginning of this talk. Only 53% of the population have constant access to safe drinking water. “Extreme Poverty” is on the rise throughout the country, and with it infectious diseases. 2.6 million people are living with AIDS. The prevalence of HIV stands at 3.1%. Non communicable diseases are also increas- ing, particularly among the higher income groups, possibly as a result of poor dietary habits and unhealthy lifestyles. Poverty and illiteracy are becoming more widespread and urban slums are growing. Venereal diseases are rife throughout much of the country and “Religion” was likened to the West’s way of polluting the minds of Ni- geria’s people. Malaria has greatly risen in incidence and the parasite is showing resistance. The economy has been severely affected by this disease. The worst death rates have been in children. Faeco-oral diseases are also on the rise and the recent cholera epidemics have been grave. Measles continues to affect many children each year. Other diseases widespread in Ni- geria are: Leprosy, Meningococcal Menin- gitis, Tuberculosis, Poliomyelitis and Neo- natal Tetanus. Malaysia /lead of the section Dr. Ara Nachiappan Arumugam and Dr. Kuljit Singh/ The country lies just north of the equator and supports a rich tropical environment. The jungles and swamps that characterize much of Malaysia provide a perfect habitat for mosquitoes, as was noted by Sir Frank Swettenham, the viceroy of British Malaya during the colonial period. Still a large per- centage of the population are farmers and fishermen. Sustainable logging accounts for a significant portion of the country’s economy. There is a long list of notifiable diseases in Malaysia. Dengue has become very com- mon in recent years. It occurs in cities as well as rural areas. Plans to release a ge- netically modified mosquito to wipe out the natural vector for the disease have had sceptical responses. Surveillance maps al- low ‘hot spots’for infection to be identified. Tuberculosis, food poisoning and Chikun- gunya are also high on the list. There have been sporadic cases of Avian Influenza, H1N1 and SARS. 3 million foreign work- ers and 1 million illegal workers provide a continual source for the re-emergence of infectious diseases. Influenza /lead of the section Dr.Tanya Melillo/ Influenza, commonly referred to as the flu, was defined as an infectious disease caused by RNA viruses of the family Orthomyxo- viridae, that affects birds and mammals.The most common symptoms of the disease were identified: chills, fever, sore throat, muscle pains, severe headache, coughing, weakness/fatigue and general discomfort are all characteristic. Vaccinations against influenza are usually given to people in developed countries and to farmed poultry. The most common hu- man vaccine is the trivalent influenza vac- cine (TIV) that contains purified and in- activated material from three viral strains. Typically, this vaccine includes material from two influenza A virus subtypes and one influenza B virus strain.The TIV carries no risk of transmitting the disease, and it has very low reactivity. A vaccine formulat- ed for one year may be ineffective in the fol- lowing year,since the influenza virus evolves rapidly, and new strains quickly replace the older ones. Antiviral drugs can be used to treat influenza, with neuraminidase inhibi- tors being particularly effective. Influenza is much more severe and lasts longer than the common cold. Most people will recover completely in about one to two weeks, but others will develop life-threat- ening complications (such as pneumonia). Influenza, thus, can be deadly, especially for the weak, young and old, or chronically ill. Those who are immunosuppressed, such as people with advanced HIV infection or transplant patients, suffer from particularly severe disease. Other high-risk groups in- clude pregnant women and young children. The flu can worsen chronic health problems. People with emphysema, chronic bronchi- tis or asthma may experience shortness of breath while they have the flu,and influenza may cause worsening of coronary heart dis- ease or congestive heart failure. Smoking is another risk factor associated with more se- rious disease and increased mortality from influenza. Reference was made to the various strains of influenza viruses: the present H1N1 pan- demic, Avian H5N1, H9N2 (China 1999) and H7N3 (Holland). wmj 2 2011 5CS.indd 75 4/29/11 11:13 AM 76 Infectious Diseases It was appreciated that the threat of H1N1 is still with us. The virus acquired its pan- demic properties in Mexico. It is known to be more prevalent and serious amongst young and pregnant females. Because the mean age of death is just 34.7 years, the number of years of life lost is high. It is understood that those who have a D222G gene mutation are the worst affected. Uganda /lead of the section Dr. Margaret Mungherera and Dr. Jenifer Kavuma/ This equatorial country has a growing pop- ulation of 31 million, 35% of whom are se- verely impoverished.Infant mortality stands at 76 per 1,000.At the forefront of Uganda’s healthcare woes are a massive ‘brain drain’ problem and a mushrooming of alternative medicine. There is a National Health Policy which aims to provide primary healthcare de- livery and financing. The majority of the outpatient workload is composed of infec- tious diseases. Malaria accounts for 40%, Respiratory infections  – 25% and HIV/ AIDS – 6.2%. Tuberculosis has re-emerged as an important and widespread infectious affliction. Key programs for infectious diseases in- clude Malaria Control, to stem the current upsurge in Malaria, AIDS Control, Clini- cal Intervention, Tuberculosis and Leprosy Control, Nutrition and Health Promotion. The 6 traditional vaccines are offered as well as the Hepatitis B and Haemophilus Influ- enzae vaccines. 70% of ill-health amongst children is relat- ed to malnutrition. Breast feeding is being promoted. Radio and television are utilized for health promotion and there is an ongo- ing handwashing and soap campaign. The challenges are varied and are financial, cul- tural, political and infrastructural in nature. Hospice Africa and a Palliative Care Uni- versity course have been highly successful in Uganda. Novel Antibiotics /lead of the section Dr. Paul Caruana/ We are living in an era where infectious dis- eases that were once notorius killers of the past are staging a collective comeback in the form of antibiotic-resistant strains of bac- teria. Bacteria obtain resistance genes from various sources. When it comes to natural- ly-derived bactericidal agents, pools of re- sistance genes exist in the wild, in plasmids, transposons and other vectors. Synthetic antibiotics on the other hand demand mu- tations of the bacterial genome in order to afford resistance. Mention was made of the emergence of highly resistant “Superbugs” such as MRSA,VISA and VRSA, and that bacteria outnumber human cells by ten to one.It was outlined from the start that the manufac- ture of new antibiotics is not cost effective. Daptomycin is used as a last line for resis- tant Gram positiveve agents. It is extremely toxic and was sold off by the original man- ufacturer to a pharmaceutical company. There is a small market for its use; hence its manufacture may not be worth the price. It is used to treat VISA and VRSA, for soft tissue staphylococcal infections and bacter- aemia and right sided endocarditis. Linezolid, which can only be given via the intravenous route, is associated with thrombocytopaenia and optic neuritis and must not be continued for over 28 days. Quinupristin and Dalfopristin are used to treat staphylococci and streptococci. Li- poglycopeptides such as Televancin and Dalbavancin are still in the third phase of clinical trials and have not yet been FDA approved. Gram negative bacteria are equipped with a semi-permeable membrane that drugs must pass through to affect the bacte- rium, hence the potential for resistance is much greater. Strains of Pseudomonas and Acinetobacter have shown extreme multi-drug resistance. Carbapenemase- producing E.coli and Klebsiella have also been recorded. Resistance genes are easily transmitted via plasmids. Tigecycline, a derivative of Minecycline, is used to treat soft tissue infections. More futuristic antibiotics include NXL 104 and antibacterial polypeptides and polymyxins derived from anywhere between frog’s skins all the way to insect secretions. It was pointed out that the situation in vet- erinary practice is just as bad, if not worse, and that species leakage of antibiotic resis- tance is an extremely important factor to consider. Ghana /lead of the section Dr. Kwabena Opuku Adusei and Dr. Rita Larsen-Reindorf/ ‘Roll Back Malaria’ is a recent incentive in Ghana to combat the upsurge of malaria that has spread relentlessly throughout the country in recent years. The severest out- comes have been in children under 5 years old and in pregnant women. Breeding grounds of the Anopheles gambiae mos- quito are targeted by indoor resisdual spray- ing with insecticides. However, poor record keeping and the poor quality of drugs used to treat the condition have limited the ef- fectiveness of this campaign. The ‘Hang Up Campaign’has been initiated to increase public awareness of the benefits of mosquito nets in the prevention of ma- laria. There is a 2.9% prevalence of malaria in Ghana,with more people in the south of the country being infected. Numbers are rising. The Ghana AIDS Community strives to establish good education, management and control of the disease and those affected by it. Anti-Retroviral Treatment services (ART) are heavily subsidized and the are free. They include CD4 counts. There are plans to set up HAART centres within the country. Challenges to adequate healthcare in the community are plentiful and diverse, wmj 2 2011 5CS.indd 76 4/29/11 11:13 AM 77 Infectious Diseases including social stigma and beliefs, funding and popular culture. Bangladesh /lead of the section Prof. Sharfuddin Ahmed/ The country is home to 162 million, the 8th most populous country in the world, and is the 6th worst Tuberculosis-affected country, along with Cambodia, Ethiopia, Afghani- stan and India. Other infectious diseases that continue to plague the country are Ma- laria, Kala-Azar, Leptospirosis, Infectious Diarrhoea, Dengue, Nipah Virus and HIV. Health and education levels remain rela- tively low, although they have improved re- cently as poverty levels have decreased.Most Bangladeshis continue to live on subsistence farming in rural villages. Health problems abound, springing from poor water quality and prevalence of infectious diseases. The water crisis is acute, with widespread bacte- rial contamination of surface water and ar- senic contamination of groundwater. There are high risk endemic districts for malaria. The incidence of Hepatitis A is currently 2–7%, that of Hepatitis B is 2–4% and that of Hepatitis C is 1–3%. Because 90% of the population are Muslim and are generally sexually disciplined, the prevalence of HIV/ AIDS is comparatively low (0.1%). Filariasis is endemic in 23 districts and 20 million are already infected. Diarrhoeal dis- eases are especially common during the sea- sonal cyclones which bring bad floods and water pollution.There have been both dengue and anthrax epidemics. H1N1 and H5N1 have also left their mark on the country Cyprus /lead of the section/lead of the section Dr. Andreas Demetirou/ In stark contrast to the developing nations, Cyprus has a very low incidence of infec- tious diseases. 40% of annual deaths are due to cardiovascular morbidity, 20% due to neoplasia and 10% due to diabetes. However,the country has seen large influxes of foreigners and tuberculosis is on the rise. There have been only 3 reported cases of MDR resistant tubercle bacilli in 10 years. Tuberculosis patients are isolated for 3 weeks in a special residence in the moun- tains until they are sputum culture negative. The question was raised as to whether or not this violated human rights. Severe Sepsis /lead of the section Dr.Tonio Piscopo/ Worldwide, 18 million people die from sepsis every year. It carries a 25–30% mor- tality rate. Sepsis cases are set to grow at a rate of 1.5% per annum. Sepsis was de- fined as a systemic inflammatory response syndrome (SIRS) resulting from infection. Infection, in turn, was defined as an inva- sion by microorganisms causing inflam- mation. The signs of sepsis were discussed. A tem- perature above 38°C, a heart rate above 90 beats/minute, a respiratory rate above 20 breaths/minute and a white cell count above 12,000/mm3 are all helpful diagnostically. The pathological mechanism underlying sepsis was discussed, with reference to the bacterial lipopolysaccharides that trigger the immune response.The role of Activated Protein C in counteracting the pro-coagu- lation pathway and of bradykinin and the cytokines in the production of oedema were also discussed. It was noted that it is the body’s reaction to infection, rather than the infection itself which produces most of the widespread damage. The organisms become ‘bystanders’. Outcomes of sepsis include confusion, change in personality, tachypnoea, jaundice and hepatic necrosis, fever, disseminated intravascular coagulation and renal failure, amongst others. The role of antibiotics in lowering the infectious load, the toxic bur- den and the inflammatory response was discussed.The causes for delays in the man- agement of sepsis include logistical delays, failure to give clear instructions and a failure to reach a correct diagnosis. Highly Infectious Diseases /lead of the section Dr. Barbara Bannister/ The regional importance of infectious diseases throughout much of the Com- monwealth was stressed. Severe disease is gaining ground in new threats such as bio- terrorism. All cause death by initiating a sepsis syndrome. Viral infections were discussed. The death and malfunction of immune N-K phago- cytic cells through interferon damage in- duced by viruses was described.It was stated that these infections are largely zoonotic. The Haemorrhagic fevers, including yellow fever, hendra, dengue, Rift Valley virus and tularaemia were mentioned. Crimean–Congo hemorrhagic fever (CCHF) is a widespread tick-borne vi- ral disease, a zoonosis of domestic animals and wild animals, that may affect humans. The pathogenic virus, especially common in East and West Africa, is a member of the Bunyaviridae family of RNA viruses. Clini- cal disease is rare in infected mammals, but commonly severe in infected humans, with a 30% mortality rate. Outbreaks of illness are usually attributable to handling infected animals or people. Sporadic infection of people is usually caused by Hyalomma tick bite. Clusters of illness typically appear after people treat, butcher or eat infected livestock, particular- ly ruminants and ostriches. Outbreaks have occurred in clinical facilities where health workers have been exposed to infected blood and fomites. The causative organism is found in Asia, Eastern Europe, the Middle East, a belt across central Africa and South Africa and Madagascar. The main environmental res- ervoir for the virus is small mammals (par- ticularly European hare, Middle-African hedgehogs and multimammate rats). Ticks carry the virus to domestic animal stock. Sheep, goats and cattle develop high titers of virus in blood, but tend not to fall ill. wmj 2 2011 5CS.indd 77 4/29/11 11:13 AM 78 Infectious Diseases Birds are generally resistant with the excep- tion of ostriches. Typically, after a 1–3 day incubation period following a tick bite (5–6 days after expo- sure to infected blood or tissues), flu-like symptoms appear, which may resolve after one week. In up to 75% of cases, however, signs of hemorrhage appear within 3–5 days of the onset of illness in case of bad con- tainment of the first symptoms: first mood instability, agitation, mental confusion and throat petechiae, then soon nosebleeds, bloody urine and vomiting,and black stools. The liver becomes swollen and painful. Dis- seminated intravascular coagulation may occur as well as acute kidney failure and shock, and sometimes acute respiratory dis- tress syndrome. Patients usually begin to recover after 9–10 days from symptom onset, but 30% die in the second week of illness. Where mammal and tick infection is com- mon agricultural regulations require de- ticking farm animals before transporta- tion or delivery for slaughter. Personal tick avoidance measures are recommended, such as use of insect repellents,adequate clothing and body inspection for adherent ticks. When feverish patients with evidence of bleeding require resuscitation or intensive care, body substance isolation precautions should be taken. The United States armed forces maintain special stocks of ribavirin to protect personnel deployed to Afghanistan and Iraq from CCHF. Treatment is primarily symptomatic and supportive,as there is no established specific treatment. Ribavirin is effective in vitro and has been used during outbreaks, but there is no trial evidence to support its use. The Filoviruses were then discussed. Filo- viridae is the family of viruses that belong to the order Mononegavirales. Filoviruses cause viral hemorrhagic fevers, character- ised by often fatal bleeding and coagulation abnormalities. The name Filovirus is de- rived from the Latin word filum, alluding to the thread-like appearance of virus particles in electron microscope images.[1] Filo- viruses are single stranded negative sense RNA viruses that target primates.There are two genera: the Ebola virus and Marburg virus. Mechanisms of transmission were described, with reference to Bundibugyo, a small town in western Uganda where fruit bats serve as the main reservoir for filovi- ruses and are transmitted via monkey bush meat.The Arena viruses are spread by rats. The Viral Haemorrhagic Fevers were then discussed.There is an acute onset of flu-like symptoms with these diseases,characterized by abdominal pain, aches, myalgia and fever. Blood tests reveal a low white cell count and a raised C-Reactive Protein level. There is frank bleeding from the nose and gums. An escalation of AST is coupled with a pro- found decrease in the platelet count.With a patient presenting with the early features of Crimean Congo Haemorrhagic Fever (pe- techiae, soft tissue bleeding and bruising, gastrointestinal bleeding and exsanguinat- ing nose bleeds) we must enquire about re- cent travel to tropical destinations. Antigen testing, such as IgM ELSIA, is insensitive because the patient has a damaged immune system. Vial culture is the gold standard. Management includes early Ribavirin to raise the platelet count and lower mortality. The bleeding must then be managed. There is no licensed vaccine. We should educate people living in endemic areas not to squash ticks and instruct them on good food and farm hygiene. Lassa Fever was next discussed. The virus comes from the Arenaviridae family and its reservoir lies in the rat population. Spread is through rat faeces, urine and bites. There is a Lassa Fever belt across West Africa from Guinea to Cameroon, but interestingly not in Ghana. The presenting features include a non-pit- ting swelling of the face and neck, as well as haemorrhagic signs. There may be neu- rological features and full-blown sseptic shock. The markers of prognosis include a viraemia, and incubation periods, which are very helpful in risk assessment. Risk factors are important and include: Ticks, handling and butchering animals, traditional funeral ceremonies, needle stick injuries,caring for a sick family member and working around drains (where rats abound). Chikungunya, first described in Tanzania in 1953, is spread by the Asian Tiger mosquito and has led to epidemics in the tropics,most notably in Mauritius.Climate may have far- reaching implications, with the mosquito being able to spread over winter months. HIV in Pregnancy /lead of the section Dr. Lisa Micallef Grimaud/ Mother to child transmission of HIV/ AIDS is exceptionally prevalent in Sub- Saharan Adfrica and 40% of all cases oc- cur within the Commonwealth. Maternal factors include the HIV viral load, genital infections with ulcers and intravenous drug abuse. Pregnancy factors include chorioam- nionitis, prolonged rupture of membranes, the gestational age at delivery and the mode of delivery. When HIV is diagnosed during Pregnancy the mother is first assessed and it must be decided whether she needs Anti-Retroviral Therapy for her own health. Is so, ART is initiated. If not, ART begins in the second trimester. The PACTG 076 Study showed that Zinovudine prophylaxis decreased ver- tical transmission by 67.5%. Anti-Retroviral Therapy in pregnancy de- creases the viral load by crossing the pla- centa and by decreasing secretions. Delivery should be by pre-labour caesarean section at 39 weeks, under intravenous zinovudine cover. In Malta HIV is usually diagnosed during the second and third trimester. wmj 2 2011 5CS.indd 78 4/29/11 11:13 AM 79 Infectious Diseases HIV in Children /lead of the section Dr. David Pace/ This is a worldwide problem, with the lat- est epidemics occurring in Eastern Europe, Central and South-East Asia and Sub- Saharan Africa. Most cases are due to peri- natal transmission. Management includes combination ART for the mother, caesar- ean section, avoidance of breastfeeding and ART prophylaxis in children. 68% of HIV cases in Malta have been in migrants from Sub-Saharan Africa, 18% in Maltese, 9% in Eastern Europeans and 5% in North Africans. The majority of moth- ers infected with HIV were unsupported. Most fathers accepted testing. The peak witnessed in 2008 corresponded with the peak in illegal immigration of that year. The mode of delivery was found to signifi- cantly affect the rates of vertical transmis- sion. Vaginal delivery, Elective Caesarean and Emergency Caesarean section resulted in 10%, 2% and 9% rates of transmission respectively. Breast milk is known to contain HIV in both cell form and free form.Administering ART to infants will not only be of benefit to their own health but will benefit the general population by rendering them potentially less infective. Challenges faced by clinicians include language barriers, poverty (many are unable to afford the formula milk), im- proper sterilization of bottles, inappropriate mixing techniques and cultural stigmas. HIV and Hepatitis – Challenging Interactions /lead of the section Dr. Alistair Miller/ It was stressed that if one blood-borne virus is diagnosed, the patient should be investi- gated for other blood-borne viruses, with similar routes of transmission. Models of care include well-equipped genitourinary, hepatology and infectious diseases clinics. Globally, 175 million are infected with HIV, 60 million are infected with Hepatitis C and amongst them, some 10 million are suffering from a co-infection between the two viruses. Chronic liver disease rates are known to coincide with HIV epidemics and co-in- fection results in a much higher grade of Hepatitis C viraemia.To add even more in- sult to injury, Anti-Retroviral Therapy pro- duces various toxic effects on the liver.Some of the drugs used cause hepatic fibrosis and non-cirrhotic portal hypertension. A liver biopsy will establish the degree of fibrosis. The need to initiate immediate Antiretro- virals should be questioned in view of the individual patient. It was pointed out that in a child the im- mune system is not yet mature. Infection with Hepatitis B results in high levels of the Hep B virus (the so called ‘Immune tolerant’ phase). Once the immune system begins to develop resistance against the Hep B virus, inflammatory processes begin to damage the liver, in contrast to Hep C infection where the virus particle itself is responsible for the liver damage, and end stage hepatic failure. Malaria – Counting it Out /lead of the section Dr. Chantal Galea and Dr. Claudia Fsadni/ Malaria is a mosquito-borne infectious dis- ease of humans caused by eukaryotic pro- tists of the genus Plasmodium. It is wide- spread in tropical and subtropical regions, including much of Subsaharan Africa, Asia and the Americas. The disease results from the multiplication of malaria parasites within red blood cells, causing symptoms that typically include fever and headache, in severe cases progressing to coma, and death. Five species of Plasmodium can infect hu- mans: severe disease is largely caused by Plasmodium falciparum. Malaria caused by Plasmodium vivax, Plasmodium ovale and Plasmodium malariae is generally a milder disease that is rarely fatal. A fifth species, Plasmodium knowlesi, is a zoonosis that causes malaria in macaques but can also in- fect humans. Malaria transmission can be reduced by preventing mosquito bites by distribution of inexpensive mosquito nets and insect repellents, or by mosquito-control mea- sures such as spraying insecticides inside houses and draining standing water where mosquitoes lay their eggs. Although many are under development, the challenge of producing a widely available vaccine that provides a high level of protection for a sustained period is still to be met. Several drugs are also available to prevent malaria in travellers to malaria-endemic countries (prophylaxis). A variety of antimalarial medications are available. In the last 5 years, treatment of P. falciparum infections in endemic coun- tries has been transformed by the use of combinations of drugs containing an arte- misinin derivative. Severe malaria is treated with intravenous or intramuscular quinine or, increasingly, the artemisinin derivative artesunate which is superior to quinine in both children and adults.Resistance has de- veloped to several antimalarial drugs, most notably chloroquine. Each year, there are more than 225 million cases of malaria, killing around 781,000 people each year according to the latest WHO Report. The majority of deaths are of young children in sub-Saharan Africa. Ninety percent of malaria-related deaths occur in sub-Saharan Africa. Malaria is commonly associated with poverty, and can indeed be a cause of poverty and a major hindrance to economic development. For areas where microscopy is not avail- able, or where laboratory staff are not ex- perienced at malaria diagnosis, there are commercial antigen detection tests that require only a drop of blood. Immunochro- matographic tests have been developed, distributed and fieldtested. These tests use finger-stick or venous blood, the completed wmj 2 2011 5CS.indd 79 4/29/11 11:13 AM 80 Infectious Diseases test takes a total of 15–20 minutes, and the results are read visually as the presence or absence of colored stripes on the dipstick, so they are suitable for use in the field. The first rapid diagnostic tests were using P. fal- ciparum glutamate dehydrogenase as anti- gen. Molecular methods are available in some clinical laboratories and rapid real-time as- says (for example, QT-NASBA based on the polymerase chain reaction) are being developed with the hope of being able to deploy them in endemic areas. PCR (and other molecular methods) is more accurate than microscopy. However, it is expensive, and requires a specialized laboratory. Moreover, levels of parasitemia are not necessarily correlative with the pro- gression of disease, particularly when the parasite is able to adhere to blood vessel walls. Therefore more sensitive, low-tech diagnosis tools need to be developed in or- der to detect low levels of parasitemia in the field. Efforts to eradicate malaria by eliminating mosquitoes have been successful in some ar- eas. Malaria was once common in the Unit- ed States and southern Europe, but vector control programs, in conjunction with the monitoring and treatment of infected hu- mans, eliminated it from those regions. In some areas, the draining of wetland breed- ing grounds and better sanitation were ad- equate. Before DDT, malaria was success- fully eradicated or controlled also in several tropical areas by removing or poisoning the breeding grounds of the mosquitoes or the aquatic habitats of the larva stages, for ex- ample by filling or applying oil to places with standing water. These methods have seen little application in Africa for more than half a century. Sterile insect technique is emerging as a po- tential mosquito control method. Progress towards transgenic, or genetically modified, insects suggest that wild mosquito popu- lations could be made malaria-resistant. Researchers at Imperial College London created the world’s first transgenic ma- laria mosquito, with the first plasmodium- resistant species announced by a team at Case Western Reserve University in Ohio in 2002. Successful replacement of current populations with a new genetically modified population, relies upon a drive mechanism, such as transposable elements to allow for non-Mendelian inheritance of the gene of interest. However, this approach contains many difficulties and success is a distant prospect. An even more futuristic method of vector control is the idea that lasers could be used to kill flying mosquitoes. Indoor residual spraying (IRS) is the prac- tice of spraying insecticides on the interior walls of homes in malaria affected areas.Af- ter feeding, many mosquito species rest on a nearby surface while digesting the blood- meal, so if the walls of dwellings have been coated with insecticides, the resting mos- quitoes will be killed before they can bite another. Although DDT has never been banned for use in malaria control and there are several other insecticides suitable for IRS,some ad- vocates have claimed that bans are responsi- ble for tens of millions of deaths in tropical countries where DDT had once been ef- fective in controlling malaria. Furthermore, most of the problems associated with DDT use stem specifically from its industrial- scale application in agriculture, rather than its use in public health. The World Health Organization (WHO) currently advises the use of 12 different insecticides in IRS operations, including DDT as well as alternative insecticides (such as the pyrethroids permethrin and deltamethrin). One problem with all forms of Indoor Residual Spraying is insecticide resistance via evolution of mosquitoes. Mosquito nets help keep mosquitoes away from people and greatly reduce the infec- tion and transmission of malaria. The nets are not a perfect barrier and they are often treated with an insecticide designed to kill the mosquito before it has time to search for a way past the net. Anopheles mosquitoes feed at night, the preferred method is to hang a large “bed net” above the center of a bed such that it drapes down and covers the bed completely. Immunity (or, more accurately, tolerance) does occur naturally, but only in response to repeated infection with multiple strains of malaria. Vaccines for malaria are under development, with no completely effective vaccine yet available. The first promising studies demonstrating the potential for a malaria vaccine were performed in 1967 by immunizing mice with live, radiation-at- tenuated sporozoites, providing protection to about 60% of the mice upon subsequent injection with normal, viable sporozoites. Since the 1970s, there has been a consid- erable effort to develop similar vaccination strategies within humans. It was deter- mined that an individual can be protected from a P. falciparum infection if they receive over 1,000 bites from infected yet irradiated mosquitoes. Education in recognizing the symptoms of malaria has reduced the number of cases in some areas of the developing world by as much as 20%. Recognizing the disease in the early stages can also stop the disease from becoming a killer. Education can also inform people to cover over areas of stag- nant, still water e.g. Water Tanks which are ideal breeding grounds for the parasite and mosquito, thus cutting down the risk of the transmission between people. This is most put in practice in urban areas where there are large centers of population in a confined space and transmission would be most likely in these areas. A World Without Tuberculosis /lead of the section Dr. Brian Farrugia/ One third of the world’s population is thought to be infected with M. tubercu- wmj 2 2011 5CS.indd 80 4/29/11 11:13 AM iii Infectious Diseases losis, and new infections occur at a rate of about one per second. The proportion of people who become sick with tuberculosis each year is stable or falling worldwide but, because of population growth, the absolute number of new cases is still increasing. In 2007 there were an estimated 13.7 million chronic active cases, 9.3 million new cases, and 1.8 million deaths, mostly in develop- ing countries. In addition, more people in the developed world contract tuberculosis because their immune systems are more likely to be compromised due to higher exposure to immunosuppressive drugs, sub- stance abuse, or AIDS. The distribution of tuberculosis is not uniform across the globe; about 80% of the population in many Asian and African countries test positive in tu- berculin tests, while only 5–10% of the US population test positive. When people suffering from active pulmo- nary TB cough, sneeze, speak, or spit, they expel infectious aerosol droplets 0.5 to 5 μm in diameter. A single sneeze can release up to 40,000 droplets. Each one of these drop- lets may transmit the disease, since the in- fectious dose of tuberculosis is very low and inhaling fewer than ten bacteria may cause an infection. People with prolonged, frequent, or in- tense contact are at particularly high risk of becoming infected. Others at risk in- clude people in areas where TB is common, people who inject drugs using unsanitary needles, residents and employees of high- risk congregate settings, medically under- served and low-income populations, high- risk racial or ethnic minority populations, children exposed to adults in high-risk categories, patients immunocompromised by conditions such as HIV/AIDS, people who take immunosuppressant drugs, and health care workers serving these high-risk patients. Drug-resistant tuberculosis is transmitted in the same way as regular TB. Primary resistance occurs in persons infected with a resistant strain of TB. A patient with fully susceptible TB develops secondary resistance (acquired resistance) during TB therapy because of inadequate treatment, not taking the prescribed regimen appro- priately, or using low-quality medication. Drug-resistant TB is a public health issue in many developing countries, as treat- ment is longer and requires more expensive drugs. Multi-drug-resistant tuberculosis (MDR-TB) is defined as resistance to the two most effective first-line TB drugs: ri- fampicin and isoniazid. Extensively drug- resistant TB (XDR-TB) is also resistant to three or more of the six classes of second- line drugs. The DOTS (Directly Observed Treatment Short-course) strategy of tuberculosis treat- ment recommended by WHO was based on clinical trials done in the 1970s by Tubercu- losis Research Centre, Chennai, India. The country in which a person with TB lives can determine what treatment they receive.This is because multidrug-resistant tuberculosis is resistant to most first-line medications, the use of second-line antituberculosis medications is necessary to cure the patient. However, the price of these medications is high; thus poor people in the developing world have no or limited access to these treatments. The World Health Organization declared TB a global health emergency in 1993, and the StopTB Partnership developed a Global Plan to Stop Tuberculosis that aims to save 14 million lives between 2006 and 2015. Since humans are the only host of Myco- bacterium tuberculosis, eradication would be possible. This goal would be helped greatly by an effective vaccine. Immunisation – The Paradigm Of Prevention /lead of the section Dr. Mark Muscat/ Immunisation is the process by which an individual’s immune system becomes forti- fied against an agent, known as the immu- nogen. Along with safe drinking water, vaccines have had an impact on health and mortal- ity reduction that by far surpasses any other health strategy, including antibiotics. The 21st Century has brought with it the Papil- loma Virus and Rotavirus vaccines. Immunisation imparts immense economic benefits.The aim is to prevent not just indi- vidual infection, but infection in the popu- lation as a whole. The approaches towards immunization were discussed,including mass,selected and routine (childhood) vaccination. The role of mass vaccination during outbreaks was described. The history and outcomes of the measles, cholera, typhoid and meningococ- cal vaccines were all mentioned. Measles is still prevalent in Africa and In- dia.The main public health strategies are to sustain high coverage with 2 MMR shots in childhood and to improve surveillance. A recent outbreak occurred amongst the Roma people of Bulgaria. Cases still occur within Traveller groups and ultraorthodox religious groups in the UK and central Eu- rope. Challenges facing effective immunization are religious beliefs, anthroposophic groups and a general lack of information.Anti-vac- cine lobbyists made an issue out of thiomer- sal in the H1N1 vaccine.It was stressed that health workers must continue to educate the public, enhance surveillance and under- go medical training in Vaccicology. Dr. Gordon CARUANA-DINGLI, President Commonwealth Medical Association E-mail: gordoncd@maltanet.net The report was compiled by Mr Stephen MICALLEF-EYNAUD wmj 2 2011 5CS.indd Sec2:iii 4/29/11 11:13 AM iv A Brief History Founded in 1978 by “Le Quotidien du Medecin” (a French maga- zine for the medical professions) and initiated by the journalist Lil- iane Laplaine-Montheard, the World Medical and Health Games (aka Medigames) have become the most important international athletic event exclusively for health professionals. They are open to all health professionals: doctors, dentists, pharmacists, nurses, vet- erinarians and students in those majors. The games offer a unique ambiance where the participants can exchange both their profes- sional ideas and life experiences as well as compete in their favourite sports. 23 Sports, One Rallying Philosophy... For the baron Pierre de Coubertin, the founder of the modern Olympic Games, the beauty of sports and the pure joy in the ath- letic effort was paramount. It is in this “Olympic” spirit that every year the participants meet in the Medigames.There is a large choice between individual sports (tennis, Judo, swimming, half marathon, squash, golf, gymnastics...) and team sports (volley-ball, beach vol- ley-ball, soccer, basket-ball...).The week that follows not only offers many athletic competitions but also a variety of entertainments. It ends with a “closing ceremony” in honor of the games. Sport... for the Neurons Every year since their creation, and beyond the focus on sports, the Medigames have always been an international forum where several medical themes are studied and discussed, thus allowing the partici- pants to ally sport with a furthering of their professional expertise. This year Dr André MONROCHE (France) will be our president. Finally, the Medigames offer an opportunity to discover a new part of the world every year. After Morroco (2007), Germany (2008), Spain (2009) and Croatia (2010) it is now the turn of the Canary Islands (Spain) to host the games. The 32nd Edition of the Medigames will take place from July 2nd to July 9th 2011 at Las Palmas De Gran Canaria. E-mail : presse@mundiavocat.com Site Internet : www.medigames.com The 2011 World Medical and Health Games Contents Council Down Under . . . . . . . . . . . . . . . . . . . . . . . . 41 New Policy Against the Tobacco . . . . . . . . . . . . . . . 42 188th WMA Council Meeting . . . . . . . . . . . . . . . . . 46 Addressing Harmful Use of Alcohol is Essential to Realising the Goals of the UN Resolution on Non-Communicable Diseases (NCDs) . . . . . . . . . . 59 Task Delegation Versus Task Shifting in the Indonesian Health Service . . . . . . . . . . . . . . . . . . . . 62 History of Georgia, Georgian Medicine and Medea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Palliative Sedation in the Netherlands . . . . . . . . . . . 67 Opinion of the Belgian Medical Association About the Law Refering to Euthanasia . . . . . . . . . . 71 Report from Infectious Diseases Conference, Malta 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 wmj 2 2011 5CS.indd Sec2:iv 4/29/11 11:13 AM