WMJ 04 2011

UNITED STATES OF AMERICA
vol. 57
MedicalWorld
JournalJournal
Official Journal of the World Medical Association, INC
G20438
Nr. 4, August 2011
• Gigantic Earthquake and Tsunami in the Japan.
Healthcare Support for Radiation Exposure
• Public Health in the Russian Federation
• Task Shifting in the Netherlands
wmj 4 2011 5CS.indd Iwmj 4 2011 5CS.indd I 09.08.2011 10:38:2709.08.2011 10:38:27
Cover picture from France
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
Dieselstr. 2, D-50859 Köln, Germany
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:
Andreas Vesalius and Ambruaz Pare at the
bed of fatally wounded French King Henri II.
Xylography, Germany 1559.
In Paris on July 1559 during the tournament
was seriously injured French King Henri II.
The greatest French surgeon of 16th
century
Ambruaz Pare (1510–1590), was invited for
his treatment, but the Spanish King Philip
II sent to Paris physician Andreas Vesalius
(1514–1564).
Xylography from the stock of The Pauls Stradins
Museum for history of medicine in Riga.
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Dr. Wonchat SUBHACHATURAS
WMA President
Thai Health Professional Alliance
Against Tobacco (THPAAT)
Royal Golden Jubilee, 2 Soi
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Bangkok,Thailand
Dr. Leonid EIDELMAN
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and Planning Committee
Israel Medical Asociation
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Dr. Masami ISHII
WMA Vice-Chairman of Council
Japan Medical Assn
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Bunkyo-ku
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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 4 2011 5CS.indd Sec1:iiwmj 4 2011 5CS.indd Sec1:ii 09.08.2011 10:38:3409.08.2011 10:38:34
121
Objective: reduction of dietary trans fatty acid consumption for all
earth’s inhabitants!
The World Medical Association faces a new challenge: Reduction
of trans fatty acid content in the world’s foods to 2% of total fat
by 2017, but a complete elimination of trans fats from food pro-
cessing by 2020. It’s an all-embracing problem – trans fatty acids
are cheaper than valuable fats, trans fatty acids are more compliant,
therefore more suited for the production of different sweets, trans
fatty acids are with different melting points, therefore easily used in
food processing in cases when natural fats cannot be used. However,
there are also evidence-based studies that clearly show: Trans fatty
acids increase low-density lipoprotein (LDL) cholesterol levels, re-
duce high-density lipoprotein (HDL) cholesterol levels, as well as
they increase TG levels in the blood. Consequently, trans fatty acids
actually promote the development of atherosclerosis, increase the
risk of stroke and infarction, and reduce life expectancy.
The struggle against dietary trans fatty acids in the world proceeds
with changeable success and quite episodically. While trans fatty
acids are banned in separate US States and are severely restricted in
Denmark, Iceland, Switzerland and separate East Asian countries,
no practicable restrictive regulations – except maybe for the require-
ment to indicate nutrition facts on the product label – exist in the
rest of the world’s countries. The world food industry bravely lob-
bies against the opposition to the use of trans fatty acids in cookery,
chocolate production, and also in the production of other foods.
Traditions around the world differ; however, high-fat sweets are
loved everywhere on a holiday. These sweets usually contain more
or less fat, they may be served in soft creams or hard cookies, but
almost everywhere the fat added with a view to economy is the
worst – the artificially hydrogenated one.
The World Medical Association should draw a mantra-like conclu-
sion that would decide what is a good fat and what is not. Good fat
includes fish fat as it contains omega fatty acids, olive oil, and any
unrefined vegetable oil.
Worse fat includes refined vegetable oils, milk fat, and meat fat,
but even this fat cannot be completely dispensed with, the more so
when the eating habits of a part of the world’s population, whose
basic diet includes beef and lamb, are considered. Saturated fatty ac-
ids also raise total cholesterol and LDL cholesterol levels, moreover,
they are most frequently found in the products which also contain
cholesterol.
Nevertheless, one should completely avoid artificially produced hy-
drogenated fats, namely – trans fatty acids. If any one of us – mem-
bers of the World Medical Association – announces in his or her
native country that processed foods should not contain trans fatty
acids,he or she receives a furious repulse from both the industry and
the politics. At such moments, politicians become defenders of the
poor creatures and say,“If pastries, cookies, wafers, ice-cream, cream
or cheese are made without trans fatty acids, the poorest people of
the world will die of starvation”.
This is not true.The increase in the price of foods,caused by lowering
dietary trans fatty acids and complete elimination of them from the
diet, will be minimal.The science of the world will quickly solve the
problem – how to process foods from natural fat – in fact, a return
to long-forgotten recipes will ensue. But the struggle against trans
fatty acids should be simply started in the name of the health of the
world’s population. As we fail to do it separately, it will be neces-
sary to decide on a joint WMA Statement in 2012, which should
include as an objective reduction of trans fatty acid content in the
world’s foods to 2% of total fat by 2017, but a complete elimination
of trans fats from food processing by 2020. Hand in hand with the
World Health Organization (WHO), we will have to address the
governments of all states.
A simple algorithm should be devised, which should be repeated
like a mantra: Fat should account for 25% of the calories con-
sumed, with one half of this fat intake consisting of monoun-
saturated fatty acids and saturated fatty acids not exceeding one
quarter of this fat intake. Trans fatty acids have no place in this
proportion.
Dr. Pēteris Apinis,
President of Latvian Medical Association
Editorial
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122
WMA news
The growing threats to health personnel
during or following uprisings and mass pro-
tests throughout the world were subject to
discussions during this year’s World Health
Assembly. The World Medical Association
took part in the debate, reiterating its firm
commitment to the international Code of
Medical Ethics as well as the Geneva Con-
ventions ensuring that physicians and other
health personnel can provide care to every-
one in need in situations of armed conflict.
Civil society calls for WHO
to take a lead in developing
methodologies and plans for
data collection and systematic
reporting of assaults on medical
functions, personnel and patients
On 12 May, in a joint letter1
to Dr. Marga-
ret Chan, Director General of the WHO,
the WMA together with other health and
human rights non-governmental orga-
nizations2
(NGOs) urged WHO to take
action on the growing number of assaults
on health personnel and facilities in areas
of conflict and civil unrest. The organiza-
1 The full text of the letter can be found at: www.
wma.net/en/20activities/20humanrights/20distre
ss/index.html
2 The organizations that signed the letter were
the World Medical Association, the International
Medical Corps, Human Rights Watch, Save the
Children UK, Merlin, IntraHealth International,
Medact, Physicians for Human Rights, Interna-
tional Federation of Health and Human Rights
Organizations, International Rehabilitation
Council for Torture Victims, the International
Rescue Committee, Health Poverty Action UK
and International Health Protection Initiative,
Public Health Institute, Management Sciences for
Health, Family Care International and People’s
Health Movement.
tions explained that these assaults pose a
threat to health, health systems and health
worker retention. Furthermore they urged
the WHO to convene a group of experts to
put in place systematic data collection from
around the world and to identify research
needed to enhance the protection of health
systems.
The letter declares: ‘In recent weeks reports
have emerged of doctors being arrested and
assaulted for complying with their ethical
duty to provide care to patients in need.
They provide only a snapshot of a much
wider problem of the lack of protection of
health functions during crises. These as-
saults not only result in obstructed access to
health, but pose a formidable challenge to
health systems,limiting their effective oper-
ation during instability while also impeding
the development of health infrastructure
and meeting human resource needs once
stability returns.’
It says the WHO has the authority to as-
sist all health personnel in such hazardous
situations by contributing its particular ex-
pertise to developing methods for collect-
ing evidence on these assaults. The NGOs
require a plan for the collection of data, for
assuring reporting of the data collected,
identifying research needs for gaining bet-
ter understanding of the problem, and pro-
viding guidance on how protection can be
enhanced.
This would be in line with the WHO’s key
functions to produce health statistics and
‘to reduce the health consequences of emer-
gencies, disasters, crises and conflicts, and
minimize their social and economic impact.’
Responding to NGOs’ concerns, Dr. Mar-
garet Chan – in her opening speech to the
64th
World Health Assembly on the 16th
of
May3
– expressed her ‘extreme distress’ at
reports of assaults on health personnel and
facilities in some of conflict situations. The
WHO Director-General then urged ‘all
parties to ensure the protection of health
workers and health facilities in conflict situ-
ations, to enable them to provide care for
the sick and injured’.
The next day, the WMA, Johns Hopkins
Bloomberg School of Public Health and
IntraHealth International echoed civil
society’s demands in a briefing meeting4
,
aimed at stimulating action by the inter-
national health community to protect doc-
tors, nurses, other health workers and pa-
tients from assaults. The event, moderated
by Maurice Middleberg from IntraHealth,
provided a means to discuss with WHO
the role it can play in providing leadership
in this area.
Dr. Torunn Janbu, Chairperson of the
WMA Medical Ethics Committee, re-
called the ongoing commitment of WMA
to protect health personnel worldwide and
expressed its commitment to continue in
this direction. Other speakers at the event
included:
Dr. Nils Daulaire, Director of the Office
of Global Health Affairs from the United
States Department of Health and Human
Service. Dr. Daulaire recommended further
research and suggested an expert meeting
on the topic.
Dr. Robin Coupland, Medical Adviser
from the International Committee of the
Red Cross, explained that the protection
of health care in armed conflicts and other
3 Dr. Margaret Chan’s address to the Sixty-fourth
World Health Assembly, Geneva, 16 May 2011 :
www.who.int/dg/speeches/2011/wha_20110516/
en/index.html
4 The event was co-sponsored by the United States
Government – For further information, see : www.
wma.net/en/20activities/20humanrights/20distre
ss/index.html
World Health Organization Urged to Act over
Assaults on Health Personnel and Facialities
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123
Counterfeit medicines
In a first for the Asian region, national
health professions organisations (nurses,
pharmacists, physical therapists, dentists
andphysicians) have discussed and en-
dorsed the WHPA Taipei Call to Action on
Counterfeit Medical Products, to reduce
the harmful impact of falsified and coun-
terfeit medical products on patients and
the public. With the WHPA Taipei Call
to Action health professions leadersare
gearing up their response to this serious
threat to patient safety and they are call-
ing on governments in the region to do
the same.
Under the banner of the “Be Aware, Take
Action”campaign against counterfeit medi-
cal products, theWorld Health Professions
Associationworkshop, held on 30 June in
Taipei, tackled the grave problem of coun-
terfeit medical products worldwide. Co-
hosted with WHPA by the Taiwan Society
of Health Systems Pharmacists (THSP),
the workshop brought together more than
50 participants from Indonesia, Japan, Ma-
laysia, the Philippines, Singapore, South
Korea,Thailand and Taiwan.
Participants jointly agreed on the follow-
ing four key strategies for the basis of a
comprehensive regional action plan against
counterfeiting of medical products – to in-
crease capacity of healthcare professionals,
to foster regional cooperation initiatives,
to strengthen collaborative practice, and to
situations of violence has been identified as
a priority theme for the ICRC for the com-
ing years and presented briefly the related
activities planned.
Ms. Miatta Gabanya, a nurse representing
Merlin, talked about her personal experi-
ence as nurse in West Africa.
Finally Leonard Rubenstein, Senior Schol-
ar at Johns Hopkins Bloomberg School of
Public Health, concluded by urging WHO
to take a lead in the protection of health
personnel as a matter of priority.
WHO representatives participating in the
event welcome the civil society initiative
and committed to take action in the near
future. We hope that tangible actions will
follow.
The US delegation suggests an
expert meeting initiated by WHO
Along the same lines, in its comments on
WHO draft resolution on Health Work-
force Strengthening5
, the US delegation
recommended research to better under-
stand assaults on health workers and in-
terference with health facilities toward the
goal of strengthening health systems. Such
5 WHO resolution on Health Workforce
Strengthening (WHA64.6): http://apps.who.int/
gb/e/e_wha64.html
research could reveal what protection strat-
egies would be most successful and pro-
vide a basis for developing new ones. As
recommended by Dr. Daulaire during the
briefing, the delegation called for an expert
meeting – including WHO staff, interested
Member States, academic experts, humani-
tarian and development NGOs, as well as
health professionals – to tackle these issues.
Recent WMA press releases related to the topic:
World Health Organization urged to act over Assaults on Health Personnel and Facili-
ties (May 2011):
www.wma.net/en/40news/20archives/2011/2011_09/index.html
Alarm Expressed Over Arrest of Nurses and Physicians (May 2011):
www.wma.net/en/40news/20archives/2011/2011_08/index.html
Attacks on Medical Personnel Causing Increasing Concern (March 2011):
www.wma.net/en/40news/20archives/2011/2011_02/index.html
WMA policy:
WMA regulations in times of armed-conflicts:
www.wma.net/en/30publications/10policies/a20/index.html
WMA Council Resolution supporting the Preservation of International Standards of
Medical Neutrality :
www.wma.net/en/30publications/10policies/30council/cr_9/index.html
Health Professionals Unite in WHPA Taipei
Call to Action, urging governments to ramp
up fight against falsified and counterfeit
medicines
Joint Initative by the Health Professions from Asian Region and WHPA1
1 World Health Professions Alliance http://www.whpa.org
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124
Counterfeit medicines
improve collaboration with health and en-
forcement authorities and with other key
stakeholders.
Ton Hoek, speaking on behalf of the
World Health Professions Alliance,
stressed the importance of vigilance when
it comes to falsified and counterfeit medi-
cal products.“Health professionals are
deeply concerned by this serious public
health threat, which demands sustained,
coordinated international action to control
it.Failure to act to prevent falsification of
essential medicines would be a fundamental
breach of the trust patients place in public
health structures.”
The keynote address was presented by Oli-
ver Yoa-Pu Hu, Ph.D., FAAPS, Minister
without Portofolio, Taiwan. He spoke on
the collaborative combat against counterfeit
medical products and summarised activities
against counterfeits around the world.
Other presenters included:
• Deng Shin Tang, President of the TSHP,
stated that health professionals must con-
tinue to work together and that in Asia,
this workshop has given the impetus to
health professionals in the region to con-
tinue this work together.
• Xuanhao Chan, of the International
Pharmaceutical Federation, also rep-
resenting WHPA, showed what drives
people to buy counterfeit medical prod-
ucts and where national multi-sectorial
initiatives against counterfeiting have
been implemented.
• TeresitaBarcelo, of the PhilipinesNurses
Association, said that the WHPA Taipei
Call to Action will be very useful for the
health professionals from the Philipines
and from throughout the region, to ad-
vocate to their governments in order to
keep counterfeiting on the public health
agenda.
• WonchatSubhachaturas, WMA Presi-
dent, Thailand urged all the health pro-
fessions to continue the combat together,
with the World Health Professions Alli-
ance,and with national alliances of health
professionals.
• Deputy Minister,Department of Health,
Mei-Ling Hsiao, stated that combatting
counterfeiting of drugs in every country
not only belongs to Ministries of Health
but also includes prosecution depart-
ments, and wider interdepartmental
cooperation. She also urged health pro-
fessionals to show the costs of counter-
feiting, and to strongly advocate to gov-
ernments in economic terms and well
as in terms of patient safety and public
health.
• Paula de Cola and Emma Andrews of
Pfizer Inc shared examples of advocacy in
action and urged healthcare professionals
to find ways to continue to work collab-
oratively and to advance the Call to Ac-
tion in their countries.
• Ivan Ho, Director of Global Security
Asia Pacific, Pfizer Inc, highlighted some
of Pfizer’s extensive activities to combat
counterfeit medicines. He noted that
Pfizer has uncovered examples of coun-
terfeit medicinal products in over one
hundred countries.
These speakers provided a clear picture of
the severity and complexity of the problem,
as well as the efforts being made by their
organisations to fight it – to define, combat
and penalise the production and distribu-
tion of counterfeit medical products.
The workshop recognised that counterfeit
medical products are, above all, a threat to
patient safety with grave consequences in
terms of increased disease burden, mortality
and costs for healthcare systems.
For more information about Be Aware,
Take Action, see www.whpa.org/counter-
feit_campaign.htmor send an email to whpa.
campaign@wma.net
See WHPA Taipei Call to Action www.
whpa.org/news/WHPA_Taipei_Call_to_Ac-
tion2011.pdf
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125
Counterfeit medicines
WHPA Taipei Call to Action
We, national member organizations1
of the
International Council of Nurses (ICN),
the International Pharmaceutical Federa-
tion (FIP), the World Confederation for
Physical Therapy (WCPT), the World
Dental Federation (FDI) and the World
Medical Association (WMA) are meeting
in Taipei on the 30th
June 2011, to address
the alarming public health threat of falsi-
fied and counterfeit2
medical products in
our region.
We recognize that in some countries, the
infiltration and sale of counterfeit and fal-
sified medicines in the legitimate supply
chain can cause disease, disability and death
to patients and healthy individuals around
the world. Failure to act to prevent this
would be a fundamental breach of the trust
patients place in public health structures.
We observe that unscrupulous vendors are
deliberately preying upon vulnerable groups
such as the elderly, poor and less well edu-
cated, thereafter misleading them into buy-
ing counterfeit medical products.
We note with grave concern that the peo-
ple of our countries are at risk of dying from
medicines that may have been accidentally
adulterated, produced to a poor standard
and/or degraded by inappropriate storage.
Such problems should not be ignored. But
neither should they be confused with delib-
erate counterfeiting.
We fear that in countries with a high bur-
den of communicable diseases such as ma-
1 Indonesia, Japan, Malaysia, the Philippines, Sin-
gapore, South Korea,Thailand and Taiwan
2 A counterfeit medicine is one which is deliber-
ately and fraudulently mislabeled with respect to
identity and/or source. Counterfeiting can apply
to both branded and generic products and coun-
terfeit products may include products with the
correct ingredients or with the wrong ingredients,
without active ingredients,with insufficient active
ingredients or with fake packaging.
laria, tuberculosis and HIV/AIDS, coun-
terfeit and falsified medical products have
already led to drug- resistant forms of in-
fective pathogens which are reversing gains
that have been achieved in fighting these
diseases.
We strongly affirm to governments and
the international community that health
professionals are uniquely positioned in
this fight and will rise up to the challenge
to increase the awareness of this problem
and implement definitive strategies towards
curbing it.
We also acknowledge the work done by the
World Health Organization, IMPACT3
and the World Health Professions Alliance
in combating against counterfeit medical
products.
Therefore, Today, as leaders representing
nurses, pharmacists, physical therapists,
dentists and physicians, we jointly agree on
the following 4 key strategies for the basis
of a comprehensive regional action plan
against counterfeiting of medical products:
1. Increase capacity of healthcare profes-
sionals
2. Foster regional cooperation initiatives
3. Strengthen collaborative practice
4. Improve collaboration with health and
enforcement authorities plus other key
stakeholders
Increase capacity of healthcare
professionals to educate public
Many patients and healthy individuals seek
advice on use of medical products from
nurses, pharmacists, physical therapists,
dentists or physicians. It then becomes
paramount that healthcare professionals
are adequately trained to be knowledgeable
about risk of buying counterfeit and falsi-
fied medicines from unknown sources and
3 International Medical Products Anti-Counter-
feiting Taskforce http://www.who.int/impact
how to better communicate those risks to
patients and the public.
Thus, where appropriate, national healthcare
professional associations should collaborate
with educational institutions of healthcare
professionals and the pharmaceutical sector
to undertake the following actions:
Raise awareness of the threat of counterfeit
medical products amongst health profes-
sionals
• Include the subject of counterfeit medi-
cal products in undergraduate healthcare
professional curriculum and pre-service
training.
• Work with medicines manufacturers, na-
tional quality control laboratories, hospi-
tals and universities to learn about quality
products and ways of detecting counter-
feits.
• Provide continuing education pro-
grammes to healthcare professionals and
community- based health workers on the
detection and reporting of counterfeit
medical products.
• Develop and implement tools4
for patient
counselling and public awareness. Con-
duct regular public campaigns educating
patients and the public about how they
can protect themselves from the dangers
of counterfeit and falsified medical prod-
ucts.
Regional cooperation initiatives
There is a need to be cognizant of the cur-
rent situation in which counterfeit and fal-
sified medical products continue to move in
international commerce including through
the Internet, representing a major threat to
public health, especially in the poorer areas
of developing countries where regulatory
and law enforcement capacities are weak.
Now more so than ever, there is a need to
4 WHPA “BE AWARE, TAKE ACTION”
Toolkit. Available from http://www.whpa.org/
counterfeit_campaign.htm
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126
NETHERLANDSTask Shifting
work together with the other organizations
of healthcare professionals in each country
and across the region in order to optimize
resources and maximize the effectiveness of
our efforts.
Thus, where appropriate, national healthcare
professional associations should collaborate
with relevant regional stakeholders to un-
dertake the following actions:
• Establish national and regional alliances
of healthcare professional associations
including patient/consumer groups and
other relevant partners to promote in-
ter- sectoral coordination for better in-
formation exchange and sharing of best
practices.
• Work together with regional entities such
as the WHO regional offices in Western
Pacific and South-East Asia, the As-
sociation of South-East Asian Nations
(ASEAN) community and Asia-Pacific
Economic Cooperation (APEC).
Collaborative practice
There is a need to understand and acknowl-
edge the fact that escalating complexity of
care demands a multidisciplinary approach.
Healthcare professionals must be vigilant
and to work together when managing un-
usual responses to medical treatment. They
need to have heightened vigilance in geo-
graphical areas where counterfeit and falsi-
fied medical products are prevalent.
Thus, where appropriate, national healthcare
professional associations should undertake
the following actions:
• Work together across various disciplines
to raise awareness of and actions against
falsified and counterfeit medical prod-
ucts amongst patients, the general public,
their colleagues and government leaders
including health authorities.
• Encourage their members to take an ac-
tive role in identifying, reporting and
eliminating counterfeit and falsified
medical products from the legitimate
supply/distribution chain.
Collaboration with relevant
authorities
Healthcare professionals and their associa-
tions need to support national drug regu-
latory authorities and relevant government
agencies to aid pharmaceutical guideline
enforcement.
Thus, where appropriate, national healthcare
professional associations should collaborate
with relevant authorities to undertake the
following actions:
• Work towards implementation of harmo-
nized guidelines on the regulatory con-
trol, export, import and transit conditions
of pharmaceutical products.
• Develop standards of practice for enti-
ties involved in international, regional
and national trade in biopharmaceuti-
cals and pharmaceutical starting mate-
rials.
• Establish national reporting systems that
enable health professionals to report and
to get feedback about adverse events,
drug-related problems, medication errors,
misuse or drug abuse, defects in product
quality or detection of counterfeit and
falsified medical products.
The Participants of this WHPA region-
al workshop agree unanimously on the
WHPA TAIPEI “CALL TO ACTION”
and plan in cooperation to support it.
Summary
Over the past few years there has been an
ongoing discussion in the Netherlands about
shifting tasks from physicians to nurses (pref-
erably specialized nurses). According to the
Dutch government, such task shifting could
be a way of solving the capacity problem in
healthcare.Now,new legislation is on its way
to making this possible. The legislation will
enable physician assistants and nurse prac-
titioners to perform certain medical health
checks and procedures independently. The
RDMA has been positive about the propos-
als, but also critical of their substance.
1. Introduction
In the coming years, finding qualified pro-
fessionals for the healthcare sector is set to
become a growing problem in the Neth-
erlands. Several studies have shown that a
shortage of professionals is to be expected.1
There are two trends contributing to this
development.The first is the overall decrease
in the size of the workforce. Following de-
1 Netherlands Bureau for economic Policy Analy-
sis (Centraal Planbureau), Derks, W., P. Hoevens,
L.E.M. Klinkers: Structurele bevolkingsdaling,
een urgente nieuwe invalshoek voor beleidsmak-
ers,The Hague 2006. www.cpb.nl
Task Shifting in the Netherlands
Diederik van Meersbergen
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127
Task ShiftingNETHERLANDS
cades of growth, the Dutch population is
moving towards a decline, which is likely
to result in a smaller pool of professionals.
The second trend is the growing demand for
healthcare as a result of demographic, tech-
nological and socio-cultural developments,
and not least because of the aging popula-
tion and increasing number of people with
chronic disorders. Faced with these devel-
opments, healthcare capacity will be unable
to meet the expanding demand. If nothing
changes, we will be seeing more and longer
waiting lists, a risk of declining quality of
care, and upward pressure on incomes.2
The
accessibility and affordability of healthcare
will therefore come under increasing pres-
sure.
Under the Dutch constitution, the govern-
ment is required to promote public health.3
This constitutional provision places an ob-
ligation on the government to ensure the
accessibility, affordability and quality of
healthcare.
Accordingly, the government must provide
sufficient resources for care providers to
deliver quality care. It also implies that the
government must adequately supervise the
quality of healthcare. These requirements
have been elaborated in Dutch healthcare
legislation, including the Quality of Health
Care Institutions Act4
(QHCI Act) and
the Individual Healthcare Professions Act
(IHCP Act)5
.
Both acts provide a few general standards,
with broad outlines that leave room for self-
regulation, but nothing more. As such, they
place great responsibility on healthcare pro-
fessionals and health institutions to ensure
the delivery of appropriate and high-quality
care.
2 Parliamentary Papers II 2009/2010, 32 261, no.
3, p. 3.
3 Section 22 of the Dutch Constitution (Grondwet).
4 Kwaliteitswet zorginstellingen.
5 Wet op de beroepen in de individuele gezondheidszorg.
Aiming to ensure the future accessibility
and affordability of care and thus honour its
constitutional obligation, the Dutch gov-
ernment introduced a bill amending current
Dutch legislation on healthcare professions
by making task shifting possible.
According to the government, task shift-
ing is one of the ways in which the capac-
ity problem in Dutch healthcare could be
solved. In 2009, the World Medical Asso-
ciation (WMA) drew up a ‘Resolution on
Task Shifting from the Medical Profession’.6
And in 2010 the Standing Committee of
European Doctors (CPME) introduced the
Policy on Task Shifting.7
The question now
is to what extent the new Dutch legislation
on task shifting may actually go beyond the
WMA Resolution or the CPME Policy.
This article gives an overview of the way
in which task shifting is being introduced
into the Dutch legal system. To this end,
I first provide a detailed definition of task
shifting and describe the positions that
the WMA and CPME have taken on task
shifting. Next, I describe the current Dutch
laws governing healthcare professions and
the new legislation being introduced to fa-
cilitate task shifting.The article ends with a
discussion and conclusion.
2. Definitions and positions
on task shifting
Definitions
In the WMA’s 2009 ‘Resolution on Task
Shifting from the Medical Profession’ the
term task shifting is used to describe a situ-
ation where a task normally performed by a
physician is transferred to a health profes-
sional with a different or lower level of edu-
6 WMA ‘Resolution on Task Shifting from the
Medical Profession’, Delhi, October 2009.
7 Comité Permanent Des Médicins Européens
(CPME), CPME Policy on Task Shifting,
2010/128.
cation and training, or to a person specifi-
cally trained to perform a limited task only,
without having a formal health education.
This definition is also used by the CPME’s
Policy on Task Shifting. The definition of-
ten used in the Netherlands is: ‘The struc-
tural redistribution of tasks between dif-
ferent professions to ensure effective use of
skills and capacity’.8
Unlike in job differentiation, task shifting
does not entail the redistribution of tasks
between jobs. Rather, tasks are distributed
over entire professions or occupational
groups, which gain direct authorization to
perform a given task. In the present context
it entails assessing the need for the task,
followed by its actual performance, both of
which are carried out independently. A case
in point is shifting tasks from a doctor to a
nurse.
Another term commonly used in this
context is task delegation. The difference
between task shifting and task delegation is
that the former refers to the predetermined
structural allocation of tasks to a new pro-
fession. That task can subsequently be in-
dependently performed by the profession
to which it has newly been assigned. In
the case of task delegation, by contrast, the
task is formally allocated to a professional
practitioner who can decide in any given
situation to delegate that task to another
practitioner. Under the current Dutch sys-
tem so called reserved procedures, as de-
scribed in section 3, qualify for task delega-
tion but not for task shifting.
WMA and CPME positions on task shifting
In its Resolution, the WMA expresses that
although task shifting may be useful in cer-
tain situations, and may sometimes improve
the level of patient care, it can also be risky.
First and foremost the WMA signals the
risk of decreased quality of patient care,
8 Parliamentary Papers II 2009/2010, 32 261, no.
3, p. 2.
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128
NETHERLANDSTask Shifting
particularly if medical judgment and deci-
sion-making is transferred. According to
the WMA, beyond the fact that the patient
may be cared for by a healthcare worker
with less training, there are other specific
quality issues involved, including reduced
patient-physician contact, fragmented and
inefficient service, lack of proper follow up,
incorrect diagnosis and treatment, and in-
ability of the less-qualified practitioner to
deal with complications.
In addition, the WMA signals that task
shifting that deploys assistive personnel
may actually increase demand on physicians.
Physicians will have increased responsibility
as trainers and supervisors, diverting scarce
time away from their many other tasks,
such as direct patient care. They may also
have increased professional and/or legal re-
sponsibility for the care given by healthcare
workers under their supervision.The WMA
expresses particular concern about the fact
that task shifting is often initiated by health
authorities, without consultation with phy-
sicians and their professional representative
associations.9
As part of its efforts to ad-
dress these issues, the WMA has drawn up
fifteen recommendations on task shifting,
the first of which states that the quality and
continuity of care and patient safety must
never be compromised and should be the
basis for all reforms and legislation dealing
with task shifting.
The CPME endorses the WMA resolu-
tion.10
It points out that the shifting of
some tasks may facilitate better use of man-
power and resources, free up valuable time
for physicians and therefore contribute to
better care for patients, provided it is done
with due care. However, it goes on to stipu-
late that, in the interests of patient safety,
responsibility for diagnoses and therapeutic
9 WMA ‘Resolution on Task Shifting from the
Medical Profession’, Delhi, October 2009.
10 Comité Permanent Des Médicins Européens
(CPME), CPME Policy on Task Shifting,
2010/128.
decisions cannot be divided and always re-
mains with the doctor.
3. Current Dutch legal situation
The Dutch Individual Healthcare Profes-
sions Act (IHCP Act)seeks to monitor and
promote the quality of professional care by
providing regulations for a number of oc-
cupations devoted to individual healthcare.
Individual healthcare comprises in particu-
lar the performance of any procedure that
directly affects an individual person and
serves to promote or maintain that person’s
health. The law further seeks to protect
patients from incompetent and negligent
treatment care.
One of the provisions laid down to achieve
this aim is the rule defining what are known
as ‘reserved procedures’ (voorbehouden
handelingen). Effectively, these are certain
medical procedures that only legally desig-
nated professionals are allowed to perform
independently. Prior to the IHCP Act, the
Netherlands had a blanket prohibition on
the performance of medical procedures by
anyone other than a physician.
That prohibition was revoked when the
IHCP Act took effect in 1997. Since then,
anyone may perform medical procedures.
The general consensus was that patients
should be given the freedom to seek out aid
and assistance for their own health situation
where and as they saw fit.11
However, the prohibition was not revoked
entirely, the exception being the rule in
respect of reserved procedures. The Act
specifies a number of procedures that may
only be carried out by designated profes-
sionals. These procedures are deemed to
pose a considerable risk to the health of
the patient if performed by anyone who is
not qualified.
11 Parliamentary Papers II 1985/1986, 19 522, no.
3, p. 1.
The reserved procedures specified in the Act
are:12
• surgical procedures;
• obstetric procedures;
• catheterizations and endoscopies;
• punctures and injections;
• general anaesthesia;
• procedures involving the use of radioac-
tive substances and ionizing radiation;
• cardioversion;
• defibrillation;
• electroconvulsive therapy;
• lithotripsy;
• artificial insemination;
• prescribing medication.
Reserved procedures may be carried out by
two groups of professionals: those with di-
rect authorization (zelfstandig bevoegd) and
those who perform the procedure on the
order of someone else with direct autho-
rization (task delegation). Physicians have
the authority to perform all categories of
reserved procedures.
Dentists and midwives do for some pro-
cedures. This authority entitles them to
perform reserved procedures in their own
name, implying responsibility for the di-
agnosis and decision to perform a specific
procedure. They are only authorized to act
to the extent that they deem themselves
competent to perform the procedure.
Reserved procedures can also be carried out
by others on the order of a professional with
direct authorization. Issuing such an order
is subject to certain conditions. Most im-
portant is that both the person giving the
order and the person receiving it are confi-
dent that the latter is in fact competent to
perform the procedure. Where necessary,
the practitioner in question must give in-
structions, supervise the performance of the
procedure and be on hand to intervene. In
2001, the Dutch Ministry of Health, Wel-
fare and Sport issued a brochure on the
IHCP Act in English. For further informa-
12 Section 36 of the IHCP Act.
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129
NETHERLANDS Task Shifting
tion about the IHCP Act, please refer to
this brochure.13
Under the current laws, nurses, nurse prac-
titioners14
and physician assistants are not
permitted to perform reserved procedures
under their own authority; they may only
do so on the orders of a physician.
4. New legislation on
task shifting
The shifting of tasks between practitio-
ners is a dynamic and continuous pro-
cess. Tasks that were once the exclusive
preserve of physicians can now be carried
out by other professions. Often, this redis-
tribution of tasks is a natural and gradual
process, acquiring structural permanence
in due time.
Many routine medical procedures that are
now performed by doctors could equally be
performed by specially trained profession-
als such as nurse practitioners and physician
assistants. This re-division of tasks would
enable doctors to spend more time on more
complex medical matters directly related to
their specializations.
Various studies have been conducted in the
Netherlands over the past few years to in-
vestigate the effects, and possible effects, of
task shifting.15
These studies have shown
that task shifting in general can contribute
to improving the quality, continuity and
efficiency of care. A report published by
the Dutch Council for Public Health and
13 Ministry of Health, Welfare and Sport, The In-
dividual Health Care Professions Act,The inter-
national publication series on Health, Welfare
and Sport, no. 10, http://english.minvws.nl/en/.
14 In Dutch: Verpleegkundig Specialist.
15 For instance: ‘Task Shifting proven to be
beneficial for quality of healthcare’, Inspectorate
for Health Care, Staat van de gezondheidszorg,
2007, december 2007, and ‘Taskshifting in
healthcare’, Health Counsel, December 2008.
Health Care16
reveals that task shifting is
being driven by a wide range of interests.
In most cases it is a combination of fac-
tors,such as the desire to establish a rational
breakdown of jobs and operational pro-
cesses, knowledge-building within and the
emancipation of professional fields, capac-
ity shortages in one or more occupational
groups, and technological developments.17
Seeking to ensure the accessibility and af-
fordability of care, the Dutch government
introduced a bill in December 2009 to le-
galize task shifting. The bill is necessary
because the current statutory regulations,
as described in section 3, offer no scope for
task shifting.
Specifically, it provides that, by way of a tri-
al, subordinate legislation may grant direct
authority to assess and perform reserved
procedures to professions that do not cur-
rently have such authority.The trial can run
for a maximum of five years. If the amend-
ment is ultimately approved and task shift-
ing enacted, the minister will therefore have
to draw up subordinate legislation specify-
ing the professions – new or existing – in
question, along with the requisite training
for those professions and which reserved
procedures may be performed directly.
The new provision will therefore also serve
to grant authorities to the professions of
physician assistant and nurse practitioner. It
is in this context that two orders in council
were recently (May 2011) submitted to the
Upper and Lower Chambers of the Dutch
parliament, granting direct authority to
the aforementioned professions to perform
certain reserved procedures – as specified
in the decisions. The new element in these
decisions is that they allocate direct author-
16 Raad voor de Volksgezondheid & Zorg.The Dutch
Health Counsel and the Dutch Council for
Public Health and Healthcare are (independent)
advisory bodies to the Dutch Government.
17 Council for Public Health and Health Care,
Task shifting in healthcare,2002.www.RVZ.net.
ity to perform both the medical health check
and the procedure.
The direct authority granted by the bill is
limited in scope, with restrictions regarding
training, personal competence and the spe-
cialization in which the practitioner is per-
mitted to work. Under the IHCP Act, each
occupational group in the medical sector is
linked with a distinct area of expertise, and
it is only within their own general area that
practitioners can operate.
In addition, the provision is restricted to
include only procedures that are of limited
complexity, routine in nature and subject to
manageable risks, and will further be subject
to national guidelines, standards and proto-
cols derived from these. According to the
explanatory notes to the decision, these pro-
tocols will be reflecting the cooperative re-
lationships between nurse practitioners and
the other disciplines with whom they work.
As is the case under the current statutory
regime, a nurse practitioner or physician as-
sistant will only be authorized to perform
the designated reserved procedure within
the designated parameters if he or she is,
in fact, qualified to do so. Once these prac-
titioners have direct authority to perform
reserved procedures, they will also, in turn,
have the inherent authority to instruct
other care workers to carry out those same
reserved procedures.
If the trial period shows this form of task
shifting to be effective, the next step would
be definitive recognition of the designated
occupational groups. The proposed regula-
tions recommend that the trial be subject
to an evaluation focusing on, among other
things, the consequences of task shifting on
the quality of actual care.
5. Discussion
The bill paving the way to task shifting has
met with mixed responses in the Neth-
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130
Task Shifting NETHERLANDS
erlands. The associations for nursing pro-
fessions and for physician assistants have
welcomed the bill, echoing the minister of
Health, Welfare and Sport’s position that
task shifting will be the key to resolving im-
pending healthcare capacity problems.18
The Royal Dutch Medical Association
(RDMA) has been positive about the spirit
of the proposals, but also critical of their
substance. Recognizing that task shifting
could offer advantages for the quality of
care, provided certain conditions are met,
the association had previously already advo-
cated the allocation of new authorizations
to practitioners by means of experimental
trials.
However, like the international physicians’
associations,the RDMA is concerned about
the risks involved. Task shifting will lead to
a rise in the number of people caring for
each individual patient, for example. If it is
to be effective, there need to be clear, defini-
tive and transparent agreements between all
involved care workers regarding the tasks
and the associated responsibilities and au-
thorizations. The RDMA considers it vital
that the proposed statutory regulations and
resulting subordinate legislation eliminate
these risks as much as possible.That has yet
to happen.19
In fact, it is debatable whether the new leg-
islation would even comply with the first
recommendation of the WMA Resolu-
tion, which states, as mentioned above, that
‘Quality and continuity of care and patient
safety must never be compromised and
should be the basis for all reforms and legis-
lation dealing with task shifting’.
18 The Verpleegkundigen & Verzorgenden
Nederland (V&VN) and the Nederlandse
Associatie Physician Assistant (NAPA).
19 A.C. Hendriks, D.Y.A. van Meersbergen, ‘Af-
spraken nodig over taakherschikking’, Medisch
Contact, 4 March 2011, nr . 9, p. 555-557.
www.medischcontact.nl or www.KNMG.nl
In a letter addressed to the Upper and
Lower Chambers of Dutch parliament, the
RDMA emphasized the need for greater
clarity on the scope of the authorization.
In addition, the RDMA stated that it sees
the delegation of reserved procedures to
new categories of practitioners as going a
step too far, resulting in a confused view
of who is supposed to do what and thereby
putting the quality of care at an increased
risk.Moreover,many of the existing medical
guidelines contain no provisions that would
allow for task shifting, prompting questions
as to their validity in the new situation.
A coordinated effort to prepare the neces-
sary treatment protocol—involving the new
professions and guided by physicians—is
therefore one of the first steps that would
need to be taken.
The minister in charge has indicated that
the bill should enter into effect as soon as
possible after its acceptance by the Upper
Chamber. It is essential that occupational
groups affected by task shifting are jointly
involved in the subsequent defining of the
basic statutory framework in order to ensure
that task shifting does, in fact, make a real
contribution to the quality of care.
Equally vital, according to the RDMA, are
the quality of cooperation between the oc-
cupational groups involved in the actual
implementation of task shifting and their
sharing of responsibility for the provision of
good care.
It further recommends conducting a thor-
ough evaluation after the first five years of
the trial in order to come to a well-founded
decision regarding the definitive statutory
enactment of task shifting.
The RDMA notes that the new legislation
does not comply with the strict CPME
Policy on Task Shifting, which states that
responsibility for diagnoses and therapeutic
decisions cannot be divided and always re-
mains with the physician.
6. Conclusion
Over the coming years the Netherlands
will be facing a growing shortage of care
workers, even as demand continues to rise.
If nothing changes, the resulting problems
could be huge. Task shifting is being held
up as a possible solution. The introduction
of an amendment to the existing legisla-
tion would make it possible to grant di-
rect authorization to certain professions to
perform specific medical health checks and
procedures on a limited trial basis.
The RDMA has been positive about the
proposals, but has serious, enduring con-
cerns related to their substance. It feels that
the conditions under which task shifting is
to be introduced fail to provide the neces-
sary degree of clarity about its scope and
limits. And without that foundation of clar-
ity, there is no firm guarantee of the quality
of care. Guaranteeing quality will require
that new treatment protocols be drawn up
under the supervision of physicians. Finally,
all of the occupational groups involved in
the implementation of task shifting must
be able to work together effectively. A sub-
sequent evaluation of that implementation
within the Dutch system should demon-
strate whether task shifting can in fact lead
to measurable improvement. Then – and
only then – can the trial make way for de-
finitive legislation. It is debatable whether
the new legislation would comply with the
WMA’s resolution and the CPME Policy
on Task Shifting.
Mr. Diederik van Meersbergen,
Legal Advisor Health Care Law,
Royal Dutch Medical Association
E- mail: D.van.Meersbergen@fed.knmg.nl
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131
DisastersJAPAN
1. Introduction
I experienced the magnitude 9.0 under-
water earthquake the moment it struck
at 14:46 JST on Friday, March 11, 2011,
rocking an area stretching 500 km from
the Tohoku region to the Kanto region
of Japan. I was in my house adjoining a
hospital in the city of Iwaki, Fukushima,
a place with the most moderate climate in
the Tohoku region and also very few natu-
ral disasters.
By right, that day I should have celebrated
the 26th
anniversary of my hospital’s open-
ing. Instead, a series of tremors suddenly
struck as if the ground were being violently
thrust up from below. Books and dishes
fell with a clatter and the pendant lighting
swung wildly, damaging the ceiling. In Iwa-
ki the shaking, which registered as a lower 6
intensity quake on the seven-point Japanese
intensity scale, was said to have gone on for
more than three minutes.
Nearly all my bookcases fell over, scat-
tering almost 4,000 records and count-
less CDs across the floor. The SP records,
which I had placed on the bottom shelves
because they are the most easily damaged,
were unharmed. The LPs were also in one
piece, although some jackets had been torn.
The biggest trouble was picking up the little
pieces of broken CD cases and CDs, many
of which had been smashed. It was also a
shock to find that my British Garrard 301
turntable, which had been made about 60
years ago, had been damaged when it fell
upside down during an aftershock.
Two days later I was supposed to leave from
Narita International Airport for Peru early
in the morning to attend a symposium and
the 30th
anniversary commemoration of the
Japan-Peru Clinic.I canceled the trip,which
was troublesome since even the mobile
phone that I had registered for emergencies
had difficulty connecting at this time.
The scale of the disaster, stretching from the
Tohoku to the Kanto region, and the extent
of the damage caused by the earthquake and
tsunami along the Pacific coast was massive
(Picture 1). Moreover, in the midst of on-
going aftershocks the accidents at the To-
kyo Electric Power Company’s (TEPCO)
Fukushima Daiichi and Fukushima Daini
Nuclear Power Plants caused huge second-
ary damage to the area.
Medical institutions throughout Iwaki,
including hospitals, nursing homes, and
clinics, as well as my own corporation’s fa-
cilities—some 50 km away from the Dai-
ichi plant—were all affected tremendously
by burst water and sewer lines and power
outages.
Japan Medical Association Teams’ (JMATs)
First Operation: Responding to the Great
Eastern Japan Earthquake
Masami Ishii
Picture 1. Tsunami damage in Toyoma, Iwaki City, Fukushima. This picture was taken
on March 30 near the coast about a ten-minute drive from the author’s house. The tsunami had
knocked utility poles down and left mountains of wreckage behind
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132
Disasters JAPAN
2. Japan Medical Association
Teams (JMATs) Activation
The situation was such that the Japan Med-
ical Association’s (JMA) Committee on
Emergency and Disaster Medicine judged
that the Japan Medical Association Teams
(JMATs), which it had been discussing,
needed to be activated. The JMA Disaster
Headquarters immediately held an emer-
gency meeting and sent a request out to
prefectural medical associations nationwide
to dispatch JMATs to the four prefectures
of Iwate, Miyagi, Fukushima, and Ibaraki.
An emergency press conference was then
held on March 15th
.
3. Process leading to the
JMAT concept
The Civic Protection Act and the Ba-
sic Act on Disaster Control Measures,
which were enacted in 2004, designated
prefectural medical associations as speci-
fied local public entities. This means that
they are incorporated into the disaster
countermeasures headquarters set up by
prefectural governments when a disaster
occurs and, as a general rule, the president
of the prefectural medical association is
positioned as a deputy head of the disas-
ter headquarters. For this reason, disaster
agreements were signed between prefec-
tural governments and medical associa-
tions in conjunction with the provision of
these laws.
The Agreement regarding Medical Assis-
tance during a Disaster [1] was entered into
between Fukushima Prefecture and Fuku-
shima Medical Association in January 2004.
In my capacity as vice-president of the Fu-
kushima Medical Association, I made sure
that the agreement included a “deemed
clause” that the deployment of medi-
cal teams sent out on the judgment of the
medical association immediately after the
occurrence of a disaster when communica-
tion may be in disarray would be deemed
as a requested action by giving notice after
the fact.
I also ensured that the agreement guaran-
tees that team members are compensated
as public servants during mobilization and
that actual expenses to perform their work
are reimbursed. After becoming responsible
for the area of emergencies and disasters in
the JMA, I encouraged prefectural medical
associations nationwide to adopt these con-
cepts in order to give the highest priority to
the saving of human life based on human-
ism.
In 2006 I was appointed an executive
board member of the JMA and that year
the World Medical Association’s (WMA)
Asian-Pacific Regional Conference was
held in Tokyo. We discussed the issue of
disaster preparedness, specifically to natural
disasters such as earthquakes and tsunami
and to infectious disease pandemics as the
main themes of the conference. The entire
contents of the conference were published
in a special edition of the Japan Medical
Association Journal (JMAJ), the JMA’s
English language journal [2].
At the same time,we built up the discussion
in the JMA’s Committee on Emergency
and Disaster Medicine, which I was presid-
ing over. The committee membership in-
cluded regional block representatives from
different prefectural medical associations
and Japan’s leading emergency aid special-
ists. In addition, members of the Ministry
of Health,Labour and Welfare,the Fire and
Disaster Management Agency, the Japan
Coast Guard, the National Institute of Ra-
diological Sciences, and the Self-Defense
Forces Central Hospital participated as ob-
servers.
After examining past major disasters,
JMATs were conceived based on the con-
cept of providing support until community
health in an afflicted area could function
again, starting from the time Disaster Med-
ical Assistance Teams (DMATs), which
were established to be responsible for
healthcare in the hyperacute phase of a di-
saster and have the capability to function for
the initial 48 hours,begin withdrawing after
finishing wide area medical transportation
and their other duties. On March 11, 2010,
exactly one year before the Great Eastern
Japan Earthquake, the basic JMAT concept
was officially proposed in the JMA’s email
newsletter, after giving a press conference
the day before, based on a newly finished
report [3].
4. Framework of JMAT
Dispatches
When activating JMATs it was presumed
that there were more than 400,000 evacu-
ees spread over an area of 500 km long. We
decided to send teams to the four afflicted
prefectures of Iwate, Miyagi, Fukushima,
and Ibaraki (Picture 2). Our basic im-
age was teams consisting of one physician,
two nurses, and one coordination staff that
would be deployed for a period of three days
to one week [4].
We divided supporting regions into prefec-
tural blocks and made it a general principle
that each block would continually support
the afflicted prefecture that they had been
assigned to help. We also provided teams
with accident insurance under an umbrella
policy taken out by the JMA for 5,000 peo-
ple, regardless of whether team members
were members of the JMA or not. We pre-
pared JMAT triage cards for use in medi-
cal activities in evacuation shelters and also
prepared a sample checklist for each evacu-
ation shelter to make it easy for the presi-
dents of municipal medical associations,
who head on-the-ground joint conferences,
to link information.
Specific matching between afflicted areas
and support providers was left to direct
contact between both sides, with the JMA
providing information and acting as a co-
ordinator.
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DisastersJAPAN
5. Second Stage
A strong inland aftershock struck Miyagi on
April 7 and another hit Fukushima on April
11.There is still disaster risk in the area.Nev-
ertheless, one month after the earthquake
the Ibaraki Medical Association requested
the discontinuation of JMAT dispatches,
indicating that it would continue operations
with its own support system. Similarly, the
remaining three prefectures requested the
vwdispatch of JMATs be limited to areas
that were severely damaged and concluded
for areas where the community and com-
munity health had recovered. We therefore
communicated to medical associations na-
tionwide a policy of ongoing support with
necessary teams on standby. Thus JMAT
support entered its second stage. Since
then, the support system has been gradu-
ally reduced as community and surrounding
healthcare systems recover and with the ap-
plication of the universal healthcare system,
which had just marked its 50th
anniversary.
In response to the crisis situation of the
nuclear power plant accident, the JMA un-
dertook medical support activities based on
gathering and disclosing information and
disseminating a better understanding of
medical treatment for radiation exposure, as
described in my another article to be pub-
lished in the WMJ [5].
Looking back at the situation up to now and
seeing that more than 1,114 JMATs have
been on the ground up to May 24 and that
71 teams are on standby, the JMAT concept
has demonstrated the truly immense pow-
er of Japan’s medical professionals and of
medical association activities in responding
to this huge disaster of unprecedented scale.
6. Conclusion
Numerous DMATs that operate in the
hyperacute phase of a disaster took part in
responding to Great Eastern Japan Earth-
quake in addition to local medical resources
in the affected areas. However, there were
very few instances of lifesaving rescues in the
midst of the enormous damage caused by
the tsunami on top of the earthquake.More-
over, lifesaving operations were restricted by
the significant damage to infrastructure, in-
cluding roads through the coastal zone. In
a case like this, had there been awareness
of the emergency situation and had it been
possible to save victims drifting on the near-
ly 0° C Pacific Ocean by carrying out land,
air, and marine rescue operations right from
the first day with support from the Japan
Self-Defense Forces, Japan Coast Guard,
and Japan-based US military, I think that
the operations in the few hours until sunset
could have produced better results.I also feel
that JMAT activities that were carried out
thereafter fulfilled healthcare for evacuees,
which accounted for the main part of opera-
tions in each afflicted area this time.
We need to prepare for the future by tak-
ing time to do an ex-post verification of the
JMAT concept in the JMA’s Committee on
Emergency and Disaster Medicine and by
establishing a training system for Japan and
holding various other discussions while col-
laborating with the WMA.
Appendix1
1. Proposal for JMATs
(Japan Medical Association Teams)
(1) JMATs
The Committee on Emergency and Disas-
ter Medicine proposes JMATs (Japan Med-
ical Association Teams) as the name for di-
saster medical assistance teams formed by
prefectural medical associations at the level
of municipal medical associations and serv-
ing in disaster areas under the name of the
Japan Medical Association (JMA).
The proposal for the name JMAT is intend-
ed to clarify the difference from’ DMATs
1 Appendix consists of excerpts from the Report by
the JMA’s Committee on Emergency and Disas-
ter Medicine released in March 2010.
Appendix
(Attached)
References
Iwate: 324 teams
Miyagi: 546 teams
Fukushima: 229 teams
Ibaraki: 12 teams
Epicenter
Picture 2. Map of JMAT dispatch locations. The map gives a general view of the areas to
which JMATs were dispatched in the Great Eastern Japan Earthquake and the number of teams
sent to each area. As of May 24, 2011, 1,114 JMATs have been dispatched including three teams
that were dispatched to several prefectures (not shown in the map), and 71 JMATs are on standby
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Disasters JAPAN
(Disaster Medical Assistance Teams) and
also includes the following meanings: these
are the JMA’s disaster medical assistance
teams; they cover all of Japan through all
the prefectural and municipal medical asso-
ciations; and they take over from Japan and
local DMATs.
JMATs go on standby and then into action
based on requests from the JMA to prefec-
tural medical associations (including retro-
spective approval). JMATs mainly provide
healthcare during the acute phase of a disas-
ter, cooperation with medical associations in
the disaster areas, and activity support while
sharing roles with and collaborating organi-
cally with DMATs (Japan/local) and medi-
cal associations in the disaster areas during
an uninterrupted period of time starting im-
mediately after the occurrence of a disaster.
However, arrangements need to be made to
avoid competition between requests from
the JMA and requests from prefectural gov-
ernments based on agreements for health-
care during a disaster.
(2) Regarding Basic policy for JMATs
A. JMATs should be organized based on
a Basic Policy for JMATs. JMATs’ rela-
tionship with the JMA, prefectural medi-
cal associations, and municipal medical
associations is as depicted in Table 1, Figs
1 and 2
Clarification of the roles of the JMA, pre-
fectural medical associations, and munici-
pal medical associations, the composition
of JMATs, training structure, contents of
activities, and the division of roles and col-
laboration with DMATs (Japan/local) will
all be important.
B. Many prefectural and municipal medi-
cal associations have already entered into
disaster medical assistance agreements with
government administrations prescribing
the dispatch of disaster medical assistance
teams by the medical association.2
The JMA and prefectural medical associa-
tions need to work out a balance between
JMATs and these already existing teams
through exchange of opinions and dis-
cussion during the processes of creating
JMATs.
Moreover, in order to implement medical
association-based medical assistance ac-
tivities nationwide, existing teams that meet
the requirements for JMATs shall be recog-
nized as JMATs, and for those that do not
meet the requirements, measures need to be
taken so that they fall in line with the Basic
Policy for JMATs.
C. It is also important for each medical
association to have the view that it could
2 According to a survey conducted in June 2001
by the JMA on medical associations’ disaster
healthcare systems, the dispatch of disaster medi-
cal assistance teams was prescribed in agreements
between 35 prefectural medical associations and
prefectural governments (Fiscal 2000-2001 re-
port by the JMA’s Committee on Emergency and
Disaster Medicine).
Table 1. Relationship between Municipal Medical Associations in a Disaster Area, JMATs, and
DMATs
Municipal
medical as-
sociations in a
disaster area
JMATs DMATs (Japan/
local)
Pre-disaster
(usual condi-
tions)
• Organize teams, register team members
• Conduct training
• Coordinate
with the JMA
and prefectural
medical associa-
tions
Immedi-
ately after
disaster (before
DMATs arrive)
• Voluntary
activities by
the medical
association in
the disaster
area
• Standby, prepare for mobiliza-
tion
• Prefectural medical associations
in disaster areas  JMA 
Request for mobilization from
prefectural medical associations
(mobilization at own discre-
tion  retrospective approval
by the JMA and prefectural
medical associations)
• Standby, prepare
for mobilization
Very early pe-
riod of disaster
• Mobilization
• Take action
under direction
of supervising
DMAT person-
nel
After arrival of
DMATs
• Cooperate
with JMATs
• Triage patients, take other
action at evacuation shelters
and temporary medical care
facilities in collaboration with
DMATs
• Cooperate with and support
municipal medical associations
in a disaster area
• Take action
under direction
of supervising
DMAT person-
nel
After with-
drawal of
DMATs
• Rebuild
healthcare
system in
disaster area
• Resume usual
healthcare
• Place DMAT members who
continue to engage in disaster
healthcare after DMAT with-
drawal in JMATs
• Evaluate withdrawal phase.
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DisastersJAPAN
become the victim of a disaster. Especially
in the case of a large-scale disaster, situa-
tions are envisioned in which a municipal
medical association in a disaster area ceas-
es to function and cannot take action as a
JMAT. Accordingly, in parallel with the es-
tablishment of the JMAT system, munici-
pal medical associations need to cooperate
with municipal governments and establish
a system that, even in such an event, will
enable nearby members in private practice
to voluntarily and systematically gather at
evacuation shelters and temporary medical
facilities and engage in disaster medical as-
sitance activities.
2. Basic Policy for JMATs
(1) Roles of the JMA, Prefectural Medical
Associations, and Municipal Medical As-
sociations
A. Role of the JMA (Table 2)
1) Promoting the signing of disaster medi-
cal assistance agreements between prefec-
tural medical associations and prefectural
governments
• With a prefecture-by-prefecture structure
in which the government administration
requests the medical association to dis-
patch teams, the system becomes ineffi-
cient in a disaster outside the prefecture
Japan
Medical
Association
Figure. 1 Depiction of JMATs, Japan Medical Association, Prefectural Medical Associations, and Municipal Medical Associations during a Disaster
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Disasters JAPAN
Figure. 2 Depiction of JMATs, the Japan Medical Association, Prefectural Medical Associations, and Municipal Medical Associations during Usual
Conditions
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DisastersJAPAN
or in a wide area disaster affecting more
than one prefecture. Accordingly, the
JMA will promote the signing of bundled
agreements between prefectural medical
associations and prefectural administra-
tions either in blocks or at the nationwide
level through an occasion arranged by the
JMA.
• The JMA will seek inclusion in the agree-
ments of provisions for cases in which
the prefectural medical associations con-
cerned act as JMATs.
• The JMA will seek inclusion in the agree-
ments of provisions for cases in which
JMATs are sent to a disaster site outside
the prefecture.
• The JMA will seek to have DMAT per-
sonnel who wish to remain on-site after
DMAT activities are concluded and en-
gage in the medical association’s disaster
medical assistance activities recognized as
JMATs.
• The JMA will periodically collect infor-
mation and provide feedback about mat-
ters such as the status of the conclusion
of agreements by each prefectural medical
association, the contents of agreements,
actual examples of disaster responses, and
the status of revisions, in an attempt to
enhance agreement contents and prevent
agreements from becoming a mere shell
(including in addition to agreements be-
tween prefectural medical associations
and government administrations, agree-
ments among medical associations within
blocks and agreements between prefec-
tural medical associations and municipal
medical associations in their jurisdiction).
2) Logistical support for local medical as-
sociations and JMATs
• It will be necessary during a disaster to
work with relevant national agencies to
gather needed information and provide it
to local medical associations and JMATs.
Particularly in regards to special disasters
(CBRN: chemical, biological, radiologi-
cal, and nuclear), important information
will include an overview of the disaster,
conceivable diseases and their diagnostic
methods, main symptoms, coping strate-
gies,measures to prevent secondary disas-
ters such as radiation exposure and con-
tamination, and the system for reporting
to government administrations.
• It is also necessary, in order to make
JMATs’ activities effective, to secure in
JMATs the participation of specialists
with experience determining the need for
DMATs and other disaster medical as-
sistance teams and deciding the areas to
which they should be dispatched.
3) Taking part in revising disaster health-
care measures
National disaster healthcare measures may
be revised based on lessons learned from a
disaster. The JMA will take part, from the
standpoint of community healthcare, in the
work of revising the basic disaster manage-
ment plans and the Guidelines on the Es-
tablishment of Healthcare System in Times
of Disaster.3
B. Role of Prefectural Medical Associa-
tions (Table 3)
1) Signing of disaster medical assistance
agreements with prefectural governments
In order to dispatch JMATs to a disaster
area, prefectural medical associations have
to have signed an agreement with the gov-
ernment administration in advance and in-
clude provisions such as the following re-
garding JMATs:
3 One of what are called the Four Diseases and
Five Programs.
Table 2. Role of the Japan Medical Association
Usual conditions (pre-disaster) During a disaster
• Request prefectural medical associations
to organize JMATs
• Coordinate with relevant national agen-
cies
• Coordinate with hospital organizations
• Promote the signing of disaster medical
assistance agreements between prefec-
tural medical associations and prefectural
governments
– Ascertain the status of disaster medical
assistance agreements in each area
– Provide useful information, such as
sample agreements for reference
• Coordinate with Japan DMAT; request
cooperation in JMAT training
• Request prefectural medical associations to put JMATs on standby and to dispatch
JMATs
• Decide the order and length of dispatch for JMATs from each prefecture
• JMAT activities
– Gather information on the ground; request materials needed
– Provide medical care
• JMAT logistical support
– Gather information from the national government
– Provide information to prefectural medical associations
• Negotiate with the national government
– Infections disease, community health measures
– Health services covered by health insurance
– Support for rebuilding of medical institutions (e.g., government subsidies, preferential
tax treatment, public financing)
– Taking part in revising national disaster healthcare measures
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Disasters JAPAN
• Position within the prefectural disaster
management plan and disaster healthcare
plan
• Content of operations
• The administration’s (prefectural govern-
ment) burden of status-based compensa-
tion, expense reimbursement.
• A provision to the effect that in a disas-
ter the medical association will mobi-
lize teams at its own discretion and the
government administration will grant
retrospective approval and provide status-
based compensation and expense reim-
bursement.
– The criteria for mobilization has to be
clarified for application of a retrospec-
tive approval provision
– This is to establish a rapid response sys-
tem, although the dispatch of disaster
medical assistance teams is on a “re-
quest basis.”
• A provision for applying the above two
points even if the deployment destination
is outside the prefecture.
– A provision included in case the disas-
ter area is in another prefecture.
• A provision with a one-year review clause.
– This is to avoid the agreement becom-
ing a mere shell or dead letter in addi-
tion to dealing with such things as the
emergence of a new disaster, adminis-
trative organizational reform, and sys-
tem reforms.
Notes
• The Niigata Medical Association has,
through the Basic Plan on Disaster
Healthcare and Relief Activities by the
Prefectural Medical Association, pro-
vided for status-based compensation and
reimbursement of expenses in the event
that members of the association or a mu-
nicipal medical association work as relief
activity personnel during a disaster (this
does not apply, however, in cases where a
work allowance for the relief squads, re-
imbursement of expenses, and compensa-
tion are provided in accordance with the
provisions of the Disaster Relief Act, nor
in cases where, regardless of the applica-
tion of the Disaster Relief Act, Niigata
Prefecture provides reimbursement of
expenses associated with the turnout of
relief squads provided for in the Niigata
Prefecture Disaster Healthcare and Relief
Activity Manual).
– Actual costs are to be reimbursed for
drugs and medical supplies used in
the event a member turns out for work
during a disaster.
– Allowances for turning out to work are
17,400 yen per day and reimbursement
of travel expenses is as stipulated in the
medical association’s regulations con-
cerning travel expenses.
– Coverage by ordinary accident insur-
ance: Coverage provided for up to 10
physicians and 20 nurses with a benefit
of 50 million yen on the death or physi-
cal impairment of a physician.
• The Aichi Medical Association has made
a contract with an insurance company for
Table 3. Role of Prefectural Medical Associations
Usual conditions (pre-disaster) During a disaster
• Request municipal medical associations
to organize JMATs
• Coordinate with prefectural government
agencies (medical, public health, welfare,
and fire and disaster management
authorities), the police, the Japan Self
Defense Forces, and the Japan Coast
Guard
• Coordinate with nuclear power facilities
• Participate in disaster drills conducted
by the prefectural administration
• Coordinate with hospital organizations
• Take part in establishing prefectural
disaster management plans and disaster
healthcare plans
• Sign disaster medical assitance agree-
ments with the prefectural government
• Coordinate with Japan DMAT-des-
ignated medical institutions and local
DMATs
• Conduct JMAT training
• Request municipal medical associations to put JMATs on standby and to dispatch JMATs
• Decide the order and length of dispatch for each JMAT
• Provide information to municipal medical associations
• Negotiate with the prefectural government
– (In the event of a disaster outside the prefecture) Obtain approval of the governor
when sending JMATs outside the prefecture
– Burden of expense for JMATs

• Ascertain the situation in the disaster area
• Request the JMA to dispatch JMATs
• Request cooperation from block and nearby medical associations
• Gather information from the prefectural government, and provide information to mu-
nicipal medical associations
• Negotiate with the prefectural government
– Secure means of transport for JMATs
– Infections disease, community health measures, health services covered by health
insurance
– Support for rebuilding of medical institutions (e.g., government subsidies, preferential
tax treatment, public financing)
• Take part in revising prefectural disaster healthcare measures
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DisastersJAPAN
the Aichi Medical Association Informa-
tion Center Disaster Compensation Plan,
which will provide status-based compen-
sation for physicians and nurses requested
by the Center to provide medical care.
– Physicians and nurses (insurance cov-
erage for 50 people)
– Death or physical impairment benefit:
70.14 million yen.
2) Role of prefectural medical associations
in municipal medical associations
Prefectural medical associations will create
a manual and standardize the activities that
should be taken by municipal medical asso-
ciations during a disaster in order to enable
uniform activities.
Prefectural medical associations will pro-
mote collaboration between municipal
medical associations and DMATs (Japan/
local) through disaster drills. They will also
arrange for DMAT physicians and others to
give lectures for municipal medical associa-
tions.
C. Role of Municipal Medical Associa-
tions
The role of municipal medical associations
is as shown in Table 4.
(2) Composition of JMATs
In Japan, private hospitals (including those
run by medical corporations and individu-
als), which are relatively small and medi-
um sized hospitals, account for 70.6% of
all hospitals and accept the vast majority
of emergency patients. In regional areas,
private-practice physicians who went in-
dependent with their respective specialties
look after patients with a wide range of
conditions.
JMATs will be underpinned by these kinds
of medical resources.In other words,JMATs
will mainly be composed of physicians and
nursing personnel working in small and
medium sized hospitals and association
members who run their own clinic.
However, small and medium sized hospitals
are faced with a serious shortage of physi-
cians and nursing personnel, and so partici-
pation in JMATs could be difficult. Also, it
is not always the case that emergency physi-
cians can participate.
Conversely, association members who run
their own clinic will have to close their clin-
ic while mobilized and so cannot participate
in long-term activities.
Taking as a reference the Oita DMAT,
which reflects the medical context in a pre-
fecture where hospitals are mostly small and
medium sized and in some cases there is
only one hospital in a large area,the smallest
possible unit is a team of two people (one
physician and one nurse), and it is conceiv-
able that other co-medical personnel and a
logistics expert could be added at the discre-
tion of the prefectural medical association.
Also,teams need to be organized on the pre-
sumption of short-term rotation.
(3) Training of JMATs
The JMA should provide support for the
implementation of JMAT training in each
region. For example, it should set out a
Standard JMAT Training Curriculum, tak-
ing as a reference the Japan DMAT’s four-
day training program, minus parts such as
staging care units (SCU). At the same time,
it should request cooperation from Japan
DMAT and seek the dispatch of instructors
to JMAT training sessions.
JMAT training should be open to per-
sons who have completed a training ses-
sion based on the existing JMA Advanced
Table 4. Role of Municipal Medical Associations
Usual conditions (pre-disaster) During a disaster
• Organize JMATs and register
team members
• Coordinate with municipal
agencies (medical, public
health, and welfare), fire de-
partments, and the police
• Take part in establishing mu-
nicipal disaster management
plans and disaster medical
care plans
• Sign disaster medical as-
sistance agreements with the
administrators of airports.
• Coordinate with nuclear
power facilities, chemicals
factories.
• Conduct JMAT training
• Create a system for healthcare
activities in case of a disaster
in one’s own municipality and
conduct drills
• Organize and mobilize JMATs

• Ascertain disaster situation
– Medical institutions within jurisdiction
– Patients receiving medical treatment at home,
people needing nursing care
– Stationing of evacuation shelters and temporary
medical care facilities
– Healthcare needs
• Request the prefectural medical association to dis-
patch JMATs
• Request cooperation from nearby municipal medical
associations
• Provide information to members
• Negotiate with municipal agencies
– Infections disease, community health measures,
health services covered by health insurance
– Support for rebuilding of medical institutions
(government subsidies, preferential tax treatment,
public financing)
– Securing means of transport for JMATs
• Take part in revising city disaster healthcare mea-
sures
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Disasters JAPAN
Cardiovascular Life Support (ACLS) Train-
ing program and should be eligible under
the JMA’s continuing education system.
The content of training should include
training on determining when to withdraw
and leave the situation in the hands of phy-
sicians and medical institutions in the di-
saster area.
Also, currently DMATs are designated on a
hospital basis, but a policy needs to be con-
sidered that will enable individual member
physicians to receive DMAT training.
For instance, a conceivable method for hav-
ing members participate together with the
physicians and staff of a DMAT-designated
medical institution would be to have the
prefectural medical association gather to-
gether member physicians within the pre-
fecture who wish to take DMAT training
and have, for example, a hospital physician
and nurse from hospital A and a private-
practice physician from clinic B participate
as one group.
(4) Contents of JMAT activities
Activities that JMATs will be required to
perform are not the extremely early disas-
ter medicine like that provided by DMATs;
rather,they are healthcare in the acute phase
of a disaster, cooperation with medical as-
sociations and other organization in the di-
saster area, and activity support.
Members of a disaster-affected medical as-
sociation are engaged in healthcare for sur-
vivors even though their own clinics have
been afflicted.It is medical association in the
disaster area that can handle the provision
of healthcare based on information about
dialysis or perinatal care that medical insti-
tutions in the disaster area have performed
or about the whereabouts of patients receiv-
ing house calls, patients undergoing oxygen
therapy at home, elderly people living alone,
and persons needing nursing care. JMATs’
role played in cooperation with the medical
association of the disaster area is therefore
important.
Activities such as the following are conceiv-
able as the main activities of JMATs:
• On-site triage
• Ascertaining needed medical supplies
and requesting their delivery
• Healthcare at evacuation shelters and
temporary healthcare facilities
– Providing healthcare in the early phase
of the disaster
– Implementing measures such as infec-
tion control measures and countermea-
sures against disuse syndrome
– Continuity of healthcare from before
the accident: dialysis, perinatal, geriat-
ric, and home care.
• Supporting continuation of medical and
nursing care by association members in
the disaster area
• Giving advice to the on-site countermea-
sures headquarters centered on the af-
flicted medical association (arrangement
of disaster medical assistance teams, de-
termination of withdrawal period, baton
passing to successor teams)
(5) JMATs and local DMATs
Separately from Japan DMAT, local
DMATs are organized in various locations
around the country.Their main scope of ac-
tivity is natural disasters within a prefecture
and urban disasters such as traffic accidents.
Local DMATs’ degree of conformity to
Japan DMAT operating procedures, re-
quirements for DMAT-designated medical
institutions, team composition (physicians,
nursing personnel, clerical staff, and logis-
tics experts), completion of Japan DMAT
training, mobilization criteria (scale of di-
saster,number of patients affected by the di-
saster), and other attributes differ according
to local characteristics such as the medical
context in the prefecture.4
4 Based on data for Oita DMAT and Kochi
DMAT.
The Oita DMAT established at the sug-
gestion of the Oita Medical Association,
for example, has characteristics including a
team composition of one physician plus one
nurse as a the smallest unit size, a scope that
includes small-scale disasters and accidents
in the prefecture (at least one injured per-
son), the ability to mobilize on independent
discretion in an emergency, and no limiting
of DMAT-designated hospitals to core di-
saster hospitals and critical care centers.
Prefectural medical associations should be
involved in the establishment and operation
(system establishment, DMAT member
registration, training, after-the-fact inspec-
tion) of local DMATs aimed mainly at di-
sasters within the prefecture and should also
clarify the sharing of roles and coordination
with JMATs.
Moreover, by having local DMAT physi-
cians conduct JMAT training, DMAT and
medical association members can commu-
nicate with each other.
References
1. Agreement regarding Medical Assistance during
a Disaster (Saigai ji no Iryo Kyugu ni kansuru
Kyotei), entered into between Fukushima Pre-
fecture and Fukushima Medical Association on
January 5, 2004. (in Japanese).
2. JMAJ 50(1), 2007. http://www.med.or.jp/eng-
lish/journal/pdf/jmaj/v50no01.pdf. (accessed
May 24, 2011).
3. 2010 Report by the JMA’s Committee on Emer-
gency and Disaster Medicine. http://dl.med.
or.jp/dl-med/teireikaiken/20100310_3.pdf (in
Japanese. accessed May 24, 2011).
4. JMAT. http://www.med.or.jp/english/report/
JMAT.pdf. (accessed May 30, 2011).
5. Ishii M. WMJ (forthcoming). Fukushima Nu-
clear Power Plant Accidents Caused by Gigantic
Earthquake and Tsunami–Healthcare Support
for radiation exposure.
Masami Ishii, MD
Executive Board Member
(responsible  or emergencies and  isasters),
Japan Medical Association,
Vice-Chair of Council,
World Medical Association
E-mail: ishiihom@ishiihp.or.jp
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DisastersJAPAN
1. Introduction
In the magnitude 9.0 Great Eastern Ja-
pan Earthquake that occurred at 14:46 on
March 11, 2011, nuclear reactors in opera-
tion went into emergency shutdown. The
six reactors at the Tokyo Electric Power
Company’s (TEPCO) Fukushima Daiichi
Nuclear Power Plant, including reactors
that were shut down beforehand for peri-
odic inspection, and the four reactors at
TEPCO’s Fukushima Daini Nuclear Power
Plant were all shut down (Picture 1).
Of these, reactors 5 and 6 at the Daiichi
Plant, which had already been shut down,
and reactor 4 at the Daini Plant seemed to
have reached the condition of a cold shut-
down. Later, however, reactors 1–4 at the
Daiichi Plant lost backup power [1]. At
16:36 the emergency core cooling system
for reactors 1 and 2 at the Daiichi Plant
stopped working,starting the nuclear power
plant crisis. At 19:03, Prime Minister Kan
issued Japan’s first Declaration of a Nuclear
Emergency Situation. At 21:23, people
within 3 km of the Daiichi Plant were in-
structed to evacuate and those within the
zone between 3 km and 10 km from the
facility were told to stay indoors.
2. Progression of the nuclear
power plant accident
At 15:36 the following day a hydrogen ex-
plosion occurred at reactor 1, which was
feared to have gone into meltdown. At
18:25 the evacuation order around the Dai-
ichi Plant was expanded to a 20 km radius
and an earnest evacuation of residents was
implemented using buses and other means.
At 11:01 on March 14 there was a hydrogen
explosion at reactor 3, where cooling was
feared since the day before to have stopped.
It was said that the reactor had been run-
ning on MOX fuel, which is a mix of pluto-
nium and uranium for a plutonium-thermal
project.
On March 15, an explosion and fire were
reported at reactors 2 and 4, respectively.
In addition to an evacuation order within
10 km around the Daini Plant, which is
about 10 km south of the Daiichi Plant, at
11:00 a.m. the government instructed near-
ly 140,000 people living within the zone
20–30 km around the Fukushima Daiichi
Plant to stay indoors.
From the 17th
the Ground Self-Defense
Forces and Tokyo Fire Department started
spraying water from the outside to cool the
reactors. In the meantime, contamination
with radioactive iodine and cesium from
near the plant to the far-away Tokyo metro-
politan area was reported in the news. Later,
on March 31 the contamination of ocean
water was reported, and then on April 4
the marine contamination progressed with
the release of over 10,000 tons of contami-
nated water into the ocean from the Daiichi
Nuclear Power Plant. It became impossible
to ship dairy and agricultural produce from
the contaminated region, and the interrup-
tion of fishing was prolonged. Additionally,
on March 17 the United States indepen-
dently issued a recommendation for evacu-
ation outside an 80 km zone around the
plant. Harmful rumors and misinformation
caused a reluctance to buy foods and other
products from Fukushima, resulting in dis-
tribution paralysis and shortages.
3.The Japan Medical
Association’s response
I experienced the earthquake in my house
adjoining a hospital in the city of Iwaki,
Fukushima, more than 50 km away from
TEPCO’s Fukushima Daiichi Nuclear
Power Plant. Immediately after the earth-
quake struck I contacted the Japan Medi-
cal Association (JMA). A countermeasures
headquarters was set up and I started activi-
ties to respond to the devastated areas as the
officer responsible for emergency and disas-
ter operations.
In addition to seismic damage, the Great
Eastern Japan Earthquake caused a gi-
Fukushima Nuclear Power Plant Accidents
Caused by Gigantic Earthquake
and Tsunami–Healthcare Support for
Radiation Exposure
Fukushima Daiichi Nuclear Power Plant Fukushima Daini Nuclear Power Plant
Picture 1. Fukushima Daiichi and Fukushima Daini Nuclear Power Plants
(Source: TEPCO. http://www.tepco.co.jp/index-j.html)
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Disasters JAPAN
gantic tsunami that dramatically devas-
tated over 500 km of Eastern Japan’s Pa-
cific coastline, resulting in nearly 25,000
dead or missing. On top of this, Fukushi-
ma prefecture suffered damage from the
coastal nuclear power plant accidents and
associated harmful rumors and misinfor-
mation.
I also started coordinating with the local
Iwaki Medical Association. In Iwaki alone
14,000 evacuees were confirmed in about
140 shelters. The government’s orders to
evacuate the zone 20 km from the Daiichi
Nuclear Power Plant and to stay indoors
in the 20–30 km zone meant in effect that
nearly the entire central part of Fukushima’s
Pacific coastal region, which was hardest hit
by the earthquake and tsunami, were shut
off from social activities.
They also required adequate medical care
setup at first-aid stations including health-
care for radiation exposure. This consider-
ably weighed down the initial movements
in Fukushima, especially along the coast,
despite healthcare support provided in the
afflicted areas by more than 1,000 Japan
Medical Association Teams (JMATs) from
outside the region.
To be sure, even at my own hospital the
situation during the first week was of work-
ing in the midst of an unfathomable chill
brought on by the lack of real-time infor-
mation from the ground or even from TEP-
CO and the government.
To deal with the seriousness of this prob-
lem, the JMA, with the cooperation of Yo-
shinari Kimura, a lecturer in the Graduate
School of Literature and Human Sciences
at Osaka City University, created a map of
published air contamination levels in Fu-
kushima’s coastal areas and made daily up-
dates to the data, which it released for JMA
members on its website (Picture 2). The
JMA also requested Nagasaki University to
dispatch experts in healthcare for radiation
exposure. Professors Shunichi Yamashita
and Noboru Takamura responded imme-
diately and became advisors to Fukushima
prefecture’s disaster countermeasures head-
quarters.
The effort to share and get reliable infor-
mation out in this way resulted in obtain-
ing sufficient healthcare support from the
eighth day for Iwaki and Soma, which are
the principal coastal cities, as well as for the
city of Mina-misoma, which is partially in-
side the 20–30 km stay-indoors-zone, and
enabled excellent first-aid station health-
care (Fig 1) [2]. Additionally, Professors
Yamashita and Takamura gave lectures
throughout the prefecture for evacuees and
residents. This communication of evidence-
Fukushim
Iitate
Iwaki
Fukushima Daiichi Nuclear Power Plant
Fukushima Daini Nuclear Power Plant
Picture 2. Onion diagrams of radioactivity readings in Fukushima prefecture. These dia-
grams were prepared with the help of Yoshinari Kimura, a lecturer in the Graduate
School of Literature and Human Sciences at Osaka City University, based on pre-
liminary environmental radioactivity readings in Fukushima prefecture. The diagram
included here is based on readings taken at 14:00 on March 29. A reading of 2.23 was
recorded in Iwaki on March 22 and a high reading of 13.1 was recorded in Iitate on
March 23, but these gradually declined afterward. On April 26, when publication of
these maps was concluded, the reading in Iwaki was 0.27 and that in Iitate was 4.07.
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DisastersJAPAN
based information to the mass media and
local residents play an important role.
4. Healthcare for
radiation exposure
The Japanese government had been con-
ducting annual evacuation drills with ad-
ministrative agencies, residents, and medi-
cal personnel in the prefectures where the
nation’s nuclear power plants and their 54
reactors are located. These drills were con-
ducted under the policy of the Nuclear
Safety Commission as a measure for im-
proving medical responses, including per-
sons associated with the local medical as-
sociation, through lectures on healthcare
for radiation exposure and other activities.
This policy was implemented after the To-
kai Village JCO Criticality Accident that
occurred in Tokai, Ibaraki, which borders
Fukushima’s southern coastal area, in 1999.
In addition, the government established
guidelines for taking iodine tablets in the
event of an accident at a nuclear power
plant, distributed iodine tablets to residents
living within 20 km of nuclear power plants,
and put survey meters in place to monitor
radioactive contamination.
I myself had gone through training sessions
in airport disaster prevention and health-
care for radiation exposure in addition to
my specialty of neurosurgery due to the
fact that I had been in charge of emergency
and disaster medicine as vice-president of
the Fukushima Medical Association and
president of the local medical associa-
tion in Iwaki, Fukushima, to the north of
which are TEPCO’s Fukushima nuclear
power plants and to the south of which is
the Tokai Nuclear Power Plant in Ibaraki.
I also attended an unforgettable intensive
symposium on disaster medicine focusing
on bioterrorism among the issues of NBC
(nuclear, biological, and chemical weapons)
at the World Medical Association (WMA)
General Assembly held in Washington DC
in 2002. From the beginning when I was
nominated an executive board member of
the JMA five years ago in 2006, I was in
charge of emergency and disaster medi-
cine. In that capacity I participated in rel-
evant committees in the Japanese govern-
ment as well as continuing discussion in
the JMA’s Committee on Emergency and
Disaster Medicine. I was also appointed to
be a member of the Radiation Emergency
Medicine Network in the National Insti-
tute of Radiological Sciences, which is in
charge of healthcare for radiation exposure
in Eastern Japan.
The Iwaki City, where the facilities in my
medical corporation are located, is a little
less than 30 km away from TEPCO’s Fu-
kushima nuclear power plants at the north-
ernmost point, and more than 50 km away
from the Tokai Nuclear Power Plant. Since
it is outside the 20 km zone around both
plants Iwaki is not located in a special ad-
ministrative zone like the one mentioned
above.
Nevertheless, with a population of 350,000
it is the second largest city in the Tohoku
region, which encompasses the northern
part of the island of Honshu,and is home to
the region’s only critical care center. It also
has a local network of about 30 hospitals
and so as a medical district it covers both
areas where the nuclear power plants are
located and has relevance on various other
levels such as industrial medicine activi-
ties. For this reason, it is an area that must
function as a support center on the medical
front once a special disaster occurs, such as
an accident at a nuclear power plant. It used
to be customary to send a number of teams
besides those that were in charge to par-
ticipate in the Fukushima Nuclear Power
Plant’s annual evacuation drill.
However, at the government level no mea-
sures were implemented for Iwaki, since it
is outside the 20 km zone. For that reason,
when a disaster prevention agreement was
signed between the city and the municipal
medical association, on the advice of the
medical association a stockpile of iodine
tablets for 300,000 people was put in the
Iwaki Health and Welfare Center under the
control of the center’s director.
On top of this it seems undeniable that in-
formation released by the government and
TEPCO was in each case, in terms of both
the amount and the speed with which it was
released, fragmentary and too little, too late.
This did nothing to dispel the past image
of information relating to nuclear power
plants being, for example, falsified or con-
cealed and then apologies given later with
declarations of intent to make improve-
ments. Evacuation drills with the admin-
Number of
Teams
JMA&Okayama MA 1
Aichi MA 20
Toyama MA 12
Kyoto MA 5
Tokyo MA 7
Fukuoka MA 15
Saitama MA 2
Chiba MA 1
Nagasaki MA 2
Total 65
* MA: Medical Association
March 11-31 April 1-15 April 16-May 4
Figure 1. Calendar of JMAT dispatches to Iwaki. The period of dispatch is from the time a
team leaves home until it returns. So, this may differ from the time actually spent in
action in the afflicted areas. There are also instances of multiple teams being dispatched
on the same day.
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Disasters JAPAN
istration, residents, and medical personnel
had been conducted for more than 10 years
and people had been educated every year
about outside contamination checking and
the taking of iodine tablets. Through this
kind of process,the local residents chose the
position of a place where a nuclear power
plant is located for nuclear power genera-
tion by TEPCO, which does not make the
power used by these residents.1
That is all the more reason why there is
still doubt over whether there was a need
for people to all suddenly follow along and
gather together like abductees without even
being able to lock their houses or get cash
or their iodine tablets to carry in a situation
like this where detailed information was
not made known. During the usual drills,
forecasts and contamination levels based on
the Ministry of Education, Culture, Sports,
Science and Technology’s System for Pre-
diction of Environmental Emergency Dose
Information (SPEEDI) had been reliably
disclosed, but unfortunately it does not
seem that such thorough procedures were
taken to gain the understanding of residents
this time.
During this disaster the Ministry of Health,
Labour and Welfare raised the limit for
workers’ radiation exposure at the site of
a nuclear power accident from 100 mSv/y
to 250 mSv/y. So far two cases of hospital-
ization due to beta radiation exposure and
several cases of internal exposure have been
reported, but none entailed serious conse-
quences.
On the other hand, the exposure limit for
the general public has been at 1–20 mSv/y.
Thus far no serious cases of radiation expo-
sure have been reported, including among
evacuees. The shipping of vegetables and
marine products from the 20 km zone and
designated areas was banned. In other ar-
eas beside these the drinking of water from
1 This region uses power from the Tohoku Electric
Power Company.
sources that had exceeded threshold values
was banned, and the shipping of vegetables,
fish, and other products was temporarily
banned. These bans were lifted one by one
after the measurements were detected to fall
below the threshold values.
Additionally, the JMA made an urgent rec-
ommendation regarding residual contami-
nation on school grounds in Fukushima
prefecture, namely that even if contamina-
tion is below 20mSv/y in the case of chil-
dren steps should be taken to reduce the
contamination as much as possible, such as
removing top soil and plowing to replace
surface soil with subsoil [3].
5. Conclusion
The nuclear power accidents triggered by
the Great Eastern Japan Earthquake caused
air, soil, and marine pollution in the vicin-
ity as a result of the meltdown of three fuel
rods, hydrogen explosions in the reactor
buildings, and other factors.
Residents living within a zone with a radius
of 20 km around the Fukushima Daiichi
Nuclear Plant and even some residents out-
side that zone are still in a state of evacu-
ation, having been compelled to take shel-
ter or been part of scheduled evacuations.
Although the power plant itself has not
yet reached a cold shutdown, it has been
brought into a stable situation through
cooling with continuous injection of water
from the outside.
In this situation the JMA, in cooperation
with the Fukushima Medical Association
and local medical associations, provided
health and medical assistance to evacuees
mainly in evacuation shelters and supported
damaged local healthcare. This resulted in
the dispatch of JMATs to Fukushima pre-
fecture being nearly over in mid-June.
During this incident I felt keenly once
again that basically it is extremely impor-
tant to get sufficient information to medical
professionals in order to provide healthcare
for radiation exposure, which entails deal-
ing with damage caused by radiation that
cannot be seen. Additionally, the continual
communication of robust information from
medical professionals to residents contrib-
uted to people’s peace of mind.
Postscript
On June 6, the Japanese government an-
nounced that radioactive emissions from the
stricken Fukushima Daiichi Nuclear Power
Plant in the first week after the March 11
earthquake and tsunami disaster might have
been 770,000 terabecquerels, which is more
than double the 370,000 terabecquerels ini-
tially estimated by TEPCO.
The next day the government admitted the
possibility that fuel could have suffered a
“melt-through,” a more serious situation
than a core meltdown. Perhaps this could
be said to be the characteristic attitude of
TEPCO and the Japanese government dur-
ing this accident.
References
1. Tokyo Electric Power Company.Status of Fuku-
shima Daiichi and Fukushima Daini Nuclear
Power Stations after Great East Japan Earth-
quake. http://www.tepco.co.jp/index-j.html (ac-
cessed May 31).
2. JMA Disaster Headquarters Status Reports,
March 19, 2011. http://www.med.or.jp/english/
(accessed May 25).
3. Japan Medical Association’s position regard-
ing the Ministry of Education, Culture, Sports,
Science and Technology’s “Tentative Thinking
in Determining whether to use Schools and
Schoolyards in Fukushima Prefecture” (May
12, 2011) http://dl.med.or.jp/dl-med/teirei-
kaiken/20110512_31.pdf (accessed June 7. In
Japanese).
Masami Ishii, MD
Executive Board Member
(responsible  or emergencies and  isasters),
Japan Medical Association,
Vice-Chair of Council,
World Medical Association
E-mail: ishiihom@ishiihp.or.jp
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KOREA Disasters
Several months have passed since the dev-
astating earthquake and tsunami near To-
hoku, Japan. The exact number of deaths is
still unknown.The recovery effort is expect-
ed to cost an astronomical 25 trillion yen.
On behalf of KMA, I once again offer my
sincere condolences to all people of Japan
as a neighboring country and greatly respect
Japanese people and colleagues for their
strong will to stand up and recover from the
unseen disaster. I am sure Japan will be able
to recover from this difficult situation with
unity and recognize the great leadership
and dedicated services in the field by fellow
physicians under JMA.
Korea’s response to the recent disaster has
been remarkably prompt and sensitive. As
Japan’s closest neighbor, Korea was quickly
aware of the seriousness of the earthquake,
which was accompanied by a tsunami and
nuclear accident. Furthermore, the ex-
tended nature of the damage necessitates
international coordination and the entire
Korean public is aware that Korea’s role as
friendly neighbor in this coordination is
critical.
Due to the complex nature of the disas-
ter, urgent medical tasks include care for
chronic conditions such as diabetes and
hypertension as well as prevention of con-
tagious diseases such as respiratory con-
ditions and norovirus infection among
people living in high density environments
including shelters. My impression is that
such urgent issues are being well addressed
by Japan’s own medical capabilities. In
the mid to long-term, mental issues re-
lated with post-traumatic stress disorder
(PTSD) and social problems from sud-
den family disruptions still pose a grave
challenge. The international medical com-
munity could play a valuable role here by
continuing interest and research support.
Exchange of experience learned from pre-
vious disasters will help devise the most ef-
fective solutions.
The most formidable challenge would be
the response to the nuclear reactor accident
and following exposure to radioactive ma-
terial. Ionizing radiation is defined as ra-
diation that has sufficient energy to displace
electrons from molecules. Free electrons can
damage macromolecules in human cells.
Ionizing radiation arises from both natural
and man-made sources. At low-dose ex-
posures, late effects such as cancer are pro-
duced many years after the initial exposure.
About 3% of total cancers in the US are at-
tributed to ionizing radiation.
Our greatest concern is the possible conse-
quences of a very or extremely low dose of
exposure. Epidemiological data is available
from several sources such as atomic bomb
survivors, nuclear facility workers and ura-
nium miners. However, such data tells us
only of results from relatively higher level
exposure. Since the annual amount of ex-
posure to all natural radioactivity is around
2.5mSv, the criteria for annual exposure to
artificial radioactivity is set at a lower level
of 1mSv, which is in turn broken down into
radioactivity standards for air, water and
food, etc. Considering the potential con-
troversy over such standards, multifaceted
analysis of scientific data on a case by case
basis is necessary for effective risk commu-
nication.
During the Great Depression, the then US
President Franklin D. Roosevelt said, “The
only thing we have to fear is fear itself.”This
applies to radioactive contamination.Fueled
by the disaster of a public faced with a never
before experienced situation, information
which is not based on science could spread
and then further be spun by the social me-
dia, creating a malicious cycle of magnify-
ing public concerns.The medical profession
is the most accurate and trusted authority
when it comes to the impact of radioac-
tive contamination on the human body.The
medical communities of Japan and Korea
need to play their roles as health commu-
nicators by providing accurate and reliable
information and behavioral guidelines on
radioactive contamination.To fulfill its role,
KMA announced its humble recommenda-
tions on nuclear contamination immediate-
ly following the Japanese disaster.
The radioactive leakage caused by the
Japanese earthquake has heightened pub-
lic interest on environmental protection
and energy management. It will be wise
for medical professionals to set the right
example by practicing proper energy man-
agement.The WMA must reiterate the im-
portance of its “Health and Environment”
policies such as the New Delhi Declaration
on Climate Change and Health and mo-
tivate each NMA to implement them in
their respective countries. In particular, the
campaigns and policy making for creating
a greener health care sector need to be ad-
opted by more NMAs, which can in turn
motivate patients and the general public to
become more active in environmental pro-
tection and energy management.
The Japanese disaster is calling upon the
health and medical community to step
up its social leadership in addition to tak-
ing care of humanity and public health. By
willingly accepting this leadership role and
thoroughly fulfilling our public obligations,
the NMAs and the WMA can progress to
the next level as organizations that maintain
continuous interaction with society.
Tai Joon Moon, MD, PhD
President Emeritus, KMA
Former President, WMA
E-mail: intl@kma.org
The Japanese Earthquake and the Role
of Medical Society
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146
UNITED STATES OF AMERICARegional and NMA news
For 40 years Americans have been breathing
easier thanks to common-sense limits on toxic
air pollution. But an emerging threat has the
medical community concerned – just as the
United States Congress begins a new assault
on public health protections
In the past two decades, extreme heat events
have killed tens of thousands around the globe,
including populations here in the United
States.Heat waves are more frequent,of longer
duration and more intense – and the lack of
nighttime relief make them all the more lethal,
causing illness and death from heart disease,
diabetes, stroke, respiratory disease and even
accidents,homicide and suicide.
Increases in winter weather anomalies are
emerging.Though winters have become short-
er (two-to- three weeks shorter in the North-
ern Hemisphere, depending on latitude), they
have grown more perilous.For several decades
more winter precipitation has been falling as
rain rather than snow,increasing the chance of
ice storms when temperatures do drop. Glob-
ally, westerly winds are also changing with
climate change, affecting the shifts in weather
fronts. Now, warming seas and melting Arctic
ice are generating harsher winters in the US
and Europe. And heavier, wetter snowstorms
can be treacherous for travel and ambulation.
Meanwhile, warming favors insect migration.
In the past decade, case reports of tick-borne
Lyme disease rose ten-fold in Maine and
northern counties are experiencing Lyme for
the first time. In Alaska, especially warm win-
ters have ushered in swarms of allergy-induc-
ing, stinging insects, along with mosquitoes
and devastating pine bark beetle infestations.
The spread of forest and crop pests – requir-
ing chemicals for control – pose additional
long term health and environmental risks.
Elevated carbon dioxide levels from burn-
ing fossil fuels boosts pollen production from
ragweed, and the pollen grains hitch rides on
particulates from diesel and coal combustion,
helping to deliver the allergens deep inside our
lungs.Meanwhile,the allergy and asthma sea-
son has lengthened some two-to-three weeks,
while,since 1980,asthma rates have more than
doubled in the U.S.In short,climate change is
hazardous to our health. We are deeply con-
cerned that climate instability and changing
weather patterns threaten our health and the
vitality of our life-support systems.The Amer-
ican Medical Association is working actively
to educate health care professionals about the
projected rise in climate-related illness. Medi-
cal and public health groups are also taking
leading roles in advocating for climate and
energy policies, and measures – like electric
vehicles,“smart”grids and healthy cities initia-
tives – that will improve public health, create
jobs and combat climate change. And physi-
cians and other health care professionals have
begun serving as role models for patients by
adopting environmentally responsible,energy-
and waste-reducing practices in the health sec-
tor. As medical professionals, our focus is first
and foremost on preventing health threats,but
a new report from the U.S. Environmental
Protection Agency (EPA)makes a clear eco-
nomic case for more action. In one year alone,
the Clean Air Act, prevented an estimated
18 million child respiratory illnesses, 850,000
asthma attacks,674,000 cases of chronic bron-
chitis, and 205,000 premature deaths. Ac-
cording to EPA,“The mere monetary value of
saving Americans from those harms through
implementing the Clean Air Act is projected
to reach $2 trillion in 2020 alone … Over the
period from 1990 through 2020,the monetary
value to Americans of the Act’s protection is
projected to exceed the cost of that protection
by a factor of more than 30 to 1.”
Lawmakers may be unaware of the stunning
returns on our investments in clean air, the
range of benefits from EPA’s efforts to protect
us from greenhouse gas pollution, and of the
work that still needs to be done. The protec-
tions some in Congress are now seeking to
undercut call on big power plants and facto-
ries to adopt cost-effective efficiency measures.
Greater efficiency means lower combustion
of fossil fuels, which translates directly into a
reduction of mercury, particulate matter, and
other health-threatening pollutants.
Now is the time to use our 40 years of experi-
ence in reducing air pollution to reduce green-
house gases and the co-pollutants. The harm
to our health and our well-being, and the as-
sociated health and social costs, will continue
to mount unless we take action.
Cecil B. Wilson, M.D.,
President of the American Medical Association
Paul R. Epstein, M.D., M.P.H.,
Associate Director, Center for Health and the
Global Environment, Harvard Medical School
Protecting Our Nation’s Health
Cecil B. WilsonPaul R. Epstein
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147
Public HealthRUSSIAN FEDERATION
Health of a nation determines the quality of
workforce, the latter being the base of any
state economic model. While developing
innovative economy, Russia has faced vari-
ous challenges connected with progressing
insufficiency of workforce, which is tackled
everywhere as one of the main long-term
strategic risks and threats to national safety
in the field of economic growth. (Russian
Federation National Safety Strategy Until
2020 adopted by the RF President’s Decree
No. 537 of 12.05.09) (Figure 1, 2, 3).
Insufficiency of workforce is explained
above all by age and sex structures. Small
population groups born in the 1990s have
started their active working life while nu-
merous after-war working cohorts (born
after World War II) are dropping out of the
working-age population (Figure 4).
In accordance with Rosstat (Official Rus-
sian Statistics Agency), the reduction of
working-age population will reached the
figure of 13 million people by the year 2030.
80% of losses are expected to occur dur-
ing the period until 2020 on the average by
1 million of people annually.
Nicolay Izmerov
Strengthening and Promotion of Working Population as the Base of
Socioeconomic and Demographic Policies in the Russian Federation
14.4%
17.5%
57.4%
69.9%
28.20%
12.60%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Females Males
Younger than acive Active workers
Older than active workers
Figure 1. Working-age population in the RF matched by age and sex, in %
Males and females ageing 0–15 Males ageing 60 and more, females ageing 55 and more
28.6%
23.3%
24.5%
18.1%
15.9%15.4%
16.3%
18.5%
20.5% 21.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
1970 1979 1989 2002 2009
Figure 2. Age-related changes: share of people younger and older than active working age com-
pared to general population, in %
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148
Public Health RUSSIAN FEDERATION
The reduction of active workforce and its
share in the general population is going to
take place on the background of growth
both of number and proportion of pension-
ers.
In 2009, 38 million was the number of re-
tired population in the country including
around 30 million old age pensioners.
In accordance with the official data, em-
ployment of pensioners has been growing
since 2002. At present, working pension-
ers make up about one fourth of the total
number of pensioners. It is of great impor-
tance nowadays to involve and effectively
employ aging workers in the economy of
Russia.
The growth of the employment of retired
pensioners will contribute to both reduction
of workforce shortage and greater resort of
work experience accumulated during work-
ing years.The main obstacle for the involve-
ment of pensioners in active work is the
state of their health.
The results of sociological research among
pensioners show that the number of work-
ing pensioners who assess their health as
“satisfactory” is three times larger than the
number of those pensioners who do not
work and thus assess their health as “unsat-
isfactory”.
In 2009, life expectancy in the Russian
Federation was 62.8 years for men, which
is 15–17 years less than globally in the de-
veloped countries, while for women it was
74.7  years, which is 7–11 years less than
globally in the developed countries.
Great success in the reduction of mortal-
ity rates among the adult population was
achieved in the majority of the world’s
countries in the second half of the 20th
cen-
tury and at the beginning of the 21st
century.
Russia stands aside from these achieve-
ments.While in the 1960s and at the begin-
Population ageing 15-72
Females. In thousands
(100%)
Males. In thousands
(100%)
Active workers
Females: 62,5%
Males: 72,2%
Groups not
engages in
economy
Females: 37,5%
Males: 27,8%
Students
Females: 10,7%
Males: 12,0%
Employed
Females: 59,2%
Males: 67,9%
Unemployed
Females: 3,3%
Males: 4,3%
Pensioners
Females: 19,6%
Males: 12,1%
Housewives
Females: 4,6%
Males: 0,3%
Others
Females: 2,6%
Males: 3,4%
Figure 3. Distribution of the population aged 15–72 by economic activities in 2008 and its
share compared to the general population of respective sex, in %
36.3%
19.9%
50.2%
57.1%
0.70% 0.50%
9.30%
6.20%
3.50% 4.70%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
2003 2008
State and municipal Private
Public and religious organizations Mixed Russian
Joint Russian and foreiign ventures
Figure 4. Structure of the mean annual number of population employed in economy with regard
to patterns of ownership
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149
Public HealthRUSSIAN FEDERATION
ning of the 1970s Russian life expectancy
was almost the same as in the greater part
of the world, at present it shows multiple
increase discrepancy, especially in males.
(Figure 5)
Impact analysis of mortality rates for
1987–2008 testifies to the fact that infan-
tile and child mortality shows a 1.5–2-fold
reduction. In senior age groups, mortality
rates were either stable or insufficiently (by
10–20%) increased whereas at active work-
ing ages 16–59 they showed a 1.5–2.5-fold
increase.
Table 1. Rates of industrial injuries are pres-
ently decreasing at a very quick pace
in Russia
Industrial
Injuries
2008 2009
Change,
in %
Index of
occupational
injuries per
1000 workers
2.5 2.1 –16.0
Lethality index
of occupational
injuries per
1000 workers
0.109 0.09 –17.4
Industrial traumatism decreased from 3.4 to
2.1 during 2004–2009 (per 1000 workers),
which made up 38%,and lethal outcomes of
occupational injuries decreased from 0.129
to 0.090, or by 30.2%, respectively.
In Europe, the share of one lethal injury is
500 to 2000 cases of injuries.
At present, this ratio is 1 to 22–23 in Rus-
sia, though in the 1970s and the 1980s it
was 50 to 60 cases of occupational injuries
per one lethal injury. (Figure 6)
At present, mean indices of the number of
cases and disability days compared with the
beginning of the 1990s have reduced by one
third. They correspond to the analogous
data in the EU countries. (Figure 7)
12.4
11.5
10.7 10.7
10.1 10.1
8.8
7.5 7.2 6.9 6.7 6.4
6 6 5.8 5.6 5.4
4.9 4.7 4.7
4
3.6
0
2
4
6
8
10
12
14
Russia
BieloRussiaLatviaEstoniaLithuaniaU
krainePolandFranceFinland
SpainRum
aniaBulgariaG
erm
any
ItalyA
ustria
SwitzerlandN
orwayG
reeceSweden
G
reatBritainTurkey
Island
Figure 5. Difference of life expectancy in men and women, in years in 2008
One lethal injury versus the number of non-lethal injuries
Work-related accidents
Lethal outcomes
2.7
16.8
26.5
28 28.5
35.8
39.4
0
5
10
15
20
25
30
35
40
45
Russia Czech
Republic
Italy Germany Finland Austria France
0.124
0.041 0.04
0.022
0.017
0.039 0.04
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
Russia Czech
Republic
Italy Germany Finland Austria France
Figure 6. Level of occupational traumas in Russia compared with developed countries of the
world in 2008 (per 1000 workers)
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150
Public Health RUSSIAN FEDERATION
Along with this, the mean duration of one
disability case increased by 16%. Increase of
the mean duration of one case indicates a
late visit to the doctor as well as the fact that
the worker’s health condition needs more
time to be restored.
The reduction of registered morbidity rates
of working population on the background
of extremely high levels of disability and
mortality of working ages speaks of:
• Social ill-being in the society, continu-
ing gap in the real income of population,
growth of poor layers for whom medical
aid is less accessible;
• High prevalence rates of alcoholism and
unhealthy life style, low standard of cul-
ture, including hygiene at home and in
working surroundings;
• Low appraisal of health and life in pop-
ulation striving for maintaining higher
life standards at the expense of their own
health
Table 2. Share of workers engaged in hazard-
ous and dangerous working condi-
tions, in %
Indicators 2008 2009
Shift,
%
Mining
operations
39.1 40.3 +3.1
Manufacturing
activity
26.8 28.2 +5.2
Distribution of
energy, gas and
water
30.6 31.0 +1.3
Construction 14.6 28.2 +93.2
Transport 31.4 33.1 +5.4
Communi-
cations
2.9 3.7 +27.6
Workers with
heavy physical
loads
9.0 9.8 +8.9
Including
females
3.5 3.8 +8.6
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Cases Disability days Mean duration
1990 2006
Figure 7. Morbidity with temporary disability
1.5%
23.8% 24.4%
26.6%
20.4%
3.4%
2.1%
17.5%
25.3%
28.1%
19.6%
7.3%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
under 20 20–29 30–39 40–49 50–59 60–72
Empoyes workers Unemployes workers
Figure 8. Structure of employed population matched by age and type of employment
in 2008, in %
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151
Public HealthRUSSIAN FEDERATION
Table 3. Actual number of working hours per
week averagely per one worker (in-
cluding the time for additional place
of employment)
Indices
Totalnumberofworkers
Workershavingoneplaceof
employment
Workershavingtwoormore
placesofemployment
2007 39.1 38.6 51.8
2008 39.3 38.9 52.5
• In accordance with the official data, more
than 2 million 600 thousand workers had
two or more places of employment.
• Excessive employment is characteristic of
workers engaged in the non-formal in-
dustrial sector at small and medium-scale
enterprises. (Figure 8)
In accordance with the Rosstat data, rates
of occupational morbidity in Russia grew by
17.8% in 2009, which was equal to 1.79 per
10,000 workers (1.52 in 2008, respectively).
(Table 4; Figure 9)
The State Concept of the Demographic
Policy for the Period until 2020, among
other tasks to be fulfilled by public health,
has a special task which includes reduction
of mortality rates and injuries from occupa-
tional accidents and occupational diseases by:
• shift in the field of safety at work to the
system of management and control of
occupational risks including informing
workers of relevant risks, development of
system for revealing such risks, evaluating
and controlling them;
• economic motivation for the improve-
ment of working conditions by employ-
ers.
Table 4. Share of workers to be compensated for their work in dangerous and hazardous conditions
(in accordance with types of economic activity) in 2008, in %
 Indicators
Types of economic activity
Mining
opera-
tions
Manu-
facturing
industries
Production
and consump-
tion of energy,
gas and water
Con-
struc-
tion
Trans-
port
Com-
muni-
cation
Workers engaged
in hazardous and
dangerous working
conditions
68.4 41.9 43.3 33.7 44.6 6.7
Among them work-
ers had the right to:
           
Additional breaks 60.2 29.8 32.7 22.9 33.6 4.1
Reduced working
hours
8.8 3.8 2.0 1.8 1.6 2.0
Free medical treat-
ment and nutrition
1.9 3.0 2.0 0.8 0.1 0.0
Free delivery of
milk and other food
products
3.0 27.7 24.5 14.3 11.7 2.0
Increased remu-
neration for work
28.1 27.5 29.0 9.6 19.7 3.4
The right to early
retirement and old
age pension reward,
List 1 and List 2
42.1 17.9 12.2 13.6 5.4 1.7
Figure 9. Distribution of occupational diseases and poisonings by number of cases in 2009
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152
Public Health RUSSIAN FEDERATION
One of the most important factors which
influence this situation is the market of
workforce where migrant workers, above all
those arriving from the NIS, change align-
ment of force.
In accordance with the assessment by the
RAS (Russian Academy of Science) Re-
search Economy Prognosis Institute, the
number of migrants at the beginning of
2009 was 6–7 mln people, or more than
10% of the full list of Russian workers in the
RF. The number of illegal migrants makes
up approximately 4–5 mln people and about
30% among them have neither registration,
nor work ticket.
More than half of legal migrants with work
tickets are employed in the shadow econo-
my sector, their employers do not send rel-
evant notifications to the Migration Service
and Rostrud (Table 5).
The Russian Federation National Safety
Strategy Until 2020 sets the following aims
for national safety in the field of public
health:
• Increase of life expectancy, reduction of
disability and mortality rates;
• Development of preventive measures and
timely qualified primary medical aid to
workers;
• Prevention of socially dangerous diseases;
• Quality and accessibility of medical ser-
vice.
In October 2010, ILO Convention No. 187
on Occupational Safety and Health was
ratified by federal authorities. The aim of
the convention is to prevent industrial ac-
cidents, occupational diseases and deaths of
workers in industry by means of working out
the relevant national policies, systems and
programs on the subject. This fully agrees
to the WHO Global Plan of Actions on
Workers’ Health for 2008–2017, which has
a recommendation directed to the WHO
member states to encourage developing na-
tional health programs and national systems
of occupational health.
Table 5. Number of migrant workers in Russia
  In %
2000 2003 2004 2005 2006 2007 2008
Totally 100 100 100 100 100 100 100
Abroad workers 50.1 52.2 51.8 51.1 47.0 32.8 26.6
Vietnam 6.2 9.3 9.1 7.9 6.8 4.6 3.9
China 12.3 19.3 20.4 22.9 20.8 13.3 11.6
Northern Korea 4.1 3.5 3.2 2.9 2.7 1.9 1.4
USA 0.9 0.5 0.4 0.4 0.4 0.3 0.2
Turkey 8.4 10.0 10.4 10.5 10.0 7.6 5.4
NIS workers: 49.9 47.8 48.2 48.9 53.0 67.1 73.4
Azerbaijan 1.5 1.6 2.1 2.5 2.8 3.4 3.1
Armenia 2.6 2.7 3.7 3.7 3.9 4.3 4.1
Georgia 2.4 0.8 0.8 0.6 0.5 0.3 0.2
Kazakhstan 1.4 1.0 0.9 0.6 0.5 0.4 0.4
Kyrgyzstan 0.4 1.3 1.7 2.3 3.3 6.4 7.6
Republic of Moldova 5.6 5.7 4.9 4.4 5.0 5.5 5.0
Tajikistan 2.9 3.6 5.1 7.5 9.7 14.6 16.1
Turkmenistan 0.1 0.1 0.1 0.2 0.1 0.1 0.1
Uzbekistan 2.9 3.9 5.2 7.0 10.4 20.1 26.5
Ukraine 30.1 27.1 23.6 20.2 16.9 12.2 10.1
39.1%
24.4%
49.8% 49.6%
38.0%
14.8%
60.2%
30.1%
62.1%
68.3%
62.4%
40.7%
21.7%
17.8%
37.9%
31.3%
18.2%
2.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
All adults groups 15–18 19–24 25–44 45–64 65+
Totally Males Females
Figure 10. Prevalence of tobacco smoking among adults (aged 15 years or older) matched by sex
and age in the Russian Federation in 2009
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153
Public HealthRUSSIAN FEDERATION
The Russian Program entitled Health in
Industry is underway in the Ministry of
Health and Social Development. The pro-
gram is based on the WHO Global Plan of
Actions on Workers’Health for 2008–2017.
The aims of it are:
• Development of medical and preventive
services for the working population of
Russia;
• Timely identification of occupational dis-
eases;
• Reduction of health risks due to unfavor-
able occupational factors;
• Bringing up of ideas of a healthy life style
to the working population.
The experience of many countries shows
that a new social key-point for preventing
and quitting bad habits can be the idea of
general health promotion in the society
along with the work at individual develop-
ment of a healthy life style. In 2009, a pro-
gram to form a healthy life style until 2012
was introduced in Russia. The Ministry of
Health and Social Development initiated
the program and called it ‘Healthy Russia’
attracting mass media and other social in-
struments to implement it. Health control
and prevention centers are being developed
in the country.
Medical specialists of the local outpatient
service fulfill the functions of hygienic edu-
cation. The system of medical prevention,
forgotten in the recent years, is now being
restored to life.
In accordance with the WHO data, the
leading mortality and morbidity factors in
the Russian Federation are as follows:
• high arterial blood pressure;
• high level of cholesterol;
• tobacco smoking and alcohol abuse.
The following correlation has been detected
between risk factors and mortality rates:
• 17.1% for tobacco smoking;
• 12.9% for unbalanced nutrition;
• 12.5% for extra weight;
• 11.9% for alcohol intake.
About 50% of Russian population are to-
bacco smokers. The rates of tobacco smok-
ing growth are the highest compared with
the rest of the world: the number of smoked
cigarettes during the recent three years has
annually increased by 2% to 5%. The num-
ber of tobacco smokers, including women
and teenagers, annually increases by 1.5% to
2% (Figure 10).
In accordance with the WHO researches,
the prevalence of tobacco smoking among
13–15-year-old teenagers is 33.4% (40.8%
among boys and 29.8% among girls, respec-
tively).
According to expert assessment,Russia occu-
pies the fourth place in the world by the prev-
alence of tobacco smoking among teenagers.
Russia joined the WHO Convention
against tobacco smoking where it was for
the first time proclaimed as global challenge
and threat. In accordance with this docu-
ment, Russia has to introduce measures to
restrict tobacco consumption.
Alcohol abuse shows high repeatability dy-
namics. In accordance with the data of Ros-
stat, the consumption of registered alcohol
per person increased from 5.83 liters of ab-
solute alcohol in 1990 to 10.1 liters in 2007,
which otherwise makes up an increase of
1.8 times. In accordance with the data of
experts, the real per capita consumption of
alcohol is around 18 liters with regard to il-
legal turnover of alcohol-containing prod-
ucts in Russia.
According to the opinion of the WHO
experts, if pure alcohol consumption per
capita increases 8 liters a year, it is already
dangerous for the health of population
(Table 6).
Great harm to the health of population is
inflicted by malnutrition.
Discrepancy between caloric content and
power inputs, extra consumption of fats, in-
sufficient intake of vitamins, minerals and
biologically active food components have
been found in the nutrition of Russians.
Table 6. Number of diseases due to alcoholism and alcoholic psychosis, drug addiction and drug
abuse in 2008 (newly diagnosed diseases)
Indicators Totally
Ages, years
0–14 15–17 18–19 20–39 40–59
Totally
Alcoholism and alcoholic
psychosis
173,430 39 660 1705 77,886 84,569
Drug addiction 26,516 28 649 1451 22,628 1754
Drug abuse 1161 288 502 135 214 19
Females 
Alcoholism and alcoholic
psychosis
38,278 6 177 286 17,577 18,503
Drug addiction 5238 4 129 284 4629 191
Drug abuse 142 25 60 17 30 7
Males
Alcoholism and alcoholic
psychosis
135,152 33 483 1419 60,309 66,066
Drug addiction 21,278 24 520 1167 17,999 1563
Drug abuse 1019 263 442 118 184 12
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154
Regional and NMA news AUSTRIA
Hospital reform, migration of doctors,
working conditions in hospitals, increasing
medical underservice in outlying areas, the
risk of quality losses due to budget cuts –
these are the considerable challenges the
Austrian health care system has to face in
2011. In addition, the reform of the funding
system, the development of medical docu-
mentation, and of electronic data exchange
is imminent. All players will be required to
make considerable efforts in order to solve
these problems. However, enduring solu-
tions can only be achieved in cooperation
with the medical profession, represented
by the Austrian Medical Chamber. Imple-
menting reforms without referring to the
expertise of the medical profession would
be comparable to a blind speaking of colour.
No doubt, the most urgent concern is the
hospital reform. First of all, the legal provi-
Health in Russia has not been a public or
personal treasure so far. Russians are not
inclined to think over their health as a per-
sonal capital, they are not accustomed to
taking care of it.
The Ministry of Health and Social Devel-
opment of the Russian Federation is pres-
ently working at a new national system of
occupational risk management and control
to prevent occupational injuries and main-
tain the health of workers at Russian enter-
prises.
Occupational risk control in the sphere of
work protection allows for establishing of
a direct link between working conditions
at workplaces and health state of the em-
ployed personnel with the necessity to work
out managerial decisions which increase the
efficiency of safety at work and work pro-
tection measures.
The analysis of foreign law enforcement
practices in the field of safety at work shows
the efficiency of occupational risk man-
agement and control at workplaces in the
EU countries. Thanks to it, the efficiency
of preventive measures in safety at work is
increased, working conditions are improved
and occupational injuries and morbidity are
reduced.
In Russia, the system of occupational risk
control and management has already been
introduced by the “R 2.2.1766-03” Guid-
ance on the Assessment of Occupational
Risks for Workers’ Health. The guidance
was approved by the Chief State Health
Physician of Russia on June 24, 2003. Also
two other legal documents were published
in 2010, namely, Prognosis of Exposure to
Harmful Factors of Working Conditions
and Assessment of Occupational Risks
for Workers’ Health; Methods Applied
to Reveal and Prevent Work-related Dis-
eases Developed by the Researchers of the
RAMS Institute of Occupational Health
with Their Co-workers.
It is necessary to develop legislative acts for
the introduction of methods aimed at the
management and control of occupational
risks and health assessment of the employed
workers as well as of the funds necessary for
their treatment and occupational rehabilita-
tion.
It is proposed to be fulfilled by introduc-
ing amendments to the Labor Code of the
Russian Federation by applying as the main
notion in the field of safety at work such a
term as “occupational risk” and establishing
rights and responsibilities of employment
parties related to occupational risk manage-
ment and control as well as to procedures
aimed at the prevention of occupational
diseases and occupational rehabilitation of
workers.
Methodological legislative acts on the pre-
vention of occupational diseases and occu-
pational rehabilitation of workers are to be
developed based on a three-staged system of
social protection and medical aid to workers
if dangerous and/or harmful industrial fac-
tors are present at a particular enterprise.
First stage is to determine the level of occu-
pational risk due to the working conditions
at workplaces and the workers’ health.
Second stage is to render medical aid in-
cluding early diagnosis based on medical
signs revealed by regular medical examina-
tions for groups with increased risk factors.
Third stage is to establish compensatory
mechanisms and other social benefits for
those who have suffered due to accidents or
occupational diseases.
It is advisable to introduce a system of social
protection into the National Plan of Action
to maintain workers’health in Russia,which
will help to solve demographic problems,
give an increase to the number and quality
of workforce of the state, work efficiency,
economy and GDP.
Prof. Nicolay Izmerov,
Russian Academy of Medical Sciences
E-mail: niimt@niimt.ru
Austrian Health Care System Faces
Considerable Challenges
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155
Regional and NMA newsAUSTRIA
sions for hospitals have to be harmonized.
At present, the country has one federal
and nine provincial regulatory systems. All
the more it is positive that the Minister of
Health has responded to this long-standing
claim of harmonization made by the Aus-
trian Medical Chamber, which shall be
implemented in the course of the hospital
reform.
In addition, the hospital reform will tackle
the exasperating funding problem, as a con-
siderable share of costs is attributable to
hospitals. This is explained mainly by high
frequencies in hospital outpatient depart-
ments, which in turn is due to medical un-
derservice of self-employed doctors in the
early morning, late evening or on weekends.
The solution is obvious: group practices are
able to disburden outpatient departments
in taking over many tasks conditional that
these services are remunerated adequately.
At the same time, the Austrian Medical
Chamber advocates two pots of funding in
order to increase transparency – this would
allow hospitals to be funded by taxes, and
extramural services including hospital out-
patient departments to be funded by health
insurance funds.
The reform should not take place exclu-
sively on political grounds, but should be
expert-based and take into consideration
both medical and social needs. In contrast
to this, the Austrian social insurances have
presented a “master plan“ for the reform-
ing of the entire health care system, which
aims to concentrate the entire power in the
hands of the social insurances. In this plan,
medical expertise and the needs of patients
are sacrificed ruthlessly to economic targets.
It appears that the social insurances, which
at present are influenced significantly by
the economy, see the health care system as
a production process under economic laws.
The medical profession has protested vehe-
mently against this trend outlining that the
development of new reforms in the health
care area should fall within the political
competence of the Minister of Health,rath-
er than being developed by representatives
of the economy.
The reforms at issue and scheduled for
2011 also concern the training of young
doctors. After graduation from Medi-
cal University, it is common to undergo
a three year hospital training in order to
become a general medical practitioner; at
this level, doctors enter specialist training.
The Austrian Medical Chamber advocates
that medical university education shall be
more practice-oriented to allow students to
directly enter specialist training at the end
of the medical curriculum.
At the same time it favours the intensifi-
cation of the training in general medical
practice in depth and in length, including
one compulsory year of training in a teach-
ing practice. Such a system would advance
intensive vocational training and prevent
doctors in training from being reduced to
sustaining and upholding the system. A re-
structuring of the present system shall also
avoid that young doctors leave the coun-
try, undergo training in another European
country, and never come back.
Several improvements like the radical im-
provement of training conditions are im-
perative in order to keep young doctors
from migrating abroad. Also, the working
conditions in hospitals and practices have
to be rendered more attractive. Despite of
several successes, hospital doctors in Aus-
tria work too much and too long.Therefore,
the working conditions have to be rendered
more quality-, patient- and doctor-centred.
This includes the creation of new working
time models which allow for compatibility
of professional activity and family life. Run-
ning a practice means facing excessive bu-
reaucratic overload while offering not a lot
of perspectives from an economical point of
view. These facts will contribute to creating
a serious shortage of doctors in the future,
as the readiness to work under these condi-
tions will decline.
In the near future one major issue will
also be the trend towards electronification.
E-medication and the introduction of an
electronic health record are imminent, how-
ever, not always well-received. Concerns
regarding data protection and data secu-
rity are increasing just as financing and cost
considerations. However, it shall be noted
that international companies are highly in-
terested in the introduction of such systems,
and economic considerations are given pri-
ority. Creating the possibility for patients to
opt out both generally and partially from an
electronic health record system in order to
prevent for instance mental illnesses from
being recorded, finally reduces the idea of
doctors having a consistent overview of
their patients’medical situation to the point
of absurdity.
Dr. Walter Dorner,
President,
Austrian Medical Chamber
Walter Dorner
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Regional and NMA news UZBEKISTAN
Improvement of the quality of medical
services is very important worldwide, in-
cluding Uzbekistan. The government and
Ministry of Health take various measures
directed at the improvement of the quality
of medical services. It is not a secret that
the improvement of the quality of medical
aid is a difficult problem which demands
carrying out of complex measures, such as
improvement of material conditions, in-
crease of medical personnel’s knowledge,
improvement of working conditions and
introduction of the modern methods of
payment and motivation of medical work-
ers’ work.
The European forum of medical associa-
tions and the World Health Organization
have made an address on December 29th,
1993 with a statement on the development
of the quality of medical aid that will allow
each patient to receive quality help. With
that end in view, national medical associa-
tions should develop perspective indicators
for the estimation of quality, independent
external estimation of the quality of medi-
cal services (accreditation), and increase the
knowledge of physicians by means of semi-
nars and training.
The Medical Association of Uzbekistan,
being one of the large non-governmental
non-commercial organizations, has author-
ity in wide circles of the medical society and
actively works at introducing the modern
methods of medical aid regulation, directed
at the improvement of the quality of the
medical aid rendered by medical institu-
tions to the population of the Republic of
Uzbekistan.
The first initiative: increase of physicians’
knowledge by introducing remote training
in the post-degree period on the basis of in-
ternational experience.
In the USA and some European countries,
physicians, for employment in clinical
practice, should obtain a license (primary
and repeated). An indispensable licensing
condition is the improvement passage. For
example, in the USA, each physician with-
in three years should pass the 150-hour
curriculum of improvement. A widespread
mode of physicians’ study is using cur-
riculums published in medical journals, for
example, in the Journal of the American
Academy of Dermatology. In Uzbekistan,
each physician within five years should pass
improvement in the course of 288 hours.
Improvement includes internal and corre-
spondence training. There is the Tashkent
Institute of Postgraduate Education of
Physicians to which the functions of car-
rying out internal post-degree training are
assigned. The Medical Association of Uz-
bekistan, together with the leading experts
of the Tashkent Institute of Postgraduate
Education of Physicians, prepares curricu-
lums (seven have already been published in
the Bulletin of the Medical Association of
Uzbekistan). Having answered tests, phy-
sicians at an affirmative reply and a set of
certain percent receive the certificate by
way of remote training with instruction of
18 hours. Since 2010, more than 200 phy-
sicians have received certificates by way of
remote training.
The second initiative: introduction of
the accreditation of medical institutions.
We have adjusted relations with one of
the most influential organizations dealing
with the introduction of medical institu-
tion accreditation, namely the Joint Com-
mission International (JCI), which is part
of the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO)
of the USA. JCI has been working on the
accreditation of medical institutions in
more than 70 countries. It renders consult-
ing services in more than 90 countries of
the world and cooperates with the World
Health Organization, ministries of health
of various countries, and also with medical
associations. The results of accreditation are
published and are accessible on the Internet
to all population.All rules and the standards
developed by the accreditation commission
are available on a site of the incorporated
commission and are accessible to all medical
clinics. According to rules, medical clinics
should pass accreditation each three years.
In Uzbekistan, the grant from the Ger-
man Agency for International Cooperation
(GIZ) for the «Development of the system
of public health services in Central Asia
with pilot actions in Kyrgyzstan, Tajikistan
and Uzbekistan» is realized. At this point,
negotiations for signing the Memorandum
of Understanding between JCI and the
Medical Association of Uzbekistan are be-
ing conducted.
The third initiative: diagnosis-related
group (DRG) system introduction for the
perfection of the mechanism for financing
Realization of the Perspective Initiatives for
Improving the Quality of Medical Services in
Uzbekistan
Zokhid Abdurakhimov
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Medical Education
medical aid in hospitals. Used methods of
financing through the global budget and by
a design procedure on duration of stay on
a cot, and also by quantity of rendered ser-
vices do not promote an intensification of
medical workers’ work, improvement of the
quality of treatment and reduction of the
hospitalization terms for patients. Design
procedure use on duration of stay on a cot,
and also by quantity of rendered services in
Uzbekistan has revealed that even in one
clinic the cost of treatment of the patient
with the same diagnosis differs ≥1,5-fold.
At the same time, the cost of the medical
services with the same name, for example,
an electrocardiography, in medical institu-
tions located in one territory (city of Tash-
kent) differs ≥2-fold. It all has demanded
studying of this problem, and also of the
international experience in this area. We
study the methods of payment for medical
services worldwide.
The Association suggests introduction of
the system of patient classification devel-
oped by R. Fetter (USA), the so-called di-
agnosis-related group system. This system
has been introduced in the USA, Canada,
Japan, Great Britain, and also in more than
20 other European countries (Germany,
France, etc.) and is an important mecha-
nism for estimating and stimulating the
activity of medical institutions and a uni-
form method for calculating the treatment
cost for each patient who has left a hos-
pital.
Introduction of this method will allow of
passing from the physician payment on
a uniform scale to the contract system of
payment allowing of stimulating the im-
provement of the quality and intensity of
physicians’ work. We understand that it is a
difficult and long process.
We know that the European countries have
gained a wide experience in the realization
of these initiatives and the Medical As-
sociations of Uzbekistan is searching for
partners that could impart experience and
would help to put these working outs into
practice.
Zokhid Abdurakhimov,
The Chief Executive,
Medical Association of Uzbekistan
EMSA is a students’ initiative under Bel-
gian law, volunteer-based organisation ad-
vocating and representing the voice of the
medical students of geographical Europe. It
was founded in 1991 to provide a common
network for these students, to share proj-
ects, culture and experience, and to repre-
sent their opinion in medical organisations
such as the EU body CPME – the Standing
Committee of European Doctors.
EMSA aims to form a network among Eu-
ropean medical students, facilitate Europe-
an integration, develop a sense of European
identity,and promote training,activities and
projects related to health in Europe for the
benefit of medical students and society.
Through a wide variety of projects, we aim
to raise the quality of medical education and
to empower students in the field of medical
science. Furthermore, we focus on medical
ethics and address the need to raise public
awareness of the social and cultural issues
that occur in the process of improving the
European healthcare system.
EMSA seeks to improve the health and
quality of care of the citizens of Europe by
acting as a conduit for increased interaction
and sharing of knowledge among European
medical students in the areas of medical
education ethics and science.
Finally, we are a platform of European in-
tegration and foster student exchange, free
flow of information, and the transfer of best
practices. While facing the oncoming chal-
lenges of the 21st
century, we recognise the
importance of standing together and ad-
dressing these challenges with a clear vision,
boldness and creative way of finding solu-
tions. After all, activation, innovation, and
determination of our mind are what truly
further positive change and constant im-
provement.
We collaborate with European medical or-
ganisations. This connection allows us to be
always updated on the ongoing topics and
the new topics to be followed. We have an
access to a platform of information, con-
tacts, and existing organisations.
We have many initiatives and projects. One
of EMSA’s initiatives is the European Med-
ical Students’ Council. The EMS Coun-
cil gives the medical students in Europe a
voice that is heard by the European health-
care stakeholders. The EMS Council works
Medical Student Impact on the Future of European Healthcare
Elif Keleş
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WMA news
towards the common goals of medical stu-
dents throughout the European Union and
geographical Europe. We have produced
several valuable policy papers in the past
years, some of which have been published
in international papers and accepted by our
partner organisations.
EMSA is interested in policy making to
support students in Europe to involve in
global health and health policy. We repre-
sent the medical students and the voices of
young people in Europe that stay unheard
regarding health policy and healthcare.
As a result of our European collaboration
with medical students, we are aware that
medical students themselves want to be
more involved in health policy as future
physicians. EMSA and the EMS Council
endeavour to make policy by informing,
raising awareness, and, most importantly,
encouraging students to engage in the fu-
ture of healthcare in Europe.
The latest paper, which was adopted by the
7th
EMS Council, is the Vienna Resolution,
a policy statement about the future of Euro-
pean healthcare. In this paper, we deal with
the development of high common health-
care standards in Europe, the shortage of
healthcare professionals, especially in rural
areas, and the intra-European mobility of
healthcare professionals.
Elif Keleş
European Medical Organizations
Liasion Officer,
European Medical
Students’ Association(EMSA)
E-mail: Elifkeles.dr@gmail.com;
emo-lo@emsa-europe.eu
Preamble
The European Medical Students’ Council 2010 in Vienna:
• Intending to contribute to a better European Healthcare,
• Wishing to participate as a stakeholder in the discussion about
the future of European health and healthcare,
• Strongly supporting the common values as defined by the Euro-
pean Ministers of Health [1] (universality, access to good quality
care, equity and solidarity) and adding integrity, transparency and
confidentiality,
• Emphasising the importance of healthcare workers within the
European society,
• Acknowledging current public priority to increase internation-
al collaboration and sharing of knowledge on improvement of
healthcare [2]
• Observing the increasing complexity of healthcare and the chang-
ing roles of healthcare professionals,
• Taking into account the changing European demographics, the
increasingly mobile workforce, the changing demands of society,
technological development and the increasing costs of health-
care [3],
• Taking into account workforce migration which affects the acces-
sibility of healthcare in rural areas,
• Building upon current European statements with regards to
healthcare as well as related policy papers [4] and scientific lit-
erature,
• Appreciating the efforts of all stakeholders in this field, from pol-
icy makers, through healthcare workers to patients,
• Expressing our belief that leadership skills are essential when
dealing with patients as well as other stakeholders,
• Affirming the importance of the continuous development of
Lifelong Learning strategies [5],
• Convinced that organizations providing healthcare must evolve
into learning organizations1
in order to increase the quality of
care,
• Keeping in mind that all our endeavours should be patient-cen-
tred, while taking into account their impact on society2
,
• Contributing to a vision of the future of European healthcare, the
European Medical Students’ Council,
• Calls for attention to the topics of access to healthcare and mobil-
ity of students and healthcare workers.
Standards of healthcare
Recommends development of high standards of healthcare with
special attention to the following:
• Increasing the importance of preventive medicine,
1 Learning Organization: an organization which has developed an infrastruc-
ture to utilize every educational opportunity for improvement of patient care,
as well as for the benefit of all individuals working within the organization, to
continuously adapt to and respond to a changing environment.
2 Impact on society: the public health and financial meanings of medical in-
terventions.
Vienna Resolution of the Future of European Healthcare
7th
European Medical Students’ Council in Vienna, Austria, 22nd
to 25th
April 2010
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• Ensuring that sufficient time is devoted to meet all the patients’
health3
needs,
• Implementing measures to improve inter- and multidisciplinary
cooperation,
• Encouraging development of leadership skills of all healthcare
professionals involved in shaping the future of healthcare,
• Promoting conflict resolution and teamwork skills to become an
integral part of the medical profession,
• Demanding communication trainings in the medical curriculum
with the aim to improve the doctor-patient relationship as well as
healthcare team dynamics.
Annotations
Permanent access to high quality healthcare has become an integral
part of European societies.Thanks to advances in modern medicine,
most illnesses can be cured or treated, or at least life is extended
significantly; we feel however, that due to the technological nature
of these improvements, certain basic aspects of the care that is pro-
vided should receive more attention than is given to it now.
Preventive medicine should take a more prominent role in health-
care, both in education and in medical practice. We would like to
remind policy makers that prevention is much more cost-efficient
than treating an illness,and therefore significant attention should be
given to it. At an early stage medical professionals should encounter
healthcare in practice, both in a clinical and a political and organi-
zational manner by ways of introducing these topics in educational
programmes.
We advise to implement communication trainings in the medical
curriculum. Work overload, lack of personnel and limited resources
lead to decreasing patient-doctor-interaction.This leads to decreas-
ing quality of healthcare as doctors lack the time to recognize the
patients’ needs and initiate adequate treatment. Training in ad-
equate communication skills of medical professionals should facili-
tate higher quality of patient-doctor-interaction.
Meeting all the patients’ needs includes tackling all their somatic,
psychological and social problems without neglecting any of these.
Doctors tend to regard their patients problem only from the doctors’
perspective. To ensure a high quality treatment, multidisciplinary
teams are the preferred working structure to view and judge all pos-
3 Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity. [Preamble to the Constitution of
the World Health Organization as adopted by the International Health Con-
ference, Ney York, 19.22 June, 1946, signed on 22 July 1946 by the representa-
tives of 61 States (Official Records of the World Health Organisation, no. 2,
p. 100) and enters into force on 7 April 1948.]
sible views of a case. Teamwork and leadership skills are therefore
essential for every doctor to ensure.
The best possible outcome for the patient. Integrating trainings in
communication and conflict solving into the curriculum as well as
the life long learning process enables future doctors to work as ef-
ficiently as possible in this integral part of the medical profession.
Access to healthcare
Expresses its concern about the shortage of healthcare professionals,
especially in rural areas [6].
Calls for structural support to healthcare professionals in this context.
Proposes a common European fund to implement the following
structural and financial support measures:
• Facilities and adapted rewards4
for healthcare workers in under-
served areas,
• Systems supporting access to academic networks and programmes
for doctors,
• Flexible working conditions in underserved areas5
,
• Distance-learning opportunities,
• Implementation of e-health, telemedicine and e-consultations,
Affirms the Heidelberg Resolution on Information to patients [7],
Calls for appropriate use of new technologies,emphasizing that sig-
nificant attention must be paid to privacy concerns, distribution and
regulations,
Recommends the establishment of a freely accessible online database
listing all health care providers in order to provide information about
available resources, treatment and diagnostics as well as waiting lists,
Strongly suggests that adequate measures are taken to ensure that
people in need of care may remain living in their own homes with
sufficient support, whenever feasible in terms of patient safety and
available resources,
Urges the following actions with regard to demographic develop-
ments:
• Integration of geriatrics and palliative care [8] into the medical
curriculum,
4 Additional benefits such as housing or transportation.
5 E.g. shortened working times, only for a limited amount of time, travelling
between areas, having shared working times (e.g. two days in a popular, three
days in an underserved area).
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• Offering clerkship opportunities in geriatric and palliative care
related fields6
,
• Provide incentives to ensure medical coverage in retirement
homes.
Draws attention to the specific needs of vulnerable minority groups
by means of:
• Approaching all patients with equality regardless of their back-
ground [9] ensuring social inclusion,
• Effective communication with the patients regardless of their
background [10],
• Providing required assistance, such as the removal of administra-
tive obstacles to healthcare access,
• Guidelines securing access to healthcare for unregistered mi-
grants and asylums,
Annotations
Many countries all over the world and also in Europe have actual
and projected shortages of physicians. Smaller EU countries are es-
pecially vulnerable to sudden changes in migratory patterns. Espe-
cially in rural areas measures need to be taken to ensure continuous
availability of necessary health care resources. Further loss of physi-
cians mainly through migration is very likely to result in reduced
availability of health services [11].
Thus, a transnational approach is needed to the emerging problems.
Following examples from the farming industry, we propose a com-
mon European fund to lower imbalanced access to healthcare in
rural and city areas by giving incentives to health care professionals
to serve in rural areas.
Even though the personal contact to a health care professional is
an integral part of treating a patient we see the potential in the
use of new technologies in the means of e-health, telemedicine or
e-consultations to maintain the constant availability of health care
in underserved areas. Privacy concerns as well as distribution and
regulations need to be taken into consideration, before such a sys-
tem can be implemented.
Using new technologies communication skills will be an even more
important part of patient-doctor interaction and we continuously
support the results of the 4th
EMS council concerning Information
to patients.
Citizens are living longer and in better health. Life expectancy has
increased consistently since the 1950s by around 2.5 years per de-
6 e.g. social medicine, geriatrics or palliative care.
cade and is expected to continue to increase. Nevertheless, as people
live longer, it is expected that there will be increasing numbers of
older people with a severe disability and in need of long-term care.
A growing number of geriatric patients will be in need of treatment
in the future and a prolonged lifespan will lead to rising numbers
of patients receiving palliative care. We therefore demand a better
training in the aforementioned fields and the necessary support to
enable people to stay as long as possible in their familiar environ-
ment at home.
For migrants, barriers to accessing healthcare represent a complex
picture. It has long been recognised that newly arriving migrants
may face special health risks and frequently do not receive the
care they need. The barriers to accessing healthcare include: lack
of knowledge about available services; language differences, varying
cultural attitudes to health and healthcare and administrative and
bureaucratic factors.
Mobility
Demands a free choice of and equal conditions for acceptance into
medical programs and postgraduate medical education throughout
Europe,
Strongly opposes any form of discrimination regarding medical
education7
,
Aims for the implementation of the European Core Curriculum [12],
Calls for high European-wide standards in regard to basic and post-
graduate medical education as well as continuous professional de-
velopment,
Reaffirms the statements on the Bologna Process created by inter-
national medical student organisations [13],
Demands all countries of Europe to provide sufficient high quality
medical school placements to meet their country’s need for doctors
[14],
Demands the freedom of movement for doctors, provided the nec-
essary language proficiency8
,
7 Referring for example to different tuition fees or selection criteria based on
country of origin, ethnicity, religion, gender, sexual orientation or social back-
ground.
8 Proficiency in this context referring to language abilities sufficient to take a
proper clinical history and communicate the diagnosis and treatment within
the framework of the appropriate socio-cultural context.
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Stresses the importance of comparable high standards of working
and living conditions as well as equal opportunities for academic
and professional development across Europe.
Annotations
The freedom of movement for workers is one of the major principles
of the European Community. Applying this principle to students
and healthcare professionals all throughout Europe is an integral
part of our vision for the future of European healthcare. We ac-
knowledge that treating every European applicant equally might
be challenging especially for small countries facing an overwhelm-
ing number of foreign candidates outnumbering local high school
graduates. We envision though that in the near future the notion
of being European will be more important than the national back-
ground and therefore strongly oppose any form of discrimination
based on the country of origin.
Migration often moves in certain directions, partly due to some
countries not educating enough doctors to meet their own needs
but instead attracting medical school graduates from poorer coun-
tries. To prevent shortages in underserved areas we therefore ask
all countries to provide enough medical school places to meet their
own country’s needs. Areas facing a shortage of doctors despite the
measures taken may benefit from the European fund mentioned
above to ensure medical coverage.
To ensure that the same high standards are met by all medical
school graduates, common goals like the European Core Curricu-
lum or guidelines such as the WFME Global Standard for Qual-
ity Improvement in Medical Education need to be implemented
throughout Europe.
Making health policy is very essential itself and much more effort
should be put by us, the future healthcare professionals. Therefore,
we will be able to encourage ourselves with enthusiasm, to get more
progress as a European Policy making platform for medical students
and to be heard by European Stakeholders.
Let us join our forces in 2012 to reach high common standards
and qualified healthcare in the whole Europe to meet the needs of
European Citizens.
References
1. Council Conclusions on Common values and principles in European Union
Health Systems (2006/C 146/ 01)
2. Together for Health: A Strategic Approach for the EU 2008-2013,WHITE
PAPER – COM(2007) 630 Final
3. Green Paper on the European Workforce for Health 2008/725/EC final
4. Together for Health: A Strategic Approach for the EU 2008-2013,WHITE
PAPER – COM(2007) 630 Final
5. Recommandation of the European Parliament and of the Council on key
competences for lifelong learning (2006/962/EC)
6. The global and European shortage of physicians: Proposals for European
strategy – La pénurie mondiale et européenne de medicines : propositions
pour une stratégie européenne (CPME 2008/097 FINAL EN/FR)
7. EMSA (2007), HeidelbergResolution on Information to Patients. Heidel-
berg (Germany)
8. 5th
EMS Council resolutions, Athens
9. IFMSA/EMSA (2006),European Core Curriculum – the Students’Perspec-
tive. Bristol (UK)
10. IFMSA/EMSA (2006),European Core Curriculum – the Students’Perspec-
tive. Bristol (UK)
11. The global and European shortage of physicians: Proposals for European
strategy – La pénurie mondiale et européenne de medicines : propositions
pour une stratégie européenne (CPME 2008/097 FINAL EN/FR)
12. IFMSA/EMSA (2006),European Core Curriculum – the Students’Perspec-
tive. Bristol (UK)
13. IFMSA / EMSA (2004), The Bologna Declaration and Medical Education.
Megève (France)
14. WFME Global Standard for Quality Improvement in Medical Education,
European Specifications
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iv
Contents
The República Oriental del Uruguay is located in the Southern Cone of South America.  Borders to the north and northeast, Brazil. To the
west, Argentina and to the south and southeast the Rio de la Plata and the Atlantic Ocean.  Uruguay has an area of 176.215 km2
(square
kilometres) and a population of 3.300.000 inhabitants with a high literacy level that reaches near 97% of the population.  The climate is
temperate and generally stable.  Its main production is based on agriculture and livestock and is surrounded by large farm neighbours such
as Brazil, Argentina, Paraguay and Chile.  Uruguay is a cosmopolitan society as a result of several successive European migrations.  It is
an open society with a democratic government elected by free elections every five years and promotes tolerance of all religions or political
ideologies and non-discrimination.
Wednesday, 12 October 2011 Preliminary Meeting of the Council Session
Medical Ethics Committee
Finance and Planning Committee
Socio-Medical Affairs Committee
Credentials Committee
Thursday, 13 October 2011 Scientific Session “Tobacco Cessation”
Friday, 14 October 2011 Council  Plenary Session
Assembly Ceremonial Session
Saturday, 15 October 2011 Council  Plenary Session
www.congresos-rohr.com/wma2011/webs/eng/contact.html
WMA General Assembly – Montevideo 2011
189th
& 190th
WMA Council Sessions
12–15 October 2011, Hotel Radisson
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
World Health Organization Urged to Act over
Assaults on Health Personnel and Facialities . . . . . . 122
Health Professionals Unite
in WHPA Taipei Call to Action . . . . . . . . . . . . . . . 123
Task Shifting in the Netherlands . . . . . . . . . . . . . . . 126
Japan Medical Association Teams’ (JMATs)
First Operation: Responding to the Great Eastern
Japan Earthquake . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Fukushima Nuclear Power Plant Accidents Caused
by Gigantic Earthquake and Tsunami–Healthcare
Support for Radiation Exposure . . . . . . . . . . . . . . . . 141
The Japanese Earthquake and the Role of Medical
Society . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Protecting Our Nation’s Health . . . . . . . . . . . . . . . . 146
Strengthening and Promotion of Working Population
as the Base of Socioeconomic and Demographic
Policies in the Russian Federation . . . . . . . . . . . . . . 147
Austrian Health Care System Faces Considerable
Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Realization of the Perspective Initiatives for
Improving the Quality of Medical Services
in Uzbekistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Medical Student Impact on the Future
of European Healthcare . . . . . . . . . . . . . . . . . . . . . . 157
Vienna Resolution of the Future of European
Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
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