wmj_1_2021_WEB

vol. 67
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 1, April 2021
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Israel’s Coronavirus Vaccine Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Socio-Medical Affairs Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
WMA Wins Prestigious Award. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Otmar Kloiber Acceptance Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
David Barbe Acceptance Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
WMA Declaration of Taipei on Ethical Considerations regarding Health Databases
and Biobanks (DoT). Possible impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Psychosomatic Medicine in China: the Current Development and Role in Future
Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Threats to Professional Autonomy Continue in Turkey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Physicians and Ethical Issues Related to Covid-19 Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Myanmar Doctors Solidarity against Military Coup d’état . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Substance Use Disorders and Addiction in Physicians:
a Dutch Physician Health Programme. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Tackling Regional Epidemics through One Health Social Policy and the UN‑2030
Sustainable Development Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Editor in Chief
Dr. Pēteris Apinis, Latvian Medical Association, Skolas iela 3, Riga, Latvia
editorin-chief@wma.net
Co-Editor
Prof. Dr. med. Elmar Doppelfeld, Deutscher Ärzte-Verlag, Dieselstr. 2, D-50859 Köln, Germany
Assistant Editor
Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 0049-8122
Dr. David BARBE
WMA President
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300 60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
PO Box 8829 Wuse
Abuja
Nigeria
Dr. Heidi STENSMYREN
WMA President-Elect
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Kenji MATSUBARA
WMA Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Dr. Miguel Roberto JORGE
WMA Immediate Past-President
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Jung Yul PARK
WMA Chairperson of the Finance
and Planning Committee
Korean Medical Association
Samgu B/D 7F 8F 40 Cheongpa-ro,
Yongsan-gu
04373 Seoul
Korea, Rep.
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
1
Editorial
Editorial
It is already a whole year since the world has been talking only about
Covid–19, about 6 feet distancing, masks, vaccination, oxygen-
breathing, treatment with monoclonal antibodies, cytokine storms
and death.
Therefore, this time the Editorial is about the flu  – a dangerous
infectious disease that now seems to have disappeared, but will cer-
tainly come back. Thanks to the flu virus and vaccination against it,
in an incredibly short time the world managed to develop a modern
vaccine against Covid–19. Let us remember – how difficult it was
with flu vaccination and how the WMA called on all doctors’organ-
isations in the world to be more actively involved in it.
Seasonal flu is an acute, highly contagious influenza virus-induced
respiratory disease that spreads through aerosols and manifests itself
with temperature and various symptoms ranging from mild fatigue
to respiratory failure and even death. Influenza is associated with a
significant number of working days lost, human suffering and in-
creased mortality.
According to WHO figures, a quarter-million or even half a million
people worldwide die of influenza and related complications each
year, but at least 5 million people are severely affected. In tropical
regions, the flu season lasts throughout the year. In the Northern
Hemisphere, the flu season typically starts in autumn, reaching the
peak in mid-February, but ending in late spring.The duration of the
influenza epidemic and the severity of the disease are determined by
the sub-type of the virus involved.
Physicians are usually worried about influenza virus types A and B.
Influenza A viruses are able to induce epidemics and pandemics. For
type A viruses, the host may be not only humans, but also a variety
of animals (pigs,horses,dolphins,whales) and birds (including poul-
try: chickens, ducks, turkeys, etc.). Type A is very variable. Type B
may cause short epidemic with clinically lighter forms.Influenza B is
mostly found in humans, but the virus variability is less pronounced.
The influenza virus belongs to compound viruses, but its genome
consists of 8 (-) fragments of single-seduced RNA (type A).
Currently there is no flu. Millions of flu tests have been conducted
in the world since autumn, but only a half percent is positive. This
winter is and apparently also spring will be the quietest and calmer
flu season since we know the flu and monitor it, i.e. since the end of
the 19th
century.
Fewer flu cases mean fewer deaths, fewer hospital beds occupied,
and that is good news for every country and the world in the grip of
SARS-CoV-2 virus.
However, the nullity of influenza is a concern for us. Without flu
cases, scientists have no relevant data to develop vaccines and fore-
cast the next outbreak.
Flu viruses are not extinct. Influenza viruses are still present in
chickens and pigs as well as in wild animals and birds.The larg-
est source of influenza virus for future influenza epidemics and
pandemics is birds. And these are not to be wild forest or water
birds. Wild birds mostly stay 6 feet apart; very rarely they are
indoors (in a bird cage?) together for more than 15 minutes. On
the other hand, chickens, turkeys and ducks in poultry farms,
confined there by humans, are densely packed in a closed space
with relatively poor ventilation. In the largest poultry farms,
tens of millions of birds live together and there are virtually
unlimited possibilities for the mutation and spread of the in-
fluenza virus.
Influenza viruses are hiding from people now, and no one knows
when and how they will come out into the open again.
It is interesting that not only influenza viruses have disappeared,
but other respiratory viruses keep silent as well – the respiratory
syncytial virus, the parainfluenza virus, even other coronaviruses,
usually causing fever, coughing and snuffling in autumn and win-
ter. The only virus which thrives, spreads, replicates, creates new
mutations is the new coronavirus SARS-CoV-2.
The public area is dominated by the view that radical behavioural
changes occurring worldwide due to the Coronavirus pandemic
play an important role in reducing the spread of the influenza vi-
rus. People wearing masks, committed to distancing and different
levels of lockdowns are the factors that have helped to reduce the
coronavirus, and possibly reduced the incidences of other respira-
tory viruses.
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2
Editorial
But it is not so simple. Last summer (June-August), the zero spread
of influenza was surprising, particularly in the Southern Hemi-
sphere, in the countries and cities of South America, Africa and
Australia, where there were cases of influenza, but in extremely low
numbers.
Man considers himself the summit of creation. Viruses see them-
selves the same way. There are more viruses on the globe, both by
their number,species,weight and the impact they have on the earth’s
oxygen cycle, climate, soil, plants, animals and humans. The virus is
a life’s indicator. Wherever there is life, there can be found viruses –
they are everywhere in the ocean, sea, soil, plants, animals, bacteria.
Viruses existed on the globe at least 4 billion years before humans
appeared, and viruses will also be here after human extinction
people may cause themselves with chemicals, weapons and oxygen
depletion, making the world uninhabitable for chordata (including
mammals, including humans).
It will not be possible for man to eradicate viruses from the world.
We are not so sure of the opposite – whether viruses can destroy
people. In any case, neither SARS-CoV-2 nor the influenza virus
will destroy humanity. But viruses occasionally cause and will cause
some kind of pandemic that will thin out the number of people
on the globe. Probably, viruses deliberately control the number of
population on the planet.
The virus is not the smallest creature on earth. Perhaps viruses see
prions as tiny creatures, just as we see viruses. The virus itself lives
only in an alien cell as a mandatory parasite, but outside the cell it
simply exists.
The virus must be considered as a compulsory parasite: the virus is
considered to be a parasite, but the virus treats the human cell as a
home, a maternity hospital, a canteen, and possibly a parliament,
because the viruses swamp in the cell in hordes. Similarly, people
regard the earth as their own home, and very likely the earth sees
humans as parasites.Just as man pollutes the planet with all possible
chemicals,explodes nuclear bombs or digs gravel pits (damaging the
earth’s skin),namely,destroys his only planet,his own home,so from
time to time the virus destroys its home – the human cell.
Theoretically, the purpose of the virus should not be killing the cell
together with the man because there will be no place to live in. But
sometimes the virus destroys its home, just as people cut forests de-
priving themselves of oxygen for breathing in the future.
Viruses treat a man as a home, but they don’t seem to perceive it as a
hotel or a dorm. To some extent, the dominant virus stimulates the
immune system so that the latter becomes more aggressive to other
viruses and prevents them from settling in “one room.”Always in late
autumn, with the outbreak of influenza epidemic, infections from
other respiratory viruses significantly drop in the list of diseases.
In the long run, however, such a balance of power is not always
maintained. Viruses settling into a human can ultimately learn to
cooperate with one another, perhaps, become affectionate room-
mates and even affecting each other cause simultaneous infection
of the individual.
The next outbreak of influenza is inevitable. What is interesting –
the assumption that the flu will surge in countries that will better
carry out vaccination against Covid–19. If the coronavirus can be
contained, other viruses will be able to return to the human airway
epithelium, and first of all – the influenza virus.
In each flu season, influenza affects mainly people who have no im-
munological memory of the influenza virus. People, who have not
been sick with influenza for a long time or not at all (e.g. small chil-
dren,) are hit harder by this influenza virus – they are affected more
severely,the virus spreads more fiercely.Seen from this point of view,
in one or two years’ time until the world has reduced coronavirus
with vaccines, there will be a number of people who had influenza
long ago and their immunity will have relatively lost its memory –
and the flu virus will have the chance to reign.
The next flu is likely to be less familiar with our immune system
leading to a more severe clinical passage.The flu of the century that
changed every year was more easily predictable thanks to a well-
working network of flu surveillance centres around the world. No
one can predict exactly when the flu will return.
However, the coronavirus SARS-CoV-2 has provided new oppor-
tunities for the fight against influenza, mainly concerning vaccine
technologies. mRNS vaccines can be made significantly faster, even
within a few weeks.Parts of viruses in such vaccines can easily be re-
placed. I really believe that mRNS vaccines will be edible or sprayed
in the nose already this year.
In a year or two, we will have universal vaccines that do not have to
be inoculated every year and for every new influenza virus. We do
not think that one flu vaccine will last for a lifetime, but still at least
for several years. In any case, four universal influenza vaccines are in
Phase 3 trial, and that is at least very promising.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal;
Mag. healths. sc. Maira Sudraba,
Editor of the World Medical Journal
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3
Covid-19 and Vaccination
Abstract
In December 2020, Israel began vaccinat-
ing its population against the coronavirus.
Currently, Israel has the highest rate of vac-
cination in the world,thanks to a number of
salient features, primarily related to the size
of the country, its governmental structure,
and its healthcare system. Along with the
increase in the rate of people vaccinated, the
health authorities in Israel are conducting
studies that have so far indicated the effec-
tiveness of the Pfizer-BioNTech vaccine,
the main vaccine used in the country.
The vaccination campaign to combat
this disease has rekindled the debate over
the imposition of mandatory vaccina-
tion against infectious diseases among the
general population and especially among
medical staffs. The Israeli government is
currently pursuing a policy that links the
abolition of coronavirus-related restrictions
and providing relief to the public with vac-
cination against the disease.The progress of
the vaccination program, therefore, is help-
ing to open up the economy. Immunization
is being made a condition for returning to
a normal life in order to encourage Israelis
who have not yet been vaccinated to do so
soon.
Background
The coronavirus pandemic originated with
the novel coronavirus (Sars-CoV-19) out-
break in Wuhan city of China in December
2019. From there it spread rapidly around
the world, with the first verified case of
coronavirus in Israel detected in February
2020 [1].With the increase in morbidity,and
around the time that the World Health Or-
ganization declared the coronavirus a global
pandemic in March 2020, Israel, like other
countries around the world, began to take
various measures to prevent the spread of the
disease. Restrictions imposed on the public
in the fight against the pandemic included:
restricting gatherings, reducing public trans-
portation, partially closing the economy and
the educational system,and,later,imposing a
mandate to wear masks covering the mouth
and nose whenever outside the home [2].
Between March and October, 2020, Is-
rael underwent two severe closures, during
which restrictions were tightened and it was
even forbidden to travel more than a speci-
fied distance from one’s place of residence.
In the summer of 2020, the Israel Minis-
try of Health announced that morbidity in
Israel was among the highest in the world,
with dozens of patients dying every day [3].
By the end of 2020, Israel had not been able
to control the pandemic to an extent that
would allow for the removal of restrictions
and a return to normal life while coping
with the coronavirus disease. Like other
countries, it had to declare a third closure
in December. During this period, there was
a significant jump in morbidity, from 3,500
verified cases daily at the end of December
to over 8,000 verified daily at the beginning
of January 2021. The number of hospital-
ized patients quadrupled, with 20% of them
on respirators [4]. Gradual relief began dur-
ing February 2021, with the launch and ex-
ecution of the vaccination campaign, which
will be described in this article.
The coronavirus pandemic has claimed
many lives worldwide, and continues to do
so. In addition, there is a growing body of
evidence of severe and long-term systemic
damage caused by the virus. Moreover, the
disease increases the existing burden on
healthcare systems, and therefore impairs
the quality of service and medical care in
general, including for those who are not ill
from the coronavirus. While closures and
restrictions may reduce the extent of infec-
tion, at least in the short term, their con-
sequences can be devastating ­
economically,
socially, medically, and psychologically.
Leonid Eidelman Malke Borow Baruch Levi Tali Rayn-Aloni
Israel’s Coronavirus Vaccine Program
ISRAEL
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4
Covid-19 and Vaccination
Against this background, and under the
assumption that eventually and inevitably
countries around the world would need to
return to and maintain some routine of life
in the shadow of the coronavirus, intensive
global efforts began in 2020 to find a medi-
cal solution that would change the rules
of dealing with the coronavirus. The race
to develop a vaccine for this disease was
the primary manifestation of these efforts,
and research institutes and pharmaceutical
companies took on this task.
On December 11, 2020, the U.S. Food and
Drug Administration (FDA) granted the first
emergency permit to Pfizer and its partner
BioNTech for a vaccine they had developed
against the coronavirus [5]. Shortly after-
wards, an emergency permit was also issued
for a vaccine developed by the Moderna
company [6]. A third emergency permit was
issued for a Johnson & Johnson vaccine in
February 2021 [7]. Additional vaccines have
been developed in Russia and China. About
60 other vaccines are currently in various
stages of clinical trials,according to the World
Health Organization, including a vaccine be-
ing developed by an Israeli company [8].
The Vaccination
Program in Israel
Authorization for the Pfizer and Moderna
vaccines was a critical milestone in the race
to curb the virus. The Israeli government
announced in early December that it had
entered into agreements with both Pfizer
and Moderna to ensure an adequate supply
of vaccines for Israeli residents. After the
imposition of the third closure, Israel began
vaccinating its population, using mainly the
Pfizer vaccine (it is not clear to what extent
the Moderna vaccine was used, if at all).
Currently, Israel ranks first in the world in
its vaccination rate, with a rate of 11 vaccine
doses per 100 people.Behind Israel are Bah-
rain, with a rate of 3.5 doses per 100 people,
and the United Kingdom, with a rate of 1.4
doses of vaccine per 100 people. All other
countries have vaccinated at a rate of less
than one vaccine dose per 100 people [9].
Therefore, Israel’s immunization program is
considered a model for global success. Ac-
cording to published reports, as of the end
of February 2021, Israel had already vacci-
nated about half of its citizens with the first
vaccine dose and about 36% had received
two doses of the vaccine. At the same time,
it should be noted that there are significant
gaps in the immunization rates among vari-
ous population sectors. Immunization rates
among Arab-Israelis and ultra-Orthodox
Jews are lower than among the general pop-
ulation. Additionally, the rate of vaccination
is lower among younger people as opposed
to older ones [10].
The CEO of Pfizer called Israel and its ad-
vanced immunization program the “labora-
tory of the world”. This follows an agree-
ment under which Israel provides Pfizer
with statistical-medical data on vaccinated
people in Israel, in order to extensively as-
sess the effect of the vaccine on various pop-
ulations.The data are anonymous and with-
out any identifying personal details [11].
Israel has a number of advantages that en-
abled it to launch its vaccination campaign
relatively quickly and efficiently. First, Is-
rael is a small country, both in terms of its
geographic size and its population of about
9 million people. Further, Israel is charac-
terized by one central government, which
directly controls the entire territory of the
country. This is in contrast to decentralized
or federation states, which consist of mul-
tiple jurisdictions, among which significant
differences may exist in various aspects of
law, regulation and bureaucracy. Israel’s
unique features made it an easier starting
point for the transport, administration and
control of vaccines [12, 13, 14].
In Israel, there are four large health main-
tenance organizations (HMOs) that all op-
erate under one regulator – the Ministry of
Health – to insure all residents of the coun-
try.All the HMOs have organized electronic
medical records,which are managed in a way
that maintains the privacy and confidenti-
ality of the insured [13]. This offers a huge
advantage in terms of obtaining an appoint-
ment to be immunized and registering im-
munization rates, in comparison to countries
lacking Israel’s type of infrastructure, and
with healthcare systems that are distributed
among various insurers. During this period
of launching and carrying out the vaccina-
tion program, supplementary staff had to be
added to the infrastructure of the health-
care system in Israel, such as immediately
available nurses in all four HMOs in order
to provide vaccines to the general public si-
multaneously and immediately. The effective
cooperation of the HMOs with the govern-
ment authorities, along with the availability
of nurses in the community,are other signifi-
cant parameters in Israel’s success [9,12].
One of the most important logistical aspects
of the vaccination program is the storage and
supply infrastructure of vaccines. This is not
an issue that is usually at the heart of public
healthcare interests. Israel has a main supply
center and an efficient infrastructure, which
was able to supply vaccines for the benefit
of remote areas and enabled vaccinations to
be given simultaneously in numerous areas
and to diverse populations.The main supply
center in Israel is located near its main air-
port, and millions of packages can be stored
there in a freezer. When storage packets are
required to be moved to more remote areas,
the vaccines are repackaged into parcels of
the appropriate size,depending on the target
population and its size [12].
The immunization program began by secur-
ing the necessary doses of the vaccine, and
continued with the optimal allocation of
vaccines to the population. First, the popu-
lations in Israel who were most vulnerable
to the disease were vaccinated: residents in
nursing homes, people aged 60 and over,
people at high risk due to medical condi-
tions, and healthcare workers [12]. Subse-
quently, and in accordance with meeting
ISRAEL
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5
Covid-19 and Vaccination
targets, the general population was invited
to receive the vaccine, in decreasing age
cohorts. The responsibility for administer-
ing the vaccines to each of these groups
was clear and pre-defined, with Israel’s four
HMOs responsible for administering the
vaccine to those aged 60 and over, people at
high risk due to background medical con-
ditions, and the general population. Vacci-
nation of the elderly in nursing homes was
carried out by Magen David Adom (MDA),
and vaccination of healthcare teams was the
responsibility of the hospitals [12].
The Israeli vaccination program is structured
but flexible. While being orderly and orga-
nized according to the degree of risk of the
various populations, the authorities in Israel
are making an effort to vaccinate everyone
as quickly as possible. Thus, although the
effort was initially directed at the high-risk
members of the public, citizens of other age
groups who arrived at vaccination centers
with the aim of trying to receive the vac-
cine as early as possible were admitted and
vaccinated without any fines or sanctions.
The HMOs allowed all insured people who
wished to be vaccinated to arrive at the end
of each day to receive any unused vaccine
doses, so that no unused vaccine doses had
to be discarded. Currently, all the HMOs
allow immunization for any insured person
aged 16 and over [15].
Yet another significant parameter for the
success of the immunization program in Is-
rael can be attributed to the effectiveness of
the media campaigns encouraging immuni-
zation. These campaigns used a wide range
of strategies, such as recruiting influencers,
including Israeli Prime Minister Benjamin
Netanyahu, who, in front of the cameras,
was the first person vaccinated in the coun-
try, followed by other senior government
officials. Credible messages, tailored to ap-
peal to various segments of the population,
including Arabs and the ultra-Orthodox,
were delivered by people recruited from the
field of health and medicine. The vaccines
were already available when these messages
were broadcast to all sectors [12]. Although
some of these parameters are not unique to
Israel, their simultaneous existence, as part
of a national effort during an emergency,
combined to bring about the success of the
immunization program in Israel.
Concurrently, with advancement in the
number of people vaccinated, authorities
have begun conducting studies to test vac-
cine effectiveness. A major study published
in February 2021 confirmed the findings of
Pfizer’s clinical trial regarding the effective-
ness of the vaccine. It found that one week
after the second dose, the vaccine has an
efficacy of 94% in preventing symptoms of
the disease, 92% in preventing serious ill-
ness from the disease and 92% in preventing
infection [16]. Data published by the Israel
Ministry of Health reinforced these find-
ings, showing that the effectiveness of the
vaccine in preventing symptomatic disease,
hospitalization, morbidity and mortality
stands at 98%–99%. The vaccine has also
been found to be effective in reducing mor-
bidity (95.8%) [17]. Hence, the Israeli test
case not only confirms the effectiveness of
the vaccine in preventing the development
of symptomatic disease, but it also indicates
efficacy in reducing infection.
Moreover, the vaccine appears to change the
age composition of patients hospitalized with
coronavirus.Since the start of the vaccination
campaign, there has been a decrease in the
proportion of adults aged 60 and over who
are hospitalized, as this population group be-
gan to be vaccinated first. At the same time,
there was an increase in the rate of hospital-
ization of younger people, who began to be
vaccinated at a later stage, and among whom
the rate of vaccination is lower [18].
The Question of Mandatory
Vaccination against Coronavirus
The coronavirus vaccine program has re-
kindled a debate that has taken place in re-
cent years in Israel over the imposition of
mandatory immunizations. According to
the World Health Organization, in order
for a vaccine to be effective and produce
herd immunity, 60%–70% of a population
must be vaccinated [19]. Thus, the question
arises as to whether it is possible to enact a
legal obligation for people to be vaccinated
and impose sanctions against those who are
not vaccinated. Making vaccination manda-
tory raises a legal difficulty, due to its broad
violation of the basic rights of citizens who
do not wish to be vaccinated, such as “hu-
man dignity and liberty” and “the right to
autonomy.”
Currently,in the State of Israel,vaccinations
in general, and vaccines against coronavi-
rus in particular, are not legally mandated.
However, in cases where there is a risk of
a significant epidemic, the Public Health
Ordinance of 1940 grants the Ministry of
Health the authority to impose mandatory
vaccination, including financial fines and
even imprisonment for those who refuse
[20].
In addition, current legislation does not
prohibit employers from imposing restric-
tions, including unpaid leave and dismissal,
on employees who refuse to be vaccinated.
Nor is there any legal impediment to pro-
hibiting the entry of an unvaccinated per-
son into any place. For example, for several
years, initiatives of private kindergartens to
prohibit the entry of unvaccinated children
has been operating in some local authorities
throughout Israel [21].
Rulings by the Supreme Court of Israel
during the coronavirus crisis have recog-
nized the need to disproportionately in-
fringe on individual rights for the protec-
tion of public health and the fight against
the pandemic. The Supreme Court also
ruled, before the outbreak of this pandemic,
that the violation of rights that result from
refusal to be vaccinated is legal and legiti-
mate [22]. While the legislature has not
yet explicitly addressed the special state of
affairs that ­
exists today, it is recommended
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6
that it do so in order to establish a clear,
definitive arrangement. However, even in
the current situation, there is no legislation
that explicitly prohibits harm to the em-
ployment terms of workers who refuse to be
vaccinated. Thus, in the absence of a legal
norm that prohibits this – it is permissible.
Employers may encourage employees to be
vaccinated through various incentives and
hold informational talks on the subject.It is,
of course,advisable to try and find solutions,
such as allowing employees to work via re-
mote technologies, or requiring presenta-
tion of an up-to-date negative coronavirus
test at the entrance to the workplace.
The situation is even more complex regard-
ing mandatory vaccination for healthcare
workers, due to the risk of infection of pa-
tients and co-workers. Circulars published
by the Ministry of Health stipulate that
healthcare workers, who may be infected
with pathogens by their patients and who
may infect their patients, must be vacci-
nated against any serious diseases for which
there is a safe and effective vaccine, with a
special obligation to receive the vaccina-
tion against seasonal flu [23,24]. However,
the data show that the immunization rate
among physicians and nursing staff is quite
low (between 36%–45%) [25]. The position
of the Israel Medical Association (IMA) is
that the public in general, and the medical
public, in particular, should be encouraged
to be vaccinated against infectious diseases.
At the same time, the IMA rejects any at-
tempt to force or coerce physicians to get
vaccinated,including discrimination or put-
ting pressure on physicians in the workplace
[26].
To date, 10%–15% of the medical staff in
the HMOs and about 20% of the staff in
hospitals have still not been vaccinated
against coronavirus, with some even refus-
ing to do so [27]. In light of these data, the
management of Hadassah Medical Center
in Jerusalem, one of the largest hospitals in
Israel, recently decided that staff members
who have not been vaccinated, and who
have not received medical dispensation to
decline the vaccine, will not be permitted to
treat patients at the hospital [27].
A recent directive issued by the Director
General of the Ministry of Health to en-
courage healthcare workers to be vaccinated
against the coronavirus imposes restrictions
on the work that can be performed by non-
vaccinated staff, and prohibits the admis-
sion to medical institutions of new employ-
ees who refuse to be vaccinated [28]. This
directive demonstrates the tension that ex-
ists between individual rights and the public
and professional responsibilities that apply
to health care workers, and the dilemma
that coronavirus vaccines pose to employers,
managers, regulators and legislators.
The Green Pass and the
Green Passport
The Israeli government is currently pur-
suing a policy linking the abolition of re-
strictions to the public and businesses with
immunization against the coronavirus. This
is being done by issuing an entry permit or
“green pass”to buildings and certain venues,
granted to those who have been vaccinated
or have recovered from the coronavirus.
The green pass is valid only within Israel’s
borders, in accordance with the policy of
the Ministry of Health. Those with a green
pass will have access to services defined as
“green-pass required.” In order to enter a
place designated as green-pass required, the
green pass must be presented along with an
identity card. As an alternative to the green
pass, a vaccination certificate can be pre-
sented, which is issued to anyone who has
received both doses of the vaccine. People
who have recovered from coronavirus may
present a recovery certificate. However, the
Ministry of Health recommends using the
green pass as much as possible [29].
The only entity authorized to issue a green
pass is the Ministry of Health (not the
HMOs, workplaces, or businesses). Issu-
ance of a green pass is possible via a website
or an application dedicated to this purpose.
The list of businesses to which entry is con-
ditional on presentation of a green pass will
be updated from time to time,in accordance
with government decisions. Currently,
the list of these businesses includes gyms,
swimming pools, theaters, cinemas, cultural
halls, sports fields, conferences, event parks,
and the like. In addition, the government
allows the activities of businesses without
the need for a green pass within the frame-
work of the permit known as the “purple
pass.” Under certain restrictions, such as
maintaining distance between people and
setting maximum occupancy in the build-
ing, it will be possible to enter places such
as street shops, food markets, malls, houses
of worship, and more [30].
The Ministry of Health is currently exam-
ining the issuance of a “green passport” for
those who have received two doses of the
vaccine. This is, in essence, an international
travel permit, allowing air travel to coun-
tries that allow entry for tourists who have
received the two vaccine doses [31].
Summary
Israel’s coronavirus vaccination program is
currently underway. The rate of vaccination
in Israel is the highest in the world today.
Israel enjoys a number of significant advan-
tages that enable it to vaccinate its popu-
lation quickly and efficiently, including its
basic national characteristics (size, govern-
mental structure, etc.) and characteristics
of its healthcare system. As a result, Israel
is considered a global “test case” for assess-
ing the success of the vaccination program,
not only in terms of medical aspects, i.e.,
the vaccine’s safety and effectiveness in the
general population, but also in terms of lo-
gistical and organizational aspects, such as
storage, transportation, distribution of the
vaccine and public access to vaccination,
via cooperation between all parties in the
system, including the government, HMOs,
Covid-19 and Vaccination ISRAEL
BACK TO CONTENTS
7
medical institutions, and caregivers in the
public sector.
Equally important, the success of the pro-
gram depends on the willingness of the
public, including the medical community
and all medical staff, to get vaccinated. This
is dependent, among other things, on rais-
ing awareness of the importance of vaccines,
conveying messages in a credible and con-
vincing manner, and providing incentives
that encourage immunization.
References
1. Elkayam O,Stein A,Dor K.Director General of
the Ministry of Health: “Corona patient verified
first in Israel”. Kan [Internet]. 2020 February 27.
[cited 2021 March 8]. Available from: https://
www.kan.org.il/Item/?itemId=67303.[Hebrew].
2. Eichner E, Senior E. Who is allowed to go out?
How many passengers in the car? The Guide
to Emergency Regulations. Ynet. [Internet].
2020 March 20. [cited 2021 March  8]. Avail-
able from: https://www.ynet.co.il/articles/
0,7340,L-5698364,00.html. [Hebrew].
3. Efrat B. Gamzo: the state of morbidity – one of
the most difficult in the world; I will not change
my mind about Uman. Walla. [Internet]. 2020
August 25. [cited 2021 March 8]. Available
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[Hebrew].
4. Cohen M. 2.5 times more patients per day: the
lost time of the imaginary closure .Walla. [Inter-
net].2021 January 6.[cited 2021 March 8].Avail-
able from: https://news.walla.co.il/item/3409736.
[Hebrew].
5. FDA. Pfizer-BioNTech COVID-19 Vaccine.
2021 February 3. [cited 2021 March 8]. Avail-
able from: https://www.fda.gov/emergency-
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2019-covid-19/pfizer-biontech-covid-19-vaccine
6. FDA. Moderna COVID-19 Vaccine. 2021 Feb-
ruary 3. [cited 2021 March 8]. Available from:
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id-19/moderna-covid-19-vaccine
7. FDA. Janssen COVID-19 Vaccine. 2021 March
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www.fda.gov/emergency-preparedness-and-
response/coronavirus-disease-2019-covid-19/
janssen-covid-19-vaccine
8. WHO. COVID-19 vaccines. [cited 2021
March 8]. Available from: https://www.who.int/
emergencies/diseases/novel-coronavirus-2019/
covid-19-vaccines
9. Rosen B, Waitzberg R, Israeli, A. Israel’s rapid
rollout of vaccinations for COVID-19. Is-
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net]. 2021 January 26. [cited 2021 March 8].
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s13584-021-00440-6
10. Ministry of Health. Data dashboard. [internet].
[cited 2021 March 8]. Available from: https://
datadashboard.health.gov.il/COVID-19/gen-
eral. [Hebrew].
11. YNET. Pfizer CEO: “Israel has become the lab-
oratory of the world”. [internet]. 2021 February
27. [cited 2021 March 8]. Available from: htt-
ps://www.ynet.co.il/news/article/HJRX7CLzd
[Hebrew].
12. Blake A, Hotez J P, Israeli A, Chinitz D. Les-
sons from an Ally: Learning from Israel to
Vaccinate the American People. Microbes and
Infection [Internet]. 2021 February 9. [cited
2021 March 8]. 104796. Available from: https://
www.sciencedirect.com/science/article/pii/
S1286457921000186?via%3Dihub
13. Rosen B, Waitzberg R, Merkur S. Israel: health
system review. Health Systems in Transition,
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14. Marchildon, GP. The rollout of the COVID-19
vaccination: what can Canada learn from Israel?.
Isr J Health Policy Res 10 (2021). https://doi.
org/10.1186/s13584-021-00449-x.
15. Cohen M. Along with the slowdown in the op-
eration, starting today, every citizen over the age
of 16 will be able to get vaccinated to Covid19.
Walla.[Internet]. 2021 February 4 [Cited 2021
March 15]. Available from: https://news.walla.
co.il/item/3415942 [Hebrew].
16. Dagan N, Barda N, Kepten E, Miron O, Perchik
S, Katz MA, Hernan MA, Lipsitch M, Reis B,
Balicer RD. BNT162b2 mRNA Covid-19 Vac-
cine in a Nationwide Mass Vaccination Setting.
NEJM 2021. doi: 10.1056/NEJMoa2101765.
Online ahead of print.
17. Ministry of Health. Efficacy of Pfizer vaccine
against coronavirus. 2021 Feb 13. [Hebrew].
18. Weinreb G. Vaccine effect: everything you
need to know about those who have already
been vaccinated, and also those who have not.
Globes [Internet]. 2021 Feb 15. Available
from: https://www.globes.co.il/news/article.
aspx?did=1001360688 . [Hebrew].
19. World Health Organization. https://www.
who.int/emergencies/diseases/novel-corona-
virus-2019/media-resources/science-in-5/epi-
sode-1. [cited 2021 March 9].
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21. Mehusgan. https://www.mehusgan.org.il/. [cit-
ed 2021 March 9].
22. HCJ 7245/10 Adalah v. Ministry of Welfare
(Isr.).
23. Ministry of Health. Vaccination of students
of health professions and healthcare workers.
A General Manager Circular no. 8/2016. 2016
Sep 8. [Hebrew].
24. Ministry of Health. Preparedness of the health-
care system to the winter. A Medical Manage-
ment Circular no. 29/2017. 2017 Oct 3. [He-
brew].
25. Doctors Only. Despite the obligation, most
doctors and nurses in Israel are not vaccinated
against influenza [Internet]. 2019 Dec 9. [cited
2021 March 8]. Available from: https://pub-
lichealth.doctorsonly.co.il/2019/12/178912/.
[Hebrew].
26. Israeli Medical Association – Ethics Board. In-
fluenza Immunization of physicians. 2014 Oct
23. [Hebrew].
27. Doctors Only. Staff members at Hadassah who
were not vaccinated will not be allowed to come
into contact with patients [Internet]. 2021
March 3. [cited 2021 March 8]. Available from:
https://doctorsonly.co.il/2021/03/222774/.
[Hebrew].
28. Ministry of Health. Addition to the circular of
the General Manager of the Ministry of Health
no. 8/16 dated 8.9.2016 on the subject of vac-
cination of students of health professions and
healthcare workers. 2021 Feb 28. [Hebrew].
29. Ministry of Health. Issuance of certificates [In-
ternet]. https://corona.health.gov.il/green-pass/
[cited 2021 March 8]. [Hebrew].
30. Ministry of Health, Ministry of Economy and
Industry and Ministry of Finance. The Pur-
ple Pass for Businesses. [Internet]. [cited 2021
March 9]. Available from: https://govextra.gov.
il/economy-tavsagol/. [Hebrew].
31. Batson A. Green Passport: Who is eligible to
receive and how is it issued? Mako [Internet].
2021 March 8. [cited 2021 March 8]. Avail-
able from: https://www.mako.co.il/travel-israel/
magazine/Article-a385dc5ca583771027.htm.
[Hebrew].
Prof. Leonid Eidelman, MD, Past president
IMA and WMA, Head of anesthesiology,
Beilinson Medical Center, Petah Tikva, Israel
Malke Borow, JD, Director, Division
of Law and Policy, Israeli Medical
Association. E-mail: malkeb@ima.org.il
Baruch Levi, PhD, Head of Research
Unit, Israeli Medical Association
Tali Rayn-Aloni, MA, Researcher,
Israeli Medical Association
Covid-19 and Vaccination
ISRAEL
BACK TO CONTENTS
8
WMA News
An extraordinary virtual meeting of the
Socio-Medical Affairs Committee was
held on January 12 to discuss items left
over from October’s online Assembly. More
than a hundred participants logged into
the resumed meeting to be welcomed by
Dr.  Frank Ulrich Montgomery, Chair of
the WMA.
Dr.  Osahon Enabulele (Nigeria) took the
chair and called the committee to order.
Taiwan
The first item on the agenda was a proposal
by the Taiwan Medical Association to revise
the WMA Council Resolution on observer
status for Taiwan to the World Health Or-
ganization.
The Taiwanese delegate submitted the pro-
posal, arguing that the Covid-19 pandemic
had highlighted the urgency and importance
of inclusiveness and leaving no one behind
in the global health network. By continuing
to refuse to grant Taiwan observer status to
the WHA and full access to its meetings,
mechanisms and activities, the WHO had
failed to fulfil the principles of universality
and equality established in its constitution,
as well as the ethical standards of the orga-
nization. Taiwan, located at a key position
in the Asia-Pacific region, had long enjoyed
close relationship with countries and areas
of the region, with more than 20  million
regional and international travellers a year.
From 2009 to 2016, Taiwan had been in-
vited to participate in the World Health
Assembly (WHA) as an observer, with very
limited access to WHO technical briefings,
mechanisms and activities. Since 2017, the
WHO had not granted observer status to
Taiwan. Although Taiwan had been of-
ficially included in the implementation
framework of the International Health
Regulations since 2009, its contact point
information was not included on the IHR
Portal established by WHO. This had im-
peded the timely exchange of information
and communication to the detriment of
Taiwan. As a result, delayed and incomplete
medical information could impact adversely
on the Taiwanese population, causing a gap
in Taiwan’s domestic disease control net-
work, with unavoidable implications for
global health.
The Taiwan Medical Association argued
that allowing the participation of Taiwan
in the WMA and fostering its inclusion in
all WHO’s health programmes and in the
International Health Regulations would
benefit the people of Taiwan, but also the
WHO and its member states.
Its motion urged the WMA and its constit-
uent members to call on the WHO to grant
Taiwan observer status to the World Health
Assembly and to ensure Taiwan’s participa-
tion in all its health programmes based on
a substantive, timely and professional basis,
and to include Taiwan as a full participating
party to the International Health Regula-
tions, allowing its critical contribution to
the global health protection network.
But the Chinese Medical Association ob-
jected to the motion, and proposed that it
be withdrawn. It argued that there was no
barrier to Taiwan’s inclusion in the WHO’s
technical activities.
However, when no seconder came forward,
the Chinese proposal fell.
The main motion from the Taiwan Medical
Association was then agreed by 13 votes to
one.
Solar Radiation and
Photoprotection
A proposed Statement on Solar Radiation
and Photoprotection was submitted by the
Romanian College of Physicians.
The committee was told that the Statement
had been circulated among constituent
members for comment and these comments
had been included in a compromised ver-
sion of the Statement.
The document declared that solar UV ra-
diation was an extremely important, yet
neglected causative factor for skin cancers,
both melanoma and non-melanoma, for oc-
ular pathologies, such as cataracts and age-
related macular degeneration, and harmful
effects on the immune system. Recurrent
and severe sunburns were a risk factor for
non-melanoma skin cancer. The incidence
of melanoma and non-melanoma skin can-
cer was increasing.
Evidence from the WHO indicated that
four out of five cases of skin cancer could be
prevented and simple preventive measures,
such as limiting UV exposure in the mid-
day sun, wearing UV protective clothing
and hats or using mineral-based sunscreens,
were recommended.
Socio-Medical Affairs Committee
Nigel Duncan
BACK TO CONTENTS
9
WMA News
The proposed Statement made a number
of recommendations for national govern-
ments,for national medical associations and
for physicians. These included support for
skin cancer screening campaigns, improved
reporting,better education of the public and
the promotion of policies to fight climate
change and air pollution.
During the debate that followed, a number
of friendly amendments to the Statement
were agreed.The Chinese Medical Associa-
tion proposed a new paragraph stating that
broad-spectrum photoprotection should be
advocated and the intake of photosensitive
foods and drugs should be reduced.
The Spanish Medical Association wanted
the Statement to make it clear that the sun,
despite its harmful consequences, was also a
great source of health benefits. It proposed
several amendments relating to the charac-
teristics which sunscreens should meet, the
environmental impact of sunscreen and the
need for more health education.
The Statement, as amended, was agreed.
Ensuring the Availability,
Quality and Safety of
Medicines Worldwide.
A proposed Statement on Ensuring the
Availability, Quality and Safety of Medi-
cines Worldwide was submitted by the
French Medical Association (Conseil Na-
tional de l’Ordre des Médecins Français).
The CGCOM delegate explained that over
the past decade, supply pressures had re-
sulted in shortages of certain medical prod-
ucts,including vaccines.In many situations,
these shortages had resulted from the pri-
oritisation of economic goals over public
health. Such shortages were detrimental to
patient welfare, to the preservation of pub-
lic health and to the organisation of health
systems.
The proposed Statement set out a series
of recommendations on the availability of
medicines and the continuity of supply of
quality medicines while ensuring their safe-
ty, with further action proposed on illegal
internet sales of drugs.
Several NMAs proposed various amend-
ments to the document.The Chinese Medi-
cal Association submitted additional word-
ing for action on falsified and substandard
drugs, while the Spanish Medical Associa-
tion proposed a number of amendments to
make it clear that the rational use of drugs
required ensuring research, regulation, pro-
duction, distribution, prescription, financ-
ing, dispensing and proper administration
of drugs with consistent and rational scien-
tific, professional, economic and social cri-
teria. It also proposed the establishment of
a national body charged with gathering and
sharing information about demand for and
supply of medicines within their jurisdic-
tion, and urged the pharmaceutical industry
to guarantee the continuity of the supply of
medicines.
Although these changes were accepted by
the French as friendly amendments, the
debate then shifted direction after the
American Medical Association proposed
splitting the Statement into two docu-
ments. It suggested one document should
deal with the availability of drugs and the
second should deal with their quality and
safety.
After further discussion, the proposal to di-
vide the Statement, as amended, was sup-
ported by seven votes to six. The proposed
Statement will now be reconsidered and
brought back to the committee for further
discussion.
Medical Technology
The Israeli Medical Association proposed
the setting up of a workgroup on Medical
Technology.
The Association argued that technology
now played a crucial role in every industry,
as well as in people’s personal lives. Tech-
nological developments in the healthcare
arena had helped to save lives, by allowing
physicians to better diagnose and treat their
patients, and generally improve patient care.
Advances in biotechnology, pharmaceuti-
cals, information technology, and the devel-
opment of medical devices and equipment
had all made significant contributions to
improving the health of people all around
the world.These advances were now helping
in the current Covid-19 pandemic.
Medical technology covered a vast range
of areas within healthcare, from introduc-
ing doctors to new equipment to connect-
ing patients and doctors thousands of miles
away through telecommunications. With
an ever-increasing number of hospitals and
medical practices using medical technology
as part of their daily practice and with this
field growing at an astounding speed, it was
important for the medical profession to be
well-informed and it was also essential that
this field was monitored and regulated ap-
propriately.
The Israeli proposal was for a workgroup to
focus on new technologies, physicians and
industry. It could recommend those areas
where the WMA could voice its opinion,
where the policy should be and decide over-
all how the WMA should work in the area
of medical technology. Big players such as
Amazon and Google were now interested
in health.The WMA could act as a network
facilitator, with the workgroup reviewing
medical ethics in this developing techno-
logical arena.The WMA could host an edu-
cational conference on new medical tech-
nologies and innovations and examine areas
such as privacy and could reach out to new
stakeholders and engage in joint ventures.
Currently the WMA had a number of
statements which addressed some of the
areas included in the field of medical tech-
nology. This number would vastly increase
BACK TO CONTENTS
10
WMA News
in the coming years and each of the current
statements would need regular updating in
order to keep them relevant to the rate of
advancements in this field.
The proposal from the Israelis was given a
warm reception by members of the commit-
tee, many of whom expressed an interest in
joining the work group. On one issue, how-
ever, there was opposition. The suggestion
that the WMA could receive sponsorship
from commercial organisations was ob-
jected to by the Norwegian Medical Asso-
ciation.The committee agreed to delete this
idea from the proposal.
The Israeli proposal,as amended,was agreed
by the committee and it will now be for the
Chair of Council to decide the membership
of the workgroup.
Pandemic Preparedness
The committee received a report on WMA
policies on epidemics,pandemics and emer-
gencies.
Members were reminded that as part of the
annual policy review process, it was being
recommended that there should be a ma-
jor revision of the Resolutions on Unproven
Therapy and the Ebola Virus and on Ebola
Viral Disease.
The recommendation put to the committee
was to archive both Ebola specific docu-
ments and to have a major revision of the
Statement on Medical Ethics in the Event
of Disasters and the Declaration on Disas-
ter Preparedness and Medical Response.
The Chinese Medical Association empha-
sized that the issue of emerging technolo-
gies should be considered when revising the
Statement on Medical Ethics in the Event
of Disasters.This should cover issues such as
big data, AI, and contact tracing.
The Spanish Medical Association wanted
to the see triage, priority criteria for hospi-
talization and the role of primary care in-
cluded in the revision.
The recommendation was agreed by the
committee, along with the points raised by
the Chinese and Spanish Medical Associa-
tions.
Plain Packaging of Cigarettes
The committee considered minor revisions
to the Resolution on Plain Packaging of
Cigarettes. These included a new sentence
reaffirming the WMA’s Resolution on
Implementation of the WHO Framework
Convention on Tobacco Control and em-
phasizing the importance of this global
mechanism to protect people from exposure
and addiction to tobacco. A further revision
suggested by the Danish Medical Associa-
tion called for national governments to sup-
port the introduction of plain packaging to
break the brand recognition/smoking cycle
and to deplore strategies from the tobacco
industry to oppose the adoption and imple-
mentation of such policy.
It was argued that the producers of tobacco
products were very creative in their efforts
to brand their products. This included add-
ing brand names and logos to the product
itself. It was therefore relevant to consider
breaking brand recognition in other ways
than just through plain packaging. It was
also relevant to mention other tobacco
products, not just cigarettes.
The committee agreed the revised Resolu-
tion.
Classification of Policies
The final item on the agenda related to the
classification of those policies that were five
years old. Constituent members had been
consulted on the issue and had put forward
their recommendations.
The Spanish Medical Association argued
strongly that the Resolution on Drug Pre-
scription should not be rescinded because
of the importance of a medical professional
prescribing.
This was agreed by the committee and
the recommendations as a whole were ac-
cepted.
The meeting was then brought to a close.
Nigel Duncan
BACK TO CONTENTS
11
WMA News
18th
Vienna Congress
A prestigious award honouring physi-
cians around the world for their work in
combating Covid-19 was presented to the
World Medical Association in Vienna on
January 31. At the 18th Vienna Congress
2021, Dr. Otmar Kloiber, Secretary Gen-
eral of the WMA, received in person the
Golden Arrow Award, given annually in
recognition of the achievements of indi-
viduals for their life’s work and of insti-
tutions for their social relevance. Previous
winners include the former Presidents of
Israel and South Africa and a number of
Nobel Laureates.
The award was the highlight of a two-day
conference held in the splendid baroque
Haus der Industrie under the patronage of
the Federal Chancellor of Austria and the
Austrian Medical Chamber. The event, en-
titled “Back to the Future”, was intended to
examine the world after the Covid-19 pan-
demic.The annual Congress brings together
decision-makers from around the world to
discuss new ideas. This year’s event focused
on the subject of Covid-19, vaccination and
therapies and was attended by a number of
Nobel Laureates and physician leaders. Na-
tional and international experts discussed
what could be learned from Covid-19 and
how health systems could be made fit for
future pandemics. Because of travel restric-
tions, the Congress took place in a hybrid
form, with some speakers attending in per-
son, others online and the speeches and
panel discussions being streamed via the
internet.
The Golden Arrow Award
Announcing that the winner of this year’s
Golden Arrow award was the World
Medical Association, David Ungar-Klein,
initiator of the Vienna Congress, said
that countless doctors had fallen ill or had
lost their lives treating patients with Co-
vid-19. Among the first was the Chinese
ophthalmologist, who recognised the dan-
ger of Covid-19 at an early stage and had
warned his medical colleagues about it. He
was reprimanded by the Chinese authori-
ties for spreading rumours and later died
of the virus aged 33. Mr Ungar-Klein said
the medical profession would play the key
role in protecting billions of people from
the virus.
President Václav Klaus, former President of
the Czech Republic, and chair of the Con-
gress award Advisory Board, said the award
belonged to all doctors, not just the insti-
tution. He said everyone expressed their
gratitude to physicians around the world.
The past 12 months had been a very special
era of human history. Almost no one living
now had experienced anything similar.They
had all, slightly irresponsibly, assumed that
nothing like this could happen. They were
wrong.They should have expected this pan-
demic.The question should have been when
it would come, not whether it would come.
They were just too self-assured and had not
prepared themselves for such a situation. So
today they were honouring people who had
been saving their lives.
He reminded people that the medical pro-
fession and freedom of science, but also
freedom of expression, were inextricably
linked.
He concluded: ‘I would like to thank doc-
tors all over the world for their services
and hope that they all will hear about this
thank you from the heart of Europe. Con-
gratulations to the World medical Asso-
ciation, which will receive the Golden Ar-
row 2021 on behalf of all doctors of the
world’.
Professor Dan Shechtman,Nobel Laureate
in Chemistry, spoke about the five partners
in this pandemic – the decision makers or
politicians; the public, who could be obe-
dient, or disobedient, and who suffered;
thirdly, the health system and those work-
ing in it, the heroes who had worked round
the clock for a whole year saving lives and
treating the ill; fourthly, the scientific com-
munity, who gave the background to the
development of future vaccinations and
current vaccinations; and finally the vac-
cine producers, the people who took all the
knowledge, put it together and produced
amazing vaccines.
He said all these five parties would have to
continue to fight the pandemic, because it
was not going away. It was going to stay and
billions of vaccinations would have to be
produced.
He said the global medical profession was
not an anonymous mass, they were highly
trained specialists who they encountered
every day.
‘They are part of our life infrastructure.
There are there when we need them. And
we need them often. The medical profes-
sion is at the forefront of the war on the
virus. For us, for our health and our free-
dom.’
Dr.  Leonid Eidelman, former President
of the World Medical Association and a
member of the Congress Advisory Board,
said physicians had been ready to deal with
the pandemic and had been acting accord-
ing to the Declaration of Geneva. He said
he was honoured and privileged to express
his deep gratitude to the organisers of the
award.
Dr.  Thomas Szekeres, President of the
Austrian Medical Association, spoke of the
super human achievements of physicians
in treating the pandemic. They had often
worked with insufficient protection, having
to make stressful decisions about continu-
WMA Wins Prestigious Award
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12
WMA News
ing or ending therapy and they were still
only at the beginning of the way back to
normality.
Dr.  Otmar Kloiber, Secretary General of
the WMA, then formally received the
award (see p. 13).
Dr. David Barbe, President of the WMA,
speaking online from the USA (see p. 14).
Testing, Vaccination
and Therapy
The Congress then moved to discuss Test-
ing, Vaccination and Therapy.
Dr. Leonid Eidelman talked about testing
in Israel and said they had to learn from
countries like Taiwan, New Zealand, South
Korea, Australia and Japan. From the be-
ginning, they decided to perform tests and
isolate those who were positive. They now
had data that performing screening tests of
the population,along with quarantine,may-
be efficient. He spoke about the importance
of point of care testing devices for everyone
and about the different vaccines being used
by various countries. For him, the heroes of
2020 were health care providers, physicians
and medical science.
Dr. Kloiber said the pandemic had become
one of the challenging factors about what
the medical profession and society did.
There had been more than 100 million cases
of Covid-19 and 26 million active cases.
More than two million people had died.
But they had learned how to deal with pan-
demic patients much better than they did to
begin with.The success story was approving
vaccines in such a short time. But the pan-
demic had also been a story of missed op-
portunities. There had been complacency in
a large part of the western world. Plans that
had been made for a pandemic had proved
to be little more than pieces of paper. But
some countries in south east Asia were pre-
pared and had done much better. Taiwan,
South Korea, Singapore, and Japan had all
had better outcomes. There had been warn-
ings that such a pandemic would happen.
The World Health Organisation had for
the last 20 years warned that there would
be a disease X that would hit the world.The
WMA had a number of strategic papers it
had produced that warned this would hap-
pen. But these did not lead to any meaning-
ful preparation.The pandemic had also been
a lost opportunity for solidarity. Yet it could
have been a test for international solidarity.
Instead, within days, it turned out to be a
showcase for the worst examples of nation-
alism,including the European Union,about
which he was very sad.
Dr. Kloiber said people should think about
the pandemic like a fire that was spreading.
Would anyone sit in their house and say
‘these are my buckets of water and my fire
extinguisher and you can’t have them, be-
cause I may need them’. No, they would run
out and help to put out the fire with their
own water and fire extinguisher. He said
there was a global programme to finance
vaccination in poor countries. But currently
it was the rich countries that were fighting
for the first doses of the vaccines, and no-
body was thinking of the poorer countries.
He said the pandemic started with lies and
camouflage and an unwillingness to invest
in proper scientific surveillance. There had
been a chance to study and measure how
the virus spread by testing. But it turned out
to be a missed opportunity to find a science
based vaccination strategy. Yet they had the
data on hand that could be used to deter-
mine which strategy would be better to save
most lives.
He referred to the early collapsing supply
chains for personal protective equipment
and said that the global financing systems
had not supported the health care systems.
Finally, he said they should be spending
more effort on developing therapies. This
was not the first pandemic and it would not
be the last. Other pandemics would not be
avoidable, but they should be able to learn
from this pandemic and they should be able
to do better next time.
Dr.  David Barbe spoke about the large
number of doses of vaccines in the pipeline
in the world, but said that at the moment
they would only cover half of the world’s
population. Yet the number of Covid cases
was increasing, with more and more people
at risk.At the moment there was an unequal
supply of vaccines, when what was needed
was an equitable distribution. But in many
countries there were infrastructure issues
that could inhibit the acquisition and dis-
tribution of vaccines. Turning to the prob-
lem of prioritizing vaccinations, he said
the easy part was deciding the top priority
tiers – the elderly, the obese and those with
chronic diseases. However, there were some
risk groups that were often overlooked. For
instance, there were the communities where
the incidence of the disease and death rates
were higher. Potentially, the vaccines could
be distributed to them. In addition, ethnic
minority communities were more likely to
experience severe illness or death than Cau-
casians. Did it not make sense to prioritise
these groups?
Dr.  Barbe also talked about the issue of
what was called vaccine hesitancy.This was a
multi factorial problem.There were the pre-
existing vaccine hesitancy or anti-vaxxers,
who seemed to be on the rise in many coun-
tries around the world.There was scepticism
and fear of vaccine, most of which was sadly
misinformed.That was already there. When
you added on top of that the fact that the
vaccines for this disease had been developed
in an extremely short period of time, there
were many questions raises, both about the
safety and efficacy of these vaccines. Al-
though they now had experience of multiple
tens of millions of doses given worldwide
and the severe reactions were extremely low
that science did not seem to be persuasive
in the current environment. He said there
was more scepticism of science now around
the world than they had ever seen before.
Much of this,particularly in the USA,relat-
BACK TO CONTENTS
13
WMA News
ed to the political high-jacking of science.
It was not the science behind a decision, it
was where the recommendation came from,
from which political party. In the worst
case, there were the conspiracy theories.
This played out in the USA with very low
uptakes of vaccination. Among health care
workers there was an uptake of only 40-50
per cent, and even among physicians it was
barely 70 per cent. That was an extremely
sad comment. The solution to this was to
continue to promote the science.
During the panel discussion that followed,
Dr. Kloiber said he was astonished at the
speed with which new vaccines had been
developed and tested. However, he re-
mained concerned about the lack of invest-
ment going into health care. He said it was
better to invest in health care than it was
to invest in many companies. Investing in
health care was something that paid off.
Three Nobel Laureates
The Congress had opened the health ses-
sion earlier in the day with speeches and a
panel discussion between three Nobel Lau-
reates – Sir Timothy Hunt, Nobel Laureate
in Physiology or Medicine, Professor Dan
Shechtman, Nobel Laureate in Chemis-
try and Kurt Wüthrich, Nobel Laureate in
Chemistry.
Sir Timothy Hunt said it looked as if the
Covid-19 vaccines were working. ‘What an
amazing triumph of science this is’, he said.
But there was still a lot of room to better
understand how the virus spread between
people. His plea was for there to be more
experiments and less propaganda in these
matters.
Prof. Shechtman said it was the scientists
who were now solving the problem of the
pandemic. Science had never been as ap-
preciated as it was now, and rightly so.
The development of the vaccines had been
done at a very impressive pace with com-
panies producing billions of vaccines in a
record time.
He talked about the way in which some
countries had done very well in controlling
the virus, and they had done it in different
ways under different types of government.
Wearing masks in the far east was common
practice. It meant social responsibility. In
the west, people did not behave in in the
same way. Yet only countries where every-
body had social responsibility could survive
this pandemic with minimum damage.
He concluded by saying that the pandemic
was not going anywhere and would stay
with them for years. They would be vac-
cinated every year like the flu. So, health
systems would have to reorganise to provide
such vaccinations every year to everybody.
Kurt Wüthrich said he had travelled be-
tween several countries as the pandemic
first developed and he contrasted what he
experienced. In China, people quickly be-
gan wearing masks. In other countries,
such as Saudi Arabia, nobody was worry-
ing about Covid. In Switzerland he was
told that wearing a mask was a health haz-
ard, although the Swiss Government would
have liked people to wear masks. He said
that really very little was known about the
virus, how it was spread by aerosols and lay
on surfaces. And yet nobody was looking
ahead and talking about the impact of this
on the architecture of public buildings and
theatres. Because, he warned, the epidemic
would flare up again.
Nigel Duncan,
WMA Public Relations Consultant
E-mail: nduncan@ndcommunications.co.uk
‘I would like to thank the Vienna Congress,
the award committee, the organizers, that
they have honored the doctors of this world
for their efforts in fighting the pandemic.
A difficult year is behind us, and the CoV-
id-19 pandemic still has a tight grip on this
world. Many of my colleagues have been
tireless in treating Covid-19 patients, and it
is them and their colleagues of other health
professions and caregivers who deserve the
honor of being recognized.
The workload that has been mastered by
them has been unbelievable. The tragedies
that they had to witness and often endure
seemed to be endless and often nerve-rack-
ing. Many of them have lost their lives, and
many others suffered long-lasting health
damage. And yet, we have been learning to-
gether; we understood to contain and cope
with the disease.
Yes, we are far away from mastering or pre-
venting it, but there is hope, and the new
vaccines are our best chance to see light at
the end of the tunnel.There are a few things
the pandemic has taught us:
Respect for nature. We are far away from
controlling our environment, and we have
to humbly accept that nature is ruling us.
There is no mercy for our mistakes, neither
in the pandemic nor in the climate change.
Our science relies on cooperation.Together
we were able to work on strategies to miti-
gate the pandemic’s consequences and de-
velop therapies and vaccines. Alone, no
nation would be able to cope; no scientist
would make the break-through, no doctor
Otmar Kloiber Acceptance Speech
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14
WMA News
could provide the necessary care. Coopera-
tion, international cooperation is the key.
And as we progress together, we have to
share together, to leave no one behind, no
frail person, no frail state. Now is not the
time for egotisms and nationalism.
Stronger health care systems are bet-
ter than weaker ones. Universal health
coverage is even more critical in times
of pandemics. High-quality health care
accessible for all requires proper invest-
ment, meaningful financing, and resilient
reserve capacities. Over the past years, we
may have made some savings in stream-
lining the health care systems for what is
called strict cost-efficiency. We have even
squeezed some health care systems to the
minimum with austerity measures. These
have been short-sighted economic strate-
gies, which now led to a deadly payback
with so many lives lost and tremendous
damage to our economies.
Finally, a word to my fellow citizens: You
can help your doctors, nurses, and other
caregivers: Reduce contacts, maintain dis-
tance, wear masks, follow hygiene rules,
and most important: get vaccinated.This is
our best and most likely our only chance
to get back what is worth calling a “normal
life”.
Otmar Kloiber
On behalf of the WMA and millions of
physicians around the world, we are very
honored to receive the Golden Arrow
Award.It is without precedent that an orga-
nization such as the WMA is a recipient of
this award rather than an individual – but,
perhaps that is fitting as we can certainly
agree that we are suffering through a pan-
demic that is also without precedent in the
last 100 years.
This pandemic has impacted all of us very
deeply – but also very differently.The risk of
contracting COVID-19 has struck fear into
the hearts of many around the world.Physi-
cians have been vocal advocates for patients
and their colleagues in calling for adequate
personal protective equipment, improved
access to hospital care, equipment and life-
saving treatments, rapid deployment of
vaccines, and responsible social policies to
reduce the burden of disease, save lives, and
bring an end to this devastating pandemic.
However, physicians and other healthcare
workers have been in an especially challeng-
ing situation. Their very calling and service
have exposed them to the risk of COVID in
ways that few others have experienced.
Physicians have demonstrated their profes-
sionalism by willingly placing themselves in
grave personal danger by caring for patients
with COVID – often under less-than-ideal
conditions. As a result of this, untold tens
of thousands have become seriously ill and
thousands have died as a direct result of
their commitment to their patients and so-
ciety.
Receiving this award on behalf of the WMA
fills me with deep emotion for a reason you
may not expect. You will not see this from
the outside, but there are many physicians
around the world who do not feel appre-
ciated or supported for the risk they have
taken or the sacrifices they have made in
caring for patients with COVID. Many are
demoralized. Many feel their governments,
and, in some cases, their hospitals have let
them down. Some feel taken for granted or
even taken advantage of.
This Golden Arrow award proclaims to the
physicians of the world – “You are appreci-
ated. We recognize all you have done and
thank you for the sacrifices you have made.”
Physicians desperately needed to hear that.
It is very gratifying and encouraging! We
will make sure they know your appreciation.
My sincere thanks to Professor Leonid
Eidelman for nominating the WMA and
to Mr. Ungar-Klein, Vaclav Klaus and the
entire Advisory Board and jury committee
for recognizing the WMA and physicians
around the world with this Award. Thank
you!
David Barbe
David Barbe Acceptance Speech
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15
Ethics, Health Databases and Biobanks
The Icelandic Saga
In the spring of 1998, the Health Minis-
try of Iceland introduced a new Bill on the
commercial use of health data and planned
for a speedy and uneventful process in the
parliament. It usually goes unnoticed to
the outside world what happens at the Ice-
landic Parliament but this time something
new was emerging that obviously could
have impact far outside the country. The
Icelandic Medical Association (IcMA) was
stunned by the ideas put forward in the Bill
and reacted immediately and publicly. The
idea, presented in the Bill, was to collect all
health data,both prospective and retrospec-
tive, from the whole population and from
all health institutions. No consent would be
sought and on top of that, a private com-
pany would have the sole responsibility
and rights of the use of data according to
a contract but granting Health authorities
rights of use. The Bill immediately gener-
ated intense public debate among Iceland’s
scientific and clinical communities, but
was supported by the public at large ac-
cording to polls. The fierce debate caused
a delay in the process but eventually the
Bill was passed as Law from Althingi (The
Icelandic Parliament) in December 1998
following several amendments such as an
introduction of “assumed consent” giving
individuals the possibility to actively opt
out. In the following year, the Health De-
partment worked on a detailed regulation
and subsequently, these were formalized in
January 2000 along with a contract with De
Code Genetics on their sole responsibility
to establish and run the database. During
this time and in the following years, discus-
sions took place internationally by articles
and debate letters. The leaders of De Code
Genetics, Jeffrey R. Gulcher and Kari Ste-
fansson published a debate article in New
England Journal of Medicine in 2000 [1]in
which they highlighted the scientific value
of a health database on the population of a
whole country. This was followed by a bal-
anced article on the use of health data in
the same issue [2] and a number of articles
on the use of big health data followed in
the coming years [3-8]. Amongst these was
a thorough study into the case published
by Welcome Trust with the aim to cast a
light to the fast developing world of bio-
information [9].The main focus of many of
these articles was consent, discussing vari-
ous models such as the classical “informed
consent” as well as “broad consent”, “open
consent” and “opt out procedures”, many of
them using the Icelandic database as an de-
terring example.
The Icelandic database was never materi-
alized as the technical issues surrounding
security proved to be very complicated and
the cost became an obstacle.The law on the
health data had to be revisited 10 years later
but in 2018, the law was abolished.
The WMA policy of 2002
In the fall of 1998, the IcMA brought the
case to the WMA, which immediately ini-
tiated work on a policy within the Stand-
ing Committee of Social Medical Affairs
(SMAC). A workgroup was established,
chaired by Jim Appleyard from BMA
and the intention was to develop a policy
on the use of health data in general. The
matter was debated at the Council meet-
ing in Santiago in Chile in 1999 and the
Ministry of Health in Iceland took the
unusual step to send two representatives
to the meeting to defend the case. The
workgroup continued its work with in-
put from National Member Associations
(NMA´s) but no external discussion took
place. Dr. E. Doppelfelt acted as a special
adviser to the workgroup and at the Gen-
eral Assembly in Washington DC in 2002,
the “WMA Declaration on Ethical Con-
siderations regarding Health Databases”
was adopted, now being replaced by the
current version with a different naming;
“WMA Declaration of Taipei on Ethical
Considerations regarding Health Databas-
es and Biobanks” [10]. The main purpose
of the new policy was to give guidance to
physicians worldwide in how to ethically
work with health data and what ethical
requirements should required by those
responsible for running health databases.
Two ethical principles were introduced
in the first paragraphs; privacy and confi-
dentiality, followed by reference to major
WMA Declarations. Rigorous rules were
given on consent: Patient´s consent is needed
if the inclusion of their information in a da-
tabase involves disclosure to a third party or
would permit access by people other than those
involved in the patient´s care (par 17).” One
exception was given to this rule: “…infor-
mation may be withhold from a patient if it is
WMA Declaration of Taipei on Ethical Considerations regarding
Health Databases and Biobanks (DoT). Possible impact
Jon Snaedal
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16
Ethics, Health Databases and Biobanks
likely that disclosure cause serious harm to the
patient or another person (par 11). However,
paragraph 18 gave leeway and proved to be
problematic, not least due to its circular ar-
gumentation rendering it rather meaning-
less. The paragraph was added at the last
moment and is a good example of the con-
flict that can exist between ethical princi-
ples and law and how not to deal with such
conflict in an ethical policy:
“Under certain conditions, personal health
information may be included on a database
without consent, for example where this con-
forms with applicable national law that con-
forms to the requirement of this statement or
where ethical approval has been given by a
specially appointed ethical review committee
(Par. 18).”
The standing committee on health at the
Icelandic parliament viewed this as a sup-
port of WMA to the main principles of the
new law on Health databases and that the
case of the IcMA had been refuted.
The WMA policy of 2016 (DoT)
Based on the principles of revisiting WMA
policies at ten years, it was decided in 2012
to enter a major revision of the 2002 policy.
The leaders of WMA regarded this to be a
very important matter and therefore it was
decided to have a broad process with a big-
ger workgroup than usually. After the first
year of working on the policy,it was decided
to enter an open consultation process,which
is an exception in the work on WMA poli-
cies. Furthermore, it was decided to include
ethical considerations regarding Biobanks
as well.This increased the work substantial-
ly, not least as the interest turned out to be
very great and almost 100 comments were
received, some extensive. The workgroup
had several meetings, both in conjunction
with the statutory WMA meetings and in
between with invited external experts as
well as WMA´s own ethical advisers, prof.
Urban Wiesing from the University of
Tübingen and Dominique Sprumont from
Neuchatel. Following more than three years
of work, the policy was adopted at the 67th
General Assembly in Taipei and thus the
name of the Declaration.
Ethical principles are at the center of the
policy as laid down in 12 out of 24 para-
graphs. In par. 9 the main ethical principles
are mentioned: dignity, autonomy, privacy
and confidentiality. Par. 12, is detailed in its
requirements for validity of consent by giv-
ing ten different items to inform individuals
of the database.
The DoT refers directly to the WMA Dec-
laration of Helsinki  – Ethical Principles for
Medical Research Involving Human Subjects
(DoH) [11] already in its first paragraph. In
paragraph 3, this reference is clarified fur-
ther:
“In concordance with the Declaration of Hel-
sinki, it provides additional ethical principles
for their use in Health Databases and Bio-
banks”. The WMA has thus divided ethi-
cal considerations in research into broadly
two categories, research involving humans
directly by one policy (DoH) and research
involving humans indirectly in another
(DoT) but those policies share many fun-
damental ethical rules such as autonomy,
non-maleficence, justice and equality.
The origin of DoT can be traced to this
paragraph 32 in DoH that reads:
“For medical research using identifiable human
material or data, such as research on material or
data contained in biobanks or similar reposito-
ries, physicians must seek informed consent for
its collection, storage and/or reuse.There may be
exceptional situations where consent would be
impossible or impracticable to obtain for such
research. In such situations the research may be
done only after consideration and approval of a
research ethics committee.”
The last revision of DoH was adopted in
2013 and thus it includes no reference to
DoT as this was adopted 3 years later. This
should be kept in mind at the next revision
of DoH.
The importance of DoT
Many policies of WMA are seemingly not
having much effect after following their
adoption. This is not correct. Even though
many policies seem to live in silence, they
form the basis WMA work; its secretariat
and elected officers. In their collaboration
with international partners, the policies
are referred to and those talking on behalf
of WMA base their views on its policies.
Only a handful of the policies are having
a “life of their own” such as the DoH that
is referred to in the work of medical sci-
entists and ethical committees around the
world and is occasionally found in national
laws and regulations. Other major ethical
policies are having effect mainly inside the
medical profession such as the Declaration
of Geneva that is intended to be the phy-
sicians pledge and the International Code
of Medical Ethics that has been used as a
template for national medical ethical codes
or is referred to.
What about DoT?
In the years following the adoption of
DoT; it gained some attention with several
publications in peer reviewed articles and
discussions on home pages [12–18]. Most
of the authors discussed the new policy in
general terms but others focused on the
relevance for legislators [15] and in a pa-
per published in 2019, its authors focused
on incidental findings and the importance
of how these are handled with reference
to DoT [19]. In 2020, a review article on
DoT and DoH was published on behalf of
Working Group on Ethics of the Interna-
tional Federation of Associations of Phar-
maceutical Physicians and Pharmaceutical
Medicine [20]. The authors discuss topics
that should be better clarified in these two
policies, not least to link them more defi-
nitely together by referring to each other.
The authors point out for example that in
DoH, there is no mention of how to deal
with incidental findings in research but this
has become a real issue in many projects,
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Ethics, Health Databases and Biobanks
not least in genetics.This is only mentioned
superficially in DoT.
The authors also mention other areas that
should be considered, not least for the next
revision of DoH such as data sharing plans
[20].
Conclusion
The Declaration of Helsinki (DoH) is a
living document, used in everyday life in
research with human subjects around the
globe but its younger sister policy, Declara-
tion of Taipei (DoT) needs more attention.
It was positively received when it was ad-
opted five years ago but there is no guaran-
tee that it will continue to have any impact
without some push from its developer, the
World Medical Association. The DoH will
be revisited in the coming years and when
the revision process begins, both of these
policies on research on human subjects,
their biomaterial and data should be revised
taken into consideration ideas for changes
that have been presented in recent years.
References
1. Jeffrey R. Gulcher and Kari Stefansson. The
Icelandic Healthcare database and informed
consent. New England Journal of Medicine
2000;342 (24):1827-1830.
2. George J. Annas. Rules for research on human ge-
netic variation – lessons from Iceland. New Eng-
land Journal of Medicine 2000;342(24):1830-1833.
3. David Winickoff. The Icelandic Healthcare Da-
tabase, letter. New England Journal of Medicine
2000;343(23):1734.
4. Einar Arnarson. The Icelandic Healthcare Da-
tabase, letter. New England Journal of Medicine
2000;343(23):1734-1735.
5. Linda Nielsen.The Icelandic Health Sector Da-
tabase. In The Commercialization of Genetic
Research. Ed. Timothy E. Caulfield and Bryn
Williams-Jones. Springer, Boston MA 1999.
doi.org/10.1007/978-1-4615-4713-6.
6. Isaac S. Kohane and Russ B. Altman, “Health-
information Altruists–A Potentially Critical
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2005; 353: 2074-2077.
7. M.A.Austin, S. Harding and C. McElroy.
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org/10.1159/000069544.
8. Jon Snaedal.The centralized Health Database in
Iceland. Japan Medical Ass. Journal 2007; 50(6):
486-7.
9. Hilary Rose. The commodification of Bioinfor-
mation; The Icelandic Health Sector Database.
Welcome Trust 2001. https://wellcome.org/
sites/default/files/wtd003281.pdf
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ration-of-taipei-on-ethical-considerations-regar-
ding-health-databases-and-biobanks/
11. https://www.wma.net/policies-post/wma-
declaration-of-helsinki-ethical-principles-for-
medical-research-involving-human-subjects/
12. Chieko Kurihara and Takeo Saio. The World
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tion of Helsinki. Clin Eval. 2018:46:29-40.
13. Ames Dhai. The WMA Declaration of Taipei:
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good. South African J. on Bioethics Law 2016;
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14. Ju-Chuan Yen, Yu- Chuan Jack Li and Min-
Huei Hsu. Health Databases and Biobanks.
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doi: 10.1016/j.jfma.2017.02.003
15. Gauthier Chassang and Emmanuelle Rial-Seb-
bag. Research Biobanks and Health Databases:
The WMA Declaration of Taipei, Added Value
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16. Legislation (Soft and Hard Law). European
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doi:10.1163/15718093-12255369 https://www.
bbmri-eric.eu/news-events/new-wma-declara-
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17. J. Béranger. Chapitre 1. De l’étude des risques à
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19. Jui-Chu Lin, Wesley Wei-Wen Hsiao and
Chien-Te Fan. Managin “incidental findings”
in biobank research: Recommendations of the
Taiwan biobank. Computational and Structural
Biotechnology Journal 2019; 17: 1135-1142.
20. Chieko Kurihara, Varvara Baroutsou, Sander
Becker, Johan Bru , Brigitte Franke-Bray, Rob-
erto Carlesi et al. Linking the Declarations of
Helsinki and of Taipei: Critical Challenges
of Future Oriented Research Ethics. Fron-
tiers in Pharmacology 2020; doi: 10.3389/
fphar.2020.579714.
Jon Snaedal,
Professor in Geriatric Medicine,
Landspitali University Hospital,
President of the World Medical
Association 2007-2008
E-mail: jsn@mmedia.is
BACK TO CONTENTS
18
Psychosomatic Medicine
Introduction to Chinese Society
of Psychosomatic Medicine
The Chinese Society of Psychosomatic
Medicine (CSPM), founded in 1993, has
developed rapidly in the past 20 years. Now
it is an important active professional asso-
ciation under the Chinese Medical Associa-
tion (CMA) [1].The CSPM is mainly com-
posed of provincial, municipal and county
branches of psychosomatic medicine, youth
committees and party leading groups (see
Fig. 1). There are 21 provincial-level ad-
ministrative regions that have developed
psychosomatic medicine.Today, the CSPM
has 20 professional committees including
specialists from diverse clinical departments
[2].The assessment, diagnosis, intervention,
psychotherapy and self-management edu-
cation based on psychosomatic ideas have
a profound influence on clinical medicine
in China. Under the guidance of national
psychosomatic medicine, various forms of
medical, teaching and research activities
have been carried out.
At present, the rapid economic and social
transformations increasingly have triggered
serious individual psychological and behav-
ioral problems, especially during the out-
break of the novel coronavirus pneumonia
(COVID-19). Therefore, there is an urgent
need to establish a health service system
focusing on psychological care. The CSPM
has entered a new critical period to develop
a new mission.
Research Progress
of Psychosomatic
Medicine in China
Important Role of CSPM in
COVID-19 epidemic
At the end of 2019, a highly infectious
disease  – novel coronavirus pneumonia
(­
COVID-19)  – was reported in Wuhan,
Hubei province, China. At this critical mo-
ment, the Chinese government and the
whole society tried their best to save the
lives of the patients. From the very start, the
CSPM worked together with the govern-
ment to battle against the COVID-19 epi-
demic. First, the CSPM issued a proposal
for preventing and controlling the new
coronavirus infection in the whole country
on 27 January 2020.The CSPM actively en-
couraged its committee members and rel-
evant experts to participate in establishing
a psychological rescue group, where special-
ists provided technical advice and carried
out emergent psychological crisis interven-
tion and psychological counseling under the
coordination of the health administration in
the early stage of the COVID-19 epidemic.
Second, on 28 January 2020, the CSPM
established a psychosomatic intervention
program for prevention and control of the
novel coronavirus infection which serves
as an important basic guidance for psycho-
social and psychosomatic work to battle
COVID-19. On 30 January 2020, Dr. Wu,
President of the CSPM, published the pa-
per titled “Thinking about Psychological In-
tervention in Epidemic Disaster”, pointing
out that psychological intervention should
be carried out online based on the specific
cases, individuals and different stages in the
epidemic development. He also stated that
we needed to avoid over-intervention.Third,
the CSPM published three E-books with
guidelines for physical and mental health
education for public through internet-plus
technology, mass media, hotline and live
broadcast platforms. Fourth, the CSPM has
held series of lectures about COVID-19 in
live webcasts, given by eleven professors,
since 6 February 2020.
The CSPM also conducted psychosomatic
symptom surveys via WeChat in the period
3-11 February 2020 for the whole country
and found that the prevalence of psycho-
somatic problems was 21.4% according to
the psychosomatic symptom scale (PSSS)
[3]. Sleeping difficulty, lack of interest and
avoidance were the most frequent symp-
toms, with prevalence of 10.3%, 6.2% and
5.1%, respectively [4]. We wrote the stan-
dard guideline for diagnosis and treatment
of psychosomatic disorders related to the
novel coronavirus pneumonia [5]. The
PSSS was recommended for evaluating
the severity of psychosomatic symptoms.
Psychotherapy, medications and traditional
Chinese medicine can be used for the treat-
ment of psychosomatic disorders caused
Psychosomatic Medicine in China: the Current Development and
Role in Future Medicine
Aiqin Wu Yonggui Yuan Yingying Yue
CHINA
BACK TO CONTENTS
19
Psychosomatic Medicine
by  COVID-19. The experience in dealing
with this public health emergency, the de-
velopment and implementation of psycho-
somatic problem assessment, treatment and
services provide crucial information for the
efficiency and quality of future crisis inter-
vention by the Chinese Government and
authorities around the world.
Establishment and Implementation
of Classifications and Diagnostic
Criteria of Psychosomatic Disorders
Psychosomatic related disorders refer to
somatic organic diseases and are a dysfunc-
tion that plays an important role in the
pathogenesis and development of psycho-
social factors. In 1982, psychosomatic disease
ranked as the last type of mental illnesses
in the classification of psychosis of the
Chinese Medical Association. In 2017, the
CSPM proposed a classification of psycho-
somatic related disorders characteristic of
the Chinese, organizing the psychosomatic
disorders into five categories, including
Figure 1. Composition of Chinese Society of Psychosomatic Medicine
Figure 2. Classification of psychosomatic related disorders
CHINA
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20
psychosomatic reactions, psychosomatic
symptoms, physiological disorders related
to psychological factors, psychosomatic
diseases, and psychosomatic symptoms as-
sociated with physical diseases. In 2019,
they were split further into 9 categories,
including psychosomatic reaction disorder,
psychosomatic symptom disorder, psycho-
somatic disease, psychological factor re-
lated physiological disorder, stress-related
psychosomatic disorder, somatic symptom
and related disorder, mental disorder closely
related to psychosomatic medicine, mental
disorder caused by somatic disease, and psy-
chosomatic syndrome [2]. In principle, psy-
chosomatic reaction is referred to a tempo-
rary physiological reaction, lasting less than
one week.Psychosomatic symptom disorder
is a group of syndromes closely related to
acute and chronic psychosocial factors.They
root in the patients’ personality, mainly
manifested as one or several symptoms, e.g.
anxiety, depression, insomnia, pain, somati-
zation, etc. Psychosomatic disease refers to
a kind of psychosomatic disorders with or-
ganic damage,which often refers to primary
psychosomatic diseases, i.e. physical diseas-
es caused by psychological factors. Primary
psychosomatic diseases include 43 diseases
in six disciplines. Psychological factors re-
lated to physiological disorders refer to the
general class of diseases with psychological
and social factors as the main predisposing
factors, and physiological disorders are the
main clinical manifestations. Stress related
psychosomatic disorder refers to a group of
psychosomatic disorders caused by a group
of psychological,social (environmental) fac-
tors or major diseases (including admission
to ICU due to major diseases, cancer and
uremia). Mental disorders closely related
to psychosomatic medicine are a group of
mental disorders characterized by depres-
sion, anxiety and compulsion. Mental dis-
orders caused by somatic diseases refer to
mental disorders caused by various physical
diseases, such as somatic infection, visceral
diseases, endocrine disorders, nutritional
and metabolic diseases which affect brain
function. Psychosomatic syndrome includes
18 syndromes referring to stress and per-
sonality, illness behavior, emotional perfor-
mance (see Fig. 2). The classification will
help clinicians to standardize the treatment
of psychosomatic diseases and improve the
level of diagnosis and their treatment. It is
possible to realize the standardized diagno-
sis and treatment of psychosomatic disor-
ders in China.
The CSPM has also developed and intro-
duced psychosomatic scales, such as health
anxiety scale [6], Chinese Version of the
Metacognitions about Health Anxiety
Questionnaire [7], post-stroke depression
scale [8], post-traumatic resentment scale
and psychosomatic symptom scale [9].
There is also a scale to estimate the sever-
ity of psychosomatic symptom disorder (see
Table 1).These scales provide important as-
sessment tools for patients with psychoso-
matic related disorders.
Investigation of Epidemiology
and Disease Burden of
Psychosomatic Disorders
It is very important for health administrative
departments to formulate relevant preven-
tion and control strategy to clarify the diag-
nostic criteria of various psychosomatic dis-
orders, followed by further investigation of
the epidemiology and disease burden of vari-
ous psychosomatic related disorders. Previ-
ous studies have analyzed the incidence rate
and susceptibility factors of some common
psychosomatic diseases.The results may pro-
vide reliable data for the government when
making decisions concerning health policy.
Exploring the Pathogenesis of
Psychosomatic Diseases
The CSPM studied common psychosomatic
disease and achieved significant results.
Yuan et al. [10] found that, compared with a
healthy control group, the major depressive
disorder (MDD) patients had small volumes
of right superior frontal cortex, left central
posterior cortex and right middle temporal
gyrus. However, patients with RGD had
larger left cingulate gyrus volume compared
with healthy control subjects. There was
a significant negative correlation between
left cingulate gyrus volume and Rey Audi-
tory Verbal Learning Test delayed recall raw
score in the MDD patients. The genetics
study displayed thatTalleleandC/Tgenotype
of Methylenetetra- hydrofolate reductase
C677T was significantly different between
the case and control groups [11]. Post stroke
depression (PSD) is a subtype of depres-
sion, which is a frequent complication after
stroke.The previous study demonstrated that
neuropeptide Y was significantly decreased
in PSD patients compared with the control
group [12]. Asthma is often accompanied
by a variety of mental disorders, such as de-
pression,anxiety and panic.Zhang et al.[13]
explored the brain mechanism of depression
in asthmatic patients through multimodal
functional magnetic resonance technology,
Table 1. Psychosomatic symptom disorder severity rating scale
Item
Score
0 1 2 3
Stress (Reasons) no mild moderate severe
Course of disease
(Time)
less than one
week
less than one
month
less than three
months
more than
three months
Severity (Degrees) no effect
mild impact
on daily life
and work
moderate im-
pact on daily
life and work
serious impact
on daily life
and work
Symptoms (Numbers) no symptom
less than three
symptoms
less than five
symptoms
more than six
symptoms
Psychosomatic Medicine CHINA
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21
and found abnormal functional connectivity
between left ventral anterior insula and left
middle temporal gyrus in asthmatic patients
with depression. Moreover, compared with
the asthmatic patients without depression,
the regional cerebral blood flow in the right
posterior cerebellar lobe was significantly in-
creased in patients with depression.
Hyperthyroidism is the most common en-
docrine disease, often accompanied by emo-
tional and cognitive problems. Zhi et al.[14]
found that the voxel mirror homotopy con-
nectivity (VMHC) of bilateral medial fron-
tal lobes in patients with hyperthyroidism
decreased, the amplitude of low frequency
fusion (ALFF) and local consistency of left
prefrontal lobe decreased, and ALFF of left
posterior cingulate gyrus decreased.VMHC
in medial frontal lobe was positively cor-
related with episodic memory score. ALFF
in medial frontal lobe was positively corre-
lated with anxiety scale score, and negatively
correlated with processing speed score. An-
orexia nervosa (AN) is a typical psychologi-
cal disorder related to psychological factors.
Guo et al.[15] reviewed the changes of white
matter in AN patients by magnetic reso-
nance diffusion tensor imaging (DTI), and
pointed out that white matter changes were
common in AN patients, including corpus
callosum, cingulate gyrus, temporal lobe,
thalamus, hypothalamus, radiation corona,
thalamus radiation and superior longitudinal
tract. Professor Zhang focused on the cor-
relation between cortisol level and clinical
symptoms of posttraumatic stress disorder
(PTSD). It was found that the serum cor-
tisol level of PTSD patients was lower than
of healthy people.The serum cortisol level of
PTSD patients was related to the total score
of Hamilton depression rating scale, which
provided biological basis for clinical evalua-
tion of PTSD symptom severity [16]. Panic
disorder patients exhibited an enhanced
mismatch negativity (MMN) in response to
panic-related sounds but a reduced MMN
responding to neutral sounds [17]. Further-
more, MMN responses were delayed irre-
spective of stimulus type in panic disorder
patients compared to healthy controls. The
findings of etiology and mechanism of psy-
chosomatic disorders will provide new ther-
apeutic targets for these diseases.
Promoting Green Psychosomatic
Therapy to Realize Simultaneous
Treatment of Mind and Body
The CSPM is also interested in develop-
ing new psychosomatic therapies, espe-
cially green psychosomatic therapies, such
as physical therapy and psychotherapy. The
development of psychosomatic integrated
therapy and green psychosomatic medicine
is another goal of psychosomatic medicine.
Combined with the popularization and
promotion of the biopsychosocial medical
model, integrated treatment also needs to
be considered. Concerning treatment with
drugs, there are still some problems, such
as inconsistency in research and evalua-
tion tools, inconsistent evaluation methods
of efficacy, and more side effects, although
the previous studies have proved that ex-
isting drugs can significantly improve the
treatment of psychosomatic diseases. In the
future, there is needed investment in the re-
search and development of new drugs that
are safe, effective, economic and tolerable.
Physical therapy can noninvasively regu-
late nerve function and treat brain diseases
by precise control of electrical, magnetic,
ultrasonic and other physical stimulation
output. At present, there is a variety of
physical therapy methods, such as electric
shock therapy, repetitive transcranial mag-
netic stimulation, transcranial direct current
stimulation,etc.Body therapy,such as dance
therapy, singing therapy, and aromatherapy
[18], has also been proved to be effective in
the treatment of psychosomatic diseases.
The various forms of psychotherapy train-
ing develop all over the country and the ef-
fectiveness has been fully proved in the past
clinical practice and scientific research [19].
Balancing psychotherapy (BPT) is a kind
of psychological treatment based on the
oriental philosophy system, which uses the
relevant theory of balance, centering on the
two core contents of “degree” and “relation-
ship”in order to help individuals achieve the
state of mind-body balance. The correct use
of BPT is conducive to the psychosomatic
rehabilitation and the improvement of life
quality of patients with psychosomatic dis-
eases [20].The way of choosing appropriate
psychotherapy for specific psychosomatic
diseases is worth an in-depth discussion.
Carrying out Psychosomatic
Medicine Education and Training
Education in medical colleges and univer-
sities should include gradual and system-
atic study of psychosomatic related courses,
mainly the basic courses, professional basic
courses and professional courses,strengthen-
ing the concept of new medical model and
psychosomatic holistic treatment. In resi-
dency training, all professional doctors are to
carry out the identification of common psy-
chosomatic problems and undergo related
training that will be included in the training
plan of doctors in various departments.
We should train primary health care work-
ers in psychosomatic medicine.Establishing
of multi-disciplinary consultation-liaison
system is needed in hospitals. Increasing
the interest in psychosomatic medicine and
cognitive level of medical staff is very im-
portant to promote psychosomatic medi-
cine.The Chinese College of Psychosomatic
Medicine (CCPM), Chinese Multidisci-
plinary Integrated Center of Psychosomatic
Medicine (CMDC-PM) and Chinese Psy-
chosomatic Medical Education Alliance
Base were established to provide guarantee
for the establishment of psychosomatic
medicine and acquiring of psychosomatic
medicine related professional knowledge
and skills. Books like Chinese Psychosomatic
Disorder Diagnosis and Treatment Guide,
Chinese Psychosomatic Disorder Clinical Di-
agnosis and Treatment Skills Training Course
[21] and Clinical Psychosomatic Medicine
can guide clinicians in the recognition,
Psychosomatic Medicine
CHINA
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22
­
diagnosis, evaluation and treatment of com-
mon psychosomatic problems.
Summary and Prospect
As to the future, the CSPM sees its role in
the following four aspects: (1) Promote the
overall diagnosis and treatment technology
and level of clinicians through continuous
education and training; (2) Focus on tack-
ling difficult and complicated diseases by
integrating a model of psychosomatic med-
icine to reduce the distress of these patients;
(3) Further improve doctor-patient rela-
tionship by training communication skills,
since doctor-patient conflict is a prominent
problem in the current health service sys-
tem; (4) Strive to solve the general problem
of expensive and burdensome medical treat-
ment so as to make the medical resources
reasonable and effective.
In conclusion, psychosomatic health is an
essential part of building Healthy China, in
which the CSPM plays an important role in
achieving this great goal. Based on the cur-
rent situation, the CSPM will continue to
promote psychosomatic medicine in China
and establish more contacts and have wide
international collaboration. Furthermore,
the CSPM will integrate experts from vari-
ous disciplines and the goal of its members is
applying precision medicine. We will go on
contributing to the improvement of human
health in China and even the world.
References
1. Yuan Y, Wu A, Jiang W. Psychosomatic Medi-
cine in China [J]. Psychother Psychosom, 2015,
84(1):59-60.
2. Wu A, Yuan Y. Progress of psychosomatic
medicine in China [M]. Beijing: China Medi-
cal Electronic Audio Visual Publishing House,
2019.
3. Li L, Peng T, Liu R, Jiang R, Liang D, Li X, Ni
A, Ma H, Wei X, Liu H, Zhang J, Li H, Pang J,
Ji Y, Zhang L, Cao Y, Chen Y, Zhou B, Wang
J, Mao X, Yang L, Fang J, Shi H, Wu A, Yuan
Y. Development of the psychosomatic symptom
scale (PSSS) and assessment of its reliability and
validity in general hospital patients in China [J].
Gen Hosp Psychiatry, 2020; 64:1-8.
4. Yue Y, Li L, Liu R, Zhang S, Sang H, Tang M,
Zou T, Shah M, Sun Y, Shen X, Chen J, Wu A,
Yuan Y. High psychosomatic problems during
the late period of the COVID-19 outbreak in
China [J]. Submitted to Psychosomatic Medi-
cine (under review).
5. Chinese Society of Psychosomatic Medicine.
Expert consensus and standard of diagnosis and
treatment for psychosomatic disorders related to
novel coronavirus pneumonia [J]. J Southeast
Univ (Med Sci Ed) (In Chinese) (In press).
6. Zhang Y, Zhao Y, Mao S, Li G, Yuan Y. The
reliability and validity of a Chinese version short
health anxiety inventory: an investigation of uni-
versity students [J]. Neuropsychiatr Dis Treat,
2015, 11:1739-47.
7. Zhou Y, Dai L, Deng Y. Reliability and validity
of Chinese version of the metacognitions about
health anxiety questionnaire [J]. Chin J Clin
Psychol (In Chinese), 2017, 31(10):906-909.
8. Yue Y, Liu R, Lu J, Wang X, Zhang S, Wu A,
Wang Q,Yuan Y.Reliability and validity of a new
post-stroke depression scale in Chinese popula-
tion [J]. J Affect Disord, 2015, 174:317-323.
9. Li L, Peng TC, Liu R, et al. Development of the
psychosomatic symptom scale (PSSS) and as-
sessment of its reliability and validity in general
hospital patients in China [J]. Gen Hosp Psy-
chiatry, 2020, 64:1-8.
10. Yuan Y, Zhu W, Zhang Z, Bai F, Yu H, Shi Y,
Qian Y, Liu W, Jiang T, You J, Liu Z. Regional
gray matter changes are associated with cogni-
tive deficits in remitted geriatric depression: an
optimized voxel-based morphometrystudy [J].
Biol Psychiatry, 2008, 64:541-544.
11. Shen X, Wu Y, Guan T, Wang X, Qian M, Lin
M, Shen Z, Sun J, Zhong H, Yang J, Li L, Yuan
Y. Association analysis of COMT/MTHFR
polymorphisms and major depressive disorder
in Chinese Han population [J]. J Affect Disord,
2014, 161:73-78.
12. Yue Y, Jiang H, Yin Y, Zhang Y, Liang J, Li S,
Wang J, Lu J, Geng D, Wu A, Yuan Y. The role
of neuropeptide Y mRNA expression level in
distinguishing different types of depression [J].
Front Aging Neurosci, 2016, 8:323.
13. Zhang Y, Yin Y, Yang Y, Bian R, Hou Z, Yue Y,
Xu Z,Yuan Y. Group cognitive behavior therapy
reversed abnormal spontaneous brain activity in
adult asthmatic patients [J]. Psychother Psycho-
som, 2017, 86(3):178-180.
14. Zhi M, Hou Z, Zhang Y, Yue Y, Li L, Yuan
Y. Cognitive deficit-related interhemispheric
asynchrony within the medial hub of the de-
fault mode network aids in classifying the hy-
perthyroid patients [J]. Neural Plast, 2018,
2018:9023604.
15. Guo L, Wang Y, Kang Q, Chen J. Research
progress of magnetic resonance diffusion ten-
sor imaging in white matter changes of anorexia
nervosa [J]. J Shanghai Jiaotong Univ (Med Ed)
(In Chinese), 2019 ,39 (10): 1209-1213.
16. Zhu Z, Xing W, Lu K, Hu M, Zhang G. Cor-
relation between cortisol and clinical symptoms
of patients with posttraumatic stress disorder
[J]. Chin Gen Prac (In Chinese), 2019, 22 (11),
1297-1301.
17. Zheng Y, Li R, Guo H, Li J, Zhang H, Liu X,
Pang X, Zhang B, Shen H, Chang Y. Height-
ened sensitivity to panic-related sounds with
reduced sensitivity to neutral sounds in preat-
tentive processing among panic patients [J]. J
Affect Disord, 2019, 250:204-209.
18. Zhang Y, Yuan Y. Progress in Aromatherapy
Research [J]. Adv Psychol (In Chinese), 2019,
99(11):1816-1825.
19. Wei J, Zhang L, Zhao X, Fritzsche K. Current
Trends of Psychosomatic Medicine in China [J].
Psychother Psychosom, 2016, 85:388-390.
20. Yuan Y,Huang H,Zhang L,Wang C,Liu X,Xu
Z, Zhang W. Balancing psychotherapy and psy-
chosomatic related disorders [J]. Prac Geriatrics
(In Chinese), 2017, 31(10):906-909.
21. Wu A, Yuan Y. Practical clinical skills training
course of psychosomatic medicine in China [M].
Beijing: China Medical Electronic Audio Visual
Publishing House, 2018.
Aiqin Wu,
Department of Psychosomatics, The Affiliated
First Hospital of Suzhou University,
Suzhou, Jiangsu, 215006, China
Chinese Society of Psychosomatic
Medicine (CSPM), Chinese Medical
Association, Beijing, 100710, China
Yingying Yue,
Department of Psychosomatics and
Psychiatry, ZhongDa Hospital,
School of Medicine, Southeast University,
Nanjing, Jiangsu, 210009, China
Yonggui Yuan,
Department of Psychosomatics and
Psychiatry, ZhongDa Hospital,
School of Medicine, Southeast University,
Nanjing, Jiangsu, 210009, China
Chinese Society of Psychosomatic
Medicine (CSPM), Chinese Medical
Association, Beijing, 100710, China
E-mail: yygylh2000@sina.com (Y. Yuan)
Psychosomatic Medicine CHINA
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23
Professional Autonomy
Dr. Şeyhmus Gökalp, member of the Turk-
ish Medical Association’s (TMA) High Dis-
ciplinary Board,was detained during a police
raid on his home early in the morning of 20
November 2020 and officially arrested on
23 November 2020 in the context of an on-
going investigation. Appeals by Dr. Gökalp’s
lawyers for a trial without arrest were turned
down and, and along with the indictment
prepared, the date for the first court hear-
ing was announced on 10 February 2021.
Beyond being an operation targeting a single
person, placing our colleague Dr. Şeyhmus
Gökalp under arrest is actually nothing less
than an assault against a professional organi-
zation, professional values and autonomy as-
suming its concrete form in the victimization
of an elected board member of theTMA,the
organization of physicians in Turkey.The ex-
amination of the TMA history reveals that
it is not the first time when professional au-
tonomy and values have come under threat
through oppressive policies pursued in dif-
ferent periods.
Threats to Professional
Autonomy and World
Medical Association
The medical profession has been in the fo-
cus of interest of political power throughout
the history due to the knowledge it accu-
mulated, ethical values that were developed
and authority it earned. The dominant pro-
duction systems, totalitarian regimes, global
or regional wars and internal conflicts con-
front us when professional independence is
threatened and professional values erode. In
the time when the medical profession and
medical practice are placed under the con-
trol of power groups, there are innumerable
cases where physicians are forced to engage
in practices that are in contrast with the
nature and ethical values of the profession.
In the past century, the crisis of the capital-
ist system that wreaked havoc throughout
the world, the rise of militarism leading to
two world wars and totalitarian regimes all
provided the ground for the abuse of the
profession of medicine.These gloomy expe-
riences brought along the need for interna-
tional cooperation and organization to pro-
tect and defend the professional autonomy
and values. Indeed, the establishment of the
World Medical Organization (WMA) by
27 national medical organizations, includ-
ing the Etibba Chamber, in 1947, when the
ashes of the Second World War were still
warm, was a response to this need and it has
its place in history as a strong institution.
The organization was created “to ensure the
independence of physicians,and to work for
the highest possible standards of ethical be-
haviour and care by physicians, at all times.”
In line with this purpose, the WMA has
since then provided for physicians guide-
lines at a universal level with its statements
and declarations on issues relating to medi-
cal ethics, medical education, professional
autonomy, and social medicine.
TMA and Struggle to Defend
Professional Values
The TMA is a professional organization
of public character established in 1953 on
the basis of Article 1, Law No 6023, stating
the foundation purpose as “protecting pro-
fessional deontology and solidarity among
physicians, ensuring the development of the
profession of medicine to the benefit of the
public and individuals, and defending the
rights and interests of the members of the
profession.” It is within the purview of the
TMA to lay down ethical norms for medical
practice and, in this context, to prepare Dis-
ciplinary Regulations and Statutes related
to Medical Deontology. As a professional
organization, the founding and operational
principles as well as the establishing of the
executive, disciplinary supervision and gen-
eral assembly that are prescribed by law are
also functional and they conduct self-audits.
Indeed, all these organs consist of elected
members and operate in ways to safeguard
the independence of the profession and au-
tonomy of the organization.
Besides its legal status, the TMA is also an
organization known for its decades-long
struggle for public health, good medi-
cal practices, professional independence,
physicians’ rights as well as dealing with
environmental health problems and pos-
sible solutions. The TMA has maintained
its uncompromising position concerning
the delivery of quality health services that
are equal and accessible to all and in line
with the ethical principles of the ­
profession.
Threats to Professional Autonomy Continue in Turkey
Mustafa Taner Goren Hafize Ozturk Turkmen Naki Bulut
TURKEY
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24
Professional Autonomy
The organization’s approach proceeds from
this principled stance that medical prac-
tice cannot be abstracted from fundamen-
tal human rights including the right to life
and the right to health as well as universal
professional values enshrined in WMA
documents. Accordingly, the same principle
required standing against the destructive
consequences of neoliberal patriarchal capi-
talism prevailing in the country with its ef-
fects on public health, oppressive regimes,
and militarism. It is for this challenging
tradition that the TMA has been one of the
main targets of political power groups. At
all times when the attitude of the profes-
sional organization clashed with the opin-
ion of the political power, the policy of op-
pression and intimidation has been directed
against the professional organization that is
regarded as the centre of opposition. In this
context, it will be sufficient to take a look at
the acts of oppression within the last forty
years which are also known as “TMA’s Tri-
als of Honour.”
Following the military coup of 12 Septem-
ber 1980, many trade unions, associations
and professional organizations became
the target of military oppression while the
archive of the TMA in its head office in
İstanbul was seized to erase the organiza-
tional memory of the organization and the
President of its Central Council was ar-
rested. Then Decrees with the force of Law
(KHK), issued in 1983, made many changes
in TMA Law No 6023, transferring the
head office of the organization to Ankara
and compulsory membership for physicians
working in the public sector was lifted with
the intention of weakening the organiza-
tion. It is after this rearrangement that the
majority of physicians are still members of
the TMA (total 65%).
The attempts by ruling governments to de-
functionalize and undermine the autonomy
of the professional organization unfortu-
nately did not remain limited to the peri-
ods of military coup. For example, KHK
No 663 of 2011 provided for establishing
the Board of Medical Occupations, most
of whose members were appointed by the
government. The Board was authorized to
deal with many issues that used to be the
responsibility of the TMA including deci-
sions on and assessment of issues related
to curricula in medical education, fields of
specialization, professional competence and
employment, professional ethics, and ex-
pulsion from the profession. Moreover, the
phrase “ensuring the practice and improve-
ment of the profession of medicine to the
benefit of the public and individuals”in Ar-
ticle 1 of the TMA Law was deleted. This
multi-pronged assault on the autonomy of
the professional organization triggered the
reaction of medical community in the coun-
try and in the world and the WMA made
a call on national medical associations to
denounce the assault and to act in solidarity
with the TMA. At the meetings – WMA
Comes Together with Doctors for their In-
dependence and Autonomy of their Profes-
sional Organization – organized in Ankara
and İstanbul on 16-17 April 2012 jointly
by the TMA and WMA, the importance of
professional independence and autonomy
was voiced strongly.The amendment (KHK
No 663) made to Article 1 of the Law on
TMA was later annulled by the Constitu-
tional Court in 2013.
In the first lawsuit brought against theTMA
in 1985, the removal of the Central Council
from office was requested on the ground that
the association was engaged in an inappro-
priate activity by asking for the abolishment
of capital sentence. Prof. Dr. Nusret Fişek,
President of the TMA Central Council,said
in his defence statement that “the TMA has
the right to state its opinion on the right to
life, which is a fundamental human right,
and on the problems of the country; we
just performed our duty by asking for the
abolition of capital punishment”, which was
in conformity with the WMA resolution
stating that it is unethical for physicians to
participate in capital punishment. The case
ended in acquittal and capital punishment
was abolished in 2004.
With a lawsuit brought in 2001, the indict-
ment had the purpose to have the Central
Council of TMA removed from office for
informing the public about the physicians’
attitude in hunger strikes as laid down by
the WMA Declaration of Malta and stand-
ing against forced feeding under the pres-
sure of the government and “return to life
by killing”. Dr. Fusan Seek, President of the
Central Council, and Council members of
the time stated: “The profession of medicine
approaches human life beyond all concepts
and concerns and builds its system of values
by placing the human life and health at the
centre of all issues. Anything and any act
that harms human life and health contradict
the nature of the profession of medicine and
the basis of its system of values and there-
fore are unacceptable.” The TMA leaders
were acquitted.
In another case opened in 2014, the lead-
ers of the Medical Chambers of Ankara,
İstanbul and Hatay were to be removed
from office because their members had pro-
vided first aid,in line with WMA principles,
to people who were injured during civilian
protests known as ”Gezi.” As in other simi-
lar cases, this one ended in acquittal, too.
Another example is the court process start-
ing with the detention of Central Coun-
cil members following the TMA Central
Council statement “War is a Public Health
Problem” on 24 January 2018. The case
opened with the allegation of explicitly in-
citing people to hatred and enmity, spread-
ing the propaganda of an organization that
stands against war and defends peace was
defined as “crime”; the Central Council
members, including Dr.  Şeyhmus Gökalp,
were sentenced to imprisonment for twenty
months. This statement by the TMA, how-
ever, falls in with the opinion of the WMA,
which says, “Physicians should encourage
politicians,governments,and others in posi-
tions of power to be more aware of the con-
sequences, including the impact on health,
of their decisions on the commencement or
continuation of armed conflict.” Presently,
TURKEY
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25
Professional Autonomy
the Ankara Regional Court of Appeals ex-
amines the case. During the court cases in
2014 and 2018, many professional organi-
zations, including the WMA and Standing
Committee of European Doctors, sided
with the TMA and enjoyed international
professional solidarity.
Besides the court cases brought against the
TMA and intimidation policies in general,
it must be added that there are also frequent
threats to and even court cases against clini-
cal independence. In this context, there are
colleagues who stood trial for having acted
in line with professional ethics, i.e. refusing
to submit reports contradicting the realities
in detention processes and standing against
handcuffed medical examination of persons
under the supervision of security forces or
refusing to conduct sexual intercourse ex-
amination upon the pressure of third par-
ties without the approval of the person con-
cerned.
Preparations for Legislative
Intervention in Professional
Organizations
Much broader in scope than the oppressive
policies mentioned above is another policy
the government has on the agenda for the
last two years. Besides the TMA, profes-
sional organizations of public character,
like the Turkish Bar Association and the
Union of the Chambers of Architects and
Engineers, have also become the targets of
the government for standing against poli-
cies that have the effect of undermining the
right to health, fair trial and environment
and defending democracy and professional
autonomy. The prevailing authoritarian and
oppressive regime is now trying to stultify
and control professional organizations op-
posing its policies through various legisla-
tive arrangements. In fact, the government
gave effect to an amendment to the Law on
Bar Associations making it possible to have
more than one bar association in a specific
constituency which was a step to split these
associations by changing election methods
and the number of delegates. It is known
that a similar path is also considered for
the TMA and in fact openly stated as ac-
companied by the discourse “TMA must be
banned”by the partner party.Presently,there
is a political climate where those opposing
the government are readily labelled as “ter-
rorists”; the elected mayors are replaced by
trustees; legal system and visual/printed
media are both instrumentalized for sup-
porting the ruling government; and where
civil society/democratic organizations and
opposing voices are silenced without any
reasonable justification. The ­
Covid-19
pandemic breaking out and spreading in
such an environment laid bare that face of
the government, which is far from scien-
tific evidence and transparency, incapable of
managing the pandemic and ineffective in
protecting people’s health. While the TMA
as a professional organization is capable of
making its unique contribution to the man-
agement of the process with its endowment
of knowledge and experience, it confronted
many obstacles including exclusion from
pandemic boards and concealment of rel-
evant information and data. In spite of all
these obstacles, the TMA became a focus of
interest with its scientific, rational and ethi-
cal approach to the issue starting from the
early days of the pandemic and gained wide
trust with its efforts to inform the public.
The political power who sought to discredit
and block the TMA on every occasion, of
course, is annoyed by this situation.
Who is Dr. Şeyhmus Gökalp?
Born in Nusaybin District of Mardin
in 1977, Dr.  Şeyhmus Gökalp spent his
childhood and adolescence in a region
that seemed to be destined to internal
conflicts and poverty. Dr.  Gökalp gradu-
ated from the Faculty of Medicine in Fi-
rat University in 2002 and the same year
started participating in the activities of the
Diyarbakır Chamber of Medicine where
his fields embraced worker’s health and oc-
cupational medicine, human rights, health
services in emergencies, and press/media
relations. He was elected to the Auditing
Board of Diyarbakır Chamber of Medicine
for the term 2004-2008 and a TMA Gen-
eral Assembly delegate from Diyarbakır in
the period 2014-2020. Recognized for his
productive work and commitment to the
organization, the Medical Chambers of
the region nominated Dr.  Gökalp and he
was elected to the Central Council of the
TMA for the term 2014-2018. During his
Council membership, Dr. Gökalp made in-
tensive efforts to ensure that TMA policies
are translated into life in line with profes-
sional ethics. Dr. Gökalp is one of the Cen-
tral Council members who were detained
and then sentenced for the Central Council
statement “War is a public health problem”
made in January 2018 at the time when war
and militarist policies escalated, and inter-
nal conflicts were refuelled in the country.
His statement during the trial “We cannot
just ignore the truth and don’t hesitate to
express the truth we see” remains fresh in
our memory as the key concept in a phi-
losophy of life. Dr. Gökalp was dismissed
from public service upon a KHK decree is-
sued during OHAL (State of Emergency)
and was elected a High Disciplinary Board
member by the 72nd
General Assembly
meeting of the TMA held in 2020.
What Does the Arrest of
TMA High Disciplinary
Board Member Dr. Şeyhmus
Gökalp Mean?
The TMA High Disciplinary Board, where
Dr. Şeyhmus Gökalp serves as a member,
occupies a critical place in protecting pro-
fessional deontology and ethical values.
Disciplinary boards of individual chambers
of medicine and the High Disciplinary
Board are authorized to act in their capac-
ity to launch investigations when examin-
ing medical practices with reference to
TURKEY
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26
professional deontology and ethical prin-
ciples including applications made by other
parties, as well as to examine files sent by
public agencies that conduct their own ad-
ministrative investigations. Qualifications
required to be elected to the High Disci-
plinary Board include 15 years of work in
the profession and not being penalized for
any deed specified in the relevant regula-
tions. The Board is composed of members
from the profession who are recognized for
their commitment to good medical prac-
tices and scientific standards in their re-
spective fields of specialization. Gender, age
and geographical representation are other
factors considered in nominations. This
sensitivity regarding the composition of the
Board is also guaranteed by regulations on
its working principles and procedures. The
High Disciplinary Board fulfils its obliga-
tion to protect the prestige of and trust in
the profession, rights of patients and phy-
sicians, professional deontology and ethi-
cal values through meticulously conducted
disciplinary investigations with reference to
national and universally recognized prin-
ciples. These principles are laid down by a
set of legislative texts and other documents
including TMA Law No 6023, the Law on
the Practice of Medicine and Other Health
Professions, Medical Deontology Statute,
Ethical Rules in the Profession of Medicine,
TMA Disciplinary Regulations, Biomedi-
cine Convention and WMA and TMA
Declarations and Statements as guiding
documents. In other words, the domain of
the TMA High Disciplinary Board is at the
intersection point of professional ethics and
health legislation and its working principles
are based on legal validity and professional
ethics. The TMA High Disciplinary Board
is the highest decision-making body to
conclude disciplinary investigations within
the profession. Challenges against penal-
ties given by individual chamber boards and
penalty of expulsion from the profession are
directly handled and resolved by the High
Disciplinary Board.
The supervision of medical practices by
boards of discipline of individual medical
chambers and the High Disciplinary Board
whose members are elected in democratic
ways by physicians and that are indepen-
dent of all outer influences is vital in ensur-
ing and safeguarding professional autono-
my. This principle is also in full conformity
with WMA policy documents including
the Seoul Declaration on Professional Au-
tonomy and Clinical Independence, Cesky
Krumlov Memorandum on Public Func-
tions and Professional Representation by
Chambers of Physicians (and Dentists) and
Madrid Declaration on Professionally-Led
Regulation.
As mentioned above, the TMA High Dis-
ciplinary Board member Dr.  Şeyhmus
Gökalp was detained and arrested under in-
vestigation while his statement could have
been taken without any such measure. The
reason for the arrest is based on the testimo-
ny of an anonymous witness who became a
confessor in 2016. The interesting point is
that while Dr. Gökalp was not mentioned
at all in the first testimony of this witness,
a new testimony given in 2019 is full of
groundless allegations against Dr.  Gökalp
with whom the witness had never met. De-
spite resolutions by the Court of Appeals,
Constitutional Court and the European
Court of Human Rights that statements
of this kind by confessors should have no
evidential value, the arrest of Dr.  Gökalp
was based on such statements. Moreover,
calls from the country, the WMA and the
Standing Committee of European Doc-
tors for the release of Dr.  Gökalp were
ignored. Above all, it must be stated that
Dr.  Gökalp’s commitment to professional
ethical values and human rights has earned
him a professional career that cannot be
stained by the statements of false witnesses.
Given his status as a representative of an
institution, Dr. Gökalp’s arrest also means
an assault to the autonomy of a professional
organization.
Conclusion
The arrest of the TMA High Disciplinary
Board member Dr. Şeyhmus Gökalp is not
a practice that can be grasped by missing the
political climate that surrounds the event.
We regard this as an act moving beyond hu-
man rights, law and justice by targeting a
physician committed to the principles and
ethics of his profession. It can be said that
the prevailing anti-democratic, unjust and
unlawful practices in the country are epito-
mized in the case of Dr. Gökalp,a respected
member of one of the most esteemed or-
gans of our organization.The expectation of
justice is maimed by acts that target phy-
sicians with false statements by confessors,
ungrounded accusations, slanders, unproven
allegations and unlawful procedures. Espe-
cially in the present pandemic environment,
these practices are tantamount to a multi-
faceted violation of human rights including
the right to work, right to health, right to a
decent life and the right to be free from any
stigmatization; it also brings along serious
threats to professional autonomy and inde-
pendence.
We are aware that the intention is to crimi-
nalize Dr.  Gökalp, our colleague known
for his uncompromising stance in defend-
ing the ethics and values of the profession
of medicine. However, we are also sure that
the truth will finally prevail, his innocence
will be proved, and all efforts will be made
for his release. We declare once more that
we are in solidarity with our colleague and
expect the same from our colleagues world-
wide.
Prof. Mustafa Taner Goren,
The Chair of the High Disciplinary Board
Assist. prof. Hafize Ozturk Turkmen,
Member of the High Disciplinary Board
Dr. Naki Bulut
Member of the High Disciplinary Board
Professional Autonomy TURKEY
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27
Covid-19 and Vaccination
The COVID-19 pandemic has heightened
awareness of the public health role of phy-
sicians. Falling rates of immunization for
childhood illnesses, public scepticism, and
emergence of new diseases have served to
underscore physicians’ responsibilities re-
lated to vaccines. These responsibilities
include protecting the health of the phy-
sician, patients, and the larger community
by promoting shared decision-making and
counteracting vaccination misinformation.
The pandemic has brought the physician’s
public health role with respect to vaccina-
tions and intertwined ethical considerations
to the fore.
Physician Vaccination
In the context of a disaster, such as the
COVID-19 pandemic, a physician’s ethi-
cal obligation is to subordinate their per-
sonal interests to those of their patients.The
American Medical Association (AMA)
Code of Medical Ethics states that a physi-
cian’s first duty in a disaster is to “provide
urgent medical care…even in the face of
greater than usual risk to physicians’ own
safety, health and life.”
Since the physician workforce is not an
unlimited resource, physicians are also ex-
pected to assess the risks of providing care
to individual patients against the ability to
provide care in the future.The AMA Code of
Medical Ethics also requires that “physicians
protect their own health to ensure that they
remain able to provide care.”
These two opinions, when considered to-
gether, argue strongly for the physician to
accept immunizations unless medically
contraindicated. This is especially true for
diseases like COVID-19 that are easily
transmitted and represent a higher medi-
cal risk for patients, co-workers and others
with whom the physician is in contact. A
physician’s responsibility is balanced against
other factors including the safety and effi-
cacy of available vaccines and the prevalence
of the disease the vaccine wards against.
Physicians should not be required to accept
immunization with a novel agent until and
unless there is a scientifically valid body of
evidence that supports its safety and efficacy.
Non-medical exemptions for physician
vaccination pose ethical concerns. Physi-
cians who decline to be vaccinated for non-
medical reasons such as long-held personal
beliefs put themselves and others at risk for
contracting a vaccine-preventable disease.
Non-medical vaccine exemptions should be
limited and squarely balanced against other
interests.
Physicians who are not or cannot be vacci-
nated have an obligation to protect patients,
fellow health care workers, and the larger
community. This includes refraining from
direct patient contact when appropriate.
Responsibility to Promote
Shared Decision-making
The patient-physician relationship is based
on trust, and patients rely on their physician
to provide them with accurate information
sound guidance. Physicians play a signifi-
cant role in influencing patient perspectives
about vaccine safety and efficacy and have
an obligation to educate patients about the
danger of delaying or denying vaccination,
while also acknowledging patient concerns
in a credible and trustworthy manner.
With regards to COVID-19 vaccinations,
patients have the following main concerns.
• Vaccine Safety: The speed at which
­
COVID-19 vaccines are being developed
and manufactured is unprecedented. This
was in part due to steps in the develop-
ment process being done simultaneously,
and that many administrative roadblocks
were streamlined or eliminated. Physi-
cians should reassure patients that no
shortcuts were taken in the scientific
process, including the careful evaluation
of the results of clinical trials and receipt
of regulatory approvals on an expedited
basis. Physicians should also educate pa-
tients about the characteristics of mRNA
vaccines, including the fact that none of
them contain live virus and therefore will
not infect vaccine recipients.
• Vaccine Side-Effects: Even though avail-
able COVID-19 vaccines generally have
few and mild side effects, as with any
vaccine, more severe effects may occur.
Physicians should carefully listen to a pa-
tient’s concerns and provide reassurance
that side effects serious enough to require
medical attention are rare and are expe-
rienced by only a small fraction of those
receiving the vaccine. Providing positive
anecdotes about others who have success-
fully received the same vaccine may be
beneficial.
• Vaccine Efficacy Across Various Patient
Cohorts: In the United States, Hispan-
ics made up 20% of those participating
in the Moderna vaccine trial and 13%
Gerald E. Harmon
Physicians and Ethical Issues Related to
Covid-19 Vaccines
USA
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28
Spotlights of National Medical Associations
of the Pfizer vaccine trial, while African
Americans made up 10% of each trial’s
participants.
The National Medical Association
(NMA) – the largest organization for Afri-
can American physicians and their patients
in the United States – found those percent-
ages to be large enough to have confidence
in the overall health outcomes in the clinical
trials.The NMA COVID-19 Task Force on
Vaccines and Therapeutics met with clinical
scientists from Moderna and Pfizer and re-
viewed clinical outcome data from the U.S.
Centres for Disease Control and Prevention
and the Food and Drug Administration
(FDA) to look for any indications that the
African American community might be at
higher risk of unfavourable outcomes from
the vaccine.
The task force found that efficacy and safety
of the vaccine were observed and consistent
across age, gender, race, ethnicity and in the
elderly. As a result, the NMA supported the
FDA grant of emergency use authorization
for both vaccines.
Responsibility to Counteract
Misinformation and
Vaccine Hesitancy
Misinformation and conspiracy campaigns
against vaccination are common and perva-
sive. Physicians have an obligation to inform
themselves of these campaigns and ideally
to counteract misinformation, especially on
social media. Failure to do so may allow un-
proven theories to proliferate and overtake
scientific truths which in turn will thwart
progress in achieving widespread immunity.
Patients who believe vaccination is a per-
sonal choice are not likely to be moved by
scientific evidence or statistics. A more ef-
fective method for physicians to encour-
age vaccination amongst those who would
otherwise decline a vaccination may be to
appeal to the patient’s desire to protect
family members and others who live or
interact with them regularly, using simple
language that communicates effectively
and makes it easy for patients to apply to
their own lives. Physicians can use their
established trust-based relationship with
their patients to communicate that they
themselves have been vaccinated and why
they personally believe it is important and
safe to vaccinate in general, and for CO-
VID-19 specifically.
Dr. Gerald E. Harmon,
President-Elect
American Medical Association
COVID-19 has wreaked havoc on the lives
and livelihoods of Myanmar communities,
who are dealing with an unprecedented cri-
sis. Myanmar doctors from public and pri-
vate sectors have collaborating together and
sacrificing their lives starting from March
2020 till early February which enable the
country to flatten the curve at this time of
greatest need.The military junta unlawfully
captured all three powers of the state on
February 1, 2021, and detained Myanmar
President U Win Myint, State Counsellor
Daw Aung San Suu Kyi,legitimate govern-
ment officials, and parliamentarians who
were elected routinely, according to demo-
cratic rules and the people’s free will. On
the evening of the coup, assistant surgeons,
who are newly graduated doctors who have
joined civil hospitals across the country
Myanmar, began discussing the issue and
how to save patients from the dictatorship
on their social private channels. On Feb-
ruary 3, 2021, assistant surgeons and post-
graduate doctors from Myanmar’s public
hospitals, along with other health profes-
sionals, launched the Civil Disobedience
Movement (CDM), vowing to close public
hospitals across the country in defiance of
the new military junta that took control of
the government and seized civilian leaders
in a coup [1].These doctors made a difficult
decision in the best interests of the Myan-
mar patients’ health and well-being in the
future. They have seen how the Myanmar
military dictatorship has harmed the health
and well-being of patients with limited re-
sources in the past. If the doctors allowed a
coup to succeed, the patients would be the
ones who suffered the most. Government
hospitals are only accepting emergency
cases, and some hospitals are refusing new
patients because the majority of their staff
is enrolled in the CDM. One week after
the coup, specialist assistant surgeons, con-
Wunna Tun
Myanmar Doctors Solidarity against Military
Coup d’état
MYANMA
BACK TO CONTENTS
29
Spotlights of National Medical Associations
sultants, and other government employees
joined the fight against the coup. No new
patients are being accepted at hospitals
in Yangon, Mandalay, Pathein, Muse, and
Sagaing. On February 9, the health and
sports ministry, which is illegally controlled
by the military junta, issued a letter urging
the doctors to return to their civil hospitals
[2].How,however,can doctors provide clin-
ical care and apply their medical knowledge
without infringing on human rights and
civil liberties under military dictatorship?
While participating in the CDM, doctors
provide free medical treatment at charity
clinics, private clinics, and hospitals with
the assistance of well-wishers from within
and outside the country [3]. Furthermore,
doctors have a strong sense of commitment
and care for their patients in the event that
they are unable to visit the clinic in person,
and they offer teleconsultation via various
telecommunication channels to provide
management for the diseases [4]. In the
latter weeks of February, some CDM doc-
tors fled from their homes to another towns
to avoid being abducted by the military
regime, but some were apprehended [5].
Doctors providing emergency care and am-
bulances transporting patients have been
targeted and shot by security forces for no
apparent reason. In the last week of Febru-
ary, the World Medical Association issued
a strongly worded statement urging the im-
mediate release of all health-care workers
and ensuring the physical and psychologi-
cal integrity of those who have been arrest-
ed in Myanmar, as well as the cessation of
all forms of harassment [6]. On February
28th, more than 200 doctors protesting the
military junta were arrested in a single day.
The military junta was increasingly tar-
geting doctors who provided emergency
medical care, whether they were CDM or
not. Armed security occupied West Yan-
gon General Hospital by force on March 7,
2021, and later Yangon General Hospital;
North Okkalapa Hospital; South Okkalapa
Women and Children’s Hospital; East Yan-
gon General Hospital; and Central Wom-
en’s Hospitals and other hospitals across
the country including Mandalay, Monywa,
and Taunggyi [7]. The United Nations Of-
fice for the Coordination of Humanitarian
Affairs (UN OHCHR) has condemned
such activity as completely unacceptable,
as hospitals are protected by international
humanitarian law. (8) These strong inter-
national statements are doing little to al-
leviate the strain on doctors who provide
emergency care in clinics and hospitals.
Every day, Myanmar doctors are forced
to relocate their clinics after being abused
and threatened by security forces attempt-
ing to prevent them from treating injured
people. Nowadays, many front-line doc-
tors are willing to give up their own lives
to save others because they do not want
to die with guilt and want to do their best
for their country [9]. There have been two
doctors killed on the frontlines while pro-
viding medical care, and one of them left
his handwritten last will and testament be-
fore being fatally shot, stating that we must
never give up until we achieve democracy
[10]. On behalf of doctors in Myanmar, we
would like to appeal to National Medical
Associations and doctors worldwide for
solidarity and understanding during these
challenging time in Myanmar.
References
1. Shepherd A. Myanmar medics resist military
coup. BMJ 2021;368.
2. Doctors joining CDM in Myanmar will con-
tinue fight against COVID-19 [Internet]. The
Myanmar Times. 2021 [cited 30 March 2021].
Available from: https://www.mmtimes.com/
news/doctors-joining-cdm-myanmar-will-con-
tinue-fight-against-covid-19.html
3. World Medical Association. 2021. WMA – The
World Medical Association-WMA Declaration
of Geneva. [online] Available at: [Accessed 30 March 2021].
4. Online support from doctors during the CDM
[Internet]. The Myanmar Times. 2021 [cited
30 March 2021]. Available from: https://www.
mmtimes.com/news/online-support-doctors-
during-cdm.html
5. The Irrawaddy. 2021. Myanmar Medics in Hid-
ing as Regime Targets Hospital-Led Disobedi-
ence Movement. [online] Available at: [Accessed 30
March 2021].
6. WMA – The World Medical Association-Har-
assment and arrest of doctors in Myanmar con-
demned by physician leaders [Internet]. Wma.
net. 2021 [cited 30 March 2021]. Available
from: https://www.wma.net/news-post/harass-
ment-and-arrest-of-doctors-in-myanmar-con-
demned-by-physician-leaders/
7. Myanmar Military Must Cease Occupation of
Hospitals and Excessive Force Against Civil-
ians: PHR  – Physicians for Human Rights
[Internet]. Physicians for Human Rights. 2021
[cited 30 March 2021]. Available from: https://
phr.org/news/myanmar-military-must-cease-
occupation-of-hospitals-and-excessive-force-
against-civilians-phr/
8. Helen Regan C. Myanmar military occu-
pies hospitals and universities ahead of mass
strike [Internet]. CNN. 2021 [cited 30 March
l 2021]. Available from: https://www.cnn.
com/2021/03/08/asia/myanmar-military-hospi-
tals-mass-strike-intl-hnk/index.html
9. Theint B, Nicola Smith. ‘I might get killed just
for doing my job’: Myanmar medics set up se-
cret clinics to avoid brutal military [Internet].
The Telegraph. 2021 [cited 30 March 2021].
Available from: https://www.telegraph.co.uk/
news/2021/03/29/might-get-killed-just-job-
myanmar-medics-set-secret-clinics/
10. Gavin Blair D. Doctor’s final message to Myan-
mar protesters: Never give up until we get de-
mocracy [Internet]. Thetimes.co.uk. 2021 [cited
30 March 2021]. Available from: https://www.
thetimes.co.uk/article/doctors-final-message-
to-myanmar-protesters-never-give-up-until-
we-get-democracy-cc79k769t
Wunna Tun,
MBBS, MD
Fellow in Medical Education
Secretary, JDN, World Medical Association
MYANMA
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30
Physician Health
Introduction
Substance use disorders and behavioural
addictions are treatable diseases that can
happen to anyone, physicians included.
These disorders not only affect the health of
the individual in question, but in the case of
healthcare professionals they can also have
a potential impact on their professional im-
age and on patient safety [1]. An American
study showed that substance use disorders
are more prevalent among physicians than
the general population, affecting 1 in 7 phy-
sicians (15.3%) compared to 1 in 8 (12.6%)
members of the general population [2].
Healthcare professionals are more likely to
misuse alcohol and prescription drugs such
as sedatives and opiates than the general
population [3]. Risk factors for addiction in
physicians include high levels of stress and
responsibility at work, a disrupted lifestyle
due to inconsistent working hours and easy
access to prescription drugs [4].
Against this background, the Royal Dutch
Medical Association (RDMA) took the
first steps in 2011 to set up a counseling ser-
vice for physicians (and those around them)
who are affected by substance use disorders
and addiction. Alongside this counseling
service, the RDMA committed to raising
awareness of physicians with substance use
disorders and addiction in healthcare since
2019. The Dutch Physician Health Pro-
gramme (PHP) is called ABS-physicians in
the Netherlands. The ‘ABS’ abbreviation in
ABS-physicians stands for abstinence from
addictive substances.
The Dutch Physician Health Programme
(PHP) currently has two tasks:
1. A counseling service for physicians that
provides confidential help, advice, guid-
ance and/or monitoring to physicians
who are affected by substance use disor-
ders and addiction and to those around
them.
2. Raising awareness within the healthcare
sector about substance use disorders and
behavioural addiction, which are treat-
able diseases. Informing and motivating
physicians and those in their profes-
sional environment to act upon this, to
ensure a healthy and safe working and
learning environment, where substance
use and addiction can be openly dis-
cussed. A special tool kit has been de-
veloped to achieve this.
Physician Health Programme:
counseling service
The RDMA set up the physicians counsel-
ing service in 2011 to help physicians who
are affected by substance use disorders or
addiction and those around them.The team,
consisting of psychiatrists, addiction doc-
tors, psychologists and social workers, is
specialised in supporting physicians, who
are affected by substance use disorders or
addiction.
Help and advice
Known barriers that prevent physicians
from seeking help include; embarrassment,
wanting to stay in control and concerns
about privacy [5]. Some physicians also feel
a great deal of responsibility towards their
patients or colleagues, which prevents them
from seeking help. These factors contribute
towards denial, downplaying matters and
delaying seeking help, creating an addition-
al risk to the physician’s own health, patient
safety and quality of care.
The PHP is an accessible service that pro-
vides physicians and those around them
with (anonymous) help, advice, guidance
and/or monitoring. The special phone
number is available on working days, be-
tween 9 a.m. and 8 p.m. Callers can speak
directly to an expert in addiction care. This
expert listens without judgement and pro-
vides advice. The expert helps to answer
Marlies de Rond
Substance Use Disorders and Addiction in Physicians:
a Dutch Physician Health Programme
Joanneke Kuppens
BACK TO CONTENTS
31
Physician Health
important questions such as ‘Do I have
an addiction?’, ‘What steps can I take to
address this?’ and ‘Where can I receive
appropriate and confidential treatment?’
Physicians calling on their own behalf are
always invited to attend a personal consul-
tation, preferably accompanied by some-
one close to them.
Family, friends, and colleagues can also
contact the PHP for advice. For instance,
regarding the suspicions or doubts whether
an individual is experiencing substance use
disorder or addiction. Or how to raise the
topic of substance use disorder or addiction
to allow it to be discussed, and about po-
tential ways to address the topic with the
physicians in question. Finally, physicians’
employers can call the PHP for advice on
next steps that can or must be taken to limit
risks to patient safety and to help their em-
ployee. The PHP therefore acts as a confi-
dential support and counselling service, not
a point of contact to report a physician, for
those in the environment of the physician
in question.
Support towards and during
treatment
Physicians often have difficulties in seeking
help, and becoming a patient themselves.
Obtaining help in the conventional way, for
instance by visiting a colleague physician,
does not always live up to expectations.
Moreover, treating a colleague physician re-
quires special skills on the part of the treat-
ing doctor [6]. The PHP refers physicians
to practitioners who specialise in addiction
medicine and are experienced in treating
physicians. As in the US PHPs, the Dutch
PHP does not carry out the treatment itself,
but rather refer physicians to an appropriate
setting [7]. However, the PHP does provide
support during the treatment, to accept the
role of being a patient and to direct physi-
cians towards monitoring. It is not always
necessary for physicians to go on sick leave
during treatment.
Monitoring during the return to work
Following successful treatment, the PHP
can support physicians in a safe and suc-
cessful resumption of work by providing a
special five-year monitoring programme.
During the monitoring programme, par-
ticipating physicians are supported by in-
dividuals in their immediate environment
and remain in close contact with their case
manager of the PHP. A colleague acts as a
workplace buddy, while someone close to
them acts as a personal buddy. The occu-
pational physician assesses the physician’s
ability to work and the physician contacts
his GP or addiction doctor when needed,
self-doctoring is not permitted within the
programme. Finally, the programme also
includes participation in a self-help group.
In addition, the physician will undergo ran-
dom abstinence testing. This involves the
random collection of urine, sputum, or hair
samples.The frequency of laboratory testing
decreases over the years, but can be scaled
up temporarily if needed in the event of a
potential or actual relapse.Tests are tailored
to the physician’s situation as much as pos-
sible to ensure minimum disruption to their
professional or personal life without losing
the effect of randomisation.
There are two reasons for physicians to take
part in the monitoring programme.The first
is a greater likelihood of personal recovery
with this programme, than with conven-
tional treatment alone. The programme is
based on the PHP’s conducted in the US
and Canada. These initiatives are effec-
tive: 79% of physicians continue to work
after following a five-year monitoring pro-
gramme and still have their substance use
under control after this period.
A second reason for taking part is the
physicians’ need for support in resump-
tion to work. Physicians who have under-
gone treatment often find it very difficult
to return to their workplace. They need to
learn to handle work-related risk factors
differently. Risk factors, such as high lev-
els of stress and responsibility and varying
working hours are inherent to the medical
profession. It is therefore important to learn
how to deal with them differently, in order
to minimise the risk of relapse and to obtain
rapid and appropriate help if relapse occurs.
Moreover, by taking part in the programme
physicians demonstrate to themselves, their
colleagues and employers that they are do-
ing everything they can, to work safely [9].
Physician Health Programme:
raising awareness
The experience gained by the support ser-
vice since 2011 shows that individuals in
a physician’s immediate environment can
play a vital role in identifying substance use
disorders and addiction, and allowing the
topic to be discussed. This has been con-
firmed by RDMA research, which shows
that getting a colleague to open up about
substance use is not easy. Almost all physi-
cians (95%) indicated that they would take
action upon a substance use presumption in
a colleague. Of the 29% who ever had this
presumption, 65% took actual action while
35% took no action [10]. To increase the
percentage of physicians who actually take
action, the RDMA launched an awareness
project in 2019 that involved the develop-
ment of a campaign and a tool kit designed
to stimulate and facilitate a dialogue on
substance use disorders and addiction with
a colleague.
Campaign
The RDMA has developed a special aware-
ness campaign on substance use disorders
and addiction, to encourage physicians to
engage with and talk about this topic. The
campaign is themed around thought-pro-
voking questions and facts, see Box 1.These
questions and facts prompt physicians to
raise the topic of substance use disorders
and addiction with their colleagues or net-
BACK TO CONTENTS
32
work, and to emphasise the urgent need for
these discussions. The questions can also be
used during peer support sessions or educa-
tion programmes. Charts, roll-up banners,
ads and online banners featuring the ques-
tions and facts are available.
Tool kit
With the PHP tool kit, RDMA supports
healthcare organisations and private practi-
tioners in creating a healthy and safe working
and learning environment, where addiction
is treated as a disease, and substance use dis-
orders and addiction are open to discussion.
The tool kit contains tools and tips for both
organisations and individual physicians.
For organisations: developing policy and
signing a declaration of intent
Substance use disorders and addiction im-
pact on an individual’s performance and
health, and do not mix well with work. In
the case of healthcare professionals, this can
lead not only to sickness and absenteeism,
but also risks to patient safety and quality
of care. Research shows that 20–25% of ac-
cidents at work are alcohol-related [11].The
annual productivity loss due to alcohol use
in the Netherlands is an estimated 1.3 bil-
lion euros [12].
It is essential for organisations to develop
policy to safeguard employees, patient safe-
ty and quality of healthcare. Organisations
can opt on the harm reduction model or
the prevention model. The harm reduction
model focuses only on setting standards,
rules and measures. The prevention model,
which is preferred, is also aimed at prevent-
ing substance use disorders and addiction
and policy aimed at offering help and sup-
port to those affected,as well as during their
rehabilitation. Most important is, that the
policy is aimed at helping employees affect-
ed by substance use disorders and addiction
and keeping them in work. See Box 2.
The tool kit provides a policy plan for or-
ganisations entitled Working in healthcare:
substance use and addiction. This format
can be used as guide for formulating and
implementing policy or optimising exist-
ing policy. In addition, there is an instruc-
tion manual and a communication plan.The
instruction manual explains how organisa-
tions can use the format to develop their
Box 1. Questions and facts used in the campaign 
Examples of questions
Would you send a text message saying ‘get
well soon’ to a colleague who has an addic-
tion?
Treat addiction as a disease
What do you prescribe yourself?
There is also an options menu for coping
Substance use and addiction: do you recog-
nise the signs?
Talking about addiction is complex
Examples of facts
Out of every ten physicians, seven are in
favour of workplace rules on substance use
and addiction.
Treat addiction as a disease
About 80% of physicians want to learn how
to act on a presumption of substance use or
addiction in a colleague.
Talking about addiction must be ap-
proached with care
Box 2. The four pillars of the policy plan
1. 
Standards and rules.The organisation describes the applicable standards and rules
regarding substance use before and during work and regarding addiction.The rules are
designed to avoid a reduced level of performance by employees as a result of substance
use or addiction.
2. 
Provision of information, training and education.This section focuses on raising
awareness of the risks of substance use disorders and addiction and preventing or
reducing these risks.
3. 
Possibilities of help.This section describes what an organisation can offer in terms of
assistance and support to employees affected by substance use disorders and addiction.
The basic principle is that addiction is a disease and is treated as such. It is important
that employees are aware of this underlying principle and feel able to seek help and
treatment where needed.
4. 
Measures.This section deals with enforcement and the measures that may be taken,
for instance if an individual is under the influence at work or drops out of a treatment
programme for no reason.
Box 3. Declaration of intent text
We endeavour to ensure that:
• Substance use disorders and behavioural addiction are a top priority for our organisation
and our employees
• Substance use disorders and behavioural addictions are treated as diseases
• After receiving treatment, healthcare professionals with substance use disorders or a
behavioural addiction can safely return to work through a monitoring programme
• Policy or a procedure aimed at substance use and addiction is developed and imple-
mented
Physician Health
BACK TO CONTENTS
33
own policy. The communication plan can
be used to inform all individuals within the
organisation.
The RDMA has also drawn up a declara-
tion of intent. By signing the declaration
of intent, organisations declare their com-
mitment to a healthy and safe working and
learning environment, where addiction is
treated as a disease, and where substance
use disorders and addiction can be openly
discussed, see Box 3.
For physicians: increasing knowledge, open-
ing up a dialogue and becoming an ambas-
sador
For physicians affected by substance use
disorders and addiction it is often not easy
to seek help and to become a patient them-
selves. This is often due to feeling ashamed
and the stigma of addiction. Colleagues can
take an important role in identifying po-
tential problems at an early stage. The ac-
credited teaching module allows physicians
to increase their knowledge of substance use
disorders and addiction, see Box 4. Physi-
cians, including those still in training, can
also follow the e-learning component of the
teaching module separately.
To accompany the teaching module, the
PHP has produced an animation and an in-
formation card with tips on how to enter the
dialogue when presuming substance use in a
colleague. Choice of language is very impor-
tant when raising this topic with a colleague.
There is a difference between opening up a
dialogue or engaging in conversation, and
confronting an individual about their behav-
iour. Opening up a dialogue and engaging
in conversation in an early stage of concern
creates an opportunity to express concerns
to a colleague in a setting between equals –
without judgement – which is vital in the
case of a disease such as addiction,see the 10
tips in Box 5. In certain situations a direct
confrontation with the behaviour is neces-
sary, it is important to take in account the
underlying disease, especially for the help
and the measures.
Box 4. Content of the teaching module
1. 
E-learning component on ‘Addiction in physicians – how to identify substance use
disorders and addiction’ (aimed at knowledge). Research carried out by the RDMA
shows that physicians struggle to recognise the early signs of substance use disorders
and addiction [13]. Physicians also want guidelines on how to open a dialogue with
a colleague they are concerned about and what action they can take if patient safety
is at risk.To improve physicians’ knowledge, the teaching module starts with an
e‑learning component on recognising substance use disorders and addiction.
2. 
Preparatory homework assignment (aimed at self-insight). Prior self-reflection is
essential if physicians want to discuss substance use disorders and addiction: know-
ing your own assumptions and ideas on this topic enables you to start a supportive
dialogue in a better way when presuming substance use in a colleague.This is why the
homework assignment also looks at the coping strategies of physicians themselves.
Carrying out the preparatory homework assignment helps physicians to develop
greater self-insight.
3. 
Group session (aimed at communication skills). In order to discuss substance
use disorders and addiction, in addition to knowledge and self-insight physicians
also need to rehearse the conversation. Physicians receive training in how to talk to
patients. If a physician wants to open a dialogue with a colleague, physicians need to
use their communication skills in a different way. Research carried out by the RDMA
shows that physicians wish training in this area in order to actually engage with a
colleague [14].
Box 5. Summary of the 10 tips for opening a dialogue on substance use and addiction when you
are concerned about a colleague
Preparing the conversation
1. 
Ensure you prepare properly for the conversation with your colleague.
2. 
Arrange a quiet location at a quiet time of day with sufficient time at hand.
3. 
You should be aware of the fact that in many cases a colleague will need multiple
signals from his environment or conversations before he recognises that he needs help
and/or seeks help.
The conversation
4. 
Start the conversation by saying that you are concerned about your colleague and/or
patient safety.
5. 
Talk to your colleague about situations and behaviours you have observed, without
judgement or subjective input.
6. 
Give your colleague the opportunity to respond and express their emotions.
7. 
Remain aware of your own emotions and non-verbal communication.
8. 
Be prepared for two scenarios: your colleague denies the problem or your colleague
acknowledges the problem.
Concluding the conversation
9. 
Discuss how you are going to record your agreements confidential and provide this to
each other.
10. 
Close the conversation as you started, by saying that you are concerned about your
colleague and/or patient safety.
Physician Health
BACK TO CONTENTS
34
Finally, the PHP has created a network of
ambassadors. This network comprises physi-
cians and other healthcare professionals who
are committed to ensuring a healthy and safe
working and learning environment where
addiction is treated as a disease, see Box 6.
Conclusion
The past decade major steps have been tak-
en in making substance use disorders and
addiction in physicians in the Netherlands a
topic. Although substance use disorders and
addiction in physicians formerly was a ta-
boo, the topic is now discussed more openly
and receives greater attention in the com-
munity of physicians. This article describes
how the RDMA has achieved this through
their PHP the past decade.
Since the launch of the counselling service
in 2011,more than 400 physicians and indi-
viduals in their environment have contacted
the PHP for confidential help, advice, guid-
ance and/or monitoring. Over the years the
number of people contacting the PHP has
gradually increased, and the PHP currently
receives calls from around 60 individuals
every year.
Significant progress has also been made in
raising awareness:
• The website of the support service and
tool kit is viewed by around 250 visitors
every week.
• Over 30 healthcare organisations signed
the declaration of intent in 2020, mak-
ing substance use disorders and addiction
part of their agenda.
• Nearly 300 physicians followed the e-
learning module in the first six months
after release.
• There are 60 ambassadors who actively
work for the PHP within their organ-
isation and who use the tool kit for this
purpose.
• Four other professional groups (dentists,
pharmacists, psychologists and physician
assistants) are investigating into how they
can set up a programme like the RDMA
PHP for their own members.
The success of the Dutch PHP is mainly
due to the combination of offering help
with the counselling service and investing
in raising awareness with the tool kit. Both
components are essential and have a mutu-
ally reinforcing effect.
References
3. Wallace JE, Lemaire JB, Ghali WA. Physician
wellness: A missing quality indicator. Lancet.
2009;374:1714-1721.
4. Oreskovich MR, Shanafelt T, Dyrbye LN,
Tan L, Sotile W, Satele D, West CP, Sloan J,
Boone S. The prevalence of substance use dis-
orders in American physicians. Am J Addict.
2015;24(1):30-8. doi: 10.1111/ajad.12173.
5. Hughes PH, Storr C, Baldwin DC, Williams
KM, Conard S, Sheehan D. Patterns of sub-
stance use in the medical professional. Medical
Journal. 2015;24:30-38.
6. Medisauskaite A, Kamau C. Does occupational
distress raise the risk of alcohol use, binge-eat-
ing,ill health and sleep problems among medical
doctors? A UK cross-sectional study. BMJ Open
2019;9:e027362.
7. Kay M, Mitchell G, Clavarino A, Doust J. Doc-
tors as patients: a systematic review of doctors’
health access and the barriers they experience.Br
J Gen Pract 2008;58:501–8.
8. Domeyer-Klenske A1,  Rosenbaum M, When
doctor becomes patient: challenges and strat-
egies in caring for physician-patients. Fam
Med. 2012 Jul-Aug;44(7):471-7.
9. DuPont, R.L.; McLellan, A.T.; White, W.L.;
Merlo, L.J.; Gold, M.S. Setting the standard for
recovery: Physicians’ Health Programs. J. Subst.
Abus.Treat. 2009,36:159–171.
10. McLellan AT, Skipper GS, Campbell M, Du-
Pont RL. Five year outcomes in a cohort study
of physicians treated for substance use disorders
in the United States. BMJ. 2008;337:a2038. doi:
10.1136/bmj.a2038.
11. Geuijen PM, van den Broek SJM, Dijkstra
BAG, Kuppens JM, de Haan HA, de Jong CAJ,
Schene AH,Atsma F,Schellekens AFA.Success
Rates of Monitoring for Healthcare Profession-
als with a Substance Use Disorder: A Meta-
Analysis. J. Clin. Med. 2021;10:264. https://doi.
org/10.3390/jcm10020264.
12. Geuijen P, de Rond M, Kuppens J, Atsma
F, Schene A, de Haan H, et al. Physicians’
norms and attitudes towards substance use in
colleague physicians: A cross-sectional sur-
vey in the Netherlands. PLOS ONE. 2020
Apr 3;15(4):e0231084. doi: 10.1371/journal.
pone.0231084.
13. European Alcohol Policy Alliance. Why should
we care about alcohol? EUROCARE: 2014.
14. de Wit GA et al. Maatschappelijke kosten-bat-
enanalyse van beleidsmaatregelen om alcohol-
gebruik te verminderen. RIVM Rapport 2018-
0146 (in Dutch).
15. van Kampen H, van Doorn K. ABS-artsen.
MWM2 rapport 2016 (in Dutch).
16. van Kampen H, van Doorn K. ABS-artsen.
MWM2 rapport 2016 (in Dutch).
17. www.abs-artsen.nl (in Dutch)
18. www.abs-artsen.nl/toolkit (in Dutch)
19. Success Rates of Monitoring for Healthcare
Professionals with a Substance Use Disorder:
A Meta-Analysis – PubMed (nih.gov)
20. PLOS ONE: Physicians’ norms and attitudes
towards substance use in colleague physicians:
A cross-sectional survey in the Netherlands
Dr. Marlies de Rond,
Policy adviser, project leader Physician Health
Program, Royal Dutch Medical Association)
Drs. Joanneke Kuppens,
Addiction doctor, member of the PHP expert
team, Royal Dutch Medical Association)
Box 6. Summary of an ambassador’s duties
What does an ambassador do?
• You will be working within your organisation and professional or scientific association
to promote the discussion of substance use disorders and addiction.
• You will be encouraging and motivating colleagues to be aware of and pay attention to
substance use disorders and addiction in healthcare professionals.
• You will be encouraging cooperation at all levels of the organisation on this topic.
• You will function as an expert on this topic within your organisation and professional
or scientific association.
• You will inform your colleagues about the PHP (the support service and the tool kit).
• Your name and profession will be listed at www.abs-artsen.nl/toolkit if you agree.
Physician Health
BACK TO CONTENTS
35
One Health Multidisciplinary Research Project
Problem Statement
Planet Earth has been here for over 4.5 bil-
lion years but in just two human generations
we have managed to place our only ‘home’
at great risk. Given existential challenges –
climate change, biosphere degradation,
zoonotic diseases, while tackling issues of
diversity and inclusivity, there is a pressing
need to re-orient society towards a sustain-
able future.
The overarching aim of this One Health
multidisciplinary research project is to build
regional capacity for valuing and promoting
the One Health concept (OH) as the foun-
dation for achieving the UN-2030 SDGs
and thereby – creating a “more just, sustain-
able and peaceful world.”
Project Objectives
Collaborating with regional/global organ-
isations, many of which presently engaged
with the international One Health for One
Planet Education (1HOPE) initiative, we
propose  – in association with 1 HOPE
education advocacy groups (Annex)  – the
establishment of regional multi-institution-
al One Health-SDG social policy research
consortia to
1. investigate the root causes (socio-eco-
nomic, geopolitical, environmental) and
impacts of epidemics;
2. explore how OH and the SDG-related
curricula across educational systems can
become key drivers of transformative
social change;
3. formulate specific systemic and social
policy recommendations (within and
across LMICs) that pursue goals of so-
cial equality and responsibility-develop-
ing and sharing values and cultures by,as
one example, working together on proj-
ects with communities, and learning to
contribute to positive change in society.
4. address the effects of Covid-19 on re-
alising the target of SDG 5: “Achieve
Gender equality and empower all wom-
en and girls,” fully recognising that the
limited progress which has been made is
in danger of reversing and that extensive
efforts will be urgently required “to re-
dress long-standing inequalities in mul-
tiple areas of women’s lives, and build a
more just and resilient world.” Regions
and countries are therefore tasked with
–
– “including women and women’s or-
ganizations in COVID-19 response
planning and decision-making;
–
– “transforming the inequities of unpaid
care work into a new, inclusive care
economy that works for everyone;
–
– “designing socio-economic plans with
an intentional focus on the lives and
futures of women and girls.”
Rationales
As mentioned previously, our fragile planet
is highly vulnerable from human activity
that continues to prioritise wealth over sus-
tainable values, division over unity, and gen-
erally failing to consider the health and well-
being of the planet and the sanctity of all life
over vested interests. Many lessons from
history have not yet been learned and new
lessons may prove equally, if not more, diffi-
cult to take on board as we head deeper into
the twenty-first century.Two of our great-
est social problems are changing the way we
relate to the planet and to one another, and
confronting how we use technology (data-
ism) for the benefit of both humankind and
the planet.”1
HOPE reinforces the urgency
put forth by the Earth Charter to “embrace
a new sense of care and responsibility to the
Earth community” with particular emphasis
1 
Survival: One Health, One Planet,
One Future (including reviews)
on the “Respect and Care for the Commu-
nity of Life”and “Ecological Integrity.”2
Lifelong learning is key to our
survival and the sustainability
of life on earth as we know it.3, 4
“Education is not only a human right it en-
ables the realization of other human rights –
reducing poverty, boosting job opportuni-
ties and fostering economic ­
prosperity”5
and is pivotal for achieving gender equality
while also ensuring that Youth and Young
2  Earth Charter International
3 
Global Population Health and Well-
Being in the 21st Century
4 
Future Africa-1 HOPE Transdisci-
plinary Research Webinar Series
Tackling Regional Epidemics through One Health Social Policy and
the UN‑2030 Sustainable Development Goals
Countries
• Africa: Cameroon, Kenya, Rwanda,
South Africa
• SE ASIA – Thailand, Malaysia
• Latin America – Chili, Brazil, Peru
Lead Applicant
University of Pretoria. Private bag X20
Hatfield 0028 South Africa
Principal Investigator
Professor Liesel Ebersöhn
Director: Centre for the Study of Resil-
ience, Full Professor: Department of Edu-
cational Psychology, Secretary General:
World Education Research Association
liesel.ebersohn@up.ac.za
Co-Principal Investigator
Professor Cheikh Mbow
Director, Future Africa
c.mbow@up.ac.za
Funding Request CAD $3,000,000
36
Adults “care about the well-being of their
friends and families, their communities and
the planet.”5
“Social justice is at the heart of climate jus-
tice and that is where we need to start…”
Methodology
Research methods will be informed by the
nature of the research problems and the
worldview assumptions the consortium
researchers bring to the study including
both procedures of inquiry (strategies) and
methods of data collection, analysis and in-
terpretation. Important considerations will
be the impact of Covid-19 on the countries,
on-going investigations at country and re-
gional levels, time available, the researchers’
personal experience along with potential
audiences of the research project. The re-
search will encompass quantitative, qualita-
tive and mixed method (e.g., ethnography,
surveys) . While socio-economic, political,
and ecological findings of each country will
be treated independently, it will be impor-
tant to synthesise these findings across the
regions to determine common issues and
arrive at meaningful solutions. The regions
involved have some of the highest propor-
tion of young people and, as UN Secretary-
General António Guterres observed several
years ago, they need to come “into the con-
versation, to enable them to express them-
selves, to listen to them, invest time and
resources in them and empower them to
realize their goals.”The Secretary-General’s
determined advocacy for intergenerational
knowledge exchange has become even more
compelling given the impact of recent epi-
demics on education, health, incomes and
regional sustainability generally.
It is conceivable that the overall approach
to the research will be a combination of
postpositive, social constructivist, advocacy/
participatory and pragmatic in terms of
conclusions and recommendations.
5 
Naidoo J. , Antoninis M. UNESCO pa-
per (2018) on global education financing
Provisional Lines of Research Inquiry
1. What are the main root causes (socio-
economic, geopolitical, environmen-
tal) of LMIC epidemics (e.g., HINI,
MERS-Cov, H7N9, Ebola)?
2. What impacts  – socio-economic, po-
litical, environmental  – have regional
epidemics had on LMIC communi-
ties? How have these been addressed
(e.g., government policy (e.g., poverty
reduction, infrastructure developments,
veterinary and human public health
systems)? What part have preventive
measures played in LMICs to ensure
regional sustainability? What have
been the immediate and longer-term
outcomes on the quality of life index
(health, education, employment)?
3. How have these epidemics affected
progress in terms of meeting UN-2030
SDG targets across LMIC regions?
4. To what extent has Covid-19 raised
global awareness about the urgency
to address large-scale interconnected
problems, such as “environmental deg-
radation, economic and political threats,
ideological extremism”6, 7
?
5. What lessons are being learned from
Covid-19 that may be timely and highly
relevant for LMIC regions and their fu-
ture sustainability?
6. The challenges facing our world gener-
ally and regions in particular cannot be
solved by individual nations or regions
alone. What fundamental values and
principles – partly derived from the OH
concept and the SDGs (e.g., proposi-
tions for global sustainability1
)  – need
to underpin the development of inter-
sectoral Social Policy (especially with
regard to green and inclusive recovery,
income and jobs, well-being, climate ac-
tion, resilience)?
7. In terms of progressing understand-
ing and valuing of OH and the SDGs,
what fundamental contributions can the
6 
Universities in the Early Decades of the Third
Millennium: Saving the World from Itself?
7 
UN Sustainable Develop-
ment Goals –Climate Justice
international One Health for One Planet
Education initiative (1 HOPE) make
across LMIC regions? How can these
assist in operationalizing Social Policy
initiatives guided by the integration of
transformative education and the build-
ing of transdisciplinary research capac-
ity (e.g., embedding an ecological knowl-
edge framework across higher education
curricula)? 8. (e.g., UNSA-A Diplomats
Leadership Conference  – University of
Cape Coast [Ghana-26.06.2020]).
8. How can digital communication sys-
tems – within and across regions  – be
evolved to strengthen networking and
collaboration with regard to imple-
menting Social Policy strategies relating
to the prevention and mitigation of fu-
ture epidemics.
9. How can the younger generation play
a more pivotal role in social policy de-
velopment and implementation across
LMICs?
Expected Results
The overall aim of the 1 HOPE educa-
tion initiative (below) is to “Build global
capacity for promoting and valuing the
One Health (& Well-Being) concept as
the foundation for achieving the UN-2030
Sustainable Development Goals. To these
ends Development and Advocacy Teams
are being established across several regions
(2021–2023), as shown below. The findings
of the research consortia are vital in order to
support the social policy recommendations
necessary to underpin the 1 HOPE vision
and purpose: “a world where people of all
ages in civil society, government/non-gov-
ernment and corporate organisations apply
the One Health (and well-being) concept/
approach – recognising the interdependen-
cies of humans, animals, plants in a shared
environment  – thereby collaboratively en-
suring the sustainability of the planet and
the species.’ A major criterion of success of
both 1 HOPE and the epidemic research
would the extent to which regions (e.g.,
ministries of education, teacher training
colleges, schools, colleges/universities and
One Health Multidisciplinary Research Project
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III
societies in general will have adopted the
1 HOPE concept and the SDGs in their
missions and strategic planning.
AFRICA (Sub-Saharan)
–
– Primary-Secondary
–
– Technical-Vocational Education
–
– Tertiary /Higher – Adult Education
–
– Civil Society/Govt/Corp – Lifelong Learn-
ing
–
– 1 HOPE Youth & Young Adults
AMERICAS (Canada, US, Latin America)
–
– Primary-Secondary
–
– Technical-Vocational Education
–
– Tertiary /Higher – Adult Education
–
– Civil Society/Govt/Corp – Lifelong Learn-
ing
• 1 HOPE Youth & Young Adults
ASIA (South East & India)
–
– Primary-Secondary
–
– Technical-Vocational Education
–
– Tertiary /Higher –Adult Education
–
– Civil Society/Govt/Corp – Lifelong Learn-
ing
–
– 1 HOPE Youth & Young Adults
Team Expertise
• Prof Liesel Ebersöhn: Director, Centre
for the Study of Resilience Full Professor:
Department of Educational Psychology
Secretary General: World Education Re-
search Association, University of Preto-
ria-p/note correct email – liesel.ebersohn@
up.ac.za 
• Prof Cheikh Mbow: Director: Future Af-
rica
• Dr. George Lueddeke, Programme Lead,
International One Health for One Planet
Education Initiative (1 HOPE), United
Kingdom, Research Associate, Univer-
sity of Pretoria, Author, Advisor, Higher,
Medical, One Health Education
• Dr. Irene Naigaga, Programme Manager,
Africa One Health University Network
(AROHUN)
• Dr.  Vipat Kuruchittham, Executive Di-
rector, South East Asia One Health Uni-
versity Network (SEAOHUN)
• Ms Alicia Jimenez, Program Manager,
Earth Charter International
• Dr. Daniele Fuega, Founder, One Health
Caribbean and Latin America Network
• Dr. John Amuasi and Dr. Andreas Win-
kler, Co-Chairs, The Lancet One Health
Commission
• Dr. Zeev Noga,Executive Director,World
Veterinary Association
• Ezra Yego, Sustainable Development Sus-
tainable Youth Initiative, Deputy Project
Lead
Budget and justification (36 months)
CAD$ 3,000,000
To be determined asap
Supporting documents
To be completed and sent asap
Concept Note
Prepared by George Lueddeke (PhD,MEd,
Dipl. AVES [Hon.])
05.04.2021
Short bio
Originally from Canada (northern/south-
ern communities) working in secondary
and post-secondary education, I now re-
side in the UK. Previously with the Faculty
of Medicine, University of Southampton,
(education&research development, UG/
PG quality assurance), one of my current
projects is leading the international  One
Health for One Planet Education initiative (1
HOPE) in association with national and
global organisations (p/see below). Com-
plementing this role is as research associate
with the Centre for the Study of Resilience,
Faculty of Education, at the University of
Pretoria, South Africa. 
Publishing and presenting widely on edu-
cation transformation, innovation and lead-
ership (including threads from two prior
volumes, Transforming Medical Education
for the 21st
Century and Global Population
Health and Well-Being), a recent book is
entitled  Survival: One Health, One Planet,
One Future (2019/2020). Three key themes
weave through this publication: (1) that the
survival of all species – including homo sa-
piens- depends on a healthy planet; (2) that
urgent action is needed to tackle existential
risks and counter the thinking that perpetu-
ates the ‘folly of a limitless world’; and (3)
that the One Health concept and the SDGs
are key drivers for enacting transformative
change toward global sustainability. Refer-
ence to the IRDC consultations carried out
in 2016 and 2017 contributed to the book’s
contextualization of global health and social
transformation. Underpinned by a pressing
concern for the whole Earth, an invited fol-
low-up chapter to Survival was Universities
in the Early Decades of the Third Millennium:
Saving the World from Itself?, which relates
to the development of interconnected ecologi-
cal knowledge systems across tertiary/higher
education – programs,research and services.
Current priorities involve establishing and
coordinating  the 1 HOPE  initiative across
several global regions and supporting stu-
dent and colleague capacity for engaging
in transdisciplinary research  – focusing in
particular on climate change, biosphere
degradation, zoonotic diseases,  alongside
issues of inequality, diversity and inclusivity.
In addition, I contribute to several publica-
tions (e.g.,guest editor/author [chapters,ar-
ticles]) with a recent commentary on a timely
article, ‘More for The World Organisation
for Animal Health (OIE).’
Recognising that Africa and the Middle
East have the highest proportion of young
people on the planet (average age  – 24),
many would have agreed with UN Secre-
tary-General António Guterres’ observa-
tion in 2018 that the time had come to bring
young people “into the conversation, to en-
able them to express themselves, to listen to
them,invest time and resources in them and
empower them to realize their goals.”1
His
advocacy has gained even more importance
in the past few years given today’s climate
and ideological challenges and,in particular,
the socio-economic impact of Covid-19 on
the regions priortised in this concept note –
collectively arguing for a global mindshift
toward sustainability  – the main rationale
for the 1 HOPE initiative.
One Health Multidisciplinary Research Project
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IV
WMA News
Tree of Life
In a void beyond places
and aeons of time,
it flickers with power
of primordial chime.
A single small tree,
a firing strife,
burns unburnt,
rooted in life.
The leaves of its branches
are we.
Be there meaning or not;
it is thee.
When battered by tempests
of decay and delight,
may it not be forgotten;
the oath is to life.
by Rikhard Ihamuotila MD
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