wmj_3_2020_WEB

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vol. 66
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 3, August 2020
Contents
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The WMA and the Foundations of Medical Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Declaration of Geneva (1948), International Code of Medical Ethics (1949). . . . . . . . . . . . . . 2
Palliative Care: Free App and Tips to Improve Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . 9
Interview with Miguel Roberto Jorge by WMJ Editor Peteris Apinis . . . . . . . . . . . . . . . . . . . . 11
What is the potential impact of the COVID-19 Pandemic on Achieving the Sustainable
Development Goal of Reaching Zero Unmet Need for Contraception by 2030? . . . . . . . . . . . 13
COVID-19 Pandemic: a Possible Reversal Mechanism for Outward Medical Tourism
by African Political Leaders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
COVID-19: Junior Doctors Response in Myanmar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emergency Care for Health Unit System Patients in Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Job Satisfaction: the Nigerian Doctor’s Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Critical Care Medicine in China–Solid Steps in the Past Forty Years and Future . . . . . . . . . . 39
Obituary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
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: 2256-0580
Dr. Miguel Roberto JORGE
WMA President,
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
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.
Dr. David Barbe
WMA President-Elect,
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300
60611-5885 Chicago, Illinois
United States
Dr. Mari MICHINAGA
WMA Vice-Chairperson of Council
Japan Medical Association
2-28-16 Honkomagome
113-8621 Bunkyo-ku,Tokyo
Japan
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. Leonid EIDELMAN
WMA Immediate Past-President
Israeli Medical Association
2 Twin Towers, 35 Jabotinsky St.,
P.O. Box 3566
52136 Ramat-Gan
Israel
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg
110 002 New Delhi
India
Dr. Joseph HEYMAN
WMA Chairperson of the Associate
Members
163 Middle Street
West Newbury, Massachusetts 01985
United States
Prof. Dr. Frank Ulrich
MONTGOMERY
Chairperson of Council
Bundesärztekammer
Herbert-Lewin-Platz 1 (Wegelystrasse)
10623 Berlin
Germany
Dr. Andreas RUDKJØBING
WMA Chairperson of the Medical
Ethics Committee
Danish Medical Association
Kristianiagade 12
2100 Copenhagen 0
Denmark
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
This is incomprehensible time. Covid-19 provides a serious lesson
for doctors, politicians and economists in the whole world. There is
still much unknown about this virus. There is no experience with
SARS-CoV-2, but virologists and clinicians have knowledge about
and experience with other RNA viruses. There is in-depth knowl-
edge about coronaviruses in veterinary medicine. There is experi-
ence in human medicine regarding other coronaviruses, especially
concerning SARS and MERS. People have experience in producing
vaccines against RNA viruses, and these vaccines are effective in
both human and veterinary medicine. And yet – we are not able
to answer the main question: how long and persistent will the im-
munity of people against SARC-CoV-2 be? We have only the views
and insights of the most distinguished specialists in the world, but
sometimes these are controversial points of view. And we believe a
scientist or a school who, to our mind, is more persuasive or whose
achievements have been acknowledged, or for example, the Nobel
Prize awarded. We believe high impact journals and we are used to
trust them. And we also listen to information we want to believe –
for example, I read articles about viruses with great interest – and
learn that the virus is self-limited, it will become less aggressive, less
infectious, and people will have milder virus symptoms in the near
future. I understand there is no convincing evidence for it, but I am
eager to believe it.
We, doctors, are not protected from disinformation, and a promi-
nent doctor may cause a chain reaction, when subject to disinfor-
mation. It is enough to come forth with exaggerated messages in
serious non-medical news channels; and many doctors also start
believing it. It is time the World Medical Association, the largest
and most serious forum of doctors, takes the initiative and defines
certain things. The need of staying 6 feet apart is to be repeated
every day, just as the requirement not to scream, not to sing and not
to be sneezed at.The virus spreads much better indoors, and people
must use the opportunity to communicate more outdoors. It must
be understood that the world population is not prepared to accept
any longer communication restrictions. We must teach people how
important it is to treat their chronic diseases – diabetes, asthma,
cardiovascular diseases, hypertension – so that the virus does not
kill them.
A key issue for the medical world will be attitudes toward newly
created vaccines. If I was able to trust the Oxford researchers in
moving towards a vaccine, I could not believe the news that military
personnel are already being vaccinated against Covid-19 in some
major post-socialist states. And indeed, we have no chance of pre-
dicting whether we can expect long-lasting and permanent immu-
nity of the SARS-CoV- 2 virus to vaccines. And we don’t know if
people have cross-immunity to coronavirus.
And in the end, we do not know how expensive, safe and effective
the vaccine will be, and whether there will be enough of it for all
the people of the world, both – in rich and poor countries.The virus
does not recognize national borders.
One thing is clear.The World Medical Association should renew its
cooperation with the World Veterinary Association without delay
and raise the concept ‘One World, One Health’ to a new level. We
have zoonoses and and we will have to face zoonoses in the near
and distant future.The more the people in this world produce meat
for their own consumption, the more industrial the keeping of pet
animals and meat production will become. The more high-density
domestic animal farming develops, the more likely the outbreaks of
zoonoses. Covid-19 reminded the world about hygiene and clean-
liness. Maybe it is time to discuss globally modern standards for
hygiene.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
BACK TO CONTENTS
2
Declaration of Geneva
Practising Medicine
“with conscience
and dignity”
Beginning with the Declaration of Ge-
neva (the Declaration), for over 70 years
the World Medical Association (WMA)
has maintained that physicians must prac-
tise medicine with conscience and dignity
[1]. On the Declaration’s 70th anniversary,
seven associate WMA members raised seri-
ous concerns about their ability to remain in
medical practice if they fulfil this obligation
by refusing to support or collaborate in the
killing of their patients by euthanasia and
assisted suicide (EAS)[2].
The physicians practise in Canada, where
euthanasia and assisted suicide (EAS)
are legal, [3,4] recognized as therapeutic
medical services by the national medical
association [5,6] and provided through a
public health care system controlled by
the state, which also regulates medical
practice and medical ethics. The national
government is now poised to make EAS
available for any serious and incurable
medical condition, vastly increasing the
number of patients legally eligible for the
service [7].
In these circumstances, it is urgent to reas-
sert that the duty to practise medicine “with
conscience and dignity”includes unyielding
refusal to do what one believes to be wrong
even in the face of overwhelming pressure
exerted by the state, the medico-legal estab-
lishment and even by medical leaders and
colleagues. That the founders of the WMA
not only supported but expected such prin-
cipled obstinacy is evident in the WMA’s
early history and the development of the
Declaration, all of which remain surpris-
ingly relevant.
Early Developments: 1945–46
A meeting of physicians from 30 coun-
tries in London in June 1945 discussed
the formation of an international medical
association [8, 9]. Some continental physi-
cians spoke of crimes by physicians in their
countries during the war [10], and over the
next 18 months the world medical commu-
nity became increasingly aware of physician
participation in crimes against humanity [8,
11, 12].
National medical association delegates re-
turning London in September 1946 were
uneasy and ambivalent about plans to na-
tionalize health care systems in Britain and
the Continent. On the one hand, they wel-
comed the growing interest in medicine by
governments around the world.On the oth-
er, they worried about the consequences of
(as later expressed) transforming all physi-
cians into “Civil Servants controlled by the
State” [13, 14]. They conceived an interna-
tional medical association as support for na-
tional associations defending practitioners
and patients from government demands.
They reminded the British health minister
that physicians treat human beings, not col-
lections of tissue, and must practise with “a
discipline of the heart that makes it difficult
to integrate [them] into the State machine”
[15].
While delegates were motivated to or-
ganize the WMA by concerns about the
profession-state relationship, they were also
deeply disturbed by physician participation
in war crimes [8].
In the month following the London gath-
ering, twenty German physicians were ar-
raigned in Nuremberg [13]. And the or-
ganizing committee drafted the WMA
constitution and prepared for the first
General Assembly while the Nuremberg
“Doctors Trial”was in session.Reports from
The WMA and the Foundations of Medical Practice.
Declaration of Geneva (1948), International Code of Medical
Ethics (1949)
Sean Murphy Ramona Coelho Philippe D. Violette Ewan C Goligher Timothy Lau Sheila Rutledge
Harding
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3
Declaration of Geneva
the trial resonated deeply with physicians
anxious about being integrated into a “State
machine” [16,17,18,19].
First General Assembly:
War Crimes and Medicine
(September 1947)
Physician war crimes dominated the agenda
of the first WMA General Assembly, dis-
placing discussion of the profession-state
relationship. Delegates heard impassioned
testimony from physician victims of the
Third Reich and received the BMA report,
War Crimes and Medicine [20, 21, 22].
The report denounced physicians respon-
sible for crimes against humanity as lack-
ing “moral and professional conscience,”
condemning them for having allowed the
state to use medical knowledge and sci-
ence as “instruments of wanton destruction
in the pursuit of war.” It asked the WMA
to endorse the prosecution of physicians
for war crimes and adopt a World Charter
of Medicine, explicitly reaffirming medi-
cal ethics “in the spirit of the Hippocratic
Oath,” suggesting that medical graduation
should include a promise to adhere to the
Charter [10].
The Assembly accepted the recommenda-
tions and approved a public apology and
undertaking to be required of the German
Medical Association as a condition for
admission to the WMA. It also approved
an oath affirming that a physician’s first
duty is to care for a patient, “to resist any
ill treatment that may be inflicted on him”
and “to refuse my consent to any authority
that requires me to ill-treat him.” Finally, it
appointed a committee to produce a report
about war crimes [23, 24].
Over the following year, the war crimes
committee solicited forms of medical en-
gagement from national associations with a
view to formulating an international medi-
cal oath. The WMA Council also agreed
to develop an international code of medi-
cal ethics, concerned that jurists reacting
to physician war crimes might do so if the
WMA did not [24,25].
Second & Third
General Assemblies
Declaration of Geneva (September 1948),
International Code of Medical Ethics
(September 1949)
At the second WMA General Assembly,
delegates were presented with War Crimes
and Medicine: The German Betrayal and a
Re-statement of Medical Ethics. It urged
the Assembly to prevent physician crimes
against humanity by reaffirming basic Hip-
pocratic principles, which, it argued, would
be universally acceptable. Requiring medi-
cal graduates to abide by a modern version
of the Hippocratic Oath would help to im-
press them with the fundamentals of medi-
cal ethics. The suggested modern version,
containing ten promises, was approved by
the Assembly and published as the Decla-
ration of Geneva [26].
The Second General Assembly also ap-
proved the development of an international
code of medical ethics. The final version,
which included the Declaration of Geneva,
was approved at the Third General Assem-
bly in 1949 [27].
Refusing the fatal surrender of conscience
The documents make clear that what the
authors of the Declaration and the ICME
meant by practising medicine “with con-
science and dignity” was not only doing
what one believes to be right, or only doing
what one believes to be best for patients,but
refusing “to make the easy and fatal surren-
der of one’s conscience to the mass mind of
the totalitarian state” (18). A British physi-
cian responding to the BMA report on war
crimes commented:
During the terrible years of occupation by a
brutal enemy the large majority of doctors of
most of the occupied countries maintained
their moral integrity, their unswerving loy-
alty to their patients, and their spiritual and
professional freedom, even at the risk of tor-
ture and death. They thereby set a great ex-
ample and vindicated the honour of their pro-
fession [19].
According to Leo Alexander, writing a year
later, just before the ICME was adopted,
Dutch physicians collectively demonstrated
such heroism [28]. Steadfast refusal to do
what one believes to be wrong was under-
stood to be central to practising medicine
“with conscience and dignity,” an essential
safeguard for personal and professional in-
tegrity and patients.
That was then; this is now
It is easy to understand this duty in rela-
tion to refusing to comply with the mur-
derous dictates of a totalitarian regime that
have been universally derided for decades.
It is more difficult to see why it should
apply to refusing to provide legal services
requested by patients in a democracy. The
difficulty disappears once one admits that
both totalitarian and democratic regimes
can make grave moral errors in law and
public policy.
Events in Germany from 1920 to 1945
demonstrate that physicians willingly en-
listed and collaborated in the implementa-
tion of a biopolitical ideology thought to
be on the cutting edge of science and pro-
gressive ideas. Exactly the same thing has
happened elsewhere and is likely to happen
again. When it does, the medical profession
is likely to be most accommodating and
even anxious to participate to ensure that
the state “gets it right.”
At issue here is the freedom, integrity, dig-
nity and obligations of individual physi-
cians who are convinced that the profession
and the state have got it wrong, yet face
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4
­
demands that they participate in activities
that they reasonably believe to be immoral
or contrary to good medical practice.
Then…
When the Nazi regime was installed, of-
ficials of the largest German medical as-
sociations “gladly” welcomed it and placed
themselves at its service, celebrating the
intimate links of the medical profession
with “the wisdom and aims of the State”.
Those intimate links were reflected in the
law directing compulsory sterilisation of
those with “genetic illnesses” (including al-
coholism and mental deficiency) enacted in
response to a petition from the associations
[29]. Physicians sterilized about 300,000
persons before the war, and began killing
the handicapped when the war began, a
project supported directly and indirectly by
colleagues and scientists [30].
Physicians were predisposed to cooperate
because they were convinced of the value of
eugenics. Eugenics was a widely accepted
scientific discipline, “on the cutting edge of
science”, supported by respected scholars,
various scientific disciplines, major univer-
sities and scholarly journals [30, 31]. The
eugenics movement propagated the belief
that people inherited not only eye and hair
colour,but were criminals,or rich,poor,lazy,
industrious,promiscuous or faithful because
they were “born that way”[32].Leading sci-
entists and activists campaigned to prevent
the reproduction of such “defectives” by
contraception and sterilization of “inferior
types,” including the mentally ill, physically
handicapped, criminals, and certain “degen-
erate” races [33,34].
Eugenics was popular among the socially
elite, including Winston Churchill, Herbert
Hoover and Alexander Graham Bell (35).
Eugenic societies and scientists successfully
lobbied for laws authorizing voluntary or
compulsory sterilization of “defectives”, in-
cluding criminals,the mentally handicapped
and mentally ill; 27 US states had such laws
in 1931.By 1935 sterilization laws had been
adopted in Canada, Denmark, Switzerland,
Germany, Norway and Sweden [36].
Eugenics was especially influential in Ger-
many after the First World War [37] and
was absorbed into Nazi party policy. Since
physicians were among eugenics’ foremost
exponents, to hear Nazi policy described
as “nothing but applied biology” was es-
pecially attractive to them. Hence, many
willingly joined the vanguard of what be-
came “the most ambitious and murderous
eugenics program in human history”. Their
characteristic response was not just acqui-
escence, but “eager and active cooperation”
[31,38,39].
Such eagerness was not limited to German
physicians. In 1936, the Canadian Medical
Association Journal featured a lengthy es-
say on the superiority of the Aryan/Nordic
Race by an author who, the year before, had
held up Germany as a model for other na-
tions and toasted Adolph Hitler as “a great
leader” [40,41]. Two years earlier it had
published a glowing report about eugenic
sterilizations authorized by the Alberta Eu-
genics Board [42].
Over 44 years Alberta physicians steril-
ized 2,822 people at the Board’s direction
[43].A court reviewing its operations found
that it had routinely flouted the law, and, as
late as the early 1960’s, physicians had per-
formed illegal sterilizations and medically
unnecessary castrations, hysterectomies,
oophorectomies and biopsies of testicular
tissue, behaviour the judge described as
“unlawful, offensive and outrageous”. He
excoriated one Board geneticist for, among
other things,encouraging the use of persons
with Down Syndrome as “medical guinea
pigs” [44]. However, she had “no regrets,”
defending her activities as “a very reasonable
approach to a very difficult problem” [45].
Awarded the Order of Canada and other
honours [46, 47, 48], she was eulogized in
2014 as one of Canada’s most respected ge-
neticists (49).
Even as the Alberta court was ruling on the
Alberta Eugenics Board, Alberto Fujimori
was mobilizing physicians in Peru for the
National Program for Reproductive Health
and Family Planning. By the time it ended
four years later, 200,000 to 300,000 people
had been sterilised, most without valid con-
sent: some forcibly, others bribed or threat-
ened by government officials or health care
personnel. Most victims were poor and of-
ten illiterate women from indigenous ethnic
groups. The technical standard of medical
care was often appalling, and numbers of
women died [50, 51, 52, 53].
The WMA’s denunciation of coercive steril-
ization came 12 years too late for Fujimori’s
victims [54]. In the United States, Oregon
abolished its eugenic sterilization law only
in 1983, and another 20 years passed be-
fore the state acknowledged the injustice
suffered by victims sterilized according to
the ethical standards of the day [55]. The
Tuskegee Syphilis Study continued until
it was exposed in 1972, the same year the
Alberta Eugenics Board was abolished. It
took almost 25 years for victims to receive a
public apology for unethical human experi-
mentation [56, 57].
In 2012, when a generation of German
physicians unconnected with the Nazi
era admitted the enthusiastic participa-
tion of German physicians at all levels of
the profession in crimes against humanity,
apologized, begged forgiveness, and de-
scribed what their predecessors had done
“as a warning for the present and the fu-
ture” [58].
The warning points, in the first place, to
the risk of sea changes with incalculable
consequences. It appears that the Ger-
man medical profession’s eugenic outlook
and interests converged with other social
and political dynamics and Hitler’s rise to
power. The convergence triggered a sud-
den, seismic socio-political shift that su-
percharged Nazi biopolitical ideology. The
medical profession rapidly transformed
Declaration of Geneva CANADA
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5
itself and was transformed to fulfil its new
biopolitical responsibilities [29], and new
possibilities suddenly materialized [59].
Carl Jung experienced this as an “earth-
quake” and an “avalanche” that was sweep-
ing all before it [60].
Second, the warning reminds us that mod-
ern biopolitical ideologies are advocated
worldwide by lobbyists as prominent, pow-
erful and influential as the eugenic enthusi-
asts of yesteryear.
Finally, we are warned that state collabora-
tion with the medical profession in support
of faulty biopolitical ideologies is far more
dangerous than the exercise of freedom of
conscience by individual physicians.Literal-
ly millions have suffered and died as victims
of what seemed like a good idea at the time,
at least in the eyes of those in positions of
power and influence.
Now…
The euthanasia/assisted suicide (EAS)
movement backs a biopolitical ideology
that is enormously popular in the developed
world, now entrenched in Canadian law
and collectively supported by the medical
profession.This has serious implications for
the nature of medical practice.
Leading Canadian EAS advocates told the
Supreme Court of Canada that physicians
are ideal EAS practitioners because they
will agree to it only “as a last resort” [61].
Indeed, they argued that “physician-assisted
dying” is not only “medical treatment,” but
“at the core of health care” [62]. This must
place killing patients at the core of the prac-
tice of medicine and require transformation
of the medical profession to fulfil its role in
the new order. How far this will go remains
to be seen.
Physicians cannot currently be compelled
to personally administer or prescribe lethal
drugs, though some prominent academics
argue that should change [63,64]. However,
the national government allows state medi-
cal regulators to compel unwilling practitio-
ners to facilitate EAS by effective referral
[65] or effective transfer of care [66], which
even some strong supporters of the proce-
dures acknowledge to be morally equivalent
to personally killing patients [64,67,68].
Courts in the province of Ontario support
this coercive policy, ruling that physicians
unwilling to comply can move into fields
like sleep medicine, hair restoration and
dermatology [69].
Unsurprisingly, some academics recom-
mend that medical schools deny admit-
tance to anyone with conscientious ob-
jections to providing whatever the state
considers medical treatment or health care,
including EAS [70]. Anecdotal reports
indicate that some dissenting medical stu-
dents face intense pressure to conform to
the EAS biopolitical agenda, experienc-
ing isolation, disregard and disdain among
their peers (71).
No wonder Canadian physicians who refuse
to support or collaborate in killing their pa-
tients feel themselves to be in the midst of a
socio-political and ethical avalanche.
Summing up
The historical record suggests that support
for physicians who refuse to kill or facilitate
the killing of their patients is justifiable on
prudential and pragmatic grounds. Tolerat-
ing refusal to participate in killing seems to
be a safer course than imposing an obliga-
tion to kill and is certainly consistent with
the high value EAS advocates have placed
on physician reluctance to kill as a primary
safeguard for patients.
As a matter of principle, one must dis-
tinguish what is demonstrably necessary
to preserve a free and democratic society
from what may be necessary to enforce a
biopolitical ideology. The difference is sig-
nificant but can be difficult to discern in an
avalanche. EAS ideology is grounded upon
metaphysical, philosophical and moral
premises that can be rationally contested
but cannot be empirically validated. Among
these is the dogmatic claim that a human
being can be better off dead. In a free and
democratic society, it ought to be unac-
ceptable to force physicians to profess this
article of faith, or to demonstrate practical
adherence to it by killing or facilitating the
killing of a patient.
Finally, there is an issue that goes to the
heart of what concerned the authors of the
Declaration of Geneva.
Competent patients may refuse even life-
saving/sustaining interventions based en-
tirely on their subjective views of what is
beneficial, harmful, or in their best interests.
Physicians ensure that patients have infor-
mation relevant to such decisions and may
make recommendations, but they are legally
and ethically obliged to respect patients’ in-
violability and abide by their decision. The
foundations of medical ethics and the per-
sonal integrity of physicians who disagree
are untouched by the patient’s decision.
While competent patients can absolutely
refuse interventions, they cannot demand
interventions because medical decisions to
intervene are not based solely upon patients’
demands [72]. Among other things, they
engage physicians as moral agents.
Patients request an intervention, including
euthanasia, because they believe it is not
harmful, is beneficial, or is in their best in-
terests. Physicians may reasonably disagree.
If, despite this, physicians are compelled to
further a patient’s request, the concepts of
benefit, harm and best interest become ir-
relevant. All that remains is the demand of
the patient,backed by the power of the state
to ensure compliance.
This treats physicians as mere technicians
or state functionaries, as cogs in a state ma-
chine delivering services upon demand, not
as responsible moral agents who, like their
Declaration of Geneva
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6
patients, must form and act upon judge-
ments about benefits and harms. It imposes
a form of servitude that is incompatible
with human equality, dignity and personal
and professional integrity.
The authors of the Declaration and ICME
denounced such instrumentalization of
physicians and the medical profession in
the strongest terms. The precept to practise
medicine with conscience and dignity im-
poses an obligation to resist and refuse such
demands, notwithstanding overwhelming
pressures exerted even in democratic soci-
eties.
References
1. Revised in 2017 to include, (and in accordance
with good medical practice. World Medical
Association. Declaration of Geneva [Internet].
[Ferney-Voltaire, France]: World Medical Asso-
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able from: https://www.wma.net/policiespost/
wmadeclarationofgeneva/.
2. Leiva R,Cottle MM,Ferrier C,Harding SR,Lau
T, Scott JF. Euthanasia in Canada: A Caution-
ary Tale.World Med J [Internet].2018 Sep [cited
2020 Mar 10]; 64:3 1723.Available from: https://
www.wma.net/wpcontent/uploads/2018/10/
WMJ_3_20181.pdf#page=19.
3. Carter v.Canada (Attorney General),2015 SCC
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CANADA
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Declaration of Geneva CANADA
BACK TO CONTENTS
9
Palliative Care
Based on 2011 data, the WHO Global
Atlas of Palliative Care [1] was released in
2014 and revealed that 42% of countries
had no palliative care and 38% had only
pockets of service provision.That same year
the World Health Assembly passed a reso-
lution [2] calling for all member states to
develop, strengthen, and implement pallia-
tive care services as part of universal health
coverage. A recently published study [3]
based on 2017 country data showed the
same categories were now 24% and 7%.
In the WHO Global Atlas Canada was rat-
ed as having “advanced integration of pallia-
tive care into mainstream service provision.”
I believe this is overly generous and would
say that Canada, like many other countries,
suffers from lack of integration of palliative
care into chronic illness care, particularly
non-cancer, and has a long way to go be-
fore claiming equitable service and quality
across urban, rural and remote areas.
One issue raised by Canadian clinicians is
not having palliative care symptom man-
agement guidelines or communication tips
on hand when seeing patients. Our pallia-
tive care program developed an app so cli-
nicians would have essential palliative care
knowledge at their fingertips. The app de-
sign follows similar thinking formats used
in medicine – assess, manage, communicate,
plan. A website-based app allows us to add
content without users having to down-
load current versions. St. Paul’s Hospital
Foundation in Vancouver Canada funded
this development and continues to fund
the costs of maintenance in order to keep
content free. It was launched in 2014 and
continues to be used on a regular basis by
doctors, nurses, social workers and others
throughout North America. It is accessible
at ipalapp.com and can be “bookmarked” or
its icon added to the home screen of a de-
vice. It is also usable on a desktop computer.
After launching and reviewing usage data
we realized many users were from parts of
the world where the palliative care chal-
lenges and available medications may be
significantly different.Thus iPal Global was
born with some significant differences.
iPal Global is a downloadable app that pro-
vides access to essential palliative care infor-
mation without requiring continuous inter-
net access. The app uses the International
Association for Hospice and Palliative Care
(IAHPC) List of Essential Medicines for
Palliative Care – the most effective and safe
commonly available medicines throughout
the world. The content of the app has been
reviewed and revised by clinicians working
with Two Worlds Cancer Collaboration to
ensure its content is relevant to resource
constrained countries.
The app contains advice on when a pallia-
tive approach to care is indicated and con-
tains basic assessment and management of
22 symptoms, as well as managing the last
hours of living. The app features advice for
planning future care and decision-making.
The Communication section, is intended to
improve therapeutic efficacy of communi-
cating as well as give suggested approaches
to specific situations such as breaking bad
news, discussing prognosis and deciding on
goals of care in managing an illness. Talk
Palliative Care: Free App and Tips to
Improve Quality of Care
Romayne Gallagher
CANADA
BACK TO CONTENTS
10
tips are placed throughout the app in ap-
propriate situations.
Downloading the app requires 15  Mb
of memory so it is quite modest for most
phones. Go to the website: https://global.
ipalapp.com where you will find links to
download the app to your smart phone, tab-
let or desktop computer.
The apps are applicable to COVID-19 as
many people can suffer with shortness of
breath if they develop Acute Respiratory
Distress Syndrome as a consequence of a
severe infection. If available and appropri-
ate, ventilation is the next step. If not avail-
able, or the person has multiple morbidities
the “Dyspnea” section under the heading
“Manage”.
Improving Palliative Care Takes
Much More than an App!
Many colleagues struggle to improve pallia-
tive care capacity in their healthcare system
in resource-constrained nations. It is often a
physician or nurse who makes it their per-
sonal mission to improve palliative care in
their area and sacrifice a great deal of their
time and energy to make that happen for
patients. That is not sustainable in the long
term because of personal burnout of the in-
dividual and it doesn’t change the way the
system provides care.
There is a greater likelihood of success in
establishing change if you form a group of
interested colleagues that includes nurses,
pharmacists, social workers, other allied
professionals and administrators. Don’t for-
get volunteers as no palliative care service is
complete without volunteers. There may be
already people in the community who do vis-
its to sick people and they can be invaluable
in understanding the barriers to accessing
care and may even have workable solutions.
Establishing who and how many people
need palliative care is an essential first step.
To win support of administrators in the
hospital and ministry and justify requests
for increased medication and salary support
you will need to show that there is an unmet
need.The Lancet Commission on Palliative
Care [4] calculated the world-wide serious
health-related suffering and developed a
package of resources to aid countries in de-
veloping their palliative care. They defined
serious health-related suffering as being
caused by illness or injury of any kind that
could be alleviated by palliative care or pain
management. One valuable resource is a da-
tabase that estimates the number of patients
needing access to palliative care and you can
find your country at the database website on
the International Association for Palliative
Care at https://hospicecare.com/what-we-do/
resources/global-data-platform-to-calculate-
shs-and-palliative-care-need/database/. You
will likely see that the estimate is greater
than what you thought it would be and that
is because the estimate covers those who are
dying from the illness as well as those living
with chronic illness.
Palliative care home visits have repeatedly
shown to reduce hospital admissions and
costs [5, 6] which is a significant help to the
healthcare system in any country. Reference
5 is available in an infographic at: https://
www.capc.org/seminar/poster-sessions/home-
based-palliative-care-reduces-hospital-read-
missions/. Having an estimate of the need
for palliative care as well as evidence that
it reduces visits and admissions to hospital
can help you to demonstrate a need for care
in the community that deals with suffering,
improves quality of life and prevents hospi-
tal admissions.
If you begin to treat more people’s pain
and shortness of breath you will use more
opioids. Opioids remain the medication
of first choice for moderate to severe pain
and shortness of breath due to advanced
illness of any cause [7, 8]. My experience
has been that if doctors don’t use opioids,
hospital and community pharmacists don’t
stock them. If you talk to doctors, they say
their prescriptions are not filled because the
pharmacy doesn’t have them. The pharma-
cist says they have thrown out opioids that
expired and don’t want to do that again so
they don’t order them in. Working together
always sorts out these issues and ongoing
communication is key to sorting out issues
with demand and supply.
The United States and Canada have expe-
rienced an increase in opioid-related deaths
over the past decade known as the “opioid
crisis”. It is a complex problem, not well
understood by media and many healthcare
providers.While the focus of the “crisis”has
been on opioids and how to reduce their use
in and out of the healthcare system, there
has been a poisoning of the illicit opioid
supply by synthetic opioids (fentanyl and
others), great stigma around opioid use
disorder (addiction) and a lack access to
treatment for the disorder. It is not a simple
relationship that the more you prescribe
the more people are harmed. It is possible
to treat pain and shortness of breath and
keep abuse of these medications to as low
as possible. More about this in a subsequent
article.
Improving the quality of the palliative care
you offer includes the use of validated tools
for assessing symptoms and tracking func-
tion. It promotes a standardized assessment
and tracks efficacy of the treatment. The
most widely used tool, available in many
languages, is the Edmonton Symptom As-
sessment Scale [9]. The reference is online
and has a description of how to use the
tool to improve quality of care. The Pallia-
tive Performance Scale is a tool to measure
patient function and progression of the
illness. It is available on line at https://vic-
toriahospice.org/how-we-can-help/clinical-
tools/ and has been widely translated. With
training these tools could be used by vol-
unteers checking up on patients at home
with serious illness to determine if a visit by
the healthcare professional is needed. This
means that the doctor/nurse save their visits
for those who most need their help.
CANADA
Palliative Care
BACK TO CONTENTS
11
COVID-19
Getting more education in palliative care
for your team is challenging as online cours-
es do not have the evidence [10] to show
that they improve palliative care practice.
Participation in the learning such as a jour-
nal club that reviews clinical articles regu-
larly may improve practice but the evidence
is not there yet. Additionally, case review
of patients, especially when the symptoms
were not well controlled or the death was
not well managed is essential. What tends
to stick with physicians is experiential
learning where they encounter a clinical
situation (e.g. neuropathic pain) and seek
evidence for its management. That is where
the app and some supplemental reading of
medical literature can boost your practice.
Most healthcare providers find palliative
care work meaningful and rewarding. If
burnout occurs it is usually due to the frus-
tration and challenges of doing this work
“off the side of your desk” or not being able
to get the resources you need to do this
work in a sustainable way (salary, necessary
medications,support from colleagues etc…)
If you have a team you can share experienc-
es and potential solutions as well as provide
emotional support to each other. Self-care
tips are on the global app under self-care.
References
1. WHO The Worldwide Hospice Palliative Care
Alliance. Global atlas of palliative care at the
end of life. World Health Organization and The
Worldwide Hospice Palliative Care Alliance,
Geneva2014
2. WHO Strengthening of palliative care as a
component of comprehensive care throughout
the life course.World Health Organization, Ge-
neva2014
3. Clark D, Baur N, Clelland D, Garrald E,
López-Fidalgo J, Connor S, Centeno C. Map-
ping Levels of Palliative Care Development in
198 Countries: The Situation in 2017. Journal of
Pain and Symptom Management 2020; 59(4):
794-807 https//doi.org/10.1016/j.jpainsym-
man.2019.11.009.
4. Knaul F, Farmer P, Krakauer E, De Lima L,
Bhadelia A, Kwete X et al. Alleviating the ac-
cess abyss in palliative care and pain relief—an
imperative of universal health coverage: The
Lancet Commission report. THE LAN-
CET 2018; 391, (10128): 1391-1454 Ac-
cessed at: https://www.thelancet.com/journals/
lancet/article/PIIS0140-6736(17)32513-8/
fulltext#articleInformation on March 22, 2020
5. Elnadry, Jeanne. Home-Based Palliative Care
Reduces Hospital Readmissions. Journal of Pain
and Symptom Management, Volume 53, Issue
2, 428 – 429
6. Akhtar S, Srinivasan V, Weisse C, DiSorbo P.
Characterizing the Financial Value of In-Home
Palliative Care for Patients, Payers, and Hospi-
tals. American Journal of Hospice and Palliative
Medicine 2020; 33(3): 196-200
7. Bruera E Paice J. Cancer Pain Management:
Safe and Effective Use of Opioids American
Society of Clinical Oncology Educational Book
2015 :35, e593-e599 Accessed at: https://ascop-
ubs.org/doi/10.14694/EdBook_AM.2015.35.
e593 on March 22, 2020
8. Ekström M, Abernethy A, Currow D.The man-
agement of chronic breathlessness in patients
with advanced and terminal illness BMJ 2015;
349 :g7617
9. Hui D, Bruera E.The Edmonton Symptom As-
sessment System 25 Years Later: Past, Present,
and Future Developments. J Pain Symptom
Manage. 2017; 53(3): 630–643. doi: 10.1016/j.
jpainsymman.2016.10.370 Full article access
at: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC5337174/
10. Hughes S, Preston NJ, Payne SA. Online learn-
ing in palliative care: does it improve practice?
Eur J Palliat Care. 2016;23(5): 236–9.
Romayne Gallagher MD,
CCFP(PC), FCFP
Department of Family and
Community Medicine
Providence Health Care
Clinical Professor, Division of
Palliative Care, UBC
1081 Burrard St.
Vancouver, BC, Canada
V6Z 1Y6
Email: rgallagher@providencehealth.bc.ca
Miguel Roberto Jorge
Interview with Miguel Roberto Jorge
by WMJ Editor Peteris Apinis
Brazil is one of the countries where Covid–19
has spread very widely. How are you in this
difficult time? How are Brazilian doctors these
days?
We see that the situation worsens day by
day. We have the second highest number of
cases and soon will also rank second as to
the number of deaths. And we know that
the current numbers are undercounted. Be-
sides this sanitary crisis, we had some years
of a crisis in economy and, unfortunately,
we are also experiencing a political crisis,
with a polarized country and a President
who is against the recommendations from
specialists on how to face the COVID-19
pandemic. Physicians, nurses and other
health personnel are trying to do their best
to help those affected by the virus, but there
is shortage of specialized people at public
hospitals, lack of PPE, lack of reliable data
(only seriously ill patients are tested) and
specialists are stigmatized by people in fear
of being infected.
BACK TO CONTENTS
12
COVID-19
As I understand, you contact your fellow col-
leagues, doctors around the world, almost every
day. What is the mood among our friends – the
leaders of National Medical Associations?
There is an enormous mobilization of medi-
cal leaders around the world in order to
overcome all sort of obstacles to have effi-
cient and safe working conditions. I am par-
ticularly following the group of NMAs that
belong to CONFEMEL (Confederation of
Medical Entities of Ibero Latin America)
and CMAAO (Confederation of Medical
Associations in Asia and Oceania). Despite
the difficulties, they are doing their work and
trying to build efficacy with great enthusiasm.
We know you as a distinguished psychiatrist,
professor and a long-term specialist of the
World Health Organization. As a special-
ist of such a kind, I must ask you, hasn’t the
­
Covid–19 pandemic caused a very large out-
break of mental diseases in the world, defined
by fear, ignorance, worry, the loss of loved ones?
The COVID-19 pandemic and the needed
confinement at home brought out a series of
mental health problems as well as new cases
or worsening of previous mental disorders.
Anxiety and different types of fears are
common reactions when facing the possi-
bility of infection and also after some weeks
of quarantine.Depression and alcohol abuse
are problems affecting the vulnerable ones.
The loss of someone close, economic loss or
becoming unemployed are factors contrib-
uting to emotional distress.
There are many interesting articles in world lit-
erature that solitude and isolation reduces non-
specific immunity, increases the risk of neurologi-
cal and endocrinological diseases. Many people
in the world now live more or less in isolation,
quarantining. Doesn’t loneliness and isolation
lead to depression, anxiety, and other psycho-
logical changes? Can these psychological chang-
es become a cause for psychosomatic diseases?
We have to be careful when considering
isolation or loneliness for a period of some
months in comparison with an endless situ-
ation. As I have said before, we are observ-
ing anxiety, depression and other emotional
reactions to the pandemic and the associ-
ated quarantine. That situation is also con-
tributing to decreasing physical activity and
the consumption of non-healthy food,gain-
ing weight and potentially triggering some
health problems. Sleep disorders have also
been observed.
It is known that isolation and confinement in
very small spaces can lead to domestic violence
and aggression. Isn’t the world threatened by a
wave of violence as a response to lasting isola-
tion?
Confinement of people in not large spaces
that create difficulties to have privacy or for
a long period of time is associated with ris-
ing tensions among them, increase of irrita-
bility, and potentially causing verbal and/or
physical aggression. Some couples can even
experience a serious marital crisis.
World experience has shown that in difficult
times like these people tend to pour out their
discontent and aggression on relatives, doctors
and pharmacists. Doctors around the world
often become victims of negative feelings, not
only verbally, but they are attacked also physi-
cally. What can we do to make doctors feel safe
at such a moment of tension?
We see reports about people applauding
health professionals and also reports about
violence against them. As regards safety,
people need to be informed in what difficult
situations professionals at the pandemic’s
frontline are, risking their lives to save oth-
ers. Physicians, nurses and other members
of the health team also experience fears of
being infected, to infect their relatives at
home, to die or not being able to save many
patients they attend to.They are people like
any other. When someone attacks health
professionals, usually it is because of a
wrong idea about getting infected from be-
ing in their presence.And if a health worker
is attacked,it will be one less at the frontline
helping patients. Public campaigns are im-
portant to educate people.
From the experience of China and Italy, we
know that doctors are really exposed to the
disease, as it is very common to get sick with
­
Covid–19. Most doctors are very afraid of get-
ting sick,mainly because they can take the disease
home to their parents, relatives. The worrying
about a potential disease can be very serious.
Can doctors in the world feel protected from the
illness and feel more or less safe?
Governments and health managers have the
responsibility to offer good and safe work-
ing conditions to doctors and health work-
ers at the frontline. Adequate personal pro-
tective equipment needs to be fully available
and services need to take into account the
required sufficient number of personnel so
as not to expose one another to a bigger risk
of being infected. Time off between shifts
and breaks during shifts also contribute to
rest and focus when returning to work.
From the experience of China and Italy, we
know that doctors who face a large number of
severely ill Covid–19 patients daily are forced
to make very difficult decisions – which patients
should be assisted to. Are doctors psychologically
supported and what can the World Medical As-
sociation, National Medical Associations and
Governments do to maintain the psychological
health of doctors?
Even before the COVID-19 outbreak, there
were reports about increasing burnout among
physicians, particularly among those in
training or with few years of practice. Good
and safe working conditions protect physi-
cians from psychological problems but even
in rich countries there are situations where
they have to choose between patients – those
who will be placed in an Intensive Care Unit
or not or have access to a ventilator. National
Medical Associations and their specialized
societies are developing guidelines with al-
gorithms to help physicians be less subjective
in their decision making and consequently
BACK TO CONTENTS
13
COVID-19
experience less psychological stress in that
undesirable situation.
Covid–19 has produced fantastic developments
in science and research. Every day there is new
research, new lessons, new information.There has
never been so much contradictory information
about one topic. How do doctors feel about this
information flow and how to adapt to it?
There is an enormous effort from scientists
worldwide to know better this new coronavi-
rus and the pathophysiology of ­
COVID-19.
The world is anxious for a vaccine to prevent
new cases and the right medication to treat the
disease. Moreover, there are lots of researches
being done to study human behavior during
the current pandemic and trying to figure out
how habits will change after the COVID-19
outbreak. Unfortunately, good research takes
time to achieve results that will last and not be
contradicted by another research.And doctors
know it better than anyone not familiar with
the development of science. What is impor-
tant – science was not properly considered or
even rejected before this pandemic and now
we see people more interested and recogniz-
ing the importance of science development.
In the world, not only doctors and patients have
conversations in Zoom, Skype or over the tele-
phone, but also the relationship between doc-
tors, their mutual advice and communication
is remote. Do we not lose much of the human
communication qualities? Don’t our doctors lose
professional ties? Maybe we need psychotherapy
for the all-global medical community?
Different forms of telemedicine and the
utility of remote work are tested during the
situation the world is experiencing since the
outbreak that started in China.I am sure that
it will affect the work of everybody and our
work as physicians as well. As a psychiatrist
and psychotherapist, I do not believe that a
virtual consultation will give us all we can
have when in the physical presence of our
patients. Unfortunately, sometimes physical
examination is replaced by labs and images,
and the patient as a person loses importance
to the signs and symptoms they present.Evi-
dence based diagnosis and treatment are of
great importance but the human contact is
an essential aspect of the practice of medi-
cine.Telemedicine can be a wonderful tool to
complement the possibilities of an encounter
between a physician and their patient.
Your final remarks?
I believe that the most important thing that
the COVID-19 outbreak brought to us was
the astonishing awareness of how unequal
is the world we live in. We discussed in the
previous questions situations that can be
more applicable to privileged people but we
must think about those who live in low and
middle income countries and even in the
outskirts of cities or urban areas of rich coun-
tries.Think about those who do not have ac-
cess to health services or have limited and
difficult access to not too good quality medi-
cal services. At this particular time, during
the current pandemic,while I am here,in my
small but comfortable apartment, answering
questions, typing on my computer, there are
millions of people fighting to survive in this
difficult situation. There are cultures were
philanthropy is not rare and I do not know
about every country but I have never seen
people being mobilized to do something or
to donate a considerable amount of money
to the underprivileged as nowadays in my
country, Brazil. I hope and wish that such
attitudes will increase and reach every corner
of the world.
The World Health Organization is re-
porting this June 2020, that there are over
6  million cases globally of COVID-19
with over 380,000 deaths and the human
cost of this pandemic could be extraordi-
nary [1]. It is important to shine a lens on
the potential impact of the pandemic on
Women’s Health Issues and the Sustain-
able Development Goal of reaching Zero
Unmet Need for Contraception by 2030.
Unplanned teenage pregnancy is a global
health issue, a women’s health issue, and a
human rights issue.
The Nairobi Summit on ICPD+25 held in
November 2019 had a major theme, Reach-
ing Zero Unmet Need for Family Planning
by 2030. At that time, in Developing coun-
tries 214 million women did not have access
to modern contraception and thus, become
pregnant as young adolescents, often while
they are still in school. There still exists a
disparity in contraceptive use between the
high and middle-low countries, even within
African countries, and between the higher
and lower income quintiles within coun-
tries. The economic and physical disrup-
tions related to COVID-19 could have vast
consequences for the sexual and reproduc-
tive rights and health of women and girls,
a new analysis by UNFPA and partners
shows.The pandemic will undermine efforts
to end gender-based violence and limit the
progress of ending gender-based violence by
2030 [2].For every 3 months the lockdown
continues, assuming high levels of disrup-
tion, up to 2 million women may be unable
to use modern contraception. Significant
levels of lockdown-related disruption over
3 months could leave 47 million women in
What is the potential impact of the COVID-19 Pandemic on
Achieving the Sustainable Development Goal of Reaching Zero
Unmet Need for Contraception by 2030?
BACK TO CONTENTS
14
Padmini Murthy
Bev Johnson Deborah Bateson Marion Okoh-Owusu
low- and middle-income countries unable
to use modern contraceptives, leading to a
projected 7 million additional unintended
pregnancies [2].In the most severe scenario,
with significant service disruptions lasting
for a full year, 51 million women would be
unable to use modern contraceptives, re-
sulting in 15 million unintended pregnan-
cies [2]. During the past 4-5 months, the​
COVID-19, a highly infectious virus that
we do not have a vaccine for yet, has spread
to every corner of the world.
Dr. Natalia Kanem, Executive Director
of the United Nations Population Fund
(UNFPA) stated “This new data shows the
catastrophic impact that COVID-19 could
soon have on women and girls globally. The
pandemic is deepening inequalities, and mil-
lions more women and girls now risk losing
the ability to plan their families and protect
their bodies and their health,” said Dr. Na-
talia Kanem, UNFPA Executive Director.
“Women’s reproductive health and rights
must be safeguarded at all costs.The services
must continue; the supplies must be deliv-
ered; and the vulnerable must be protected
and supported [3].” ​
Some clinics may not
have the Personal Protective Equipment
(PPE) to protect themselves or the patients
and staff illness may impact service provi-
sion. Staff will need to focus on COVID-19
patient care and may not have the resources
to provide contraceptive advice and services.
The function of supply chains in some coun-
tries has been disrupted with the closure of
borders and production of some contracep-
tives have been disrupted. It is essential to
ensure supply chains of contraceptive prod-
ucts so that there is unimpeded flow from
manufacturer to the patient.FP2020 has cre-
ated a platform to ensure information from
global experts about family planning [4].
Key action points to consider maintenance of
essential Family Planning services during the
COVID-19 pandemic have been published
by the International Federation of Obstetrics
and Gynecology [5].These include an urgent
need to use points of care such as postpar-
tum and prenatal visits for providing educa-
tion and access to long acting reversible con-
traceptive (LARC) options. Also, self-care
family planning methods which include self
injectables,condoms and vaginal rings which
can be supplied to women are important.
Implementation of telemedicine using mo-
bile phones and social media can be used for
both information and access to supplies [5]
Adolescents are particularly vulnerable in the
pandemic as they may have restricted ability
to seek services away from home but there
are opportunities to remove some barriers to
care with use of telemedicine.
Contraception is a human right for adoles-
cent girls,and healthy families are by choice,
The impact of the COVID-19 Pandemic
on Family Planning requires a collaborative
and novel approach so that we can continue
to strive towards Zero Unmet Need for
Contraception by 2030.
Medical Women’s International Association
(MWIA): Teenage Pregnancy Task Force
References
1. WHO Coronavirus Disease (COVID-19)
Dashboard. [Internet]. 2020 [cited 4 June 2020].
Available from: https://covid19.who.int/
2. Impact of the COVID-19 Pandemic on Fam-
ily Planning and Ending Gender-based Vio-
lence, Female Genital Mutilation and Child
Marriage. [Internet]. 2020 [cited 4 June 2020].
Available from: https://www.unfpa.org/re-
sources/impact-covid-19-pandemic-family-
planning-and-ending-gender-based-violence-
female-genital
3. New UNFPA projections predict calamitous
impact on women’s health as COVID-19 pan-
demic continues. [Internet]. 2020 [cited 28
April 2020]. Available from: https://www.
unfpa.org/press/new-unfpa-projections-pre-
dict-calamitous-impact-womens-health-covid-
19-pandemic-continues
4. FP2020 COVID-19 & Family Planning.[Inter-
net]. 2020 [cited 4 June 2020]. Available from:
http://familyplanning2020.org/covid-19
5. Contraception and Family Planning. Federation
of International Gynaecology and Obstetrics.
[Internet]. 2020 [cited 4 June 2020]. Available
from: https://www.figo.org/covid-19-contracep-
tion-family-planning
Dr. Bev Johnson
E-mail: beverlyjohnsonmd@gmail.com;
Dr. Padmini Murthy
E-mail: minimurthy1234@gmail.com;
Dr. Deborah Bateson
E-mail: deborahb@fpnsw.org.au;
Dr. Marion Okoh-Owusu
E-mail: drokohowusu@gmail.com
COVID-19
BACK TO CONTENTS
15
Medical Tourism is the process of people
travelling to another country, across inter-
national borders and outside their country
of residence, for the purpose of obtaining
medical care, which may include the full
range of medical services such as preventive,
promotive, curative and rehabilitative ser-
vices. Importantly, it includes the range of
socio-economic activities undertaken by an
individual or group of persons in the process
of accessing medical care/health care ser-
vices outside his/her country of residence.
These activities,which are usually undertak-
en after completion of the primary medical
procedure, could include leisure and busi-
ness activities in the destination country.
Outward Medical tourism, particularly po-
litical health tourism by African political
leaders, has been a major challenge con-
fronting the African continent,with health-
care systems in most of the African conti-
nent left undeveloped, at huge cost to the
health of African people and the economy
of the African continent. Instead of invest-
ing required resources in the development
of their healthcare systems, some African
political leaders prefer to seek medical care
abroad, outside their respective countries.
However, with the outbreak of Coronavi-
rus disease (COVID-19) in China and its
subsequent spread to other regions of the
world, including Africa, most parts of the
world have been on lockdown with closures
of international airports, land and sea bor-
ders.
Apart from the COVID-19 pandemic ex-
posing the long-standing challenges and
fragility of African healthcare systems, it
has severely limited the opportunity to seek
medical care abroad, with African political
leaders and elites left with no choice but to
seek healthcare in their home countries.
While it may be premature to tell if this
switch to the utilization of local health
facilities by African political leaders will
remain a permanent feature in the post-
COVID-19 era, this article is aimed at
reviewing the impact of outward medical
tourism by Africa’s political leaders and the
likelihood of the COVID-19 pandemic
serving as a reversal mechanism, with a pro-
jection into the post-COVID-19 era.
Funding: This research/paper did not re-
ceive any specific grant from funding agen-
cies in the public, commercial, or not-for-
profit sectors.
The global community is currently con-
fronted with the challenge of containing
coronavirus disease (COVID-19) caused by
a novel strain of coronavirus, called SARS-
COV-2 [1].The disease first came to public
attention following the outbreak of an acute
respiratory illness in Wuhan City, Hubei
province of China in December 2019 [2].
Since the outbreak was reported to the
World Health Organization (WHO) by
Chinese authorities [3], it has spread be-
yond China to many other countries of
the world. This trend of regional and con-
tinental spread, as well as the increase in the
number of cases, informed WHO’s declara-
tion of the disease as a Public Health Emer-
gency of International Concern (PHEIC)
on January 30, 2020 [4], and as a Pandemic
on 11th
March, 2020 [5]. As at Sunday, 14th
June, 2020, over 200 countries have been
affected by COVID-19, with 7,948,001
persons confirmed to have COVID-19 and
434, 097 deaths recorded, globally [6]. Af-
rica recorded her first case of COVID-19 in
Egypt on the 14th
of February,2020 [7],and
as at Sunday, 14th
June, 2020, over 50 Af-
rican countries have been affected by CO-
VID-19, with a total of 233, 732 persons
confirmed to have COVID-19 and 6, 253
deaths recorded [8].
Coronavirus disease (COVID-19) is spread
through respiratory droplets from infected
individuals (especially when they cough or
sneeze), aerosols, and contact with infected
objects and surfaces [9]. It is characterized
by symptoms such as fever, cough, sore
throat, difficulty with breathing/short-
ness of breath, myalgia, anosmia, fatigue,
as well as complications such as acute re-
spiratory distress, septic shock, metabolic
acidosis, bleeding and coagulation dysfunc-
tion [10]. There is currently no approved
drug treatment or vaccine for the disease
[11]. Therefore, Infection Prevention and
Control measures and other public health
interventions such as respiratory and hand
hygiene, social distancing, use of face mask,
public lockdown, risk communication, etc.
have been the mainstay of containment ef-
forts  [12]. This has resulted in movement
restrictions, including stoppage of interna-
tional, national and local travels, closure of
international and domestic airports, closure
of land and sea borders, closure of schools
COVID-19 Pandemic: a Possible Reversal Mechanism for Outward
Medical Tourism by African Political Leaders
Osahon Enabulele
COVID-19
NIGERIA
BACK TO CONTENTS
16
and offices, and prohibition of mass gather-
ings [13].
Covid-19 has had great impact on many
countries. Indeed, the health, socio-eco-
nomic,political and cultural implications of
COVID-19 have been quite evident. Even
countries with well-developed healthcare
systems have had their healthcare systems
seriously challenged and overwhelmed by
COVID-19 [14]. The lives and livelihoods
of the people have been grossly affected
by the shutting down of the economy and
people’s sources of livelihood/income. It
has been estimated that half a billion more
people in the world could be pushed into
poverty as governments shut down entire
economies to manage the spread of the vi-
rus [15]. COVID-19 has enthroned a “new
normal” and way of life, with various cop-
ing strategies developed to cope with the
effects of COVID-19, including new ways
of living and conduct of human affairs and
transactions, increased local production of
essential commodities and human needs,
increased utilization of local, homegrown
resources and facilities, etc [16]. These im-
plications are more glaring in most of the
developing countries of the world, includ-
ing the African continent where most of
the countries have fragile economies, in-
stitutions, and fragile health care systems
[17, 18].
Impact of COVID-19
Pandemic on Outward
Medical Tourism
What is Medical Tourism?
Medical tourism as a concept has been
practiced for centuries in Africa and other
parts of the world. However, the emergence
of technology and globalization, as well as
the involvement of political leaders, govern-
ments, and the corporate world, has accel-
erated its transformation and significance
over the decades.
Though there is currently no universally
agreed definition of medical tourism [19],
it is sometimes simply defined as the pro-
cess of people travelling to another coun-
try, across international borders and outside
their country of residence, for the purpose
of obtaining medical care [19, 20].This may
include the full range of medical services,in-
cluding preventive, promotive, curative and
rehabilitative services [19]. This simplified
definition may however not truly reflect the
important factor of tourism associated with
these foreign medical travels [21]. There-
fore, to better appreciate its significance, it
may be better defined as the range of socio-
economic activities undertaken by an indi-
vidual or group of persons in the process of
accessing medical care/ health care services
outside his/her country of residence. These
activities, which are usually undertaken af-
ter completion of the primary medical pro-
cedure, could include leisure and business
activities in the destination country [21].
Medical Tourism is usually classed into
Outward Medical Tourism (when it in-
volves travel for medical care outside one’s
country of residence) and Inward/In-bound
Medical Tourism (when it involves travel
for medical care within one’s country of
residence) [21].
Aside from the patients, there are sev-
eral stakeholders currently involved in the
multi-billion dollars medical tourism mar-
ket. These include the healthcare providers,
medical tourism agents, insurance and trav-
el agencies, national governments, etc [21].
Reasons for Outward Medical Tourism
There are various reasons for outward medi-
cal tourism (foreign medical travels) by in-
dividuals and groups. These include better
quality of health infrastructure and health-
care services in the destination country, re-
duced cost of healthcare services in the des-
tination country, lack of access to required
health care and diagnostic services in the
source country (such as reproductive tech-
nologies and cancer diagnostic facilities),
political instability and insecurity in the
source country, availability of the required
expertise/highly skilled medical person-
nel in the destination country, ambience of
the health facilities and receptiveness of the
health personnel, etc [21, 22]. In the case
of Africa, Nigeria inclusive, it sometimes
also includes the absurd such as inordinate
quest for government estacodes by some
political and public office holders, poor po-
litical commitment to the development of
the health system and health of the citizens,
and official secrecy [21].Indeed,some elites,
public and political office holders see it as
a status symbol, even when such medical
conditions or medical care needs can be sat-
isfactorily attended to in Africa [21]. This
notwithstanding, it is important to note
that there are Africans who genuinely travel
abroad to access quality healthcare services
and technologies (such as heart surgeries
and oncological treatments) which may
not be readily available in most of Africa’s
healthcare facilities [21].
Outward Medical Tourism by
Africa’s Political Leaders
It is well known that rather than invest-
ing resources in the sustained development
of their healthcare systems, some African
political leaders and public office holders
utilize public resources to undertake fre-
quent travels abroad to receive medical care,
sometimes for medical conditions that can
be readily managed in their respective coun-
tries [21, 23, 24]. The common destination
countries for African political leaders and
elites include India, United States, United
Kingdom,United Arab Emirates,Germany,
Turkey,Thailand, and Israel.
Aside from the huge loss to their country’s
healthcare systems and economies, some
of these African political leaders have un-
fortunately kicked the bucket either in the
course of obtaining foreign medical care in
the destination countries, or shortly after
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17
returning to their home countries. Some
have also had to spend upwards of 4months
in the destination countries, at great loss
to the governance/political leadership and
economy of their countries [24].
In the words of Professor Khama Rogo of
the World Bank, much as Africa is heavily
resource constrained,a lot of money is spent
on treatment abroad that could have instead
helped develop capacity locally. Africa, ac-
cording to Prof. Khama Rogo, is exporting
money and patients to the East, especially
India, which has largely contributed to a
flourishing private health sector at the ex-
pense of Africa’s. Prof. Rogo went further
to state that 25% of the passenger loads on
major airlines such as Kenya Airways and
Ethiopian Airlines, are medical tourists
from Africa to foreign countries [25].
The unceasing trend of outward medical
tourism by African political leaders in the
pre-COVID-19 era is a reflection of their
poor priority for the health of their citizens.
It is also a strong reflection of their unsat-
isfactory level of political commitment to
the development and utilization of health
facilities/systems within their respective
countries.
Amongst several enablers of health sys-
tem development are two critical enablers,
which clearly depict the poor priority for
health and unsatisfactory level of political
commitment to the development of health-
care systems by most African political lead-
ers/governments, viz:
1. Inadequate Government Health Financ-
ing and Budgetary allocations.
One of the major factors that has blighted
African health systems is inadequate health
financing and budgetary allocations to the
health sector by most African governments.
This is coupled with the injudicious utiliza-
tion of even the insufficient funds allocated
to the health sector. An evidence of this is
the fact that many African countries are yet
to meet up with the 2001 Abuja declaration
of African Heads of Government (signed
over 18 years ago) in which they pledged to
allocate a minimum of 15% of their annual
budgets to the health sector [24, 26, 27].
Whereas Africa currently (as at Sunday,
June 14, 2020) constitutes about 16.72% of
the global population [28], and bears about
24% of the global disease burden [29], pub-
lic health spending in Africa is reported to
be 1% of global health spending [30, 31],
with the average public expenditure on
health in the African region put at 10% of
total public spending [32].
This state of poor financial investment in
African healthcare systems has led to poor
and fragile health infrastructure, equipment
and diagnostic facilities, poor investment
in research, poor emergency preparedness
and response to epidemics, as well as a se-
rious dearth in human resource for health,
amongst other challenges [33, 34].
2. Dearth of Human Resource for Health.
A very significant factor in the develop-
ment of healthcare systems is the Human
Resource for Health, comprised largely of
physicians, nurses, pharmacists and other
allied health professionals/health workers.
These professionals play a significant role
in the provision of the much-needed access
to quality, effective and efficient health care
services.
Currently, there is a global crisis of avail-
ability of human resource for health, re-
flected in the acute and chronic shortages
of health care workers in most countries of
the world.This crisis is even worse off in the
African continent, which though accounts
for about 24% of the global disease bur-
den, only boast of about 3% of the global
health work force [29]. Notwithstanding
the globally acknowledged significance of
the human resource for health, most Afri-
can countries hardly accord this component
of the healthcare system serious consider-
ation and importance, an attitude that has
led to continuous emigration of medical
doctors and other healthcare professionals
to countries in the developed parts of the
world with better economic climate and
more enabling health care environments,
such as United States of America, United
Kingdom, Canada, United Arab Emirates,
Germany, etc [35, 36].
Consequences of Outward
Medical Tourism on African
Healthcare Systems
There have been several consequences of
outbound/outward medical tourism by Af-
rican political leaders and elites in the pre-
COVID-19 era. One of such consequences
is the huge outflow of foreign exchange
(capital flight) to other countries outside
Africa, in the course of accessing foreign
medical facilities, healthcare services and
technologies that ought to be available lo-
cally in Africa.
In 2016 alone, Africa is reported to have
lost over $6 billion from outward medical
tourism [37]. Indeed, it is important to note
that there are some African countries whose
economic loss (country wise) to outward
medical tourism exceeds $1billion. This is
more so as each foreign medical trip typi-
cally cost an average of $20,000–$40, 000
per individual traveler, with each traveler
usually accompanied, most of the time [21].
In the case of foreign medical travels by Af-
rican political leaders, the expenditures are
even more, on account of the fact that they
usually travel with outlandish entourages/
horde of aides and in expensive chartered
jets which sometimes incur huge parking
costs in the destination countries. For in-
stance, in the year 2013, Nigeria alone, lost
over $1billion to capital flight from outward
medical tourism [21, 23, 38, 39].
The unfortunate trend of frequent foreign
medical travels by African political leaders
in the pre-COVID-19 era has also led to the
sustained de-marketing of the healthcare
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18
systems of their respective countries  [21].
This has been at great loss to the econo-
mies of African countries with tremendous
negative knock-on effects on the healthcare
systems of African countries, with most of
them left in very fragile states.
The fragile and deteriorated state of health
facilities in most African countries has over
time led to loss of confidence in the avail-
able local health facilities, thus promoting
outward medical tourism for the average
African citizen.
The emergence of COVID-19 on African
soil on the 14th
of February 2020 [7], has
only exposed further, the fragility of most
African healthcare systems. The current
COVID-19 pandemic revealed that most
African healthcare systems lacked enough
capacity to respond to COVID-19 as was
evident by the insufficient numbers of suit-
able isolation centers and inadequate hu-
man resource for health, as well as the in-
sufficient diagnostic capacity to screen and
detect COVID-19 [40]. Before the first
recorded case in Africa on the 14th
of Feb-
ruary, 2020, most of the African countries
had very limited number of Laboratories to
process confirmatory tests for COVID-19
[40].In Nigeria (the most populous country
in Africa),for example,as at the 27th
of Feb-
ruary 2020 when the country recorded her
first case of COVID-19, there were only 5
diagnostic laboratories (4 public and 1 pri-
vate) for test confirmation of COVID-19.
This was to serve a Nigerian population of
over 200 million people resident in the 36
States of Nigeria and the Federal Capital
territory, Abuja [41].
Expectations in the Post-
COVID-19 Era
With the deficits in African healthcare sys-
tems exposed by the COVID-19 pandemic,
there are lots of expectations by African
people, particularly in terms of African
political leaders recommitting themselves
to health system development in the post-
COVID-19 era.
Interestingly, COVID-19 has indubita-
bly compelled most governments in Af-
rica with poor priority for health, to have
a rethink about their commitment to their
healthcare systems, particularly with the
grim reality that COVID-19 is no respecter
of social class, age, gender or race, and the
fact that the opportunity for foreign medi-
cal travels does not currently exist. Truly,
African governments have been compelled
by ­
COVID-19 to make the kind of invest-
ments in the healthcare system that they
may ordinarily not have made in the pre-
COVID-19 era; a fact that is evident when
their current responses to the COVID-19
pandemic is compared with their responses
to other epidemic and endemic diseases
like Malaria, Lassa fever, Tuberculosis,
and Cholera, some of which have caused
more deaths in the African continent than
­COVID-19.
These COVID-19 induced investments
have led to the development of new health
infrastructure and equipment, including
Isolation centres and Infectious Disease
Hospitals,the upgrade of existing ones,pur-
chase of diagnostic machines, recruitment
and motivation of healthcare personnel,
encouragement of local production of some
essential commodities like Ventilators, Face
masks, and Personal Protective Equipment
(PPEs),amongst other initiatives to contain
COVID-19 in Africa.
This notwithstanding, it remains to be seen
if these investments and commitment to
emergency preparedness and response, as
well as health system development, will be
sustained in the post-COVID-19 era. This
author hopes that it will no longer be “busi-
ness as usual” in the post-­
COVID-19 era,
and that African governments will emplace
an effective and focused strategic develop-
ment plan that incorporates effective per-
formance monitoring and evaluation (in the
short, medium and long-term), to address
the following expectations, amongst others,
in the post-COVID-19 era:
(1) Improved healthcare financing and
level of political commitment by African
political leaders to the health of African
people and the development of African
healthcare systems.
With the grim realities thrown up by the
COVID-19 pandemic,it is expected that Af-
rican political leaders will step up their level
of political commitment to the health of Af-
rican people, through more sincere commit-
ment to the protection of their health rights
and sustained development of the healthcare
systems in their respective countries. It is ex-
pected that they will continually appreciate
the significant nexus between investments
in healthcare, and the productivity and eco-
nomic prosperity/wealth of their respective
countries and people. They need to appreci-
ate the imperative of making greater invest-
ments in the health of African people,health
system development and quality healthcare
service provision, particularly through im-
proved budgetary allocations to the health
sector, in line with the 2001 Abuja declara-
tion of African Heads of Government [26].
(2) Reversal and restriction of Outward
Medical Tourism by African political
leaders.
The first real step towards limiting or re-
versing outward medical tourism in the
African continent, particularly the frequent
foreign medical travels by African political
leaders, is the recommitment of African po-
litical leaders and governments at all levels,
to quality healthcare development and the
health of their citizens. This is the first real
step towards limiting the huge loss of for-
eign exchange from Africa and ploughing
back the saved resources to the development
of the healthcare systems in the African
continent, on a sustainable basis.
Interestingly, one obvious effect of the
­
COVID-19 pandemic is the fact that it
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has apparently conditioned African peo-
ple, particularly the African political lead-
ers and elites, with a penchant for foreign
medical travels, to stay back home to utilize
the healthcare facilities and systems in their
respective countries to resolve their health-
care needs. Instructively, since ­
COVID-19
arrived in Africa, various political leaders
have come down with the disease. How-
ever, unlike what was the case in the pre-
COVID-19 era where they could easily
travel abroad to resolve their medical chal-
lenges, the option of foreign medical travel
has been virtually blotted by the restrictions
and challenges imposed by the COVID-19
pandemic. The main choice available to
them has been to use the healthcare facili-
ties that are available in-country. This may
be seen as a positive effect of COVID-19,
particularly when viewed against the hu-
mongous capital flight out of the various
countries in Africa on account of outward
medical tourism/foreign medical travels,
with grave consequences for the economies
and healthcare systems of African countries.
It is therefore expected that this trend of re-
versal of outward medical tourism along with
the associated reversal of capital flight will be
sustained and consolidated upon in the post-
COVID-19 era. A critical factor in the real-
ization of this objective is the commitment
of African political and public office holders
to leadership by example through their utili-
zation of health facilities in their respective
communities and countries, rather than in-
dulging in frequent foreign medical trips for
their healthcare needs.The positive knock-on
effect on the confidence of their citizens (Af-
rican people) in utilizing health facilities in
their communities and countries, along with
the growth and development of the health-
care system, cannot be over-emphasized.
(3) Sincere development and effective
management of the Human Resource for
Health.
A critical element needed for health sys-
tem development is the presence of an
adequate number and distribution of well
skilled and motivated health workforce.
For African healthcare systems to make the
needed progress in the post-COVID-19
era, there is urgent need for African gov-
ernments to pay greater attention and care
for their human resource for health. They
must develop a focused, strategic, dynamic
and robust Human Resource for Health
Development plan; one that takes cogni-
zance of the need for sustained produc-
tion of sufficient numbers of quality and
competent physicians and other healthcare
professionals, as well as their recruitment
and retention in Africa.
They must pay attention to the push and
pull factors that influence the emigration of
physicians and other healthcare personnel
from the African region. This will particu-
larly require the institution of motivational
mechanisms, incentives and competitive
wages, training and retraining of health-
care personnel, better conditions of service
and enabling work/practice environments
for healthcare personnel, improved security
and safety of healthcare personnel, as well
as schemes for turning brain drain to brain
gain.
(4) Improved Quality of Health Infra-
structure and Technologies.
It is expected that African governments will
make greater commitments to the sustained
provision of quality health infrastructure,
technologies and equipment, along with
the development of a maintenance policy
to guarantee continuous upgrade of existing
health infrastructure, diagnostic facilities
and technologies, in the post-COVID-19
era.
(5) Development of the Primary Health-
care System.
One of the realities of the COVID-19
pandemic is that the existence of a robust
primary healthcare system is a significant
factor in the containment and management
of the pandemic. This is particularly on ac-
count of the report that over 80% of cases of
COVID-19 affected individuals are in the
mild category [42]. The primary healthcare
system is therefore well suited for the man-
agement of these mild cases, thus removing
some burden from the higher levels of the
healthcare system. This is also of particular
relevance in Africa where home manage-
ment of mild cases of COVID-19 may be
challenging because of the multiple number
of occupants that generally characterizes
each African household.
Unfortunately, most African countries can-
not boast of having a robust and effective
Primary health care and referral system,
hence the overburdening of the secondary
and tertiary levels of care in the manage-
ment of individuals with COVID-19.
Arising from the foregoing, it is expected
that African governments will invest more
in the strengthening of the Primary health-
care system, but without relegating their in-
vestments in the development of the other
levels of the African healthcare system.
Along with this is the need for strengthen-
ing of the referral system, and the national
system in general, in a way that improves
confidence in the system by communities
and consumers of care.
(6) Development of the Private health
sector.
It is not in doubt that most patients first
visit private healthcare facilities in an at-
tempt to get solutions to their healthcare
needs. It is therefore imperative that in
advancing progress in the African health-
care system, the sustained development and
quality regulation of the African private
healthcare sector must be given priority
consideration. The private healthcare sector
and private healthcare providers should not
be seen as competitors but as great partners
in the quest for enthronement of robust, ef-
fective and efficient healthcare systems.This
will require the blurring of old concepts
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20
and ideological frameworks, and modifica-
tion of health seeking behaviours in Africa,
to enable the private healthcare sector get
the required significant support.This can be
in the form of sustained grants and single-
digit (very minimal) interest loans extended
to private healthcare providers in the post-
COVID-19 era, the institution of a Health
and Hospital/Health system Development
Intervention Fund (HHDIF) and strength-
ening of beneficial and productive Public-
Private-Partnership arrangements.All these
will help guarantee the development of an
effective, efficient and responsive private
healthcare sector, to complement the pub-
lic healthcare sector in the delivery of ac-
cessible and quality healthcare to African
people.
(7) Strengthening the Quality Regulatory
and Clinical Governance Framework.
For real progress to be made by African
healthcare systems in the post-COVID-19
era, African governments must pay particu-
lar attention to the quality component of
their healthcare systems. This will require
the enthronement of clinical governance
frameworks at all levels, with the develop-
ment of quality, ethical and safety frame-
works and protocols/practice guidelines.
Additionally, there is need to support and
empower the health professional regulatory
bodies meant to enforce quality standards in
the health sector.
There is no doubt that sustained implemen-
tation and adherence to clinical governance
protocols, safety and quality standards/
regulatory frameworks, will improve the
quality accreditation of healthcare facilities
in the African region, and the people’s con-
fidence in African healthcare systems.
(8) Self-sufficiency in Pharmaceutics and
Vaccine production
The challenges thrown up by the
­
COVID-19 pandemic revealed once again
that, the African continent is imbued with
lots of talents, initiatives and energies,
which need to be harnessed and developed
for the progress of the African continent
and its healthcare system. In this regard, it
should no longer be fashionable in the post-
COVID-19 era for African governments to
sustain the practice of importing most of
Africa’s healthcare requirements, including
drugs and vaccines. Indeed, time has come
for African countries to be self-sufficient in
drug and vaccine production. It is therefore
expected that the post-COVID-19 era will
witness more commitment by African gov-
ernments to sustained efforts at supporting
and boosting local drug manufacturing and
vaccine production, on a sustainable basis.
(9) Research,Data and ICT/Health Man-
agement Information System
It is important for African governments to
significantly invest in Research develop-
ment and innovations so as to improve the
quantum and quality of research and inno-
vations in African healthcare systems.
It is also necessary to promote the effective
and ethical management of data and the
Health Management Information architec-
ture by African countries, to aid more pro-
ductive data deployment for development of
the healthcare system, and improvement of
the health and well-being of African people.
The dazzling opportunities and avenues cre-
ated by the Information, Communication
and Technology (ICT)/Digital age, should
be explored to advance equitable, afford-
able, quality and ethical access to healthcare
services and commodities.This will particu-
larly be of benefit to African people residing
in rural and hard-to-reach communities.
(10) Legal framework for health/Regula-
tions restricting use of public resources
for Outward Medical Tourism by Public
and Political Office Holders, and Em-
powerment of the Citizens.
An empowered citizenry is a necessary
ingredient for the advancement of good
governance. To enthrone good governance
of African healthcare systems, and good
governance in general, it is important that
the perspectives and needs of the governed
(citizens) are given due
consideration. It is therefore fundamental
that African citizens are empowered to play
their expected roles more responsibly and
courageously, in the post-COVID-19 era.
This is especially as it is expected that in
the post-COVID-19 era, African citizens
will consistently and courageously demand
accountability and transparency from their
African political leaders (and managers of
the healthcare system) at all levels. It is also
expected that African citizens will consis-
tently demand for sustained development of
the healthcare system, as well as the unre-
pressed expression of their health rights (in-
cluding their right to access quality health
care), particularly as enshrined in the con-
stitution of the World Health Organization
[43] and other declarative International in-
struments such as the Universal Declaration
of Human Rights [44].
It is the author’s considered view that for
sustained commitment to the expected
post-COVID-19 healthcare reforms and
expression of the health rights of African
citizens, it is imperative for African coun-
tries without an existing National Legal
framework for health, to consciously de-
velop one, with the inputs of the citizens,
professional health associations, Civil Soci-
ety Organizations (CSOs), and other stake-
holders in the health sector, incorporated.
The Legal framework for health should
contain provisions that guarantee the sus-
tained development, growth and regulation
of the healthcare system,including the obli-
gations and commitment of government to
this objective. It should importantly contain
protective provisions for the health rights
of African citizens, including their right to
hold their leaders to account, particularly as
it concerns the development of the health-
care system and expression of their health
rights.
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21
Additionally, the Legal framework for
health should, amongst other provi-
sions, contain provisions restricting the
use of public/tax payers’ resources for the
sponsorship of foreign medical travels by
African political and public office hold-
ers. Necessary criteria should however
be established for exceptional cases that
may be considered for sponsorship. For
instance, where a Medical Board of Ex-
perts have conclusively determined that
a medical condition cannot be handled
by healthcare facilities in the country,
or where the required experts/expertise,
health technologies or diagnostic services
are unavailable in the country, an approval
could be considered in these instances, but
with a proviso that such identified gaps be
filled by the relevant authorities/govern-
ment with a specified period. These sug-
gested restrictions are without prejudice
to the fundamental right of such politi-
cal and public office holders to use their
private resources to access healthcare ser-
vices and technologies wherever they may
so wish.
Conclusion
While the new spirit of commitment to the
development of African healthcare systems
by African political leaders during the cur-
rent COVID-19 pandemic is commend-
able, the big question remains whether this
new spirit of healthcare investment and
commitment is going to be sustained in the
post-COVID-19 era or not. Will it be one
of sustained sincere commitment or an-
other flash in the pan, as was the case dur-
ing and after the ravaging scourge of Ebola
Viral Hemorrhagic Disease and other pre-
vious epidemics that ravaged the African
continent?
While it may be difficult to immediately
resolve these questions, one critical fac-
tor needed to ensure that African political
leaders/Governments do not turn back to
their old ways is the Citizens’ capacity to
demand for their health rights to access
health care facilities and services compa-
rable to those in the developed countries
of the world. African people must stand
against the use of their commonwealth/
public resources or tax payers’ resources for
financing foreign medical travels by Afri-
can political and public office holders.They
must insist that African political and public
office holders utilize healthcare facilities
and services in their various countries, ex-
cept for cases where it is proven by a team
of indigenous medical experts that facilities
for managing such medical conditions are
unavailable in their countries.
The citizens’ decision to vote for their lead-
ers during electoral contestations should be
predicated on the ability of such candidates
to make significant commitments in their
electoral manifestos, to health system de-
velopment, the citizens’ health and health
rights.
For countries without a Legal framework
for health, the citizens should demand for
its enactment, with significant provisions
protecting and promoting their health
rights incorporated. Above all, African
people should consistently demand for
good governance, transparency and ac-
countability from their leaders.
If these and other progressive steps are
taken, the African continent may yet see
brighter days ahead for African people and
African healthcare systems.
Indeed, the author is convinced that with
the commitment of African political and
public office holders to leadership by ex-
ample, with commitment to good gover-
nance and transparency frameworks, with
political stability and political will, backed
by the support of all Africans, the trend of
outward medical tourism, particularly as it
concerns frequent foreign medical travels
by African political leaders, may be sub-
stantially reversed in the post-COVID-19
era.
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COVID-19
NIGERIA
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22
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crobes Infect. 2020; 22(2):80-85. doi:10.1016/j.
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18. KUJENGA AMANI. Covid-19 Responses
in Africa: Implications for Peace, Security, and
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Dr. Osahon Enabulele,
President, Commonwealth
Medical Association.
Chair, Socio-Medical Affairs Committee,
World Medical Association.
Past President, Nigerian Medical
Association (2012-2014).
Coordinator, Coalition of African National
Medical Associations (CANMA).
Chief Consultant Family Physician,
University of Benin Teaching Hospital.
E-mail: osahoncmavp@gmail.com
COVID-19 NIGERIA
BACK TO CONTENTS
23
The outbreak of COVID-19 started as a
cluster of pneumonia in China, reported
in other Asian countries, Europe, Africa
and America. COVID-19 has devastated
the lives and livelihoods of communities
globally as they grapple with such an un-
precedented crisis [1]. The State Counsel-
lor played a key and prominent role in the
government’s response, heading two newly
established committees, using social media,
and hosting televised virtual meetings en-
gaging with health care workers, officials,
volunteers, and union representatives [2].
MMA also communicates and cooper-
ates with the Government Response Plan
for reacting to the epidemic of COVID.
A significant contribution comes from ju-
nior doctors who have made an immense
amount of voluntary commitment stepping
into new roles to support their colleagues in
a range of positions in this time of uncer-
tainties.
It is clear that many junior doctors in
Myanmar are working frontline across the
government hospitals fighting the pan-
demic. There was a significant reduction
in surgical activity – elective operating and
some outpatients were cancelled. Given
the discrepancy in the workload between
specialties and COVID 19 dedicated hos-
pitals, the junior doctors across the spe-
cialties had re-organized as part of the
COVID-19 response. These doctors have
generic skills that can be used anywhere.
They voluntarily took park in hospitals
designed for treating COVID-19 cases
to help their colleagues in these hospi-
tals. As Myanmar is one of the developing
countries, there are shortages of personal
protective equipment in hospitals and re-
serving this equipment for doctors who
are involved in the direct care and treat-
ment of patients. A junior doctor across
the country has been fundraising for es-
sential protective gears for their hospitals.
The well-wishers from Myanmar and those
working overseas generously have donated
ventilators, monitors and personal protec-
tive equipment, foods directly to hospitals
in need and to the government [3, 4].
A thousands of brave junior doctors who
are working in
private sectors
have signed up as
volunteers doctors
for MMA and
other local health
services to keep all
safe from the vi-
rus. National and
regional govern-
ments have rolled
out increasingly
stringent social
distancing mea-
sures to mitigate
the pandemic’s
spread, including
localized lock-
downs of buildings and streets with con-
firmed cases, “Stay at Home” programs,
de facto curfews, and mandatory quaran-
tines for travellers [5]. The need for the
most accurate, latest information on self-
protection is critical. The junior doctors
took part in mask campaign, hand washing
campaign, and strict stay at home & social
distancing.
In this pandemic, millions of Myanmar
people lack basic information about how to
keep themselves and their communities safe
and well. The misinformation and disinfor-
mation is overwhelming all over the coun-
try. People started panicking, calling health
care centres for more information.There are
many people who give advice, quoting from
books that don’t exist, deliberate wrong and
misleadingtranslationoftextandthingsthat
are never evidence based and never tested.
There were also a lot of rumours circulating,
including through social media channels,
which spreads faster than the infection and
or disease. Failing to address their informa-
tion and communication needs will prevent
the pandemic response from being as ef-
fective as we all need it to be. In efforts to
speed up the prevention, containment and
treatment of the ­
COVID-19 disease, the
national COVID-19 call centre was estab-
lished by MOHS with the help from com-
COVID-19: Junior Doctors Response
in Myanmar
Osahon Enabulele
COVID-19
MYANMAR
BACK TO CONTENTS
24
munications operators. Junior doctors from
MMA voluntarily joined their hands to the
staff from the Medical Research Depart-
ment to provide free of charge live consulta-
tion for information about disease preven-
tion and how to access medical treatment to
an estimated 60 million mobile subscribers
in Myanmar [6, 7].
The fever clinic in Myanmar serves a front-
line role to test patients for COVID-19
and, if necessary, to send them to the near-
est public hospital for further tests. The fe-
ver clinics are run by collaborative effort of
junior doctors and MMA to relieve pressure
on the under-staffed and under-resourced
hospitals and health care system, to reduce
infection in primary care doctors and re-
duce nosocomial infection transmission of
patients in hospitals. With the help of well-
wishers, doctors in fever clinics are well
equipped with level 2 PPE for screening of
COVID-19 and diagnosis and treatment of
other aetiology and proper referral to hospi-
tals throughout the country [8].
Currently, there are no effective medicines
or vaccines available to treat or prevent
COVID-19. (9) Early implementation of
quarantine and its combination with other
public health measures may reduce spread
of the disease. For this reason, restrictive
public health measures such as social dis-
tancing, and quarantine have been used to
reduce transmission of the virus.The Com-
munity Based Facility Quarantine play
major role for containment of COVID-19
spread. Those who had close contacts with
the COVID-19 positive patients and the
peopled travelling from foreign countries
need to take part in this program. Despite
no symptoms, they need to stay under sur-
veillance for a total of 28 days during incu-
bation period – 21 days facility quarantine
and the 7- day home quarantine. Those in
community based facility quarantine will
require assistance of well-trained volun-
teers. For the specific process and period,
the volunteers will have to perform their
daily duties in inner circle or outer circle
depending on the requirement and avail-
able services for the whole period of 21
days. They will also have to live at specific
places for the 7-day recreation [10]. Ju-
nior doctors from MMA provide training
course to these volunteers, which includes
the topics of public communications,
counselling, taking care of vulnerable pop-
ulation, practical use of PPE, safe disposal
of hazardous material and environmental
cleaning all over the country. In addition,
junior doctors working in private sector
stepping forward as quarantine site doc-
tors to early detection, and prompt man-
agement of the patients [11].
To conclude, having such enthusiastic and
selfless junior doctors from public and pri-
vate sector in Myanmar has further boosted
for other junior doctors participation and
help the country to flatten the curve at this
time of greatest need.
References
1. www.mohs.gov.mm. (n.d.). Coronavirus Disease
2019 (COVID-19) Situation Reports (Myanmar).
[online] Available at: https://mohs.gov.mm/
page/9575 [Accessed 11 Jul. 2020a].
2. Kyaw, W. (2020). Myanmar and COVID-19.
[online] thediplomat.com. Available at: https://
thediplomat.com/2020/05/myanmar-and-cov-
id-19/.
3. YPO. (2020). Responding to COVID-19 in
Conflict-Ridden Myanmar. [online] Available
at: https://www.ypo.org/2020/06/responding-
to-covid-19-in-conflict-ridden-myanmar/ [Ac-
cessed 11 Jul. 2020].
4. www.mohs.gov.mm. (n.d.). COVID-19 (Coro-
navirus Disease 2019) Acute Respiratory Disease.
[online] Available at: https://www.mohs.gov.
mm/Main/content/publication/2019-ncov [Ac-
cessed 11 Jul. 2020b].
5. Nan, L. (2020). Timeline: Myanmar’s Govern-
ment Responses to the COVID-19 Pandemic. [on-
line] The Irrawaddy. Available at: https://www.
irrawaddy.com/specials/myanmar-covid-19/
timeline-myanmars-government-responses-to-
the-covid-19-pandemic.html [Accessed 11 Jul.
2020].
6. MDN – Myanmar DigitalNews. (n.d.). Invita-
tion for Volunteer COVID-19 National Volunteer
Steering Unit. [online] Available at: https://
www.mdn.gov.mm/en/invitation-volunteer-
covid-19-national-volunteer-steering-unit [Ac-
cessed 11 Jul. 2020].
7. Global New Light Of Myanmar. (2020). COV-
ID-19 Call Centre opens daily. [online] Available
at: https://www.globalnewlightofmyanmar.com/
covid-19-call-centre-opens-daily/[Accessed 11
Jul. 2020].
8. Lynn, K.Y. 2020. Fever clinics: the first line of
defence against COVID-19. Frontier Myanmar.
https://frontiermyanmar.net/en/fever-clinics-
the-first-line-of-defence-against-covid-19
12 July 2020.
9. www.who.int. (n.d.). Accelerating a safe and ef-
fective COVID-19 vaccine. [online] Available
at: https://www.who.int/emergencies/diseases/
novel-coronavirus-2019/global-research-on-
novel-coronavirus-2019-ncov/accelerating-a-
safe-and-effective-covid-19-vaccine.
10. Khin,A.(n.d.).Volunteer Invitation to COVID-19
National Volunteer Steering Unit. [online] Minis-
try Of Information. Available at: https://www.
moi.gov.mm/moi:eng/?q=news/13/05/2020/id-
21645 [Accessed 12 Jul. 2020].
11. Thit, M. (2020). ToT course conducted for
­
COVID-19 volunteers – Global New Light Of My-
anmar. [online] www.globalnewlightofmyanmar.
com. Available at: https://www.globalnewlightof-
myanmar.com/tot-course-conducted-for-covid-
19-volunteers/ [Accessed 11 Jul. 2020].
Wunna Tun,
MBBS, MD,
Fellow in Medical Education
Founder, Myanmar Medical
Associaton, Young Doctor Society
Past Communication Director, JDN, WMA
COVID-19 MYANMAR
BACK TO CONTENTS
25
Introduction
In Brazil, one of the health care priorities
is emergency care. As everywhere, there are
challenges related to the models of care that
accompany population growth, increase in
health problems and aging. The spectrum
of patients seen in emergency medical situ-
ations is generally associated with increased
risks of undesirable outcomes, and obvi-
ously greater than in chronic or subacute
conditions. And despite the population
differences between the different parts of
the world, this is very common among all
and thus the frequency of the character-
istics of these patients: upper respiratory
tract infection, cough, pharyngitis, tonsil-
litis, myocardial infarction, angina pecto-
ris, coronary heart disease, lower respira-
tory tract infection, bronchitis, pneumonia,
acute hyperthermia, acute abdominal pain,
stroke, cerebral hemorrhage, cerebral apo-
plexy, fracture and contusion, stomachache
and gastroenteritis, vomiting, diarrhea, he-
matochezia, bloody stool, urinary calculi,
renal colic, hypertension, hemorrhage of
digestive tract, dizziness, fainting, acute ap-
pendicitis, acute pancreatitis, drug and food
poisoning, urination disorders and deliv-
ery/parturition [1].
Emergency care has been defined by vari-
ous attributes, such as time-to-care provi-
sion and acuity of the condition addressed.
Common definitions include care delivered
within minutes or hours and care for con-
ditions that require rapid intervention to
avoid death or disability or for which delays
of hours can worsen prognosis or render care
less effective. People in need of care may ac-
cess the system at many points,including by
activating the pre-hospital system, by visit-
ing a primary health centre,or by presenting
directly to a hospital-based emergency unit;
providers at every level of the health system
deliver emergency care, whether or not they
have the dedicated training and resources to
do so effectively. Frontline emergency care
may involve early recognition and initial
resuscitation for dangerous conditions fol-
lowed by transfer for definitive care or may
encompass definitive therapy [2].
A systematic approach to emergency care –
centred on acuity-based triage, early recog-
nition and resuscitation, and simple initial
management and referral – has been shown
to decrease the mortality associated with a
range of medical and surgical conditions.
Despite the substantial positive impact
emergency care can have, however, many
low- and middle-income countries (LMICs)
lack the fundamentals of organized emer-
gency care: basic pre-hospital care and
transport, a dedicated area and standards for
hospital-based emergency care,and a core of
nonrotating providers trained in the care of
emergencies and assigned to the emergency
unit. These gaps are reflected in wide global
discrepancies in outcomes across the range
of emergency conditions [2].
Although severe global discrepancies exist
in outcomes from emergency conditions,
both these modelling estimates and direct
evidence suggest that emergency care has
the potential to narrow this gap dramatical-
ly. Powerful examples of feasible life-saving
emergency care interventions in LMICs
may include: organizing low-cost pre-hos-
pital systems with a dramatic decrease in
all-condition or in road-traffic mortality;
designating an area for emergency care of
all critical patients at a third-level hospital
transformed care and halved mortality; re-
structuring a hospital intake area to create
a dedicated emergency care area and initi-
ating formal triage associated with halved
inpatient mortality and a reduction in the
proportion of deaths occurring within
24 hours; timely simple interventions (flu-
ids, antibiotics, and clinical monitoring)
within the first six hours of hospitalization
in adults with serious infection reduced
mortality; in rural area improved access to
emergency obstetric care halved the risk
of maternal mortality and reduced the risk
among women with hemorrhage; the intro-
duction of standardized resuscitation pro-
tocols reduced hospital length of stay and
all-cause mortality among injured patients;
short course trainings in trauma manage-
ment associated with reduced mortality in
Emergency Care for Health Unit System
Patients in Brazil
Lincoln Ferreira Wanderley Bernardo
Emergency Health
BRAZIL
BACK TO CONTENTS
26
injured patient with no significant increase
in resource usage; the use of pulse oximetry,
combined with current guidelines for recog-
nition of severe illness, has the potential to
avert deaths per year [2].
Evidence from around the world shows
that emergency care is an effective means
of saving lives, and evidence from LMICs
suggests that feasible and simple steps to
improve emergency care could rapidly im-
prove outcomes and reduce global dispari-
ties in outcomes [2].
It is then possible to reflect on relevant
Brazilian and global aspects in medical
emergency to assist decision making by the
leaders regarding priority actions to reduce
the risk of these patients who face acute
and potentially serious situations. The chal-
lenges are enormous, but they have many
experiences that point in an apolitical and
technical-scientific direction.
The Unified Health System
in Brazil (SUS) [3]
The Brazilian Unified Health System
(Sistema Único de Saúde, known by the ac-
ronym SUS) is one of the largest and most
complex public health systems in the world
and includes primary, medium and high
complexities, urgency and emergency ser-
vices, hospital care, epidemiological surveil-
lance actions and services, sanitary and en-
vironmental and pharmaceutical assistance.
The conceptual principles of SUS are Uni-
versalization, Equity and Integrality. The
organizational principles are Regionaliza-
tion and Hierarchization, Decentralization
and Single Command, and Popular Par-
ticipation. These responsibilities are shared
between the Union (Ministry of Health of
Brazil), States (State Health Departments)
and Municipalities (Municipal Health
Departments). The Charter of Rights of
Health Users contains the six basic prin-
ciples of citizenship that ensure the Bra-
zilian dignified entry into health systems,
whether public or private, and which pre-
scribes to every citizen the following rights:
orderly access to organized health systems;
adequate and effective treatment for their
problem; humane, welcoming and free from
any discrimination treatment; care that re-
spects their person, their values and their
rights; treatment conducted in an appro-
priate manner; the commitment of health
managers so that the above principles are
adhered to.
The Brazilian Urgency and
Emergency Program [4, 5]
The analysis of the rules that regulate the
National Emergency Care Policy shows
that  – in a context of increased demand,
overload of care at hospital doors as a result
of the increase in accidents, violence and
chronic diseases and insufficiency of the ba-
sic network – attention to emergency care in
Brazil was centred on hospital care, on the
implementation of the Centres for Medical
Regulation of Urgencies and the Mobile
Emergency Care Service (SAMU) in large
capitals as an auxiliary line to the hospital
door. However, the recent implementation
of Emergency Care Units (UPAs 24hs) in-
duces even more the urgencies inserted in a
care network,tuned in the national policy of
forming regional networks.
However, among the various barriers to
the implementation of this policy are: the
fragmented nature of assistance with the
logic of the market; the insufficient supply
of beds; the public financing; the relation-
ship and inequality between private opera-
tors and the philanthropic network due to
technological requirements and the con-
centration of this market in the richest and
most developed regional headquarters. In
addition, the number of doctors in Brazil is
permeated by profound inequalities, related
to geographical distribution, unbalance be-
tween the public and private health sectors,
and the lack of professional specialization,
including the emergency specialty.
Urgency and Emergency
Care Network (RUE) [4, 5]
The organization of the RUE has the pur-
pose of articulating and integrating all
health equipment aiming to expand and
qualify humanized and integral access to
users in urgent/emergency situations in
health services in an agile and timely man-
ner. Its components and interfaces are the
following: the basic health units (patients
in need of observation in urgent/emergen-
cy cases in the period of operation of the
unit, articulated and connected to the other
services of the emergency care network for
later transport and referral); the Emergency
Care Units (UPAs) and other services open
24 hours a day; the Emergency Medical
Service (SAMU/192); hospital doors for
emergency care; rear wards and intensive
care units; and home care.
The principles of this network are guided by
expanding access, with acceptance, to acute
cases and in all points of care; articulation
and integration between points of care,with
primary care as the centre of communica-
tion; risk rating; regionalization of health
and territorial action; institutionalization
of the practice of monitoring and evalu-
ation through process, performance and
result indicators; promotion, coordination
and execution of strategic projects to meet
collective health needs of an urgent and
transitory nature, resulting from situations
of imminent danger, public calamities and
accidents with multiple victims; qualifi-
cation of urgent and emergency hospital
doors and of care for critically ill patients
through qualification of intensive care units;
organization and expansion of clinical rear
beds; creation of inpatient long-term care
units (UCP) and specialized long-term
care hospitals (HCP); qualification of care
through the organization of cardiovascular,
cerebrovascular and traumatological care
lines; definition of home care organized
through multidisciplinary home care teams
(EMAD) and multidisciplinary support
teams (EMAP).
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Mobile Emergency
Service (SAMU) [4, 5]
It is the component of the urgency and
emergency care network that aims to order
the flow of assistance and provide early care
and adequate, fast and resolving transport
to victims affected by health problems of a
clinical, surgical, gynecological-obstetric,
traumatic and psychiatric nature through
the sending of manned vehicles by a trained
team, accessed by the number 192 and acti-
vated by an Emergency Regulation Centre,
reducing morbidity and mortality. SAMU
is fundamental in the rapid assistance and
transportation of victims of exogenous in-
toxication, serious burns, mistreatment,
suicide attempts, accidents/traumas, cases
of drowning, electric shock, accidents with
dangerous products and in cases of hyper-
tensive crises, cardiorespiratory problems,
labour in which there is a risk of death for
the mother and/or the fetus, as well as in the
inter-hospital transfer of patients at risk of
death. The mobile units for emergency care
can be basic terrestrial life support (USB),
advanced terrestrial life support (USA),
aeromedical and rapid intervention vehicle
(VIR),varying the composition of the teams
in each unit.The emergency medical regula-
tion centre is an integral part of SAMU 192,
defined as a physical structure with the per-
formance of medical professionals, auxiliary
telephone operators for medical regulation
and radio operators trained in the regula-
tion of telephone calls that require guidance
and/ or emergency care through a classifica-
tion and prioritization of urgent care needs,
in addition to ordering the effective flow
of referrals and against referrals within the
Health Care Network.
The Emergency Care
Units (UPAs 24h) [4–6]
The 24-hour emergency care units are struc-
tures of intermediate complexity between
the basic health units (UBS), family health
units (USF) and the hospital network,
which must operate 24 hours a day, every
day of the week, and compose an organized
network of attention to urgencies and emer-
gencies, with pacts and flows previously de-
fined,with the objective of guaranteeing the
reception of patients, intervening in their
clinical condition and against referring
them to other points of care, to primary or
specialized care services or to hospitaliza-
tion, providing continuity of treatment with
positive impact on the population’s individ-
ual and collective health.
However, there are some limitations in its
implementation, such as: the fragmenta-
tion between the sectors involved, due to
the presence of several instances of coor-
dination, without articulation with each
other; little interference in the formulation
of municipal networks and, therefore, in
the choice of the location and size of the
UPAs; the municipalities stop allocating
the resources that are needed by the UPAs
to philanthropic hospitals; the activation of
emergency units without the proper hospi-
tal backup; and the impossibility of regu-
lating the totality of beds in regional and
teaching hospitals.
Hospital Component of the
Emergency Care Network [7]
It is the qualified service of the Emergency
Hospital Entrance Doors, the rear clini-
cal wards, the long-term care beds and the
Intensive Care Unit Beds belonging to the
Emergency Care Network. The Hospital
Component is part of the Emergency Care
Network. The Hospital Component must
be integrated and articulated with the oth-
er components belonging to the Urgency
and Emergency Network: Health Promo-
tion, Prevention and Surveillance; Primary
Health Care; SAMU 192; Stabilization
Room; SUS National Health Force; UPA
24h and the set of 24h emergency services
and Home Care. The organization of the
Hospital Component of the Urgency and
Emergency Care Network aims to qualify
the service to spontaneous and/ or refer-
enced demand from other points of care of
less complexity in the care of patients in ur-
gent or emergency situations; ensuring sup-
port for medium to high complexity care,
offering diagnostic procedures, clinical rear
beds, Extended Care beds and ICU beds;
reinforcing the guarantee of hospital care in
the priority lines: traumatology, cardiovas-
cular and cerebrovascular.
Pre-hospital Emergency
Medicine
Pre-hospital care is emergency medical care
given to patients before arrival in hospital
after activation of emergency medical ser-
vices. It traditionally incorporated a breadth
of care from bystander resuscitation to
statutory emergency medical services treat-
ment and transfer. New concepts of care
including community paramedicine, novel
roles such as emergency care practitioners,
and physician delivered pre-hospital emer-
gency medicine are re-defining the scope of
pre-hospital care. For severely ill or injured
patients, acting quickly in the pre-hospital
period is crucial with decisions and inter-
ventions greatly affecting outcomes. Pre-
hospital clinicians should be generalists
with a broad understanding of medical,
surgical, and trauma pathologies, who will
often work from locally developed standard
operating procedures, but who are able to
revert to core principles. Pre-hospital emer-
gency medicine consists of not only clinical
care, but also logistics, rescue competencies,
and scene management skills (especially
in major incidents, which have their own
set of management principles). Tradition-
ally, research into the hyper-acute phase
(the first hour) of disease has been difficult,
largely because physicians are rarely pres-
ent and issues of consent, transport expedi-
ency, and resourcing of research. However,
the pre-hospital phase is acknowledged as a
crucial period, when irreversible pathology
and secondary injury to neuronal and car-
diac tissue can be prevented [8].
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When pre-hospital emergency personnel
reach an injured person,two types of strategic
evaluations are performed to determine the
patient’s needs: a diagnostic analytical deci-
sion-making process and an interpretation
of the patient’s needs based on their health
status. Depending on severity, the transfer
time to a care facility differs; however, al-
most all emergency patients are transferred
to an appropriate care hospital regardless of
condition severity. In general, the three tasks
of emergency teams involve arriving at the
scene, providing fast and effective treatment,
and transferring the patient to the hospital.
Generally,pre-hospital emergencies are char-
acterized by judgment and decision making
in uncertain situations. Physicians and pre-
hospital specialists must make advanced de-
cisions and evaluate and treat patients with
various symptoms. Clinical decision support
systems help users make decisions by using
available resources, thus promoting effective
decision-making and optimal medical emer-
gency care.Clinical decision support systems
in pre-hospital emergency care result in bet-
ter triage of patients, reduced pre-hospital
time, facilitate mass gathering management,
optimize resources, increase diagnostic accu-
racy, improve patient outcomes, and enhance
the quality of pre-hospital care [9].
Physician treatment was associated with in-
creased survival in patients with out-of-hos-
pital cardiac arrest and patients with severe
trauma; in the latter group, the result was
based on more limited evidence. The success
rate of pre-hospital endotracheal intubation
(ETI) has improved over the years, but ETI
by physicians is still associated with higher
success rates than intubation by paramedics.
In patients with severe traumatic brain injury,
intubation by paramedics who were not well
skilled to do so markedly increased mortal-
ity. Current evidence is hinting at a benefit of
physicians in selected aspects of pre-hospital
emergency services, including treatment of
patients with out-of-hospital cardiac arrest
and critically ill or injured patients in need of
pre-hospital intubation.Evidence is,however,
limited by confounding and bias, and com-
parison is hampered by differences in case
mix and the organization of emergency med-
ical services. Future research should strive to
design studies that enable appropriate control
of baseline confounding and obtain follow-
up data for the proportion of patients who die
in the pre-hospital setting [10].
Pre-hospital care has evolved dramatically
during the past decades from being a basic
transport facility into offering advanced pa-
tient care on scene and during transportation.
In recent years, much focus has been placed
on the utilization and effect of pre-hospital
resources underlining the need for research
and system performance evaluations. The
pre-hospital organizations are responsible
for the care and treatment on scene and dur-
ing transportation until the patient reaches
the hospital. Helicopter Emergency Service
(HEMS) acts as a supplement to ground
EMS (ambulances and nurse- or physician-
staffed rapid response vehicles). The HEMS
is organized and staffed by a consultant-
level anaesthesiologist, a pilot and a specially
trained paramedic and operating 24 h/day, 7
days a week. Most parts of the country can
be reached within 30 min. The decision to
dispatch a helicopter is taken by the medi-
cal dispatchers who are healthcare profes-
sionals (specially trained nurses, ambulance
technicians and paramedics) handling medi-
cal emergency calls from the public dialling
the emergency phone number 112.Technical
dispatchers trained in logistics undertake the
actual dispatch.The HEMS undertakes both
primary critical care missions (request from
citizens through emergency calls and crew
request from ambulances and rapid response
vehicles on scene) and time critical second-
ary missions (inter-facility transfers). Fur-
thermore, the HEMS also provides pre-hos-
pital care and transport for less ill or injured
patients located on islands not connected by
road to the mainland [11].
Developing integrated emergency medi-
cal services in a low-income country can be
referred to as “the neglect model” where no
rules and regulations exist about service pro-
viders. Pre-hospital care is very minimal, and
the EMS system is still a new concept. In an
emergency room of a hospital only 9.9% pa-
tients arrived in ambulance, whereas 53.6%
came in a taxi,11.4% came by private vehicle,
13.5% came by bus, 5.4% came by bike, and
the rest 6.2% came by other modes of trans-
portation. Police are always the first person
to be asked for help in case of road traffic ac-
cidents. Ambulance services are operated by
not just government but multiple trusts,non-
profitable organizations, and also almost all
private hospitals. Most of the ambulances
have no formal paramedics and are not able
to accommodate any medical equipment.
These ambulances carry pediatric and adult
patients, and even those who require a ven-
tilator. The general population lacks proper
knowledge and information about hospitals
and health care. Most of the time patients
land up in the wrong hospital where the
service for a particular disease or condition
is not available. They are further referred to
another hospital causing loss of critical time
period increasing morbidity and mortality
of the patient. Most of the private hospitals
have their own ambulance and are also re-
sponsible for their function and maintenance.
The patient is charged by these hospitals for
their use of services. Charge usually depends
on the amount of distance covered which
is similar or more than the cab service. A
non-profitable private organized ambulance
service system (NAS) was established and
began its service of pre-hospital emergency
care. It provides pre-hospital medical care by
emergency medical technicians (EMTs) who
undergo 3 months training. These EMTs
provide variety of medical interventions in-
cluding BLS, ALS, splinting fractures, brac-
ing spinal cord injuries bleeding control, air-
way management, and starting IV fluids for
patients in shock.It also has helicopter-based
emergency services (HEMS). Lack of medi-
cal personnel and equipment has reduced its
efficiency below its potency. The fragmented
system, high demand–low supply, inequity
with the service, and low quality of the re-
sponders are major problems associated with
the EMS. Although the HEMS rescue has
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boosted the system, it still does not have its
own proper air ambulance which is more
spacious than a helicopter and can accom-
modate more people required for rescue.The
HEMS often resulted in over triage leading
to higher financial burden and workload at
trauma centres. Patients with minor injuries
make the majority of transport accounting
for unnecessary larger funding requirements.
The HEMS are expensive and its misuse can
have a great deal of financial burden to a poor
country [22].
Quality of Emergency Care
The organization of acute care can be im-
proved by strengthening the primary care
and community systems by improving ac-
cess closer to home, increasing the acces-
sibility of General Practitioner (GP) and
optimizing the use of out of office hours
GP services.The system can improve ambu-
latory care to reduce pressure on in-patient
beds and improve patient experience, rather
than the more traditional models of out-pa-
tient care. Ambulatory emergency care can
provide an appropriate support to primary
care when escalation is needed, and reduce
the use of the inpatient bed base, thereby
facilitating more treatment of acute illnesses
from a community setting [12].
Freestanding Emergency
Departments
Freestanding emergency departments
(EDs) are changing the landscape of emer-
gency care in the United States and are
being considered around the world. These
facilities provide emergency care to patients
while remaining physically distinct from a
hospital, unlike a traditional hospital-based
ED. These facilities may help alleviate the
stress faced by the emergency care system
and may help address crowding at tradition-
al hospital based EDs and improve access to
care. They may be able to improve access to
care for trauma patients in rural areas. Free-
standing EDs, however, face their fair share
of criticism. Many individuals worry that
patients are mistaking freestanding EDs for
cheaper urgent care centres, that freestand-
ing EDs may be misleading patients about
their insurance network status, and that
these facilities may be exacerbating increas-
ing medical costs.
According to American College of Emer-
gency Physicians (ACEP),facilities should be
available to the public 24 hours a day, 7 days
a week,365 days per year; be staffed by quali-
fied emergency physicians; have adequate
staffing by qualified medical and nursing per-
sonnel to meet the written emergency proce-
dures and needs anticipated by the facility; al-
ways be staffed by a registered nurse currently
certified in advanced cardiac life support and
pediatric advanced life support; have policies
and procedures in place to transfer patients
in need of a higher level of care to appropri-
ate facilities; and have the same standards
as hospital-based EDs for quality improve-
ment, medical leadership, medical directors,
credentials, and referral policies. In most
metrics, freestanding EDs perform as well as
if not better than hospital based EDs, with
some significant exceptions. Freestanding
EDs tended to have higher patient satisfac-
tion rates compared with hospital based EDs.
The wait times, treatment times, and time to
pain medication administration for long bone
fractures were similar between freestanding
EDs and hospital based EDs. Freestanding
EDs had shorter lengths of stays, lower hos-
pital admission rates, and lower radiograph
and ECG use.They found similar usage rates
for ultrasonography, computed tomography,
and laboratory testing compared with that
for hospital based EDs. Although this may
indicate better care,it may also just reflect the
lower acuity level of patients presenting at
freestanding EDs [13].
Hospital ED visits, wait times, length of
visit for discharged patients were not asso-
ciated with the number of competitor Free-
standing Emergency Departments (FrEDs)
in the local market. Hospitals that opened
satellite FrEDs had significantly higher
visit volume in general but did not experi-
ence shorter wait times or length of visit if
located in large metropolitan areas. The en-
try of FrEDs did not help relieve congestion
in nearby hospitals in major metropolitan
areas. By offering more treatment options
to patients, FrEDs are associated with in-
creased usage of emergency services [14].
Patient-centred Access
to Health Care
Access is central to the performance of
health care systems around the world.There
are five dimensions of accessibility: 1) ap-
proachability; 2) acceptability; 3) availabil-
ity and accommodation; 4) affordability;
5) appropriateness. And five corresponding
abilities of population interact with the di-
mensions of accessibility to generate access:
the ability 1) to perceive; 2) to seek; 3) to
reach; 4) to pay; and 5) to engage [15].
Emergency Department (ED) crowding has
been identified as a major issue in health
services research. Access block, leading to
prolonged ED length of stay (EDLoS) for
admitted patients has been associated with
ED overcrowding. Adverse effects associated
with delays in ED have included: increased
mortality and morbidity, delayed pain relief,
longer hospital stays, increased aggression
and delayed ambulance offloads with poorer
response times.The National Emergency Ac-
cess Target (NEAT) policy was implement-
ed to increase ED flow.The policy stated that
90% of patients presenting to EDs were to
be admitted,transferred or discharged within
4 hours. After the NEAT introduction, ED
length of stay ≤4 h increased and access
block decreased. Short-stay admissions in-
creased. Unplanned ED re-attendances did
not change significantly. ED presentations
continued to increase over time in all juris-
dictions. There showed significant improve-
ments in time-based measures. Significant
increases in short-stay admissions suggest
a strategic change in ED process associated
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with the NEAT implementation. Rates of
unplanned ED re-attendances and those
leaving at their own risk showed no evidence
for adverse effects from NEAT [16].
Maternal Emergency Health
An access framework for integrating emer-
gency medicine with maternal health to re-
duce the burden of maternal mortality can
be divided in three components or phases:
Phase I: Seeking care-approachability and
acceptability within access, approachability
(the ability to perceive that EC services are
required) and acceptability (the ability to seek
EC services) are part of the care-seeking at-
tributes of the first delay in maternal health
theory. The individual has to subjectively
decide that they require emergency care and
treatment based on a set of personal health
beliefs, their health literacy, trust, and expec-
tations of the healthcare system. However,
their ability to seek the desired services de-
pends on if they have the personal autonomy
to seek the care, they perceive they need. Au-
tonomy is determined by a set of norms and
expectations that are attributed to individuals
in a given society. The community should be
educated about EMS operations and the life-
sustaining benefits of using ambulance ser-
vices over taxis and other traditional modes
of transport. Education curricula should
cover how ambulances are alerted (toll free
numbers),qualifications and training of EMS
providers,types of life sustaining care for ma-
ternal and other emergencies provided on
ambulances versus commercial vehicles, etc.
Barriers to approachability and acceptability
will be unique to each community, based on
their distinct social structures and cultural be-
liefs. A community that perceives EMS to be
approachable, acceptable and “normal”would
(increasingly) initiate EMS services.
Phase II: Reaching care-availability and ac-
commodation, affordability once emergency
care is initiated, the ability to reach the de-
sired services is often determined by issues
of mobility.The availability (desired services
available) and accommodation (ability to
reach desired services) and affordability
(ability to pay for the services) of emergency
transport depends on the physical and geo-
graphic infrastructure of the environment
(road conditions, traffic rules, season/weath-
er, etc.). It is during this second phase of the
delay model that EMS competes with taxis
and other commercial vehicles that are per-
ceived to be more expeditious and less costly.
Critics cite that even though ambulances are
underutilized, levying a fee for ambulance
use will further delay care for the most vul-
nerable. Measureable outcomes for EC in-
terventions in this phase should incorporate
ambulance response time (the time it takes
for ambulances to arrive on-scene),on-scene
time (time spent on scene, preparing the
labouring woman for transport) and arrival
time (duration of time spent transporting
the woman to the healthcare facility). Other
outcomes could include number of ambu-
lance dispatches and dispatch types.
Phase III: Receiving care-appropriateness;
appropriateness is subjective, and denotes
the fit between services rendered, the pa-
tient’s needs, and their expectations. Addi-
tionally, appropriateness is highly dependent
on outcome. In maternal health, survival of
both mother and fetus is perhaps the greatest
motivator for encouraging labouring moth-
ers to deliver in-hospital, where the staff is
expected to be trained to manage labour
complications and other obstetric emergen-
cies. Reducing the time to in-hospital in-
terventions is crucial to patient survival, and
expeditious services rendered by skilled and
well-equipped EC providers can drastically
reduce in-hospital maternal mortality. EC
interventions in this phase of the integrated
model should take a two-pronged approach.
The first approach should focus on bridg-
ing the care gap in the pre-hospital context.
This would involve training EMS providers
paramedics and Emergency Medical Tech-
nicians (EMTs) to cater to labouring moth-
ers in the field, before they get to hospital.
The “golden hour” shows that expediting
urgent care for patients within the first hour
after symptom onset can drastically decrease
morbidity and mortality outcomes. Having
trained EMS providers interact with labour-
ing women before they reach the healthcare
facility, expedites the woman’s access to ob-
stetric care, and consequentially, improves
her (and the fetus’) chances of survival. The
second approach to EC interventions in
this phase should focus on in-hospital care,
with the creation and training of Emergency
Medicine providers who are adept at prop-
erly triaging patients, and skilfully trained to
deliver appropriate life-saving interventions.
Deliveries necessitating analgesia, forceps
or vacuum extraction, and cesarean section
should be triaged from lower-risk pregnan-
cies with less maternal and/or fetal distress.
Emergency and labour wards should be well
equipped and appropriately staffed to deliver
the care needed in various emergency situa-
tions, so challenging obstetric cases are dealt
with appropriately. Subpar outcomes in the
third delay heavily influence the cyclical na-
ture of the entire Three Delays model. Thus,
measurable benchmarks in this phase of the
framework should correlate EMS and EM
training programs with in-hospital interven-
tions and maternal mortality metrics to en-
sure that there is a “fit” between the needs
and expectations of the target population,
and the services rendered by both pre- and
in-hospital providers [17].
Pediatric Emergency Care
Differences in emergency care for children
exist between general and pediatric emergen-
cy departments (EDs). Some pediatric qual-
ity measures are available but are not routine-
ly employed nationwide.We sought to create
a short list of applied measures that would
provide a starting point for EDs to measure
pediatric emergency care quality and to com-
pare care between general and pediatric EDs
for these measures. Previously reported lists
comprising 465 pediatric emergency care
quality measures were reconciled. Perfor-
mance was better in pediatric EDs for three
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31
of seven condition-specific measures,includ-
ing antibiotics for viral infections, chest X-
rays for asthma, and topical anesthesia for
wound closures. Performance was similar for
four of seven condition-specific measures:
computed tomography for head trauma, ste-
roids for asthma, steroids for croup, and oral
rehydration for dehydration. Compared with
pediatric EDs, general EDs discharged and
transferred higher proportions of children,
had shorter lengths of stay, and sent patients
home with fewer prescriptions. General
EDs obtained fewer pain scores for injured
children. Pediatric EDs had a lower propor-
tion of pediatric visits in which patients left
against medical advice. General and pediat-
ric EDs had similar rates of mortality, left
without being seen, incomplete vital signs,
labs in non-acute patients, and similar num-
bers of medications given per patient [18].
Emergency Physician-Based
Intensive Care Unit
To provide a prompt and optimal inten-
sive care to critically ill patients visiting our
emergency department (ED),a specific type
of emergency intensive care unit (EICU)
managed by emergency physician (EP) in-
tensivists was established.The ED-ICU in-
terval for the EICU group was significantly
shorter than that for the other ICUs group.
The ICU mortality and hospital mortality of
the EICU group were not inferior to those
of the other ICUs group. The EICU run by
EP intensivists reduced the time interval
from ED arrival to ICU transfer without
altering hospital mortality [19].
Community Emergency
Medicine
Background and objectives. International
and national health policies advocate great-
er integration of emergency and community
care. The Physician Response Unit (PRU)
responds to 999 calls ‘taking the Emergency
Department to the patient’, when 1924 pa-
tients were attended, averaging 5.3 per day,
and 1289 (67.0%) patients were managed in
the community. The service was estimated
to deliver a reduction of 868 inpatient bed
days and generate a net economic benefit of
£530 107. The PRU model provides com-
munity emergency medical care and early
patient contact with a senior clinical de-
cision-maker. It engages with community
providers in order to manage 67.0% of pa-
tients in the community.The PRU offers an
effective model of community emergency
medicine and helps to integrate local emer-
gency and community providers [20].
Emergency care is under pressure, with de-
mand continuing to increase across the emer-
gency care system. Significant staffing short-
ages coupled with rising demand may have
implications for the quality of care and safety
of patients. One solution to this may be to
concentrate resources on fewer sites by clos-
ing some of these EDs or suspending services
overnight. In recent years a small number of
EDs have been closed or downgraded to a
less acute facility,reportedly due to reasons of
inadequate staffing and safety implications.
For residents in the areas affected by closure,
journey time to the nearest ED increased,but
no statistically reliable evidence of a change
in overall mortality following reorganiza-
tion of ED care was found. There was some
evidence to suggest that there was a small
increase in case fatality, an indicator of the
‘risk of death’, but this may have arisen due
to changes in hospital admissions. We found
no evidence that reorganization of emer-
gency care was associated with a change in
population mortality in the five areas studied.
Further research should establish the eco-
nomic consequences and impact on patient
experience and neighbouring hospitals [21].
Emergency Training and
Physician Quality
An Emergency Medicine post-gradu-
ate program was initiated, followed by a
residency-training program. Prior to the
programs, care was provided exclusively
by general practice physicians (GPs); sub-
sequently, care has been provided through
mutually exclusive shifts allocated between
GPs and EM trainees. Patients seeking
Emergency Centre (EC) care during pre-
training and post-training were assessed.
Pre-training EC mortality was 6.3%, while
that of post-training  – 1.2%. Pre-training
overall hospital mortality was 12.2% while
that of post-training – 8.2% [23].
Emergency Medicine is a relatively recent
medical specialty. Currently, Emergency
Medicine is a primary medical specialty in
nineteen member states of the European
Union (EU)/ European Economic Area
and a supra-specialty in two EU countries.
One of the main functions of the European
Core Curriculum for Emergency Medicine
is to define the specialty by spelling out the
core concepts that underlie its distinctive-
ness and by listing the competences that
can be expected of specialists in Emer-
gency Medicine. A shared understanding of
what Emergency Medicine represents as a
specialty, common training goals, training
standards and exit examination are intend-
ed to promote the development of the spe-
cialty throughout Europe and skills transfer
across national borders. The European So-
ciety for Emergency Medicine (EUSEM)
incorporates 30 European national societ-
ies of Emergency Medicine with more than
14,000 medical members. The European
Core Curriculum for Emergency Medicine
lists the core competences in Emergency
Medicine, namely: the ability to triage and
resuscitate patients; the symptoms, signs
and situations Emergency Physicians (EPs)
should be able to address; the conditions
EPs should be able to recognize and ini-
tially manage; the procedures EPs should
be able to carry out and investigations they
should be able to interpret; the ability to
make judicious decisions regarding further
investigations and treatments; professional
competences EPs should master. Most sub-
sections feature introductory paragraphs
that describe the inclusion criteria the lists
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are based on and the level of competence
expected of Emergency Physicians [25].
Bringing value, balance and humanity to
the emergency department determine a list
of quality physician attitudes: (1) ‘The quix-
otic search for certainty’describes the all too
common attempt by clinicians to find the
last few patients who may be in danger even
though an evaluation has shown that risk
is minimal. Along with this fear of missing
even a single patient with a serious problem,
most clinicians have been taught to believe
(incorrectly) that ‘tests’ are more ‘objective’
than clinical judgement and, thus, that do-
ing more is ‘safer’and more ‘evidence based’.
Even if there is some small benefit in find-
ing the few cases that would otherwise be
missed after routine evaluation (in most cas-
es based on clinical gestalt alone), this fails
to consider the diminishing returns that in-
evitably occur as we endeavour to lower the
miss rate from ‘too many’ to ‘a few’ to ‘rarely’
to ‘never’. More importantly, when further
testing is done in a population of patients
who can be classified as minimal risk, based
on gestalt, this almost cannot fail to cause
more harm than benefit – even if the tests
themselves are ‘non-invasive  – because of
the downstream consequences of false posi-
tives, ‘incidentalomas’ and overdiagnosis; (2)
Medical care is not the sole,or even the most
important, determinant of health outcomes.
Social determinants  – including, but not
limited to, food insecurity, homelessness and
addiction – are profoundly important to the
health of a great many patients; Avoid fur-
ther testing beyond history, physical exam,
clinical gestalt and ECG in patients who are
at minimal risk of an acute coronary syn-
drome (ACS); Avoid further testing beyond
history, physical exam and clinical gestalt in
patients who are at minimal risk of pulmo-
nary embolus (PE); Be judicious with the
use of imaging, especially advanced imaging,
in trauma patients; Avoid routine laboratory
testing; Consider non-medical reasons for a
patient’s presentation to the ED; Tailor the
intensity of care to the goals of the patient;
Employ shared decision-making (SDM)
where appropriate; When prescribing an in-
tervention, make an effort to ensure that the
patient is capable of accomplishing what is
recommended; Tailor discharge instructions
and follow-up recommendations to the in-
dividual patient; Be an advocate [26].
Components of Emergency Medicine: we
always help the sick; work tirelessly with
colleagues to provide universal high-quality
care to those in need every second of every
day; from a fractured ankle to a cardiac ar-
rest, arterial lines to shoulder relocations
and from sick children to the frail, comorbid
elderly the breadth of our practice is stag-
gering; be and are ready to respond at a mo-
ment’s notice to a new more pressing need
or a change in circumstance; implement-
ing evidence-based medicine and shaping
future practice; moving into understanding
the theory of how we think and make deci-
sions,meta-cognition and clinical reasoning;
recognition of staff well-being and working
to improve our system of safety alert high-
lighting the need for staff to take adequate
breaks; adoption of new technology; change
even further as new solutions, including ar-
tificial intelligence and immersive technolo-
gies,evolve from research environments; free
open access medical education; democratiz-
ing and spreading clinical knowledge [27].
The roles of emergency physicians and acute
physicians should be clear and complement-
ing which may be reached by more uniform
staffing. Given the increased complexity of
care, experienced consultants need to be
present at the ED, providing optimal care
pathways, training junior doctors and im-
proving timely and right decision-making
and patient flow. It has been shown that
presence of consultants at the ED, beside
Emergency Physicians, leads to a shorter
Length of Stay and higher patient satisfac-
tion. In both countries the ageing popula-
tion has led to a changing case mix at the
ED with an increased amount of multimor-
bid patients with polypharmacy. As a result,
ED presentations are becoming increas-
ingly complex. This requires specialists who
are able to deal with these problems, such as
internists and geriatricians, and generalists
with the ability to coordinate care for these
complex patients, such as Emergency Phy-
sicians and acute physicians. A way to reach
this broader expertise and treat patients in
a holistic way, is assuring superspecialism
instead of subspecialism for at least inter-
nists. Superspecialism requires persisting
interest in areas beyond the subspecialty
and willingness to practice medicine in a
patient-oriented way, in contrast to sub-
specialism which focuses on a specific area
of interest leading to treatment of a disease
rather than treating a patient. Therefore, a
proportion of all medical specialists should
change their attitude and adapt their train-
ing and daily practice to superspecialism,
which will match the demand of the future
case mix. To improve the organisation of
health care, we believe that doctors need to
be visible medical leaders and participate in
the organisation of care. Doctors should use
their experience and medical knowledge to
establish the best acute care working with
patients and introduce changes in the or-
ganisation in concert with the managers.
Medical leadership is considered to play an
important role in improving organizational
performance, including quality of care, pa-
tient safety and cost-efficient care [28].
Innovation
Clinician-led design for optimizing flow for
an Emergency Department:
1. Pivot nurse: Standard triage and regis-
tration is inefficient, delays care and is
of low value to the patient. Alternative
systems such as a pivot or ‘quick-look’
nurse are validated and are now estab-
lished; this nurse greets the patient and
rapidly acquires limited critical infor-
mation including the chief complaint.
Following triage category decision, the
patient is escorted to one of several
‘tracks’ in ED;
2. Advanced split-flow system: The track
system is designed to increase efficiency,
Emergency Health BRAZIL
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33
reduce clinical risk, increase patient sat-
isfaction and reduce those leaving ED
prior to treatment or after treatment
commences: Core Track; Mid Track;
Fast and Super Track; Paediatric Track
(except children requiring resuscitation)
[29].
Evolution of the Strategies to Innovate
Emergency Care Clinical Trials Network
(SIREN) offers an efficient mechanism for
conducting large trials in emergency care
research. SIREN has successfully submit-
ted several grant applications for trials, and
several other trials are in various stages of
development. All sponsored trials within
SIREN will significantly benefit from the
leadership of experienced researchers with
established track records of success and a
strong culture of cooperation within the
network. Another major aim of SIREN will
be furthering innovation in trial design, fo-
cusing on adaptive trials and registry-based
methods. Registry based studies would
make use of relationships between the SI-
REN Clinical Coordinating Centre with
other groups, such as the American College
of Surgeons Committee on Trauma and
the American Heart Association, for use
of larger nationwide databases for analysis.
Another strength of SIREN  – it has al-
lowed access and feedback from the Data
and Clinical Coordinating Centres, and it
is hoped that it will facilitate increased ap-
plications. SIREN is an ideal place where
investigators can seek input from both the
Clinical and Data Coordinating Centres to
increase chances for successful funding of
large grants that seek complex adaptive de-
signs outside of the scope of most clinicians.
SIREN offers a unique and exciting oppor-
tunity to advance the clinical trial enterprise
by creating a culture of studying clinical trial
methodology and processes. These investi-
gations may enhance the overall conduct of
clinical trials, thereby leading to important
developments in emergency care research.
For individual research sites, engagement
with the SIREN network offers the po-
tential for expanding enrolment sites to a
larger diverse geographic area with greater
possibilities for clinical investigation. Al-
though infrastructure burdens for research
must still be shared between the centralized
resources and the clinical sites, the support
of the broader SIREN network promises to
expand the field for future research studies.
In summary, through a strong collaborative
research network, SIREN offers the oppor-
tunity to significantly enhance emergency
care research, with the aim of improvement
in patient outcomes [30].
Large-scale quality and performance mea-
surement across unaffiliated hospitals is an
important strategy to drive practice change.
The Michigan Emergency Department
Improvement Collaborative (MEDIC) is a
unique physician-led partnership supported
by a major third-party payer. Member sites
contribute electronic health record data and
trained abstractors add supplementary data
for eligible cases. Quality measures include
computed tomography (CT) appropriate-
ness for minor head injury, using the Cana-
dian CT Head Rule for adults and Pediatric
Emergency Care Applied Network rules for
children; chest radiograph use for children
with asthma, bronchiolitis, and croup; and
diagnostic yield of CTs for suspected pul-
monary embolism. Baseline performance
was established with statistical process con-
trol charts. Overall baseline performance
included the following: 40.9% of adult pa-
tients with minor head injury had appro-
priate CTs, 10.3% of pediatric minor head
injury cases exhibited CT overuse, 38.1% of
pediatric patients with a respiratory condi-
tion received a chest radiograph, and 8.7%
of pulmonary embolism CT results were
positive. Performance varied greatly, with
demonstrated opportunity for improve-
ment. MEDIC provides a robust platform
for emergency physician engagement across
ED practice settings to improve care and is
a model for other states [31].
New research findings may not lead to
change in practice, or a change at the front
line may be delayed by years. A number of
terms have been used to describe efforts and
strategies to speed a change in evidence-
based practice, such as: implementation sci-
ence, knowledge translation, research trans-
lation and others. In contrast to traditional
clinical research, implementation science
generally aims to understand and change
health professional behaviour to promote
evidence uptake as opposed to attempt-
ing to change patient behaviour. There are
now theoretical frameworks and evolving
evidence providing guidance how to change
clinician behaviour and, specifically, emerg-
ing evidence on how to achieve this in the
emergency setting [32].
Today we have many kinds of possible ac-
tions in the field of emergency care, varying
from education to structural, but all of them
that produce proves of efficacy do not use
an adaptation process or an old structure
of care. Everybody that look to emergency
like a individualized and specialized type of
care, innovate and are based in a really ca-
pacitation process of the emergency teams,
with evidence based protocols and with a
new flow and decentralized interconnected
network that are capable to give an atten-
tion adequate, ethical, equitable and effec-
tive in the point of care.
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Emergency Health
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4. Os hospitais e a Rede de Atenção às Urgências e
Emergências: desafios. Available at: http://www.
conass.org.br/consensus/os-hospitais-e-rede-
de-atencao-urgencias-e-emergencias desafios/.
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5. Manual Instrutivo da Rede de Atenção às Urgên-
cias e Emergências no Sistema Único de Saúde
(SUS). Available at: http://bvsms.saude.gov.br/
bvs/publicacoes/manual_instrutivo_rede_at-
enção_urgências.pdf. Accessed on 22 February
2020.
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unidades de pronto atendimento (UPAS).Avail-
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pdf/Conass_ Documenta_28.pdf. Accessed on
22 February 2020.
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Urgências. Available at: https://www.saude.gov.
br/saude-de-a-z/componente-hospitalar-da-
rede-de-atencao-as-urgencias. Accessed on 22
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9. Bashiri A, Alizadeh Savareh B, Ghazisaee-
di M. Promotion of prehospital emergency
care through clinical decision support sys-
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Emerg Med 2019; 6: 288-296. doi: 10.15441/
ceem.18.032. PMID: 31910499.
10. Valentin G, Jensen LG. What is the impact of
physicians in prehospital treatment for patients
in need of acute critical care? – An overview of
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35: 27-35. doi: 10.1017/S0266462318003616.
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11. Alstrup K, Petersen JAK, Barfod C, Knudsen
L, Rognås L, et al. The Danish helicopter emer-
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with great potential. Scand J Trauma Resusc
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12. Kremers MNT, Nanayakkara PWB, Levi M,
Bell D, Haak HR. Strengths and weaknesses of
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Dye T. A woman’s worth: an access framework
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halgh R, Goodsman D, et al. Community emer-
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28. Kremers MNT, Nanayakkara PWB, Levi M,
Bell D, Haak HR. Strengths and weaknesses of
the acute care systems in the United Kingdom
and the Netherlands: what can we learn from
each other? BMC Emerg Med 2019; 19: 40. doi:
10.1186/s12873-019-0257-y. PMID: 31349797.
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Lincoln Ferreira,
President of the
Brazilian Medical Association
Wanderley Bernardo,
Coordinator of Guidelines Program of
the Brazilian Medical Association
Emergency Health BRAZIL
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35
NIGERIA
Introduction
Job satisfaction affects the entire satisfac-
tion with life and it is an indicator of the
situation at the workplace [1, 2]. It does
not refer to the medical sphere but to other
professions as well. Worldwide, chief ex-
ecutives including Chief Medical Directors
and Medical Directors face the problem of
ensuring job satisfaction for their employees
[3–5]. Human resources are the priority for
quality in healthcare [4]. This involves cad-
res of healthcare workers, medical doctors
and junior doctors inclusive. Hence, doctors
need to be satisfied with their job in order to
carry out their duties effectively as a doctor
who is dissatisfied with the job will get tired
out [2]. The training to become a doctor is
expensive,challenging,long and demanding
[6]. Doctors should enjoy and be satisfied
with their job as training takes a long time.
Moreover during the period of medical
training, physicians are expected to deprive
themselves of sleep and leisure. They are
encouraged to disregard their needs when
practicing [7]. In most parts of the world,
Nigeria including, doctors in hospitals are
expected to serve selflessly and emphasis
is on patient care [1,8]. Therefore, it is im-
portant that doctors are satisfied with their
job as it will affect the doctor-patient rela-
tionship [9]. The job satisfaction of doctors
is also necessary to promote commitment
and loyalty to healthcare delivery, effective,
service provision and more importantly
preventing migration of doctors to other
countries [6].
Definition of Job Satisfaction
Job satisfaction has been defined by several
scholars. It can be defined as the extent or
degree to which an employee likes their job
[3, 4, 8–11]. Job satisfaction is related to the
attitudes of an employee to their job [5]. It
also represents both the positive and nega-
tive feelings about the job and also the ful-
fillment gotten from the job [3, 12]. Hence
job satisfaction is a very crucial element for
an effective performance of the health care
sector [13].
Factors Affecting Job
Satisfaction of Doctors
There are some factors that affect job sat-
isfaction. Some of them are related to the
individual or the hospital management.
The attitude towards job satisfaction results
from three areas which are specific job fac-
tors, individual characteristics and group
relationships outside the job [5]. These
factors include job security, interaction
with other health workers and colleagues,
finance incentives which include salaries
and allowances, the number of work days,
supervision, conditions of service, conflict
and conflict resolution, age, sex, years of
employment, opportunities for training and
career advancement [3, 5, 9, 14–15]. In a
study conducted among doctors working
in a tertiary hospital in the capital of India,
there was a positive relationship between
the dissatisfaction with the job and the av-
erage number of work hours per day and
also the number of night shifts per month
[15]. Various researches have revealed that
there is a positive association between the
health of staff and job satisfaction as staff
who are not satisfied with their job tend
to be frequently absent from work due to
ill health [12]. In another study conducted
in a government hospital in eastern India,
younger doctors and those in medical spe-
cialties that require spending more time in
the hospital were dissatisfied with their job
compared to doctors of an older age group
and those working in non-clinical special-
ties. In this study increasing age was found
to be associated with a higher level of job
satisfaction [9].
In a study conducted among health workers
in Zaria, Northern Nigeria, job stress, op-
portunities for training and the salaries were
the determinants of job satisfaction among
doctors [12].
Consequences of Job
Satisfaction of Doctors
Users of healthcare facilities i.e. patients
and hospital clients are the ones who suf-
fer if a doctor has job dissatisfaction.This is
because job satisfaction affects job perfor-
mance and the quality of healthcare service
rendered [2, 14–16]. High level of job satis-
faction among junior doctors at a Sudanese
hospital impacted positively on the quality
of the healthcare services and patient’s sat-
isfaction [4]. Low job satisfaction predicts
the intention to leave the job as doctors
who are dissatisfied with their job may be
considering leaving the job for elsewhere,
either to another hospital or migrating to a
developed country as shown in a study con-
ducted in South-East Nigeria [13]. It has
been proved that job dissatisfaction leads
to migration of doctors as seen in a study
conducted in Zaria, Northern Nigeria [12].
Job Satisfaction: the Nigerian Doctor’s Story
Dabota Yvonne Buowari
Health Care
BACK TO CONTENTS
36
There is a positive association between job
satisfaction and employee absenteeism as
when the job satisfaction is high, absentee-
ism is low and vice versa [3]. Oche et al in
their study in Sokoto, Northern Nigeria,
revealed that was a high rate of absentee-
ism noticed among resident doctors because
they were not satisfied with their job [17].
Therefore it can be seen that the impact of
dissatisfaction of a physician with the job
is overwhelming. Various researches con-
ducted in the developing countries which
are low resource settings and developed
countries have shown a difference in job
satisfaction [9].
Job Satisfaction Of Doctors
Several studies have been conducted world-
wide on job satisfaction amongst doctors but
few specifically about junior doctors. Some
of these studies were done in conjunction
with other healthcare workers. High rate of
job dissatisfaction is seen among Nigerian
doctors compared to their counterparts in
Europe and North America [18]. Job satis-
faction brings a lot of benefits [8]. The job
satisfaction of doctors is beneficial for the
patient/client and the physician [19]. Doc-
tors derive their satisfaction from their work
but may not be happy with their work envi-
ronment [2].Some doctors may not be hap-
py with their jobs because of long working
hours, overwork and heavy workload due to
understaffing [15] and this affects the atti-
tude of the doctors towards their colleagues,
coworkers, patients and clients [14] as well
as this affects the way they carry out their
duties [16,20].
In an Indian study, 59.6% of doctors satis-
fied with their job [9]. In a Nigerian study
58 doctors were studied under four do-
mains, namely, the hospital management,
hospital facilities, healthcare providers as
well as pay and benefits, and there was a
low rate of job satisfaction [20]. In a study
conducted among junior doctors in Ibadan,
Western Nigeria job satisfaction was a pre-
dictor of job stress [7]. This was also seen
in another Nigerian study conducted in
Sokoto, northern Nigeria [17]. This may be
due to the stressful nature of the residency
training program [17, 21]. Job stress has an
impact on the health of the doctor and their
ability to cope with the demands associated
with their job [16].
One of the best ways to strengthen the Ni-
gerian weak healthcare sector is the devel-
opment of human capacity and identifica-
tion of factors affecting the job satisfaction
of healthcare professionals including doc-
tors [8, 12]. Several reforms and policies
have been developed in Nigeria to address
the challenges in the healthcare system but
the creation of a desirable workplace en-
vironment which will eventually lead to a
higher rate of job satisfaction has received
little or no attention.
Conclusion
Job satisfaction of healthcare workers es-
pecially doctors is necessary for the quality
healthcare delivery as this will help reduce
the current brain drain and migration of
doctors to countries with better work envi-
ronments.
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workers in a tertiary Centre in Kano, North
Western Nigeria. Nigerian Journal of Basic and
Clinical Sciences. 2018, 15, 87-91.
9. Bhattacherjee S, Ray K, Roy JK, Mukherjee A,
Roy H, Data S. Job satisfaction among doctors
of a government medical college and hospital,
Eastern India. Nepal Journal of Epidemiology.
2016, 6(3), 595-602.
10. Yongu TW, Hondoaver U, Danen PT. Emotion-
al intelligence and job satisfaction as predictors
of organizational commitment among resident
doctors at Benue State University Teaching
Hospital, Makurdi. African Journal of Social Is-
sues, 2018, 21 (3), 61-76.
11. Omalase CO, Seidu MA, Omalase BO, Ag-
borubere DE. Job satisfaction amongst Nigerian
ophthalmologists: an exploratory study. Libyan
Journal of Medicine. 2010, 5, 46-69.
12. Butawa NN, Sule AG, Omole VN, Yere JK,
Dogo M, Gyuro J. Assessment of job satisfac-
tion among health workers in a tertiary hospital
in Zaria, Northern Nigeria. Savannah Journal
of Medical Research and Practice. 2013, 2 (2),
54-62.
13. Ogbuabor DS, Okoronkwo L, Uzochukwu B,
Onwujekwe O. Determinants of job satisfac-
tion and retention of public sector health worker
in South East Nigeria. International Journal of
Medical Health Development.2016,2 (2),27-39.
14. Gedam SR, Babar V, Bahhulkar S. Study of
job satisfaction and stress among doctors from
tertiary care institute rural region of Cen-
tral India. International Archives of Addic-
tion Research and Medicine. 2018, 4 (1), doi.
org/10.23937/2474-3631/15/0026
15. Kaur S, Sharma R, Talwar R, Verma A, Singh
A. A study of job satisfaction and work environ-
ment perception among doctors in a tertiary
hospital in Delhi. Indian Journal of Medical
Sciences. 2009, 63 (4), 139-144.
16. Meinam M, Behara BK. Job satisfaction of doc-
tors in government hospitals in Manipur: a soci-
ological study. Journal of Humanities and Social
sciences. 2015, 20 (5), 22-24.
17. Oche MO, Oladigbolu R, Ango JT, Okafogu
N, Ango U. Work absenteeism amongst health-
care workers in a tertiary health institutions in
Health Care NIGERIA
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Organ Donation
Sokoto, Nigeria. Journal of Advances in Medi-
cine and Medical Research, 2018, 26 (2), 1-9.
doi.10.9734/JAMMR/2018/40467
18. Ofili AN,Asurzu MC,Isah EC,Ogbeide O.Job
satisfaction and psychological health of doctors
at the University of Benin Teaching Hospital.
Occupational Medicine. 2004, 54(4), 400-403.
Doi.10.1093/occmed/kqh081
19. Jongbloed LJS, Sehonrock-Adema J, Borleffs
JCC, Stewart RE, Cohen-Schotanus J. physi-
cians job satisfaction in their begin, mid and end
career stage. Journal of Hospital Administration.
2017, 6 (1), 1-9.
20. Olutayo FM, Dahiru T, Danburam A, Salwau
FK. Job satisfaction among doctors and nurses: a
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cine and Public Health. 2016, 3 (6), 1640-1647.
21. Ogunnubi OP, Ojo TM, Oyelohumu MA, Ola-
gunju AT, Tshuma N. stress and training satis-
faction among resident doctors in Nigeria: any
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nal of Clinical Sciences. 2018, 15, 32-40.
Dabota Yvoone Buowari,
Ibinye Avenue, Behind Genesis Fastfood,
Woji, Port Harcourt,
Nigeria
E-mail: dabotabuowari@yahoo.com
We have engaged in research and writing into organ transplant
abuse in China since 2006 and have come to the conclusion, as have
others after us, that prisoners of conscience have been and are being
killed in China in large numbers for their organs. The primary vic-
tims are practitioners of the spiritually based set of exercises Falun
Gong and Uyghurs.1
One focus of our research has been official Chinese government
statistics on transplant volumes. We have attempted to determine if
these statistics are accurate and what the sources of these volumes
are. Shi Bingyi, the author of the article “Reform Proceeding of
Organ Donation and Transplantation System in China” published
in the World Medical Journal of April 2020, has in the past been
quoted in Chinese publications as providing statistical information
on transplant volumes and then denied he has done so.
An article posted on Health Paper Net in March 2006 contained
this statement:
“Professor Shi said that in the past 10 years, organ transplantation
in China had grown rapidly; the types of transplant operations
that can be performed were very wide, ranging from kidney, liver,
heart, pancreas, lung, bone marrow, cornea; so far, there had been
over 90,000 transplants completed country-wide;”2
In an interview with Science Times in May 2007, Dr. Shi said:
“The number of organ transplants in China reached a historic peak
in 2006, in which nearly 20,000 cases of organ transplants were
performed.” 3
1  See https://seraphimeditions.com/portfolio-posts/bloody-harvest/
https://endtransplantabuse.org/; http://www.david-kilgour.com/
2 
https://web.archive.org/web/20060826070646/http://www.
transplantation.org.cn/html/200603/394.html
3 
http://web.archive.org/web/2010*/news.sciencenet.cn/html/showsbnews1.
aspx?id=182075
Dr. Shi was interviewed for a TV documentary titled “Davids’ Re-
port Re-examined” produced by Phoenix TV and broadcast in Oc-
tober 2007.4
We are the Davids of the documentary title.
Some of the questions asked of Dr. Shi in the TV interview and his
answers are these:
“Question: We recently saw a report produced by two Canadian
independent investigators. It quotes your statement that by 2005
China had conducted some 90,000 transplants. They include
60,000 such operations from 2000 and [to] 2005 which is a period
when the Falun Gong was suppressed. This shows a numerical in-
crease. Under what conditions did you say this?
Answer: I didn’t make such a statement because I have no
knowledge of these figures. I have not made [a] detailed inves-
tigation about the subject. Therefore I have no figures to show
how many were carried out and in which year. So I could not
have said this.
Question: Although you have not revealed concrete figures, do the
figures in the report match the reality?
Answer: I don’t think that these figures are correct as the report
shows they were calculated on the basis of phone calls to hospitals.
They asked for figures from those hospitals in the names of families
of patients.
Question: You have read the report. Have you ventured to clarify
figures the report says you produced?
Answer: Yes I did. Because I am a soldier what I did was to lodge
a protest through legal channels. I sent the protest to the Ministry
of Health through the Department of Health of the PLA General
Logistics Department. I made it clear in the protest that I never
said what is attributed to me.
4 
http://web.archive.org/web/20140816105904/http://www.facts.
org.cn/Reports/World/200710/26/t20071026_779607.htm
Comment: Reform of Transplantation in China
BACK TO CONTENTS
38
Organ Donation
…
Question: Some other figures contained in the report say some
Chinese hospital websites advertised to say donors could be found
in two weeks in China. In other countries, the waiting period may
last more than one year. How do you explain the difference?
Answer: I can tell you the fact that some people have waited for
three or four years in our hospital.The number of those who have to
wait for over one year absolutely exceeds 200.”
Manfred Nowak, the then United Nations Rapporteur on Torture,
asked the Government of China to explain the discrepancy between
volume of organ transplants and volume of identified sources, rely-
ing, in part, in our report and its reference to the article of March
2006 quoting Dr. Shi. The Chinese government, in a response sent
to the Rapporteurs by letter dated March 19, 2007 and published in
the report of Professor Nowak to the UN Human Rights Council
dated February 19, 2008, stated that
“Professor Shi Bingyi expressly clarified that on no occasion had he
made such a statement or given figures of this kind, and these al-
legations and the related figures are pure fabrication.”5
Dr. Shi, MD and Li-Ping Chen wrote in the issue of the Journal of
the American Medical Association in November 2011:
“Dr Trey and colleagues mention that in 2005, transplant figures
peaked with 20 000 transplants. However, as organ transplant
specialists, we and our colleagues have never heard of this many
transplants per year in China”6
Dr. Shi then, in four instances, professed ignorance of something
about which his earlier statements show that he knew – the 20,000
and 90,000 figures and our research on the mass killing through
forced organ extraction of practitioners of the spiritually based set
of exercises Falun Gong.
Neither the article in Health Paper Net nor the article in Science
Times nor the Phoenix TV interview are available any more on the
internet on their original websites. They are available only because
they have been archived through a web crawler, the Wayback Ma-
chine.
The Wayback Machine captured the Health Paper Net March 2006
article first on August 26,2006.The last capture was August 7,2008.
The next web crawler capture of the URL after that date,on June 20,
2009, reports that the page could not be found.
5 
https://documentsddsny.un.org/doc/UNDOC/GEN/G08/106/97/PDF/
G0810697.pdf?OpenElement
6  November 2, 2011 Volume 306 number 17 page 1864
As noted, the Phoenix TV interview was October 2007. So, Dr. Shi
was saying during this TV interview that he did not say something
which, at the very moment of his denial, was posted on the internet
as something he said.
If one looks at the translation of the original Chinese Health Pa-
per Net of March 2006 article which the Google Chrome browser
generates, the sentence which contains the 90,000 figure disappears,
not just in the English translation, but in all of the many language
translations we have examined. Yet, the number 9 appears in the
original Chinese paragraph, as one can plainly see.
If one saves the original Chinese language article as PDF through a
printing option, convert the PDF to Word, through an optical char-
acter recognition app which can recognize Chinese characters, and
then put this Word text into Google translate, the sentence with the
90,000 figure appears in the translation. The phrase with the figure
90,000 in Google translate is this: “More than 90,000 cases were
transplanted last year”.
Because of translations we have had done of the original by per-
sons proficient in Chinese, a better translation would be “More
than 90,000 cases were transplanted so far” or “More than 90,000
cases were transplanted up to last year“ or “More than 90,000 cases
were transplanted last year to date”or “More than 90,000 cases were
transplanted by last year”. As for the 20,000 figure in the Science
Times article, that remains in the translation of the original Chi-
nese Science Times article of May 2007 which the Google Chrome
browser generates.
Given this history, the article “Reform Proceeding of Organ Dona-
tion and Transplantation System in China” should be approached
with caution. Anything Dr. Shi writes about organ transplantation
reform in China needs to be independently verified.
Sincerely yours,
David Matas
David Kilgour
BACK TO CONTENTS
39
Critical Care Medicine
Novel coronavirus pneumonia is highly in-
fectious and can cause patients to develop
acute respiratory failure and multiple organ
system dysfunction or even death. To con-
trol the epidemic and spread of the virus,the
government of China has taken the most
stringent isolation and control measures.
All provinces and cities across the country
have responded to the call of the country.
0n January 29, 2020, The Chinese Society
of Critical Care Medicine of The Chinese
Medical Association (CMA-CSCCM),The
Chinese Society of Pathophysiology and
The Chinese Medical Doctor Association,
issued a joint call for the colleagues of criti-
cal care medicine in China to fight together
in danger. As we always said, where there is
the need to save lives, there will be intensive
care doctors. Medical teams from all over
the country which were consisted of more
than 40000 medical staffs rushed to Wuhan
and Hubei to fight.Among them,more than
19000 medical staffs were from departments
of critical care medicine. The total number
was more than 10% of the critical care pro-
fessionals all over the country.In such a high
intensity,high risk working,the team of crit-
ical care medicine was not only the leader
of the clinical front line, they also summa-
rized and published very valuable Clinical
research results about the novel coronavirus
pneumonia, what’s more they wrote the
Diagnosis and Treatment Protocol for CO-
VID-19 Critical Cases and Severe Critical
Cases, which guided frontline doctors treat-
ing critical patients all over the country.The
battle of the novel coronavirus pneumonia
has again witnessed the importance and
prospects of critical care medicine for the
people in China and all over the world.
Discipline Construction
Compared with western countries, the
development of critical care medicine in
China started later but rapidly. In 1970s
and1980s, few intensive care units were es-
tablished in China mainland. In 1990, the
Ministry of Health of The People’s Repub-
lic of China started to include the establish-
ment of ICU as one of the key evaluations
of hospital accreditation. Since then ICU
constructions all around the country were
in full swing. In 1997, the Committee of
Critical Care Medicine of Chinese Patho-
physiological Society was established. On
March 18, 2005, Chinese Society of Criti-
cal Care Medicine (CSCCM) was founded
in Beijing. On July 4, 2008, The Standard-
ization Administration of the State Council
approved critical care medicine as a second-
level discipline (320.58). In 2009, Intensive
Care Unit (ICU), a national key clinical
specialty construction project of the Min-
istry of Health, became the only specialty
covering all provinces in China. In 2010,
the intermediate and senior promotion as-
sessment of critical care medicine was in-
cluded in the National Examination of the
Ministry of Health. In 2013, ICU received
special support from the National Natural
Science Foundation of the Ministry of Sci-
ence and Technology. In 2017, critical care
medicine was one of the four key support
directions for the 15 billion ‘National Proj-
ect to improve the diagnosis and treatment
of critical diseases’. Nowadays, in China,
critical care medicine is the preferred major
for emergency treatment of major disasters
and a showcase for modern hospitals.
The results of three national ICU surveys in
2006, 2011 and 2015 showed that the num-
ber of ICUs in China increased from more
than 1,000 to nearly 4,000 [1]. The num-
ber of intensivists in China has increased to
63,605, and the number of ICU nurses has
increased to over 100,000 [1]. The propor-
tion of ICUs in third-grade class-A hospi-
tals increased significantly. The ratio of in-
tensivist to bed and the ratio of nurse to bed
also increased significantly [1]. The growth
rate and range indicate that China’s criti-
cal care medicine develops rapidly and has
abundant reserves. According to the data
from the three national surveys of ICU, at
the beginning of the establishment of the
CSCCM, only about 30% of the ICUs in
China were subordinate to the ICU depart-
ment. With the unremitting efforts of the
CSCCM, nearly 66% of the ICUs in China
had been included in the ICU department
management by 2015, which indicates the
rapid development of the ICU department
in China [1].
Quality and Staffing
Improvement
For the development of critical care medi-
cine, we tried further strengthen the dis-
cipline standardization construction and
management, and build the discipline con-
struction platform of critical care medi-
cine. On this platform, multidisciplinary
integration and innovation can be realized
which promised the effective diagnosis and
treatment and finally reduce the mortality.
With the unremitting efforts of the chap-
Critical Care Medicine in China–Solid Steps
in the Past Forty Years and Future
Xiang-Dong Guan
CHINA
BACK TO CONTENTS
40
ter, critical care medicine was finally listed
in the national best Specialty ranking list in
2016 (evaluated by the Hospital Manage-
ment Research Institute of Fudan Univer-
sity), which is of great significance to the
promotion of the influence of critical care
medicine. In April 2015, the CSCCM was
awarded the title of Outstanding Specialist
Chapter of the CMA at the commendation
conference for the 100th anniversary of the
establishment of the CMA, which is the
recognition of the work by the CMA.
The development of the discipline of criti-
cal care medicine needs to be based on
clinical work and scientific research, which
cannot be separated from each other. More
than 180 scientific researches of critical
care medicine were funded by the National
Natural Science Foundation of China in
2018 alone. In 2018, more than 430 articles
related to critical care medicine in China
were published in foreign journals related
to critical care. According to the prelimi-
nary statistics of the top five journals re-
lated to critical care, such as INTENSIVE
CARE MEDICINE, CRITICAL CARE
MEDICINE,CRITICAL CARE and so
on, more than 121 research articles were
presented by Chinese authors. These voices
will certainly represent China’s critical care
medicine and resound through the critical
care medicine field in the world.
The key to resolve the shortage of human
resources is not only to increase the staff
numbers but also to improve their capabili-
ties (15). 5C was initiated in 2009, which
devotes to equipping intensivists with pro-
fessional knowledge and skills in mainland
China. So far, 120 training sessions have
been held, with a total of 24,202 students
and 208 teachers. It has been held in 31
provinces, autonomous regions and mu-
nicipalities, and is “the only continuing
education quality project”of 88 specialized
chapters of the CMA. In order to further
improve the professional knowledge and
skills of intensivists, the Multiprofessional
Critical Care Review Course and current
concepts of Critical Care Medicine from
the Society of Critical Care Medicine of
the United States to the local critical care
society was introduced since 2016.
International Influence
Over the past 10 years, the communication
between Chinese critical care medicine and
the international community has been in-
creasingly close, and the depth and breadth
have been expanding. The voice of Chinese
critical care medicine has been increasingly
appearing on the stage of important inter-
national academic congresses at different
levels.
During the 2018 Chinese critical care
medicine society annual conference, the
society held the launching ceremony of
“the Belt and Road initiative” in the spirit
of friendly cooperation. The heads of criti-
cal care medical academic groups from 16
countries along “the  Belt  and  Road  ini-
tiative” were warmly welcomed to attend
this annual meeting. Up to now, more
than 20 countries and regions have signed
“the  Belt  and  Road  initiative” Agreement
with the CSCCM which promoted the
integration of CSCCM with the interna-
tional community.
In 2018, a special session in Chinese was
held on the 31st Annual European Confer-
ence on Critical Care Medicine. Professors
of critical care medicine from China were
invited to give keynote speeches. These
achievements show that Chinese experts
in critical care medicine are playing an in-
creasingly important roles in promoting
the development of critical care medicine
around the world.
In recent years, international communica-
tion boards have been set up in the annual
academic conferences of critical care medi-
cine in China (such as the annual academic
conferences of CMA-CSCCM).This inno-
vative international communications have
greatly promoted the development of inter-
national cooperation in critical care medi-
cine in China.
Challenges and Opportunities
in the Future
While reviewing the great achievements of
critical care medicine in the past 40 years,
we must be soberly aware of the problems
and challenges in the development of the
discipline.
The Number of Icu Beds is Still
Unable to Meet the Demand
According to the results of the national sur-
vey of ICU beds, the ratio of ICU to hos-
pital beds increased from 1.49% in 2011 to
1.7% in 2015[1], but still failed to meet the
national minimum standard (2%-8%) [2].
In 2010, the ratio of ICU to hospital beds
in the United States has reached 13.4% [3].
Challenges of Discipline
Construction
It is necessary to gradually improve the
‘Peri-Critical Care Medicine’ discipline
system of ‘early warning, prevention, organ
support and long-term prognosis’. There is
still a need to improve and strengthen the
treatment of pre-hospital critical transport,
in-hospital critical rapid response team,
critical care and life support, and post-criti-
cal quality of life management.
Challenges of Informatization
Construction
No information, no modernization. Critical
care informatization isolated island is a cur-
rent phenomenon in China. With the top-
level design and support at the national level,
it is imperative to establish a national online
database of critical care medicine in China.
Critical Care Medicine CHINA
BACK TO CONTENTS
III
Obituary
Tai Joon Moon, MD, PhD
14 January 1928–11 March 2020
Tai Joon Moon was born in 1928 in Youngdeok City, north Gyong-
sang Province, South Korea. He graduated from the Seoul National
University School of Medicine in 1950, just one month before the
Korean War broke out, during which he served as a surgeon on the
frontline. Shortly after the war ended in 1954, he continued his
studies at the Thomas Jefferson Graduate School of Medicine, Phil-
adelphia, USA, where he completed his residency in neurosurgery
and neurology to become a neurosurgeon. He returned to Korea in
1957 and started teaching at the department of surgery at the Yon-
sei University Severance Hospital. In 1961 he was the main con-
tributor in establishing the department of neurosurgery, which until
then had been part of the neurology department, as an independent
department. He was a founding member of the Korean Neurosur-
gery Society and served as its President from 1968–1969. Tai Joon
Moon received his Ph.D. in Medicine from the Nihon University
in Tokyo, Japan in 1969. Among the honours that were bestowed
on him were an Honorary Doctorate in Science from Chungbuk
University in Korea in 1986, and an Honorary Law Degree from
Thomas Jefferson University in 1987.
In 1967 Dr Moon entered politics to devote his life to the good
of society. He ran for election to the national legislative and was
elected in his hometown at the age of 39. He was subsequently re-
elected four times, with his main focus and activities being around
the enhancement of community health. He served as chair of the
National Assembly, chair of the National Assembly’s Commerce
Committee, a member of the Democratic Republican Party, and
chair of the Gyungbuk Provincial Party.
After 14 years in the Korean National Assembly, he was elected
as President of the Korean Medical Association (KMA) and re-
elected three times,serving with the KMA until 1988.Following on
from his 9-year presidency of the KMA, he was appointed as Min-
ister of Health and Welfare for 8 months. During his term, Korea
implemented National Health Insurance, which covered the entire
population. He continued to serve the KMA as President Emeritus,
especially in the area of international relations.
His leadership skills were extended to an affiliated regional orga-
nization of the WMA, namely the Confederation of Medical As-
sociations in Asia and Oceania (CMAAO),as its President between
1981-1983, and subsequently as Senior Advisor until recent years.
He made a remarkable impact in strengthening the Asian voice on
the global stage.
Talent Training
Critically ill patients should be managed by
skilled intensivists with the most special-
ized training in critical care, not by physi-
cians who only receive other specialized
training to qualify for ‘standardized training’
and then perform treatment at the bedside
of the ICU. It is an urgent and critical prob-
lem to establish a unified and standardized
talent training system for critical medical
staff. In July 2020, Critical care medicine
was included in the national resident train-
ing system which will promote the reserva-
tion of professionals and development of
the discipline.
Integration and Innovation
The development of modern medicine has
put forward higher requirements for the
connotation of critical care medicine, which
greatly promotes the sustainable develop-
ment of critical care medicine. Therefore,
multi-disciplinary integration and innova-
tion are needed to complement each other.
Interdisciplinary integration and innova-
tion are not only the needs of the overall
development of critical care medicine, but
also an important symbol of the develop-
ment of modern medicine.
Critical care medicine is about to enter the
third decade of the 21st century, a decade
of opportunity and possibility, a decade of
great times. With a clear discipline devel-
opment plan, clear development ideas, and
adherence to integration and innovation,
critical care medicine will surely stand at
the forefront of modern medicine in the fu-
ture, have a better tomorrow, and make the
greatest contribution to modern medicine
and human health.
References
1. Wu JF, Pei F, Ouyang B, et al. Critical Care Re-
sources in Guangdong Province of China: Three
Surveys from 2005 to 2015.  Crit Care Med.
2017;45(12): e1218-e1225.
2. Rhodes A, Ferdinande P, Flaatten H, et al: The
variability of critical care bed numbers in Eu-
rope. Intensive Care Med 2012; 38:1647–1653
3. Halpern NA, Goldman DA, Tan KS, et al:
Trends in critical care beds and use among pop-
ulation groups and medicare and medicaid ben-
efciaries in the United States: 2000-2010. Crit
Care Med 2016; 44:1490–1499
Xiang-Dong Guan, Ph.D., MD
Zi-Meng Liu, MD
Department of Critical Care
Medicine, The First Affiliated
Hospital, Sun Yat-sen University.
President of Chinese Society
of Critical Care Medicine of
Chinese Medical Association
E-mail: guanxiangdong1962@163.com
BACK TO CONTENTS
xxx
The World Medical Association’s (WMA) members elected Tai
Joon Moon as their President in 1984 and he was inaugurated
in 1985 at the WMA General Assembly in Brussels, Belgium.
Remaining committed to the WMA, he was later elected as
Vice-Chair of Council from 1995 to 2005. We all have special
memories of the WMA General Assembly in Seoul in 2008
and his tireless work as Chairperson of the organizing com-
mittee to make it one of the most successful meetings of the
WMA. Right up until his final WMA meeting in Vancouver
in 2010 he displayed outstanding leadership and charisma, es-
pecially in the midst of critical debates. We knew him as an
Elder Statesman who, in his wisdom, was able to reconcile the
different ideas within the WMA. His charisma gave him great
influence even without any formal authority.
We, together with our colleagues in Korea, the Asia and Pa-
cific regions and globally, remember him as a great mentor.
Dr. Moon is not with us any longer, but the life he devoted to
the health of people and society through politics and interna-
Inauguration at the 37th
World Medical Assembly, Brussels in 1985
(left:Tai Joon Moon, right: J. J. Coury)
180th
WMA Council Session during the 59th WMA General Assembly,
Seoul in 2008
Assembly dinner with his wife Mrs Young Boo CHO at the 59th WMA General Assembly,
Seoul in 2008
tional relations will be remembered as an everlasting footprint.
He is deeply missed.
Sunny Park, Otmar Kloiber