WMJ_3_2021_WEB

vol. 67
Medical
World
Journal
Official Journal of The World Medical Association, Inc.
ISSN 2256-0580
Nr. 3, October 2021
Contents
Editorial as a Call for Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Health is a Creative Adaptive Process: Implications for Improving Health Care and
Reducing Burn-out Around the World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Self-Care, Inter-Care and Wellbeing in ­COVID-19 Times at the 13th
Geneva Conference
on Person Centered Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
COVID-19 the Need to Act, to Learn and to Prepare – Lessons for the Next Pandemic –
the Experience of Norway. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
The Coronavirus situation in Finland in brief (11th
of August, 2021). . . . . . . . . . . . . . . . . . . . . 21
Acute Medicine during the ­COVID-19 Pandemic in Switzerland. . . . . . . . . . . . . . . . . . . . . . . 22
A Report on a Symposium Titled ‘Violence Against Doctors with Focus on Women
Doctors’ Presented at the Mwia Near East and Africa Conference, Abuja 2021. . . . . . . . . . . . 24
The ­
COVID-19 Pandemic Revealed the Need for Increased National Governance
of Healthcare in Sweden. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
COVID-19 and War-Related Stress and Somatized Mental Health Disorders Among
General Population. Armenian Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Beyond the Number, Balancing Epidemiological Reporting with the Need for Patient
Empathy During the ­COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
The Impact of ­
COVID-19 Pandemic on Hospital-Based Health Services . . . . . . . . . . . . . . . . 36
Covid-19 Infection and the Vaccination Process in Albania . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medical Masks and their Challenges during the ­COVID-19 Pandemic . . . . . . . . . . . . . . . . . . 41
Covid-19 Fourth and Subsequent Waves-Readiness and Preparedness . . . . . . . . . . . . . . . . . . 44
How Myanmar Doctors Taking Care of Patients under Heavy Fire
in the Time of COVID-19 and Military Coup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Ethiopia’s Medical Talent Dilemma: Lessons Learned and The Way Forward . . . . . . . . . . . . . 51
Top 10 Progress Events in Clinical engineering in China in 2020 . . . . . . . . . . . . . . . . . . . . . . . 54
Promoting Self-Care in Children and Youth: A challenge in itself. . . . . . . . . . . . . . . . . . . . . . . 59
Editor in Chief
Dr. med. h. c. 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
Advisor
Helena Chapman, MD, MPH, PhD
Assistant Editor
Mg. Health. sc. Maira Sudraba, Velta Pozņaka; lma@arstubiedriba.lv
Journal design by
Pēteris Gricenko
Layout and Artwork
The Latvian Medical Publisher, “Medicīnas apgāds”, President Dr. Maija Šetlere, Skolas street 3, Riga, Latvia
Publisher
Medicīnas apgāds, Ltd
Skolas street 3, Riga, Latvia.
ISSN: 0049-8122
Dr. David BARBE
WMA President
American Medical Association
AMA Plaza, 330 N. Wabash, Suite
39300 60611-5885 Chicago, Illinois
United States
Dr. Otmar KLOIBER
Secretary General
World Medical Association
13 chemin du Levant
01212 Ferney-Voltaire
France
Dr. 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. Heidi STENSMYREN
WMA President-Elect
Swedish Medical Association
(Villagatan 5) P.O. Box 5610
SE-114 86 Stockholm
Sweden
Dr. Kenji MATSUBARA
WMA Vice-Chairperson of Council
Japan Medical Association
113-8621 Bunkyo-ku,Tokyo
Japan
Dr. Osahon ENABULELE
WMA Chairperson of the Socio-
Medical Affairs Committee
Nigerian Medical Association
8 Benghazi Street, Off Addis Ababa
Crescent Wuse Zone 4, FCT,
P.O. Box 8829 Wuse
Abuja
Nigeria
Dr. Miguel Roberto JORGE
WMA Immediate Past-President
Brazilian Medical Association
Rua-Sao Carlos do Pinhal 324,
CEP-01333-903 Sao Paulo-SP
Brazil
Dr. Ravindra Sitaram
WANKHEDKAR
WMA Treasurer
Indian Medical Association
Indraprastha Marg 110 002
New Delhi
India
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. Marit HERMANSEN
WMA Chair of the Medical Ethics
Committee
Norwegian Medical Association
P.O. Box 1152 sentrum
107 Oslo
Norway
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 as a Call for Advice
Soon it will be two years since we have been living in the shadow of
Covid–19. Each country fights the pandemic the way it can, involv-
ing medical professionals.Yet, too often most countries in the world
take political decisions without a direct correlation with medical
and epidemiological experience, research and knowledge.
Globally, we have succeeded poorly with vaccination. Country per-
formance is very different for different countries,but unless vaccina-
tion is global and the approach is proactive, the Covid–19 pandemic
will continue.
Such circumstances have formed the background also for the activi-
ties and performance of the World Medical Association during the
last two years. In reality, we have not met one another in person,
but remote communication and distance meetings are not effective.
Moreover,at remote meetings the corporate spirit and global view of
development and challenges are declining. The WMA has worked
hard and seriously and has been very active to promote limiting the
pandemic, safety of medical workers and fight attacks against medi-
cal professionals.
However, information exchange is slower than we were accustomed
to. Local problems, local lockouts, restrictions on medical activities,
local discussions seem to be more important to many national medi-
cal organizations.
To be honest, I can say that in these two years I have lost the sense
of identity and direction of the World Medical Journal (WMJ).The
world’s medical information room is inundated with a huge amount
of information in a wide variety of electronic formats. Completely
new methods for disseminating hybrid medical information have
emerged. It seems that printed publications have lost their positions
forever. I get the impression that the WMJ is issued in its classical
form mainly due to customs and traditions.
Therefore I address my readers in the national medical associations
of the world. What are your ideas about the further development of
the Journal? I truly believe that it is the time to change the editor-
in-chief and my functions should be passed on to a younger, more
modern and more energetic medical doctor with better knowledge
of languages and information technology, with a wide circle of ac-
quaintances among the world’s younger physicians. I will be very
happy to transfer my experience to a new colleague,just as I received
a lot of good advice and knowledge from my predecessor Dr. Alan
J. Rowe.
I would like the Journal to be global,be more philosophical and unit-
ing the interests of all doctors in the world. I would like ­
Covid–19
to give us more knowledge, not only about masks, vaccinations and
hospital treatments, but also about prevention, outpatient assis-
tance, medical organisation, rehabilitation and even palliative care.
But above all, let us face the future pandemics with confidence and
readiness to act swiftly and accurately at any place in this world.
Dr. med. h. c. Peteris Apinis,
Editor-in-Chief of the World Medical Journal
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2
Person-centered Medicine
C. Robert Cloninger James Appleyard Juan E. Mezzich Ihsan Salloum
Health is a Creative Adaptive Process: Implications for Improving
Health Care and Reducing Burn-out Around the World
Jon Snaedal
Abstract
World medicine is currently suffering from
multiple crises that can only be remedied
by fundamental changes in health care pri-
orities. Both genomic and biopsychosocial
research on the basis of human health and
well-being show that health and well-being
depend on creative adaptive processes and
that most common diseases are complex
consequences of unhealthy lifestyles and
inequitable socioeconomic conditions, not
discrete diseases with specific causes. Evi-
dence-based medicine works best for the
acute treatment of injuries and rare homo-
geneous disorders with specific causes, but
its benefits are weak and inconsistent for
common conditions that are heterogeneous
and involve complex adaptive biopsycho-
social processes. Treatment guided primar-
ily by symptom-based diagnosis provides
little insight into the actual biopsychoso-
cial causes of the person’s symptoms and
is severely limited in its ability to promote
healthy longevity in individuals or to reduce
disease burden in populations. Health care
that does not effectively and equitably pro-
mote the well-being of individual persons
and their communities violates a physician’s
innate sense of vocation and duty, so it leads
to burnout among professionals provid-
ing health care, as well as dissatisfaction
and distrust by its recipients. World health
needs and the professional duties of physi-
cians can only be effectively and efficiently
addressed by person-centred approaches
to clinical care and by people-centred ap-
proaches to health promotion and disease
prevention as the major priorities in health
care.
Introduction
Much of contemporary disease care is built
on a paradigm that assumes people are
separate from the rest of nature and un-
der attack from pathogens or traumas that
are specific causes of discrete diseases. It
originated from scientific efforts to iden-
tify separate diseases with a distinctive set
of symptoms, discrete clinical boundaries
from other diseases, a predictable natural
course and outcome, and a specific caus-
al abnormality [1–4]. Put another way,
the goal of the discrete disease paradigm
has been to “carve nature at its joints” by
separating disorders from one another and
from healthy functioning by specifying
discrete natural boundaries [4, 5]. Natural
boundaries require identifying evidence
of zones of a rarity in symptoms that are
supposed to distinguish each disease from
similar conditions, using techniques like
discriminant, admixture, and cluster analy-
ses [4, 6, 7].
Are diseases really discrete?
The discrete disease paradigm may seem
reasonable and laudable to those of us who
have been professionally educated and
trained in this perspective for many years.
In fact, it is difficult for most physicians to
question the validity and effectiveness of
the system of categorical classification of
diseases because diagnoses do have practi-
cal utility to provide substantial, but only
approximate, information about aetiology,
treatment, and health outcomes. Disease
classifications can provide a simplified ac-
count of ideal prototypes that allow phy-
sicians to organize their work, simplify
communication, and conduct large-scale
statistical investigations, even though
there are no real discrete boundaries to
separate most diseases [5]. For example,
there are obviously clinical differences
among patients with cardiovascular dis-
orders, diabetes mellitus, obstructive lung
disease, cancer, dementia, and depression,
but often there are shared etiological influ-
ences and clinical overlap because all body
components interact in the maintenance
of health. Furthermore, as people age, they
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3
Person-centered Medicine
frequently have combinations of disorders,
making distinctions difficult. The idea that
diseases are discrete is more difficult to
question for physicians who work in sec-
ondary and tertiary care settings that are
structured around diseases or organ sys-
tems than for generalist physicians who
provide a holistic person-centred approach
to the patient’s presenting symptoms, pref-
erences, and priorities in their health care,
rather than viewing them as a case with a
specific condition [8].
Nevertheless, there is little evidence that
most medical or psychiatric disorders re-
ally have discrete natural boundaries, except
for some rare conditions [4, 5]. Even when
relatively distinct disorders are found by
advanced statistical methods, they are only
partially distinguished from one another
and from normality because they are not
fully dissociable from the complex func-
tional systems necessary for the life of the
person,who is,in turn,an inseparable aspect
of the ecological web of all living things. As
a result, despite sequencing the entire hu-
man genome between 1990 and 2003, the
causes of the common medical disorders
are still not precisely specified because they
have proven to be dysfunctions in complex
biopsychosocial systems. Consequently, the
search for precise causes of complex pro-
cesses and the practical utility of approxi-
mate disease categories for classification has
distracted medicine from asking the larger
questions of “What is health?” and “What
is disease?”.
What is health?
It is the larger questions about the funda-
mental nature of health and disease that
we must understand in order to prioritize
rationally how we can really improve peo-
ple’s well-being and reduce the burden of
disease in the world. Our current system of
classification of diseases is actually rooted
in outdated scientific constructs prevalent
prior to the modern understanding of com-
plex adaptive systems [9, 10], the quantum
revolution in physics and biology [11, 12],
and the recognition that symbiosis and co-
operation are more fundamental to all liv-
ing systems than competition and conflict
[13, 14].
Rigorous modern scientific research shows
that the well-being of all organisms in the
web of life depends on complex biopsycho-
social processes that are interdependent,
adaptive, and creative, enabling dynamic
changes that both shape and respond to
changing internal and external conditions
[13, 15, 16]. Because of the interdepen-
dent functioning of the components of liv-
ing systems, they function in ways that are
qualitatively distinct from machines com-
prised of independent and separable parts.
Rather than being separate from nature and
under attack from others, human beings
even have the potential capacity to be aware
of their being inseparably interdependent
with other life forms and more-or-less able
to regulate and integrate their own hab-
its, goals, and values to live in harmonious
ways that are healthy, satisfying and good
for themselves and others [16, 17]. We are
less healthy and happy when we revert to an
outlook of separation in which fear,immod-
erate self-interest, and vanity or self-doubt
bias our perceptions and impair our aware-
ness of our connections with other people
and the mysterious glory of the universe as
a whole [12, 17].
When are discrete diagnoses useful?
Nevertheless, categorical diagnoses may
also be adequate approximations for moni-
toring the prevalence of clinical syndromes
at different times and locations in epide-
miology when it is not necessary to know
the precise cause or causes of the syn-
dromes [5]. Diagnoses of discrete diseases
are sometimes adequate approximations to
treat clinical signs and symptoms acute-
ly, just as there are conditions in physics
under which Newtonian mechanics is an
adequate approximation to quantum me-
chanics when engineers build a bridge
[18]. Likewise, the Western paradigm of
discrete diseases can be usefully applied
by medical specialists to disorders with a
specific and consistent cause, such as acute
infections by specific bacteria, acute physi-
cal injuries, or other disorders with a single
specific abnormality (e.g., genetic, meta-
bolic). Sometimes it is adequate in prelimi-
nary discussions to use broad categories of
diagnoses to distinguish disorders with few
overlapping features, such as those treated
by different medical specialities, but then
assessment and treatment for even the
acute condition are still likely to benefit
from an expert understanding of the com-
plex alternative pathways to similar clinical
syndromes. Physicians have been criticized
because they do not have solid evidence
from randomized controlled trials or ad-
here to recommended guidelines for most
of what they do [19], but the reality is that
greater information has not accumulated or
been used because the definitive diagnoses
imagined by the discrete disease paradigm
itself are unrealistic most of the time and
evidence-based guidelines are often not
informative for the complex comorbidity
of any particular patient [20–22]. Diag-
noses are rarely discrete and homogeneous
because their cross-sectional features and
health outcomes are strongly influenced
in complex ways by demographic charac-
teristics, behavioural lifestyles and socio-
cultural conditions [23].
In the rare cases in which diagnostic dis-
creteness and causal specificity can be
documented, the effective acute treatments
(e.g., drugs or procedures) depend almost
entirely on the specific and discrete diag-
nosis, not on the person or their psychoso-
cial, economic, or ecological circumstances.
Then evidence-based treatment targets the
single specific pathogen or tries to correct
the defect or injury by specific drugs and/or
procedures. Under these highly restrictive
conditions, randomized controlled trials
can identify differences in health outcomes
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4
between actively treated cases and controls,
which may then provide a consistent guide
to effective treatment of individual patients,
as is advocated in algorithms for evidence-
based medicine.
When are discrete
diagnoses not useful?
However, the discrete diseases paradigm
with an emphasis on treatment by medi-
cal specialists has limitations as a compre-
hensive clinical approach because the most
prevalent medical disorders have fuzzy
clinical features that frequently overlap with
one another across multiple specialities,
have variable natural course and outcome,
and causes that are heterogeneous with
complex contributions from multiple bio-
logical, psychological, social, environmental,
and spiritual influences [6, 7, 23–25]. Gen-
eralizations from outcomes of randomized
controlled trials are also frequently flawed
because of restrictive inclusion and exclu-
sion criteria to produce a more homoge-
neous population in the trial, which is not
at all representative of the heterogeneous
population of the disorder that physicians
treat in clinical practice. For example, age
and comorbid conditions are very common
exclusion criteria, and results from clini-
cal trials that restrict the upper age of par-
ticipants are frequently extrapolated to the
general older population that they do not
represent well, leading to either under-or
over-treatment [26].
The discrete disease paradigm also has
severe limitations from a public health
perspective because there are often, if not
always, differences between individual
persons in their susceptibility, response
to treatment, and long-term outcome,
as is well known even for infectious dis-
eases [27], including infections of SARS-
CoV-2 for which the socioeconomic de-
terminants are indistinguishable from
average all-sources mortality in the gen-
eral population [28]. The discrete disease
paradigm has also proven to be generally
inadequate when extended to conditions
in which there are multiple heterogeneous
causal factors and biopsychosocial influ-
ences on vulnerability and resilience; it is
inadequate for such complex disorders be-
cause so-called evidence-based treatments,
which are based on the standard of aver-
age differences between groups, yield weak
and inconsistent benefits that are similar
for diverse evidence-based or alternative
treatments [29]. Put another way, reliance
on the discrete disease paradigm is inad-
equate for most common diseases because
it fails to provide reliable guidance on how
to treat any particular individual.
The adaptive nature of the processes under-
lying common and complex diseases also
frequently leads to an inefficient and self-
defeating treatment process when clinical
symptoms and syndromes are the targets of
treatment rather than the actual complex
biopsychosocial process in the whole per-
son. Over their long evolutionary history,
human beings have acquired multiple reg-
ulatory feedback processes for maintaining
homeostasis and allostasis. Homeostasis
involves maintaining body systems (such
as blood pH and body temperature) within
a narrow physiological range, whereas al-
lostasis involves maintaining stable func-
tional capacity despite changing situations,
such as challenges from of stressors, trau-
ma, pathogens, and circadian or seasonal
environmental changes, which is a natu-
ral and unavoidable aspect of adaptation
to life [30]. For example, blood pressure
is regulated by multiple interactive bodily
systems, such as the kidneys, the heart, and
the blood vasculature. In response to pain
or stressful personal and social situations,
blood pressure can increase to dangerous
levels. Diuretics may reduce blood pressure
initially even if the stressful psychosocial
conditions are not corrected, but then the
body continues to adapt to the stressful
conditions by increasing blood pressure.
Other drugs, such as calcium channel
blockers, may then be added with tran-
sient success, but the body will continue to
adapt by increasing blood pressure in other
ways unless the actual cause is corrected.
The addition of beta-blockers may reduce
blood pressure by reducing the pulse rate
but also increase insulin resistance and lead
to type-2 diabetes.
The result of treating the symptoms rather
than the causes of an adaptive process is
polypharmacy, adverse drug effects, and
other iatrogenic diseases with only a pre-
carious regulation of symptoms because
the actual psychosocial cause of the dys-
function has not been recognized or
treated. When one adaptive abnormality
is treated, the treatment is likely to induce
abnormalities in other systems, generat-
ing adverse effects or interfering with the
adaptation to comorbidity. The same pro-
cess of trial, initial partial success and then
weak benefits and adverse effects or failure
occurs with the most common complex
disease regardless of the medical special-
ity to which the disorder is assigned in
our classification of diseases. When this
“evidence-based” approach is applied to
common complex diseases or multimorbid
conditions, the results produce inadequate
benefits with no cure, so that people accu-
mulate multiple chronic diseases [8]. This
unfortunate result of long-term treatment
of multiple chronic diseases without a cure
is profitable for medical-industrial disease
alliances, but not for the well-being of in-
dividual persons or communities, or for the
fulfilment of noble aspirations and duties
of health care professionals to serve the
well-being of others.
What are the major challenges
facing medicine as a result
of current practices?
Consequently, a holistic biopsychosocial
approach is essential for effective and ef-
ficient health promotion, disease preven-
tion, and treatment of complex disorders
that are strongly influenced by the unique
Person-centered Medicine
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5
characteristics of a person, including their
personality, lifestyle, and socioeconomic
and environmental conditions [31–35].
Strong evidence that the paradigm for dis-
crete diseases with specific causes is inap-
propriate and has become unsustainable as a
general comprehensive model of health care
has become undeniable because of (i) the
weak and inconsistent results and frequent
adverse effects obtained from depersonal-
ized evidence-based treatment for suppos-
edly discrete diseases [33], (ii) the increas-
ing global burden of disease from the high
prevalence of people with multiple chronic
diseases [8], (iii) the high prevalence of
burn-out (40 to 60%) in health care profes-
sionals from dehumanized and monetized
health care environments [36, 37], (iv) the
chronic underfunding of health promotion
and disease prevention that is motivated by
short-term special interests and falsely jus-
tified by policies that assume the adequacy
and sustainability of specialized and costly
clinical care for discrete diseases as a com-
prehensive system of health care [38], and
(v) the growing pattern of dissatisfaction
with disease care along with preference for
self-care and holistic alternative medicine,
which many, if not most, people find to
be more congruent with their own values,
beliefs, and philosophical orientation to
healthy living [39].
To identify a constructive path to restore
medicine to its effective and respected role
in society, we will first consider a more sci-
entifically grounded paradigm of health as
a complex biopsychosocial process that is
creative and adaptive based on rigorous ge-
netic and biopsychosocial research. Second,
we will then consider in more detail the
inadequacies of the discrete disease model
to which most physicians have become ac-
customed without questioning its assump-
tions and adverse consequences. Third,
we will consider the fundamental shift in
perspective underlying integrative medical
approaches to person-centred care of indi-
viduals and people-centred care of popu-
lations. Finally, we make a call for action
on initiatives that can efficiently enhance
the health and well-being of both provid-
ers and recipients of health care around the
world.
Research on health as a
creative adaptive process
Human beings are innately resilient
We need to understand the complex pro-
cesses that promote and maintain human
health to make health care systems around
the world more effective, efficient, and eq-
uitable. To begin that process of under-
standing it is useful to recall that modern
Homo sapiens prospered as a species for over
100,000 years prior to the advances in med-
icine that were introduced about 250 years
ago in fields such as pathology, obstetrics,
and vaccination. Increased human longevity
in the industrial era is largely the result of
reduced infant and maternal mortality due
to improvements in many factors besides
medical care, including nutrition, personal
hygiene, environmental control, and socio-
economic conditions [35, 40].
Prolonged healthy longevity after repro-
ductive age has been a human character-
istic since antiquity prior to the advent of
modern medicine due to innate molecular
mechanisms for adaptation to stress, inju-
ries, pathogens, and degenerative processes
under conditions that we now can specify
from research on the science of well-being
[41]. Throughout the ages, people who in-
tentionally cultivated well-being (i.e., a
healthy, happy, and good life) have been
able to enjoy healthy longevity accompanied
by prosocial behaviour and life satisfac-
tion even without the advances of modern
medicine [12,17,42,43].These facts may be
startling until it is recalled that, even with
all the amazing technological advances in
disease care available today, the quality of
clinical care only accounts for 16% of health
outcomes compared to 84% from socioeco-
nomic factors (47%), behavioural lifestyle
(34%), and environmental conditions (3%)
[44]. It has always been the lifestyle, socio-
economic conditions, and an individual’s
personality and associated outlook on life
(viz. separateness versus unity, self-interest
versus self-transcendence) that contribute
most to the health of individuals and their
communities [16, 17]. Human beings co-
evolved with other components of the web
of life so that we have remarkable innate
resilience to disease and injury when we are
living in ways that naturally promote the
health of ourselves, others, and our environ-
ment [45].
What are the conditions
for healthy living?
As described by Hippocrates and Plato
nearly 2500 years ago, healthy life is gen-
erally characterized by prudent use of hu-
man insight and judgment to regulate our
lifestyle and habits in ways that are good
for others as well as for ourselves [46–48].
Put another way, when people cultivate the
character strengths of being self-directed,
cooperative, and self-transcendent, they
have the insight and self-control to regulate
their habits to live in accordance with the
goals and values that promote the physi-
cal, mental, and social aspects of health
in themselves and their community. They
embody and enact virtues including mod-
eration, perseverance, and social justice that
correspond well to findings in modern re-
search on the social determinants of health
[49, 50]. Most reasonable people in diverse
cultures and environments know that they
would do well in life to eat nutritious food
moderately, exercise regularly, treat oth-
ers respectfully, act responsibly, and aspire
to understand our role in the mysterious
wonders of the universe in which we find
ourselves [43, 47, 51]. There have always
been some remarkable individuals who
lived such a good life [12], but at dysfunc-
tional times, like today, there are many who
do not. Instead, many acts viciously out of
Person-centered Medicine
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6
fear, greed, and arrogance, so that their life
is unhappy, brutal, and short. Consequently,
many medical sages since the time of Hip-
pocrates have advised their colleagues that
“It is more important to know what sort of
person has a disease than to know what sort
of disease a person has [52].”
The challenge for the modern science of
health and well-being has been to be able
to measure and understand the philosophi-
cal descriptions of healthy life in ways that
are valid and objective. Over the past few
decades, Cloninger and his colleagues have
developed a comprehensive inventory of
human personality that measures the bio-
psychosocial learning abilities that allow a
person to shape and adapt to ever-changing
internal and external conditions that are
essential for human health and well-being
[53]. Using the Temperament and Char-
acter Inventory (TCI), human personality
is based on three genetic-environmental
networks for learning and memory that are
fundamental to human health: associative
conditioning, intentionality, and self-aware-
ness [17].
Three systems for learning regulate
human personality and health
Human temperament is based on associa-
tive conditioning processes that regulate
synaptic plasticity by activating the two
major cellular mechanisms for responding
to extracellular stimuli that we share with
all animals (i.e., the Ras-MEK-ERK and
PI3K-AKT-mTOR cascades) [45, 54].
Differences between individuals in their
irrational emotional drives (i.e., tempera-
ment) can be measured in terms of differ-
ences in four dimensions including willing-
ness to take risks or to avoid them (“Harm
Avoidance”), curiosity and approach to
what is novel (“Novelty Seeking”), desire
for social recognition and social attach-
ments (“Reward Dependence”), and perse-
verance despite inconsistent success (“Per-
sistence”).
In addition, early humans evolved the abil-
ity to regulate their temperament inten-
tionally a little less than 2 million years
ago, as shown by Homo ergaster (“working
man”) developing the capacity for being
self-directed and cooperative for mutual
benefit in social groups using brain systems
involving the cellular Calcium-Second
Messenger signalling system in the brain
network for executive self-control [16, 55].
Then about 100,000 years ago modern
Homo sapiens (“wise man”) developed the
capacity for self-awareness with associated
capacities for healthy longevity, creativity,
and prosocial behaviours including a sac-
rifice for others to form communities with
trust and altruistic support of one another
[16, 41].
Hence health-promoting human self-gov-
ernment is comprised of executive functions
for self-direction (i.e., being intentionally
resourceful, purposeful, and responsible to
achieve personal goals), legislative functions
for cooperation (i.e., being intentionally
tolerant, helpful, and principled in interper-
sonal interactions), and judicial functions
for self-transcendence (i.e., insight in the
appraisal of values and theories, so that a
person can identify with something greater
than their individual self) [12].
The temperament and character traits can
be measured reliably, and they are strongly
predictive of differences between people
in their physical, emotional, cognitive, and
spiritual aspects of health and well-being
[16, 17, 56].The heritability of personality
and of well-being is approximately 50%
and nearly all of their heritability is ex-
plained by 972 genes that are organized
in clusters for particular functions that
regulate and maintain health. Nearly all
the genes are expressed in brain circuits
for learning and memory, and over 70%
are expressed in nearly all organs and
tissues throughout the body, so they are
organized in ways that support the adap-
tive regulation of health for a person as a
whole [17].
Health depends on many
complex adaptive processes
The organization and development of the
human systems for learning to adapt to
changing conditions in a healthy, satisfy-
ing, and meaningful way is complex [45].
At all levels of expression (molecules, cells,
learning circuits, behaviour, cognition), the
components interact through many feed-
back and feedforward loops modulating
their functions. At the behavioural-cogni-
tive level, the same traits can have different
outcomes (i.e., pleiotropy in genetics and
multi-finality in development) and differ-
ent traits can have the same outcome (i.e.,
heterogeneity in genetics and equi-finality
in development). The genes that regulate
the three learning systems are largely sepa-
rate from one another and are expressed in
different brain networks. Nevertheless, they
operate cooperatively with one another, and
within each system, they function in clus-
ters of interdependent components, not as
independent parts like a machine. Much
more about this complexity is summarized
in more detail elsewhere [45].
The complexity of systems regulating
health and well-being is adaptive, that is,
it involves learning to adapt to changing
opportunities and conditions in order to
maintain and improve health and reduce
the risk of disorder in response to internal
or external stressors and challenges [55].
Such complex adaptive systems allow for
plasticity and meta-stability: that is, they
allow maintenance of stable functioning
despite changing internal and external
conditions, but small changes can also
lead to major functional shifts at tipping
points (the so-called “butterfly effect”)
[12]. These properties of plasticity and
meta-stability are also discussed in terms
of the allostatic load of complex adaptive
systems under stressful conditions [30].
When threatened or distressed, a person’s
blood pressure is likely to automatically
rise to high levels as part of a fight-or-
flight response, and their body will strive
Person-centered Medicine
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7
to maintain hypertension as long as the
threat to survival is present.
People create health
Furthermore, the human system for regu-
lating health is not merely adaptive, it is
creative [16, 33]. What is most important
to recognize is that human personality is
not fixed: it involves learning abilities so
that human can deliberately and creatively
change their own way of functioning and in
doing so actually modify how their genome
is expressed through epigenetic regulation
by more than 200 long-non-coding RNA
genes that are unique to modern Homo
sapiens [16]. These regulatory lncRNAs
orchestrate the functioning of other genes
throughout the body to promote human
awareness and well-being so that Homo sa-
piens can cultivate practical wisdom. That
is, human beings can become self-aware of
their own habits, goals, and values, so they
can exert self-control over their habits to
bring them in accord with their goals and
values. This integrative functional process
in which we create health is called self-
actualization in humanistic psychology [57,
58] and salutogenesis in health sociology
[32, 59].
It has long been recognized that health is
a complex integrative process that is both
adaptive and creative [31, 32]. So how do
we promote and create health? Most adults
do not respond well to being told what they
should do. That approach has been ineffec-
tive when presented dogmatically by health
care professionals. However, people can be
motivated to change their knowledge, at-
titude, and engagement with healthy liv-
ing when it is encouraged in dialogue and
participation in experiences that allow them
to be creative in facing current realities and
then to imagine vividly what they want for
themselves [60].Then they are creatively ac-
tualizing their own vision of a satisfying and
meaningful future, which is more valued by
them than transient pleasures and maladap-
tive habits [47]. Such self-identified mean-
ingful goals motivate people to regulate and
change their unhealthy habits to actualize
what they aspire to be and to do for them-
selves and for others. Much more about
health care as a creative person-centred
process is described elsewhere [29, 47, 60].
The self-actualization process requires the
integrative activation of all three systems
of human learning in order for a person
to bring their habits into accord with their
goals and values, as described below. What
has been briefly summarized here is intend-
ed only to provide the scientific foundation
for recognizing why over-reliance on the
simplifying and approximate assumptions
of the discrete disease paradigm for practi-
cal aspects of health care has led us to ignore
the underlying creative path to health and
well-being. Our ignoring the real pathway
to health and well-being has allowed the
current confluence of crises in health care
to emerge around the world, but our mis-
takes can be corrected. Now let’s examine
the limitations of the discrete disease para-
digm in more detail to recognize where it
goes wrong.
Inadequacies of the medical
model of discrete diseases
with specific causes
What is called “evidence-based”medicine is
hardly what it claims to be because it re-
ally provides little or no information about
how to treat any individual patient except
for people with rare homogeneous con-
ditions with a specific cause and with no
comorbidity. Evidence-based medicine is
strongly guided by algorithms to treat dis-
crete diseases with specific medications
and procedures identified by differences in
average health outcomes between groups
of people in randomized controlled trials.
This has serious limitations because of its
false assumptions about disease taxonomy,
specificity and homogeneity of causation,
and socioeconomic determinants of health.
Even advocates emphasize that evidence
from randomized controlled trials must be
supplemented by individual clinical experi-
ence and patients’ choice [61], but there is
no systematic method for actually doing so
within the discrete disease paradigm. As a
result, most medical decisions are currently
made without a high degree of scientific
certainty [19].Accordingly,we will consider
the challenges of trying to do so in relation
to each of these assumptions in turn for
clarity.
Diagnoses are not specific
enough to be prescriptive
First, regarding taxonomy, despite centu-
ries of effort it has never been possible to
develop a classification of medical diseases
in which individuals have a consistent set
of clinical features that are discrete (that is,
with a non-overlapping set of pathogno-
monic features) [5]. Put another way, the
symptoms used for medical diagnosis and
disease classification are nearly always non-
specific individually and the boundaries be-
tween neighbouring conditions are overlap-
ping (“fuzzy”) even when multiple features
are combined in polythetic criterion sets. It
has always been hoped and promised that
diagnostic criteria based on symptoms and
natural history will soon be replaced by spe-
cific laboratory tests, but the same problem
of fuzziness and non-specificity occurs with
laboratory test results, symptoms, and signs
of the disorder [3, 4, 18, 62]. Fuzzy bound-
aries and non-specificity of criteria based on
symptoms and/or tests persist because the
causes of most medical dysfunction involve
complex adaptive systems. In other words,
different people with the same diagnosis
become ill by way of different developmen-
tal pathways in which multiple causal vari-
ables interact with one another to produce
similar signs and symptoms [25].
Diagnoses of disorders in all medical spe-
cialities suffer from the limitations of het-
erogeneity and complexity, even though it
Person-centered Medicine
BACK TO CONTENTS
8
is most widely acknowledged in psychia-
try: that is, all common medical disorders
turn out to be heterogeneous in aetiology
and development because of their complex
biopsychosocial nature. For example, about
40% of the risk of dementia may be delayed
or prevented by changes in modifiable life-
style factors and comorbid conditions, in-
cluding a reduction in alcohol intake,smok-
ing, obesity, exposure to air pollution, as
well as improvements in sleep, frequency of
physical activity and social contact, educa-
tion, cognitive stimulation, hearing, control
of diabetes, hypertension, and depression,
and prevention of head trauma [63]. As a
result, diagnostic categories lack prescriptive
specificity: the pharmaceutical industry can
offer a wide variety of drugs acting by dif-
ferent mechanisms for people with the same
diagnosis, which are usually prescribed by
physicians to particular patients by trial and
error with partial or transient success and
no cure. For research purposes, the problem
of heterogeneity within diagnostic catego-
ries can be partly mitigated, but not elimi-
nated, using advanced statistical methods of
clustering, or by the exclusion of “atypical”
cases [25]. However, general classification
systems are expected to assign everyone to
some class, and physicians must treat each
person who presents for help without the
luxury of accumulating a large series of sim-
ilar cases or excluding atypical cases.
Diagnoses are highly
heterogeneous and imprecise
Second, regarding causation, common
medical disorders have multiple biological,
psychological, and social determinants of
risk that interact to influence vulnerability,
so their pathogenesis cannot be reduced
to material (physical, cellular, molecular)
causes [44]. These biopsychosocial pro-
cesses are not deterministic, but actually
are adaptive in the sense that a person has
multiple systems of learning and memory
that function to maintain homeostasis and
allostasis, as mentioned in the introduction.
Consequently, there has been little success
in developing specific laboratory tests that
identify the actual causes of most diseases,
which are most frequently attributable to
lifestyle factors (e.g., smoking, drinking,
poor diet and exercise, reckless behaviour)
and socioeconomic factors (e.g., economic
inequity, poverty, inequitable access to care,
social distrust, exposure to violence) [18,
49, 64]. Even markers of dysfunction, such
as abnormal glucose tolerance tests, do not
specify the actual fundamental cause of the
abnormality, which may be based on a va-
riety of biological abnormalities and/or on
lifestyle, rather than a specific biogenetic
defect.
There are claims of a future of precision
medicine based on analysis of the human
genome [65], which is promoted by re-
searchers and commercial companies, even
though the validity of assessments of the
vulnerability of any specific individual that
is based on individual genes or polygen-
etic risk scores without a personalized as-
sessment of the whole person in their life
context is doubtful [45]. In other words,
even though genetic testing and genome
sequencing are objective and reliable proce-
dures, health does not depend on the aver-
age effects of genes acting independently.
Rather health depends on the interactions
of many genetic and environmental factors
operating in complex sets of biopsychoso-
cial pathways that regulate the expression of
genes, the co-expression of groups of genes,
and the epigenetic modification of genes
in response to individual life experiences,
socioeconomic conditions, and creative hu-
man aspirations [16, 17, 45].The promise of
precise treatment algorithms for common
diseases is no more valid than earlier hopes
and promises of reductionists over many de-
cades that pathognomonic laboratory tests
are expected to emerge in the near future.
The undeniable reason for the persistent
failure of this promise over centuries is that
organs, cells, and molecules do not operate
separately in living organisms; rather their
functioning is interdependent and adaptive
in order to maintain plasticity and allostasis
as needed for health, as described in the in-
troduction.
Health and disease depend
mostly on personal behaviours
and socioeconomic conditions
Third, regarding the social determinants of
health, the discrete disease model assumes
that categorical diagnosis is an adequate ba-
sis to guide effective treatment without re-
gard for an individual’s personality, lifestyle,
or their psychosocial, ecological, and eco-
nomic circumstances, such as levels of eco-
nomic inequity and social distrust in their
community. In fact, health outcomes are
much more influenced by such psychoso-
cial influences on health, which account for
more than 80% of the variability in health
outcomes [44, 49]. Even for some specific
infections, such as Sars-CoV-2, the social
determinants of health are indistinguish-
able from those for average all-sources mor-
tality, so transdiagnostic health promotion,
such as building communities that are more
caring, equitable, and educated is likely to
be more effective for overall societal well-
being, socioeconomic stability, and disease
prevention than a large set of specific treat-
ments based on categorical diagnosis [28].
Despite this, current health policies do little
to address the actual determinants of dis-
ease despite prudent recommendations on
what needs to be done [28, 63].
Heritable personality traits account for
about half of the variability in physical,
mental, social, and spiritual aspects of well-
being, including overall healthy longevity
and resilience to injury, ageing, and degen-
erative processes by activating molecular
processes that promote longevity, healing,
and resilience from injury and disease [17].
It is important to recognize that what is in-
herited are systems of learning to adapt in an
integrative manner, not fixed traits or separate
functions with individual cells or organs [16,
17, 30]. Three systems of learning underlie
Person-centered Medicine
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9
the development of well-being: associative
conditioning of habits and skills,intentional
self-control of goal-seeking,and self-aware-
ness of creative and flexible means to realize
what is valuable and meaningful for one’s
self and others [16, 17]. Consequently, well-
being depends on learning in which nature
and nurture are always both involved.
Put another way,health and well-being can-
not be reduced to fixed materialistic deter-
minants, so we cannot measure a person’s
health or even their vulnerabilities without
also assessing their habits, goals, and values
for their congruence and strengths. First,
to predict the physical aspects of capacity
for physical well-being and vulnerability to
disease with precision, we must know the
extent to which a person’s habits are in ac-
cord with their goals and values. Second, to
predict the emotional and cognitive aspects
of health, we must also know if they can
self-regulate their work, lifestyle, social re-
lationships, and aspirations in ways that ac-
tivate molecular processes for plasticity, in-
cluding energy production to support their
resilience, cellular maintenance, and repair
of injury, ageing and other degenerative
processes. Third, to predict the social and
spiritual aspects of health, we must know
if a person is sufficiently self-aware of cre-
ative ways of adapting in ways that will give
their life meaning and purpose, as shown by
their actively cultivating epigenetic changes
in the expression of their genome by wise
health-promoting ways of living, such as
working in the service of others, letting
go of fighting and worry, and growing in
awareness of what is meaningful in life.
For example, health-promoting self-actu-
alization of a person’s intrinsic aspirations
and vocation is observed when a person
cultivates positive emotions and social trust
by awareness of their inseparable connec-
tions with other people and nature [12].
Such social and spiritual aspects of health
promotion and maintenance are expressed
by frequent acts of kindness, compassion,
gratitude, patience, fairness, moderation,
humility, peace-making, and other virtues
[47]. Such conscious health-promoting
practices are quite distinct from the char-
acteristics of the materialistic life that is
strongly promoted in social media in secu-
lar societies around the world; what is most
often promoted in media is the desirability
of self-interested profit-seeking, immoder-
ate consumption, and striving for power or
celebrity, which are harmful to health and
well-being for both individuals and com-
munities [43].
All three aspects of health (physical, mental,
and spiritual) are interdependent, so all need
to be cultivated simultaneously, not just one or
two at a time. For example, reductionistic
approaches that emphasize only one aspect
of the path to well-being do not produce
consistent and strong benefits: approaches
that emphasize materialistic aspects of well-
being, or behavioural and cognitive aspects,
or social and spiritual aspects need to be
combined in an integrative fashion for ef-
fective and consistent health care.
Optimal learning about physical,mental,so-
cial, or spiritual aspects of well-being occurs
in the context of a personal and therapeu-
tic alliance directed toward common goals
by the people involved in a person-centred
relationship [66]. Such person-centred care
has been described as “of the person, by the
person, for the person, and with the per-
son” [66]. As a result, continuity of person-
centred assessment and care is crucial for
effective health outcomes. Person-centred
integrative diagnosis (PID) provides a
comprehensive biopsychosocial model that
includes illness categories in the context of
assessments of functioning and quality of
life, as well as risk and protective factors,
and the person’s health experience and val-
ues planning [67]. In this way, the person’s
own resources, habits, goals, and values can
are assessed so that both their strengths for
positive health and symptoms of ill-health
are considered jointly in treatment planning
[68]. When health care administrators treat
physicians as interchangeable parts, rather
than prioritizing continuity of care by the
same physician, much is lost in health out-
comes of both the recipients and providers
of care.
Need to Prioritize Person-
centered and People-
centered Values
Both health care and disease care
are necessary and complementary
A person is much more than their mate-
rial body: our health depends on our learn-
ing to take care of our individual self and
one another in families, communities, and
the world. Whereas the medical paradigm
popular in the West has usually emphasized
technological treatment of discrete diseases
by specialists,the medical paradigm popular
in the East has emphasized promotion of
health of whole person and prevention of
disease by person-centred generalists and
people-centred promotion of public health.
The technological approach emphasized
in the West has been excellent for specif-
ic injuries and diseases acutely, but it has
unfortunately been ineffective for health
promotion and disease prevention due to
underfunding of public priorities and em-
phasis on private profit.
These are actually complementary strate-
gies, but overall health promotion and dis-
ease prevention are more effective and ef-
ficient in improving health care than is the
specialized clinical care of multiple diseases
separately. Put another way, the shift to fo-
cus on separate diseases and specialization
in medical education has profited medical-
industrial alliances, but it has dehumanized
medicine by its failure to prioritize the well-
being of the whole person and of the com-
munity in health care [69]. Discrete disease
care has provided inadequate attention to
self-care, motivation of healthy lifestyle,
and the social determinants of health. Both
disease care and health care have their roles
Person-centered Medicine
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10
to play: disease care can be most helpful
when its foundation is person- and people-
centred health care.
Competition and cost control
are not effective approaches
to good health care.
When person-centred health care is not
understood and practised pervasively as the
foundation of medical practice,the benefits
of disease care become weak, inconsistent,
costly, and inefficient. Consequently, the
solution to the rising cost of the burden
of disease is not stricter business manage-
ment and competition in health care. In
fact, the inefficiency and dysfunction of
health care in developed countries in the
West currently is the result of applying
a model of health that is an extension of
the industrial business perspective to hu-
man health care. The Flexner report in the
USA in 1910 was funded by industrialists,
notably Andrew Carnegie and the Rock-
efellers. It emphasized biomedical reduc-
tionism in medical education and research
and has had the long-term effect of reduc-
ing person-centred communication and
caring for the well-being of patients [70].
Any model of human nature that ignores
humanistic and transpersonal sources of
satisfaction and value has proven to be in-
adequate to account for human evolution
[16] or the conditions in which health and
well-being flourish in individuals and na-
tions [28]. Specifically, it turns out that the
separatist view of human nature and func-
tioning is simply not appropriate scientifi-
cally for health care and is also doubtful
for the long-term prosperity of business
[71, 72]. Corporations that are recognized
as having the rights of a citizen also need
to accept the social duties of a citizen for
societies and their economies to flourish,
rather than focusing only on continuous
economic growth unrestrained by respect
for social justice. Socioeconomic inequity
consistently leads to the collapse of econo-
mies and societies, as is predicted for the
world by 2040 unless we thoroughly revise
the priorities of our socioeconomic [72,
73] and ecological [74, 75] policies.
Unfortunately, the proposed solution to ris-
ing costs from specialized disease care dur-
ing the 1980s was to bring in strict busi-
ness management to maximize profit and/
or to reduce costs, but these policies have
not proven to be beneficial. Business man-
agement, which adopted the profit policies
of business with little or no commitment to
social justice or personal well-being,was de-
signed to reduce the cost of health care, but
it has failed to do so [76, 77]. It has not only
failed to achieve its cost-control objectives
but has impaired the noble values and ide-
als of medicine because health care is much
more than running a profitable business or
implementing scientific knowledge with
no recognition or commitment to personal
creativity, freedom, and dignity or to social
justice and diversity [28, 70].
Furthermore, prioritizing profit over peo-
ple has been detrimental to the health of
both providers and recipients of health
care, and has led to high rates of burn-out
of providers (viz. 40 to 60%) and to dis-
satisfaction and distrust of patients along
with worse health outcomes when care
providers have too little time to know who
is being treated and what their life situ-
ations and values are [36, 37]. The burn-
out of health care professionals is due to
the monetization and dehumanization of
health care, as is also occurring in most
other societal institutions [78].
Person-centred medicine is the
foundation for effective health care
Therefore, we propose that the solution to
the current crises in health care is the recog-
nition that effective and sustainable health
care for the vast majority of disorders of
health needs to adopt a person-centred and
biopsychosocial approach that recognizes
the intrinsic dignity of every person and
the interdependence of the physical, men-
tal, social and spiritual aspects of well-be-
ing. The science of well-being is rigorously
documented now and reveals the serious
misconceptions and limitations of the dis-
crete disease paradigm of health care, which
prioritizes costly technological treatment of
the ills of unhealthy lifestyles and inequi-
table social conditions while neglecting the
actual causes of disease. Policies for educa-
tion and treatment are failing to provide for
the health care needs of people in ways that
are affordable, efficient, and effective in the
long term.
Call to action
Medicine is now in several interrelated
emergencies that are not sustainable: esca-
lating disease burden,weak and inconsistent
efficacy, burn-out of providers, and public
distrust and dissatisfaction. There is an ur-
gent need for change.
What we know now about the basis for
health and well-being calls for a shift in the
priorities of medicine around the world.We
need health care systems that are more eq-
uitably accessible, more effective in promot-
ing health and preventing disease, and less
costly. Priorities need to address the major
psychosocial determinants of health that
promote healthy longevity, rather than pri-
oritizing costly technologies for acute care
of dysfunctions that becomes chronic while
neglecting the psychosocial determinants of
health.
At the individual level, the health care envi-
ronment needs to be personalized and hu-
manized for all the providers and recipients
of care, rather than treating persons like
they were material robots and objects on an
automated assembly line. At the population
level, more recognition is needed about the
interdependence of diverse communities
around the world in order to reduce the
global burden of disease in ways that are eq-
uitable, efficient and effective.
Person-centered Medicine
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11
In summary, health care around the world
would benefit greatly if medicine as a profes-
sion were to declare decisively that its prima-
ry purpose to serve the health and well-being
of people can only be effectively addressed by
considering all the major biological, psycho-
logical,social,and ecological determinants of
health systematically. That priority of pur-
pose needs to be sustained and developed by
adopting universally shared values to achieve
that purpose. Then clinical units serving the
needs of communities need to drive the sys-
tem to fulfil their purpose in unison with
other components of an integrated system
of universal health care.The role of manage-
ment is to support the fulfilment of this pri-
ority as a facilitative component of a diverse
and multifaceted system, no central bureau-
cratic control for extraneous goals of profit
and politics that interfere with the autonomy
needed by medical experts for flexible day-
to-day functioning to address diverse needs
of individuals and local communities in a
person-centred manner [79].
Much needs to be weighed in order to act
quickly and prudently about how to make
transitions that are needed in education,
clinical practice, administration, and fund-
ing priorities. The current paradigm of
discrete diseases is outmoded, and the ra-
tionale for prioritizing disease care over
person- and people-centred health care is
invalid, harmful, and inefficient. Denial and
procrastination about the inadequacies of
current priorities in health care policies are
no longer sustainable – medicine through-
out the world needs to recognize that health
care is primarily a complex and creative
adaptive process of self-care, health promo-
tion, and disease prevention, not a clinically
managed multitude of chronic discrete dis-
eases. People and communities can improve
their health most effectively and efficiently
by individuals learning how to live healthy,
happy and good lives – that is, lives that
serve the health and happiness of others,
not just themselves. This is a lesson we are
all learning and need to share with those
willing to listen and take action.
Acknowledgements
This article is based on a presentation by
the authors at the 13th Geneva Confer-
ence on Person-Centered Medicine on
Self-Care and Well-being in the Times of
­
COVID-19, 5–7 April 2021 held virtually
with partial WMA sponsorship.
The work reviewed here was supported
in part by NIH grant R01 AA023540 to
Dr. Salloum.
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C. Robert Cloninger, MD, PhD
Professor Emeritus of Psychiatry,
Washington University Medical School,
St. Louis, MO, USA
E-mail: crcloninger44@gmail.com
James Appleyard, MD
Former President of World
Medical Association and
International College of Person-
centered Medicine (ICPCM);
Former Consultant Pediatrician, Kent and
Canterbury Hospital, Canterbury, UK
Juan E. Mezzich, MD, PhD
Secretary-General, ICPCM;
Former President of the World
Psychiatric Association
Professor of Psychiatry, Icahn School of
Medicine at Mount Sinai, New York, USA
Ihsan Salloum, MD
President, ICPCM;
Professor and Chair, Department
of Neuroscience, University of
Texas at Rio Grande
Valley, Harlingen, TX, USA
Jon Snaedal, MD
Past President of World Medical
Association and ICPCM;
Professor of Geriatric Medicine,
Landspitali University Hospital,
Reykjavik, Iceland
A humanistic and integrative response to
the limitations and challenges of contem-
porary medicine is being offered by the
programmatic movement built by the In-
ternational College of Person Centered
Medicine (ICPCM) in collaboration with
a large number of global health institutions
[1]. Initial steps from 2005 to 2008 took
place at the World Psychiatric Association
(WPA) in the form of an Institutional Pro-
gram on Psychiatry for the Person [2, 3]. Since
2008 to date, it is being extended to medi-
cine and health at large and has matured
concepts and procedures through annual
Geneva Conferences. In these conferences,
each receiving valuable support from the
World Medical Association (WMA), per-
son centered medicine has been addressed
Self-Care, Inter-Care and Wellbeing in ­
COVID-19 Times at the 13th
Geneva Conference on Person Centered Medicine
Juan E. Mezzich Jon Snaedal
Person-centered Medicine
BACK TO CONTENTS
14
from various thematic perspectives followed
by publication of a declaration on respec-
tive themes. In addition, since 2013 Inter-
national Congresses on person centered
medicine have been held across the world,
including Zagreb, Buenos Aires, London,
Madrid, New Delhi, Tokyo, Montevideo
and Kuwait.
These declarations, published on the web-
site of the College [4] involve placing the
person in context as the center of the con-
cept of health and the goal of health actions,
and proposing clinical care as informed by
evidence, experience and values [5]. It also
involves the empowerment (rights and du-
ties) of persons to care for their own health
and that of others in the community.
An innovative and virtual 13th
Geneva
Conference on Person Centered Medicine,
Self-Care, and Well-Being in Pandemic Times
was held on 5-7 April 2021. The program
designed by Robert Cloninger, Professor
of Psychiatry and Genetics at Washington
University, St Louis, and Austen El-Osta,
Director of the Self-Care Academic Re-
search Unit (SCARU) at Imperial Col-
lege, London covered the main theme of
the event through five symposia as follows:
General Health Strategies, Self-Care &
Person-centeredness in Pandemic Times,
Self-Care Measurement and Determinants,
Concepts of Well-being and Self-Care
amid Social Disruption, Self-Care & Well-
Being in Contemporary Society and across
the Life Cycle; and the Role of Public
Health Systems & Professional Organiza-
tions in Self-care and Health Promotion in
Pandemic Times.
The program also included four panels. One
Panel on Advances on Mental Health dis-
cussed person centered psychiatry and the
World Psychiatric Association Action Plan
2020-2023; disasters and mental health,
person centered clinical care and medical
education in Latin America, how herme-
neutics may promote person centered men-
tal health in pandemic times, the pandemic
impact on LIMIC mental health, coping
with death and anxiety as an ICU psychia-
trist and, community development, person-
centered medicine and women’s mental
health among other interesting presenta-
tions.
A second Panel on Advances in Gen-
eral Practice covered: The urgent need for
people centered primary care  – the case
of ­
COVID-19 in Bolivia; Critical gaps in
understanding people-centered care Les-
sons from the pandemic in Mexico; Latin-
American perspectives on self-care and
well-being in pandemic times, among oth-
ers.
The third Panel on Public Health included
presentations on Contributions of a Na-
tional Primary Care Registry to People-
centered Public Health; Person-centered
approach to non-communicable diseases in
pandemic times; Global health security &
pandemic preparedness; Age in times of a
Pandemic: Some population centered public
health aspects; Experience with person cen-
tered medicine for the education of medi-
cal students; Fostering Person-­
Centered
­
Medicine in Times of ­
COVID-19: The
Uruguayan Experience; and Social deter-
minants of health in Latin America during
pandemic times.
The fourth Panel on Person-Centered
Nursing in Pandemic Times included pre-
sentations on Impact of ­
COVID-19 on
nurses and person centered nursing; The
duty to care dilemma and the psychologi-
cal well-being among nurses in pandemic
times: Preliminary findings from a cross-
sectional study in Chile and Spain; Public
health measures in Community Centers in
the face of the ­
COVID-19 pandemic; As-
pects of work of recent years and reflections
on self-care and the pandemic in Norway.
The program also included a session on
Brief Oral Presentations. The topics cov-
ered were: The origins of Médecine de la
Personne: Tournier’s legacy; Virtual Envi-
ronment as a Factor of Adaptation in the
Face of Social Constraints; Integrating
self-care into mainstream health service;
Art and Literature as Therapy for Healing
and Health Promotion; Quality Circles  –
Learning processes of participants and the
potential for strengthening the work in self-
help groups; Self-Care and wellbeing in
older persons during pandemic times; and
Self-Care and wellbeing in families during
­COVID-19.
At the ICPCM General Assembly, Ih-
san Salloum (WPA Classification Section
Chair) was elected President. An important
session was dedicated to the Paul Tourni-
er Prize, a yearly award supported by the
Person-centered Medicine
BACK TO CONTENTS
15
­
ICPCM and the Paul Tournier Foundation
to recognize academics who had made major
contribution to Person Centered Medicine
internationally. The Paul Tournier Prize for
2020 was presented to George Christodou-
lou and John Cox, and that for 2021 to Jim
Appleyard. In order to extend the impact of
the conference, a 2021 Geneva Declaration
on Self-Care,Inter-Care and Well-Being in
Pandemic Times was issued. It is displayed
in full here.
Geneva Declaration 2021
On Self-Care, Inter-Care
and Well-Being in
Pandemic Times
Emerging from the 13th
Geneva Conference
on Person Centered Medicine organized as a
virtual event on 5-7 April 2021 by the Inter-
national College of Person-Centered Medicine
(ICPCM) in collaboration with the World
Medical Association, the International Council
of Nurses, and the Pan-American Health Or-
ganization.
Considering
1. That person centered medicine (PCM)
focuses on the health, needs and values
of the whole person in their context.
People-centered healthcare extends the
concept to individuals, families, com-
munities and society as a whole, thus
shaping the health of a person through
shared determinants and social inter-
connectedness, making both concepts
complementary.
2. That health is a state of complete physi-
cal, mental and social well-being and
not merely the absence of disease or in-
firmity as affirmed in the WHO Con-
stitution. This cannot be achieved by
governments, the healthcare system and
healthcare professionals without the full
involvement of all in the community as
proclaimed in the Alma Ata Declara-
tion: (Integral care of all by all), and in
the ICPCM Montevideo Declaration
2020 (Persons-centered integral health
care). Consideration of other general
social sectors is fundamental in order
to attend to the social determinants of
health and the UN Sustainable Devel-
opment Goals.
3. That the dignity and responsibility of
each person implies that individuals
have the right to health and the duty to
participate individually and collectively
in the planning and implementation of
self-care and care for each other in vari-
ous contexts including health promo-
tion, disease prevention, health restora-
tion and palliative care.
4. That promotion of PCM, self-care and
inter-care can effectively improve the
quality of life of individuals and the
wellbeing of communities. While Self-
Care implies the cultivation of healthy
lifestyles,avoidance of risk,maintenance
of mental well-being, strengthening of
health literacy, and the rational and re-
sponsible use of professional healthcare
professionals, products and services;
Inter-care extends the concept to the
interconnectedness of the self with oth-
ers by way of their capacity to care for
each other related to patients, families,
the health and social care workforce, the
wider community and the environment
at large, connecting to the collective
wisdom of ancient cultures.
5. That self-care and inter-care within a
health framework that involves the gov-
ernment and all stakeholders, can ben-
efit from multisector support on train-
ing and properly evaluated procedures,
medication and technology.
6. That the progressive monetization and
dehumanization of society’s institutions
including those actors and organiza-
tions that constitute the medical infra-
structure is undesirable and counters the
public interest. Medicine as a field has
been commercialized and prioritizes a
biomedical individual disease focused
approach to the exclusion of other ap-
proaches, including a whole person-
centered approach that seeks to pro-
mote and preserve the health of persons
and the general public in a humanistic
and equitable manner.
7. That the response to the ­
COVID-19
pandemic has highlighted an imbal-
ance between how funding is priori-
tized for medical-industrial complexes
(technology) to the detriment of public
health infrastructure (services), leading
to widespread burn-out in healthcare
providers and the erosion of trust. This
demonstrates the need for well-inte-
grated, balanced and resilient healthcare
systems with humanistically-oriented,
scientifically informed and competent
governments, able to adapt the public
health systems to evolving needs and to
hold the health industry to account in
promoting effective self-care and inter-
care policies.
8. That the pandemic exacerbated health
inequity caused by socio-economic and
ethnic disparities.This calls for the wider
implementation of people-centered care
that is culturally informed and promotes
solidarity, equity and social justice.
9. That the actual broadening of epide-
miological concerns highlighted by
the pandemic encompasses non-com-
municable and communicable diseases,
multi-morbidity, mental health chal-
lenges, their interactions and syndemic
complexity, all of which reinforces the
importance of championing compre-
hensive, integrated and people-cen-
tered healthcare.
10. That the International College of Per-
son-Centered Medicine, through its
Geneva Conference and International
Congress Declarations – and those of
the Latin American Network of Per-
son-Centered Medicine in collabora-
tion with the Pan-American Health
Organization- has proposed person-
centered paradigmatic health concepts
and procedures, articulating science
and humanism to address broad health
challenges including the current pan-
demic.
Person-centered Medicine
BACK TO CONTENTS
16
We call for
1. Health policies, services and actions
that include person- and people-cen-
tered self-care and inter-care practices
aimed at promoting individual and col-
lective well-being.
2. Educating people about health and
its determinants and providing them
with reliable and unbiased informa-
tion and training to promote self-care
and inter-care encompassing a wide
range of person-centered activities. This
­
includes enhancing people’s awareness
of the Seven Pillars of Self-Care and the
emergent concept of inter-care.
3. Examining the relationship between
people’s health and their environment
and the need to support them through
well thought-out economic and social
development policies that incorporate
person-centered self-care and inter-care
policies and practices.
4. Broadly engaging all societal institu-
tions to affirm healthcare as a human
right and to uphold humanism in
medicine. This involves the account-
ability of governments, health systems,
health care professionals, health indus-
try and the community at large in or-
der to conduct and attain fully ethical
health care.
5. The rededication of health systems
and public health infrastructure to
address the social determinants of
health and to attain the Sustain-
able Development Goals promoting
health equity. These are fundamental
requirements to activate self-care and
inter-care, and to promote well-being,
particularly when facing pandemics
and other disasters.
6. Building public health and educational
structures to effectively promote social
trust, social justice and social equity to
support both the mental and physical
health and well-being of informed, self-
aware and empowered communities.
7. Empowering people to become active in
the development and monitoring of the
proposed innovative health services and
policies as well as creative protagonists
of their own health. The latter would
involve awakening individual and com-
munity self-awareness, self-reliance and
inter-care solidarity that may enhance
the quality of life for all in a way that
is congruent with personal and commu-
nity goals and values.
8. Promoting cooperative international
leadership to coordinate cohesive global
responses to pandemics and to address
the underlying causes of failure in many
countries to strengthen their health sys-
tems and policies, and to attend to the
needs of the general population with
dedicated efforts to support margin-
alized communities. This should lead
to the activation of mechanisms that
promote and accelerate universal access
to vaccines and other effective public
health measures.
9. Examining and documenting through
pertinent workgroups the fundamental
relationships between self-care, inter-
care, well-being and person-centered
integral healthcare in response to the
challenges of the ­COVID-19 pandemic.
10. Committing the International College
of Person-Centered Medicine to up-
holding and fulfilling the above recom-
mendations in collaboration with like-
minded groups and institutions.
As Conclusion, one could say that the 13th
Geneva Conference on Person Centered
Medicine was quite successful in terms of
the interest of its themes and the quality
of its presentations as well as because of its
virtual format, imposed by the ­
COVID-19
Pandemic, which allowed the participation
of speakers and audience from across the
world.
References
1. Mezzich JE, Snaedal J, van Weel C, Heath I:
The International Network for Person-centered
Medicine: Background and First Steps. World
Medical Journal 55: 104-107, 2009.
2. Mezzich JE: Psychiatry for the Person: Ar-
ticulating Medicine’s Science and Humanism.
World Psychiatry, 6: 65-67, 2007
3. Christodoulou G.,Fulford B.,Mezzich JE.: Psy-
chiatry for the Person and its Conceptual Bases.
International Psychiatry, 5: 1-3, 2008
4. https://www.personcenteredmedicine.org/
5. Mezzich JE, Snaedal J, van Weel C, Heath I:
Toward Person-centered Medicine: From dis-
ease to patient to person. Mount Sinai Journal
of Medicine 77: 304-306, 2010.
Juan E. Mezzich, MD PhD,
Professor of Psychiatry, Icahn School of
Medicine at Mount Sinai, New York;
President 2005-2008, World Psychiatric
Association; President 2008-2013 and
Secretary General 2013- , International
College of Person Centered Medicine
Jon Snaedal, MD,
Professor of Geriatric Medicine, Landspitali
University Hospital, Reykjavik;
President 2007-2008, World
Medical Association; President
2017-2021, International College
of Person Centered Medicine
Person-centered Medicine
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17
Covid-19 Pandemic
The Swine flu of 2009 revealed major
deficits in Norwegian pandemic pre-
paredness. Since then, despite several
evaluations and studies, little progress
has been made in rectifying the serious
shortcomings revealed. Influenza epi-
demics of varying degrees of severity have
repeatedly reminded us of the potential
consequences a pandemic could have on
societies and health services as demon-
strated by the Asian flu of 1956 to 1958
and the Hong Kong flu of 1968 to 1970.
Outbreaks in recent decades have also
provided warnings; the Bird flu of 1997,
Sars in 2002-2003, the Swine flu of 2009
and the MERS outbreak of 2012.
The experience in Norway seems to indi-
cate that the necessity of good levels of pre-
paredness is “forgotten” after an event. The
evaluations and studies of the 2009- pan-
demic indicated a lack of:
• Intensive care units
• Stockpiles of personal protective equip-
ment
• Medical technical equipment
• Registers on critical equipment
• Plans on how to rapidly increase the
overall capacity
• A joint national system of contact trac-
ing
• Plans for the operation of testing stations
and contact tracing
• Plans and tools for the identification of
and vaccination of vulnerable groups.
• A comprehensive database of contact de-
tails for general practitioners and local
public health officers
The same deficiencies have been witnessed
during the Covid-19 pandemic.
While we may now see signs of the current
pandemic receding, we need to start prepar-
ing for the next.
The NMA’s evaluation [1], published April
2021, is based on descriptions and input
from its members and officials who have
been at the front line of the pandemic. In
this article, to a large extent based on the
Norwegian Medical Association’s evalua-
tion of the first year of the Covid-19 pan-
demic, we will describe the Norwegian ap-
proach and key learning points from the
period.
We will try and identify key failings and key
success factors, ending with some general
perspectives on factors that have benefited
Norway in its attempts to manage the pan-
demic.
The message from the Norwegian medical
experts is that despite failing to maintain an
adequate level of preparedness in the hospi-
tal sector, lacking a systematic preparedness
at the municipal level, a failure to secure
adequate stockpiles and secure supply lines
of personal protective equipment and other
essential materials, during the Covid-19
pandemic, Norway has experienced lower-
than-normal mortality, no breakdown of
the health care system, a remarkably high
level of vaccine acceptance and maintained
levels of trust in the political system. This
outcome is due to an interesting mix of ef-
fective governance from national politicians
and health care officials, an extraordinary
mobilisation of resources in the health care
service, a high level of trust in the popula-
tion and an extraordinary effort by local
health officers. Such a combination of fac-
tors cannot be counted on for the next pan-
demic.
What happened – Timeline
February 2020 via three waves
to end of summer 2021
February 26, 2020, the national broad-
caster in Norway reported the first case
of ­
COVID-19 in the country [2]. Subse-
quent weeks would see rising figures, one
of the main sources would be travellers
returning from a winter vacation in Eu-
rope. On March 12, after increasing public
pressure – and following the example from
Denmark- the government implemented
the strongest restrictions on personal free-
dom in peacetime, albeit stopping short of
curfew. Schools and kindergartens were
closed with exemptions for the children
of key workers. The government recom-
mended teleworking for all who were able
to. Travel on public transport was discour-
aged, in order to make this a safe option
for key workers, travel abroad was banned
for health personnel, quarantine was intro-
duced for people having been abroad in the
previous 14 days, etc.
Marit Hermansen
COVID-19 the Need to Act, to Learn and to Prepare – Lessons for
the Next Pandemic – the Experience of Norway
NORWAY
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18
Covid-19 Pandemic
This first phase saw shortages in personal
protective equipment in hospitals, elderly
care institutions and primary health care.
Furthermore, it soon became clear that the
country’s intensive care capacity became
stretched, even at the very low levels of
infection witnessed during the first wave.
Test capacity was also low, with strong rec-
ommendations to only seek testing if the
person was symptomatic. The low capacity
stemmed from a lack of test kits, poorly de-
veloped systems to analyse tests and poorly
developed systems to register and log posi-
tive tests.
The infection numbers declined soon, and
in early May, schools and kindergartens
were back in operation, alongside many
commercial services. The situation seemed
under control until late summer, when
isolated outbreaks connected with e.g.,
weddings, industries employing migrant
workers were reported. Late October, the
second wave struck, and stronger measures
were again introduced – although less re-
strictive than the first wave. Oslo saw these
restrictions being lifted only toward the
summer of 2021 – having gone through a
third wave. At the time of writing  – the
situation seems again to be partially under
control, with a very strong level of vaccine
acceptance in the populace and while the
delta variant – the variant of current con-
cern – is dominant, and infection numbers
are rising – the situation seems to be under
control [3].
Primary health care
service as the front line
In the Norwegian experience, a well-devel-
oped primary health care system composed
of general practitioners and specialists in
community medicine is a prerequisite to
effectively deal with the current and future
pandemics [1].
One of the key success factors in the man-
agement of the first and second waves of
the pandemic has been a strong, well-func-
tioning primary health care service. The or-
ganisation at the municipal level of testing,
isolation,contact tracing and quarantine has
clearly reduced the pressure on hospital ca-
pacity.
This approach has however highlighted
other bottlenecks in the system such as
the lack of efficient ICT tools for com-
munication between local health officers
and central health authorities, making
coordinated efforts more demanding and
time-intensive. A system relying on pri-
mary health services to the extent seen in
Norway needs, in the opinion of the Nor-
wegian Medical Association, to be more
resilient.
Factors to achieve this would include a
more central role of local public health of-
ficers in the management structure of the
municipalities, strengthened capacities of
the local public health officer function and
reducing the reliance on individuals.
Hospitals with sub­
optimal capacities
As the first infections in Norway appeared
in February 2020, it became clear that no
hospitals in Norway were adequately pre-
pared for such a situation.The first phase of
the pandemic showed that Norwegian hos-
pitals are still poorly equipped to handle a
major pandemic [1].
Over the course of the previous decades,the
number of hospital beds and Intensive care
units has been reduced. The stockpiles built
up after the Swine flu of 2009 were done
away with, and new stockpiles of equip-
ment necessary in a pandemic were not es-
tablished.
Several reports since the year 2000 have
indicated the lack of concrete plans, of re-
sources (e.g., respirators), of exercises of
supply security and of other equipment.
Norwegian hospitals were despite these
shortcomings not overrun by Covid-pa-
tients during the first wave of the pandemic
in the spring of 2020. The main reason is
the very low levels of infection and disease
compared to many other countries. The ca-
pacity of hospitals was not exceeded, hospi-
tals did not run out of personal protective
equipment and testing capacities were un-
der less stress than in many countries. The
Government’s decision to close most public
activities, including schools and kindergar-
tens, is believed to have had a decisive effect
on limiting the extent of infections. Deci-
sions to put many elective procedures on
hold as well as the well-developed primary
health care system mentioned above fur-
thermore contributed to reducing the strain
on hospitals.
Had the government’s response been less
resolute, or implemented at a later stage,
it is believed that Norwegian hospitals
would have found it difficult to manage
the situation without serious negative con-
sequences.
Communication as key
The pandemic has underlined the need
to invest in more effective tools for com-
munication that may be adapted to dif-
ferent situations. Digital communication
platforms have allowed large parts of the
workforce to telework, freeing up public
transport capacity and making it easier to
maintain distance. We have also seen how
many meetings may just as well be carried
out via online platforms instead of face to
face.
Experience with e-consultations indicates
that more consultations can be carried out
online. Knowledge on patient outcomes
is however lacking, and the physician will
always need to consider on a case-by-case
basis whether e-consultations maintain
patients’ safety and efficient operations. It
is also clear that certain specialities lend
NORWAY
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19
Covid-19 Pandemic
themselves more easily to e-consultations
than others.
While Norway, in general, is characterised
by high penetration of digital public servic-
es, strong and reliable internet connections
and a high degree of computer literacy in
the population,the pandemic has illustrated
how many key systems fail to communicate
with each other appropriately [1].
This situation often leads to the physician
resorting to pen and paper and regular mail
as the interface between systems, rather
than logging into several separate systems
in order to punch the same information
multiple times.
Similarly, we have witnessed how impor-
tant it would be for the authorities to have
an overview of contact details for the local
public health officers in case there is a need
to communicate contact tracing efforts, test
results and the need to introduce quarantine
and isolation.
A contact tracing app was developed by the
Norwegian Institute for Public health but
was suspended due to data protection issues.
Improving these shortcomings, the app was
later reintroduced – but failed to generate
sufficient use to be an effective tool. Such
tools would also necessitate enough test-
ing  – which was not in place until later
stages in the pandemic.
A very high vaccine acceptance
As vaccines were being developed and ap-
proved, the national authorities entered
into cooperation agreements with the EU
on vaccine deliveries. As a result, the ar-
rival of vaccines mirrored the situation
in EU member states. A national vaccine
programme was instituted, with geographi-
cal distribution according to the distribu-
tion of priority groups. The main target
of the programme was to reduce mortal-
ity. The vaccines employed during the first
phase of the programme were from Pfizer/­
BioNTech, Moderna and Astra Zeneca.
The programme has been designed by the
National Institute of Public Health [4]
and implemented by municipal authori-
ties. High-quality public registries and high
penetration of digital communication tools
in the populace has allowed for a strongly
structured queue system, where the individ-
ual citizen is contacted directly and offered
a vaccine appointment at a clinic close to his
or her residency.
In March, cases were reported of deaths as-
sociated with the Astra Zeneca. According
to a report published in the New England
Journal of Medicine [5], by researchers at
the Rikshospitalet in Oslo, the case histo-
ries of the first five deaths reported, indi-
cated a powerful immune system response
as causing thromboembolic events. Follow-
ing these cases associated with the Astra
Zeneca vaccine, and similar cases reported
from other countries, associated with the
Janssen vaccine, the health authorities de-
cided to remove these vaccines from the
national vaccine programme. The Janssen
vaccine was further assessed, and decided
to be offered on a voluntary basis, but with
strict criteria. The Norwegian Medical As-
sociation has strongly advised its members
not to administer this vaccine, due to the
potential risks associated with it, and the
conclusion that the risk of, in Norway at
the time being, of severe side effects from
this vaccine, is greater than the risk of se-
vere Covid-illness.
At the time of writing, the acceptance
levels of the vaccines against ­
COVID-19
are exceptionally high, reaching 98 % of
certain cohorts. While there are indica-
tions that the acceptance rate is unequal
in different groups of the population – the
data is very promising. It could be argued
that this is indicative of a very high level of
trust in authorities, also reported in other
instances [6]. Current projections indicate
that the vaccine acceptance rates will be
above 90 percent of the target groups by
the end of October (all citizens above the
age of 18).
Levels of trust – a resource
not to be squandered
According to an article from Statistics
Norway [6], Norwegians, and Nordic citi-
zens generally have a high degree of trust
in different political institutions. This high
level of trust has been expressed during
the current pandemic as well. There has
generally been a high degree of accep-
tance of the measures adopted, and while
the measures introduced to increase social
distancing has been moderate compared to
some countries, evidence from e.g., mobile
phone networks indicate that they have
been quite effective in reducing the mobil-
ity of the populace.
As in most countries, there have been ex-
amples of protests against the restrictions,
against the use of face masks and other poli-
cies implemented.A most disagreement has
however been challenged through public
debate and professional discourse on the ef-
fectiveness and the need for different mea-
sures, differences in professional opinion on
the modalities of the vaccine programme,
etc.
We would argue that the level of trust in
our population to a large degree stem from
a well-functioning public sector, with uni-
versal health coverage and similar service
level provision to all groups in society. We
would also argue that such a level of trust
is a vital resource for the authorities but
also for the health care service. It means
that less resources are required to ensure
compliance with medical advice. It means
that the population is responsive to con-
tact tracing and, in most cases accept rules
on quarantine and isolation. It also seems
to translate into a very high level of vac-
cine acceptance without the need to offer
incentives beyond the protection against
disease.
NORWAY
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20
Covid-19 Pandemic
The role of the Norwegian
Medical Association
The Norwegian Medical Association has
traditionally maintained strong cooperation
with health authorities, not least in terms of
channelling professional medical advice to
policymakers. During the first phases of the
pandemic, as the health care services of sev-
eral countries became stretched beyond ca-
pacity, it became clear that guidelines were
needed to assist prioritization within differ-
ent specialities and patient groups.Through
its colleges, the Norwegian Medical Asso-
ciation, therefore, compiled comprehensive
advice on which treatments to prioritize
should resource become stretched [7].
The Journal of the Norwegian Medical As-
sociation [8] took early measures to invite
physicians to present Covid-19 case de-
scriptions in order to facilitate rapid dis-
semination of the rapidly increasing knowl-
edge on the virus.
Furthermore, several webinars were organ-
ised where physicians from different parts
of the country exchanged experiences
The Association furthermore took measures
to facilitate members’ ongoing work during
the pandemic  – negotiating special rates
and compensation schemes for physicians
needing to work beyond normal working
hours and for physicians losing income due
to quarantine and other restrictions. The
Association of General Practitioners and
the College of General Practice established
a task force to provide professional advice to
general practitioners,to share practical solu-
tions to prioritise capacity at the local level
and to negotiate compensation schemes for
general practitioners who had to quarantine
or isolate due to Covid-19.
Ethics in a pandemic
Despite our efforts to continually update
our ethical considerations, a new crisis will
bring new ethical dilemmas. Some of these
dilemmas pertain to society at large, others
to us as a medical profession with responsi-
bility for all our patients.
During this pandemic, we have seen civil
liberties constrained in order to control
infection rates. The closing of services
and maintenance of social distance has
and will carry costs to individuals and
society. We expect that rates of depres-
sion and feelings of isolation will rise.
We fear children needing support have
received less than needed, exacerbating
their situation.
When treatment capacities are under strain,
we need to be prepared to prioritise and tri-
age. We found that engaging with our col-
leges to identify key priorities for treatment
was a valuable exercise that we will find a
use for also in the future.
A pandemic shows us the necessity to think
globally, and to act both locally and globally.
We need to consider the balance between
caring for our own populations and striving
for global solidarity. In an interconnected
world, we cannot defeat a pandemic with
national measures only. Discussions in the
Medical Ethics Committee of the World
Medical Association will surely reflect this
in the years to come.
COVID-19 has shown us again how vul-
nerable our societies are to new diseases.
We believe that a fundamental lesson
learned is that we need to strengthen pre-
paredness for new diseases. It is time to put
health first.
References
1. The Norwegian Medical Association, 2021,
­
COVID-19 Underveisrapport– Berettelsen om
en varslet katastrofe, Oslo, available at: legefore-
ningens-underveisrapport-om-covid-19.pdf
2. Kolberg M., Vestrum Olsson S., Elster K., Lote
P.A., Mjaaland O., Åsali S., Første tilfelle av ko-
ronasmitte i Norge [Internet, Nrk.no, 26. febru-
ary 2020 [updated 27 february 2020]; accessed
12 August 2021, available at: Første tilfelle av
koronasmitte i Norge – NRK Norge – Oversikt
over nyheter fra ulike deler av landet
3. Norwegian Institute of Public Health,
­
COVID-19 Ukerapport uke 31 [Internet],
Folkehelseinstituttet, 11 August 2021, accessed
12. August 2021, available at: Situasjonsrapport
­COVID-19 (fhi.no)
4. Norwegian Institute of Public Health, Korona-
vaksinasjonsprogrammet [Internet}, Folkehel-
seinstituttet, accessed 12. August 2021, available
at: Koronavaksinasjonsprogrammet – FHI
5. Schultz NH,Sørvoll IH,Michelsen AE,Munthe
LA, Lund-Johansen F, Ahlen MT, Wiedmann
M, Aamodt AH, Skattør TH, Tjønnfjord GE,
Holme PA. Thrombosis and Thrombocytopenia
after ChAdOx1 nCoV‑19 Vaccination. N Engl
J Med. 2021 Jun 3;384(22):2124-2130. doi:
10.1056/NEJMoa2104882. Epub 2021 Apr 9.
PMID: 33835768; PMCID: PMC8112568.
6. Øyvin K., Nordmenn på tillitstoppen i Europa
[Internet], Oslo, Statistisk Sentralbyrå, 15 June
2016, accessed 12 August 2021, available at:
https://www.ssb.no/kultur-og-fritid/artikler-
og-publikasjoner/_attachment/269579?_
ts=1555305a1f0
7. Legeforeningens fagmedisinske foreninger har
laget prioriteringsråd i forbindelse med koro-
navirus-epidemien [Internet], The Norwegian
Medical Association, accessed 12 August 2021,
available at: Legeforeningens fagmedisinske
foreninger har laget prioriteringsråd i forbindel-
se med koronavirus-epidemien
8. Texts relevant to covid-19, Tidsskriftet for den
norske Legeforening (Journal of the Norwegian
Medical Association), accessed 12 August 2021,
available at: Søk | Tidsskrift for Den norske
legeforening (tidsskriftet.no)
Marit Hermansen,
WMA Chair of the Medical Ethics Committee
Norwegian Medical Association
NORWAY
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21
Covid-19 Pandemic
The population of Finland is 5,5 million.
• Reported cases in total: 114,281
–
– 700-1100 new cases daily in August –
mostly delta-variant
• Tested samples in total approx. 6,105,900
• Cumulative number of deaths associated
with the disease: 995
• Number of patients in specialised medical
care wards: 50
• Number of patients in primary healthcare
wards: 14
• Number of patients in intensive care: 19
• 67% of the population have received their
first vaccination
• 39% of the population have received their
second vaccination
• Vaccination for 12-15-year-old children
started in August, just before schools
opened after the summer holidays
Source: Finnish institute for health and welfare https://thl.
fi/en/web/thlfi-en
COVID-19 pandemic has affected whole
society for 18 months as offices changed
to remote work, theatres, cinemas, concert
halls, swimming halls, health clubs were
closed and even secondary and technical
schools, as well as universities, went virtual.
Many restaurants were closed or the open-
ing hours were strictly limited. In March
2020 also the southern part of Finland
(capital region) was isolated from the rest of
the country because the virus was spreading
so rapidly. I must say it was most peculiar
to see roadblocks and police guards assisted
with soldiers on the border of our southern
province. When lockdown and summer-
time slowed down epidemy this isolation
was cancelled after a couple of months.
I must say that I never could have imagined
seeing roadblocks and soldiers between
Helsinki and my hometown in peacetime.
Maybe that shows that we are at war – really
fighting – against this virus.
Also travelling to and from abroad stopped –
as in many other countries. There was a
heated discussion about the fundamental
rights of citizens – because according to our
constitution every citizen has the right to
leave the country as well as to come back
home. There was also great concern about
the ­
COVID-19 epidemy in our neighbour
countries: Estonia, Sweden and Russia.
All through this epidemy, our health care
system has been under pressure and inten-
sive care units and infection departments
have worked hard. Doctors and nurses are
rather tired but we have managed to take
care of all the COVID-19 patients. Instead
waiting times for surgery and diagnostics
have lengthened. Especially in primary
care, we have problems as so many nurses,
dentists and doctors have been trans-
ferred to do infection tracking or vaccina-
tion. Now we have a new word in Finnish:
­
HOITOVELKA, which translates to treat-
ment debt. So the concern is rising, if we are
getting more health problems because of
this overload/lock-down and mental, social
problems get worse and diagnosis for seri-
ous diseases may be delayed.
At the moment it looks like the fourth wave
of this pandemic is rising in Finland, so we
are competing with vaccination against this
virus.
Lately, there has been activity in social me-
dia against vaccination and also a denial of
the whole pandemic – different conspiracy
theories like Qanon and unfortunately also
campaigning in Instagram and TikTok to
convince children not to take the vaccina-
tion. Also, some dissident physicians are
spreading fake news and disinformation.
In Finnish Medical Association we are very
proud of our members  – how hard they
have worked and also how rapidly scientists,
medical researchers all over the world have
been able to develop treatment and several
vaccines against this virus. This truly proves
the importance of international co-opera-
tion in medical research.
Kati Myllymäki,
MD, Specialist in general practice
CEO, Finnish Medical Association
E-mail: kati.myllymaki@laakariliitto.fi
Kati Myllymäki
The Coronavirus situation in Finland in brief
(11th
of August, 2021)
FINLAND
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22
Covid-19 Pandemic
For more than a hundred years no world-
wide pestilence has affected the world as
much as the ­
COVID-19 pandemic. More
than 180 million people were infected
worldwide and millions had to have cared
for acute, severe ­
COVID-19 disease. Of-
ficial numbers document that close to 4
million people have died, and it is not
yet over. Switzerland, like most other
countries, has been much affected by
­
COVID-19. Consequences for individu-
als, society and life in general since Febru-
ary 2020 have been enormous. This article
highlights the main aspects and speci-
ficities of the acute medicine response in
Switzerland during the ­
COVID-19 pan-
demic.
As of June 2021, Switzerland has docu-
mented over 700’000 confirmed SARS-
CoV-2-infections. Almost 30’000 patients
with ­
COVID-19 were hospitalised since
February 2020 during the entire epidemic
and 10’315 individuals have died from
­
COVID-19. Switzerland has one of the
most advanced healthcare systems world-
wide. Over 150 acute care hospitals are dis-
tributed throughout the country, with five
University Hospitals and 9 larger Cantonal
Hospitals (> 500 beds) as the main pillars
of acute medicine. Switzerland is built up
by 26 Cantons corresponding to States in
other countries. In a normal situation, the
health care system is mostly organized at
the cantonal level, within the legal frame-
work of federal laws and regulations. In ad-
dition, Switzerland is characterized by four
language regions (German, French, Italian,
Reto-romanic), with significant cultural
differences.
Since February 2020, hospitalization num-
bers strongly reflected the epidemiologi-
cal situation, with the typical delay of one
to several weeks between an increase in
population cases followed by hospital and
intensive care admissions and deaths. Vice
versa numbers of infected patients who had
to be hospitalized decreased quickly after
strengthening measures against the spread
of the virus. Peak values were observed dur-
ing the first wave on March 23rd
2020 with
1’321 new daily cases and in fall with peak
values on November 2nd
2020 with 21’926
new daily cases especially in the French-
speaking part of Switzerland. Hospitalisa-
tion numbers in particular in intensive care
units were very high and at the very limit
of hospital capacities, in particular in the
French and Southern part of Switzerland
during the first wave and in the German
part of Switzerland during the second wave.
At the peak of the 2nd
wave, on November
16th
2020, 3’787 ­
COVID-19 patients were
hospitalized, with over 900 ICU patients at
this time.
Very rapidly early in 2020, many profes-
sional societies issued guidelines for the
management of ­
COVID-19 patients. This
was particularly the case for the Swiss So-
cieties of Intensive Medicine, Infectious
Diseases and Internal Medicine, who con-
tributed to the coordination of acute care,
mostly with joint recommendations. Acute
medicine benefited also from the ongoing
collaboration with the Federal Office of
Public Health regarding the procurement
of medications as well as the analyses of
the Swiss National ­
COVID-19 Science
Task Force regarding the development of
the epidemic or the critical appraisal of new
treatment strategies.
During the first wave, it became obvious
that the coordination of available hospi-
tal and ICU beds across Switzerland was
necessary to ensure balanced use of the
acute health care system resources. Fol-
lowing this first wave, the national coor-
dination system was adapted to become
fully functional for the second wave. The
coordinated health care service (‘Koordi-
nierter Sanitätsdienst’, KSD), the Federal
Office of Public Health, the Swiss Society
for Intensive Care Medicine, the Hospital
Manuel Battegay Thierry Fumeaux Nicolas J. Mueller Hans Pargger
Acute Medicine during the ­
COVID-19 Pandemic in Switzerland
SWITZERLAND
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23
Covid-19 Pandemic
Organisation (H+) and the Board of Di-
rectors of the cantonal ministers of health
were able to collectively set up an organ-
isational crisis platform and a live ongoing
survey system with very detailed data on
the hospital and ICU situation through-
out Switzerland. Such data presented with
dashboards included daily numbers of
ICU occupancy (for ­
COVID-19 and non-
COVID-19 patients), numbers of hospi-
talizations on wards and free bed capaci-
ties. Based on this, a short-term prediction
model was set up (www.icumonitoring.ch).
Data were accessible also to the public and
published in the news media on a daily
basis. Based on this, the total number of
available, staffed and functional ICU beds
was increased from 865 to around 1100,
in order to prevent deterioration of qual-
ity of care. Based on available resources
in trained personal, material, machines
and locations the hospitals were prepared
to further increase this number to about
1400, but with decreasing staff density. In
addition, intermediate care unit capaci-
ties were increased and normal wards were
equipped and staffed to apply treatments
such as high flow oxygen.
During the ­
COVID-19 pandemic, the high
quality of the Swiss acute medicine was
preserved, notably due to the quality of the
general practitioners and hospital networks.
According to the ongoing survey data of the
FOPH, hospital mortality has been one of
the lowest in the international setting, i.e.
between 10% and 14% in different hospi-
tals throughout the country. Several factors,
likely a combination thereof, could have led
to this low hospital mortality:
1. Switzerland has a well-developed
health care system with a dense network
of primary care practitioners through-
out the country and universal access to
high-level healthcare. This is reflected
by one of the highest life expectancies
worldwide. In particular, the good level
of care of patients presenting the risk
factors for ­
COVID-19, such as high
blood pressure, diabetes and other car-
diovascular risk factors may play an im-
portant role.
2. The low hospital mortality in acute hos-
pitals can in part be explained by the
fact that many elderly and frail patients
were not admitted to a hospital or in-
tensive care unit. Death rates reached a
new height in 2020 never seen since the
1940’. Indeed, in Switzerland, many el-
derly living either at home or in nursing
homes were engaged in a shared deci-
sion-making process, and opted to stay
at home or in a geriatric hospital with-
out acute care or intensive care manage-
ment.Importantly,there were no restric-
tions to the access to a hospital or ICU
beds, so that there was no admission re-
fusal at any time point, for any patients.
A guideline for the ICU admission
triage in case of limited resource avail-
ability was published already in March
2020, based mainly on short-term prog-
nosis determined by co-morbidities and
the addition of frailty in a revised ver-
sion in November 2020 (https://www.
samw.ch/dam/jcr:d0299ca3-c2be-49e8-
9a55-e3cff66dc3e7/guidelines_sams_tri-
age_intensive_care_resource_scarci-
ty_20200320.pdf). But this guideline
had never to be implemented through-
out Switzerland.
3. Third and most importantly, high-end
medicine could be maintained in all
hospitals which ensured high qual-
ity. Interdisciplinary collaboration with
key teams contributing additionally to
acute care included cardiology, pulmo-
nary medicine, nephrology, radiology,
microbiology, radiology, psychosomat-
ics, in addition to intensive care, infec-
tious disease, infection prevention and
-control and internal medicine special-
ists. All this teamwork was essential for
maintaining a functional system, to-
gether with an interprofessional work of
physicians, nurses and supporting teams
including hospital task forces to coordi-
nate within the hospital but also with
Cantonal authorities and primary care
practitioners.
Despite the adaptation of the organiza-
tion of the healthcare system, Switzerland’s
hospital-and ICU-bed capacity has almost
reached its limits in November 2020. How-
ever,the level of quality of care seemed to be
preserved throughout the whole pandemic,
but this was at the cost of postponing non-
emergent surgical interventions requiring
postoperative intensive care. During the
first and the second wave, there was also a
clear decrease in the admission of patients
presenting with acute stroke or myocardial
infarction, and a lower than expected num-
ber of ‘usual’ICU patients including trauma
patients.
It became clear from this pandemic and
epidemic in Switzerland that processes
and coordination are the most important
aspects. Trust building aspects were local
and national guidelines of infection pre-
vention and control within hospitals from
the very beginning learning then already
from the national and international ex-
perience. In this context, a humble view
helped much to learn and to constantly
optimize.
Manuel Battegay, MD
Division of Infectious Diseases and Hospital
Epidemiology, Department of Acute Medicine,
University Hospital Basel, University of Basel
Thierry Fumeaux, MD, EMBA IMD
Dr. Thierry Fumeaux, Spécialiste en
médecine interne et médecine intensive
EMBA IMD-UNIL
Nicolas J. Mueller,
Division of Infectious Diseases and
Hospital Epidemiology, University
Hospital Zürich, University of Zürich
Hans Pargger,
Intensive Care Unit, Department of
Acute Medicine, University Hospital
Basel, University of Basel
E-mail: Manuel.battegay@usb.ch
SWITZERLAND
BACK TO CONTENTS
24
Violence in Healtcare
Introduction
Violence against healthcare workers includ-
ing doctors is a global epidemic and it is
unacceptable [1]. Workplace violence is vio-
lence that occurs at the workplace [2]. This
includes physical and psychological abuse
(emotional abuse), bullying, verbal abuse,
sexual harassment and racial discrimina-
tion.The exact burden of this problem is not
known but according to the World Health
Organization between 8% and 38% of
healthcare professionals have been victims of
physical abuse in the course of their work [1].
This prompted the International Labour Of-
fice, International Council of Nurses, World
Health Organization and Public Services
International to launch a joint programme
for the reduction and elimination of the im-
pact of violence at the medical workplace [1].
Violence against doctors can occur on the
way to work [3].The consequences are direct
and indirect effects; temporal or permanent
physical disability, death, low worker mo-
rale; increased job stress, turnover; hostile
working environment, reduced confidence
in hospital management and colleagues [2].
The perpetrators are doctors or patients and
their families. Trainer – trainee bullying is
common during residency training espe-
cially in settings where there are no policies
against it or policies guarding interpersonal
relations within the medical workplace. Sig-
nificant incidents of workplace violence oc-
cur in the hospital because the emotion of
patients and their caregivers are involved [4].
The Medical Women’s International As-
sociation (MWIA) is an international as-
sociation of women doctors globally, for
easier support and governing is divided into
various regions; the Near East and Africa is
one of the regions, comprising of countries
in the Near East and African continent.The
Near East and Africa MWIA region orga-
nize a regional conference every three years.
In 2021, the MWIA Near East and African
regional conference took place in Abuja, the
Nigerian Capital City.It was a hybrid confer-
ence of physical and virtual participants due
to the ­
COVID-19 pandemic.The conference
was earlier scheduled to take place in Sep-
tember 2020 but it was rescheduled due to
the ­
COVID-19 pandemic.There were differ-
ent sessions at the conference which included
plenary sessions, opening ceremony, panel
symposium, oral and poster presentations.
The Violence against Doctors
Panel Symposium
The panel symposium on violence against
doctors with a focus on women doctors
was held at the MWIA Near East and
Africa regional conference. The host for
this symposium was Dr.  Dabota Yvonne
Buowari.The Chair of the symposium was
Prof. Elizabeth Ogoli Nwasor, a Chief
Consultant Obstetric Anaesthetist, Criti-
cal Care and Pain management at the Ah-
madu Bello University Teaching Hospital,
Zaria, Kaduna State, Nigeria. This sym-
posium was attended by 66 physical and
33 online conference attendees from four
countries: Nigeria, Tanzania, Ghana, and
Germany.
The Panelists
There were three speakers at the panel sym-
posium: Dr.  Ogugua Osi-Ogbu, a geri-
atrician; Dr.  Margaret Owoyili Popoola,
an Orthopaedic surgeon in training; and
Dr. Dabota Yvonne Buowari.
Brief Report on Individual
Contributions
The topics discussed by the panellists are:
Panelists Topics
Dr. Dabota
Yvonne Buowari
Workplace violence in
healthcare
Dr. Margaret
Owoliyi Popoola
Violence against
female doctors, a
growing trend
Dr. Ogugua
Osi-Ogbu
The role of chief
executives in the
prevention of violence
at the medical
workplace
A Report on a Symposium Titled ‘Violence Against Doctors with
Focus on Women Doctors’ Presented at the Mwia Near East and
Africa Conference, Abuja 2021
Dabota Yvonne Buowari
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25
Violence in Healtcare
Workplace Violence
in Healthcare
The definition of violence according to
World Health Organization was given as
violence in the workplace. According to the
World Health Organization, the workplace
should be free from any form of violence
and harassment. When friction, conflicts
and grievances occur, they should be re-
solved amicably. The International Labour
Office, International Council of Nurses,
World Health Organization and Public
Services International launched a joint
programme for the reduction and elimina-
tion of the impact of violence at the medi-
cal workplace in 2003 (5). In 2016, Nige-
ria proposed Resolution 5 at the MWIA
triennial conference in Vienna, Austria
“Whereas patient-initiated violence against
health workers has serious health effects on
the health workers and the community.
MWIA resolves that health workers are en-
titled to work free from occupational stress
and threat in a safe environment free from
harassment, discrimination, violence, verbal
and physical abuse [6]. At the workplace,
violence can occur between healthcare
workers and patients, healthcare workers
and patient’s relatives/caregivers, between
healthcare co-workers. In as much as any
physician can be assaulted at the workplace,
emergency physicians, psychiatrists and
primary care physicians are at risk of be-
ing assaulted while caring for their patients.
Violence at the medical workplace can take
various forms; verbal, psychological, physi-
cal abuse and sexual harassment.
The causes of violence against health work-
ers as:
• Individual, organization and environ-
mental factors.
• Patient-related, physician-related and
healthcare institution related factors.
Some of the risk factors that predispose
doctors to be assaulted by patients and their
caregivers are female health workers and
young doctors. Violence at the workplace
in healthcare is a global problem; therefore
women doctors who have been assaulted
needs support especially mental health
support. It is necessary to conduct studies
on workplace bullying and sexual harass-
ment especially as the International Labour
Office (ILO), International Council of
Nurses (ICN), World Health Organization
(WHO) and Public Service International
(PSI) jointly developed a reliable and vali-
dated research instrument “The workplace
violence in the health sector research instru-
ments for quantitative research and guide-
lines for focus group discussion through
the joint programme on workplace violence
in the health sector. This will enable vari-
ous countries to provide a solution to this
problem.
Workplace Violence
against Female Doctors,
A Growing Trend
The female sex is a risk factor for been as-
saulted at the medical workplace. Women
doctors face a lot of challenges in the course
of their work. It is important various strate-
gies are taken to end this menace. Violence
against women is one of the oldest global
public health issues and by extension to
women doctors.
Generally, receivers of psychological vio-
lence are also likely to be victims of physi-
cal violence. Though many cases tend not
to be reported especially in developing
countries, women doctors compared to
their male counterparts are at a high risk
of psychological violence which is perpe-
trated by their patients, caregivers, male
colleagues, senior colleagues and visitors to
the hospitals. She gave the United Nations
declaration on the elimination of violence
against women (1993) states that “as vio-
lence against women is any act of gender-
based violence that results in or is likely to
result in physical, sexual or mental harm
or suffering to women including threats of
acts, coercion or arbitrary, deprivation of
liberty, whether occurring in the public or
private life. Doctors especially women doc-
tors encounter several forms of violence at
work making women doctors not to be safe
at work. The emergency units and psychia-
try are known to be hotspots for violence
against health workers. Violence against
women doctors has impacts on the carrier,
finances, health institutions, economy and
the society at large. On the way forward,
the responsibilities of doctors, health in-
stitutions, the media and the government
was given. The annual 16 days of activism
against violence against women should also
be used as a campaign on violence against
women doctors. There is a rising rate of
violence against doctors and not neces-
sarily women doctors is increasing leading
to reluctance to take up challenging cases,
thereby comprising healthcare delivery.
There is therefore an urgent need to make
health care facilities safe havens for doctors
as only then can they work with complete
dedication.
The Role of Chief Executives
in the Prevention of Violence
at the Medical Workplace
Some of the preventive strategies of vio-
lence at the medical workplace include the
provision of protection and security. Also,
health workers should be trained on good
communications, show empathy to their
patients and also leave the scene once they
sense any form of psychological abuse to
avoid its progression into a physical as-
sault.
The topic of violence against healthcare
workers is apt at this time of the ­COVID-19
pandemic. Most of the cases have been un-
derreported and much attention has not
been given to this issue. Sometimes health-
care workers are beaten by patients and their
caregivers outside the hospital premises on
their way home after the close of work.
BACK TO CONTENTS
26
Conclusion
Participants who are chief executives of hos-
pitals were urged to put measures in place
to protect women doctors from every form
of workplace violence. Conducting studies
on workplace bullying and violence against
doctors is necessary to determine the actual
burden of the problem.
References
1. World Health Organization. Preventing Vio-
lence against health workers. www.who.int/
activities/preventing-violence-against-health
workers
2. Violence: occupational hazards in hospital. Cin-
nati. Occupational health USA. National Insti-
tute for Occupational Safety and Health. Cent-
ers Disease Center Control Prevention. 2002.
www.cdc.gov/niosh/docs/2002-101/default.
html
3. Kamchuchart C, Chongssuvivatwong V, On-
cheunjit S, Yip TW, Sangthong R. Workplace
violence directed at nursing staff at a general
hospital in Southern Thailand. Journal of Occu-
pational Health. 2008, 50 (2), 201-7.
4. Gohil RK, Singh PK, Saxena N, Patel G. Work-
place violence against resident doctors of a ter-
tiary care hospital in Delhi, India. International
Surgery Journal. 2019,6 (3), 975-981.
5. Chappell d, martino vd, violence at work. In-
ternational labour office. Geneva. Third edition.
2006., http://www.ilo.org/wcmsp5/g
6. MWIA Resolution No 6, 2016. https://mwia.
net/about/resolutions
Dr. Dabota Yvonne Buowari,
Department of Accident and
emergency, University of Port
Harcourt Teaching Hospital,
Port Harcourt, Rivers State. Nigeria.
E-mail: dabotabuowari@yahoo.com
The governance of
healthcare in Sweden
In Sweden,the state,regions and municipali-
ties share the legal responsibility for health-
care. The state has overall responsibility for
the healthcare system and the state sets the
requirements through legislation on which
care is to be provided and the framework for
its organisation. Governmental authorities
are responsible for issuing binding guide-
lines, exercise supervision and coordinate
healthcare. The state also decides which care
is to be considered national highly special-
ized care.The state has the primary responsi-
bility for research and education in the field
of healthcare through state universities. Fi-
nally, the state contributes significant fund-
ing of healthcare through both general and
targeted governmental grants.
The provision of health care is the respon-
sibility of 21 regions and 290 municipali-
ties. They are obliged under the Health and
Medical Services Act to offer health and
medical care, which means that it is a man-
datory task imposed by the state on mu-
nicipalities and regions [1].The law also de-
scribes the obligation for the municipalities
and regions to cooperate on the care of the
elderly both at the overall and individual
levels. However, the law gives great freedom
to the regions and municipalities to decide
how to provide healthcare according to lo-
cal and regional conditions and needs. This
is called local self-government. Self-gov-
ernment is exercised by decision-making
assemblies representing the local popula-
tion. At the same time, the main objective
of the Health and Medical Services Act is
clear – healthcare must be equal throughout
the country.
Each healthcare region decides what kind
of healthcare is to be performed and where,
for example at which hospitals. Each region
also decides on investments in hospitals and
other care facilities, as well as investments in
medical technology and other equipment.
All of Sweden’s municipalities and regions
are members of the SALAR (The Swedish
Association of Local Authorities and Re-
gions) which is both an employers’organisa-
tion and an organisation that represents and
advocates for local government in Sweden.
It is a politically controlled organisation
with a board consisting of elected represen-
tatives from municipalities and regions [2].
Various difficulties with the cur-
rent Swedish governance model
For a long time, the Swedish model for
healthcare with the division of responsibili-
Sofia Rydgren Stale
The ­
COVID-19 Pandemic Revealed the Need for Increased National
Governance of Healthcare in Sweden
Violence in Healtcare
BACK TO CONTENTS
27
ties between the state, region and munici-
pality,has struggled with various difficulties.
Several governmental investigations have
tried to solve the problems by putting for-
ward proposals for a more optimal division
of responsibilities. But nothing has hap-
pened that has fundamentally reformed the
division of responsibilities. For healthcare,
the situation is problematic in many ways
and a large part of these problems can be
referred to the healthcare regions being un-
able to deliver equal healthcare.
Based on the principle of subsidiarity, the
majority of the welfare sector’s commit-
ments rest on local self-government. In
this way, citizens are able to more easily
influence priorities and strategies and, in
the best of worlds, learn from each other’s
mistakes. The principle of proximity and
the principle of learning from each other
(institutional learning) are traditionally two
strong arguments that in theory support
the Swedish regional self-government. But
what in theory is a strength, turns out to
be a disadvantage in practice in the case of
Swedish governance of healthcare. For ex-
ample, the length of the waiting list for sur-
gery or the availability of primary care is of-
ten determined by the prioritisations made
by the regional politicians. Regional elec-
tions every four years may not be enough
as an instrument to shorten the waiting list
for hip surgery or to get access to the same
doctor at each visit at the primary care.The
regions’ exchange of experiences, which in
Sweden takes place through national clini-
cal knowledge management, does not seem
to bring Sweden any closer to the goal of
the entire population having equal health-
care.
The healthcare regions face major challeng-
es in the coming years. The rapid develop-
ment of new advanced treatment methods
and drugs in recent decades will not slow
down. On the contrary, the demands on ex-
pensive investments in medical technology
equipment, new effective medicines and ap-
propriate premises will continue to increase.
In addition, the need to train and recruit
staff with the skills to use the new high-tech
equipment and to perform new advanced
operations and treatments is increasing.
An average Swedish region, except for the
metropolitan regions, has approximately
260,000 inhabitants. These sparsely popu-
lated regions are expected to maintain the
same accessibility and quality of care as
Stockholm, the capital region with more
than 2 million inhabitants.This is very diffi-
cult today and will be even more difficult in
the future, considering the fact that urban-
isation does not seem to diminish. Many
regions are simply too small to cope with
the heavy investments that are necessary to
be able to provide healthcare in a rational,
equal and patient-safe manner.
The difficulty of recruiting staff with the
right skills and getting the staff to stay and
be content with their work environment is
also an escalating problem and a challenge
for the future in all parts of the country.
Another key issue for the healthcare of
the future concerns the conditions for re-
search and innovation. Today’s model with
21 regions does not facilitate research and
innovation in Sweden. The collaboration
between healthcare, universities and the in-
dustry needs to be strengthened.
In addition, it is not efficient to carry out
digital development in 21 different ways.
The fact that all Swedish regions have pro-
cured different medical record systems does
not facilitate the management of health-
care.
The ­
COVID-19 pandemic
revealed inequality in healthcare
The ­
COVID-19 pandemic has exposed
several of the shortcomings in the current
Swedish model of healthcare governance,
including insufficient regional emergency
stocks, the slow start of testing and weak-
nesses in the care for the elderly in elderly
homes. After the vaccinations started, the
vaccination rate has shown to vary greatly
between regions.
Structural deficiencies in
the care for the elderly
According to the principle of liability, the
person responsible for activity in normal
situations has a corresponding operational
responsibility in the event of a crisis. It is
a simple principle in theory, but the more
people that share the responsibility, the
more difficult it will be to make the entire
system work well in practice.In Sweden,the
responsibility for healthcare and other care
of the elderly is divided between the regions
and municipalities. In many regions and
municipalities, there are also a large number
of private care providers.
As early as 2017, the governmental inves-
tigation “National quality plan for care for
the elderly” [3] reported several shortcom-
ings in how the care was organized for the
elderly suffering from multiple diagnoses,
reduced mobility and a failing social net-
work. It was stated that there was a lack of
interaction between inpatient care and pri-
mary care as well as between primary care
and elderly care, and nobody had overall
responsibility.
In June 2020, the government decided to
appoint a Corona Commission with the
task of evaluating the measures taken by
the government, the administrative au-
thorities, regions and municipalities to limit
the spread of ­
COVID-19 [4]. The Corona
Commission’s conclusions showed that al-
most 90 % of the more than 7,500 of those
who died in Sweden up to the beginning of
December 2020, were 70 years and older,
almost half of them lived in nursing homes
(see Figure 1). The Commission’s overall
assessment stated that, in addition to the
general spread of infection in society, the
greatest impact on the number of infected
and deceased due to ­
COVID-19 within
Violence in Healtcare
BACK TO CONTENTS
28
the Swedish elderly, was the well-known
structural weaknesses. These weaknesses
made the elderly care unprepared and ill-
equipped to deal with a pandemic.
Differences in vaccination rate
Several Swedish government agencies
have been responsible for different areas
during the ­
COVID-19 pandemic. The
Swedish Medical Products Agency is re-
sponsible for making decisions on the ap-
proval of vaccines for ­
COVID-19 but it is
the Swedish Public Health Agency who is
responsible for recommendations regarding
which groups of the population should be
vaccinated, and in which vaccination phase
and also distributing the vaccines to the re-
gions. This distribution to the regions was
initially based on the proportion of elderly
people living in the different regions. As
later phases of the vaccinations for younger
people started, other factors controlled the
distribution.
The healthcare services in the 21 regions in
Sweden are responsible for carrying out all
vaccinations. The ­
COVID-19 vaccinations
in the regions should have been conducted
in accordance with the Swedish Public
Health Agency’s recommendations [5].The
regions had, however, different interpreta-
tions on who should be vaccinated in which
phase.For instance,individuals with a high-
er risk of ­
COVID-19 should according to
the recommendations have been vaccinated
in an earlier phase than their age suggests.
However, one of the largest regions in
Sweden decided to deviate from this rec-
ommendation as they claimed it would be
administratively too demanding [6]. After
massive criticism, the region backtracked
their decision, but this kind of back-and-
forth information made public guidance
and compliance to vaccinations more dif-
ficult.
Due to these kinds of alternate priorities,
the last and final phase of the vaccinations,
Figure 1. 
Proportion (percent) of deaths with Covid-19 per age group and form of elderly
care
Source:
Äldreomsorgen under pandemin (The elderly care during the pandemic). 7 December 2020.
Official state investigation. Available in Swedish at:
https://www.regeringen.se/4af379/contentassets/a8e708fff5e84279bf11adbd0f78fcc1/sou_2020_80_aldreomsorgen-under-
pandemin.pdf
Figure 2. 
Vaccination coverage (%) among people who are 65 years and older and who live
at nursing homes, in 21 different healthcare regions on the 26 May 2021. Green
= 1 dose of vaccine, violet = 2 doses of vaccine
Source: The Public Health Agency of Sweden. Available in Swedish at:
https://www.folkhalsomyndigheten.se/folkhalsorapportering-statistik/statistikdatabaser-och-visualisering/vaccinations-
statistik/statistik-for-vaccination-mot-covid-19/uppfoljning-av-vaccination/vaccinationstackning-i-prioriterade-grupper/
Violence in Healtcare
BACK TO CONTENTS
29
ages 18-60, did not start at the same time
in the different healthcare regions. In ad-
dition, the way the vaccinations could be
booked also differed between the regions
(e.g. booking app, phone, notice by mail).
Thus, the vaccination coverage differs across
the country (see Figure 2).
Swedish healthcare
needs reforms
As previously mentioned, the problems
of inequality in healthcare have existed in
Sweden long before the pandemic: long
waiting lists for treatment, poor acces-
sibility and poor continuity between the
doctor and patient. A recently published
governmental investigation “Increased
conditions for sustainable investment
projects in the healthcare of the future”
states that the pandemic has only clari-
fied the problem that the different parts
of Swedish healthcare infrastructure are
not connected.
For example, an ICU bed does not mean
the same thing in all hospitals [7].When an
ICU patient needs to be moved in a criti-
cal phase, the situation may arise that part
of the care included in an ICU bed at one
hospital is not included at another hospital.
These differences also make it more difficult
to borrow staff between hospitals in crisis
situations. The hospital buildings also look
different, different wards are located dif-
ferently in relation to each other, medical
equipment is of different brands, has differ-
ent capacities and is not compatible. These
differences were not created deliberately but
unfortunately, they were not acknowledged
by the hospitals until the pandemic revealed
them.
Today, approximately 120,000 patients are
on the waiting list for surgery in Sweden.
Half of them have waited over 90 days
(more than the national “care guarantee” al-
lows). For many, the waiting time is much
longer. In Denmark, this problem does not
exist at all, due to governmental control,
economic incentives and significantly fewer
regions. Danish patients almost always re-
ceive care at “their own hospital” within
30 days.
The Swedish people expect that the health-
care of the future will function equally re-
gardless of geographical and administrative
boundaries.In a recent survey commissioned
by the Swedish Medical Association [8], 64
percent of the public respondents answered
that instead of the regions, the state should
be responsible for healthcare. The Swedes
think that today’s healthcare system works
poorly. With increased state governance, it
is possible to get national coordination of
the waiting lists and in this way offer pa-
tients treatment more quickly in another
part of Sweden than in their “own region”.
In the event of extreme situations, such as
the pandemic, some of the healthcare staff
could also be relocated according to the na-
tional needs.
The Swedish Medical Association calls
on joint tax-financed healthcare with a
variety of different kinds of care provid-
ers. Private doctors and privately run units
can also help to shorten the waiting list
of the postponed care. But it must be the
state and the state authorities that have
overall responsibility for the governance
of healthcare. The healthcare regions and
their umbrella organisation SALAR have
developed almost into a government agen-
cy with a lot of power, even though the
SALAR should only be an employer and
lobby organisation for the municipalities
and regions.
To increase national governance,The Swed-
ish Medical Association has developed a
comprehensive 29-point action program in
the wake of the pandemic. We believe that
improved governmental control will even
out the regional differences in healthcare
and provide equally good care for the entire
population,regardless of where in the coun-
try one lives!
References:
1. Riksintressen i hälso- och sjukvården  – stärkt
statlig styrning för hållbar vårdinfrastruktur
(National interests in health care – strengthened
state governance for sustainable care infrastruc-
ture ). Official state investigation. August 2021.
Available in Swedish at: https://www.regerin-
gen.se/4a47a9/contentassets/1228dce1e5674
e3b9308151cc56bb200/riksintressen-i-halso-
-och-sjukvarden-sou-2021_71.pdf
2. The Swedish Association of Local Authorities
and Regions (SALAR): An association for its
members. 2013. Available in English at: htt-
ps://webbutik.skr.se/bilder/artiklar/pdf/5264.
pdf?issuusl=ignore
3. Läs mig! Nationell kvalitetsplan för vård och
omsorg om äldre personer (Read me! National
quality plan for care for the elderly). Official
state investigation. March 2017. Available in
Swedish at: https://www.regeringen.se/4969b7/
contentassets/9378aff4b35a427c99b772345
af79539/sou-2017_21_webb_del1.pdf
4. Äldreomsorgen under pandemin (The elderly
care during the pandemic). 7 December 2020.
Official state investigation. Available in Swed-
ish at: https://www.regeringen.se/4af379/con-
tentassets/a8e708fff5e84279bf11adbd0f78fcc1/
sou_2020_80_aldreomsorgen-under-pandemin.
pdf
5. Who will be vaccinated when. Emergency in-
formation from Swedish authorities. Septem-
ber 2021. Available in English at: https://www.
krisinformation.se/en/hazards-and-risks/disas-
ters-and-incidents/2020/official-information-
on-the-new-coronavirus/vaccination-against-
covid-19/when-is-it-my-turn
6. Vaccinordningen ändras – flera riskgrupper tv-
ingas vänta (Vaccine priority groups are being
changed – several risk groups are forced to wait).
Aftonbladet. 27 April 2021. Available in Swed-
ish at: https://www.aftonbladet.se/nyheter/a/
X802QB/vaccinordningen-andras–flera-risk-
grupper-tvingas-vanta
7. Låt staten äga sjukhusen – det gör vården bättre
(Let the state own the hospitals – it makes the
healthcare better). Dagens Nyheter. 31 August
2021. Available in Swedish at: https://www.
dn.se/debatt/lat-staten-aga-sjukhusen-det-gor-
varden-battre/
8. Många vill att staten ska styra vården (Many
people want the state to control healthcare).
Läkartidningen. 9 June 2021. Available in
Swedish at: https://lakartidningen.se/aktuellt/
nyheter/2021/06/manga-vill-att-staten-ska-
styra-sjukvarden/
Sofia Rydgren Stale, MD
President of the Swedish Medical Association
E-mail: hanna.vihavainen@slf.se
Violence in Healtcare
BACK TO CONTENTS
30
Covid-19 Pandemic
COVID-19 and War-Related Stress and Somatized Mental Health
Disorders Among General Population. Armenian Experience
COVID-19 pandemic related lockdown in
Armenia started in March 2020. The on-
line survey was conducted on social plat-
forms among the general population in
May-June 2020 to identify stress levels and
somatic expressions of mental health dis-
orders. The survey indicates moderate and
severe stress levels to be 40% and symp-
toms of psychosomatic origin to be 20%
among the survey population. On Septem-
ber 27, 2020, Azerbaijan started a war in
Nagorno-Karabagh (Republic of Artsakh).
After the signed ceasefire agreement new
survey was initiated and the preliminary
analyses of the results showed a highly in-
creased level of stress and psychosomatic
manifestations.
The World Association for Social Psychia-
try [1] defines the ­
COVID-19 pandemic
as “one of the most significant events since
the Second World War”, which affected
most countries in the world, regardless of
their “human development index”, which
caused great social upheavals, an economic
crisis and a host of social, psychological and
health problems. One of the consequences
of the pandemic was stress among the gen-
eral public. Stress has become the content
of the life of a modern person. Due to peri-
odically recurring infections, wars and other
disasters since the beginning of the 21st
century, the escalation of the epidemic of
­
COVID-19 infection into a pandemic and
the accompanying socio-political upheavals,
stress is increasingly becoming destructive
in nature, causing serious problems in the
personal, social, somatic and psychologi-
cal existences of a person [2]. Not only the
­
COVID-19 related changes in social life,
such as lockdown and other restrictions
were found to be the stress factors for the
general public,but also the virus itself found
to have an impact on the mental health of
the infected. ­
COVID-19 is a rather multi-
faceted, multi-local disease, with far from
clear dynamics and features; the causative
agent of the disease (SARS-CoV-2 Corona-
virus) can infect the brain, trigger immune
responses, disrupt blood clotting, cause
thrombosis of small vessels, further adverse-
ly affecting the brain function and mental
health of patients [3]. A whole series of
works over the past less than a year has been
devoted to mental health problems caused
by Coronavirus infection [4, 5, 6, 7, 8]. In a
study conducted in China among the popu-
lation,more than half of the respondents re-
ported moderate to the severe psychological
impact.In the same study 16.5% and 28.8%,
respectively, reported moderately severe de-
pressive and anxiety symptoms [6]. The
situation in Armenia was worsened by the
Nagorno Karabakh conflict excavation and
44-day war that took lots of lives and had a
huge impact on the mental health of Arme-
nia and the Nagorno Karabakh population.
This study aimed to identify the stress level
and somatization level of mental health dis-
orders of the Armenia population during
the ­
COVID-19 pandemic and Armenian–
Azerbaijani war.
Taking into account the situation of strict
lockdown in the country it was not possible
to survey people, thus the online platforms,
namely through the Facebook social net-
work was used for online survey. The on-
line survey platform was designed consist-
ing of several blocks: a socio-demographic
block, standardized questionnaires to assess
the mental state of the population and the
level of stress severity. The PSM-25 Psy-
chological Stress Scale [10] and question-
naires for detection of asthenia, depression,
hypochondria, somatization [9,11] were
translated, pretested with back-translation.
The participation was anonymous, on a
voluntary basis. The survey could be inter-
rupted at any time. The sample size with a
confidence error of 95% and a margin of
error of 5% was estimated to be 1,066.2.
The first phase of the survey was conducted
from May 12 to July 24, 2020. The second
phase was initiated in November 2020 and
is continued till now (June 2021) to reach
the necessary sample size. The data were
processed and analysed by the IBM SPSS
Statistics v.23.0
Samvel Sukiasyan Lilit Baghdasaryan Ani Soghoyan Armen Grigoryan Marietta Khurshudyan
ARMENIA
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31
Covid-19 Pandemic
1076 respondents took place in the survey.
Among the survey participants, both men
(509 or 47.3%) and women (487 or 45.3%)
were approximately equally represented.
79  respondents (7.3%) did not indicate
their gender. The age of the respondents
varied within a fairly wide range  – from
18 to 75  years, with the majority being
between 18 and 40 years old (921 partici-
pants- 85.7%). The marital status of the
participants was calculated to 487 married
(45%) and there were 471 unmarried par-
ticipants (44%), and in general 588 people
were single for the period of the survey
(54.7%). The surveyed sample was char-
acterized by a high level of education and
employment. 779 people had higher edu-
cation (72%), 45  people mentioned post-
graduate education/scientific degree (4%)
(see Graphic 1). 547 participants had per-
manent employment (50.9%) and another
160 people (14.9%) introduced themselves
as college and university students (see
Graphic 2).Thus, 707 people (65.8%) had a
permanent and main occupation.According
to the PSM-25 Psychological Stress Scale,
the respondents were found to have mild,
moderate and severe psychological stress:
613 (57.0%), 215 (20.0%) and 210 people
(19.6%) respectively (see Graphic 3). Over-
all, 40% of the survey population identified
to have moderate to severe levels of stress.
The scale was ignored by 37 respondents
(3.4%). It is interesting to note that the
most stress-resistant were students and peo-
ple with permanent employment. Together
they made up 65.8% (707 people) of the
surveyed population. The other factor con-
tributing to the severe stress reactions is the
presence of chronic disease. Among people
with chronic somatic diseases (146 people,
13.6%), symptoms of severe stress were
found among 27.4% of the respondents
(40  people); in the group of somatically
healthy people (929 people, 86.4%), only
18% (168 people) of respondents found
symptoms of severe stress (see Graphic
4). Regardless of the severity of stress, the
questioned population had symptoms of
asthenic (489 people, 45.5%), depressive
72%
24%
4%
Higher Education
Student/No Education
Sientific Degree
Graphic 1. Education of study population
51%
15%
34%
Permanently Employed
Student
Non-Employed
Graphic 2. Employment status of study population
57%
20% 19.6%
0%
10%
20%
30%
40%
50%
60%
Mild Moderate Severe
Graphic 3. Stress levels of study population
ARMENIA
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32
Covid-19 Pandemic
(361  people, 33.5%) and ­
hypochondriacal
(183 people, 17%) disorders (see Graph-
ic 5). In general, the somatization on all
three scales was identified among 268 re-
spondents (24.9%). In the second phase of
the survey, which was conducted after the
Armenian- Azerbaijan war 2020, the pre-
liminary data analyses showed that moder-
ate and severe stress levels increased up to
60%.The data is not finalized, but even pre-
liminary analysis shows that war added on
­
COVID-19 related stress level and almost
doubled stress level.
The extensive data was subjected to statis-
tical processing to understand all possible
and impossible connections, correlations,
dependencies between different types,
levels, and severity of stress factors and
other parameters, such as demographic
and other features of the survey popula-
tion. We hypothesised that possible psy-
chopathological phenomena may be due
to the severity of stress factors, personal-
ity characteristics of the respondents, and
some socio-demographic parameters. The
development of stress occurs under the
influence of both external environmen-
tal factors and individual psychological
and socio-demographic characteristics of
the personality. Each individual functions
quite specifically (despite a number of
general, universal mechanisms) in a stress-
ful situation due to personal peculiarities,
characteristics of the situation, the severity
of the trauma, its duration and intensity,
etc. The following significant relationships
were identified.To study the role and place
of demographic parameters in this study,
the T-Student method was used to imple-
ment group comparisons and the method
of more than two-group comparisons
(One-way Anova). Gender characteristics
of the response to extraordinary stressful
influences in this study showed signifi-
cant differences. Statistical analysis of the
data identified that men and women show
differences in the level of stress and hypo-
chondria (t1985.4)  = -2.094; p1  =  0.037;
t2 (987)  =  2.33; p2  =  0.02). Women
have a higher level of stress (M = 92.41;
SD = 39.175) and a low level of hypochon-
dria (M = 3.39; SD = 2.974). The develop-
ment of asthenia,depressive and hypochon-
driacal manifestations (somatization) was
related to a number of socio-demographic
factors: education, social activity, disabil-
ity, etc. Individuals with higher education
(M = 4.9; SD = 3.659) found the lowest
rate of depression, and the highest rate was
found in people with secondary education
(M = 5.87, SD = 3.697) and below (F (4,
1041) = 2, 49; p = 0.042). A similar pat-
tern was revealed with respect to hypo-
chondria – persons with higher education
showed the lowest level of hypochondria
(F (4, 1041) = 3.633; p = 0.006). The high
level of education of the population con-
tributes to an increase in stress resistance
to traumatic effects, which contributes to
lower rates of depression and hypochon-
dria. The socially active group of respon-
dents (students, working respondents) was
least of all prone to somatic manifestations
of mental health disorders. They had the
lowest rates of asthenia, depression and
hypochondria, while among pensioners,
unemployed and unemployed these indi-
cators were the highest. Thus, a low level
of depression (M = 4.66; SD = 3.601) and
hypochondria (M = 3.35; SD = 2.873), as
well as asthenia (M  =  5.6; SD  =  3.407)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Severe Stress Among Thouse
with Chronic Desease
Severe Stress Among Healthy
Population
27.4%
18%
Graphic 4. Stress level and somatic disorders
45.5%
33.5%
17.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Asthenic Depressive Hypochondriacal
Graphic 5. Distribution of somatized mental health disorders
ARMENIA
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33
Covid-19 Pandemic
were detected in individuals with high
social activity (F1  (5.1036)  =  6.774,
p = 0.000…; F2 (5.1036) = 8.379,p = 0.000;
F3 (5.1036) = 5.098, p = 0.000, respectively
for depression, hypochondria and asthe-
nia). And low rates were found by pen-
sioners and unemployed. Correlation that
there is a pronounced positive relationship
between the severity of stress and clini-
cal manifestations of asthenia (r  =  0.676
**, p = 0.000…), depression (r = 0.632 **,
p = 0.000 …) and hypochondria (r = 0.387
**, p = 0.000 …). The important observa-
tion that needs to be proved by statistical
analysis is that a combination of the stress
factors, such as the ­
COVID-19 pandemic
and war consequences could multiply the
stress level of the general population.
The results of the study indicated that in a
“non-clinical”, conditionally healthy popu-
lation individuals are identified to express
clinical signs of a neurotic level, both at the
symptomatic and syndromic levels.The fre-
quency of their detection under conditions
of ongoing quarantine (possibly also in oth-
er emergencies) will tend to increase, which
is confirmed by the patterns of development
we have identified. The real and probable
possibility of a worsening epidemiological
situation, like any other emergency, fraught
with an increase in the level of stress, puts
mental health problems at the level of na-
tional security problems, requiring a state
approach to solving these problems with
the wide involvement of professional and
nongovernmental organizations.
Based on our research and taking into ac-
count world experience, we consider it nec-
essary to organize the following activities:
• To organize units for the provision of
direct and remote psychological, psycho-
therapeutic and psychiatric assistance.
• To organization psychiatric care and
psychosocial recovery services at general
somatic hospitals and in primary health
care.
• To organize emergency psychological and
psychiatric intervention groups, consist-
ing of psychiatrists,experts in psychologi-
cal interventions, social workers.
• To the creation of 24/7 psychological as-
sistance hotlines.
• To establishment centres for an online
survey of the population to collect infor-
mation on the state of mental health and
make recommendations on this basis.
References
1. Chadda R, Bennegadi R, Nicola V, Molodynski
A, Basu D, Kallivayalil R, Moussaoui D. World
Association of Social Psychiatry Position State-
ment on the Coronavirus Disease 2019 Pan-
demic. World Social Psychiatry. 2020; 2: 2: 57.
DOI: 10.4103/WSP.WSP_22_20
2. Марценковский ИА, Марценковская ИИ,
Здорик ИФ. Пандемия коронавирусной бо-
лезни как вызов для системы охраны пси-
хического здоровья. Архив психиатрии.
2020; 26: 2. DOI: https://doi.org/10.37822/2410-
7484.2020.26.2.covid-19
3. Torales J, O’Higgins M, Castaldelli-
Maia JM, Ventriglio A. The outbreak of
­
COVID-19 coronavirus and its impact on
global mental health. Int J Social Psychia-
try. 2020; 66: 4: 317–320. DOI: https://doi.
org/10.1177/0020764020915212
4. Luykx JJ, Vinkers CH, Tijdink JK. Psychia-
try in Times of the Coronavirus Disease 2019
(COVID-19) Pandemic: An Imperative for Psy-
chiatrists to Act Now. JAMA Psychiatry. 2020;
77: 11: 1097–1098. DOI:10.1001/jamapsychia-
try.2020.1225;
5. Kelly B.Coronavirus disease:Challenges for psy-
chiatry. The British Journal of Psychiatry. 2020;
217: 1: 352-353. DOI:10.1192/bjp.2020.86
6. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho
C.S. Immediate psychological responses and
associated factors during the initial stage of
the 2019 coronavirus disease (COVID-19)
epidemic among the general population in
China. Int J Environ Res Public Health. 2020;
17: 5: 1729. DOI: https://doi.org/10.3390/
ijerph17051729
7. Сукиасян СГ, Тадевосян МЯ. Психоло-
го-психиатрические последствия корона-
вирусной инфекции в Армении. Армянский
журнал психического здоровья. 2020; 11: 1:
3-13.
8. De Girolamo G, Cerveri G, Clerici M, Mon-
zani E, Spinogatti F, Starace F, Tura G, Vita A.
Mental Health in the Coronavirus Disease 2019
Emergency – The Italian Response. JAMA Psy-
chiatry. 2020; 77: 9: 974–976. DOI: 10.1001/
jamapsychiatry.2020.1276 Park SC,
9. Сукиасян СГ, Минасян АМ. Клинические
опросники для раннего выявления сомати-
зированных психических нарушений. Обо-
зрение психиатрии и медицинской психоло-
гии им. ВМ Бехтерева. 1994; 2: 73–76.
10. Грецов АГ, Азбель АА. Психологические
тесты для старшеклассников и студентов.
СПб.: Питер, 2012. 201 с.
11. Хромов АБ. Пятифакторный личностный
опросник: тест 5FPQ. Методические указа-
ния к выполнению контрольного задания по
общему психологическому практикуму для
студентов направлений (специальностей)
030301. Курган: РИЦ Курганского государ-
ственного университета, 2010. 27 c.
Samvel G. Sukiasyan,
“ArtMed” Medical Rehabilitation Centre,
“Stress” Department of Mental Health
Rehabilitation; Yerevan State Medical
University after M. Heratsi, Department of
Psychiatry and Mental Health; Yerevan State
Pedagogical University after Kh. Abovyan,
Department of Practical Psychology
Lilit V. Baghdasaryan,
Yervena State Univeristy, Department
of Personality Psychology;
Centre for Psychosocial Recovery
Ani F. Soghoyan,
Centre for Psychosocial Recovery
Armen K. Grigoryan,
Yerevan State University,
Research Laboratory “Personality
and Social Environment”
Marietta D. Khurshudyan,
Armenian Psychiatric Association
E-mail: soghoyan@yahoo.com
ARMENIA
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34
Covid-19 Pandemic
Overview of Pandemics
A substantial number of pandemics and
communicable disease epidemics that have
occurred were caused by novel strains of vi-
ruses. [1] By 2020, three of these epidem-
ics have been caused by the novel strains of
beta coronaviruses and present like influen-
za, the Severe Acute Respiratory Syndrome
coronavirus (SARS-CoV), the Middle East
Respiratory Syndrome (MERS) and the
Severe Acute Respiratory Syndrome coro-
navirus-2 (SARS-CoV-2) [2].
SARS-CoV-2 (COVID-19) is a coronavirus
that caused an outbreak in December 2019 in
Wuhan, in the Hubei Province of China; the
disease progressively spread and was declared
a pandemic by the World Health Organiza-
tion in March 2020. [3-6] ­
COVID-19 trans-
mission occurs through the contact or virus
particles, from an infectious host to the mu-
cous membrane of an individual at risk [7-10].
Epidemiological Reporting
During Pandemics
Epidemiological reporting (ER) is an im-
portant tool in public health especially
during any community health outbreaks
such as epidemics and pandemics. Epide-
miological reports are essential instruments
for the rapid and accurate dissemination of
epidemiological information on cases and
disease outbreaks including other commu-
nicable diseases of public health importance
with emerging and re-emerging infections
inclusive [11]. An epidemiological report
contains information drawn from surveil-
lance of a disease condition; this is because
it provides an overview of the epidemiol-
ogy of a disease of public health importance
[12]. The systematic collection, collation
and analysis of data with its dissemination
to those who are in a position to take ac-
tion is known as surveillance; Surveillance
is important in the practice of public health
[13, 14, 16].
It is necessary as it provides information
about a disease according to person, time
and place [17]. Reporting of surveillance is
important for the development of strategies
that address some specific health conditions
[18].
Epidemiological reports aids in real-time
planning, provision and evaluation of health
care services during pandemics [19]. The
­
COVID-19 pandemic has had many epide-
miological reports from different countries
since the beginning of the pandemic with
the country releasing reports. Each country
decides if its agency is authorized to devel-
op and to release such reports deciding on
the frequency at which the reports are re-
leased [20]. There are challenges globally in
the capacity for health institutions to pro-
duces Epidemiological Reports consistently
and accurately [20]. Literature has found
that Low- and Meddle- Income countries
predominately having the most challenges
than higher-income countries [21]. Epi-
demiological data are necessary to provide
interventional strategies for the coronavirus
disease outbreak [22].
Empathy during
Pandemics with Focus on
Epidemiological Reporting
Empathy is an umbrella term that captures
the range of responses of an individual to
another individual’s experience or an indi-
vidual’s ability to show concern to the feel-
ing of others [23]. Undoubtedly, empathy
remains critical to the quality of patient
Francesco Rosiello Damilola Ayowole Lwando Maki
Dabota Yvonne Buowari
Beyond the Number, Balancing Epidemiological Reporting with the
Need for Patient Empathy During the ­
COVID-19 Pandemic
BACK TO CONTENTS
35
Covid-19 Pandemic
care, but the well-being of healthcare pro-
fessionals cannot be neglected in the pro-
cess too [24, 25].
Literature has found that the empathy at-
tribute of health professionals becomes
tried and sometimes be lacking in pan-
demic circumstances [28, 29]. Even though
individual choices are legally limited dur-
ing epidemics and pandemics; it is also im-
portant to ensure that human dignity is not
eroded.
Empathy and Epidemiological
Reporting In ­
COVID-19
The global emergence of SARS-CoV-2 in-
fection has led to the strengthening of the
capacity and organization of public health
institutions in rolling out daily statistical
data [30]. However, ER doesn’t have any
empathetic component to assist in the
planning of actions to address pandemics;
the literature has shown direct or indirect
negative effects of epidemiological report-
ing and subsequent measures [30, 31, 32,
33, 34]. Indirect consequences of ER on
patient empathy could stem from strict ad-
herence to ­
COVID-19 control measures
and its negative effect on mental health. For
instance, patients might get relatively lim-
ited empathy as a result of healthcare pro-
fessionals over-reliance on Telemedicine in
response to ER guidance or healthcare pro-
fessionals fear invasive medical procedures
due to misinterpreting ER guidance [35].
ER has been found to have led to the isola-
tion of the elderly from their support sys-
tems which could have negative outcomes
related to physical injuries or mental health
conditions such as depression [36, 37].
There is a need for ER to have a component
that addresses empathy in its reporting.This
component will hopefully address the inclu-
sion of empathy in the plans or activities of
governments, institutions and healthcare
professionals utilize to address health chal-
lenges.
References
1. Xiao J, Chiu EYC, Gao H, Wong JY, Fong
MW, Syu S, Cowling BL. Nonpharmaceutical
measures for pandemic influenza in nonhealth-
care settings personal protective and environ-
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gov/eid. 2020.26 (5), 965-975 doi.https://doi.
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2. Taubenberger JK, Morens DM. 1918 influenza:
the mother of all pandemics. Emerging Infec-
tious Diseases. www.cdc.gov/eid. 2006, 12, 12
(1), 15-22
3. Adhikari SP, Meng S, Wu YJ et al. Epidemiol-
ogy, causes, clinical manifestation and diagnosis,
prevention and control of coronavirus disease
(COVID-19) during the early outbreak period:
a scoping review. Infect Dis Poverty, 2020; 9:29
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diagnosis and treatment of ­
COVID-19. Int J
Antimicrob Agents. 2020 May; 55(5): 105955.
5. Ahn DG, Shin HJ, Kim MH et al. Current Sta-
tus of Epidemiology, Diagnosis, Therapeutics,
and Vaccines for Novel Coronavirus Disease
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2020 Mar 28;30(3):313-324.
6. Lai CC, Shih TP, Ko WC et al. Severe acute
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7. Shi,Y.,Wang, G., Cai, X. P., Deng, J.W., Zheng,
L., Zhu, H. H., Zheng, M.,Yang, B., & Chen, Z.
(2020). An overview of ­
COVID-19. Journal of
Zhejiang University. Science. B, 21(5), 343–360.
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the emerging 2019 novel coronavirus pneumonia
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­
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14. Last JM, Greenland S. A dictionary of epidemi-
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15. Report of the technical discussions at the twenty
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18. Last JM. Ed. Dictionary of epidemiology. Sec-
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19. Friis RH, Sellers TA. Epidemiology of public
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20. Department of health of the Australian govern-
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21. Lewin PJ, Gebbie EN, Qureshi K. Can the
healthcare system meet the challenge of pan-
demic flu? Planning, ethical and workforce con-
siderations. Public Health Rep. 2007, 122 (5),
573-578
22. Suu K, Chen J, Viboud C. Early epidemiologi-
cal analysis of the coronavirus disease 2019 out-
break based on crowdsourced data a population-
level observational study. Lancet Digital Health.
2020, 2: e201-8
23. Singer, T., Klimecki, O., 2014. Empathy and
compassion. Curr. Biol. 24 (18), R875–R878.
24. Ekman,E.,Krasner,M.,2017.Empathy in med-
icine: neuroscience, education and challenges.
Medical Teacher 39 (2), 164–173. https://doi.
org/10.1080/0142159X.2016. 1248925.
25. Riess, H., 2018. The Empathy Effect. Sounds
True Inc, Bolder Colorado.
26. Hodges, S. D., Myers, M. W. Empathy. In R. F.
Baumeister, & K. D. Vohs, Encyclopedia of So-
cial Psychology. 2007, 296-298.
27. Sudeh C-S, Hole AR, Mead N, McDonald R,
Whalley D, Bower P, Roland M. What patients
want from primary care consultations: A discrete
choice experiment to identify patients’priorities.
Ann Fam Med. 2008; 6:107–115.
28. Hodgson I. Empathy, inclusion and enclaves:
The culture of care of people with HIV/AIDS
and nursing implications. J Adv Nurs. 2006;
55:283–290.
BACK TO CONTENTS
36
Covid-19 Pandemic
29. Webster D. Promoting empathy through a crea-
tive reflective teaching strategy: A mixed-meth-
od study. J Nurs Educ. 2010; 49(2):87–94.
30. Emanuele Torri, Luca Gino Sbrogiò, Enrico
Di Rosa, Sandro Cinquetti, Fausto Francia, and
Antonio Ferro, Italian Public Health Response
to the ­
COVID-19 Pandemic: Case Report from
the Field, Insights and Challenges for the De-
partment of Prevention, Int J Environ Res Pub-
lic Health. 2020 May; 17(10): 3666.
31. Catrin Sohrabi, Zaid Alsafi, Niamh O’Neill,
Mehdi Khan, Ahmed Kerwan, Ahmed ­Al-Jabir,
Christos Iosifidis, and Riaz Aghad, World
Health Organization declares global emergency:
A review of the 2019 novel coronavirus (COV-
ID-19), Int J Surg. 2020 Apr; 76: 71–76.
32. Isere EE, Adejugbagbe AM, Oladoyin V,
Abiona S, Omorogbe EN. Pre-symptomatic
and asymptomatic ­
COVID-19 cases in Nige-
ria amidst prevailing socio-cultural beliefs, and
practices,implications for ­
COVID-19 transmis-
sion and way forward. Archives of Preventive
Medicine. 2020. 5(1), v038-042. Doi.https//
dx.doi,org/10.17352/apm.000018
33. Van de Groep S, Zanolie K, Green KH, Sweijen
SW, Crone EA. A daily diary study on adoles-
cents’ mood, empathy, and prosocial behavior
during the ­
COVID-19 pandemic. PLoS ONE
15 (10) (2020) e0240349.
34. Settersten, RA Jr., Bernardi L, Härkönen J, An-
tonucci TC, Dykstra PA, Heckhausen J, et al.
The effects of ­
COVID-19 through a life course
lens. Current perspective of aging and life cycle.
2020. doi: 10.1016/j.alcr.2020.100360
35. Scott AM, Van Scoy LJ. What counts as “good”
clinical communication in the ­
COVID-19
era and beyond? Chest. 2020:1-2. https://doi.
org/10.1016/j.chest.2020.05.539
36. Schade EC,Elkaddoum R,Kourie HR.The psy-
chological challenges for oncological patients in
times of ­
COVID-19 pandemic: telemedicine, a
solution? Future Oncol. 2020
37. Shea EO, Ruiz M, Reina A. Remembering peo-
ple with dementia during the covid-19 crisis.
HRB Open Res. 2020; 3
38. Chochinov HM, Bolton J, Sareen J. Death, dy-
ing and dignity in the time of the ­
COVID-19
pandemic. J Palliat Med. 2020, 1-2. http://www.
ncbi.nlm.nih.gov/pubmed/32639895
Dabota Yvonne Buowari,
Department of Accident
and Emergency, University
of Port Harcourt Teaching Hospital,
Port Harcourt, Rivers State,
Nigeria
Ogundipe Damilola Habeeb,
Department of Surgery, University
College Hospital, Ibadan, Nigeria
Musliu Adetola Tolani,
Division of Urology,
Department of Surgery,
Ahmadu Bello University
and Ahmadu Bello
University Teaching Hospital,
Zaria, Kaduna State,
Nigeria
Francesco Rosiello, Department
of Public Health and Infectious
Disease, Sapienza-Universita
di Roma, Roma 00100(RM),
Italy
Damilola Ayowole,
Federal Medical Centre, Owo,
Ondo State
Lwando Maki,
Department of Medicine,
University of Cape Town, Cape Town,
South Africa
E-mail: Lwando.Maki@uct.ac.za
A health system consists of all organiza-
tions, people and actions whose primary
intent is to promote, restore or maintain
health [1].This includes efforts to influence
determinants of health as well as more direct
health-improving activities [1]. Hospital-
based services (HBS) are a vital component
to a health system: they are an important
endpoint in a health systems patient referral
pathway and play a key role in supporting
primary level health services [2]. Globally,
HBS are a limited resource and the lower-
income countries tend to have greater chal-
lenges in HBS resource availability than the
high-income countries [3]. There are on
average only 113 hospital beds per 100,000
inhabitants in low-income countries less
than half the number in other developing
countries and around 80% below high-in-
come countries [3]. The difficulty for coun-
tries to achieve their HBS goals was further
compounded on the 11th
March 2020 when
WHO declared that ­
COVID-19 can be
categorized as a pandemic [4].
Impact of ­COVID-19 on
hospital-based services
COVID-19 has posed serious challenges to
health systems globally HBS being impact-
Shiv Joshi Rujvee Patel Lwando Maki
The Impact of ­
COVID-19 Pandemic on Hospital-Based Health Services
BACK TO CONTENTS
37
Covid-19 Pandemic
ed [3]. Low-income, as well as high-income
countries, are struggling to mitigate this
outbreak and to efficiently manage and em-
ploy health resources [3, 5]. The pandemic
resulted in countries needing to alter their
HBS with prioritization of services being
reviewed; the result of the review was not
the same for all countries and we shall look
at the impact it had on HBS [6–9]. The
number of ICU beds, ventilation devices,
hospital admissions, and ICU admissions
per day due to ­
COVID-19 is found to be
the important predictors of mortality in the
USA, Italy, Spain, and Germany [10]. An
urgent need to expand hospitals’ infrastruc-
ture and services and increase the produc-
tion of devices used to treat patients with
­
COVID-19 was emphasized [10].
COVID-19 resulted in countries mainly
categorizing health services into essen-
tial and non-essential health services [5].
Across the five WHO regions, 66% of re-
sponding countries had defined essential
health services to be maintained during the
­
COVID-19 pandemic through a national
policy or document [5]. However, almost
90% of the countries experienced disrup-
tion of these services to some extent, with
greater disruptions being reported in low-
and-middle-income countries as compared
to the high-income countries [5]. Fig-
ure 1 illustrates that low to low-middle in-
come countries had more disruption of ser-
vice [5]. It was also found that the Eastern
Mediterranean Region was the most affect-
ed, followed by the African and the South-
East Asia Regions while the services in the
countries in the European and the Western
Pacific Regions were the least affected [5].
The most frequently disrupted services in-
cluded: routine immunization services  –
outreach services (70%) and facility-based
services (61%), non-communicable disease
diagnosis and treatment (69%),family plan-
ning and contraception (68%), treatment
for mental health disorders (61%), antenatal
care (56%) and cancer diagnosis and treat-
ment (55%) [5].
Literature has found that there is a major
burden of cancelled elective surgery due to
the ­
COVID-19 pandemic; there is a risk
that delayed treatment can result in disease
progression that can cause the patient sig-
nificant disability, poor quality of life and
possible death [11]. Stratified by specialty
and indication (surgery for cancer versus
benign disease The delay in treatment also
has a significant impact on HBS as disease
progression/complication can impact bud-
get expenditures due to longer patient hos-
pital stays and frequent use of HBS [12,13].
Further, the role of political leaders and
healthcare officials in ensuring that mini-
mum resources are safely provided, includ-
ing staff, hospital beds, and ICU is impor-
tant [10].
The pandemic is an extraordinary situation
that can affect parts of the world differently.
The hospitals need to employ context-spe-
cific resource allocation strategies in order
to cope up with the urgent demand for
healthcare services which should essentially
lie within the constructs of the core ethical
principles of autonomy, beneficence, non-
maleficence and justice. The effect of such
strategies can have long term implications in
terms of strengthening of the health system.
References
1. WHO. Everybody’s business: strengthening
health systems to improve health outcomes:
WHO’s framework for action. Production [In-
ternet]. 2007;1–56. Available from: http://www.
who.int/healthsystems/strategy/everybodys_
business.pdf
2. WHO. Hospitals in the health system [Inter-
net]. Who. 2020 [cited 2021 Mar 3]. Available
from: https://www.who.int/hospitals/hospitals-
in-the-health-system/en/
3. COVID-19 and the least developed countries.
In: Development Policy and Multilateralism af-
ter ­
COVID-19 [Internet]. UN; 2020. p. 45–52.
Available from: https://www.un-ilibrary.org/
content/books/9789210051828c008
4. OMS. WHO Director-General’s opening re-
marks at the media briefing on ­
COVID-19 – 11
March 2020 [Internet]. WHO Director Gen-
eral’s speeches. 2020 [cited 2021 Mar 3]. p. 4.
Available from: https://www.who.int/director-
general/speeches/detail/who-director-general-
s-opening-remarks-at-the-media-briefing-on-
covid-19—11-march-2020
5. WHO. Pulse survey on continuity of essential
health services during the ­
COVID-19 pan-
demic. Pulse Surv Contin Essent Heal Serv
Dur ­
COVID-19 pandemic [Internet]. 2020;
23%
45%
30%
13%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Global (n=105) Low income (n=22) Lower-middle income
(n=33)
Upper-middle income
(n=23)
High income (n=27)
Percentage
of
countries
Income Group
Figure 1.
Percentage of countries reporting at least partial disruption in at least 75% of es-
sential services (n=105) [5]
BACK TO CONTENTS
38
Covid-19 Pandemic
­
(August):1–21. Available from: https://www.
who.int/publications/i/item/WHO-2019-
nCoV-EHS_continuity-survey-2020.1
6. Lai AG, Pasea L, Banerjee A, Hall G, Denaxas
S, Chang WH, et al. Estimated impact of the
­
COVID-19 pandemic on cancer services and
excess 1-year mortality in people with cancer
and multimorbidity: Near real-time data on can-
cer care, cancer deaths and a population-based
cohort study. BMJ Open. 2020 Nov 17;10(11).
7. Yeung CA. Provision of dental hospital services
during the ­
COVID-19 epidemic. Vol. 21, Evi-
dence-Based Dentistry. Springer Nature; 2020.
p. 63.
8. Nuñez JH, Porcel JA, Pijoan J, Batalla L, Teixi-
dor J, Guerra-Farfan E, et al. Rethinking Trau-
ma Hospital Services in one of Spain’s Largest
University Hospitals during the ­
COVID-19
pandemic. How can we organize and help? Our
experience. Injury. 2020 Dec 1;
9. Lim ZJ, Ponnapa Reddy M, Afroz A, Billah
B, Shekar K, Subramaniam A. Incidence and
outcome of out-of-hospital cardiac arrests in
the ­
COVID-19 era: A systematic review and
meta-analysis. Resuscitation. Elsevier Ireland
Ltd; 2020.
10. Cobre A de F, Böger B, Vilhena R de O, Fachi
MM, dos Santos JMMF, Tonin FS. A multi-
variate analysis of risk factors associated with
death by ­
COVID-19 in the USA, Italy, Spain,
and Germany. Journal of Public Health (Ger-
many). Springer Science and Business Media
Deutschland GmbH; 2020.
11. Nepogodiev D, Omar OM, Glasbey JC, Li E,
Simoes JFF, Abbott TEF, et al. Elective sur-
gery cancellations due to the ­
COVID-19 pan-
demic: global predictive modelling to inform
surgical recovery plans. Br J Surg. 2020 Oct
1;107(11):1440–9.
12. Shrime MG, Dare A, Alkire BC, Meara JG.
A global country-level comparison of the finan-
cial burden of surgery. Br J Surg. 2016;
13. Shrime MG, Dare AJ, Alkire BC, O’Neill K,
Meara JG. Catastrophic expenditure to pay for
surgery worldwide: A modelling study. Lancet
Glob Heal. 2015.
Shiv Joshi,
Community Medicine, MGIMS,
Sewagram, India
Jihoo Lee,
Internal Medicine,
Seoul National University
Hospital, Seoul, South Korea
Rujvee Patel,
Yale School of Public Health, USA
Lwando Maki,
Department of Medicine,
University of Cape Town, Cape
Town, South Africa
E-mail: Lwando.Maki@uct.ac.za
In the context of the Sars Cov2 Pandem-
ic, Albania had a total number of cases of
134746 [1], confirmed during the 65 weeks
of the pandemic. Until June 6th
2021, the
incidence of ­
COVID-19 disease in Alba-
nia was 4707.4 cases per 100000 inhabit-
ants and the mortality was 85.6 deaths per
100000 inhabitants [2]. The first case of
Covid 19 was diagnosed on March 8th
2020.
The vaccination process started on Janu-
ary 11th
2021 and continues at an acceler-
ated rate throughout the target population.
The vaccines used were Comirnaty-Pfizer-
BioNTech, Coronavac-Sinovac, Vaxzevria-
Astrazeneca, Covishield-Astrazeneca and
Gam-Covid-vac, Gamaleya. No significant
side effects were observed during the vac-
cination process in the population receiving
the vaccine [2].
The ­COVID-19 infection in Albania as well
as in other countries has had epidemiologi-
cal waves, with a peak in early autumn and
January – March 2021 [2, 3, 4]. The course
of cases and incidence according to different
periods is presented in the following graph:
Covid-19 Infection and the Vaccination Process in Albania
0
20
40
60
80
100
120
140
160
180
10 11 12 13 14 15 16 17 18 19 20 21 22
Incidence
per
100000
inhabitants
Week
Incidenca 2020 Incidenca 2021
Figure 1.2.
Incidence of confirmed cases ­
COVID-19 by weeks for the years 2020-2021
ALBANIA
Silva Bino Erida Nelaj Gjeorgjina Kuli Lito
Fatmir Brahimaj
BACK TO CONTENTS
39
Covid-19 Pandemic
Figure 1.1 shows the incidence from the
10th
week of 2020 and 2021 compared be-
tween them, which shows a lower incidence
for the same period in 2020.
Figure 1.2 shows the distribution of
­
COVID-19 confirmed cases for the period
from week 10 of 2020 to week 22 of 2021.
The daily average of new cases for week
22 of 2021 was 10.9 cases/day [2, 5].
The percentage of positivity in week 22 of
2021 was 0.4%. The distribution of cases
by age group was as in figure 2. The high-
est number of confirmed cases belongs to
the age group 55–64 years with 21% of con-
firmed cases, followed by the age group 45–
54 years with 17% of confirmed cases. It was
noticed that the age group 65–74 years oc-
cupied a considerable percentage of 14% [2].
Whereas figure 2.1 is presented the in-
cidence according to age groups per 100
000 inhabitants. The highest incidence of
affected cases was in the age group 65–74
years,followed by the age group 55–64 years
[1, 2].
Figure 3 shows the prevalence of fatalities
by pandemic weeks [4, 6]
Vaccination against ­
COVID-19 started on
the date with the Comirnaty® vaccine (Pfiz-
er/BioNTech) for the most identified prior-
ity groups of health workers as follows; (2)
• Health workers of ­
COVID hospitals
• Health workers of laboratories diagnos-
ing ­COVID-19;
• Health workers who perform sampling
or nasopharyngeal tampons and conduct
field investigation;
• Health workers who work in emergency
services and intensive care
• Health workers working in infectious dis-
ease, pneumology and paediatrics services
of infectious diseases.
A second phase involved all individuals
living in long-term care institutions along
with the staff working in them.
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
0
5000
10000
15000
20000
25000
30000
35000
40000
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21
%
Number of cases
Week
Te konfirmuar testime % pozitivitetit
Figure 1.2.
Percentage of positivity for COVID-19 in the tested samples
0-4 vjec
1%
5-14 vjec
2%
15-24 vjec
7%
25-34 vjec
16%
35-44 vjec
15%
45-54 vjec
17%
55-64 vjec
21%
65-74 vjec
14%
75+ vjec
7%
Figure 2.1.
Distribution of confirmed cases by age groups (%)
610.2 609.2
2037.7
4543.8
5422.0
5705.7
6450.4
6923.8
5410.5
0.0
1000.0
2000.0
3000.0
4000.0
5000.0
6000.0
7000.0
8000.0
0-4 vjec 5-14 vjec 15-24 vjec 25-34 vjec 35-44 vjec 45-54 vjec 55-64 vjec 65-74 vjec 75+ vjec
Figure 2.2.
Incidence by age group per 100000 inhabitants
ALBANIA
BACK TO CONTENTS
40
Covid-19 Pandemic
With the increase of the quantities of in-
coming vaccines, the vaccination of the el-
derly has continued,starting from the age of
90+ and gradually decreasing until the age
bands of 60+. In parallel with them are con-
ducted teachers, law enforcement, tourism
staff as well as employees working in key
institutions for the country.
Gradually, each CHU has opened its own
vaccination points in special facilities (facil-
ities where sports, cultural or school activi-
ties take place) as well as in health centres.
Until the 22nd
epidemiological week the
quantities of vaccines received and the doses
administered for each of them are as follows:
• 134,550 doses Comirnaty-Pfizer-BioN-
Tech/96,726 doses administered
• 560,000 doses Coronavac-Sinovac/
542,221 doses administered
• 120,000 doses Vaxzevria-Astrazeneca/
89,359 doses administered
• 50,000 doses Covishield-Astrazeneca/
47,808 doses administered
• 35,000 doses of Gam-Covid-vac, Gama-
leya/ 25,558 doses administered
Table 1.
Total vaccinations against ­
COVID
until the 22nd
week
Covid-19 vaccination
Number of
doses
First doses 492,905
Second doses 308,767
Total number of
administered doses
801,672
In Albania, from 3 January 2020 to 17 June
2021, there have been 132,476 confirmed
cases of ­
COVID-19 with 2,454 deaths, re-
ported to WHO. As of 6 June 2021, a total
of 798,826 vaccine doses have been admin-
istered [3].
References
1. https://www.worldometers.info/coronavirus/
country/albania/
2. Buletini ISHP java 23
3. https://covid19.who.int/region/euro/country/al
0
20
40
60
80
100
120
140
160
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 1 3 5 7 9 11 13 15 17 19 21
Number
of
deaths
Week
Figure 3.
Distribution of fatalities by weeks
Figure 4. Doses administered per vaccine type
Figure 5. Doses administered by type of vaccine
ALBANIA
BACK TO CONTENTS
41
Covid-19 Pandemic
4. http://www.instat.gov.al/en/
5. https://www.oecd.org/south-east-europe/
COVID-19-Crisis-in-Albania.pdf
6. https://ourworldindata.org/coronavirus/coun-
try/albania
Fatmir Brahimaj, MD
President, National Council, Order
of physicians of Albania
Silva Bino, MD, Ph.D
Director, Public Health Institute
Erida Nelaj, MD, PH D
Director, Public Health Institute
Gjeorgjina Kuli Lito, Md, PH.D
Head of pediatric service in “Mother
Teresa” University Hospital Figure 6. Coverage of the target population with the first dose
Personal protective equipment (PPE)
is an article used to prevent the wearer
from coming in contact with hazardous,
infectious, chemical, radiological, electri-
cal, and physical agents [1]. It is worn to
protect health care workers or any other
persons from getting infected. The World
Health Organization (WHO) has listed
the following as PPE for the prevention
and control of coronavirus disease 2019
(­COVID-19):
• Medical/surgical masks hereafter referred
to as ‘medical masks’,
• Filtering facepiece respirators hereafter
referred to as ‘respirators’,
• Gloves, goggles, face shields and gowns
[2].
According to the WHO, masks are clas-
sified broadly into two categories: medical
and non-medical/fabric masks. The WHO
defines a medical mask as a surgical or pro-
cedure mask that is flat or pleated, affixed
to the head with straps that go around the
ears or head, or both [3]. They must block
droplets and particles while at the same time
they must also be breathable by allowing air
to pass. Medical masks are regulated medical
devices [3]. For the fabric masks, the WHO
has recommended a three-layer composition:
an inner layer of hydrophilic material, for ex-
ample, cotton; a middle layer of polypropyl-
ene spun bond hand-woven fabric material;
and an outer layer of a hydrophobic material,
for example, synthetic material [4].
Studies have shown that medical masks ef-
fectively control respiratory virus transmis-
sion in households and health care settings
[5–9].Studies of influenza,influenza-like ill-
ness, and human coronaviruses (not includ-
ing ­
COVID-19) provide evidence that the
use of a medical mask can prevent the spread
of infectious droplets from an asymptomatic
infected person (source control) to someone
else and potential contamination of the envi-
ronment by these droplets [5–7]. Therefore,
medical masks are vital in the fight against
viruses transmitted via respiratory droplets.
On 11th
March 2020, the WHO charac-
terised ­
COVID-19 as a pandemic [10]. Se-
vere acute respiratory syndrome coronavirus
2 (SARS-CoV-2), the strain of coronavirus
Medical Masks and their Challenges during the ­
COVID-19 Pandemic
Chigozie Clarence
Ozurumba
Ugbeda Timothy
Ojima
Natasha Roya
Matthews
Mary Adaeze
Obi
Lwando Maki
Debra Ukamaka
Okeh
BACK TO CONTENTS
42
Covid-19 Pandemic
that causes ­
COVID-19, is transmissible via
respiratory droplets, contact or aerosol [3].
The WHO advises using masks as part of
a complete package of prevention and con-
trol measures to curb the spread of SARS-
CoV-2. Even when used correctly, a mask
alone does not sufficiently provide adequate
protection or source control [3].
Other infection prevention and control
(IPC) measures include hand hygiene, the
physical distancing of at least one metre,
avoidance of touching one’s face, respiratory
etiquette, adequate ventilation in indoor
settings, testing, contact tracing, quaran-
tine, isolation and vaccination [3, 11] To-
gether, these measures are critical to prevent
human-to-human transmission of SARS-
CoV-2 and serious illness or death from
­COVID-19 [3].
According to the WHO, in areas of known
or suspected community transmission),uni-
versal masking for all persons (staff,patients,
visitors,service providers and others) within
the health facility is recommended [3].Like-
wise, targeted continuous medical masking,
the practice of mask-wearing by all health
workers in clinical areas where patients are
present, is advised [3]. Health workers pro-
viding direct care to ­
COVID-19 patients
should wear a medical mask (in addition
to other PPE). Where aerosol-generating
procedures are performed, health work-
ers should wear a respirator continuously
throughout the entire shift [3]. The WHO
further recommends that persons with any
symptoms suggestive of ­
COVID-19 and
caregivers or those sharing living space with
people with suspected ­
COVID-19 should
also wear a medical mask [3]. The wearing
of non-medical masks in places where close
gatherings are inevitable, like in work and
school environments, as well as, maintain-
ing good hand hygiene when handling the
mask, is also advised. Those not supposed
to wear a mask include children below two
years, people with breathing problems, un-
conscious, or anyone who cannot remove
their mask by themselves [12].
Challenges
Access to masks
China is the leading manufacturer of masks
in the world; it contributes about fifty per
cent to global mask production [13]. The
­
COVID-19 outbreak increased the demand
for masks and resulted in a shortage in the
worldwide supply [14-16]. The WHO esti-
mated that 89 million medical masks were
needed monthly to meet the global demand,
requiring a forty per cent increase in pro-
duction of the masks [17]. The shortage of
masks caused by rising demand, panic buy-
ing, hoarding and misuse put lives at risk
from the new coronavirus and other infec-
tious diseases [17, 18]. Low-resource coun-
tries were the most affected, with healthcare
professionals in public service not having
masks and procuring them by their own
means [13, 16, 17, 19–23].
Quality of masks
Inadequate quality control standards for
the manufacturing of masks have been
reported in Asian [24, 25] and African
countries. Various types of cloth masks
(i.e. cotton/woven or gauze) are widely uti-
lized in various healthcare settings in re-
source-poor countries. In countries such as
China and Vietnam, where the historical
risk from emerging infections is high, the
use of cloth masks by health care workers
is widespread, despite that they are rarely
mentioned in infection control policies
and guidelines [21].
Cost of masks
Globally,since the onset of the ­COVID-19
pandemic, the cost of masks has surged
[3, 16, 26]. The cost increase occurred in
both low and high-income countries with
an increase of 319%, 220% and 600% in
the United States, Russia and Nigeria, re-
spectively [14, 15, 17, 20]. The high-cost
impacts access to masks with the low-
income countries being more affected [13,
16, 20, 27].
Use of masks
The available literature has shown that in-
correct usage of masks is substantial, with:
1. fabric mask used in health care set-
tings;
2. medical masks used for longer periods
than the recommended extended use
policy;
3. the single-use mask being reused [23,28].
This misuse leads to an increased risk of
transmission of ­
COVID-19 [14, 29, 30];
and is also associated with:
1. incorrect wearing techniques [23].
2. the mask being a source of infection [3];
3. poor comfortability and skin injury [3].
The use of a mask alone is insufficient to
prevent ­
COVID-19 infection. The imple-
mentation of other social and hygienic be-
haviours is also required [3,9].The literature
has shown that stigma arises when mask-
wearing is only for those with the disease or
high risk. Therefore, universal masking also
decreases stigma against ­
COVID-19 posi-
tive patients as all individuals wear a mask
[28].
The global health community is still work-
ing towards the goal of improved access and
affordability of masks to help control the
spread of ­
COVID-19 [13, 15–17, 20]. It is
an ethical responsibility for healthcare em-
ployers to ensure medical masks are avail-
able to all healthcare workers, irrespective
of gender, age, socioeconomic status, race,
religion, tribe, or sexual orientation [22, 31,
32]. The misuse and irrational use of the
masks pose a danger to the control of the
­
COVID-19 pandemic. Improper mask use
does not prevent the spread of ­
COVID-19
among the population; rather, it potentiates
its spread, as well as, the spread of other
disease conditions [28]. Individuals and or-
ganizations must be trained and supported
to assume responsibility in their use of
the appropriate mask in the correct man-
ner, as per their country’s laws/regulations
[28, 32].
BACK TO CONTENTS
43
Covid-19 Pandemic
References
1. Mahmood SU, Crimbly F, Khan S, Choudry
E, Mehwish S. Strategies for Rational Use of
Personal Protective Equipment (PPE) Among
Healthcare Providers During the ­
COVID-19
Crisis. Cureus. 2020;12(5).
2. World Health Organization. Rational use of
personal protective equipment for coronavi-
rus disease (COVID-19) and considerations
during severe shortages. Interim guidance 6
April 2020 [Internet]. 2020 [cited 2020 Oct
19]. Available from: https://apps.who.int/
iris/bitstream/handle/10665/331695/WHO-
2019-nCov-IPC_PPE_use-2020.3-eng.
pdf?sequence=9&isAllowed=y
3. World Health Organization. Advice on the use
of masks in the context of ­
COVID-19: interim
guidance-2. 2020 Jun 5;1–5. Available from:
https://www.who.int/docs/default-
4. World Health Organization. Q&A: Masks
and ­
COVID-19 [Internet]. 2020 [cited 2020
Aug 21]. Available from: https://www.who.int/
emergencies/diseases/novel-coronavirus-2019/
question-and-answers-hub/q-a-detail/q-a-on-
covid-19-and-masks
5. Canini L, Andreoletti L, Ferrari P, D’Angelo
R, Blanchon T, Lemaitre M. Surgical mask
to prevent influenza transmission in house-
holds: a cluster randomized trial. PLoS One.
2010;5(11):e13998.
6. MacIntyre C, Zhang Y, Chughtai A, Seale H,
Zhang D,Chu Y.Cluster randomised controlled
trial to examine medical mask use as source
control for people with respiratory illness. BMJ
Open. 2016;6(12):e012330.
7. MacIntyre C, Cauchemez S, Dwyer D, Seale H,
Cheung P, Browne G, et al. Face mask use and
control of respiratory virus transmission in house-
holds. Emerg Infect Dis. 2009;15(2):233–41.
8. Wong S, Teoh J, Leung C, Wu W, Yip B, Wong
M, et al. ­
COVID-19 and public interest in
face mask use. Am J Respir Crit Care Med.
2020;202(3):453–5.
9. Schunemann H, Akil E, Chou R, Chu D, Loeb
M,LotfiT.Use of face masks during ­COVID-19
pandemic. Lancet Respir Med. 2020 Aug 30;
10. World Health Organization. WHO Director-
General’s opening remarks at the media brief-
ing on ­
COVID-19  – 11 March 2020 [In-
ternet]. 2020 [cited 2020 Sep 3]. Available
from: https://www.who.int/director-general/
speeches/detail/who-director-general-s-open-
ing-remarks-at-the-media-briefing-on-covid-
19—11-march-2020
11. World Health Organization. ­
COVID-19 advice
for the public: Getting vaccinated [Internet].
2021 [cited 2021 Apr 4].Available from: https://
www.who.int/emergencies/diseases/novel-coro-
navirus-2019/covid-19-vaccines/advice
12. Eikenberry S, Mancuso M, Iboi E, Phan T,
Eikenberry K, Kuang Y, et al. To mask or not to
mask: Modeling the potential for face mask use
by the general public to curtail the ­
COVID-19
pandemic. Infect Dis Model. 2020;5:293–308.
13. Wu H, Huang J, Zhang C, He Z, Ming W.
Facemask shortage and the novel coronavirus
disease (COVID-19) outbreak: Reflections on
public health measures. Lancet. 2020;21:1–7.
14. Aloui-Zarrouk Z, El Youssfi L, Badu K, Fag-
bamigbe A, Matoke-Muhia D, Ngugi C, et al.
The wearing of face masks in African countries
under the ­
COVID-19 crisis: luxury or necessity?
AAS Open Res. 2020;3:36.
15. Organisation for Economic Co-operation and
Development. Africa’s Response to ­
COVID-19:
What roles for trade, manufacturing and intel-
lectual property? Paris: OECD; 2020.
16. Mehrotra P, Malani P, Yadav P. Personal
Protective Equipment Shortages During
­
COVID-19—Supply Chain–Related Causes
and Mitigation Strategies [Internet]. 2020
[cited 2020 Sep 1]. Available from: https://ja-
manetwork.com/channels/health-forum/fullar-
ticle/2766118
17. World Health Organization. Shortage of per-
sonal protective equipment endangering health
workers worldwide [Internet]. 2020 [cited 2020
Aug 31]. Available from: https://www.who.int/
news-room/detail/03-03-2020-shortage-of-
personal-protective-equipment-endangering-
health-workers-worldwide
18. Ji D, Fan L, Li X, Ramakrishna S. Address-
ing the worldwide shortages of face masks.
BMC Mater [Internet]. 2020;2(1):1–11. Avail-
able from: https://doi.org/10.1186/s42833-020-
00015-w
19. McMahon D, Peters G, Ivers L, Freeman E.
Global resource shortages during ­
COVID-19:
Bad news for low-income countries. PloS Negl
Trop Dis. 2020;14(7):e0008412.
20. Organisation for Economic Co-operation and
Development. The Face Mask Global Value
Chain in the ­
COVID-19 Outbreak: Evidence
and Policy Lessons. Paris: OECD; 2020.
21. Chughtai A, Seale H, PhD T, Maher L, Nga
P, MacIntyre C. Current practices and barriers
to the use of facemasks and respirators among
hospital-based health care workers in Vietnam.
Am J Infect Control. 2015;43(1):72–7.
22. Chersich M, Gray G, Fairlie L, Eichbaum Q,
Mayhew S, Allwood B, et al. ­
COVID-19 in Af-
rica: care and protection for frontline healthcare
workers. Glob Heal. 2020;46(16):1–6.
23. Ogoina D. Improving Appropriate Use of Med-
ical Masks for ­
COVID-19 Prevention: The Role
of Face Mask Containers. Am J Trop Med Hyg.
2020;103(3):965–6.
24. L H. ­
COVID-19 and face mask crises: wear-
ing a low-quality mask is potentially dangerous.
BMJ. 2020;369:m2005.
25. Chua M, Cheng W, Goh S, Kong J, Li B, Lim J,
et al. Face Masks in the New ­
COVID-19 Nor-
mal: Materials, Testing, and Perspectives. Re-
search. 2020;2020:1–40.
26. Nigeria Centre for Disease Control. Use of
Cloth Face Masks [Internet]. 2020 [cited 2020
Aug 24]. p. 1–4. Available from: https://covid19.
ncdc.gov.ng/media/files/UseOfClothFace-
Masks.pdf
27. Ebrahimy E, Igan D, Peria S. The Impact of
­
COVID-19 on Inflation: Potential Drivers and
Dynamics.IMF ­
COVID-19 Spec Ser.2020;1–14.
28. Feng S, Shen C, Xia N, Song W, Fan M,
Cowling B. Rational use of face masks in the
­
COVID-19 pandemic. Lancet Respir Med.
2020;8(5):434–6.
29. Aminnejad R, Hormati A.The Equal Danger of
Improper Use of Face Mask and Use of Improper
Mask. Arch Clin Infect Dis. 2020;e103100:1–2.
30. Swarna PB, Begum J H, Priya M Y. An Assess-
ment on the Awareness and Education among
General Public 
: Concerning Rational Use of
Face Masks during the ­
COVID-19 Pandemic.
Int J Pharm Pharm Res. 2020;18(3):2–13.
31. World Health Organization. Rolling updates on
coronavirus disease (COVID-19). 2020.
32. Jahn WT. The 4 basic ethical principles that ap-
ply to forensic activities are respect for auton-
omy, beneficence, nonmaleficence, and justice.
J Chiropr Med [Internet]. 2011;10(3):225–6.
Available from: http://dx.doi.org/10.1016/j.
jcm.2011.08.004
Debra Ukamaka Okeh,
Federal Medical Centre, Umuahia,
Abia, Nigeria; Brandeis University,
Massachusetts, USA
Chigozie Clarence Ozurumba,
Federal Medical Centre
Umuahia, Abia, Nigeria
Ugbeda Timothy Ojima,
Ahmadu Bello University Teaching
Hospital, Kaduna, Nigeria
Grace Ikpo Onyike,
Federal Medical Centre
Umuahia, Abia, Nigeria
Natasha Roya Matthews,
Faculty of Medical Leadership and
Management, London, UK
Mary Adaeze Obi,
The Hills Medical Centre, Benin, Nigeria
Lwando Maki,
Department of Medicine, University of
Cape Town, Cape Town, South Africa
E-mail: Lwando.Maki@uct.ac.za
BACK TO CONTENTS
44
Covid-19 Pandemic
Data from various sources correctly predict-
ed the third wave in advance before it oc-
curred. Most of the predictions were based
on the 2020 experience predictive models.
Furthermore, the rate of infections seem
to follow a seasonality pattern peaking be-
tween June- July and Dec  – Jan. Accord-
ing to John Hopkins University, the current
third wave appear to be at the same levels
as the first two (John Hopkins University,
17 June 2021) as depicted in figure 1 be-
low. Various ­
COVID variants that emerge
across multiple countries that may impact
the surge or ­
COVID-19 indicate a possibil-
ity of a 4th
wave.A survey study conducted in
Canada revealed that more than two-thirds
of the participants reported concerns about
the potential for a fourth [1]. The study has
further shown that participants depicting
those vaccines would mitigate the impact
of any future surge. Another report in the
United Kingdom (UK) illustrates that the
rising cases of ­
COVID-19 in Alberta and
British Columbia could result in the fourth
wave [2]. A recent report shows that Coun-
tries like Italy are already experiencing the
fourth wave.These few studies indeed depict
that the fourth wave is undoubtedly on the
near horizon, thus offering South Africa an
opportunity to plan and prepare for the 4th
wave and put measures in place for mid-
December. Nearly half (47%) of the France
population had been fully vaccinated as of
31 July 2021,relative to almost 5% (4.8%) in
South Africa, as depicted in figure 3 below.
France in the early window of the 4th
wave,
further illustrating a possibility in South Af-
rica. Preparedness also entails putting pro-
cesses and standards in place, and recently
a Bill was approved in France to tackle the
fourth wave [3]. Countries could certainly
use experiences from others to prepare for
what is imminent, and critical learnings
could be derived from interventions that did
not work in the previous waves.
COVID-19 Vaccination Drive
Various reports have depicted a surge in
­
COVID-19 cases in some countries as the
global demand for vaccines increases. Many
countries have also set targets to achieve
herd immunity, with some countries per-
forming better than others. South Africa
accounts for a significant proportion of Af-
rican ­
COVID-19 infections and deaths (un-
adjusted for population). Figure 2 below de-
pictsthatasof30July2021,SouthAfricahad
recorded a total of 2.4 million lives infected
by ­
COVID-19 disease, and nearly 72 000
had succumbed to ­
COVID-19.Comparison
figures for Morocco are 616 000 lives and
about 10 000 deaths, respectively [4]. Figure
2 further depicts that South African is al-
ready on the third wave while a country like
Morocco is still into the second wave with a
fully vaccinated population of 27.4% com-
pared to 4.8% in South Africa (see figure 3
below). However, what is also unique about
South Africa is the number of tests con-
ducted which are relatively high compared
Covid-19 Fourth and Subsequent Waves-Readiness and Preparedness
Michael Mncedisi Willie Sipho Kabane
Figure 1.
South African ­
Covid-19: third wave chart
Source: John Hopkins University, 17 June 2021
BACK TO CONTENTS
45
Covid-19 Pandemic
to other African countries (unadjusted).The
recent data indicates that South Africa has
achieved lower herd immunity as of 30 July
compared with neighbouring countries like
Zimbabwe and Botswana. Comparatively
speaking, Morocco has acquired higher herd
immunity, with nearly thirty percent of its
population fully vaccinated. Morocco is also
the hardest hit in Africa, with the second-
highest number of infections after South
Africa (unadjusted). Table 1 below depicts
key learnings from Morocco.
Types of Vaccines Approved in
South Africa and Morocco
According to track vaccines, South Africa
has six ongoing ­
COVID-19 vaccine clinical
trials,while in Morocco,there is one clinical
trial running [13]. Both countries have four
approved vaccines, with the Serum Institute
of India – Covishield (Oxford/AstraZen-
eca formulation) the only common vaccine
in the two countries. The following section
depicts a comparison analysis of the types of
Vaccines approved in two countries with the
highest numbers of COVD-19 cases. The
two countries also demonstrate evidence of
capacity to manufacture vaccines.
Strategies to Prevent the Surge
The case studies of South Africa and Mo-
rocco depicted in the previous section il-
lustrate that despite massive strategies and
drive for vaccinations, each country utilis-
ing its four types of approved vaccines. Evi-
dence presented also shows that even high
herd immunity levels in countries such as
Morocco are nearly twice that of China at
27.4% vs 15.5%, respectively (figure 3), the
numbers continue to rise.
Herd immunity
Literature and medical experts depict that
the purge of the ­
COVID19 epidemic can
Figure 2. ­
COVID-19 Key statistics for South Africa and Morocco as of 30 July 2021 [11]
Table 1. Morocco ­
COVID-19 Vaccine’s strategy- Key learnings [5]
Strategy employed Interventions
Optimal use of technology
“Any citizen or resident is automatically assigned to the
nearest vaccination centre using its digitised identity
card number, unlike South Africa where vaccination is
carried out in only 18 hospitals and is based on a pre-
vaccination registration and appointment system [6, 7].”
Anticipation and preparedness
With anticipations and preparedness of what was
reported elsewhere regarding vaccines demand, “As
early as August 2020, Morocco became one of the first
countries procure vaccines and placed orders [8].”.
In January 2021, the country confirmed orders of 65
million doses of vaccines:
•  British AstraZeneca – 25 million doses and
•  Chinese Sinopharm – 40 million doses.
Furthermore, the country announced an agreement with
Russia to deliver 8 m doses of the Sputnik vaccine. [9]
Mass communication strategy
“In August 2021, the health ministry deployed a large
communications campaign to provide information,
reassure and encourage people to get vaccinated [10].”
Early identification of vulner-
able groups and populations
at risk – use health insurance
files to identify patients with
chronic conditions.
“The country was proactive in early identifying vulner-
able groups and population at risks such as the elderly
and employed measures to reach these population
people and others who live in rural areas, for example,
are informed directly at their homes by social workers.”
BACK TO CONTENTS
46
Covid-19 Pandemic
be achieved with a herd immunity of be-
tween 50%-60% through a vaccine [16].
Kleczkowski estimates that 75% of the
population will need to be vaccinated to ac-
quire a herd immunity level of 67%, assum-
ing a vaccine efficacy of 90% [17]. Evidence
suggests that herd immunity level needs to
be pushed up as high as 86%. Studies have
shown varying efficacy levels across vac-
cines, and as depicted in the previous il-
lustration, a combination of more than one
approved vaccine in countries will still face
many challenges in demonstrating effec-
tiveness with their level of herd immunity.
Kleczkowski further warns that even with
higher immunity levels in high efficacy vac-
cines might not eradicate the pandemic.
“If a vaccine is only 50-70% effective, as the
Oxford and Sinovac vaccines appear to be, this
is the highest herd immunity level that can be
achieved if everybody gets the vaccine. Even
with the higher efficacy of the Pfizer and Mod-
erna vaccines, vaccinating nearly 90% of the
population will be very difficult, as not every-
body can or will want to be treated.” [18]
Table 3 below depicts other challenges that
many countries likely face with a combina-
tion of vaccines with varying efficacy levels.
Uncertainties on the emergence of new
variants, non-adherence to non-pharma-
ceutical interventions principally continue
to impact the surge.
Containment and
Mitigation Strategies
There is evidence that the numbers surge
exponentially as soon as there is a relaxation
on this measure.Stricter standards and poli-
cies such as lockdown, non-pharmaceutical
efforts are effective in flattening the curve.
Ferguson et al. showed the impact of self-
isolation in reducing influenza by 10%, and
the authors further showed the effective-
ness of using a combination of measures
such as school and workplace closures, ad-
equate border controls, and others to an ef-
fectiveness rate high as 70% [20]. Another
study by Brauner et al.found that closing all
educational institutions, limiting gatherings
to 10 people or less, and closing face-to-
face businesses each reduced transmission
considerably. The additional effect of stay-
at-home orders was comparatively small
[21]. Figure 4 below in a study conducted
by Haung, Geyrhofer, Londei et al. showed
small gathering cancellation, closure of
education institutions, border restrictions,
mass gathering cancellation and increased
Table 2.
Types of Vaccines Used: Comparison Analysis Between South Africa and
Morocco
Country COVID-19 Vaccines Vaccine Characteristics
Morocco
[14]
Gamaleya – Sputnik V
Oxford/AstraZeneca –
AZD1222
Serum Institute of India –
Covishield (Oxford/
AstraZeneca formulation)
Sinopharm (Beijing) –
BBIBP-CorV
Approved in 70 countries, 19 trials in
7 countries
Approved in 119 countries, 33 trials in
19 countries
Approved in 45 countries, 2 trials in 1 country
Approved in 59 countries, 7 trials in
7 countries
South
Africa
[15]
Pfizer/BioNTech-BNT162b2
Janssen (Johnson &
Johnson) – Ad26.COV2.S
Serum Institute of India –
Covishield (Oxford/
AstraZeneca formulation)
Sinovac-CoronaVac
Approved in 97 countries, 24 trials in
16 countries
Approved in 56 countries, 11 trials in
17 countries
Approved in 45 countries, 2 trials in 1 country
Approved in 39 countries, 16 trials in
7 countries
Figure 3.
Share of people fully vaccinated per hundred 31 July 2021 from select countries
Source: Our World in Data [12]
BACK TO CONTENTS
47
Covid-19 Pandemic
availability of PPEs as the most effective
government intervention [22]. With un-
certainly on herd immunity and limitations
depicted in this article, consistency in non-
pharmaceutical measures coupled with ag-
gressive vaccinations programs remains the
appropriate strategy to flattening the curve.
References
1. https://globalnews.ca/news/8066278/covid-
fourth-wave-canada-ipsos-poll/
2. https://globalnews.ca/video/8068980/covid-
19-resurges-in-bc-alberta-prompting-fears-of-
4th-wave
3. https://www.reuters.com/world/europe/french-
lawmakers-approve-bill-tackle-fourth-wave-
coronavirus-2021-07-25/
4. https://en.wikipedia.org/wiki/Template:
­COVID-19_pandemic_datattps://news.google.
com/covid19/as of 31 Jul 2021
5. https://www.oecd.org/coronavirus/policy-re-
sponses/flattening-the-covid-19-peak-contain-
ment-and-mitigation-policies-e96a4226/
6. South African Government. Electronic Vacci-
nation Data System (EVDS) Self Registration
Portal. https://www.gov.za/covid-19/vacci ne/
evds (31 July 2021, date last accessed).
7. Drissi Bourhanbour A, Ouchetto O. Morocco
achieves the highest ­
COVID-19 vaccine rates in
Africa in the first phase: what are reasons for its
success? J Travel Med.2021 Jun 1;28(4):taab040.
doi: 10.1093/jtm/taab040. PMID: 33748858;
PMCID: PMC8083781.
8. https://newafricanmagazine.com/25754/
9. https://newafricanmagazine.com/25754/
10. Drissi Bourhanbour A, Ouchetto O. Morocco
achieves the highest ­
COVID-19 vaccine rates in
Africa in the first phase: what are reasons for its
success? J Travel Med. 2021 Jun 1; 28(4)
11. Our World in Data. 2021. Statistics and Re-
search Coronavirus (COVID-19) Cases.
Sourced from “John Hopkins University CSSE
COVID-19 Data. Available at https://our-
worldindata.org/covid-cases
12. https://ourworldindata.org/covid-vaccinations
13. https://covid19.trackvaccines.org
14. https://covid19.trackvaccines.org/country/mo-
rocco/, as of 26 July 2021
15. https://covid19.trackvaccines.org/country/
SouthAfrica/, as of 26 July 2021
16. https://www.oecd.org/coronavirus/policy-re-
sponses/flattening-the-covid-19-peak-contain-
ment-and-mitigation-policies-e96a4226/
17. https://www.gavi.org/vaccineswork/mutating-
coronavirus-reaching-herd-immunity-just-got-
harder-there-still-hope?gclid=EAIaIQobChMI
kdHwx7eO8gIVSbTtCh0GFw9zEAAYAiAA
EgLzO_D_BwE
18. ttps://www.gavi.org/vaccineswork/mutating-
coronavirus-reaching-herd-immunity-just-got-
harder-there-still-hope?gclid=EAIaIQobChMI
kdHwx7eO8gIVSbTtCh0GFw9zEAAYAiAA
EgLzO_D_BwE
19. https://www.nature.com/articles/d41586-021-
00728-2
20. Ferguson, N., Cummings, D., Fraser, C. et al.
Strategies for mitigating an influenza pan-
demic. Nature 442, 448–452 (2006). https://doi.
org/10.1038/nature04795
21. https://science.sciencemag.org/con-
tent/371/6531/eabd9338
22. Haug, N., Geyrhofer, L., Londei, A. et al. Rank-
ing the effectiveness of worldwide ­
COVID-19
government interventions. Nat Hum Behav 4,
1303–1312 (2020). https://doi.org/10.1038/
s41562-020-01009-0
Michael Mncedisi Willie,
Policy Research and Monitoring,
Council for Medical Schemes, South Africa
and Sipho Kabane
E-mail: m.willie@medicalschemes.co.za
Table 3: Possible factors against achieving herd immunity [19]
Vaccine roll-out is uneven, and
disparities in the distribution
Use of vaccines with varying efficacy levels and con-
siderable variations in the efficiency of vaccine rollouts
between countries and even within them.There are also
regional disparities in some countries where single-dose
vaccines are prioritised for remote areas, and two-dose
vaccines are primarily in affluent urban and accessible
places.
Uncertainty on transmission
The possibility is that people vaccinated cannot trans-
mit and spread the virus.There is evidence that people
who have been vaccinated also succumb to the disease,
similar there are data showing reinfection.
Uncertainty on New variants
The new variants of SARS-CoV-2 are developing and
seem to be more transmissible and resistant to vaccines.
Longevity of immunity
Possibility of Infection-associated immunity that wanes
over time
Non-compliance to Non-phar-
maceutical interventions
Behavioural change, the more people get vaccinated,
the more they are likely to interact
83
73
56
53
51
48
42
41
40
37
35
30
29
25
25
25
23
20
13
11
0 10 20 30 40 50 60 70 80 90
Small gathering cancellation
Closure of educational institutions
Border restriction
Mass gathering cancellation
Increased avaiability of PPE
Educate and actively communicate with the public
Individual movement restrictions
The goernment provides assistance to vulnerable populations
Actively communicate with managers
Measures for secial populations
Increase healthcare workforce
Quarantine
Activate or establish emergency response
National lockdown
Enhance detection system
Increase in medical supplies and equipment
Police and army interventions
Travel alert and warning
Public transport restrictions
Actively communicate with healthcare professionals
%
Figure 4.
Effectiveness of government interventions during ­
COVID-19
Source: Haug, N., Geyrhofer, L., Londei, A. et al. (2020)
BACK TO CONTENTS
48
Healthcare
Myanmar is a developing country in South
East Asia with a population of 54 mil-
lion people representing over 130 ethnic
groups. Myanmar’s journey to democracy
began barely a decade ago, with the mili-
tary dictatorship that had been in control
since 1962 finally relinquishing power and
Nobel Peace Prize laureate Aung San Suu
Kyi being released from house imprison-
ment [1].
On February 1, 2021, at predawn, the
Myanmar military and security forces con-
ducted an unlawful and unconstitutional
military coup. President U Win Myint,
State Counsellor Aung San Suu Kyi, and
several elected ministries and MPs were
detained by the military [2]. Despite grow-
ing sorrow and fury, calls for anti-coup pro-
tests went viral within hours of the coup,
including on social media and the internet
[3]. Throughout history, doctors operating
under dictatorships have committed crimes
against humanity with or without their will.
In the historic Nuremberg Physicians’Trial,
Nazi doctors were imprisoned and executed
for war crimes and crimes against human-
ity for conducting medical experiments on
concentration camp prisoners, as well as
euthanasia and other executions on follow-
ing orders from the dictator [4].The Myan-
mar doctors also witnessed how Myanmar’s
military rule fuels poverty, weakens health
systems and contributes to poor health
outcomes over semi-centennial. Myanmar
doctors have firsthand knowledge of the
former military regime’s devastation of
the country’s healthcare system and viola-
tions of human rights. It is apparent that
Myanmar’s democratic government, led by
the State Counsellor, is attempting to re-
organize in the five years she has been in
office [5].
As fresh hope from neglect of the health
sector to mending of the health system was
crushed by the military takeover, Myanmar
junior doctors debated what they might
do to halt the coup in the best interests
of patients. Junior doctors, nurses, and
health care professionals led the resis-
tance through the Civilian Disobedience
Movement (CDM) on February 3, 2021,
declaring that they would not accept any
instructions from the illegal military dic-
tatorship, which has proven that they have
no respect for our impoverished patients
[6]. Following the Physician Pledge, they
provide emergency care to the people
through charity clinics and private clinics
at no cost, or some major surgical proce-
dures at reduced fees with the help of well-
wishers, while closing down medicine and
nursing universities, hospitals, and clinics
under military control [7].
Myanmar CDM junior doctors and
health care professionals also engage with
general practitioners, charity ambulance
providers, and local non-governmental
organizations to continue delivering HIV
and other chronic illness treatments via
teleconsultation, home visits, and charity
clinics [8]. Myanmar doctors and patients
were largely secure until the bloodiest day
since the coup, which triggered regular
anti-military protests and demanded the
release of elected government officials and
legislators.
At the end of February, the military and
security forces used live and rubber bul-
lets, tear gas, and water cannon to disperse
protestors around the nation and have
killed, including shooting protesters dead
in the streets and have laid siege to entire
towns, with severe torture [9]. Private clin-
ics, charity makeshift clinics, medical staff
providing emergency care, and ambulances
have been shot at for no apparent cause,
with doctors jailed and others leaving their
homes to avoid the military dictatorship.
The World Medical Association (WMA)
condemns the harassment and imprison-
ment of doctors in Myanmar on February
24, 2021 [10].
At the end of February, the situation has
worsened. If the junior doctors were able
to set up a charity base, the military could
easily demolish it. The security forces
watched the doctor’s whereabouts and ac-
tions, which resulted in the quick closure
of the charity clinics and the doctor’s mi-
gration from one location to another, de-
livering services at deserted medical facili-
ties across the country. Junior doctors have
set up mobile clinics around the nation to
treat the ill and injured during protests, but
the main concern is not to get shot when
delivering care on the ground. When it
came to killing individuals, the military
made no distinction between whether the
doctors wore badges and uniforms or not.
Junior doctors and health care profession-
als are putting their lives in danger to pro-
Wunna Tun
How Myanmar Doctors Taking Care of Patients under Heavy Fire
in the Time of COVID-19 and Military Coup
MYANMAR
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49
Healthcare
vide life-saving treatment to protesters and
the people of Myanmar [11]. The WMA
and its members are deeply troubled by the
military and security forces harassing, ar-
resting, kidnapping, and killing health care
professionals.
At the April WMA Council Meeting in
Seoul, the WMA and the National Medi-
cal Associations (NMAs) reviewed the
situation in Myanmar. WMA published a
council resolution in support of Medical
Personnel and Citizens of Myanmar at the
217th Council Session in Seoul,April 2021,
to immediately cease assaults on health per-
sonnel and medical facility and secure their
security to offer appropriate health care
provisions to everyone [12].
The increase of attacks against doctors
continues, and junior doctors are being
detained at night or apprehended during
the day. The junior doctors could not treat
patients openly as previously, move among
their places every month, hide, consider the
patient first, and treat following the Physi-
cian Pledge [13]. There is no assurance that
young doctors will be secure because their
names have been revealed and they are be-
ing watched by the security forces. Before
the coup, the State Counselor secured
3.5 million vaccinations from India for the
Myanmar people. The junta took control of
the majority of the vaccine injections but
rejected plans to prioritize vaccines for the
elderly, and the doses were used to vacci-
nate soldiers. Due to the military’s refusal
to share details about its immunization pro-
gram, Covax, the worldwide vaccine-shar-
ing organization, postponed a shipment of
5.5 million doses in March.
In Myanmar, where the Myanmar military
controls immunization, the third wave of
COVID-19 began in June 2021 [14]. The
military junta has prohibited commercial
suppliers from selling oxygen to the public.
Furthermore, the junta has ordered charity
oxygen supply groups to stop giving essen-
tial oxygen to individuals in need, as well
as denying oxygen supplies to private and
charity clinics. COVID-19 infections have
also made their way into prisons, particu-
larly those harbouring anti-coup protestors
[15]. The military has rejected COVID-19
patients at military-run medical facilities,
leaving scared locals to self-treat at home.
When people do travel to the hospital, they
have frequently turned away because the
facilities are short of oxygen, treatments,
and beds. The security forces opened fire
on individuals queued up for oxygen cyl-
inders for their ailing families, and oxygen
was being funnelled to the military hos-
pitals [16]. Personal protective equipment
(PPE) and oxygen were seized for exclusive
military use, and vaccinations provided by
India were hoarded for exclusive military
use. Doctors had been arrested for provid-
ing vaccinations in remote regions, and nu-
merous individuals had died at home from
COVID-19, resulting in long queues at
crematoria.
The Myanmar dictatorship has turned
coronavirus into a weapon by restricting
access to treatment, which amounts to
“weaponizing COVID-19 to destroy its
opponents” [17]. Desperate family mem-
bers browse social media groups and en-
crypted smartphone applications every day
in quest of oxygen supply for their loved
ones. The phrases “urgent,” “emergency,”
and “please assist me” kept appearing in a
never-ending stream of frantic texts. Doc-
tors forced to flee to avoid imprisonment
have re-established underground networks
of clinics and teleconsultation services for
COVID-19. Every day, they respond to
thousands of inquiries from ­
COVID-19
patients and patient attendants via appli-
cations, social media, and video channels
to reach the people.They worked diligently
all day and night to provide quality care,
responding to urgent messages on encrypt-
ed smartphone applications or providing
video consultations [18]. Many Myanmar
physicians, nurses, and their families have
died as a result of COVID-19 due to a lack
of oxygen in the current third wave, and
the number is steadily increasing. Social
media looks to be a condolence site, as it
is packed with funeral announcements of
health professionals and their parents [19].
In addition, doctors in Myanmar who are
treating patients infected with the coro-
navirus are being detained. Doctors have
independently made free house visits to
assist people sick with the critical Coro-
navirus to preserve the patient’s life, de-
spite the danger of being imprisoned. The
military and security personnel enticed
the doctors to a residence by claiming to
be critical ­
COVID-19 patients in need of
urgent medical treatment and then arrest-
ed them upon arrival, while the military
stormed the doctor’s offices and arrested
the doctors [20]. Doctors are revered and
safeguarded, even during times of war
without being arrested. No country in the
world has jailed its physicians for saving
the lives of ­
COVID-19 patients. Doctors
and nurses are being murdered, injured,
or abducted; charity and makeshift clin-
ics are being destroyed or damaged, and
medical equipment is being taken; as a re-
sult, the military has violated the Geneva
Conventions willingly and committed a
crime against humanity [21]. The junta’s
attack on Myanmar’s healthcare system
and healthcare professionals was under-
mining the right to health. As there is no
meaningful action to stop military junta by
the international community but by offer-
ing rhetorical responses, there is no more
option left for Myanmar, National Unity
Government and People of Myanmar de-
clared war against the military on 7th
Sep-
tember 2021 to restore collapsed health
care and democracy in Myanmar [22].
More than 200 health professionals have
been imprisoned in the eight months since
the military coup, and thousands of profes-
sionals have had their medical licenses and
passports revoked. There is catastrophic af-
fliction on medical personals in terms of
mental and physical breakdown due to fac-
ing dual enemies of Myanmar. In amidst all
Myanmar’s darkness and gloom, beams of
MYANMAR
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50
light and hope may be found in the doc-
tors’ perseverance and togetherness. How-
ever, Myanmar junior doctors and health
care workers are continuing to doing their
utmost to save patients’ lives and others in
need how dire and dangerous the situation
has become, risking their own lives of being
killed, tortured or abducted from human
adversaries – merciless military junta and
the covid19 infection.
References
1. Steinberg D. The Military Coup, the Socialist
Period (1962–1988), and the Perpetuation of
Military Rule. Burma/Myanmar 2013.
2. Taylor A. What is going on in Myanmar after
military coup removes Aung San Suu Kyi. The
Washington Post 2021. https://www.washing-
tonpost.com/world/2021/02/01/myanmar-mili-
tary-coup/ (accessed September 26, 2021).
3. Myanmar’s Doctors Vow to Shut Hospi-
tals in Anti-Coup Protests. Bloombergcom.
https://www.bloomberg.com/news/articles/
2021-02-03/myanmar-anti-coup-protesters-
call-to-shut-hospitals-bang-pots (accessed Sep-
tember 26, 2021).
4. Ergo A, Htoo TS, Badiani-Magnusson R, Roy-
ono R. A new hope: from neglect of the health
sector to aspirations for Universal Health Cov-
erage in Myanmar. Health Policy and Planning
2019;34:i38–i46. doi:10.1093/heapol/czy110.
5. NMT Case 1. Nuremberg. https://nuremberg.
law.harvard.edu/nmt_1_intro (accessed Sep-
tember 26, 2021).
6. Shepherd A. Myanmar medics resist military
coup. Bmj 2021. doi:10.1136/bmj.n368.
7. WMA – The World Medical Association-
WMA Declaration of Geneva. The World
Medical Association. https://www.wma.net/
policies-post/wma-declaration-of-geneva/ (ac-
cessed September 26, 2021).
8. Lalley A. From COVID-19 to the Coup, My-
anmar’s Doctors Are Risking Their Lives.  –
The Diplomat 2021. https://thediplomat.
com/2021/03/from-covid-19-to-the-coup-
myanmars-doctors-are-risking-their-lives/. (ac-
cessed September 26, 2021).
9. news24. ‘How many dead bodies?’ asked Myan-
mar protester killed on bloodiest day. News24.
https://www.news24.com/news24/world/news/
how-many-dead-bodies-asked-myanmar-pro-
tester-killed-on-bloodiest-day-20210228 (ac-
cessed September 26, 2021).
10. WMA  – The World Medical Association-
Harassment and arrest of doctors in Myanmar
condemned by physician leaders. The World
Medical Association. https://www.wma.net/
news-post/harassment-and-arrest-of-doctors-
in-myanmar-condemned-by-physician-leaders/
(accessed September 26, 2021).
11. Hlaing KH, Fishbein E. Medics risk lives to
treat injured in Myanmar anti-coup protests.
Health News | Al Jazeera 2021. https://www.al-
jazeera.com/news/2021/3/3/myanmar-medics-
risk-lives-to-treat-injured-in-anti-coup-pro-
tests (accessed September 26, 2021).
12. WMA – The World Medical Association-
WMA Council Resolution in support of Medi-
cal Personnel and Citizens of Myanmar. The
World Medical Association. https://www.wma.
net/policies-post/wma-council-resolution-in-
support-of-medical-personnel-and-citizens-of-
myanmar/ (accessed September 26, 2021).
13. Parsa-Parsi RW. The revised declaration of Ge-
neva: a modern-day physician’s pledge. JAMA.
2017;318:1971-1972.
14. Paddock RC. Virus Surges in Myanmar, Where
Generals Control Vaccines.The New YorkTimes
2021. https://www.nytimes.com/2021/07/01/
world/asia/covid-myanmar-coup.html (accessed
September 26, 2021).
15. Regan H. Myanmar doctors in hiding and
hunted by the junta as Covid crisis ravages
the country. CNN 2021. https://edition.cnn.
com/2021/07/21/asia/myanmar-covid-oxygen-
intl-hnk/index.html (accessed September 26,
2021).
16. Myint GTand M. Covid and a coup: The
double crisis pushing Myanmar to the brink.
BBC News 2021. https://www.bbc.com/news/
world-asia-57993930 (accessed September 26,
2021).
17. [Internet]. Theaustralian.com.au. 2021 [cited
26 September 2021]. Available from: https://
www.theaustralian.com.au/world/myanmar-
junta-has-turned-coronavirus-into-a-weap-
on/news-story/eb4372050e14951be640f-
1635c2f36b3
18. Thuzar M, Strefford P, Editors EAF, Gravers M,
Steinberg DI, Chongkittavorn K, et al.The My-
anmar military’s politicisation of COVID-19.
East Asia Forum 2021. https://www.eastasia-
forum.org/2021/09/14/the-myanmar-militarys-
politicisation-of-covid-19/ (accessed September
26, 2021).
19. Solomon F. Myanmar Doctors Risk Arrest to
Treat COVID-19 Patients in Secret. The Wall
Street Journal 2021. https://www.wsj.com/
articles/myanmar-doctors-risk-arrest-to-treat-
covid-19-patients-in-secret-11628601972 (ac-
cessed September 26, 2021).
20. Lonas L. Doctors treating COVID-19 patients
arrested in Myanmar.TheHill 2021. https://the-
hill.com/policy/international/564450-doctors-
treating-covid-19-patients-arrested-in-myan-
mar (accessed September 26, 2021).
21. Geneva Convention 1864. https://web.ics.pur-
due.edu/~wggray/Teaching/His300/Handouts/
Geneva-Convention-1864.html (accessed Sep-
tember 26, 2021).
22. Myanmar: UN expert says current international
efforts failing, calls for “change of course” – My-
anmar. ReliefWeb. https://reliefweb.int/report/
myanmar/myanmar-un-expert-says-current-in-
ternational-efforts-failing-calls-change-course
(accessed September 26, 2021).
Wunna Tun, MBBS, MD
Fellow in Medical Education
Myanmar
Secretary, JDN,
World Medical Association
Healthcare MYANMAR
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51
Background
Determinants of public health are complex
and depend on factors such as social infra-
structure, political stability, economic devel-
opment and most importantly, availability
of an appropriate and accessible health ser-
vice through well-trained providers.
Universal health coverage is realized when
everyone has access to quality essential
healthcare services with financial risk pro-
tection. The primary public health goal of
developing countries like Ethiopia is im-
proved quality of care, increased service
utilization and better health outcomes,
and improvement of the health workforce
efficiency is important in that regard. This
approach, however, is one that Ethiopia has
struggled to achieve. In 2019, the universal
health service coverage index in the country
was still very low at 39% [1].
To achieve universal health coverage, it is
essential to ensure the quality as well as
the sustainability of the health workforce,
through regulation of education and prac-
tice mechanisms. In Ethiopia, these regula-
tory mechanisms and resources are under
stress due to a mismatch between health
professional education, public healthcare
and speciality field demands, as well as in-
creased international mobility by health
professionals.
The Dilemma
Career Preference and
Starved Specialty Fields
Health workforce education and training is
a complex investment, along the intersec-
tion of educational systems, labour market
policies, and translational public health im-
pact. [2, 3] These challenges remain a cru-
cial bottleneck in achieving universal health
coverage in low and middle-income coun-
tries.
In Ethiopia, medical training is rather dis-
connected from the needs of the health sys-
tem and that of the public at large. Efforts
are continuously being made to bridge the
gap between the supply of well-qualified
physicians and the ever-increasing de-
mand for their services. One such effort is
the “flood and retain” strategy, rolled out
by the Ministry of Health to strengthen
the healthcare system by expanding phy-
sician training. The enforcement of this
policy has been an attempt to address the
health demands of the public by encourag-
ing meaningful change in the number of
available professionals at all levels [4, 5, 6].
This was done through medical training
unit expansion and subsequent large in-
put of trainees with currently more than
thirty recognized and operating medical
schools, including private institutions, in
the country.
The overwhelming number of physician
output that followed the implementa-
tion of this strategy, however, was not able
to provide a satisfactory interface in line
with balanced accommodation between
universal health coverage and job creation.
Ethiopia’s Medical Talent Dilemma: Lessons Learned
and The Way Forward
Eleleta Surafel Jenerit Hadush Beza Seleshi
Healthcare
ETHIOPIA
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52
This in turn has left room for the skewed
distribution of skill sets and health profes-
sionals with inclination to a specific area of
speciality and place of practice, leaving the
healthcare demand of the vast majority of
the population unmet.
A 2015 study [3] done on final year medi-
cal students and interns, found that 70.1%
of its participants showed intent to practice
clinical medicine in an urban setting, with
76% gravitating towards internal medi-
cine and surgery. The inclination towards
these fields, and the neglect of paediatrics
and gynaecology, is at clear odds with the
healthcare needs of the population given
the country’s maternal and neonatal/child
mortality status [7]. The study also found
income potential (42%) to be a factor that
significantly affected students’ field and
placement choices. In addition to prestige,
the intent to work in urban settings is also
rooted in the reality that very few students
from rural households reach higher educa-
tion, causing a further impediment to uni-
versal health coverage by skewing the pool
of professionals willing to work in rural set-
tings [8].
Talent Exodus
Ethiopia has a healthcare workforce ra-
tio of 0.7/1000 against the WHO ratio
of 2.3/1000 which is recommended as the
ideal imperative for health coverage and
impactful healthcare interventions [4].
Despite the implementation of the “flood
and retain” strategy to mitigate this, the
country still continues to suffer physician
shortage through the mass exodus from
the country, impeding progress toward
the attainment of universal health cov-
erage [4]. Reasons for health migration
from the Sub-Saharan region in general,
and Ethiopia in particular, have been
summarized as an absence of adequate
professional support and development,
inadequate financial incentive, and de-
sire for professional prestige and respect
that are better fulfilled in other nations
[9, 10].
Reports have shown that Ethiopia remains
one of the countries with the highest phy-
sician emigration in Sub-Saharan Africa,
with significant intent shown by medical
students to emigrate within 5-10 years of
graduation [11]. It must also be noted that,
while emigration continues to be the main
reason that talent continues to bleed out of
the country, physicians leave public service
to better-paying jobs in NGOs and the pri-
vate sector [12].
A study [11] done on medical students re-
ported that 53% of its participants indicated
an aspiration to emigrate following gradu-
ation, with such an attitude predominantly
prevalent among final year students and in-
terns. This same pattern of intent was also
shown to be more prevalent among students
in clinical training than their preclinical
counterparts, which stands as an indication
of factors in clinical years that significantly
affect students’ need to emigrate.
Compared to other professional areas, the
medical profession appears to be the most
susceptible to emigration owing to the in-
creasing demand for health professionals in
the developed world that offer better pay,
better living conditions, and a better work-
ing environment. Educating medical pro-
fessionals is an expensive enterprise for any
developing country, and through a conser-
vative estimate, it has been shown that close
to 30.000 USD is lost for every Ethiopian
medical school graduate who emigrates [4,
10, 11, 13]. As it stands, the ‘flood’has done
more to flood the needs of other nations
and has inadvertently negated the very aim
it was established to achieve.
Strike and the Paradox that Ensued
In May 2019, a nationwide strike was ani-
mated by medical interns of several teach-
ing hospitals protesting against the long
hours of work, little pay, substandard work-
ing conditions, and limited employment
and career advancement opportunities,
with a call for leniency in license and de-
gree acquisition, and healthcare insurance
[14, 15].
Among the demands, the issue of employ-
ment was met with an uncalled-for conse-
quence as the Ministry of Health lifted its
central responsibility of assigning physi-
cians to health facilities across the country.
The central deployment freeze shifted the
mandate of hire to regional and city admin-
istration health bureaus, opening doors to
corruption and nepotism, and leaving grad-
uates with the only option of seeking em-
ployment for themselves. This outcome has
put the country in a state of paradox: a na-
tion whose healthcare needs are unmet, and
medical professionals are unemployed. As it
remains, there is no estimate of the amount
of unemployed general practitioners at this
time,and/or an estimate of its impact on the
unaddressed healthcare needs of the public
[14, 15].
COVID-19 Pandemic
and Current Reality
As the pandemic continued to wreak havoc
in its health systems, the Ethiopian gov-
ernment responded to the low healthcare
professional-to-population ratio by bring-
ing on unemployed practitioners in rapid
response and treatment teams through con-
tract and volunteering agreements. While
such an arrangement came at a great loss
for practitioners, it still failed to address the
needs of most treatment centres, especially
those in peri-urban and rural areas, as phy-
sicians left posts due to substandard work-
ing conditions and compensations.
Unemployed practitioners who did not
choose this path now find themselves in a
predicament: contemplating exile, or ex-
ploring other professional avenues far from
their expertise.
Healthcare ETHIOPIA
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53
Conclusion and Call to action
Needless to say that, neither the healthcare
needs of the population nor the needs of
the medical students and graduates have
been addressed. A starting point for recon-
ciliation towards universal health coverage
can be the placement of medical graduates
to proportionally address the healthcare
workforce. As medical education directly
impacts public health and the quality of
healthcare, it must base its framework on
the needs of the health system and the
public.
Longitudinal analyses are warranted to
address healthcare demands with priority
set on understanding students’ preference,
placement choice, attitude towards training
and future practice of clinical medicine for
evidence-based mitigation efforts. In addi-
tion, beyond local training, investments in
students and graduates from rural areas, to
address the high population concentration
and health demand in those areas are called
for.
Since the existing curricular policy has been
employed aggressively toward increasing
healthcare professionals through the ‘flood’,
a parallel amount of work on the ‘retain’ to
prevent further hindrance of health care eq-
uity, is an imminent necessity. Policy review
of regulatory frameworks, management and
information systems for health human re-
sources are needed to create a system that is
able to meet the current and future needs of
health professionals,and that of the popula-
tion.
Statistical updates on the areas of emigra-
tion and unemployment are also mandated.
Through emigration, in addition to the loss
of significant investment of public funds
made for medical training, subsequent criti-
cal contributions to the improvement of
health systems are lost as well. In that re-
gard, improvements in retention incentives,
employment, professional development and
career advancement opportunities, and ad-
dressing administrative inefficiencies and
corrupt practices in the system are warrant-
ed interventions.
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national paradox: Ethiopia struggles with short-
age of physicians while physicians struggle to
find employment. Addis Standard. Accessed
03 June 2021 https://www.google.com/amp/s/
addisstandard.com/feature-analysis-a-national-
paradox-ethiopia-struggles-with-struggles-
with-shortaage-of-physicians-while-physicians-
struggle-to-find-employment/amp/
15. Biniam E (2020) Op-ed: the flood and retain
strategy and the future of Ethiopian doctors.
Addis Standard. Accessed 03 June 2021 https://
www.google.com/amp/s/addisstandard.com/
op-ed-the-flood-and-retain-strategy-and-the-
future-of-ethiopian-doctors/amp/
Eleleta Surafel Abay, M.D.,
Kadisco General Hospital
E-mail: eleletasabay@gmail.com
Jenerit Hadush M.D.,
Star Metropolis Clinical Laboratories
Beza Seleshi M.D.,
San Diego State University
Healthcare
ETHIOPIA
BACK TO CONTENTS
54
Healthcare Industry
The ­
COVID-19 pandemic posed a huge
challenge to healthcare systems. The new
healthcare demand accelerated the conver-
gence of new technologies, medical tech-
nology innovation and application across
boundaries. A large number of new tech-
nologies and products have emerged in the
field of clinical engineering, and the appli-
cation of related technologies and products
have been greatly accelerated. We reviewed
the hot topics and the progress of technol-
ogy management in the field of clinical
engineering. With the guidance of the rel-
evant policies issued by relevant ministries
and commissions in 2020, the opinions
on the important progress in this field in
2020 were collected by the Chinese Soci-
ety of Clinical Engineering of the Chinese
Medical Association.We collected all kinds
of guidelines and norms formulated annu-
ally by clinical engineering societies, qual-
ity control centres and clinical engineering
departments in various provinces and cities.
At the same time, we gathered experts’con-
sensus and formed the annual ten research
progress events report in the field of clini-
cal engineering, which may help the medi-
cal technology industry and the healthcare
organizations to grasp the future develop-
ment direction in the field of clinical en-
gineering.
1. Prepares and applies
Infection Control Technology
Plan for Medical Equipment
and Medical Supplies Use
Guide for Global
Epidemic Prevention
The ­
COVID-19 coronavirus is character-
ized by rapid transmission, wide infection
range and great difficulty in prevention and
control. For major public health emergen-
cies, clinical engineering, as one of the four
pillars of healthcare delivery organizations,
working together with physicians and clini-
cians, nurses and pharmaceutists, shoulders
the shared responsibility. And clinical en-
gineering departments of healthcare deliv-
ery organizations across the country have
worked out various emergency prepared-
ness schemes [1]. The Chinese Society of
Clinical Engineering of the Chinese Medi-
cal Association and its provincial Clinical
Engineering Branches gave full play to the
advantages of the experts nationwide, and
quickly organized a series of online meet-
ings to discuss and reach consensus [2].The
topics covered the emergency classification
scheme of epidemic prevention materials,
emergency management of medical equip-
ment and emergency technical standards,
etc., which made important contributions
to the formulation of standardized pro-
cedures and emergency response plans in
epidemic prevention and control for public
health emergencies.
In February 2020, the Clinical Engineering
Branch of Shanxi Medical Association is-
sued the Guidance for Medical Equipment
Cleaning and Disinfection during the Pre-
vention and Control Period of ­
COVID -19
in Shanxi Province. The guidance included
the safe use of CT, MR, DSA, X-ray ma-
chine, ultrasound equipment, ventilator,
monitor, infusion pump and defibrillator,
as well as the prevention and control plan
of cleaning and disinfection for these nine
Li Bin
Top 10 Progress Events in Clinical engineering in China in 2020
Zheng Kun Chu Chengchen
CHINA
BACK TO CONTENTS
55
Healthcare Industry
types of equipment. In February, the Clini-
cal Engineering Branch of Jilin Medical
Association, together with Jilin Medical
Imaging Quality Control Center, orga-
nized experts in the fields of clinical engi-
neering, imaging, metrological testing and
standardization, and led the formulation
of the Technical Specifications for Mutual
Recognition and Sharing of Medical Im-
aging Examination for Epidemiological
Prevention and Control. In March, Guang-
dong Medical Equipment Management
and Quality Control Center organized ex-
perts to formulate the Guiding Opinions
on Strengthening Medical Device Emer-
gency Support and Quality Control dur-
ing ­
COVID-19 Prevention and Control in
Guangdong Province [3]. In April, accord-
ing to the requirements of the joint preven-
tion mechanism of the three provinces and
one city in the Yangtze River Delta Re-
gion, the medical equipment quality con-
trol centres of Shanghai, Jiangsu, Zhejiang
and Anhui jointly formulated the Guiding
Opinions on the Quality Control of Medi-
cal Equipment in the Yangtze River Delta
Region during the Prevention and Control
of ­
COVID-19[4]. The guidance opinions
included suggestions on the configuration
of medical equipment in the fever clinic
and guidance on the emergency modifi-
cation of isolation gown. In September,
clinical engineering at the First Affiliated
Hospital of Zhejiang University School of
Medicine published the Guidance Manual
for the Application of Personal Protec-
tive Equipment for Respiratory Infectious
Diseases.This book introduces ­
COVID-19
PPE management and use experience of
five categories namely face protection, re-
spiratory protection, body protection and
foot protection, and nearly one hundred
kinds of protective materials in total col-
lected from all over the world, their identi-
fication, classification, and evaluation. The
book summarizes and compares relevant
PPE standards and principles both at home
and abroad, combined with bench test and
evaluation puts forward suggestions for
PPE selection and use.
2. New Policies on the
management of medical supplies
accelerated the application
and promotion of medical
device technology evaluation
With the strengthening of national man-
agement on the use of medical supplies in
hospitals, health technology assessment
for hospital medical technology, especially
medical supplies and consumables, is being
promoted in China. In 2020, the Institute
of Hospital Management of the National
Health Commission and its clinical en-
gineering laboratory conducted a project,
which combines evidence-based informa-
tion at home and abroad with hospital
consumables management experience and
reviews from the haemostatic materials clas-
sification and selection, specification, use
evaluation, supervision and outcome, and
formulates the expert consensus for haemo-
static materials management. In 2020, the
Chinese Society of Clinical Engineering
of Chinese Medical Association organized
an interdisciplinary expert group, taking
antimicrobial sutures as an example, and
cooperated with professional health eco-
nomics research institutions to carry out the
relevant health technology evaluation. By
researching from the perspectives of safety,
effectiveness, economy and sociality, this
project generates a value evaluation report of
antimicrobial sutures [5]. It has been issued
in many regions of the country and provides
an important reference for the management
of other kinds of medical consumables.
3. Clinical engineering’s
participation and contribution
to the region-wide evaluation
and demonstration of
digital diagnosis and
treatment equipment
In recent years, some of China’s leading
academic clinical engineering departments
have made great breakthroughs in par-
ticipating in the national key research and
development projects of digital diagnosis
and treatment equipment sponsored by the
Ministry of Science and Technology. The
clinical engineering departments of more
and more medical institutions, such as Chi-
na-Japan Union Hospital of Jilin University,
Union Hospital affiliated to Tongji Medical
College of Huazhong University of Science
and Technology, Shanghai Jiao Tong Uni-
versity Affiliated Sixth People’s Hospital
[6], Inner Mongolia Autonomous Region
People’s Hospital, and the First Affiliated
Hospital Zhejiang University School of
Medicine, have presided over or partici-
pated in the digital diagnosis and treatment
equipment evaluation and demonstration
projects to establish a batch of digital diag-
nosis and treatment equipment evaluation
system for large medical equipment such
as radiography, magnetic resonance, ultra-
sonic diagnosis and radiotherapy. In 2020,
the Institute of Hospital Management of
the National Health Commission set up
ten clinical engineering research bases na-
tionwide, aiming to further promote the
research and talent training in the field of
clinical engineering in China, to support
the development of healthcare and medi-
cine, and to enhance the scientific research
ability and influence of clinical engineering
departments.
4. Pilot application of medical
device unique identification
(UDI) technology in-hospital
medical device management
The International Medical Device Regu-
lators Forum (IMDRF) issued the UDI
Guidelines in December 2013, marking
the beginning of the global implementa-
tion of UDI. At the end of 2019, the Na-
tional Medical Products Administration in
China issued the Notice on the First Batch
of Implementation of the Unique Labeling
of Medical Devices, and various provinces
CHINA
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56
and cities across the country organized
several medical institutions to launch the
pilot program. UDI, as the electronic ID
of medical devices, is the link and bridge
connecting the hospital with management
departments at all levels and external en-
terprises [7]. It is the basis for the full life
cycle supply chain management of medi-
cal devices within the hospital, and the key
role for realizing the standardization and
lean management of medical devices in the
hospital. 108 hospitals, such as the General
Hospital of the Chinese People’s Liberation
Army and the First Affiliated Hospital of
Sun Yat-sen University, as the first batch of
pilot units, have continuously improved and
optimized their medical supplies manage-
ment structure within the hospitals, devel-
oped and upgraded the information system
related to medical supplies, and explored
the construction of a UDI-based whole life
cycle management system [8]. It realizes
the bidirectional traceability management
of medical consumables supply and use in
the hospital as well as the unification and
standardization of basic logistics informa-
tion both inside and outside the hospital.
5. The ­
COVID-19 epidemic
accelerated the use of
telemedicine technologies
The ­
COVID-19 epidemic had accelerated
the explosive growth and widespread ap-
plication of telemedicine. The telemedicine
support has been increased significantly in
various countries, including the coverage by
more and more health insurance programs.
Social acceptance of telemedicine is rapidly
spreading as well.The service volume of tele-
medicine has increased greatly, the related
technologies and industry are also develop-
ing rapidly, and the role of clinical engineer-
ing in it has been further recognized [9]
[10]. On February 7th
, 2020, China National
Health Commission released a document
about promoting the internet medical con-
sultation service during epidemic prevention
and control and strengthening its manage-
ment. Hundreds of hospitals opened their
relevant online service accordingly. Over the
same period last year, the number of online
diagnoses and treatment in all hospitals of
China’s National Health Commission in-
creased by 17 times.The number of medical
consultations on some third-party internet
service platforms increased by more than 20
times and the number of online prescrip-
tions increased by nearly 10 times.
6. Chinese Society of
Clinical Engineering hosts
Medical Device Innovation
Competition to promote the
innovation and application
of clinical engineering
In response to the call for scientific and
technological innovation in China, the
Chinese Society of Clinical Engineering of
the Chinese Medical Association (CSCE)
gave full play to the advantages of clinical
engineering to promote the innovation and
application of the medical device in China.
Since 2019, the Clinical Engineering Soci-
ety of Chinese Medical Association has co-
operated with Henan Tuoren Medical De-
vice Group Co., Ltd to jointly carry out the
“Tuoren Medical Device Technology Inno-
vation Competition” in clinical engineering
nationwide for two consecutive years.“Tuo-
ren Medical Device Technology Innovation
Award” was a national science and tech-
nology award approved by the Ministry of
Science and Technology of China and the
State Office for Science and Technology
Awards in January 2011.
From 2019 to 2020,with the strong support
of clinical engineering chapters of medical
associations and medical institutions in all
provinces, the “TuoRen-Medical Device
Science and Technology Innovation” com-
petition had been actively responded and
enthusiastically participated by more than
500 clinical engineering staff and clinicians
in 25 provinces and autonomous regions.
In two years, a total of 345 medical device
innovation projects were collected, among
which 229 were product research and devel-
opment projects and 116 were innovation
management projects. After the submit-
ted project passed the project evaluation of
each province, it would be recommended to
participate in the National Tuoren Medical
Device Science and Technology Innovation
Contest, and the winning project will be
selected by national experts finally. In two
years,a total of 58 outstanding projects have
been selected, respectively winning the first,
second and third prizes accordingly in the
country. Some of the outstanding projects
are undergoing product transformation.
Through the construction of the clinical
engineering innovation competition plat-
form, it further promotes the integration of
medical and industrial, as well as the inno-
vation and development of medical devices
in China.
7. Ten medical AI products
entered the Chinese market
after being approved by
National Medical Products
Administration
In recent years, the investment in the field
of medical artificial intelligence around the
world shows a trend of rapid growth,and the
industries related to intelligent assisted di-
agnosis in China are also rising rapidly [11].
In 2017, China Food and Drug Adminis-
tration issued a new version of the Classifi-
cation of Medical Devices. If the diagnostic
software provides diagnostic suggestions
through algorithms, only has auxiliary di-
agnostic functions, and does not directly
provide diagnostic conclusions, then the
application of Class II medical devices shall
be declared. If the diagnostic software auto-
matically identifies the lesion site through
the algorithm and provides clear diagnostic
tips, the Class III category of medical de-
vices shall be applied.Since the end of 2019,
Healthcare Industry CHINA
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57
AI products has been extended from lung
nodules to cover heart, brain, endocrine,
pathology, ultrasound and other directions,
realizing the auxiliary diagnosis and predic-
tion of a variety of diseases.
From late 2019 the AI healthcare industry
went through an intensive clinical trial pro-
cess and submitted registration applications.
In 2020, there were 10 products from 8 AI
medical enterprises, including Keya Medi-
cal,LEPU Medical,BioMind,Silicon Intel-
ligence,AIRDOC,InferVision,­
SHUKUN,
United Imaging Intelligence and Deepwise,
which had been approved by the National
Medical Products Administration of China
and obtained the Class III type of AI medi-
cal certificate. They will become mature
products for market use after clinical tri-
als, in cardiology, neurology, endocrinology,
orthopaedics, thoracic surgery and other
disciplines. Among them, the number of
cardiology products is the largest.
8. Rapid application of
intelligent management of
medical equipment based
on Internet of Things
A number of Tier Three Grade A hospitals
in China have built IOT technology-based
data acquisition and management plat-
forms for hospital medical equipment.Data
of large medical equipment and emergency
medical equipment are transferred to the
data centre of the hospital. And real-time
integration, development and utilization
are carried out with the clinical diagnosis
and treatment system [12]. Beijing China-
Japan Friendship Hospital has integrated
the Internet of Things, mobile Internet,
5G private network, face recognition, and
“micro-service” system integration archi-
tecture, and carried out a comprehensive
exploration of the haemodialysis diagno-
sis and treatment management system. In
February 2020, Wuhan Tongji Hospital
established a three-level monitoring and
treatment system, namely the automatic
early warning and rapid response system
for patients with critical events, which can
monitor patients’ vital sign parameters in
real-time and conduct a comprehensive
evaluation, and provide timely early warn-
ings for patients with critical situations.
Jiangsu Provincial People’s Hospital has
developed a monitoring system for tem-
perature, humidity and power supply in
the locations of large medical equipment
installed [13]. By collecting the require-
ments of the equipment manufacturers for
temperature, humidity and auxiliary pow-
er supply voltage of all kinds of medical
equipment, the AC voltage in the machine
room environment is sampled and moni-
tored, and the stored data are also retriev-
able. By pushing the alarm information to
the platform, the cloud platform monitor-
ing system based on the Internet of Things
technology for the collection, transmission
and storage of environmental state data of
medical equipment was established. West
China Hospital has developed online
quality control and early warning platform
based on real-time data. By monitoring
the output parameters of medical equip-
ment in real-time and comparing with the
established quality control model, the plat-
form can give early warning in real-time
if abnormal happens, which helps a lot in
enhancing the safety of patients.
9. ­
COVID-19 is driving
the rapid growth of disinfection
and logistic robotics
technology and their
practical application in
hospitals in China
The application of intelligent robots in hos-
pitals has seen explosive growth in recent
years. The need for safer and more reliable
services in the medical industry is the key
to the commercial products of medical
service robots. Applications include clini-
cal settings such as isolation wards, ICU,
operating rooms, fever clinics, etc. The
disinfection robot has become the popular
product in the fight against ­
COVID-19
in 2020 due to its ability to solve problems
such as difficulty in disinfection, manpower
shortage and overall cleaning [14]. Driven
by the need to combat ­
COVID-19, many
technologies and robotics companies have
shipped their latest generation of robots
across the country. In terms of logistics ro-
bots, China’s domestic AGV logistics robot
industry has seen explosive growth in recent
years. The growth rate has been maintained
at more than 30% for several years, and the
scale of the logistics robot industry is con-
stantly expanding. With the outbreak of
COVID-19, the logistic robot has become
an important measure for hospitals to cope
with infection risk and manpower shortage.
Clinical engineering departments in many
medical institutions across the country have
deployed logistic robots in areas such as iso-
lation wards and fever clinics to reduce the
risk of cross-infection.
10. Rapid approval and
emergency deployment of
novel coronavirus assay
reagents to enhance nucleic
acid test capability
COVID-19 is a highly infectious virus
disease. Nucleic acid detection is an impor-
tant method to identify novel coronavirus
infections. Rapid and accurate nucleic acid
detection method is of great significance
for early detection of infected persons and
control of epidemic spread. ­
COVID-19,
according to Novel Pneumonia Diagnosis
and Treatment Protocol for Coronavirus
Infection, mainly adopts two methods for
nucleic acid detection, one is real-time flu-
orescence RT-PCR kit detection, the other
is virus gene sequencing. Nucleic acid de-
tection kits could produce detection results
faster, which is more suitable for the cur-
rent prevention and control of ­
COVID-19.
Nucleic acid detection methods mainly
Healthcare Industry
CHINA
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58
include PCR, thermostatic amplification,
sequencing, CRISPR detection, gene chip
technology and so on[15]. The second-
generation PCR technology (fluorescent
PCR) is the mainstream method for virus
detection, and it is also the most widely
used technology for Novel Coronavirus
detection kits approved and marketed in
various countries at present. On January 26,
2020, China’s National Medical Products
Administration approved the first batch
of 4  novel coronavirus testing products
from 4 enterprises. It includes BGI Novel
Coronavirus assay kit, BGI DNBSeq-T7
sequencing system, and two nucleic acid
assay kits produced by Shanghai Zhijiang
Biotechnology Co., Ltd and Shanghai Jen-
uoBiotech Co., Ltd. In 2020, China’s State
Medical Products Administration ap-
proved a total of 54 nucleic acid detection
reagents for Novel Coronavirus, including
8 nucleic acid rapid detection products,
forming a complete detection technol-
ogy system, with a production capacity of
24.018 million copies per day. During the
­
COVID-19 period, China’s clinical engi-
neering departments purchased various nu-
cleic acid testing equipment and reagents
in an emergency manner, and expanded
the capacity of rapid testing reagents and
testing equipment in accordance with the
needs of epidemic prevention and control,
so as to continuously improve the nucleic
acid testing capacity of medical institutions.
Summary
Based on the consultation of experts from
the Chinese Society of Clinical Engineer-
ing of the Chinese Medical Association, we
sorted out the top Ten Progress Events in
the field of clinical engineering. This paper
may be helpful to sort out relevant research
hot-spots and development trends, helps
hospital managers and clinical engineers to
grasp the future development direction of
clinical engineering in China, and provide
support for decision-making analysis of
new technology management.
References
1. Li Bin. Development of Clinical Engineering
Disciplines to Promote National Health. China
Medical Devices, 2020, 35(11): 1-4, 8.
2. LU Ruyi, SUN Jing, XIONG Wei. Discussion
on the Role of Clinical Clinical engineers in
Major Public Health Emergencies. China Med-
ical Devices, 2020, 35(6): 112-116.
3. Chen Hongwen. Guiding Opinions on
Strengthening Emergency Support and Quality
Control of Medical Devices during ­
COVID-19
Epidemics Prevention and Control in Guang-
dong Province (1st Edition). Modern Hospital,
2020, 20(03):472-476.
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mei.Current Unique Devices Identification
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Li Bin, Professor, Senior Engineer,
Master’s Supervisor, President of
Chinese Society of Clinical Engineering,
Chinese Medical Association
Zheng Kun, Senior Engineer, General
Secretary of Chinese Society of Clinical
Engineering Chinese Medical Association,
Director of Logistic Service Department
at Children’s hospital Zhejiang University
School of Medicine, Hangzhou China.
Chu Chengchen, Master, Sixth People’s
Hospital Affiliated to Shanghai Jiao
Tong University, Shanghai China
E-mail: mazhaoweili@163.com
Healthcare Industry CHINA
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59
Person-centered Medicine
As with adults, self-care with children and
adolescents has received good press in edu-
cational science literature and health pro-
motion journals. Both consider it as a key
factor in a person-centered perspective in
health. Typically, these publications see the
promotion of self-care at the centre of the
education that a functional family should
provide to their children to comply with its
ambition to develop their well-being. An
example of this approach is provided by an
article which, under the title “Self-Care for
Youth and Families”[1] lists several ideas of
“self-care strategies to get started”; to such
extent that it becomes a sort of treatise on
knowing how to live, designed for function-
al families aiming to develop the self-care of
their children and adolescents: indeed, fol-
lowing a caveat where the author reminds
that self-care is an activity or action that one
enjoys and makes him feel good during and
after.
Here are some of the ideas proposed “to get
started” in this perspective:
• Get enough sleep at night.
• Exercise, make sure it is something you
enjoy,such as a walk,yoga,swimming,etc.
• Meditate for a short time every day.
• Spend quality time with your family or
friends.
• Read a book.
• Take a nice relaxing bath.
• Start a hobby such as crafting, writing, or
cooking.
• Start a journal.
• Listen to music.
• Dancing.
• Practice mindfulness strategies.
• Have a date night.
• Take time away from technology.
• Volunteering.
• Family game night.
Certainly, as the authors underline it in
their caveat, these are only suggestions of
common sense which cannot be dangerous
and are surely the object of a broad consen-
sus in the target population: that is, in those
who are doing well enough to have only
positive behaviours and who are integrated
or globalized enough to share the same type
of representation of ​​
what is positive. But it
is all the same surprising for a clinician of
the old continent, that this type of article
is accepted without giving rise, it seems,
to sharp criticisms, at least on the internet
which is however not stingy with excessive
or even unreasonable comments on all and
every subject; i.e. is not disputed either the
ideas of general ​​
normativity (on which the
all concept is based) or the cultural or social
biases underlying these ideas, everything
happening as if they were the subject of
such a consensus that it would appear irrel-
evant to discuss them. However, criticisms
exist, but, appearing only in clinical publi-
cations involving health professionals, their
critics are directed exclusively to self-care in
children and adolescents.
This is particularly the case if we refer to the
publications indexed in Medline in the rare
cases where they address the topic of Self
Care in Children and Adolescents
In these publications, they first wonder if
self-care in children and adolescents is not
above all sign of their neglect: Very repre-
sentative of this current is the article entitled
“Should we care about Adolescents Who
Care for Themselves? What we have learned
and what we need to know about youth in
Self-Care“ [2]. In this paper, the authors ar-
gue that Self-care would be an indicator of
a failure of parental support except in very
competent families.In other words,self-care
should be seen primarily as a sign of the
weak capability of the parents and their lack
of ability to use the educational standards to
help their children to deal with everything
related to care. These results are consistent
with Amartya Sen capabilities theory [3]
and impose to avoid a diversion of the no-
tion of self-care to mask the absence of suit-
able professional and non-professional help
to the children and adolescents in need.
These publications question also the fact
that is in certain complex conditions, self-
care is mainly directed towards the self-
management of care and, that, in that sense,
it is, above all, an attempt to reduce the
risks linked to poor management of treat-
ment, rather than a positive and desirable
development. In the situations of children
and adolescents with medically or socially
complex chronic conditions, supporting
self-management should be seen as a prior-
ity even if it remains far from the ideal of
autonomy to which is referred the model we
presented at the beginning of this paper [4].
By examining these two types of limita-
tions of the concept of the ideal model of
self-care, some authors were thus led to
introduce the idea of ​​
a self-care distinc-
tion between universal self-care and health
deviation self-care in children and ado-
lescents: in entering in the details of the
concept, they show that participants ap-
Michel Botbol
Promoting Self-Care in Children and Youth:
A challenge in itself
BACK TO CONTENTS
60
Person-centered Medicine
pear as competent agents in universal and
developmental self-care requisites but need
supportive-educative nursing interventions
for health-deviation self-care [5].
Surprisingly,the studies on self-care in chil-
dren and adolescents leave in the shade a
question that is crucial when dealing with
adolescents: the role of motivation in self-
care. It is well documented that motiva-
tion is crucial in the effect of interventions.
aiming at behavioural changes, with data
suggesting a greater influence of intrinsic
motivation (internal motives) over extrinsic
motivation (external motives).
In children and adolescents, the balance
between these two forms of motivation is
deeply affected by the alteration of the self/
others balance which is crucial at various
developmental stages. Psychological devel-
opment can indeed be seen,at least partially,
as a continuous journey from dependence to
autonomy.
It is particularly the case in adolescence in
which the adolescent is challenged by the
necessity to become autonomous (that is to
say to separate from those who supported
him during his childhood); with, here, an
additional difficulty due to the fact that
this burning needs to become autonomous
occurs at the very moment in which the
stress of the adolescence process increases
his needs to be helped by his parents and or
the other persons of his environment. It is a
paradoxical situation that challenge the ad-
olescent’s capacity to deal with separation.
It is of course crucial because the most vul-
nerable Adolescent are those in which this
capacity is the weakest and are additionally
those who are the most reluctant to accept
or ask for help, they would need, particularly
regarding mental health.The problem is that
they are also those who are the most likely
to engage in problematic behaviours and the
less likely to be self-care oriented [6].
Adolescence Psychiatry teaches us that in
that type of situation (which is frequent in
the field of mental health) the most efficient
way to get out of this paradoxical situation
is to find an interactive way to overcome the
relational threat this situation triggers in
the adolescent: his/her fear of dependency
and his/her feeling of failure dependency
induces in him/her. Educational mediations
are considered generally as the most effi-
cient tool for that stake because it reduces
the challenge of the relation by masking
it behind the pleasure of doing interesting
and gratifying things. Notably, some of the
normative proposals we mentioned at the
beginning of this brief note can be seen as
non-asymmetrical educational mediations.
References
1. Roudabush Claire: “Self-Care for Youth and
Families“: South Dakota State University Ex-
tension Website (2020).
2. Mahoney J & Parente M,“Should we care about
Adolescents Who Care for Themselves? What
we have learned and what we need to know
about youth in Self-Care” Child Dev. Perspect.
(2009), 189-195.
3. Amartya Sen The Idea of Justice, London Pen-
guin (2010).
4. Lozano P & Houtrow A,Management in Chil-
dren and Adolescents with Complex Chronic
Conditions Pediatrics, (2018), e201771284.
5. Burley-Moor J & Beckwitt A, “Children with
cancer and their parents: Self-Care and De-
pendent-Care Practices” Issues in Comprehen-
sive Pediatric Nursing, Published online (2009).
6. Botbol M “Le rapport au monde de l’adolescent:
comment changer en restant le même” (Ado-
lescents’ relation to the World: how to change
while remaining the same) Nouvelle Revue de
l’Adaptation et de la Scolarisation (2007).
Prof. Michel Botbol,
Emeritus of Child and Adolescent Psychiatry
(University of Western Brittany)
Board of Directors of the International
College of Person-Centered Medicine
E-mail: botbolmichel@orange.fr
Extreme Heat: A Guide for Health Professionals & Patients
Heat kills more people than floods, hur-
ricanes, tornadoes, and earthquakes com-
bined. This is why health professionals and
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tion. Doctors and nurses can advise patients
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nol). You can do this!
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III
Axe the Fax: Save Money & Lower Your Climate Footprint
It’s time to takes step to abandon your
fax machines. Your healthcare practice
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IV
Covid-19 Pandemic
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